Kombolcha General Hospital

Revised Protocol Oreintation On

SBFR Audit Tool

By Haile Chanyalew (MPH)
Quality Coordinator
Dec/2017E.C
Kombolcha,Ethiopia
Presentation Out Line
• Introduction

• Objective

• Scope

• Audit Scoring

• Audit score

• SBFR output level assessment tool

Introduction
• The System Bottleneck Focused Reform (SBFR) initiative is a strategic approach aimed at
identifying and addressing critical bottlenecks within healthcare systems.

• This initiative seeks to improve the efficiency, quality, and accessibility of healthcare
services by targeting areas that impede the smooth functioning of the system.

• To support this initiative, an Audit Tool has been developed to systematically assess the
hospital's performance across various key areas, including leadership,clinical practice,
nursing care, pharmacy services, diagnostic services, data quality ,quality and service
integration.

• By identifying and addressing bottlenecks through the use of this tool, Kombolcha General
Objective
• To evaluate the extent to which SBFR interventions have been implemented at KGH,
assess their impact on key performance indicators, and identify areas requiring further
improvement.
Scope
1. High Impact Leadership

2. Emergency Care

3. Outpatient Care:

4. IPD service

5. Surgical service

6. Pharmacy Service

7. MCC

8. Diagnostics:

9. Data qaulity and decision

10. Service integration and Quality of Care

Audit Scoring
• A scoring system will be used to evaluate the implementation of SBFR
interventions. Each section will be assigned a score based on the following
criteria:
Not Implemented or partially implement : 0 points

Fully Implemented: full points

• The overall score will be calculated by summing up the scores from each
section.
Audit score
Number Section Maximum Score

1. High Impact Leadership 44

2. Emergency and Critical Care and Scope-Based Clinical Practice 60

3. Outpatient Service and Scope of Practice 64

4. Inpatient Service 48

5. Surgical and Anesthesia Care 36

6. Pharmacy Service 52

7. Motivated, Competent, and Compassionate Care 20

8. Data quality and reporting 27

9. Diagnostic service 29

10. Service integration and Quality of care 65

Total maximum Score: 445

SBFR output level assessment tool
1.High impact leadership
Activities Maximum Validation methods
No
score
1. BFR Task force established 2 Document review ,staff interviews and observations of assignment letter and JD for
task force members
2. Daily CEO/CCO - SBFR task-force 4 Document review - last 2 weeks and check regular meetings and participation
forum using a dashboard Document review

3. Develop local indicator and user 2 Review documentation

manual the development process for facility-specific indicators (evidence of case team
involvement) and analyze the facility-specific indicators and confirm their
relevance to departmental operations

4. Point of care level Vertical Unit based 3 Staff interview - 1 nurse, 1 physician, 1 senior physician in each focus area to assess
administrative leadership structure their understanding and implementation of administrative leadership practices.
Check assignment of clear role and responsibilities for each focus area

5. Point of care level clinical leadership 3 Staff interview - 1 senior, 1 nurse, 1 GP (1 for each)to assess their understanding
practice is in place and implementation of clinical leadership practices.
1.High impact leadership ---------------
Activities Maximum Validation methods
No score
6 Weekly Clinical Forum 2 Document review the last 3 weeks of meeting minutes or recordings.
Check regular meetings and participation
Interview clinical staff about their participation and awareness of the
forum.
improvement plan or action after
7 Display Major Service Areas' 1 Observe physical or digital displays showcasing performance data.
Performances Weekly and Interview team leaders and department heads about their access to and
Make Data Accessible use of performance data.
8 Intensive Supportive 2 Check regular supportive report and feedback
Supervision Led by SMT Observation and check action plan and progressive report
Review schedules
Interview staff who participated in SMT-led supportive supervision to
understand the process and effectiveness

9 SBFR Task Force Led by 2 Review task force leadership structure to confirm the presence of senior
Senior Champions champions,TOR prepared and team members will be assigned officially
for full time job
10 SBFR task force perform daily 2 Document review on service audit for start time, productivity , Chart
dashboard based performance audit, Client interview (scope adherence, quality of care) and Corridor
audit audit
1.High impact leadership ---------
Activities Maximum Validation methods
No
score
11 SBFR Task Force Acts for 4 Review documentation ,the process for incident management by the SBFR task force
SMT and Manages Incidents such as resource sharing b/n units and departments (including admission beds),manage
duty hours, weekends and supporting function interruptions (water, electricity etc),manage disagreement b/n staffs
holidays with in a team or b/n different teams
Interview 3 staff and 2 task force members regarding their role in incident management

