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Quality Series No.3
National Guidelines for Improvement of Quality and Safety of Healthcare Institutions
(For Offices of Medical Officer of Health)
First Edition
Editors: Dr. Wimal Jayantha
Deputy Director General/Planning, Ministry of Health
Dr. S. Sridharan
Director Organization Development, Ministry of Health
Dr. C.J. Aluthweera
Coordinator for National Quality Assurance Programme, Ministry of Health
Mr. Shogo Kanamori
JICA Expert on Medical Services Administration
October 2010
COPYRIGHT © Management Development & Planning Unit Ministry of Health 385 Baddegama Wimalawansa Thero Mawatha., Colombo 10, Sri Lanka October 2010 National Library of Sri Lanka Cataloguing in Publication Data Quality Series No.3 National Guidelines for Improvement of Quality and Safety of Healthcare Institutions (for Offices of Medical Officer of Health) ISBN: 978-955-0505-06-7 Printed in Sri Lanka This Publication is sponsored by: Japan International Cooperation Agency (JICA)
Preface
Sri Lanka has reached a high level of health status amongst its population in comparison with the countries in the neighbourhood. The preventive care service network which has evolved since 1920s in Sri Lanka is known to be one of the leading contributors to the country’s achievement in improvement of the health outcomes. Nevertheless, there is still room for further improvement of the quality of the current preventive care services.
The National Guidelines for Improvement of Quality and Safety of Healthcare Institutions provide a comprehensive set of quality and safety standards and affordable measures to improve the preventive care services. All the offices of Medical Officer of Health in Sri Lanka are therefore expected to be fully oriented on these Guidelines and prepared to improve their service delivery structure and process. Needless to say, the strong commitment of heads of institutions, PDHSs and RDHSs is critical in achieving the goals aimed by these Guidelines.
I wish to thank all the stakeholders involved in the development of this document as well as Japan International Cooperation Agency (JICA) for its technical assistance. In particular, I am grateful to Dr. Wimal Jayantha, DDG/Planning, who supervised the whole developmental process, Dr. S. Sridharan, Director OD, who led and facilitated the drafting work, and Mr. Shogo Kanamori, JICA Expert on Medical Services Administration, who provided coordinative and technical assistance.
Dr. Ravindra Ruberu Secretary Ministry of Health
1 October 2010
List of Contributors
Dr. Aluthweera, Champa; Coordinator for National Quality Assurance Programme, Ministry of Health
Dr. Balasooriya, B.A.P.R.; Senior Registrar, MDPU, Ministry of Health
Dr. Batuwanthudawa, B.K.R., Consultant Epidemiologist
Dr. Deniyage, Sarath; Director, Malaria Control Programme, Ministry of Health
Mr. Dissanayake, Chaturanga; Project Assistant, JICA Advisor’s Office
Dr. Fernando, Rani; Director, Castle Street Hospital for Women
Dr. Gamage, G.L.N.D.; DMO, DH Polpithigama
Dr. Gamage, Rehan; Research Assistant, JICA Advisor’s Office
Dr. Gamlath, G.; MS, DGH Kegalle
Dr. Jayanath, B.L.D.; MOIC, PU Madampe
Dr. Jayantha, Wimal; DDG (Planning), Ministry of Health
Dr. Jayasooriya, Usha; MO, National Programme for Tuberculosis Control and Chest Diseases, Ministry of Health
Mr. Kanamori, Shogo; JICA Expert on Medical Services Administration
Dr. Pranagama, N.; Director, Cancer Control Programme, Ministry of Health
Dr. Ruwanpathirana, T.; Reg/Community Physician, Family Health Bureau, Ministry of Health
Dr. Sridharan, S.; Director Organization Development, Ministry of Health
Dr. Wedamulla, Asanka; MO Planning, MDPU, Ministry of Health
Dr. Wijerathne, Lalitha; MO/QMU, DGH Gampaha
Dr. Wijesinghe, W.A.K.; RDHS, Kegalle District
TABLE OF CONTENTS
1. Introduction ……………………………………………………………………………….. 1
1.1. Target Institutions of the Guidelines ..……………………………………………..… 1
1.2. The Guidelines in the Context of Quality Assurance Programme ………………... 2
1.3. Institutional Arrangements for Improvement of Quality and Safety of Preventive Healthcare Services ………………………………………………………………...… 3
2. Quality and Safety Standards of Preventive Healthcare Services …...………….. 3
I. Internal and External Customer Environment (5S) ………………………….…. 4 1. Seiri (Sorting)
2. Seiton (Organisation) 3. Seiso (Cleaning with Meaning and for Beautifying) 4. Seiketsu (Standardisation) 5. Shitsuke (Training & Self-Discipline)
II. Preventive Service Provision …………………………..…………………......….. 10 6. Work performance
7. Healthcare and educational service provision 8. Medical/pharmaceutical supplies management 9. Health information 10. Management of outbreaks and disasters 11. Responsiveness 12. Waste management
III. Overall Management of the Institution …..…………………………………....…. 16 13. Leadership and performance review
14. Human resource management 15. Productivity and quality improvement programme 16. Inter-sectoral coordination, public relations and community mobilisation
ANNEXES ……………………………………………………………………………………….. 19 ANNEX 1: Isles for Stationeries ………………………………………………………….. 19 ANNEX 2: Cleaning Checklist (Sample) …...……………………………………………. 20 ANNEX 3: Standardised Colour Codes ………………………………………………….. 21 ANNEX 4: Emergency Tray Items for MOH (Sample) …...…………………………….. 22 ANNEX 5: Customer Satisfaction Survey Form (Sample) …………………………….. 23
APPENDIX: General Circular on National Quality Assurance Programme in Health 29
1. Introduction
These Guidelines will provide guidance to those working at offices of Medical Officer of Health (MOH) in strengthening the organisational and individual preparedness for improvement of the quality and safety of preventive care services. It is assumed that these Guidelines will be used for the following purposes.
As a handbook for the MOH staff in implementing quality improvement programmes and related activities
As a guiding document for orientation programmes to the MOH staff conducted by the National Quality Secretariat of the Ministry of Health and the Provincial Quality Secretariats
1.1. Target institutions of the Guidelines
The target institutions of these Guidelines include all the MOH Offices in Sri Lanka. The PDHS/RDHS offices supervising activities of the MOH offices will also be potential users of this document.
Province District MOH Offices
Western Province 1 Colombo 12 2 Gampaha 13 3 Kalutara 10
Central Province 4 Kandy 22 5 Nuwaraeliya 13 6 Matale 12
Southern Province 7 Galle 17 8 Matara 17 9 Hambantota 20
Northern Province
10 Jaffna 12 11 Kilinochchi 4 12 Mannar 5 13 Mullativu 2 14 Vavuniya 4
Eastern Province
15 Batticaloa 13 16 Ampara 7 17 Kalmunai 13 18 Trincomalee 10
North Western Province 19 Kurunegala 20 20 Puttalam 9
North Central Province 21 Anuradhapura 19 22 Polonnaruwa 7
Uva Province 23 Badulla 15 24 Monaragala 11
Sabaragamuwa 25 Kegalle 11 26 Ratnapura 18
316
1
1.2. The Guidelines in the Context of Quality Assurance Programme
Two separate guidelines will be used to implement the National Quality Assurance Programme for preventive care services. One serves to provide guidance to MOH Offices in quality and safety improvement, and the other to provide protocols for external monitoring and evaluation of the preventive care services provided by them.
(1) Guideline for External Monitoring and Evaluation of Preventive Healthcare Services
(2) Guideline for Improvement of Quality and Safety of Preventive Healthcare Services
The present Guidelines mainly focus on the improvement of the quality and safety at the MOH Offices.
