Performance Assessment Tool for Level 1 Hospitalspdf.usaid.gov/pdf_docs/PNADR335.pdf · Performance...

Republic of Zambia

MINISTRY of HEALTH

PREPARED BY:

DIRECTORATE OF TECHNICAL SUPPORT SERVICES

WITH SUPPORT FROM THE HEALTH SYSTEMS SUPPORT PROGRAMME

JULY 2007

Performance Assessment Tool

for

Level 1 Hospitals

of 24Performance Assessment Tool – Level 1 HospitalFinal document post pilot

Republic of Zambia - Ministry of HealthPerformance Assessment Tool for Level 1 Hospitals

Province:…………………………………………….. District: ……………………………………… Name of Hospital: ………………………………………

Date of Assessment:……………………………………………………… Period under review (Months): ……………………………………………………...

FUNCTIONAL AREA MINIMUM ACCEPTABLESTANDARD

INDICATOR SOURCE OFINFORMATION

PREVIOUSPA PERIOD

Number /Rate/yes/no(6 months)

CURRENTPA PERIOD


COMMENTS

1. General Administration / Systems Strengthening / GovernanceObjective: To strengthen existing operational systems, financing mechanisms and governance arrangements for efficient and effective delivery of healthservices

1.1.1 80% of action pointsfrom previous PeformanceAssessment addressedaccording to agreed timelines.

# of recommendationsmade during previousPeformance Assessmentaddressed /# of recommendations

Actions taken reportand previousPeformanceAssessment report;records andphysical checks

1.1 Action points fromprevious PeformanceAssessment

List unresolved ActionPoints’s and indicatereasons why

Actions taken reportand previousPeformanceAssessment report;records andphysical checks

1.2 Review of hospitalPeformance AssessmentSelf-Assessment

1.2.1 Hospital PeformanceAssessment Self-Assessmenttool completed and relevantactions formulated

Availability of Hospitalself assessment usingPeformance Assessmenttools

PeformanceAssessmentReports,PeformanceAssessment Self-Assessment




PREVIOUSPA PERIOD


CURRENTPA PERIOD


COMMENTS

1.3.1 Action plan review usesinformation from HMIS andPeformance Assessment Self-Assessment

Availability of a reviewedAction plan and Budgetshowing evidence of use ofHMIS/ PeformanceAssessment SelfAssessment

Reviewed ActionPlan, Reports

1.3.2 80% of the plannedactivities for the period underreview fully completed.

# of planned activitiescompleted /total # of activities planned

Activity reports;Action Plan

1.3 Review of action plan

1.3.3 At least 80% ofexpenditure according toaction plan

Total expenditure onplanned activities /Total budget for the sameperiod

Action Plan;Financial reports

1.3.4 80% ofrecommendations in reports/assessments from vertical andad hoc programmes addressedaccording to agreed timelines

# of actions taken/ # ofrecommendations

Reports formvertical and ad hocprogrammes (e.g.WHO, ZPCT,EMoC etc.)

1.4 Communitypartnership

1.4.1 Hospital AdvisoryCommittee in existence andfunctioning

# of meetings held /# of meetings planned

Minutes,Physical Checks

MoH to provide guidance on ToR andcomposition of Advisory committees.

1.4.2 Functional system toresponds to

1.5.1 Management Meetingsheld monthly andrecommendationsimplemented

# of meetings held /# of meetings planned forperiod


1.5 Institutional meetings

# of recommendationimplemented /total # of recommendations

Records andminutes




PREVIOUSPA PERIOD


CURRENTPA PERIOD


COMMENTS

1.5.2 Finance & tendercommittee meet monthly andrecommendationsimplemented




Records andminutes

1.5.3 Human ResourceDevelopment Committee meetquarterly andrecommendationsimplemented




Records andminutes

1.5.4 Infection Control /prevention Committee meetquarterly andrecommendationsimplemented




Records andminutes

1.5.5 Quality Assurancemeetings held andrecommendationsimplemented.

# of meetings held duringperiod /# of meetings planned

Records andminutes




PREVIOUSPA PERIOD


CURRENTPA PERIOD


COMMENTS


Records andminutes

1.6.1 Financial Managementaccording to FMIS standards

# of standards achieved /# of standards set

Accounts recordsObservations

1.6.2 Timely retirement ofimprest

Total amount of unretiredimprest at end of period /Total amount of imprestgiven during period underreview.