12 SBFR Task Force Analyzes 3 Review reports documenting data analysis performed by the SBFR task force.
Data and Identifies Gaps Interview task force members regarding their processes for identifying operational and
clinical care gaps (root cause analysis ,department level issues communication
mechanism before morning forum and feedback /or accountability

13 Top 20 drugs utilization 3 Document review for consistent monitoring and evidence of improvement
monitoring

14 Top 5 supplies utilization 3 Document review for consistent monitoring and evidence of improvement
monitoring
1.High impact leadership -------
Activities Maximum Validation methods
No
score
15 Imaging service efficiency 3 Document review for consistent monitoring and evidence of
monitoring improvement
16 Monitoring for 3 major test 3 Document review for consistent monitoring and evidence of
requests justification improvement
17 Performance based payment 2 Review documentation of the performance-based payment system and
system in place for lack of its implementation.
compliance to roles and
responsibilities

Total 44
2.Emergency and critical care and scope based clinical practice
No Activities Maximu Validation methods
m score
1.
Accept all emergency clients who 3 Observation and patient records
already arrived to at emergency No refusal of emergency patients and Check timely and
unit appropriate care for all emergency patients with in 5 minute
2.
Scope based triage disposal at 3 Chart audit - 3 random charts (1 score for each)
adult emergency Check appropriate initial assessment and evaluation
3.
Scope based initial evaluation at 3 Observe and chart audit - 3 random charts (1 score for each)
adult emergency
4.
Scope based triage disposal at 3 Observe and chart audit - 3 random charts (1 score for each)
pediatrics emergency Check appropriate initial assessment and evaluation
2.Emergency and critical care and scope based clinical
practice-----
Activities Maximum Validation methods
No
score

5 Scope based initial evaluation at pediatrics 3 Observe and chart audit - 3 random charts (1 score for each)
emergency Check appropriate initial assessment and evaluation

6 Scope based triage disposal at Emergency 3 Observe and chart audit - 3 random charts (1 score for each) and Check
triage appropriate initial assessment and evaluation

7 Scope based initial evaluation at EOPDs 3 Observe and chart audit - 3 random charts from different EOPDs (1 score
( for 1st time visit) for each)
Check appropriate initial assessment and evaluation

8 MDT round led by specialists in the 3 Chart audit - 3 random charts from different wards (1 score for each) and
morning look for MDT round progress sheet form

9 MDT round led by specialists in the 3 Chart audit - 3 random charts from different wards (1 score for each) and
evening look for MDT round progress sheet form

10 All MDT rounds are participatory and 3 Observation and Check regular log MDT registration book and team
addresses roles of all team members composition
2.Emergency and critical care and scope based clinical practice-----
Activities Maximum Validation methods
No
score
11 Emergency Evaluation Room Reorganized 2 Observe and check patient record ,the layout of the emergency evaluation
as One-Stop Shop room to confirm
12 Scope of Practice for Top 20 emergency 2 Review documentation and staff interview ,check defining the scope of
Conditions practice guideline ,Interview at least 2 staff working at EOPD to their
awareness and understanding of the defined scopes.
13. Senior led daily and quarterly clinical 4 Check audit proposal,audit reports and QI project
audit and QI project designed and Observation and check regularity of clinical audits with corrective actions
conducted QI project reports and observe its implementation of QI projects status
14 All intra-departmental consultations has to 3 l Observation and patient records and timely and appropriate
be made immediately from the assigned consultations
pool of physicians with different scope l Variability of protocol ,adherence mechanism and improvement plan
15 Evaluates daily and weekly performance 3 Check dashboard reports and regularity of meeting ,check minutes book
based on the emergency service dashboard
2.Emergency and critical care and scope based clinical practice----
Activities Maximum Validation methods
No
score
16 All identified gaps will be linked with an 3 Development and implementation of
improvement plan improvement plans
17 All kept emergency cases should have a nursing 2 Observation and patient records
process
18 Adequate pain control practice is implemented 2 Patient records and observation
19 Patient transportation protocol with adherence 2 Protocol document and observation
2.Emergency and critical care and scope based clinical practice----
Activities Maximum Validation methods
No
score
20 2 Round schedules and minute book
Regular matron lead daily nursing management
Check Regularity
rounds in place
Availability of written Protocol in service area
21. 2 Competency assessment records and
Nursing management should conduct regular nurses
observation
competency assessment
Document review protocol
22. 3 Review protocol and availability at service area
Protocol for common nursing problems and their Staff interview to their adherence
management Check adherence mechanism for the utilization
of this protocol
Total 60
3.Out patient service and scope of practice
Activities Maximum Validation methods Scor
No
score e