MOH Office
PDHS/RDHS
Guidance & Monitoring
Guidance & Monitoring
1. Guidelines for External Monitoring and Evaluation
- External monitoring system
- National quality award system
2. Guidelines for Improvement of Quality and Safety
- Organizational arrangements
- Quality and safety standards & checklist
DDG/Planning
This Guideline Document
Director Organisational Development
2
1.3. Institutional Arrangements for Improvement of Quality and Safety of Preventive Healthcare Services
All MOH Offices are expected to plan and implement the Quality Management Programme under the guidance of the Quality Management Unit of RDHS, according to the “General Circular No.01-29/2009” of the Ministry of Healthcare & Nutrition dated 22 September 2009 (attached as APPENDIX).
2. Quality and Safety Standards of Preventive Healthcare Services
This chapter provides the quality and safety standards of preventive care services to which all the MOH Offices shall adhere. They are divided into three aspects and 16 areas.
I. Internal and External Customer Environment (5S) 1. Seiri (Sorting) 2. Seiton (Organisation) 3. Seiso (Cleaning with Meaning and for Beautifying) 4. Seiketsu (Standardisation) 5. Shitsuke (Training & Self-Discipline)
II. Preventive Service Provision 6. Work performance 7. Healthcare and education service provision 8. Medical/pharmaceutical supplies management 9. Health information 10. Management of outbreaks and disasters 11. Responsiveness 12. Waste management
III. Overall Management of the Institution 13. Leadership and performance review 14. Human resource management 15. Productivity and quality improvement programme 16. Inter-sectoral coordination, public relations and community mobilisation
These standards will be referred to whenever an MOH Office conducts quality and safety improvement activities as well as internal audit. They are also in line with the criteria for external audits and for selection of the National Health Excellency Award recipients.
3
I. In
tern
al a
nd E
xter
nal C
usto
mer
Env
ironm
ent (
5S)
Area
of C
once
rn
Stan
dard
s Me
asur
able
Elem
ents
1 Se
iri (S
ortin
g)
Elim
inat
ing
unne
cess
ary
item
s fro
m th
e w
orkp
lace
that
are
not
nee
ded
for c
urre
nt p
roce
ss a
t wor
k
1.1
Outsi
de an
d ins
ide pr
emise
s 1.1
.1 Un
wante
d item
s re
move
d fro
m the
wo
rkplac
e
- An
estab
lishe
d pro
cess
in so
rting w
anted
and u
nwan
ted ite
ms is
pres
ent.
- A
prop
er pr
oces
s for
cond
emnin
g item
s is p
rese
nt.
- Un
wante
d item
s are
not le
ft in t
he w
orkp
lace o
r mar
ked w
ith ta
gs.
Re
d tag
s for
thos
e item
s to b
e disp
osed
Oran
ge ta
gs fo
r tho
se ite
ms un
der c
onsid
erati
on.
- To
ps an
d ins
ides o
f all c
upbo
ards
, she
lves,
tables
and d
rawe
rs ar
e fre
e of u
nwan
ted /ir
relev
ant it
ems.
1.1.2
The f
loors
and
pass
agew
ays i
n the
pu
blic a
reas
equip
ped
with
garb
age b
ins fo
r ge
nera
l was
te an
d kep
t fre
e of li
tters
- Ga
rbag
e bins
for g
ener
al wa
ste ar
e in p
lace a
nd co
lour c
oded
. -
The t
ime f
or re
movin
g litte
rs fro
m the
garb
age b
ins ar
e ind
icated
. -
The p
lace i
s fre
e of li
tter.
1.1.3
Unwa
nted t
rees
and
bran
ches
remo
ved
- Tr
ees w
hich a
re ob
struc
ting t
he dr
ainag
e are
remo
ved.
-Tr
ee br
anch
es ab
ove t
he ro
of an
d ove
r the
elec
tric an
d tele
phon
e wire
s are
trim
med.
1.2
Wall
s and
notic
e bo
ards
1.2
.1 W
alls b
eing f
ree o
f old
poste
rs, pi
cture
s or
calen
dars.
- Po
sters/
pictur
es ar
e not
fading
or to
rn.
- Inf
orma
tion o
n pos
ters/p
ictur
es is
not o
bsole
te.
- Ca
lenda
rs ar
e upd
ated.
1.2.2
Notic
e boa
rds b
eing
free o
f obs
olete
notic
es
- Re
mova
l instr
uctio
ns ar
e in p
lace.
- Th
e rem
oval
instru
ction
is co
mplie
d. -
Notic
e boa
rds a
re ca
tegor
ized a
ccor
ding t
o the
need
s. -
Resp
onsib
le pe
rsons
for e
ach n
otice
boar
d are
iden
tified
. -
The a
lignm
ent a
nd an
X-Y
axis
tool a
re m
aintai
ned i
n the
notic
e boa
rd.
4
I. In
tern
al a
nd E
xter
nal C
usto
mer
Env
ironm
ent (
5S)
Area
of C
once
rn
Stan
dard
s Me
asur
able
Elem
ents
2 Se
iton
(Org
anis
atio
n)
Ens
urin
g al
l the
item
s th
at h
ave
been
sor
ted
are
arra
nged
and
pla
ced
in p
re-a
ssig
ned
posi
tions
in o
rder
to fa
cilit
ate
effic
ienc
y at
wor
k.
2.1
Offic
e ide
ntific
ation
2.1
.1 An
offic
e nam
e boa
rd
and a
site
map
avail
able
- An
offic
e nam
e boa
rd is
disp
layed
outsi
de in
all th
ree l
angu
ages
. -
A sit
e map
is di
splay
ed at
the e
ntran
ce / r
ecep
tion a
rea i
n all t
hree
lang
uage
s.
2.2
Dire
ction
al ind
icatio
ns
2.2.1
Dire
ction
al bo
ards
av
ailab
le at
ever
y jun
ction
- Di
recti
onal
boar
ds ar
e disp
layed
at ev
ery j
uncti
on ou
tside
and i
nside
of th
e offic
e to a
ll fac
ilities
from
the
entra
nce i
n all t
hree
lang
uage
s.
2.2.2
Corri
dors
clear
ly ma
rked w
ith en
tranc
es
and e
xit lin
es, c
urve
d do
or op
ening
s, an
d dir
ectio
n of tr
avel
- Cu
rved d
oor o
penin
gs ar
e mar
ked a
t entr
ance
door
s to r
ooms
. -
The d
irecti
on of
trav
el is
indica
ted on
the c
orrid
ors.
- Th
e slid
ing do
ors a
re pr
ovide
d with
dire
ction
al ar
rows
.
2.3
Labe
lling a
nd
marki
ng
2.3.1
Room
s and
toile
ts cle
arly
identi
fied w
ith
labels
- Al
l room
s and
toile
ts ar
e ide
ntifie
d with
labe
ls, na
me bo
ards
or nu
mber
s.
2.3.2
Stor
es an
d stor
age
area
s pro
perly
or
ganis
ed
- Ite
ms in
stor
es an
d stor
age a
reas
are k
ept in
shelv
es, r
acks
or bi
ns an
d clea
rly m
arke
d. -
Shelf
grids
are m
arke
d with
refer
ence
numb
ers/n
ames
for e
asy r
etriev
al of
items
. -
All s
tation
eries
in th
e cup
boar
d are
kept
in pla
ces i
denti
fied w
ith sy
mbols
and m
arks
(visu
al co
ntrol
of sta
tione
ries).
-
Items
are s
tored
in an
alph
abeti
cal o
rder
and i
n a lo
gical
mann
er (le
ft to r
ight /
top to
botto
m).
- A
mech
anism
to re
plenis
h item
s is o
rgan
ized w
ith co
lour c
odes
:
Maxim
um st
ock l
evel:
Gre
en
Re
orde
r stoc
k lev
el: O
rang
e Mi
nimum
stoc
k lev
el: R
ed
2.3.3
Switc
hes a
nd fa
ns
easil
y ide
ntifie
d -
All s
witch
es an
d fan
regu
lator
s are
labe
lled a
ccor
dingly
. -
A se
para
te ele
ctrica
l poin
t plan
is in
plac
e for
each
room
at en
tranc
e.