1.6 FAMS / FMIS

1.6.3 Grant income accordingto budget

Total amount in grantsreceived /total amount in grantsbudegted

1 6.4 Hospital income andexpenditure reports updatedmonthly

# monthly income andexpenditure reportsupdated monthly/ # incomeand expenditure reports.

Accounts records,financial reports

1.7.1 Registers completed inaccordance with HMISguidelines

# of registers correctlycompleted /# of registers sampled

HMIS registers,Physical checks

1.7.2 HMIS report data areconsistent with hospitalregisters

# of selected IPD and OPDdiagnosis from register /HMIS report data for samediagnoses(audit a minimum of 2diagnoses IPD and OPD)

IPD and OPDregisters and HMISreports

1.7 HMIS

1.7.3 Monthly and quarterlyreports completed andsubmitted in a correct andtimely manner.

# of reports completed andsubmitted /total # of reports expected

Records of monthlyreports




PREVIOUSPA PERIOD


CURRENTPA PERIOD


COMMENTS

1.7.4 HMIS data is beinganalysed with disease andhealth performance trendsbeing followed.

Availability of updatedanalytical tools

Reports, graphs,charts, reports, self-assessment reports,maps

1.8 Stores 1.8.1 Use of StandardOperating Procedures forstores management and storeroom


Stores recordsObservations

1.9 Security 1.9.1 Hopital securityaccording to standards


2. Human Resources:Objective: To provide a well-motivated, committed and skilled professional workforce who will deliver cost effective quality health care services as close tothe family as possible.

2.1.1 Disaggregated staffreturns completed andsubmitted in a correct manner(quarterly)

# of staff returns submitted/ # of staff returns due

Records of staffreturns

2.1.2 At least 75% of theestablishment for professionalmedical staff at the Hospitalfilled

# available professionalmedical staff /Establishment for facility

HR Registers;HR reports

2.1.3 At least 75% of theestablishment for non-medicaland support staff at thehospital filled

#available non-medicalstaff /Establishment for facility

HR registers;HR reports

2.1 Staff Returns

2.1.4 Analysis of staff attritionand recommendations made

Numbers and categories ofstaff attrition for the periodunder review

Registers / reports/interviews




PREVIOUSPA PERIOD


CURRENTPA PERIOD


COMMENTS

Actions taken by categoryof attrition

Registers / reports/interviews

2.2.1 Human Resource levelsand types adequate for allhospital departments

# of professional andsupport staff available /establishment bydepartment

Staff rotas / HumanResource records/In patient and OPDregisters (todetermineworkload)

2.2.2 All staff appraisedaccording to job descriptionannually and individual careerplan developed.

# of employees appraisedand career plan developed /number of employees duefor appraisal

Records andinterviews

Existence of Staffdevelopment and trainingplan

Human Resourcerecords

2.2.3 Staff development andtraining plan in place andadhered to

# of staff training activitiesduring the period /total # of staff trainingactivities planned

Reports, minutes of(technical) meetings

2.2 HR management

2.2.4 Leave Plan in place andadhered to.

# of staff who have takenleave during period /total # of staff(analyze by type of leaveand number of leave days)

Reports

2.2.5 All trained staff havevalid license

#staff with validlicense/#staff employed

Human Resourcerecords

2.2.6 Human Resources levelsand personal details/trainingsundertaken included on adatabase

Human Resources databaseavailable and maintanined




PREVIOUSPA PERIOD


CURRENTPA PERIOD


COMMENTS

2.2.7 Knowledge and skillsacquired at capacity buildingworkshops and meetingspassed on to other staff withina month of training