1 Scope based triage disposal 3 Observe and chart audit - 3 random charts (1 score for each) and Check

at central triage appropriate initial assessment and evaluation

Check assigned GP with letter and nurse

2 Scope based initial 3 Observe and chart audit - 3 random charts from all OPDs (1 score for each)

evaluation at OPDs ( for 1st Check appropriate initial assessment and evaluation

time visit)

3 Specialist led referral clinics 3 Chart audit - 3 random charts from all referral clinics (1 score for each)
Check appropriate referrals and follow-up mechanism or system

4 Digitalize Patient Triage and 3 Review documentation of the digital triage and disposal system (e.g., software,

Disposal System user manuals).

Observe staff utilizing the digital system for patient triage and disposition.
Interview staff regarding their experience and satisfaction with the digital
system.
3.Out patient service and scope of practice ------
Activities Maximu Validation methods Score
No
m score
Observe and check patient record ,the layout of the OPD evaluation room to confirm
5 One stop shop triage, registration and payment 2
system integrating all payment modalities at Patient interview and check integrated registration and payment system

OPD payment corners/windows

(credit/cash/social …)

6 Scope of Practice for Top 20 Conditions 2 Review documentation and staff interview
Defining the scope of practice for the top 20 clinical conditions at OPD
Interview at least 2 staff working at OPD to their awareness and understanding of the
defined scopes.

7 Scope of Practice for Chronic Follow-Up 2 l Review documentation outlining the scope of practice for each type of clinic.
Clinics, Specialty Clinics, and Sub specialty
l Ensure sub specialists are engaged in specialty activities 90% of the time.
Clinics
l Interview healthcare providers regarding their understanding and adherence to the
defined scopes of practice.

8 All intra-departmental consultations has to be 3 l Observation and patient records ,

made immediately from the assigned pool of l Timely and appropriate consultations
physicians with different scope l Availability of protocol ,adherence mechanism and improvement plan
3.Out patient service and scope of practice ----
Activities Maxim Validation methods Score
No
um
score
9 All OPDs should start at 8:00am 2 Observe timely opening of OPDs and Schedule of physician
assignment and check monitoring mechanism.
10. Shift based physicians assignment 2 Observation and interview
Check assigned staff and schedules
Check functionality by interview assigned staff and patient
11 Appointment system should be in 3 Check appointment scheduling and review registration
blocks of hours Check appointment monitoring mechanism and observation
functionality
12 Define minimum interval required
Document review and availability of clear guidelines for who
to be evaluated by a senior for
need senior follow-up,
common chronic clinical condition
3.Out patient service and scope of practice-----
13
Refill mechanism should be in place 6 Check a refill system for chronic medications are including on
protocol ,Observation and review 2 patient chart for each OPD
Check and interview staff and client for adherence to treatment
Check Adherence monitoring system and Action plan or QI
project based on gap
14
For controlled patients who meet the 4 Patient records and observation
criteria appointment should be made at Check it should be protocol and criteria including
least quarterly Check appropriate follow-up schedules for chronic patient
15
During the quarter wait period facility 3 observation and patient records
should arrange clinical pharmacy visit Check the provision of clinical pharmacy services
Staff and client interview
16
Conduct monthly 3R audit that done by 3 Audit reports and observation
GP (Right physician or scope, Right Regular audits to assess the quality of care and Action and QI
time, Right way) project based on gap.
3.Out patient service and scope of practice-----
Activities Maximu Validation methods Score
No
m score
17 Chronic clinic management 3 Document review and observation
protocol should be established Availability of clear protocols for chronic disease management
based on hospital tier level and Check Adherence monitoring mechanism and action based on
communicated gap
18 Establish a functional Health 4 Observation and document review
literacy Unit which links and Established functional health literacy unit
closely works with DIS Unit led by at least GP and above (assignment letter and JD)
Interview at least 2 staff and 3 patient for their functionality
19 Establish a Focus group 3 Meeting minutes and observation
discussion for selected chronic Check regular focus group discussions with patients and Action
follow up patients plan based on gap
3.Out patient service and scope of practice-----
Activities Maximu Validation methods Score
No
m score
Senior led daily and quarterly 4 Check audit proposal,audit reports and QI project
20
clinical audit and QI project Observation and check regularity of clinical audits with
designed and conducted corrective actions
QI project reports and observe its implementation of QI projects
status
Evaluates daily and weekly 3 Check dashboard reports and regularity of meeting ,check
21
performance based on the OPD minutes book
service dashboard
All identified gaps will be linked 3
22 Development and implementation of improvement plans
with an improvement plan