5
I. In
tern
al a
nd E
xter
nal C
usto
mer
Env
ironm
ent (
5S)
Area
of C
once
rn
Stan
dard
s Me
asur
able
Elem
ents
2.4
Pl
acing
and
parki
ng ru
les
2.4.1
Equip
ment
and t
ools
being
kept
in or
igina
l pla
ces a
fter u
se
- ‘Is
les’ a
re id
entifi
ed fo
r eac
h equ
ipmen
t and
tool
to be
kept
after
use w
ith th
e stra
ight li
ne m
ethod
and
shad
ow dr
awing
s disp
layed
. -
A me
chan
ism to
iden
tify pe
rsons
remo
ving i
tems f
rom
‘isles
’ Item
s is i
n plac
e.
An ex
ampl
e of ‘
Isles
’ is sh
own
in “A
NNEX
1: Is
les fo
r Sta
tione
ries”
.
2.4.2
Files
and f
older
s ar
rang
ed us
ing th
e mi
stake
proo
fing
conc
ept
- Fil
es an
d box
folde
rs ar
e arra
nged
using
the m
istak
e pro
ofing
conc
ept to
facil
itate
identi
ficati
on of
partic
ular
files (
withi
n 30 s
econ
ds) a
nd st
oring
in or
igina
l plac
es.
2.4.3
Parki
ng ar
eas f
or
vehic
les sp
ecifie
d and
ma
rked
- Pa
rking
area
s for
vehic
les ar
e spe
cified
and m
arke
d. -
Vehic
le flo
ws ar
e ide
ntifie
d and
mar
ked.
- Si
gn bo
ards
for v
ehicl
es of
disa
bled p
erso
ns ar
e in p
lace.
3 Se
iso
(Cle
anin
g w
ith M
eani
ng a
nd fo
r Bea
utify
ing)
Cle
anin
g up
one
’s w
orkp
lace
com
plet
ely
to e
limin
ate
dust
on
floor
s, m
achi
nes
or e
quip
men
t.
3.1
Gene
ral
appe
aran
ce of
cle
anlin
ess
3.1.1
Offic
e pre
mise
s ma
intain
ed w
ith
healt
hy an
d safe
en
viron
ment
- Th
e gar
den i
s pro
perly
main
taine
d and
land
scap
ing is
done
by a
gard
ener
. -
Drain
s are
not le
aking
or ov
erflo
wing
. -
Stag
natio
n of w
ater is
avoid
ed in
all d
rains
. -
Unple
asan
t odo
ur is
not p
rodu
ced f
rom
the ho
spita
l was
te sit
e or o
ther p
laces
. -
The v
isible
parts
of th
e roo
f are
free
of un
wante
d item
s. 3.1
.2 Flo
ors,
walls
, wind
ows
and c
urtai
n & ot
her
fitting
s bein
g kep
t cle
an
- Th
e clea
nline
ss is
main
taine
d at:
Flo
ors
W
alls
W
indow
s
Curta
ins
Ot
her f
itting
s
Gu
tters
- A
clean
ing ch
eckli
st is
avail
able
and u
pdate
d.
6
I. In
tern
al a
nd E
xter
nal C
usto
mer
Env
ironm
ent (
5S)
Area
of C
once
rn
Stan
dard
s Me
asur
able
Elem
ents
3.1
.3 To
ilets
are c
lean a
nd in
wo
rking
orde
r -
Unple
asan
t odo
ur is
not e
xper
ience
d in t
oilets
. -
Toile
t facil
ities a
re ke
pt re
ady f
or us
e. -
A cle
aning
chec
klist
is av
ailab
le an
d upd
ated.
- Ad
equa
te ve
ntilat
ion is
prov
ided i
n all t
he to
ilets.
3.2
Clea
ning o
f ma
chine
s, eq
uipme
nt, to
ols
and f
urnit
ure
3.2.1
The c
leanli
ness
of
build
ings,
mach
ines,
equip
ment,
tools
and
furnit
ure m
aintai
ned
- Th
e high
leve
l of c
leanli
ness
is m
aintai
ned w
ith no
visib
le dir
t:
Build
ings
Of
fice v
ehicl
es
Of
fice e
quipm
ent
Fu
rnitu
re (t
ables
, des
ks, c
hairs
, etc.
)
3.3
Clea
ning p
racti
ce
3.3.1
An or
ganis
ed cl
eanin
g sy
stem
in pla
ce
- Th
e foll
owing
tools
and d
ocum
ents
are d
isplay
ed/av
ailab
le:
Cl
eanin
g res
pons
ibility
char
t
Clea
ning s
ched
ules
Cl
eanin
g guid
eline
s -
The a
bove
tools
and d
ocum
ents
are u
pdate
d mon
thly.
3.3.2
Clea
ning t
ools
and
deter
gents
prop
erly
store
d
- Pr
oper
stor
age f
acilit
ies fo
r clea
ning t
ools
and d
eterg
ents
are a
vaila
ble.
- Cl
eanin
g too
ls for
outsi
de ar
eas/t
oilets
and i
nside
area
s are
sepa
rated
.
3.3.3
An up
dated
clea
ning
chec
klist
avail
able
- A
clean
ing ch
eckli
st is
displa
yed a
nd m
ade v
isible
to th
e staf
f mem
bers.
-
Resp
onsib
le pe
rsonn
el for
clea
ning i
s ide
ntifie
d and
men
tione
d in t
he cl
eanin
g che
cklis
t. -
The c
leanin
g che
cklis
t is up
dated
wee
kly.
A sa
mpl
e clea
ning
chec
klist
is p
rovid
ed in
“ANN
EX 2:
Clea
ning
Che
cklis
t (Sa
mpl
e)”.
7
I. In
tern
al a
nd E
xter
nal C
usto
mer
Env
ironm
ent (
5S)
Area
of C
once
rn
Stan
dard
s Me
asur
able
Elem
ents
4 Se
iket
su (S
tand
ardi
zatio
n)
Gen
erat
ing
mec
hani
sms
to m
aint
ain
the
thre
e S
s (S
eiri,
Sei
ton
and
Sei
so) b
y de
velo
ping
pro
cedu
res,
sch
edul
es a
nd to
ols
for c
ontin
uous
ass
essm
ent a
nd
regu
lar a
udit.
4.1
Stan
dard
ized
visua
ls
4.1.1
Sign
boar
ds an
d dir
ectio
nal b
oard
s sta
ndar
dised
- Al
l sign
boar
ds an
d dire
ction
al bo
ards
are s
tanda
rdise
d wi
th pr
oper
align
ment
and c
onsis
tent fo
nts, a
nd by
co
lour c
odes
.
4.1.2
Identi
ficati
on la
bels
place
d on a
ll mac
hines
an
d equ
ipmen
t
- Al
l mac
hines
and e
quipm
ent h
ave i
denti
ficati
on la
bels
with
the fo
llowi
ng in
forma
tion:
Na
me of
the i
tems
Ide
ntific
ation
and b
atch n
umbe
rs
Date
of ac
quisi
tion
Co
ntact
detai
ls of
maint
enan
ce co
mpan
y
Resp
onsib
le pe
rson f
or m
ainten
ance
Co
st of
equip
ment
4.1.3
Cauti
on si
gns
displa
yed a
t ap
prop
riate
place
s
- “D
ange
r” sig
ns ar
e disp
layed
at el
ectric
switc
hboa
rds a
nd tr
ansfo
rmer
s. -
“Slop
es” s
igns a
re di
splay
ed at
whe
reve
r the
re is
a slo
pe.
- “S
lippe
ry” si
gns w
ith ze
bra c
ode a
re pl
aced
at w
et flo
or af
ter cl
eanin
g. 4.1
.4 Op
en an
d shu
t dir
ectio
nal la
bels
avail
able
on do
ors
- Th
e dire
ction
al lab
els ar
e put
on do
or ha
ndles
of cu
pboa
rds.