# of reports disseminatedor presentations abouttraining undertakenaccessed by relevant staff/total # of capacity buildingworkshops and meetingsattended during period ofreview

Reports/presentationsStaff interviews

2.2.8 All eligible staffreceiving their housing andother benefits.

# staff receiving housingallowance/ total # staff

Accounts records

2.3 HIV & AIDSworkplace policy

2.3.1 HIV & AIDS workplacepolicy available and adheredto

Policy available and stafforiented on key elements

Policy,Staff interviews

3. Quality of care and curative servicesObjective: To provide quality health services according to national approved guidelines and SOP

# of patients treatedaccording to treatmentprotocols /# of patients sampled(minimum 5)

Patient records3.1.1 Patients are treatedaccording to treatmentprotocols

# of patients managedaccording to nursing careplan /# of patients sampled(This includes: fluidbalance, TPR, neurologicalcharts, drug charts, etc.)

Patient records

3.1 Quality of care(Clinical, Nursing careand rehabilitation)

3.1.2 All patients revieweddaily by medical officer

# of patients reviewed daily/ # of patients sampled(minimum 5)

Patient records




PREVIOUSPA PERIOD


CURRENTPA PERIOD


COMMENTS

3.1.3 All patients files havedetailed history, physicalexamination, diagnosis andtreatment on first contact.

# of patient files correctlycompleted /# of patient files sampled(Minimum 5)

Patient Records

# of clinical meetings held /# of clinical meetingsplanned

Minutes3.1.4 Clinical meetings held(including review the rationaluse of diagnostic procedures)

# of recommendationsmade during clinicalmeetings followed up /# of recommendationsmade

Minutes

3.2 OPD for Specialisedcases referred from HealthCentres

3.2.1 Patients are treatedaccording to treatmentprotocols

# of patients treatedaccording to treatmentprotocols /# of patients sampled(minimum 5)

OPD Register;Patient records

3.3.1 Maximum waiting timeless than 30 minutes

# of patient with waitingtime < 30 minutes /# of patients sampled

Files, registers,observations

3.3 Casualty / Emergency

3.3.2 Supplies and equipmentavailable according tostandards


Physical checkRecords

3.4 Quality Assurance: 3.4.2 Mortality reviewmeeting held monthly

# of meetings held /# of meetings planned

Records andminutes




PREVIOUSPA PERIOD


CURRENTPA PERIOD


COMMENTS

CFR for each of the top 5causes of death (total andunder 5)

HMIS

3.5 Theatre / Surgery 3.5.1 Post-operative woundinfections identified, reviewedand recommendations adheredto

# of post-operativeinfections identified

HMIS; nursing andpatients records,physical checks,staff interview

Reviews conducted of allinfected wounds andactions followed up

Nursing andpatients records,physical checks,staff interview

3.6 Mortuary 3.6.1 All unclaimed bodiesremoved within 3 – 6 weeks.

# of unclaimed bodies keptmore than six weeks

Mortuary records

3.7 Mental health 3.7.1 Area reserved forpsychiatric OPD and IPD

Availability of area forpsychiatry (yes/no)

Physical checkinterview

3.8 Laboratory 3.8.1 Tests are subjected toQuality Control through re-testing by reference orindependent laboratory

10% +ve and 5% -vemalaria slides, 100% TBsputum smears and 100%+ve HIV tests are sent toreference/independentlaboratory for QualityControl

