checklist for assessing - quality health care awards
TRANSCRIPT
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Ministry of Health
CHECKLIST FOR ASSESSING QUALITY OF HEALTHCARE
Kenya Quality Model for Health
LEVEL 3 HEALTH FACILITIES
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CONTENTS CONTENTS ............................................................................................................................ 2 FOREWORD ........................................................................................................................... 4 ACKNOWLEDGEMENTS ..................................................................................................... 5 LIST OF CONTRIBUTORS .................................................................................................... 6 ABBREVIATIONS ................................................................................................................. 7 INTRODUCTION ................................................................................................................... 8
Background ........................................................................................................................... 8 Rationale for the Review of KQMH ...................................................................................... 8 Review Objective .................................................................................................................. 9 Principles of the KQMH and Dimensions of Quality ............................................................. 9 Requirement ........................................................................................................................ 10 Documents required during assessment ................................................................................ 12 Facility profile ..................................................................................................................... 13
STRUCTURE ........................................................................................................................ 14
Dimension 1: Leadership ..................................................................................................... 14 Dimension 2: Human Resources Management and Development ......................................... 19 Dimension 3: Policies, Standards and Guidelines ................................................................. 23 Dimension 4: Facilities and Infrastructure ............................................................................ 25 Dimension 5: Supplies Management .................................................................................... 35 Dimension 6: Equipment Management ................................................................................ 37 Dimension 7: Transport and Fleet Management ................................................................... 41 Dimension 8: Referral System ............................................................................................. 42 Dimension 9: Health Records and Health Management Information Systems ...................... 45 Dimension 10: Financial Management ................................................................................. 49
DIMENSION 11: PROCESSES ............................................................................................. 51
11.1 Outpatient Services ...................................................................................................... 51 11.2 Patient Centred Care .................................................................................................... 57 11.3 Infection Prevention and Control ................................................................................. 61 11.4 Inpatient Care .............................................................................................................. 64 11.5 Accidents and Emergency ............................................................................................ 69 11.8 Safe delivery ................................................................................................................ 72 11.9 Neonatal Care .............................................................................................................. 76 11.11 Laboratory ................................................................................................................. 81 11.12 Pharmacy ................................................................................................................... 90
DIMENSION 12: RESULTS ................................................................................................. 93 APPENDICES ....................................................................................................................... 98
Appendix 1: A&E Equipment .............................................................................................. 98 Appendix 2: Essential Medicines ....................................................................................... 100 Appendix 3: List of Tracer Non-pharmaceutical products .................................................. 101 Appendix 4: Assessment for critical intra-partum care ....................................................... 102
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Appendix 5: List of equipment for maternal care ............................................................... 103 Appendix 6: List of laboratory Equipment ......................................................................... 104 Appendix 7: Surgical Safety Checklist ............................................................................... 105
TERMINOLOGY ................................................................................................................ 106
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LIST OF CONTRIBUTORS Dr. Annah Wamae Department of Health Standards Quality Assurance and Regulation Dr. Charles Kandie Department of Health Standards Quality Assurance and Regulation Manasseh Bocha Department of Health Standards Quality Assurance and Regulation Idah Ombura Department of Health Standards Quality Assurance and Regulation Dr. Jamlick Karumbi Department of Health Standards Quality Assurance and Regulation Dr. Judy Awinja Department of Health Standards Quality Assurance and Regulation Francis Muma Department of Health Standards Quality Assurance and Regulation Gaudencia Mokaya Department of Health Standards Quality Assurance and Regulation John Towett Department of Health Standards Quality Assurance and Regulation Agnes Mutinda Department of Curative and Rehabilitative Services Florence Opiyo Nairobi City County Health Services Joseph Githinji National Hospital Insurance Fund Titus Oyoo Kenya Bureau of Standards Doris Mueni Mengo Kenya Accreditation Service Michael Talam Kenya Accreditation Service Rebekka Oetz Christian Health Association of Kenya Dr. Frank Wafula World Bank Kasmil Masheti PharmAccess Dr. Maureen Nafula Institute of Health Policy, Management and Research Dr. Subiri Obwogo USAID-ASSIST Peter Mutanda USAID-ASSIST Dr. Kirsteen Awori Surgical Society of Kenya Dr. Lydia Okutoyi Kenya Obstetrics and Gynaecology Society Dr. Anne Kihara Kenya Obstetrics and Gynaecology Society Dr. Ahmed Twahir Kenya Renal Association Dr. Jonathan Wala Kenya Renal Association Dr. P. Onyancha Mathari National Referral Hospital Dr. Alice Maingi Kenyatta National Hospital Anne Karume Kenyatta National Hospital Abby Muembu Kenyatta National Hospital David Were Kenyatta National Hospital Dr. B. Wachira Aga Khan University Hospital Lawrence Wamiti Association of Kenya Medical Laboratory Scientific Officers Valentine Magero Association of Kenya Medical Laboratory Scientific Officers Dr. Caroline Wafula Pharmaceutical Society of Kenya Dr. Brian Maugo Pediatric Association of Kenya Carolyne Kawira National Nurses Association of Kenya Elijah Kinyangi Japan International Cooperation Agency Prof. Rolf Korte Deutsche Gesellschaft für Internationale Zusammenarbeit. Irene Omogi Deutsche Gesellschaft für Internationale Zusammenarbeit.
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ABBREVIATIONS DHIS District Health Information System
HMIS Health Management Information System
HRH Human Resources for Health
KHSSP Kenya Health Sector Strategic Plan
KQMH Kenya Quality Model for Health
KPI Key Performance Indicator
IQC Internal Quality Control
MCH Maternal and Child Health
MOH Ministry of Health
MOV Mode of Verification
QMS Quality Management System
SOP Standard Operating Procedure
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INTRODUCTION Background Improving the quality of healthcare is a key priority in Kenya as reflected in a number of policy and strategy documents. According to Vision 2030, Kenya’s economic blueprint, the country aims to have an equitable and affordable healthcare system of the highest possible quality by the year 2030. The overarching goal of the Kenya Health Policy (Ministry of Health, 2014) is ‘attaining the highest possible health standards in a manner responsive to the population needs’. The policy aims to achieve this goal through supporting the provision of equitable, affordable and quality health and related services at the highest attainable standards to all Kenyans.
Rationale for the Review of KQMH The KQMH is a conceptual framework for an integrated approach to improved quality of healthcare in Kenya. In 2001, the Kenya Quality Model (KQM) was developed and introduced by the Ministry of Health (MOH), to guide the organisation of health services to deliver positive health impacts by addressing quality issues. The KQM consisted of standards and a master checklist. In 2008, the KQM was revised to customise it for the various levels of the healthcare system as described in the Kenya Essential Package of Health (KEPH). However, the 2008 review did not consider the clinical content of the quality model. Further, since 2008, there have been changes in the health sector, which needed to be reflected in a new model. These changes include the enactment of a new constitution in 2010; the development of the Kenya Health Policy 2014-2030; the adaption of the World Health Organisation Health Systems Building in the Kenya Health Sector Strategic and Investment Plan (KHSSP) 2014-2018; and the development of various clinical standards and guidelines among others. The first National Quality Policy Seminar held in Nairobi in 2013 recommended a review of the KQMH, to make it a national quality improvement tool and one that could be legitimized through regulation requiring all providers to use it. The seminar recognized that even though multiple approaches allow implementers to innovate, to be creative and to experiment, there is need to have a common national framework to guide all quality improvement initiatives. In addition, the MOH has identified the KQMH as the vehicle for improving quality of care in the health sector, therefore there is need to review and update it as a prelude for the development of national standards to be used in the national accreditation framework. The goal of the model is to improve adherence to standards and guidelines based on evidence-based medicine, as well as applying quality principles and tools and satisfying patient / client’s needs in a culturally appropriate way. The model uses Standards and Guidelines that are evidence-based and proven to be effective, efficient, affordable and acceptable. It also integrates patient partnership in the healthcare process.