4.1.5
Was
te bin
s sep
arate
d, lab
elled
and
colou
r-cod
ed
- Al
l the w
aste
bins a
re se
para
ted, la
belle
d and
colou
r-cod
ed.
The c
olou
r-cod
es ar
e elab
orat
ed in
“ANN
EX 3:
Sta
ndar
dise
d Co
lour
Cod
es”
4.2
Maint
enan
ce of
ve
hicles
, ma
chine
s and
eq
uipme
nt
4.2.1
Vehic
les, m
achin
es
and e
quipm
ent
prop
erly
maint
ained
- Ma
inten
ance
sche
dules
and r
ecor
ds ar
e ava
ilable
and u
pdate
d for
the f
ollow
ing ite
ms:
Ve
hicles
Mach
ines
Of
fice e
quipm
ent
-Op
erati
onal
instru
ction
s are
mad
e ava
ilable
for m
achin
es an
d equ
ipmen
t.
8
I. In
tern
al a
nd E
xter
nal C
usto
mer
Env
ironm
ent (
5S)
Area
of C
once
rn
Stan
dard
s Me
asur
able
Elem
ents
4.3
Sa
fety a
nd
secu
rity
meas
ures
4.3.1
Secu
rity m
easu
res i
n pla
ce fo
r a fir
e eve
nt -
Func
tiona
l fire
extin
guish
ers o
r san
d buc
kets
are a
vaila
ble.
- Th
e guid
eline
s or a
proto
col fo
r the
fire e
vent
is av
ailab
le.
5 Sh
itsuk
e (T
rain
ing
& S
elf-D
isci
plin
e)
Wor
king
on
5S a
s da
ily ro
utin
es a
nd e
nsur
ing
that
it b
ecom
es a
n in
tegr
al p
art o
f the
wor
kpla
ce fa
bric
.
5.1
Inter
nal a
udit
5.1.1
Inter
nal a
udits
on th
e qu
ality
and s
afety
impr
ovem
ent
cond
ucted
with
the
chec
klist
- An
inter
nal a
udit s
heet
on th
e hos
pital
quali
ty im
prov
emen
t is av
ailab
le.
- A
team
has b
een a
ppoin
ted to
cond
uct th
e inte
rnal
audit
. -
The i
ntern
al au
dit is
cond
ucted
at le
ast o
nce i
n thr
ee m
onths
.
5.2
Train
ing an
d ra
ising
aw
aren
ess
5.2.1
The s
taff tr
ained
on 5S
, pr
oduc
tivity
and q
uality
-
All th
e staf
f are
train
ed on
5S, p
rodu
ctivit
y and
quali
ty.
- A
prog
ramm
e to t
rain
new
staff o
n 5S,
prod
uctiv
ity an
d qua
lity is
avail
able.
5.2
.2 A
syste
m to
give
awar
ds to
we
ll-per
forme
d staf
f an
d unit
s ava
ilable
- An
even
t to ap
prec
iate b
est p
erfor
ming
emplo
yees
is ca
rried
out a
nnua
lly.
9
II.
Prev
entiv
e Se
rvic
e Pr
ovis
ion
Area
s of C
once
rn
Stan
dard
s
Meas
urab
le El
emen
ts
6 W
ork
perf
orm
ance
6.1
Wor
k pe
rform
ance
6.1
.1 Pr
egna
nt mo
thers
regis
tered
befor
e 8
week
s
- Mo
re th
an 80
% of
the p
regn
ant m
other
s are
regis
tered
befor
e 8 w
eeks
.
6.1.2
Postp
artum
visit
s co
nduc
ted 4
times
after
the
deliv
ery
- Th
e pos
tpartu
m vis
its ar
e con
ducte
d 4 tim
es by
PHM
for a
ll the
deliv
ery c
ases
.
6.1.3
The i
mmun
izatio
n co
vera
ge un
der 1
year
old
satis
factor
y
- Th
e cov
erag
e of m
easle
s vac
cine u
nder
1 ye
ar ol
d (us
ually
take
n at 9
mon
th)*
- Th
e cov
erag
e of th
e trip
le va
ccine
(usu
ally t
aken
at 2,
4 & 6
month
s)*
* Rat
ings f
or a
sses
smen
t: 0
(0-8
0%),
1 (8
0-85
%),
2 (8
5-90
%),
3 (9
0-95
%),
4 (9
5-10
0%)
6.1.4
Contr
acep
tive
prev
alenc
e rate
sa
tisfac
tory
- Th
e con
trace
ptive
prev
alenc
e amo
ng el
igible
coup
les is
betw
een 7
0% an
d 72%
. -
The I
UCD
prev
alenc
e amo
ng el
igible
coup
les is
13%
.
6.1.5
The s
choo
l hea
lth
activ
ities c
ondu
cted
- Th
e med
ical in
spec
tion v
isits
cove
red a
ll the
scho
ols an
d all t
he ch
ildre
n at th
e Yea
r 1, 4
and 7
acco
rding
to
the pr
eviou
s yea
r’s re
cord
. -
The d
ental
insp
ectio
n visi
ts co
vere
d all t
he sc
hools
and a
ll the
child
ren a
t the Y
ear 1
, 4 an
d 7 ac
cord
ing to
the
prev
ious y
ear’s
reco
rd.
-Th
e hea
lth pr
omoti
on ac
tivitie
s are
cond
ucted
at al
l the s
choo
ls an
d rec
orde
d.
7 H
ealth
care
and
edu
catio
nal s
ervi
ce p
rovi
sion
7.1
Wait
ing ar
ea
7.1.1
A sp
aciou
s and
ve
ntilat
ed w
aiting
area
av
ailab
le wi
th ad
equa
te se
ating
fac
ilities
- A
spac
ious a
nd ve
ntilat
ed w
aiting
area
is av
ailab
le.
- A
suffic
ient n
umbe
r of s
eatin
g fac
ilities
is av
ailab
le at
the w
aiting
area
.
10
II.
Prev
entiv
e Se
rvic
e Pr
ovis
ion
Area
s of C
once
rn
Stan
dard
s
Meas
urab
le El
emen
ts
7.2
Clini
c ser
vice
prov
ision
7.2
.1 Fu
nctio
nal a
nte-n
atal
clinic
s ava
ilable
-
Ante-
natal
clini
cs ar
e ava
ilable
once
in tw
o wee
ks at
the M
OH pr
emise
s and
othe
r loca
tions
and o
pera
ted
from
7:30 i
n the
mor
ning.
- Du
ty ro
sters
are p
repa
red a
t the b
eginn
ing of
the y
ear a
nd av
ailab
le for
the a
nte-n
atal c
linic
servi
ces.
- Th
e foll
owing
equip
ment
are a
vaila
ble an
d fun
ction
ing.
BP
appa
ratus
Heigh
t mea
sure
Weig
hing s
cale
- Th
e foll
owing
inve
stiga
tions
are c
ondu
cted.
Ur
ine gl
ucos
e
Urine
prote
in -
A lis
t of h
ealth
educ
ation
topic
s for
the a
nte-n
atal c
linics
is av
ailab
le.
7.2.2
Func
tiona
l pos
t-nata
l cli
nics a
vaila
ble
- Po
st-na
tal cl
inics
are a
vaila
ble on
ce in
two w
eeks
at th
e MOH
prem
ises a
nd ot
her lo
catio
ns.
7.2.3
Func
tiona
l fami
ly pla
nning
clini
cs
avail
able
- Fa
mily
plann
ing cl
inics
are a
vaila
ble on
ce in
two w
eeks
at th
e MOH
prem
ises a
nd ot
her lo
catio
ns.
7.2.4
A fun
ction
al we
ll-wom
en cl
inic
avail
able
- W
ell-w
omen
clini
cs ar
e ava
ilable
once
in tw
o wee
ks at
the M
OH pr
emise
s and
othe
r loca
tions
. -
The f
ollow
ing in
vesti
gatio
ns ar
e con
ducte
d with
esse
ntial
facilit
ies.