Laboratory Records

3.9.1 Safety measures againstradiation in place and adheredto.

Badges read, protection forpatients, annual inspectionby Radiation board

Badge readings,physical checks,patient infromation,Radiation Boardreports

3.9 Imaging / X-ray

3.9.2 Availability of suppliesas per level of Hospital

# of supplies/ # of suppliesin SOPs

Physical Check




PREVIOUSPA PERIOD


CURRENTPA PERIOD


COMMENTS

3.9.3 Availability of SOPaccording to level of Hospital

SOP available andfollowed

Physical Check

3.9.4 Safe disposal of radio-active material

Safe mechanism fordisposal of radio-activematerial in place

Physical Check

3.10 Research 3.10.1 Hospitals usingresearch findings to improveon quality care services

# of clinical meetingspresenting researchfindings and actions takenaccordingly

Meeting notes andphysical check ofactions taken

3.11 Gender 3.11.1 Gender mainstreamingplan developed and adhered to

# of actions taken tomainstream gender issues/# of recommendations inplan

Physical check,staff and patientsinterviews

3.12 Infection Prevention 3.12.1 Hosptial meetsinfection prevention standards

# standards met/ #standards

Physical check

3.13 Referral 3.13.1 20% of patients referredto higher level

# of referrals /total numberof patients

3.13.2 All patients referredhave feedback given toreferring institution

# of referred patients withfeedback / Total # ofpatients referred

Referral documentsPatients’ registersPatients’ records

4. Integrated Child Health and NutritionObjective: To reduce Under-5 mortality by 20%, from the current level of 168 per 1000 live births to 134 by 2011, and significantly improve nutrition.

Case Management 4.1.1 All children seen bydoctor on admission and atleast every other day

# of children reviewed bydoctor daily and onadmission /# of children sampled

4.2 IEC & preventiveservices

4.2.1 Health educationprogramme schedule availableand adhered to

# of health educationsessions/ # health educationsessions scheduled

Care giversinterviews andschedule




PREVIOUSPA PERIOD


CURRENTPA PERIOD


COMMENTS

4.2.2 All newborns givenBCG / OPV before discharge

# of newborns vaccinatedwith BCG and OPV 0 /# of live births at facility

Vaccine stocks/patients notes/maternity unit

4.2.3 All <1 childrendischarged have up to datevaccine schedules

# of children <1 dischargedwith up to date vaccineschedules /total # of children <1discharged

Patients notes/vaccine records

4.3.1 Opt-out HIV testingpolicy implemented inpaediatric ward

# of children tested for HIV/ total # of admittedchildren sampled

Pateint recordsWard register

4.3.2 Infants born to HIV+vemothers protected throughPMTCT

# infants born to HIV+vemothers protected throughPMTCT/#infants born toHIV+ve mothers

Patientrecords/ARTrecords

4.3.3 At least 80% of infantsborn to HIV +ve mothersreceiving cotrimoxazoleprophylaxis

Number of babies born toHIV +ve mothers receivingcotrimoxazoleprophylaxis/Total numberof babies born from HIV+ve mothers

PMTCT registersand ART records

4.3 HIV

4.3.4 All eligible paediatricpatients on ART

#. of eligible paediatricpatients on ART / Total #of eligible paediatricpatients

RegisterART records

4.4 Neonatal care toreproductive health

4.4.1 Availability of skilledstaff and equipment inneonatal resuscitation

# of staff skilled inneonatal resuscitation

Observation,Interview




PREVIOUSPA PERIOD


CURRENTPA PERIOD


COMMENTS

Availability of workingresuscitation equipmentincluding neonatal ambubag

Observation,Interview

4.4.2 Neonatal resuscitationaccording to guidelines

# of children resuscitatedusing guidelines /# of children needingresuscitation

Patient notes

# of stillbirths reviewed /# of stillbirths duringperiod.

Maternity register,reports HMIS

4.4.3 Review of stillbirthscarried out andrecommendations made.

# of recommendationsfollowed up /total # of recommendations

4.5.1 80% infants managedaccording to Baby FriendlyHospital Initiative (BFHI)guidelines

#infants managedaccording to Baby FriendlyHospital Initiativeguidelines/# of severelymalnourished childrenadmitted