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Review Objective To ensure that the KQMH is comprehensive and reflects current national policies and strategies, as well as international developments and best practices in the delivery of health services.
Principles of the KQMH and Dimensions of Quality The KQMH integrates evidence-based medicine through wide dissemination of public health and clinical standards and guidelines embedded with total quality management and patient partnership. The eight principles underlying KQMH are:
Leadership Customer orientation Involvement of people and stakeholders Systems approach to management Process orientation Continuous quality improvement Evidence-based decision making
The 12 dimensions of the KQMH implemented through the standards described in this document are organised around structure, processes and results, as follows: I. Structure:
a) Leadership b) Human Resources c) Policies, Standards and Guidelines d) Facility and Infrastructure e) Supplies Management f) Equipment g) Transport h) Referral Systems i) Health Records and Health Management Information Systems j) Financial Management
II. Processes:
a) Outpatient services b) Patient-centred care c) Infection prevention and control d) Outpatient services e) Accidents and emergencies f) Surgical emergencies g) Anaesthesia h) Safe delivery i) Neonatal care j) Dialysis services k) Laboratory services l) Pharmacy services m) Radiology services
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n) Mortuary services
III. Results, measured against set key performance indicators.
Requirement This checklist is intended for use in all levels of health facilities, in line with the services provided. It should be used for facility self-assessment, peer assessment of network of facilities and by external assessors such as regulator or certification bodies. All facilities shall carry out self-assessment. The role of the assessor will be to validate the assessment results. The classification of levels of healthcare delivery is as defined by the Health ACT 2017 as shown in the table below. Level of healthcare delivery Roles Level 2: Dispensary/clinic Treatment of minor ailments
Rehabilitative services Preventive and promotive services. Does not provide in-patient services
Level 3: Health Centre Out-patient care Limited emergency care Maternity for normal deliveries Laboratories, oral health and referral services; Preventive and promotive services; In-patient observations
Level 4: Primary Hospital Clinical supportive supervision to lower level facilities Referral level out-patient care In-patient services Emergency obstetric care and oral health services Surgery on inpatient basis Client health education Specialized laboratory tests Radiology services Proper case management of referral cases Proper counter referral Provision of logistical support to the lower facilities in
the catchment area; Coordination of information flow from facilities in the
catchment area. Level 5: Secondary Hospital Provision of specialized services
Training facilities for cadres of health workers who function at the primary care level
Serve as an internship centre for all staff, up to medical officers
Serves as a research centre, that provides research services for issues of county importance
Level 6: Tertiary Hospital Provides highly specialized services. These include
general specialization; discipline specialization; and
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Level of healthcare delivery Roles geographical/regional specialization including highly specialized healthcare for area/regional specialization;
Research centre, provides training and research services for issues of national importance.
Scoring system Dimension 1-11 Score Notes
0 No documented/observable effort of compliance. (This is denoted NO in the scoring sheet)
1 Partial. (Standard is not fully met, there is need for improvement. State areas for improvement under remarks). This is denoted P in the scoring sheet
3 Fully compliant. This is denoted YES in the scoring sheet
Dimension 12 Score Notes
0 - More than 75% off target
1 - 75 to 50% off target 2 - 49 to 25% off target 3 - 25 to 1% off target 4 - Met Target
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Documents required during assessment The following documents should be available at the beginning of the assessment process. Availability of a full self-assessment report prepared during the previous 12 months is highly desirable. Health facility strategic plan or annual work
plans
Facility risk assessment report
Facility license and lease certificate
Quality improvement implementation
reports
KQMH self-assessment reports
Human resource records
Staff satisfaction survey report
Infrastructure maintenance report
5S audit & implementation report
Equipment maintenance report
Quarterly referral reports
Data analysis and dissemination report
Financial audit report
Patient satisfaction survey reports
IPC audit report
HAI surveillance report
Quarterly reports on turn-around-time at the
A&E
Mortality audit reports
Quarterly resuscitation drills reports for all
clinical areas
Internal audit report for the laboratory
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Facility profile
Facility Name:
Facility Contacts: Kenya Master Health Facility List coordinates:
Tier/Level: County: Sub-county: Population of catchment area:
Type of facility: a) Public facility b) Private facility c) FBOs/CBOs Range of services offered (Fill in the services offered by the facility in the space provided below):
14 |
Pa
ge
STR
UC
TUR
E
Dim
ensi
on 1
: Lea
ders
hip
Qua
lity
Stan
dard
Re
quire
men
t Sc
ore
(tick
app
ropr
iate
bo
x)
Rem
arks
1.1
Lead
ersh
ip a
nd M
anag
emen
t Res
pons
ibili
ties
1.1.
1 T
he h
ealth
faci
lity
man
agem
ent s
hall
ensu
re
com
plia
nce
with
re
gula
tory
req
uire
men
ts.
Faci
lity
has a
val
id li
cenc
e or
is g
azet
ted
to o
ffer
he
alth
care
serv
ices
(M
OV-
Gaz
ette
not
ice
/lice
nce)
Y
es
No
The
faci
lity
is lic
ense
d fo
r pro
visio
n of
la
bora
tory
, rad
iolo
gy a
nd o
ther
rele
vant
serv
ices
(M
OV-
rele
vant
lice
nses
)
Yes
N
o
P1
N
/A
1.1.
2 T
he fa
cilit
y sh
all
have
in p
lace
gov
erna
nce
stru
ctur
es in
line
with
re
leva
nt le
gisla
tion
(10)
Org
anog
ram
in p
lace
(M
OV-
Obs
erva
tion)
Y
es
No
Faci
lity
has a
man
agem
ent u
nit
cons
titut
ed a
s per
le
gisl
atio
n (M
OV-
In P
ublic
faci
litie
s- G
azet
te n
otic
e, li
st o
f bo
ard
mem
bers
In
Pri
vate
faci
litie
s- le
tters
of a
ppoi
ntm
ent f
or
boar
d m
embe
rs,
list o
f boa
rd m
embe
rs)
Yes
N
o
1 P –
Par
tially
; N/A
– N
ot A
pplic
able
15 |
Pa
ge
Q
ualit
y St
anda
rd
Requ
irem
ent
Scor
e (ti
ck a
ppro
pria
te
box)
R
emar
ks
Faci
lity
man
agem
ent u
nit h
as te
rms o
f ref
eren
ce
(MO
V- T
ORs
ava
ilabl
e)
Yes
N
o
1.1.
3 T
he h
ealth
faci
lity
lead
ersh
ip sh
all i
dent
ify
and
plan
for
the
serv
ices
it
offe
rs
Faci
lity
has a
stra
tegi
c pl
an/ b
usin
ess p
lan
(M
OV-
avai
labi
lity
of c
urre
nt p
lan)
Y
es
No
Ann
ual w
ork
plan
with
a b
udge
t (M
OV-
avai
labi
lity
of c
urre
nt p
lan)
Y
es
No
Dep
artm
enta
l wor
k pl
ans i
n pl
ace
(MO
V-av
aila
bilit
y of
cur
rent
pla
n)
Yes
N
o
P
1.1.
4 T
he h
ealth
faci
lity
man
agem
ent s
hall
com
mit
to th
e im
plem
enta
tion
of th
e K
enya
Qua
lity
Mod
el fo
r H
ealth
(KQ
MH
) (9)
Man
agem
ent a
lloca
tes r
esou
rces
for
impl
emen
tatio
n of
qua
lity
impr
ovem
ent
initi
ativ
es(M
OV-
repo
rt on
cap
acity
dev
elop
men
t of
staf
f on
KQ
MH
, bud
get,
staffi
ng)
Yes
N
o
P
Miss
ion
and
visio
n st
atem
ents
are
alig
ned
to th
e co
unty
/nat
iona
l hea
lth se
ctor
's m
issio
n an
d vi
sion
(MO
V- c
onfir
m a
lignm
ent w
ith K
enya
Hea
lth
Polic
y)
Yes
N
o
P
1.1.