Bl
ood p
ress
ure
Di
abete
s
Brea
st ca
ncer
Cervi
cal c
ance
r (pa
p sme
ar)
7.2.5
A fun
ction
al we
ll-bab
y cli
nic av
ailab
le -
Well
-bab
y clin
ics ar
e ava
ilable
once
in tw
o wee
ks at
the M
OH pr
emise
s and
othe
r loca
tions
. -
The f
ollow
ing eq
uipme
nt ar
e ava
ilable
and f
uncti
oning
.
Weig
hing s
cale
He
ight m
easu
re
7.2.6
A re
sour
ce ce
ntre
avail
able
and
functi
oning
- A
reso
urce
centr
e whic
h pro
vides
broc
hure
s, lea
flets
and o
ther h
ealth
educ
ation
mate
rials
is av
ailab
le.
- A
TV an
d a vi
deo p
layer
are a
vaila
ble an
d use
d to p
rovid
e hea
lth ed
ucati
on to
visit
ors.
- He
alth e
duca
tion p
oster
s are
put o
n the
wall
in th
e foll
owing
man
ners:
Poste
rs ar
e fra
med.
Al
l the p
oster
s are
cons
isten
t in si
ze.
Area
s to p
ut po
sters
are c
atego
rised
by su
bjects
.
11
II.
Prev
entiv
e Se
rvic
e Pr
ovis
ion
Area
s of C
once
rn
Stan
dard
s
Meas
urab
le El
emen
ts
7.3
Emer
genc
y car
e se
rvice
s 7.3
.1 An
emer
genc
y tra
y av
ailab
le an
d fun
ction
ing
- An
emer
genc
y tra
y is a
vaila
ble w
ith es
senti
al su
pplie
s, so
lution
s and
drug
s. -
A ch
eckli
st for
the e
merg
ency
tray
items
is av
ailab
le an
d che
cked
at le
ast o
nce a
wee
k. -
A re
spon
sible
office
r is in
dicate
d for
the m
ainten
ance
of th
e eme
rgen
cy tr
ay.
A lis
t of t
he em
erge
ncy t
ray i
tem
s are
pro
vided
in “A
NNEX
4: E
mer
genc
y Tra
y Ite
ms f
or M
OH (S
ampl
e)”
7.4
Beha
viour
al ch
ange
activ
ities
7.4.1
Beha
viour
al ch
ange
ac
tivitie
s con
ducte
d -
A be
havio
ural
chan
ge pl
an fo
r the
gene
ral p
opula
tion i
s dev
elope
d bas
ed on
healt
h iss
ues i
denti
fied i
n the
co
verin
g are
a. -
The b
ehav
ioura
l cha
nge p
lan is
imple
mente
d and
reco
rded
.
8 M
edic
al/p
harm
aceu
tical
sup
plie
s m
anag
emen
t
8.1
Medic
al/ph
arma
ceu
tical
supp
lies
8.1.1
Esse
ntial
medic
al/ph
arma
ceuti
cal s
uppli
es av
ailab
le
- Es
senti
al me
dical
and p
harm
aceu
tical
supp
lies (
drug
s, va
ccine
s, co
ntrac
eptiv
e dev
ices)
are a
vaila
ble.
- Re
cord
s on m
edica
l and
phar
mace
utica
l sup
plies
are k
ept p
rope
rly.
-Av
ailab
ility o
f dru
gs/va
ccine
s is i
nform
ed to
relev
ant s
taff.
8.1.2
Annu
al es
timate
s of
medic
al an
d ph
arma
ceuti
cal
supp
lies p
repa
red
- An
annu
al es
timate
of m
edica
l and
phar
mace
utica
l sup
plies
is pr
epar
ed an
d sen
t to R
DHS
by O
ctobe
r eve
ry ye
ar.
8.2
Stor
age a
nd
stock
ma
inten
ance
of
medic
al su
pplie
s
8.2.1
Phar
mace
utica
l item
s sto
red a
ccor
ding t
o the
ma
nufac
turer
’s sta
ndar
ds
- Ph
arma
ceuti
cal it
ems a
re st
ored
at op
timum
temp
eratu
res a
ccor
ding t
o the
man
ufactu
rer’s
stan
dard
s. -
A re
friger
ator t
o kee
p pha
rmac
eutic
al ite
ms is
avail
able
and f
uncti
oning
. -
Temp
eratu
res o
f the r
efrige
rator
are m
easu
red a
nd re
cord
ed in
a re
gister
twice
a da
y. -
A po
wer b
acku
p is a
vaila
ble to
keep
the r
efrige
rator
func
tionin
g. 8.2
.2 St
ock i
tems o
f ph
arma
ceuti
cal
supp
lies a
ppro
priat
ely
mana
ged
- Inf
orma
tion o
n dail
y stoc
k item
s is a
vaila
ble.
- A
vacc
ine m
ovem
ent r
egist
er is
avail
able
and u
pdate
d. -
‘First
expir
y firs
t out
syste
m’ is
main
taine
d. -
Infor
matio
n is u
pdate
d on S
URPL
US ite
ms.
8.2.3
Expir
ing ite
ms
appr
opria
tely m
anag
ed
- Pe
riodic
chec
ks ar
e don
e for
expir
ing ite
ms re
gular
ly.
- A
regis
ter bo
ok of
perio
dic ch
ecks
for e
xpirin
g item
s is a
vaila
ble an
d upd
ated.
- A
mech
anism
to pr
even
t mix-
up of
expir
ed an
d non
-exp
ired d
rugs
and t
o disp
ose t
he ex
pired
items
on tim
e is
in pla
ce.
12
II.
Prev
entiv
e Se
rvic
e Pr
ovis
ion
Area
s of C
once
rn
Stan
dard
s
Meas
urab
le El
emen
ts
9 H
ealth
info
rmat
ion
9.1
Healt
h inf
orma
tion
mana
geme
nt
9.1.1
Comp
lete r
eturn
s pr
epar
ed an
d dis
patch
ed in
time
- Co
mplet
e retu
rns a
re pr
epar
ed an
d disp
atche
d to R
DHS,
FHB
and E
pidem
iolog
y Unit
in tim
e (be
fore 1
0th da
y of th
e mon
th), in
cludin
g:
Quar
terly
MCH
Retur
n (H5
09)
Qu
arter
ly EP
I Retu
rn
Qu
arter
ly Sc
hool
Healt
h Ins
pecti
on R
eturn
(H79
7)
Qu
arter
ly Su
pervi
sory
Form
ats (F
orm
C)
Mo
nthly
Fami
ly Pl
annin
g Retu
rn (H
1200
b)
AE
FI M
onthl
y Retu
rns
Quar
terly
Healt
h Edu
catio
n and
Pro
motio
n Retu
rns
9.1.2
Reco
rds k
ept a
t a
reco
rd ro
om in
an
orga
nised
man
ner
- Re
cord
s are
kept
at a r
ecor
d roo
m an
d pile
d acc
ordin
g to t
he ye
ar an
d cate
gorie
s.
9.1.3
Comp
uter-b
ased
da
tabas
e ava
ilable
-
Comp
uter-b
ased
datab
ase i
s ava
ilable
and f
uncti
oning
. -
An da
ta op
erato
r to e
nter d
ata is
assig
ned.
-An
e-re
portin
g sys
tem fo
r sen
ding r
eturn
s is a
vaila
ble.
9.2
Dise
ase
surve
illanc
e 9.2
.1 Inv
estig
ation
s of
notifi
able
disea
ses
done
in a
timely
ma
nner
- Th
e per
centa
ge of
the i
nves
tigati
ons f
or no
tifiab
le dis
ease
s don
e with
in 7 d
ays*
* Rat
ings f
or a
sses
smen
t: 0
(0-8
0%),
1 (8
0-85
%),
2 (8
5-90
%),
3 (9
0-95
%),
4 (9
5-10
0%)
9.2.2
Infec
tious
dise
ases
pr
oper
ly re
cord
ed an
d re
porte
d
- A
Notifi
catio
n reg
ister
is up
dated
. -
Infec
tious
dise
ase r
egist
er is
prop
erly
maint
ained
. -
Wee
kly E
pidem
iolog
y Rep
orts
are d
ispatc
hed t
o Epid
emiol
ogy U
nit at
the l
atest
by th
e foll
owing
Mon
day o
f the
wee
k. 9.3
Co
mmun
ity
surve
y 9.3
.1 Co
mmun
ity-b
ased
be
havio
ur su
rveys
co
nduc
ted
- Co
mmun
ity-b
ased
beha
viour
surve
ys ar
e con
ducte
d reg
ularly
and r
esult
s are
comp
iled i
nto re
ports
.