Patient interviews

4.5.2 80% of severelymalnourished childrenmanaged according to WHOguidelines

# of severely malnourishedchildren managedaccording to WHOguidelines /# of severely malnourishedchildren admitted

Patient records

4.5 Nutrition /Malnutrition

4.5.3 All mothers withadmitted children (under2years) receive infant feedingcounseling / support

# of mothers with admittedchildren (under 2years)received infant feedingcounseling or support /# of mothers with admittedchildren (under 2 years)

Records sample




PREVIOUSPA PERIOD


CURRENTPA PERIOD


COMMENTS

sampled

5. Integrated Reproductive HealthObjective: To increase access to integrated reproductive health services and family planning services that reduce the maternal mortality ratio (MMR) byone quarter, from 729 per 100,000 live birth to 457 by 2011

5.1.1 ComprehensiveEmergency Obstetric Careincluding resuscitationavailable at all times accordingto the standards

# of standards achieved /# of standards

Physical checkspatients’ records

5.1 Emergency ObstetricCare (EmOC)

5.1.2 Protocols available forall maternal emergencies (e.g.eclampsia, rupture of uterus,placenta praevia, ect.)

All protocols for obstetricemergencies available

ProtocolsPhysical check

5.2.1 100% maternal deathsreviewed andrecommendations made(according to MDR tools)

# of maternal deaths withcompleted MDR forms andrecommendations made /total # of maternal deaths

Reports

5.2.2 At least 85% maternaldeaths recommendationsfollowed up

# of recommendationsfollowed up /total # of recommendations

Reports

5.2.3 Deliveries conducted bydoctor or midwife

# of deliveries by doctor ormidwife /total # of deliveries

Delivery books

5.2 Deliveries

5.2.4 80% deliveries havepartograms recorded accordingto guidelines

# of institutional deliveriesmonitored by partograms /total # of institutionaldeliveries

Partograms




PREVIOUSPA PERIOD


CURRENTPA PERIOD


COMMENTS

5.2.5 At least 5% of expectedbirths in hospital catchmentarea are delivered by C/S(analyze if below 5%).

# of C/S performed /Total # of expecteddeliveries in hospitalcatchment area

HMIS,Delivery records

5.2.6 All Indications for C/Sreviewed and justified

All C/S reviewed by seniordoctors

HMIS, reviews,patients records,delivery book

5.2.7 Referral systems in placeand adhered to

#of patients referredaccording to standards andfeedback to districts ondischarge

Referral letters,nurses notes

5.2.8 All mothers receivevitamin A supplementationbefore discharge

# of mothers who receivedVitamin A supplementation/ Total # of mothers whodelivered

Delivery register

5.3 Gynaecology services 5.3.1 Staff trained in cervicalsmears/ acid testing

# of staff trained /# of eligible staff(midwives and doctors)

Records

5.4 Family planning 5.4.1 All eligible in-patientsoffered a full range of familyplanning methods includinglong term and permanentmethods for family planning(requires staff trained,equipment and suppliesavailable)

# of BTL done# of IUD inserted# of Jadell implanted# of oral contraceptivesissued# of clients administeredinjectables# inpatients of reproductiveage councelled/# inpatientsof reproductive age

FP registersIn patient recordsTheatre registers,Physical checks forsupplies andequipment

5.5 PMTCT 5.5.1 Focused ANC includingPMTCT provided as perguidelines (including ART)

80% referred ANC clientsreceiving FANC as perguidelines

ANC register




PREVIOUSPA PERIOD


CURRENTPA PERIOD


COMMENTS

6. HIV/AIDS, STIs and Blood SafetyObjective: To halt and begin to reduce the spread of HIV/AIDS and STIs by increasing access to quality HIV/AIDS, STI and Blood Safety interventions