5 T
he h
ealth
faci
lity
man
agem
ent s
hall
have
a
desi
gnat
ed q
ualit
y im
prov
emen
t tea
m
(QIT
).
Qua
lity
impr
ovem
ent t
eam
app
oint
ed w
ith te
rms
of re
fere
nce
(MO
V- H
R re
cord
s)
Yes
N
o
QIT
coo
rdin
ator
app
oint
ed w
ith te
rms o
f re
fere
nce
(MO
V-H
R re
cord
s)
Yes
N
o
16 |
Pa
ge
Q
ualit
y St
anda
rd
Requ
irem
ent
Scor
e (ti
ck a
ppro
pria
te
box)
R
emar
ks
QIT
mee
ts at
leas
t onc
e ev
ery
quar
ter.
(M
OV-
min
utes
)
Y
es
No
All
Wor
k Im
prov
emen
t Tea
ms
(WIT
s) m
eet
mon
thly
(M
OV-
min
utes
)
Yes
N
o
1.1.
6 T
he h
ealth
faci
lity
shal
l com
ply
with
eth
ical
pr
inci
ples
.
Doc
umen
ted
proc
edur
e fo
r adm
inis
trativ
e co
nsen
t for
und
erta
king
of h
ealth
inte
rven
tions
an
d re
sear
ch (M
OV
-Doc
umen
ted
proc
edur
e)
Yes
N
o
Doc
umen
ted
proc
edur
e fo
r mon
itorin
g ad
vers
e ef
fect
of h
ealth
inte
rven
tions
and
rese
arch
(M
OV-
Doc
umen
ted
proc
edur
e)
Yes
N
o
1.2
Man
agem
ent R
evie
w a
nd C
ontin
uous
Impr
ovem
ent
1.2.
1 M
anag
emen
t sha
ll co
ntin
ually
rev
iew
the
faci
lity
oper
atio
ns
Faci
lity
man
agem
ent t
eam
mee
ts on
a m
onth
ly
basis
(M
OV-
Min
utes
)
Y
es
No
Faci
lity
hold
s mon
thly
clin
ical
mee
tings
(M
OV-
Min
utes
)
Y
es
No
Qua
lity
man
agem
ent r
evie
w m
eetin
gs a
re h
eld
on a
qua
rterly
bas
is. (M
OV-
Min
utes
)
Y
es
No
17 |
Pa
ge
Q
ualit
y St
anda
rd
Requ
irem
ent
Scor
e (ti
ck a
ppro
pria
te
box)
R
emar
ks
Clea
r qua
lity
impr
ovem
ent a
gend
a fo
r the
m
eetin
gs (t
o in
clud
e am
ong
othe
rs re
sults
of
self-
asse
ssm
ent;
Custo
mer
satis
fact
ion
feed
back
; Pro
cess
per
form
ance
; Sta
tus o
f pr
even
tive
and
corr
ectiv
e ac
tions
; Ris
k m
anag
emen
t; Fo
llow
-up
actio
ns fr
om
prev
ious
man
agem
ent r
evie
ws;
Reco
mm
enda
tions
for i
mpr
ovem
ent)
(MO
V-M
inut
es fo
r man
agem
ent r
evie
w m
eetin
gs)
Yes
N
o
P
1.2.
2 M
anag
emen
t sha
ll su
ppor
t sta
ff to
eng
age
in
a co
ntin
uous
qua
lity
impr
ovem
ent p
roce
ss.
Are
as fo
r im
prov
emen
t are
iden
tifie
d th
roug
h bi
annu
al q
ualit
y as
sess
men
ts (M
OV-
repo
rt on
id
entif
ied
area
s for
impr
ovem
ent).
Yes
N
o
P
Faci
lity
impl
emen
tats
of q
ualit
y im
prov
emen
t pl
ans
(MO
V- re
ports
on
qual
ity im
prov
emen
t pr
ojec
ts)
Yes
N
o
P
1.2.
3 T
he fa
cilit
y sh
all
carr
y ou
t reg
ular
qua
lity
revi
ew a
nd a
sses
smen
t of
the
effe
ctiv
enes
s of i
ts
qual
ity im
prov
emen
t in
itiat
ives
Self-
asse
ssm
ent c
arrie
d ou
t bia
nnua
lly
(MO
V- a
sses
smen
t rep
orts)
Y
es
No
P
1.2.
4 T
he fa
cilit
y sh
all
eval
uate
ben
efits
of
impr
ovem
ent
inte
rven
tions
at l
east
The
faci
lity
eval
uate
s ben
efits
of i
mpr
ovem
ent
inte
rven
tions
at l
east
once
ann
ually
(M
OV-
eva
luat
ion
repo
rt)
Yes
N
o
P
The
faci
lity
diss
emin
ates
succ
ess s
torie
s and
le
sson
s lea
rnt a
t lea
st on
ce a
nnua
lly.
Yes
N
o
18 |
Pa
ge
Q
ualit
y St
anda
rd
Requ
irem
ent
Scor
e (ti
ck a
ppro
pria
te
box)
R
emar
ks
once
ann
ually
and
su
cces
s sto
ries
and
le
sson
s lea
rnt
com
mun
icat
ed
(MO
V- m
inut
es/r
epor
t of d
issem
inat
ion
mee
tings
/ bro
chur
es/ s
ocia
l med
ia/
inte
rnet
lin
ks )
P
1.3
Risk
Man
agem
ent
The
faci
lity
has i
n pl
ace
mea
sure
s to
redu
ce o
r el
imin
ate
clin
ical
risk
s
The
faci
lity
cond
ucts
risk
asse
ssm
ent f
or a
ll cl
inic
al se
rvic
es
(MO
V- ri
sk a
sses
smen
t re
port)
Yes
N
o
The
faci
lity
has p
ut in
pla
ce m
easu
res t
o m
itiga
te th
e id
entif
ied
risks
(M
OV-
miti
gatio
n pl
an/re
port)
Yes
N
o
19 |
Pa
ge
D
imen
sion
2: H
uman
Res
ourc
es M
anag
emen
t and
Dev
elop
men
t
Stan
dard
Re
quir
emen
ts
Scor
e (t
ick
appr
opri
ate
box)
R
emar
ks
2.1
The
heal
th fa
cilit
y is
ad
equa
tely
staf
fed
as p
er
the
esta
blis
hed
HR
H
norm
s and
stan
dard
s.
Faci
lity
is sta
ffed
as p
er e
stabl
ishe
d H
RH
norm
s (M
OV-
HR
reco
rds)
Y
es
N
o
Faci
lity
has a
doc
umen
ted
proc
edur
e fo
r tas
k sh
iftin
g or
resp
onsi
bilit
y sh
arin
g be
twee
n di
ffere
nt p
rofe
ssio
nal c
adre
s (M
OV-
docu
men
ted
prot
ocol
)
Yes
No
2.2
The
heal
th fa
cilit
y m
aint
ains
an
upda
ted
reco
rd o
f all
staf
f.
Faci
lity
has
an
up to
dat
e pe
rson
nel f
ile t
hat
cont
ains
the
follo
win
g a
t a
min
imum
:
Re
gistr
atio
n w
ith re
leva
nt p
rofe
ssio
nal
bodi
es.
(MO
V-pe
rson
nel f
ile w
ith li
sted
doc
umen
ts.
Sam
ple
5 fil
es)
Yes
No
P
Re
leva
nt a
cade
mic
cer
tific
ates
(M
OV-
pers
onne
l file
with
list
ed d
ocum
ents.
Sa
mpl
e 5
files
)
Yes
No
P
Cu
rren
t cur
ricul
um v
itae
(MO
V-pe
rson
nel f
ile w
ith li
sted
doc
umen
ts.