13
II.
Prev
entiv
e Se
rvic
e Pr
ovis
ion
Area
s of C
once
rn
Stan
dard
s
Meas
urab
le El
emen
ts
10
Man
agem
ent o
f out
brea
ks a
nd d
isas
ters
10.1
Mana
geme
nt of
outbr
eaks
and
disas
ters
10.1.
1 A
disas
ter
mana
geme
nt pla
n av
ailab
le
- A
disas
ter m
anag
emen
t plan
is av
ailab
le at
MOH.
-
MOH
staff a
re or
iented
on th
e disa
ster m
anag
emen
t plan
.
10.1.
2 Ou
tbrea
ks pr
oper
ly ma
nage
d -
Outbr
eaks
are i
nves
tigate
d in a
timely
man
ner.
- Re
ports
on ou
tbrea
ks ar
e pro
perly
main
taine
d. -
A pr
otoco
l for c
oord
inatio
n and
comm
unica
tion w
ith hi
gher
autho
rities
in ou
tbrea
k eve
nts is
avail
able.
11
Res
pons
iven
ess
11.1
Resp
onsiv
enes
s to
visito
rs 11
.1.1
Infor
matio
n ava
ilable
for
visit
ors
- A
rece
ption
desk
is av
ailab
le at
the cl
inic w
ith a
relev
ant p
erso
n in c
harg
e. -
Esse
ntial
infor
matio
n is p
rovid
ed fo
r visi
tors t
o the
clini
cs.
11.1.
2 Ba
sic fa
cilitie
s av
ailab
le -
Suffic
ient s
eatin
g fac
ilities
are a
vaila
ble fo
r pati
ents
and v
isitor
s. -
Basic
facil
ities i
nclud
ing dr
inking
wate
r and
a cle
an us
able
toilet
are a
vaila
ble.
11.2
Resp
onsiv
enes
s in
healt
hcar
e se
rvice
prov
ision
11.2.
1 Pr
ivacy
and
confi
denti
ality
maint
ained
- Pr
ivacy
and c
onfid
entia
lity is
main
taine
d dur
ing cl
inic c
onsu
ltatio
ns.
11.2.
2 He
alth e
duca
tion
cond
ucted
-
Healt
h edu
catio
n acti
vities
are c
ondu
cted w
ith re
levan
t mate
rials.
11.2.
3 Cl
inics
avail
able
for
worki
ng m
other
s -
MCH,
fami
ly pla
nning
and i
mmun
izatio
n clin
ics ar
e ope
n on a
t leas
t eve
ry oth
er S
aturd
ay pa
rticula
rly fo
r wo
rking
moth
ers.
14
II.
Prev
entiv
e Se
rvic
e Pr
ovis
ion
Area
s of C
once
rn
Stan
dard
s
Meas
urab
le El
emen
ts
12
Was
te m
anag
emen
t
12.1
Was
te ma
nage
ment
12.1.
1 W
astes
adeq
uatel
y dis
pose
d -
Five t
ypes
of w
astes
are s
egre
gated
by th
e colo
ur co
des:
Ge
nera
l was
tes
Sh
arps
Infec
ted w
astes
Plas
tics
Gl
asse
s -
A co
lour c
oding
char
t for t
he w
aste
segr
egati
on is
disp
layed
. -
The w
aste
segr
egati
on is
orga
nised
at th
e was
te dis
posa
l are
a acc
ordin
g to t
he co
lour c
odes
. -
An in
ciner
ator o
r a pr
oper
mec
hanis
m for
the f
inal d
ispos
al of
waste
s is a
vaila
ble an
d fun
ction
ing.
12.1.
2 Ha
zard
ous w
astes
dis
pose
d pro
perly
-
Disp
osal
bins f
or sh
arps
inclu
ding n
eedle
s are
in pl
ace a
ccor
dingly
. -
A pr
otoco
l for d
ispos
al of
waste
body
fluid
and b
lood c
ompo
nents
are a
vaila
ble an
d adh
ered
to.
15
III.
Ove
rall
Man
agem
ent o
f the
Inst
itutio
n Ar
eas o
f Con
cern
St
anda
rds
Me
asur
able
Elem
ents
13 L
eade
rshi
p an
d pe
rfor
man
ce re
view
13.1
Lead
ersh
ip qu
ality
13.1.
1 Vi
sion,
Miss
ion an
d va
lues o
f the
orga
nisati
on av
ailab
le
- Th
e Visi
on, M
ission
and v
alues
of th
e org
anisa
tion a
re di
splay
ed in
a vis
ible p
lace.
- Of
fice s
taff a
re aw
are o
f the V
ision
, Miss
ion an
d valu
es, a
nd un
derst
and t
hem.
13.1.
2 Se
nior m
anag
ers
involv
ed in
quali
ty im
prov
emen
t, co
mmun
ity m
obilis
ation
an
d welf
are a
ctivit
ies
- Se
nior m
anag
ers i
nclud
ing M
OH, S
PHM,
PHN
S an
d SPH
I initia
te me
eting
s to i
mplem
ent q
uality
ma
nage
ment,
comm
unity
mob
ilizati
on an
d welf
are a
ctivit
ies.
- Re
cord
s ind
icatin
g the
partic
ipatio
n of th
e sen
ior m
anag
ers i
n the
abov
e acti
vities
are a
vaila
ble.
13.1.
3 Th
e man
agem
ent o
f the
insti
tution
base
d on
plans
- Th
e foll
owing
plan
s are
deve
loped
and a
vaila
ble.
Ad
vanc
e pro
gram
mes f
or al
l the k
ey st
aff
An
nual
plan o
f the i
nstitu
tion
Mediu
m-ter
m pla
n of th
e ins
titutio
n 13
.2 Pe
rform
ance
re
view
13.2.
1 A
functi
onal
supe
rviso
ry sy
stem
in pla
ce
- A
supe
rviso
ry sta
ff cha
rt is
avail
able.
-
Regu
lar in
spec
tions
of th
e fiel
d staf
f per
forma
nce a
re co
nduc
ted by
supe
rvisin
g staf
f (e.g
. MOH
, PHN
S,
SPHI
, SPH
M at
MOH
Offic
es) a
t leas
t onc
e in t
hree
mon
ths.
- Re
ports
on su
pervi
sory
visits
are a
vaila
ble an
d upd
ated.
13.2.
2 Pe
rform
ance
comp
iled
and r
eview
ed
- Th
e mon
thly m
eetin
g is c
ondu
cted a
nd m
inutes
are k
ept.
- Qu
arter
ly MC
H an
d EPI
revie
ws ar
e con
ducte
d. -
Quar
terly
work
perfo
rman
ce re
views
are c
ondu
cted.
- Re
cord
s on t
he pe
rform
ance
revie
ws ar
e kep
t. -
Perfo
rman
ce re
sults
are d
isplay
ed.
- An
nual
repo
rts ar
e com
piled
and d
istrib
uted.
14
Hum
an re
sour
ce m
anag
emen
t
14.1
Huma
n res
ource
ma
nage
ment
14.1.
1 St
aff tr
aining
co
nduc
ted re
gular
ly -
A sta
ff tra
ining
annu
al pla
n is a
vaila
ble.
- A
staff t
raini
ng re
cord
book
is av
ailab
le an
d upd
ated.
-A
coor
dinato
r for
staff
train
ing is
assig
ned.