Total 64
4.Inpatient Service
Activities Maximum Validation methods Perfor
No
score mance
1. MDT round led by specialists in 3 Chart audit - 3 random charts from different wards (1 score for
the morning each) and look for MDT round progress sheet form
2. MDT round led by specialists in 3 Chart audit - 3 random charts from different wards (1 score for
the evening each) and look for MDT round progress sheet form
3. All MDT rounds are participatory 3 Observation and Check regular log MDT registration book and
and addresses roles of all team team composition
members
4. Scope of Practice for Top 20 2 Review documentation and staff interview
Conditions Defining the scope of practice for the top 20 clinical
conditions at IPD
Interview at least 2 staff working at IPD to their awareness
and understanding of the defined scopes.
4.Inpatient Service
Activities Maximum Validation methods Perfor
No
score mance
5 Senior led daily and quarterly clinical 4 Check audit proposal,audit reports and QI project
audit and QI project designed and Observation and check regularity of clinical audits with corrective
conducted actions
QI project reports and observe its implementation of QI projects status
6 All intra-departmental 3 l Observation and patient records and timely and appropriate
consultations has to be made consultations
immediately from the assigned pool of l Variability of protocol ,adherence mechanism and improvement plan
physicians with different scope
7 Evaluates daily and weekly 3 Check dashboard reports and regularity of meeting ,check minutes
performance based on the IPD service book
dashboard
8 All identified gaps will be linked with 3
Development and implementation of improvement plans
an improvement plan
4.Inpatient Service
No Activities Maximum Validation methods Performanc
score e
9 Senior physicians are assigned 2 · Observe duty schedule for weekends and
on duty including weekends and holy days
holidays. · Conduct staff interview
· Review patient charts seen by senior
physians on weekends and holidays
10 All new admissions are audited 2 · Check for availability of such protocol
and co-signed by day time and · Conduct chart review
duty time assigned senior · Conduct staff interview
physicians
11 Duty senior physician should 2 · Check for the availability of handover
make handover from day time protocol
senior physician · Conduct chart review
· Conduct staff interview
12 Weekly senior chart round 2 · Review weekly chart review schedule
practice is implemented and · Check for the status of QI linked to Chart
identified gaps are linked with review finding
CQI. · Conduct staff interview
4.Inpatient Service
No Activities Maximum score Validation methods Performance

13 Chart round should address clinical 2 · Review for the availability chart round
evaluation and decision process, use checklist and verify that it includes those
of an appropriate and justified work contents
up, rational use of drugs, nursing · Conduct staff interview
care · Review for the clinical pharmacy medication
care plan within the patient chart
14 Correct and complete nursing 3 Chart audit - 3 random charts from different
assessment is done wards (2 score for each)
15 Correct and complete nursing 3 Chart audit - 3 random charts from different
diagnosis is made wards (2 score for each)
16 Correct and complete nursing care 3 Chart audit - 3 random charts from different
plan is outlined wards (2 score for each
4.Inpatient Service
No Activities Maximum Validation methods Performance
score
17 Correct and complete nursing care plan 3 Chart audit - 3 random charts from
implementation is done different wards (2 score for each)
18 Correct and complete nursing evaluation is 3 Chart audit - 3 random charts from
made (at least twice per day) different wards (2 score for each)
19 Nurses have adequate knowledge on common 3 Randomly assess 3 nurses (2 for each)
nursing problems and their management
20 Nurses have adequate knowledge and skill on 3 Randomly assess 3 nurses (2 for each
common nursing procedures
21 Client education practice is optimal (client 3 Client interview - 3 clients from different
should be aware of their clinical diagnosis, wards
treatment they are taking, prognosis expected,
IPPS, Life style modifications if any ...)
4.Inpatient Service
No Activities Maximum score Validation methods Performance
Observe patient care in the ICU/HDU to confirm
22 Admitted Patients 3
adherence to the 4P's approach.
in the ICU/HDU Review patient records to document assessment and
Are Followed management of pain, positioning, toileting, and
possessions.
Closely with 4P's
Interview ICU/HDU staff regarding their
(Pain, Position, understanding and implementation of the 4P's
Potty, Possess) approach.
23 Functional Skill 3 Review documentation and Interview ,Establishment
Lab of a functional skill lab.
Interview 5 staff regarding their use of the skill lab for
training and skill development.
Analyze training records to confirm the effectiveness
of the skill lab in improving staff skills.
4.Inpatient Service
No Activities Maximum score Validation methods Performance