Sam
ple
5 fil
es)
Yes
No
P
Le
tters
of a
ppoi
ntm
ent
(MO
V-pe
rson
nel f
ile w
ith li
sted
doc
umen
ts.
Sam
ple
5 fil
es)
Yes
No
P
20 |
Pa
ge
St
anda
rd
Requ
irem
ents
Sc
ore
(tic
k ap
prop
riat
e bo
x)
Rem
arks
Si
gned
job
desc
riptio
n (M
OV-
pers
onne
l file
with
list
ed d
ocum
ents.
Sa
mpl
e 5
files
)
Yes
No
P
2.3
The
heal
th fa
cilit
y im
plem
ents
staf
f pe
rfor
man
ce a
ppra
isal
.
Man
agem
ent s
taff
hav
e si
gned
thei
r ann
ual
perf
orm
ance
con
tract
s (M
OV-
HR
reco
rds f
or
upda
ted
perfo
rman
ce c
ontr
acts)
Yes
No
P
Staf
f app
raise
d at
leas
t onc
e in
a y
ear (
MO
V-pe
rson
nel f
ile w
ith a
ppra
isal
doc
umen
ts)
Yes
No
P
Reco
mm
enda
tions
of t
he a
ppra
isals
impl
emen
ted
by th
e H
R (M
OV-
docu
men
ted
actio
ns o
n re
com
men
datio
ns)
Yes
No
P
2.4
Faci
lity
staf
f eng
ages
in
cont
inuo
us m
edic
al
educ
atio
n.
Faci
lity
impl
emen
ts a
cont
inuo
us m
edic
al
educ
atio
n pr
ogra
mm
e (M
OV-
HR
reco
rds a
nd
sche
dule
and
file
with
min
utes
on
CME
sess
ions
)
Yes
No
All
staff
who
pro
vide
dire
ct p
atie
nt c
are
have
re
ceiv
ed tr
aini
ng in
bas
ic c
ardi
opul
mon
ary
resu
scita
tion
and
the
train
ing
is re
peat
ed a
t lea
st
ever
y tw
o ye
ars
(MO
V- H
R re
cord
s)
Yes
No
P
21 |
Pa
ge
St
anda
rd
Requ
irem
ents
Sc
ore
(tic
k ap
prop
riat
e bo
x)
Rem
arks
2.5
Faci
lity
has s
taff
m
otiv
atio
n pr
ogra
mm
e
Faci
lity
has a
syste
m fo
r rec
ogni
tion
and/
or
rew
ards
of h
igh
achi
ever
s (M
OV-
Adm
inis
tratio
n re
cord
s)
Yes
No
Team
bui
ldin
g ac
tivity
car
ried
out a
t lea
st on
ce
per y
ear
(MO
V-Ad
min
istra
tion
reco
rds)
Yes
No
Mot
ivat
ion
plan
com
mun
icat
ed to
all
staf
f (M
OV-
HR
reco
rds)
Y
es
N
o
2.6
Ther
e sh
all b
e an
in
duct
ion
into
serv
ice
prog
ram
me
for
all n
ew
staf
f.
Ther
e is
an in
duct
ion
sche
dule
for a
ll th
e ne
w
staff
. In
duct
ion
to in
clud
e bu
t not
lim
ited
to
the
orga
niza
tiona
l stru
ctur
e, w
ork
area
, sta
ff
faci
litie
s, he
alth
& sa
fety
requ
irem
ents
and
oc
cupa
tiona
l haz
ards
(M
OV-
docu
men
ted
sche
dule
)
Yes
No
P
Indu
ctio
n re
port
coun
ters
igne
d by
new
staf
f an
d by
the
desig
nate
d st
aff i
n th
e va
rious
de
partm
ents
with
in th
e he
alth
faci
lity
(MO
V-In
duct
ion
repo
rts fi
led
in th
e sta
ff fil
es)
Yes
No
P
2.7
The
heal
th fa
cilit
y sh
all
allo
cate
fund
s for
trai
ning
of
staf
f as i
nfor
med
by
capa
city
nee
ds
Ann
ual t
rain
ing
need
s ass
essm
ent c
ondu
cted
an
d do
cum
ente
d
(MO
V-Tr
aini
ng n
eeds
ass
essm
ent f
or th
e cu
rren
t cal
enda
r or f
inan
cial
yea
r)
Yes
No
Coste
d tra
inin
g sc
hedu
le in
pla
ce
(MO
V-tra
inin
g sc
hedu
le)
Yes
No
22 |
Pa
ge
St
anda
rd
Requ
irem
ents
Sc
ore
(tic
k ap
prop
riat
e bo
x)
Rem
arks
Budg
et a
lloca
ted
for t
rain
ing
(MO
V-ad
min
istra
tion
reco
rds)
Y
es
N
o
2.8
The
heal
th fa
cilit
y ha
s in
pla
ce a
mec
hani
sm fo
r kn
owle
dge
man
agem
ent.
The
faci
lity
has a
doc
umen
ted
proc
edur
e fo
r sh
arin
g of
new
kno
wle
dge
whi
ch in
clud
es
sche
dule
of k
now
ledg
e m
anag
emen
t act
iviti
es
incl
udin
g fe
edba
ck fr
om tr
aini
ng, c
onfe
renc
e re
ports
, lea
rnin
g se
ssio
ns
(MO
V-do
cum
ente
d pr
oced
ure)
Yes
No
P
2.9
The
faci
lity
prov
ides
in
tern
ship
pro
gram
me
in
acco
rdan
ce to
MO
H a
nd
othe
r re
leva
nt g
uide
lines
Ther
e is
evid
ence
of a
ppro
val o
f the
hea
lth
faci
lity
to a
ct a
s an
inte
rnsh
ip c
entre
(M
OV-
Doc
umen
ted
appr
oval
)
Yes
No
NA
Ther
e is
a do
cum
ente
d M
oU b
etw
een
the
heal
th
faci
lity
and
train
ing
insti
tutio
n on
inte
rnsh
ip
prog
ram
s (M
OV-
Doc
umen
ted
appr
oval
)
Yes
No
NA
Ther
e ar
e do
cum
ente
d gu
idel
ines
for i
nter
ns,
stude
nts a
nd re
gistr
ars o
n at
tach
men
t (M
OV-
HR
reco
rds)
Yes
No
NA
Ther
e is
an u
p to
dat
e re
giste
r for
inte
rns a
nd
stude
nts
(MO
V- H
R re
cord
s)
Yes
No
NA
2.10
Sta
ff sa
tisfa
ctio
n sh
all
be a
sses
sed
and
mon
itore
d.
The
faci
lity
asse
ss a
nd m
onito
r job
satis
fact
ion
(M
OV-
Sta
ff sa
tisfa
ctio
n re
port)
Y
es
N
o
23 |
Pa
ge
D
imen
sion
3: P
olic
ies,
Stan
dard
s and
Gui
delin
es
Stan
dard
Re
quir
emen
ts
Scor
e (t
ick
appr
opri
ate
box)
R
emar
ks
3.1
Hea
lth c
are
faci
lity
shal
l alig
n th
eir
oper
atio
ns
with
cur
rent
Hea
lth A
ct,
Ken
ya H
ealth
Pol
icy
and
the
Ken
ya H
ealth
Sec
tor
Stra
tegi
c Pl
an.