6.1.1 All blood for transfusionscreened for HIV, Hepatitis C,Hepatitis B and Syphilis.

All units of blood screenedas per guidelines

Blood bank records6.1 Blood Bank /transfusions

6.1.2 Blood supplies meethospital requirements

# of units requested /# of units supplied

Blood bank records

6.2.1 Guidelines on treatmentinitiation available andadhered to.

All eligible client on ARTas per guidelines

ART clinicrecords/patientsnotes

6.2.2 All patients on ART areevaluated and entered inappropriate registers

100% patients evaluatedand entered in register

ART records

6.2.3 Availability of eligibilityforms; pre ART registers withtally sheets; ART registerswith tally sheets; ART carecards

ART materials available Physical check

6.2.4 All HIV+ve eligiblepersons accessing ART

# of persons accessingART /total # of eligible patients

ART records

6.2 ART clinic

6.2.5 All HIV+ ve clients aremanaged according to theguidelines

# HIV+ve clients managedaccording toguidelines/#HIV+veclients records sampled

ART records




PREVIOUSPA PERIOD


CURRENTPA PERIOD


COMMENTS

6.2.6 80% of patients on ARThave a 95% compliance

# patients registered onART/ # collecting drugsmonthly/quarterly

HMIS, ARTregisters and reports

6.2.7 Referral systems in placefrom all Councelling nadTesting entry points in thedistricts to ART clinic.Including feedbackmechanism

All eligible patientsreferred to ART clinic

Referral slips fromwards to ARTclinic, ARTregisterscords,meetings withDHMT

# of referral slips sent toDHMT/ # clients enrolledon ART

6.2.8 Adherence counsellingon site

# of ART clients receivingadherencecounseling/#ART clientsattended in reporting period

Patient record/ ARTclinic records

6.2.9 Hospital adheres to freeART guidelines

# of patients receivinginvestigations, consultationand treatment free ofcharge / # receiving ART

Financial records,Client/ staffinteviews

6.2.10 Hospital accredited forART service provision

Accreditation certificateavailable

Accreditationcertificate

6.3.1 Opt-out HIV testingpolicy implemented in InPatients Department

# in patients tested for HIV/ total # of in patientssampled

6.3.2 Referral systems forART in place from In PatientsDepartment to ART clinic

# of eligible in-patientsreferred to ART clinic /total #eligible in-patients

Referral slips fromwards to ARTclinic, ARTIS, ARTregisters andmeetings withDHMT

6.3 HIV management inIn Patients Department

6.3.3 All eligible pregnantwomen on HAART

# of pregnant womenreferred for ART /# pregnant women eligible

PMTCT registers




PREVIOUSPA PERIOD


CURRENTPA PERIOD


COMMENTS

6.4.1 80% STI clients testedfor HIV

# of STI clients tested /Total # of STI clientssampled

Patient records, STIclinic registers

6.4.2 100% STI patientstreated according to guideline

# of STI patients treatedaccording to guidelines /Total # STI patientssampled

Patients records

6.4 STI management

6.4.3 75% STI clients’partners investigated for STI

# of STI clients’ partnersinvestigated /Total # of STI clients

STI register

7. TuberculosisObjective: To halt and begin to reduce the spread of TB through effective interventions

7.1.1 At least 70% ofpulmonary TB cases supportedby a positive sputum test

# of PTB smear positivecases /Total # of PTB cases

7.1.2All TB patients offeredHIV testing

# TB cases tested forHIV/#TB cases

ARTIS

7.1.3 All in-patients screenedfor PTB ( history taken andfollow up diagnostic tests ifindicated)

# of in-patients screenedfor TB /# of inpatients sampled

Patients records

7.1.4 All TB cases managedaccording to standards

# of TB patients treatedaccording to standards /# of TB patients sampled

Patient records

7.1 TB diagnosis and casemanagement

7.1.5 DHMT is informed of atleast 80% TB cases diagnosedat the hospital

# of TB cases diagnosed inthe hospital with diagnosisforwarded to the DHMT /# of TB cases diagnosed athospital

8. MalariaObjective: To halt and reduce the incidence of malaria by 75% and mortality due to malaria in children under five by 20%