24 Pressure Ulcer Tracking 3 Review pressure ulcer tracking and surveillance procedures.
and Surveillance
Analyze pressure ulcer incidence data to assess the effectiveness of
prevention and management strategies.

Interview nursing staff regarding their understanding and

implementation of pressure ulcer prevention and management
protocols. Registration

Chek Adherance monitoring mechanism

25 Discharge Screening for 2 l Review discharge documentation to confirm that all patients are
Pressure Ulcers screened for pressure ulcers.

l Interview nursing staff regarding their adherence to the pressure

ulcer screening checklist.

l Analyze screening data to identify any gaps in pressure ulcer

prevention and
4.Inpatient Service
All kept emergency cases should have 2 Observation and patient records
a nursing process
Adequate pain control practice is 2
Patient records and observation
implemented
2
Patient transportation protocol with adherence Protocol document and observation

2 Round schedules and minute book

Regular matron lead daily nursing
Check Regularity
management rounds in place
Availability of written Protocol in service area

Nursing management should conduct regular 2 Competency assessment records and observation
nurses competency assessment Document review protocol
3 Review protocol and availability at service area
Protocol for common nursing problems and
Staff interview to their adherence
their management
Check adherence mechanism for the utilization of this protocol
Total 48
5. Surgical and Anesthesia Care
Maximum Perform
No Activities Verification Criteria
score ance
1.
OR director Assigned 2 Document Review (Letter of Assignment)
2. OR Dashboard Developed (includes first
Incision time and time between cases) 2 Document Review
3. OR dashboard includes Cancellation and
Reason for cancellation 3 Document Review
4. OR Daily and weekly analysis of performance Document Review (OR performance analysis
and action taken 3 and actions taken document)
5. Elective Surgery Digital Backlog System is in
place 3 Observation
5. Surgical and Anesthesia Care----
Maximum Perform
No Activities Verification Criteria
score ance
Pre-admission surgical and anesthetic evaluation 2 Observation (the clinic should have both
6 clinic is established Anesthesia professional and Surgeon together
during patient evaluation)

Preventive and curative maintenance check for

7 all major OR medical equipment to ensure safety Document Review (Preventive Maintenance
and avoid unnecessary cancellations 3 schedule posted at Major OR)

OR zoning based on the national IPPS guideline

(Restricted, semi restricted, Transitional and
8
Unrestricted) and adherence to the
recommendations 3 Observation
9

Establish day care surgery unit 3 Observation and staff interview

5. Surgical and Anesthesia Care-----
Maximum Perfor
No Activities Verification Criteria
score mance
Standardize table productivity
per day (3 surgeries/table/day
unless there is a clear