The
oper
atio
n pl
an fo
r the
hea
lth fa
cilit
y is
alig
ned
to th
e cu
rren
t Hea
lth A
ct, K
enya
Hea
lth
Polic
y an
d K
HSS
P (M
OV-
Cur
rent
ann
ual
oper
atio
nal p
lan
and
obje
ctiv
es)
Yes
No
3.2
Hea
lth fa
cilit
ies s
hall,
at
the
min
imum
, hav
e th
e re
leva
nt p
olic
y an
d st
rate
gic
docu
men
ts
avai
labl
e on
site
(
The
faci
lity
has i
n pl
ace
all k
ey p
olic
y do
cum
ents
and
stra
tegi
c pl
an in
clud
ing
but n
ot
limite
d to
the
follo
win
g:
(MO
V- c
onfir
m a
vaila
bilit
y of
doc
umen
ts o
r in
tern
et a
cces
s)
Cu
rren
t Ken
ya H
ealth
Pol
icy
Yes
No
Cu
rren
t K
enya
Hea
lth S
ecto
r Stra
tegi
c an
d In
vestm
ent P
lan
Yes
No
H
uman
Res
ourc
es
Nor
ms a
nd S
tand
ards
Y
es
N
o
In
fras
truct
ure
Nor
ms a
nd S
tand
ards
Y
es
N
o
Pr
evio
us y
ear’
s ann
ual p
erfo
rman
ce
repo
rt(s)
Yes
No
24 |
Pa
ge
St
anda
rd
Requ
irem
ents
Sc
ore
(tic
k ap
prop
riat
e bo
x)
Rem
arks
3.3
A m
anag
emen
t sys
tem
sh
all b
e in
pla
ce fo
r th
e im
plem
enta
tion
and
regu
lar
revi
ew o
f sta
ndar
d op
erat
ing
proc
edur
es
SOPs
stra
tegi
cally
disp
laye
d
(MO
V-SO
Ps i
n ea
ch se
rvic
e de
liver
y ar
ea)
Yes
No
P
Evid
ence
that
stan
dard
ope
ratin
g pr
oced
ures
an
d ar
e re
view
ed a
t lea
st on
ce a
yea
r (M
OV-
SO
P wi
th d
ate
of u
pdat
e di
spla
yed)
Yes
No
P
3.4
Sta
ff m
embe
rs a
re
regu
larl
y up
date
d on
the
curr
ent p
olic
ies,
stan
dard
s an
d gu
idel
ines
Ther
e is
a do
cum
ente
d pl
an fo
r upd
atin
g sta
ff
on th
e cu
rren
t pol
icie
s, st
anda
rds a
nd g
uide
line
(MO
V-do
cum
ente
d pl
an )
Yes
No
3.5
Faci
lity
shal
l ens
ure
the
avai
labi
lity
of st
anda
rd
clin
ical
trea
tmen
t gu
idel
ines
.
The
faci
lity
has r
elev
ant s
tand
ard
clin
ical
tre
atm
ent g
uide
lines
. (M
OV-
con
firm
phy
sical
or v
irtu
al a
cces
s)
Yes
No
Use
and
adh
eren
ce to
gui
delin
es is
mon
itore
d.
(MO
V-m
onito
ring
repo
rt)
Yes
No
25 |
Pa
ge
D
imen
sion
4: F
acili
ties a
nd In
fras
truc
ture
Stan
dard
R
equi
rem
ents
Sc
ore
(tick
app
ropr
iate
bo
x)
Rem
arks
4.1
The
hea
lth fa
cilit
y sh
all b
e pl
anne
d, m
anag
ed,
and
com
ply
with
the
appl
icab
le g
uide
lines
, po
licie
s, ga
zett
e no
tices
an
d re
gula
tions
.
The
desi
gn o
f the
faci
lity
is ap
prov
ed b
y th
e re
leva
nt a
utho
ritie
s.
(MO
V-Ap
prov
al o
f des
ign)
Yes
No
The
desi
gn o
f the
faci
lity
com
plie
s with
th
e in
frastr
uctu
re n
orm
s and
stan
dard
s. (M
OV-
Che
cklis
t for
ass
essi
ng a
nd
mon
itorin
g in
fras
truct
ure)
Yes
No
4.2
Phys
ical
faci
litie
s and
Env
iron
men
tal c
ondi
tions
4.2.
1 T
he h
ealth
faci
lity
layo
ut sh
all p
rovi
de
adeq
uate
spac
e fo
r qu
ality
he
alth
serv
ice
deliv
ery,
w
hile
ens
urin
g sa
fety
of
pers
onne
l, pa
tient
s and
vi
sito
rs.
-The
faci
lity
layo
ut is
app
ropr
iate
for
deliv
erin
g he
alth
serv
ices
. (M
OV-
sam
ple
1 ou
tpat
ient
and
2 in
patie
nt
serv
ice
area
s)
Yes
No
P
The
serv
ice
deliv
ery
room
s are
wel
l ve
ntila
ted.
(M
OV-
sam
ple
1 ou
tpat
ient
and
2 in
patie
nt
serv
ice
area
)
Yes
No
The
serv
ice
deliv
ery
room
s are
wel
l lit.
(M
OV-
sam
ple
1 ou
tpat
ient
and
2 in
patie
nt
serv
ice
area
)
Yes
No
26 |
Pa
ge
St
anda
rd
Req
uire
men
ts
Scor
e (ti
ck a
ppro
pria
te
box)
Re
mar
ks
The
serv
ice
deliv
ery
room
s hav
e th
e re
quire
d eq
uipm
ent
(MO
V- sa
mpl
e 1
outp
atie
nt a
nd 2
inpa
tient
se
rvic
e ar
ea)
Yes
No
The
serv
ice
deliv
ery
room
s hav
e ha
nd
hygi
ene
faci
litie
s (M
OV-
sam
ple
1 ou
tpat
ient
and
2 in
patie
nt
serv
ice
area
)
Yes
No
p
The
faci
lity
has a
n ac
cess
ibili
ty ra
mp
for
disa
bled
/whe
elch
air p
atie
nts
(MO
V-ob
serv
atio
n)
Yes
No
4.2.
2 E
nvir
onm
ent
mon
itori
ng sh
all b
e do
ne
in a
ll re
leva
nt a
reas
.
Envi
ronm
enta
l mon
itorin
g do
ne in
all
rele
vant
are
as fo
r th
e fo
llow
ing
(MO
V-M
onito
ring
log
shee
ts, o
bser
vatio
n)
Hum
idity
Y
es
N
o
P
Ligh
t
Y
es
N
o
P
27 |
Pa
ge
St
anda
rd
Req
uire
men
ts
Scor
e (ti
ck a
ppro
pria
te
box)
Re
mar
ks
Elec
trica
l sup
ply
Yes
No
P
Tem
pera
ture
Y
es
N
o
P
Soun
d
Y
es
N
o
P
Vib
ratio
ns
Yes
No
P
Ther
e is
evid
ence
of c
orre
ctiv
e ac
tion
on
oppo
rtuni
ties i
dent
ified
for i
mpr
ovem
ent
in th
e fo
llow
ing
area
s (M
OV-
Doc
umen
ted
plan
s for
cor
rect
ive
mea
sure
s)
Hum
idity
Y
es
N
o
P
Ligh
t
Y
es
N
o
P
28 |
Pa
ge
St
anda
rd
Req
uire
men
ts
Scor
e (ti
ck a
ppro
pria
te
box)
Re
mar
ks
Elec
trica
l sup
ply
Yes
No
P
Tem
pera
ture
Y
es
N
o
P
Soun
d
Y
es
N
o
P
Vib
ratio
ns
Yes
No
P
4. 3
San
itatio
n an
d H
ygie
ne
4.3.
1 T
he h
ealth
faci
lity
infr
astr
uctu
re sh
all b
e de
sign
ed, c
onst
ruct
ed a
nd
mai
ntai
ned
to fa
cilit
ate
prop
er c
lean
ing
and
drai
nage
, inf
ectio
n pr
even
tion
and
cont
rol a
nd
pest
, rod
ents
and
sc
aven
ger
cont
rol
The
faci
lity
mai
ntai
ns sm
ooth
surf
aces
th
roug
hout
to fa
cilit
ate
clea
ning
(M
OV-
obse
rvat
ion
of e
vide
nce
of sm
ooth
su
rfac
es)
Yes
No
P
Des
ign,
con
struc
tion
and
mai
nten
ance
of
the
heal
th fa
cilit
y al
low
s fas
t dra
inag
e of
w
ater
in si
nks,
was
h ba
sins,
ablu
tion
and
laun
dry
area
(MO
V-- i
nter
view
m
aint
enan
ce st
aff a
nd o
bser
vatio
n )
Yes
No
P
29 |
Pa
ge
St
anda
rd
Req
uire
men
ts
Scor
e (ti
ck a
ppro
pria
te
box)
Re
mar
ks
Mai
nten
ance
of t
he h
ealth
faci
lity
aids
co
ntro
l of p
ests,
rode
nts a
nd sc
aven
gers
(M
OV-
inte
rvie
w pu
blic
hea
lth st
aff a
nd
obse
rvat
ion)
Yes
No
4.3.