16
III.
Ove
rall
Man
agem
ent o
f the
Inst
itutio
n Ar
eas o
f Con
cern
St
anda
rds
Me
asur
able
Elem
ents
14
.1.2
Staff
deplo
ymen
t ad
equa
tely m
anag
ed
- Th
e cad
re an
d the
curre
nt sta
tus of
the s
taff a
re di
splay
ed an
d upd
ated.
- St
aff de
ploym
ent r
ecor
d boo
ks ar
e ava
ilable
for a
ll cate
gorie
s of s
taff a
nd up
dated
. -
Perso
nal fi
les ar
e ava
ilable
for e
ach s
taff a
nd up
dated
. 14
.1.3
Job d
escri
ption
s for
all
categ
ories
of st
aff
avail
able
- Jo
b des
cripti
ons f
or al
l cate
gorie
s of s
taff a
re av
ailab
le.
15
Prod
uctiv
ity a
nd q
ualit
y im
prov
emen
t pro
gram
me
15.1
Prod
uctiv
ity an
d qu
ality
impr
ovem
ent
prog
ramm
e
15.1.
1 Qu
ality
impr
ovem
ent
syste
m in
place
-
Quali
ty cir
cles o
r wor
k imp
rove
ment
teams
are e
stabli
shed
and f
uncti
onal.
-
Prod
uctiv
ity an
d qua
lity im
prov
emen
t pro
gram
mes s
uch a
s staf
f train
ing an
d 5S
imple
menta
tion a
re
cond
ucted
regu
larly.
15
.1.2
A me
chan
ism to
ide
ntify
and m
inimi
ze
erro
rs an
d risk
s in
place
- Ac
ciden
ts an
d adv
erse
even
ts su
ch as
staff
injur
ies, fa
lls of
custo
mers
and a
ccide
ntal n
eedle
prick
s are
re
cord
ed.
- Me
eting
s to r
eview
thos
e eve
nts ar
e org
anize
d and
mea
sure
s are
take
n to p
reve
nt the
m.
15.1.
3 Cu
stome
r sati
sfacti
on
surve
ys co
nduc
ted
- Cu
stome
r sati
sfacti
on su
rveys
are c
ondu
cted a
nd di
ssem
inated
to re
levan
t staf
f.
A sa
mpl
e pa
tient
sat
isfac
tion
surv
ey fo
rm is
pro
vided
in “A
NNEX
5: C
usto
mer
Sat
isfac
tion
Surv
ey F
orm
(S
ampl
e)”.
15.1.
4 Pu
blic c
ompla
ints
hand
led pr
oper
ly -
A re
gister
for p
ublic
comp
laints
and a
ction
s tak
en is
avail
able
and m
aintai
ned.
16
Inte
r-se
ctor
al c
oord
inat
ion,
pub
lic re
latio
ns a
nd c
omm
unity
mob
ilisa
tion
16.1
Comm
unity
pa
rticipa
tion
16.1.
1 Co
mmun
ity
partic
ipatio
n me
chan
ism in
plac
e
- A
mech
anism
to ha
ndle
dona
tions
and o
ther a
ssist
ance
from
the c
ommu
nity i
s org
anise
d. -
Healt
h pro
motio
n sett
ings a
re in
plac
e at th
e com
munit
y lev
el.
16.1.
2 Co
mmen
datio
n fro
m the
publi
c ade
quate
ly ma
nage
d
- Co
mmen
datio
ns fr
om th
e pub
lic ar
e rec
orde
d. -
A me
chan
ism to
diss
emina
te co
mmen
datio
ns fr
om th
e pub
lic to
the s
taff m
embe
rs is
in pla
ce.
17
III.
Ove
rall
Man
agem
ent o
f the
Inst
itutio
n Ar
eas o
f Con
cern
St
anda
rds
Me
asur
able
Elem
ents
16
.2 Int
er-se
ctora
l co
ordin
ation
16
.2.1
Inter
/intra
-secto
ral
meeti
ngs a
ttend
ed
- Re
cord
s are
avail
able
on th
e par
ticipa
tion o
f the s
enior
man
ager
s in t
he fo
llowi
ng m
eetin
gs:
Me
eting
with
Divi
siona
l Sec
retar
iat of
ficer
s
Meeti
ng w
ith co
mmun
ity le
ader
s
Month
ly me
eting
at R
DHS
Me
eting
with
hosp
itals
and o
ther h
ealth
care
insti
tution
s.
18
AN
NEX
1: I
sles
for S
tatio
nerie
s
Sh
adow
dra
win
g
19
ANNEX 2: Cleaning Checklist (Sample)
Cleaning Checklist (Sample)
Month/Year: September 2010
Item Responsible Person Time Week I II III IV
Wheel chair Mr. Fernando Sat. 3.00pm X
Trolley Mrs. Perera Sun. 10.00am X
20
AN
NEX
3: S
tand
ardi
sed
Col
our C
odes
(Info
rmat
ion
prov
ided
by
cour
tesy
of C
astle
Stre
et H
ospi
tal f
or W
omen
)
Stan
dard
ised
Col
our C
odes
Red
:
Un-
ster
ile
Em
pty
N
egat
ive
Blu
e:
Ster
ile
Fu
ll
Posi
tive
Gre
en:
Saf
e
Qua
lity
& S
afet
y
Yello
w:
Infe
ctio
n
Bla
ck:
Gen
eral
21
ANNEX 4: Emergency Tray Items for MOH (Sample)
Item Quantity (of one set) Disposable syringe 5cc 5 Disposable syringe 10cc 5 Disposable syringe 1cc 5 Disposable Needle 24G 10 Disposable I.V. Cannula 22G 5 Butterfly Cannula 23G 5 0.9% NaCl 1 Water for injection 1 Disposable IV sets 3 25% Glucose solution 1 Adrenaline (S/D) 1:1000 3 Atropine Sulphate injection 5 Hydrocortisone injection 10 Chlorpheniramine 10mg injection 3 Piriton 4mg tablets 13 Prednisolone 5mg tablets 50 Cotton wool 50g 1 Surgical tape 3” roll 1 Plastic carrier with lid 1
22
ANNEX 5: Customer Satisfaction Survey Form (Sample)
Customer Satisfaction Survey (MOH Clinics)
I. About you
1. Are you Male Female
2. How old are you? -18 19-34 35-54 54-74 74+
3. Is this your first visit to this clinic?
Yes No
4. How did you select this clinic?
Recommendation from a doctor
From the previous visit
According to my knowledge
Close to house
5. How far are you living from the clinic?
1-10 kms 11-20 kms 21-30 kms 31-50 kms 50+ kms
II. How do you feel about the clinic?
Ex
celle
nt
Very
Goo
d
Good
Fair
Poor
N/A
or D
K
6. Information given prior to arrival
7. Easiness of coming to the clinic
8. Clinic arrangement
9. Your welcome by reception
10. The registration process
III. Patients’ Care
Exce
llent
Very
Goo
d
Good
Fair
Poor
N/A
or D
K
11. The way we explained about Clinics
12. Doctors attention
13. Nurses’ attention on you
23
ANNEX 5: Customer Satisfaction Survey Form (Sample)