10 justification due to the nature of a

specific procedure and/or
unexpected preoperative
incidents) 4 Document review
Establish system of early 2 Observe and review timely to start of surgeries
initiation of surgery with and Check monitoring mechanism of TAT and
11 incision time at or before 8 Protocol
am
5. Surgical and Anesthesia Care----
1 3 Patient records(10 from OR,Surgical
2 Ward and PNC) and observation
Ensuring all surgical patients have screened Review SSI register and Protocol
for SSI based on WHO SSI surveillance Use of SSI surveillance data for
checklist at the time of discharge improvement-action plan, QIP
Check Monitoring mechanism after
discharge
Surgical records and observation
1 Avoid unjustified cancellation for a 3
Check analysis and trend of data to SSI
3scheduled patient rate over time.
Check monitoring system about cause of
cancellation
Total 36
6.Pharmacy service
Activities Maximu Validation methods Perfo
No
m score rman
ce
1. Select 20 prioritized drugs for 3 Monitor weekly with Dashboard and Checked approved
monitoring. Protocol
2. Decide on a list of 5 prioritized supplies 3 Monitor Weekly with Dashboard and check including
and Monitor using the Dashboard. the protocol
3. Regular audits on the appropriate use of 2 Monitor Weekly with Dashboard and check including
drugs and supplies for an exempted the protocol
service.
4. Assign staff clinic/physician. 1 Observe staff clinic
5. Daily stock status report for the 2 Check stock reports and observe regular monitoring of
prioritized drugs with an emphasis on drug stock levels
near stock out items
6.Pharmacy service
6 Daily prescription audit (who 2 Prescription records and observation
prescribed, how much, rational use) Regular performance review of prescription audit and
action taken
7. Link all identified gaps with an 2
Check implementation of corrective action plans and
improvement and/or accountability
accountability measures
mechanism
8 2 Review guidelines for prescribing priority supplies
Define scope for prescribing selected
Staff interview and adherence mechanism and action
items
based on gap

9 2 Observe and review audit report

Weekly audit on dispensed drugs and Check regularity of audits both drug and supply
supplies for an exempted, CBHI and dispensing
other credit services Action and accountability measure based on finding
6.Pharmacy service-----
10 Presence of properly recorded and filed 2 Document review and observation of proper documentation
prescriptions, sales tickets and registers at
dispensaries
11 Implementation of coding to uniquely 2
Document review and observation
identify medicines (service areas, stores)
12 Bin ownership and updating is 2
Observation and stock records, bin card updated
implemented
13 Presence of regular monthly reports for 1 Monthly reports and performance review report,meeting
products, finance and services which is minutes
evaluated by DTC and SMT with Action and improvement plan
corrective actions
14 Annual ABC and VEN analyses report in 2 Check regular inventory analysis and categorization
place Check inventory analysis reports with action plan
6.Pharmacy service
15 3 Patient records and observation
Monitoring and follow up of oxygen
Check regular monitoring of oxygen therapy and
therapy as vital medication
action plan
16 Oxygen road map guideline and flow 1 Document review on the utilization and avail
chart were avail guideline in service area
17 Oxygen device and consumable are 2 Drug list and observation
incorporated and updated in hospital Check inclusion of oxygen devices and consumables
drug list in the drug list
18 Monitoring and follow up 2 Oxygen consumption records and observation
mechanism of oxygen consumption Check regular monitoring of oxygen consumption
6.Pharmacy service
19 2 Inspection records and observation
Oxygen fullness and Quality check Regular checks of oxygen cylinder fullness and
quality(log book)
20 MEMIS functionality 2 System review and observation
21 Dedicated store for oxygen cylinder 2 Observe proper storage area of oxygen cylinders
Review 10 patient patient chart for each all service
22 The three oxygen prescribing 2
unit
(pattern, target of saturation and
Check appropriate measure is taken and progress
mode of administration)clearly label report is recorded
on patient chart
23 Clinical pharmacy service is availed 2 Observation and patient records for provision of
for all admitted patients clinical pharmacy services to all inpatients
24 Clinical pharmacy service audit 2 Audit reports and observation for regular audits of
conducted clinical pharmacy services , Staff clinic Protocol
6.Pharmacy service
25 All audit findings should be linked 2 Audit reports and observation
with improvement and/or Check implementation of corrective action plans and
administrative accountability accountability measures
mechanisms. Weekly report submission to quality unit
26 Clinical Pharmacy Visits and Drug 2 Review documentation outlining the process for clinical
Refills pharmacy visits and drug refill options.

Interview patients and pharmacy staff regarding their

experience with the refill process.

Analyze pharmacy records to confirm timely and accurate

drug refills.
Total 52
7.Motivated, Competent, and Compassionate Care
Activities Maximu Validation methods Performa
No
m score nce
1. Gender-Based Duty Room 2 l Inspect duty rooms to ensure separate facilities for male and female
Arrangement staff.

2. Adequate Number of Beds 2 l Count the number of beds in duty rooms and compare it to the
number of duty staff.

l Ensure that at least 50% of duty staff have access to a bed.