2 Fa
cilit
y sh
all e
nsur
e th
ere
is a
dequ
ate
safe
ru
nnin
g w
ater
at a
ll tim
es
Rel
iabl
e so
urce
s of s
afe
runn
ing
wat
er
(MO
V- o
bser
vatio
n)
Yes
No
4.4
Man
agem
ent o
f was
te a
nd h
azar
dous
mat
eria
ls
4.4.
1 T
he h
ealth
faci
lity
shal
l im
plem
ent m
easu
res
on u
se, h
andl
ing,
stor
age
and
disp
osal
of h
azar
dous
m
ater
ials
and
was
te.
Safe
loca
tion
for h
azar
dous
mat
eria
ls a
nd
was
tes
(MO
V-ph
ysic
al fa
cilit
y or
con
trac
t for
ou
tsour
ced
serv
ices
)
Yes
No
Labe
lling
of h
azar
dous
mat
eria
ls an
d w
aste
s (M
OV-
obse
rvat
ion)
Yes
No
Acc
ess t
o ce
rtifie
d in
cine
rato
r (M
OV
-Inte
rvie
w w
ith st
aff)
Y
es
N
o
Dis
posa
l pro
toco
ls in
pla
ce
(MO
V- d
ispos
al p
roto
cols
)
Yes
No
30 |
Pa
ge
St
anda
rd
Req
uire
men
ts
Scor
e (ti
ck a
ppro
pria
te
box)
Re
mar
ks
Faci
lity
repo
rts in
cide
nts t
o al
low
co
rrec
tive
actio
ns (M
OV-
per
iodi
c re
port
s)
Yes
No
The
faci
lity
has c
ompe
tent
per
sonn
el
resp
onsib
le fo
r was
te d
ispo
sal
(MO
V-de
sign
ated
offi
cer w
ith te
rms o
f re
fere
nce
or c
ontra
ct in
cas
e of
out
sour
ced
serv
ices
)
Yes
No
4.5
Ligh
ting
and
secu
rity
4.5.
1 T
he h
ealth
faci
lity
shal
l hav
e a
relia
ble
and
stab
le p
ower
supp
ly.
The
faci
lity
has a
relia
ble
and
stabl
e po
wer
su
pply
(MO
V-ob
serv
atio
n )
Yes
No
The
faci
lity
has a
pow
er b
ack-
up
(MO
V-ev
iden
ce o
f fun
ctio
nal a
nd
serv
icea
ble
pow
er b
ack-
up e
quip
men
t)
Yes
No
4.5.
2 T
he h
ealth
faci
lity
shal
l hav
e ad
equa
te
prec
autio
ns to
ens
ure
the
secu
rity
of i
ts p
rem
ises
, st
aff,
patie
nts a
nd v
isito
rs
The
faci
lity
has a
doc
umen
ted
secu
rity
plan
(MO
V-D
ocum
ente
d se
curit
y pl
an
Yes
No
Faci
lity
impl
emen
ts th
e se
curit
y pl
an
(MO
V- fe
ncin
g, se
curit
y gu
ards
, met
allic
gr
ills i
n re
leva
nt a
reas
, sec
ure
lock
s)
Yes
No
31 |
Pa
ge
St
anda
rd
Req
uire
men
ts
Scor
e (ti
ck a
ppro
pria
te
box)
Re
mar
ks
4.6
Disa
ster
Man
agem
ent,
Em
erge
ncy
prep
ared
ness
, and
risk
re
duct
ion
4.6.
1 T
he h
ealth
faci
lity
shal
l hav
e in
pla
ce
mea
sure
s to
faci
litat
e em
erge
ncy
prep
ared
ness
, di
sast
er m
anag
emen
t and
ri
sk r
educ
tion.
Trai
ning
pro
gram
s on
em
erge
ncy
prep
ared
ness
, disa
ster m
anag
emen
t and
ris
k re
duct
ion
(MO
V-H
R re
cord
s)
Yes
No
Stan
dard
ope
ratin
g pr
oced
ures
on
emer
genc
y pr
epar
edne
ss, d
isast
er
man
agem
ent a
nd ri
sk re
duct
ion
(MO
V-SO
P)
Yes
No
Fire
, saf
ety
and
secu
rity
drill
s (M
OV-
dril
ls sc
hedu
le a
nd re
port)
Y
es
N
o
Emer
genc
y ex
its a
nd fi
re a
ssem
bly
poin
ts
(MO
V-O
bser
vatio
n)
Yes
No
Fire
fight
ing
equi
pmen
t
(MO
V-O
bser
vatio
n)
Yes
No
Firs
t aid
kits
(M
OV-
Obs
erva
tion)
Y
es
N
o
The
faci
lity
has p
erso
nnel
resp
onsi
ble
for
emer
genc
y pr
epar
edne
ss, d
isast
er
man
agem
ent a
nd ri
sk re
duct
ion
(MO
V-H
R re
cord
s)
Yes
No
32 |
Pa
ge
St
anda
rd
Req
uire
men
ts
Scor
e (ti
ck a
ppro
pria
te
box)
Re
mar
ks
4.7
Stor
age
faci
litie
s
Th
e he
alth
faci
lity
shal
l pr
ovid
e fo
r ad
equa
te
stor
age
spac
e an
d co
nditi
ons t
hat m
aint
ain
the
qual
ity o
f mat
eria
l st
ored
ther
ein.
The
heal
th fa
cilit
y ha
s ade
quat
e sto
rage
sp
ace
(MO
V-ob
serv
atio
n)
Yes
No
The
stor
age
spac
e is
orga
nize
d to
allo
w fo
r fir
st ex
piry
firs
t out
(M
OV-
Bin
card
s and
obs
erva
tion)
Yes
No
The
stor
age
spac
e ha
s the
righ
t en
viro
nmen
tal c
ondi
tions
(tem
pera
ture
and
hu
mid
ity)
(MO
V-te
mpe
ratu
re a
nd h
umid
ity
mon
itorin
g ch
arts
as a
pplic
able
)
Yes
No
4.8
Am
eniti
es
4.8
The
heal
th fa
cilit
y ha
s am
eniti
es fo
r st
aff a
nd
clie
nts
Ava
ilabi
lity
of c
hang
ing
room
s for
staf
f (M
OV-
obse
rvat
ion)
Y
es
N
o
Ava
ilabi
lity
of st
aff l
oung
e (M
OV-
obse
rvat
ion)
Y
es
N
o
Ade
quat
e sto
rage
for s
taff
's pe
rson
al
poss
essio
ns (M
OV-
obse
rvat
ion)
Y
es
N
o
Ava
ilabi
lity
of sa
fe d
rinki
ng w
ater
(M
OV-
inte
rvie
w sta
ff)
Yes
No
33 |
Pa
ge
St
anda
rd
Req
uire
men
ts
Scor
e (ti
ck a
ppro
pria
te
box)
Re
mar
ks
Cle
an a
nd fu
nctio
nal t
oile
ts a
re a
vaila
ble
for s
taff
and
clie
nts
(MO
V-ob
serv
atio
n)
Yes
No
The
faci
lity
has a
blut
ion
serv
ices
for t
he
disa
bled
(MO
V-ob
serv
atio
n)
Yes
No
4.9
Lin
en a
nd la
undr
y se
rvic
es
4.9
The
faci
lity
linen
and
la
undr
y se
rvic
es a
re
oper
ated
acc
ordi
ng to
do
cum
ente
d pr
oced
ure.