PREVIOUSPA PERIOD


CURRENTPA PERIOD


COMMENTS

8.1.1 All patients diagnosedby laboratory tests and treatedas per guidelines

# of malaria patients withlaboratory diagnosis /# of patients treated formalaria

Patient records

# of malaria patientstreated according toguidelines /# of malaria patientssampled

8.1 Malaria casemanagement

8.1.2 All in-patients sleepunder an ITN each night

# patients sleeping underan ITN/# inpatients

Physical check,patient interviewsAvailability of ITNs

9. Epidemics Control and Public Health SurveillanceObjective: To significantly improve public health surveillance and control of epidemics, so as to reduce morbidity and mortality associated with epidemics

9.1.1 Hospital has anEmergency Preparedness Plandescribing how theorganization will effectivelyrespond to disasters oremergencies and epidemics

Plan exists and rehearsedby staff members twice ayear.

Observations andRecords /Interviews

# staff knowledgeable onplan/# staff interviewed

9.1 Emergency anddisaster preparedness

9.1.2 Hospital prepared for fire # departments with fireequipment available andserviced and staff preparedfor fires/ # departements

Physical check andstaff interviews

9.2 Surveillance 9.2.1 System in place toconduct surveillance fornotifiable diseases

# notifiable diseasesreported/ #notifiablediseases admitted or seenas Out Patients

WeeklyEpidemiologicalreportsDHMT reports




PREVIOUSPA PERIOD


CURRENTPA PERIOD


COMMENTS

OPD and IPregisters

10. Environmental Health and Food SafetyObjective: To promote and improve hygiene and universal access to safe and adequate water, food safety and acceptable sanitation, with the aim ofreducing the incidence of water and food borne diseases

10.1.1 Food handlers testedevery 6 months

# of food handlersexamined and declared fit /Total # of food handlers

Certificates10.1 Hygiene

10.1.2 Patients access to cleandrinking water

# of water samples takenconforming to WHOstandards /total # of water samplestaken

Results in EHTDepartment

10.2.1 Medical waste disposalaccording to SOPs

Medical waste disposalplan adhered to.

Physical checks10.2 Waste managment

10.2.2 Solid wastemanagement as per guidelines

Waste disposal planadhered to.

Physical checks

11. Essential drugs and medical suppliesObjective: To ensure availability of adequate, quality, efficacious, safe and affordable essential drugs and medical supplies at all levels, through effectiveprocurement management and cooperation with pharmaceutical companies

11.1.1 All essential drugs andmedical supplies for eachdepartment listed have stockcontrol cards

Comprehensive list andstock control cardsavailable for all drugsrequired by eachdepartment

Stock control cards/recommended listof essential drugsfor each department

11.1 Pharmacy

11.1.2 All essential drugs areavailable at all times for all

# of essential drug stockouts /

Stock control cards




PREVIOUSPA PERIOD


CURRENTPA PERIOD


COMMENTS

departments # of stock control cardssampled

11.1.3 All essential suppliesare available at all times for alldepartments

# of medical supply stockouts /# of stock control cardssampled

Stock control cards

11.1.4 Drug and medicalsupplies management as perstandards

# of pharmacy standardsachieved /# of pharmacy standardsset

Physical checks andrecords

# of meetings held /# of expected meetings

Records andphysical checks

11.1.5 Drug & TherapeuticsCommittees meeting as perguidelines (monthly)

# recommendations of theDrug & TherapeuticsCommittees followed up/ #recommendations.

11.1.6 Activepharmacovigilance (sideeffects of drugs andcompletion ofpharmacovigelence forms)

# of patients monitored forside effects /total # of patients sampled

Pharmaco-vigilancereports,Patients notes

11.1.7 Distribution proceduresof drugs to wards: for wardstock, 6 hours; for drug chart,30 minutes.

Time taken for processingand dispensing drugs towards/ expected time

Interviews withward in-charges andpharmacy staff

12. Infrastructure and equipmentObjective: To significantly improve on the availability, distribution and condition of essential infrastructure and equipment so as to improve equity of accessto the basic health care package