3. 2 l Inspect duty rooms to confirm the presence of furniture, computers,
Equip duty rooms with furniture, and
internet access, and televisions.
computers.
l Test internet and television connectivity.
4. Personal Belongings Storage 2 l Inspect duty rooms for cupboards or lockers where staff can store
personal belongings, gowns, and uniforms.

l Ensure that these storage areas are secure and accessible to all staff.
7.Motivated, Competent, and Compassionate Care
5 24-Hour Water 2 Test the functionality of portable purifiers in duty rooms.
Access Ensure that water is readily available at all times.
6 Central Coffee 2 Confirm the availability of central coffee and tea service for duty room
and Tea Service staff.

Observe the frequency and quality of the service.

7 Housekeeping 2 Inspect duty rooms for cleanliness and the presence of fresh linens on a
Services daily basis.

Interview housekeeping staff regarding the frequency and quality of

cleaning services.
7.Motivated, Competent, and Compassionate Care
8 Zonal Duty Room Service 2 • Confirm the assignment of a zonal duty room service focal.
Focal
• Review documentation of the focal responsibilities and activities.

• Interview the focal regarding their role and performance.

9 Duty Payment 2 • Review duty payment records to ensure that payments are only made to
individuals who have executed all required activities and submitted
expected reports.

• Interview finance staff regarding the payment verification process.

10 Duty Schedule Omissions 2 • Review duty schedules and payment records to identify any instances
where individuals have been omitted due to non-adherence to
minimum expectations.

• Interview department heads regarding their decision-making process

for omitting individuals.

Total 20
8.Data Quality and Its Use for Decision Making
Activities Maxim Validation methods Perfor
No
um mance
score
1. Data quality audit for completeness, 2
Audit reports and observation and check regular data quality audits
correctness and timeliness
2. Use of daily, weekly, monthly, quarterly, 2
biannually etc EMR dashboard
Dashboard review and observation
encompassing facility specific, regional and
national HMIS and KPI indicators
3. Full automation and digitization of electronic 5
Presence of a fully functional EMR system
medical record system were in place
4. Monitor overall productivity, clinical and 4
Performance reports and observation
nonclinical functions of the hospital using
Check regular monitoring of performance using relevant indicators
facility specific, regional and national HMIS
Check data triangulation across service area and action plan
and KPI indicators
8.Data Quality and Its Use for Decision Making-----
5 Data-Driven Decision 2 Assess the extent to which data is used in decision-making processes.
Making
. Culture Observe how data is incorporated into strategic planning, operational
decisions, and performance evaluation.

Interview staff to understand their awareness and use of data for

decision making.
6 Established IT structure and 2
has adequate staffs to support Observe IT infrastructure assessment and staff interviews
EMR system
7 24 hrs IT personnel is 2 Staff schedules and observation and 24/7 IT support
assigned
.
8.Data Quality and Its Use for Decision Making-----
8 Data-Driven Performance 3 Review performance evaluation metrics and ensure they are based on
Evaluation relevant data.

Analyze performance data to identify trends and areas for improvement.

Use data to inform decision making regarding resource allocation and

performance management.

9 Data driven continuous 5 Check implement a culture of continuous improvement based on data-driven
improvement insights.

Regularly review and update data quality and utilization practices.

Check evaluations to assess the effectiveness of data-driven decision making.

Check status of QI project

Total 27
9.Diagnostic Care
Activities Maximum Validation methods Performance
No
score
1. Establish audit and monitoring 3 Conduct weekly audit
system for five prioritized lab test
reagents and supplies.
2. Establish a system of auditing 3 Conduct weekly audit
justifications for major
laboratory/imaging requests.
3. System of auditing laboratory and 3 Conduct weekly audit,
imaging requests that are sent Check the presence of registration
outside the institution for Check improvement plan and accountability
unacceptable reasons. measure