The
faci
lity
has a
pro
toco
l for
laun
dry
and
linen
serv
ices
whi
ch c
over
s:
C
olle
ctio
n an
d sto
rage
of
cont
amin
ated
line
n
Cle
anin
g of
con
tam
inat
ed li
nen
St
orag
e an
d di
strib
utio
n of
cle
an li
nen
(MO
V-Li
nen
and
laun
dry
prot
ocol
)
Yes
No
Ther
e is
at le
ast o
ne fu
nctio
ning
, ful
ly
auto
mat
ic w
ashi
ng m
achi
ne (M
OV-
Obs
erva
tion)
Yes
No
All
laun
dry
wor
kers
are
trai
ned
(M
OV-
HR
reco
rds)
Y
es
N
o
Th
e sp
ace
in th
e la
undr
y is
adeq
uate
for
calc
ulat
ed o
r est
imat
ed d
ry w
eigh
t of
artic
les t
o be
pro
cess
ed a
nd th
e ty
pe o
f w
ashi
ng e
quip
men
t. (M
OV-
obse
rvat
ion)
Yes
No
34 |
Pa
ge
St
anda
rd
Req
uire
men
ts
Scor
e (ti
ck a
ppro
pria
te
box)
Re
mar
ks
4.10
Hea
lth fa
cilit
y m
aint
enan
ce
4.10
The
hea
lthca
re fa
cilit
y in
fras
truc
ture
shal
l be
mai
ntai
ned
in a
func
tiona
l co
nditi
on.
The
faci
lity
has a
mai
nten
ance
uni
t with
tra
ined
staf
f/ ac
cess
to m
aint
enan
ce
serv
ices
(M
OV-
HR
reco
rds)
Yes
No
The
faci
lity
has a
cos
ted
rout
ine
and
perio
dic
mai
nten
ance
pla
n (M
OV-
Mai
nten
ance
pla
n)
Yes
No
The
faci
lity
impl
emen
ts th
e ro
utin
e an
d pe
riodi
c m
aint
enan
ce p
lans
(MO
V-Re
ports
of
cor
rect
ive
actio
ns, u
p to
dat
e se
rvic
e or
se
rvic
e co
ntra
cts f
or o
utso
urce
d se
rvic
es)
Yes
No
4.11
Impl
emen
tatio
n of
5S
The
faci
lity
shal
l im
plem
ent 5
S in
all
its
depa
rtm
ents
All
staff
hav
e be
en tr
aine
d on
5S
(MO
V-Tr
aini
ng lo
g sh
eet)
Yes
No
P
Faci
lity
impl
emen
ts 5S
in a
ll its
de
partm
ents
(MO
V-O
bser
vatio
n,
impl
emen
tatio
n re
ports
)
Yes
No
P
Impl
emen
tatio
n of
5S
mon
itore
d an
d ev
alua
ted
(MO
V- 5
S au
dit r
epor
ts)
Yes
No
35 |
Pa
ge
D
imen
sion
5: S
uppl
ies M
anag
emen
t
Stan
dard
R
equi
rem
ents
Sc
ore
(tic
k ap
prop
riat
e bo
x)
Rem
arks
5.1
Plan
ning
for
proc
urem
ent
App
rove
d pl
ans f
or
proc
urem
ent o
f goo
ds a
nd
serv
ices
are
ava
ilabl
e an
d in
corp
orat
ed in
the
faci
lity
budg
et.
The
faci
lity
has a
n ap
prov
ed p
rocu
rem
ent
plan
(MO
V-D
ocum
ente
d pl
an fo
r cur
rent
fin
anci
al/c
alen
dar y
ear,
min
utes
)
Yes
No
The
proc
urem
ent p
lan
is in
corp
orat
ed in
th
e fa
cilit
y bu
dget
. (M
OV-
Appr
oved
bud
get)
Yes
No
5.2
Preq
ualif
icat
ion
of su
pplie
rs
Preq
ualif
icat
ion
of
supp
liers
shal
l be
done
in
line
with
gui
delin
es a
nd
regu
latio
ns.
The
faci
lity
carr
ies o
ut th
e pr
equa
lific
atio
n of
supp
liers
(M
OV-
List
of p
re-q
ualif
ied
supp
liers
/ven
dors
, lic
ence
s of s
uppl
ies)
Yes
No
The
faci
lity
eval
uate
s per
form
ance
of
supp
liers
ann
ually
(MO
V- M
inut
es o
f ev
alua
tion
mee
tings
)
Yes
No
36 |
Pa
ge
St
anda
rd
Requ
irem
ents
Sc
ore
(tic
k ap
prop
riate
bo
x)
Rem
arks
5.3
Proc
edur
e fo
r pr
ocur
emen
t
Ther
e sh
all b
e a
docu
men
ted
proc
edur
e fo
r or
deri
ng, r
ecep
tion
and
stor
age
of g
oods
and
se
rvic
es.
The
faci
lity
has
qua
lifie
d pe
rson
nel
desig
nate
d to
han
dle
proc
urem
ent
(MO
V-H
R re
cord
s)
Yes
No
An
inve
ntor
y m
anag
emen
t sys
tem
is in
pl
ace
(M
OV-
conf
irm fo
r pap
er b
ased
or
elec
tron
ic sy
stem
)
Yes
No
Spec
ifica
tions
for a
ll pr
oduc
ts an
d se
rvic
es to
be
proc
ured
are
in p
lace
(M
OV-
List/
log
shee
t of s
peci
ficat
ions
)
Yes
No
P
The
inve
ntor
y re
cord
s are
up
to d
ate
(M
OV-
Inve
ntor
y bo
ok)
Yes
No
P
Goo
ds st
ored
acc
ordi
ng to
man
ufac
ture
r’s
spec
ifica
tion
(MO
V-sa
mpl
e 3
item
s eac
h fro
m p
harm
acy
store
s, la
bora
tory
, ge
nera
l sto
re a
nd fo
od st
ore)
Yes
No
P
37 |
Pa
ge
D
imen
sion
6: E
quip
men
t Man
agem
ent
Stan
dard
R
equi
rem
ents
Sc
ore
(tic
k ap
prop
riate
bo
x)
Rem
arks
6.1
The
heal
th fa
cilit
y sh
all
have
ade
quat
e eq
uipm
ent
as p
er sc
ope
of se
rvic
e.
The
faci
lity
has a
def
ined
list
of e
quip
men
t an
d qu
antit
ies r
equi
red
to p
rovi
de e
ach
of
the
serv
ices
off
ered
(M
OV-
File
with
list
of e
quip
men
t)
Yes
No
The
faci
lity
has a
dequ
ate
num
ber o
f fu
nctio
nal e
quip
men
t as p
er th
e sc
ope
of
serv
ice
(M
OV-
Sam
ple
thre
e se
rvic
e de
liver
y ar
eas
one
for r
outin
e ou
tpat
ient
car
e, su
ppor
t se
rvic
es a
nd in
patie
nt c
are)
Yes
No
The
faci
lity
verif
ies t
hat u
pon
insta
llatio
n an
d be
fore
use
, equ
ipm
ent i
s cap
able
of
achi
evin
g th
e ne
cess
ary
perf
orm
ance
and
co
mpl
ies w
ith re
leva
nt re
quire
men
ts.
(MO
V- R
ecor
ds o
f ins
talla
tion,
reco
rds o
f va
lidat
ion
and
verif
icat
ion)
Yes
No
6.2
Ther
e sh
all b
e an
up
date
d in
vent
ory
for
all
equi
pmen
t in
the
faci
lity.