14. The consistency of your doctor’s care
15. The consistency of your nurse’s care
16. Support of other staff
17. The way staff made you feel confident in them
18. Were you given an opportunity to ask questions?
19. Drug issuing procedure at the pharmacy
20. Did they issue the medicine according to the doctor’s prescription?
21. If you had questions to ask, did you get answers you could understand?
22. Did your consultant explain about your condition?
23. Instructions you received from the doctor
IV. Time spent at Clinics
Exce
llent
Very
Goo
d
Good
Fair
Poor
N/A
or D
K
24. Time spent for registration
25. Time waited to meet the doctor
26. Time spent with the doctor
27. Time spent to get the medicine
28. Overall time you spent at the clinic
24
ANNEX 5: Customer Satisfaction Survey Form (Sample)
V. Facilities provided from the clinic
Exce
llent
Very
Goo
d
Good
Fair
Poor
N/A
or D
K
29. Directions given to you
30. Promptness of attention on you
31. Seating facilities
32. Waiting room privacy
33. Waiting room comfort
34. Waiting room décor
35. Toilet facilities
36. Support and caring of the clinic staff
37. Overall cleanliness
38. Overall amenities
VI. Comments on Overall Quality of the Service
Exce
llent
Very
Goo
d
Good
Fair
Poor
N/A
or D
K
39. Overall rating on quality of care
40. Overall rating on quality of facilities
41. Total time spent at the clinic
42. Did you get the treatments and care as you expected?
25
ANNEX 5: Customer Satisfaction Survey Form (Sample)
43. Would you recommend the clinic to others? Yes No
If not, Comments
…………………………………………………………………..…………………………………………………
………………..……………………………………………………………………………………………………
………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………
(Information provided by courtesy of DGH Ampara)
26
APPENDIX
27
APPENDIX: General Circular on National Quality Assurance Programme in Health
28
APPENDIX: General Circular on National Quality Assurance Programme in Health
General Circular Letter No. 01-29/ 2009 My No. HPI/ OD/ 06/ 2009. Ministry of Healthcare & Nutrition
“Suwasiripaya”, 385, Rev. Baddegama Wimalawansa Thero Mawatha, Colombo 10. 22, September 2009.
To : Addl. Secretaries All Provincial Secretaries of Health, Director General of Health Services, All Deputy Director Generals and Directors, All Provincial Directors of Health Services, All Regional Directors of Health Services, and All Heads of Health Institutions.
National Quality Assurance Programme in Health We are pleased to note that some of our hospitals and other health institutions have initiated
productivity and quality improvement programmes as per instruction given by the General
Circular No 02-109/2003 and dated 08th October 2003.
The Ministry of Healthcare and Nutrition has decided to expand the Quality Assurance
Programme to all health institutions in Sri Lanka, in order to improve the quality and safety of
health care services. It aims at establishing a continuous quality improvement process by setting up
organizational structures and mechanisms at all health care institutions.
1. Quality Secretariat (QS)
Ministry of Healthcare & Nutrition has established a Quality Secretariat (QS) to direct
management of the Quality Assurance Programme.
2. Quality Management Units (QMU)
All health institutions should establish a Quality Management Unit (QMU) to create quality
and safety culture towards improving Quality of Healthcare. This unit will undertake planning
the implementation and monitoring of the National Quality Assurance Programme with the
29
APPENDIX: General Circular on National Quality Assurance Programme in Health
guidance of the Quality Secretariat, Ministry of Healthcare & Nutrition. Please see the
Organizational Structure in annexure.
3. Roles and Functions
I. Quality Secretariat
i. To facilitate the implementation of national policies related to quality and safety.
ii. Prepare and disseminate standards, guidelines and procedures.
iii. Development of training packages in order to strengthen capacity building of staff.
iv. Coordination with relevant health and health related sectors for quality assessment and
improvement.
v. Facilitate the development of a shared learning environment and continued achievement
of best practices.
vi. Develop and implement a continuous monitoring & evaluation system.
vii. Mobilize resources for the continuous improvement of quality and safety in the health
system.
viii. To facilitate the development of the legal and regulatory framework for the
implementation of quality and safety policy.
II. Quality Management Unit (QMU)
i. Quality Management Units (QMU) will be established in National Hospital of Sri Lanka,
Teaching Hospitals, Provincial General Hospitals, District General Hospitals and Base
Hospitals and specialised hospitals.
ii. All campaigns, decentralized units and special units under the Ministry of Healthcare &
Nutrition are expected to establish Quality Management Unit.
iii. Divisional Hospitals (District Hospitals, Peripheral Units and Rural Hospitals), and
Primary Medical Care Units (Central Dispensary & Maternity Home and Central
Dispensary) are expected to conduct their Quality Management Programme under a
designated officer who will be guided by the Quality Management Unit of RDHS.
iv. All MOOH are expected to plan and implement the Quality Management Programme,
under the guidance of the Quality Management Unit of RDHS.
30
APPENDIX: General Circular on National Quality Assurance Programme in Health
v. To facilitate development of a shared learning environment and continued achievement
of best practices.
III. Functions of QMU
QMU would coordinate the quality assurance and client safety program of the healthcare institutions through following functions.
i. Promote employee participation in management of quality by establishing Work Improvement
Teams (WIT) /Quality Circles (QC) in for the different departments/units within the health
institution.
ii. Conduct training of Work Improvement Teams (WIT).
iii. Maintain a database in staff training and conduct a planned In-service Training Programme.
iv. Conduct programs and workshops on quality improvement and patient safety focussing on
problem solving approaches and measurements.
v. Initiate a quality culture in health institutions by introducing 5S concepts leading towards Total
Quality Improvement (TQI).
vi. Ensure management leadership and involvement of medical consultants in the quality
improvement process.
vii. Assist in preparing strategic plans for the institutions with focus on reduction of waiting times,
instituting a smooth patient flow, infection control and waste disposal.
viii. Implementation of standards, guidelines and protocols relevant to customer/ patient care
including clinical pathways.
ix. Maintain a computer based data system by collecting and analysing data related to quality
improvement of services (eg. Patient accidents and adverse events, near misses re-admissions,
case fatality rates, complication arising from medical and surgical procedures, referrals, adverse
events following immunization and transfers, etc).
x. Prepare and distribute half yearly / quarterly bulletins and annual performance reports with
the assistance of Medical Record Unit (MRU) and other relevant units.
xi. Promote an environment friendly healthcare institution.
xii. Conduct customer satisfaction surveys, and employee satisfaction surveys, maintain and take
corrective action for public complaints. Encourage suggestion scheme in healthcare
institutions.
31
APPENDIX: General Circular on National Quality Assurance Programme in Health
xiii. Ensure quality of supplies by encouraging maintenance contract agreements for support
services in order to impalement Total Productivity Maintenance of the supplies.
xiv. Develop Annual Procurement plans for different variety of purchases.
xv. Organize and update supplier and maintenance information system and disseminate to the
relevant Units.
xvi. Facilitate assessment and improvement of performance through regular monitoring of the
programme using quality measurement indicators (Guidelines will be sent).
xvii. Assist and conduct performance reviews and maintain records of such reviews.
xviii. Promote studies, research and medical audits in the institutions.
xix. Assist Non Health Sectors to implement Productivity and Quality Assurance Programmes.
Contact Details
Quality Secretariat is located at;
Castle Street Hospital Complex, Colombo 08.
Tele: 011 2678598, 011 2678599, Fax 011 - 2695244
e- mail: Quality Secretariat" <[email protected]>. Dr. Athula Kahadaliyanage Dr. Ajith Mendis Secretary Director General of Health Service Ministry of Healthcare & Nutrition
32
APPENDIX: General Circular on National Quality Assurance Programme in Health
Annexure
Organizational Structure
Quality Secretariat Ministry of Healthcare &
Nutrition
Quality Management Unit
TH & Other Special hospitals under MoH
Quality Management Unit All Campaigns & Specialized Units
Quality Management Unit
PH, DGH, BH
Divisional Hospitals & Primary Medical Care
Units
MOH Office
Quality Management Unit
PDHS (Planning Unit)
Quality Management Unit RDHS
(Planning Unit)
33
APPENDIX: General Circular on National Quality Assurance Programme in Health
34
Feedback Form National Guidelines for Improvement of Quality and Safety of Healthcare Institutions
(For Offices of Medical Officer of Health)
Kindly provide feedback for improvement of this document. We will try our best to incorporate your views and opinions into the next edition of these Guidelines.
Name: Title: Institution: Address: Tel: E-mail: Please write your suggestions for improvement of these Guidelines below:
Kindly mail this form to:
Director Organization Development, Ministry of Health, 385 Baddegama Wimalawansa Thero Mw., Colombo 10, Sri Lanka