4. Document Review (dashboard including daily

Daily Diagnostic dashboard is in place 2 performance of U/S, and x-ray)
9.Diagnostic Care
5 Ensure availability of all test 2
Document review and observation
menu based on expected standard
6. Result should be delivered based on 3 Observe and check adherence to TAT for laboratory and
the agreed TAT imaging tests
7. Specific tests based methods of 3
TAT data and improvement plans
TAT monitoring for compliance to
Regular monitoring of TAT and implementation of
the TAT and link identified gaps
improvement plans
with an improvement plan
8 2 Observe and review document regular of laboratory requests
Monitor for unnecessary lab repeats
and results
9 Scope might be defined for some 2 Document review and observation ,
diagnostic workups like US and x- Interview two staff for their understanding and utilization of
ray guideline
10 System of preventive and curative 2
Maintenance records and
maintenance system for laboratory and
observation
imaging medical equipment
11. Blood mobilization strategy in 2 Blood bank records and
collaboration with blood bank observation and strategy
12. Actively functioning HTC and regularly 2
audits practice of appropriate and safe HTC meeting minutes and blood
use of blood, reports safety related bank records
incidents to all stake
Total 29
10. Quality of Care and Service Integration
Activities Maximum Validation methods Perfor
No
score mance
1. Regular and programmed preventive and 2 Check regular maintenance records and schedule
curative maintenance system for major
Observe workshop and maintenance protocol
facility functions
2. Hospital compound and surrounding (within 2 Observe clean and green hospital environment
3 meters of hospital fences) are clean and
green
Conduct patient satisfaction surveys to gather feedback on the
3. Patient Satisfaction 3
quality of care.
Analyze survey results to identify areas for improvement.
Check action plan
4. All sockets are fixed, electric lines are safely 2
secured/covered and sewerage lines are Observe safe and functional electrical and plumbing systems
tightly closed
10. Quality of Care and Service Integration
5 Strong quality structure is established 1 Document review and observation
6. Quality unit in collaboration with 3 QI project reports and observation and regular
other units/departments graduate at implementation of QI projects
least 2 QI projects per quarter
7. Strong institutional learning 3
culture with bench marking activities Observation and check meeting minutes, report
within department
8. 3 Document review report and observation of unit
Social service is provided based on an
functionality
established protocol
Check audit report and action plan
9. 3 Check assign team ,schedule and staff interview from 2
Assign a team to each health center member
and provide Mentorship and coaching. Check agreed activity plan,TOR and mentership report
Interview 2 health center head from member
10. Quality of Care and Service Integration
10 In collaboration with WoHo support the 3
review meeting and PHCU performance Monthly performance review

mentoring
11 In collaboration with WoHo recognize high- 3 Check selection criteria and policy
performing health centers and health posts. Performance report and photo
12 Establish a separate scope based triage 3 Ensure separate Obstetric triage unit and Ensure
disposal obstetric care services availability of Obstetric triage management
Protocol
Chart audit - 3 random charts (1 score for each)
Check appropriate initial assessment and evaluation
13 Scope based initial evaluation at Gyn-obs and 3 Observe and chart audit - 3 random charts from Gyn
Labouring ward ( for 1st time visit) OPD and Labour ward(1 score for each)
Check appropriate initial assessment and evaluation
Quality of Care and Service Integration
13. Evaluates daily and weekly performance 3 Check dashboard reports and regularity of
based on the MCH service dashboard meeting ,check minutes book
14. All identified gaps will be linked with an 3 Development and implementation of improvement
improvement plan plans
15. The hospital has established 3 Observe and ensure preconception service
preconception service as per the national availability
protocol for improving obstetric Ensure the services provided using Pre-conception
outcome. protocols
16 Midwives should implement the 4 Select randomly 5 MR and check the
midwifery process for admitted patients. availability of completeness of Midwifery process
17. Partograph initiated for all laboring 3 Chart audit 3 random parthograph correct and
women after admission to the labor complete
ward?
10. Quality of Care and Service Integration
18 Fetal Heart Rate Monitoring are 3 Chart audit 3 random parthograph correct and complete
appropriate and documented
19 Cervical Examination and Fetal 3 Chart audit 3 random parthograph correct and complete
Descent are monitored and
documented
20 Is the alert line and action line used to 1 Chart audit 3 random parthograph correct and complete
identify deviations from normal labor
progress?
21 Are appropriate interventions initiated 2 Chart audit 3 random parthograph correct and complete
when the fetal heart rate or maternal
vital signs cross the alert line or action
line?
22 Is the partograph used to communicate 2 Chart audit 3 random parthograph correct and complete
information between shifts?
10. Quality of Care and Service Integration
23 Is the partograph reviewed 2 Chart audit 3 random parthograph
and analyzed regularly by correct and complete
the midwifery team?
24 Are parthograph filed and 2 Chart audit 3 random parthograph
insert appropriately on correct and complete
maternal file future
reference?
Total 65
Thanks