PREVIOUSPA PERIOD


CURRENTPA PERIOD


COMMENTS

12.1.1 Hospital has aninventory list of medicalequipment, including state ofrepair.

Inventory list available Physical checkagainst list ofequipment

12.1.2 Hospital preventativemaintenance and repair planavailable (includingmaintenance contracts)

# medical equipmentserviced routinely andrepaired when necessary/ #equipment sampled.

Physical checkagainst preventativemaintenance plan;Maintenancecontracts

12.1.3 Hospital procurementplan available and adhered to

Essential equipmentprocured according to plan/# required equipment

Physical checkagainst procurementplan

12.1 Medical equipment

12.1.4 Availability andmaintenance of cold chain atall times

Temperature controlmaintained forspecifications of drugs andreagents at all times/ #drugs and reagents sampled

Temperature chartsin fridges/physicalchecks of fridges

12.2 Infrastructure 12.2.1 Infrastructure extensionand major renovations areincluded in action plan andproposals developed andsubmitted through PHO forfunding

# proposals submitted toPHO for funding for majorrenovations / extensions/ #extensions and removationsrequired

Proposals

12.3 Dental clinic 12.3.1 Dental clinic equipmentand supplies availableaccording to SOP


Records andObservations

12.4 Theatre / surgery 12.4.1 Theatre equipment andsupplies available according toSOP






PREVIOUSPA PERIOD


CURRENTPA PERIOD


COMMENTS

12.5 Physiotherapy 12.5.1 Physiotherapyequipment and suppliesavailable according to SOP





12.6 Wards 12.6.1 Facility structures,furnishings and equipmentaccording to standards perlevel of hospital.

# of bed sheets andblankets /total # required(by department)


12.6.2 Infection preventionsupplies available according tostandards

# of standards achieved/#ofstandards set


12.7 Laboratory 12.7.1 Lab Equipment andsupplies according to standardfor level of Hospital


Observation,records

12.8 Imaging / X-ray 12.8.1 Imaging and X-rayequipment and suppliesaccording to standard for levelof hospital


Observation,records

# of vehicles available /Recommended # ofvehicles for institution

Physical check,Transport records

12.9.1 Transport availableaccording to standards

# of ambulances available /Recommended # ofambulances for institution

Physical check,Transport records

12.9 Transport

12.9.2 Transport managementaccording to standards


Observation,records

12.10 Laundry department 12.10.1 Equipment andsupplies according to standardfor level of hospital


Observation,records




PREVIOUSPA PERIOD


CURRENTPA PERIOD


COMMENTS

12.11 Kitchen 12.11.1 Equipment andsupplies according to standardfor level of hospital


Observation,records

12.12 Mortuary 12.12.1 Equipment presentand functioning according tostandards for levelof hospital


Observation,records

12.13 Relatives Shelter 12.13.1 Structure according tostandards


Observations andRecords

12.8 Communication 12.8.1 Hospital has emailconnection

Hospital with emailconnection and using emailto communicate withDistrict Office

Physical checksEmail messages

12.8.2 Hospital able tocommunicate with all healthcentres in catchment area andvice versa, stationed in or nearlabour room. (radio, cellphone, and/or land line)

# health centres reachableon time of assessment/ #health centres in catchmentarea

Physical check


Summary………………………………………………………………………………………………………………………………..…………………………………………………………………………………………………………………..

List of participants- ............- ………List of achievements- ……….- ……….

PROBLEM IDENTIFIED ANALYSIS RECOMMENDATIONS BYWHEN

BYWHOM

Technical Support to be provided by District Health Office- …..- …..

District Health Office Assessed Hospital

Date Date

Performance Assessment Tool for Level 1 Hospitalspdf.usaid.gov/pdf_docs/PNADR335.pdf · Performance...

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