The
faci
lity
has a
n up
date
d in
vent
ory
of a
ll eq
uipm
ent w
hich
shou
ld in
clud
e:
(MO
V-Eq
uipm
ent i
nven
tory
boo
k or
log
shee
t)
Id
entit
y of
equ
ipm
ent
Yes
No
38 |
Pa
ge
St
anda
rd
Req
uire
men
ts
Scor
e (t
ick
appr
opria
te
box)
Re
mar
ks
M
anuf
actu
rer ‘
s nam
e, m
odel
and
se
rial n
umbe
r or o
ther
uni
que
num
ber
Yes
No
C
onta
ct in
form
atio
n fo
r the
supp
lier o
r m
anuf
actu
rer
Yes
No
D
ate
of r
ecei
ving
and
insta
llatio
n at
fa
cilit
y
Yes
No
Lo
catio
n
Y
es
N
o
C
ondi
tion
whe
n re
ceiv
ed
Yes
No
A
ccep
tanc
e te
stin
g re
ports
Y
es
N
o
Pr
even
tive
mai
nten
ance
reco
rds
Yes
No
Se
rvic
e re
cord
s
Y
es
N
o
39 |
Pa
ge
St
anda
rd
Req
uire
men
ts
Scor
e (t
ick
appr
opria
te
box)
R
emar
ks
6.3.
Don
ated
equ
ipm
ent
rece
ived
by
the
faci
lity
shal
l mee
t the
nat
iona
l po
licy,
stan
dard
s and
fa
cilit
y sp
ecifi
catio
ns
The
faci
lity
has a
cces
s to
Nat
iona
l Pol
icy
on
hand
ling
of d
onat
ed e
quip
men
t (M
OV-
avai
labi
lity
of th
e po
licy)
Yes
No
The
faci
lity
has s
tand
ard
oper
atio
n pr
oced
ures
fo
r rec
eivi
ng d
onat
ed e
quip
men
t alig
ned
to
natio
nal p
olic
y, st
anda
rds a
nd fa
cilit
y sp
ecifi
catio
n
(MO
V- a
vaila
bilit
y of
SO
P)
Yes
No
6.4
All
equi
pmen
t sha
ll be
op
erat
ed b
y tr
aine
d an
d au
thor
ized
per
sonn
el.
The
faci
lity
equi
pmen
t is o
pera
ted
by tr
aine
d an
d au
thor
ised
pers
onne
l (M
OV
-HR
reco
rds)
Yes
No
P
6.5
Ope
ratio
n m
anua
ls on
th
e us
e, sa
fety
and
m
aint
enan
ce o
f equ
ipm
ent
are
avai
labl
e.
All
equi
pmen
t hav
e op
erat
ion
man
uals/
SOPs
fo
r use
, saf
ety
and
mai
nten
ance
. (M
OV
– m
anua
ls av
aila
ble
on si
te)
Yes
No
p
Equi
pmen
t ope
ratio
n m
anua
ls ar
e in
a
lang
uage
that
is u
nder
stood
by
user
s (M
OV
– ob
serv
atio
n of
man
uals)
Yes
No
P
6.6
All
equi
pmen
t sha
ll be
m
aint
aine
d in
a fu
nctio
nal
Ther
e is
a p
reve
ntiv
e an
d pe
riodi
c m
aint
enan
ce p
lan
for a
ll eq
uipm
ent i
n th
e fa
cilit
y (M
OV-
Mai
nten
ance
pla
n)
Yes
No
40 |
Pa
ge
St
anda
rd
Req
uire
men
ts
Scor
e (t
ick
appr
opria
te
box)
R
emar
ks
cond
ition
. A
ll eq
uipm
ent m
onito
red
in a
ccor
danc
e w
ith
the
man
ufac
ture
rs’ s
peci
ficat
ions
and
ap
plic
able
stan
dard
s (M
OV-
Sam
ple
one
equi
pmen
t fro
m th
e su
ppor
t ser
vice
s)
Yes
No
P
The
faci
lity
has d
esig
nate
d pe
rson
nel f
or
equi
pmen
t mai
nten
ance
or
serv
ice
cont
ract
s fo
r mai
nten
ance
with
supp
liers
/man
ufac
ture
rs
(MO
V- e
vide
nce
of d
esig
natio
n or
con
tract
fo
r out
sour
ced
serv
ices
)
Yes
No
Ther
e is
a sy
stem
for c
alib
ratio
n an
d va
lidat
ion
of e
quip
men
t (M
OV-
Qua
lity
assu
ranc
e lo
g sh
eets/
repo
rts)
Yes
No
6.7
Disp
osal
of e
quip
men
t
6.7
Ther
e sh
all b
e a
proc
edur
e fo
r di
spos
al o
f ob
sole
te e
quip
men
t in
line
with
cur
rent
reg
ulat
ion
The
faci
lity
has a
pro
cedu
re fo
r the
disp
osal
of
obs
olet
e eq
uipm
ent
(MO
V-S
OPs
)
Yes
No
The
disp
osal
is d
one
in a
ccor
danc
e w
ith th
e gu
idel
ines
and
regu
latio
ns (M
OV-
Inte
rvie
w
staf
f res
pons
ible
equ
ipm
ent d
ispos
al)
Yes
No
41 |
Pa
ge
D
imen
sion
7: T
rans
port
and
Fle
et M
anag
emen
t
Stan
dard
Re
quir
emen
ts
Scor
e (t
ick
appr
opria
te b
ox)
Rem
arks
7.1
The
heal
th fa
cilit
y sh
all h
ave
acce
ss to
ade
quat
e an
d re
liabl
e tr
ansp
ort f
acili
ties t
o su
ppor
t saf
e an
d ef
fect
ive
serv
ice
prov
isio
n.
The
faci
lity
has a
cces
s to
adeq
uate
num
ber o
f ut
ility
veh
icle
s (M
OV-
feed
back
from
adm
inist
ratio
n)
Yes
No
Ther
e is
suff
icie
nt b
udge
t allo
catio
n fo
r tra
nspo
rt (M
OV-
Faci
lity
plan
with
app
rove
d bu
dget
for
trans
port
, int
ervi
ew w
ith st
aff)
Yes
No
7.2
The
faci
lity
shal
l mai
ntai
n al
l m
eans
of t
rans
port
in a
serv
icea
ble
cond
ition
The
faci
lity
has p
roto
cols
for t
he m
aint
enan
ce o
f m
eans
of t
rans
port
(whe
re a
pplic
able
) (M
OV-
avai
labi
lity
of p
roto
cols
)
Yes
No
N
/A
Serv
ice
sche
dule
s and
mai
nten
ance
reco
rds a
re
avai
labl
e an
d up
-to-d
ate
(MO
V- se
rvic
es sc
hedu
les a
nd m
aint
enan
ce
reco
rds)
Yes
No
P
NA
7.3
Ther
e is
a d
ocum
ente
d ha
ndov
er p
roce
ss fo
r al
l veh
icle
s.
Ther
e is
docu
men
ted
SOP
for t
he h
ando
ver o
f all
mea
ns o
f tra
nspo
rt
(MO
V-SO
P av
aila
ble)
Yes
No
NA
Evid
ence
of i
mpl
emen
tatio
n of
han
dove
r SO
Ps
(MO
V- h
ando
ver r
ecor
ds)
Yes
No
NA
42 |
Pa
ge
D
imen
sion
8: R
efer
ral S
yste
m
Stan
dard
Re
quire
men
ts
Scor
e (ti
ck a
ppro
pria
te
box)
R
emar
ks
8.1
The
faci
lity
shal
l en
sure
that
ref
erra
l gu
idel
ines
and
SO
Ps a
re
avai
labl
e an
d co
mm
unic
ated
to th
e re
leva
nt st
aff
Nat
iona
l Ref
erra
l Gui
delin
es a
re a
vaila
ble
and
acce
ssib
le to
rele
vant
staf
f (M
OV-
con
firm
ava
ilabi
lity/
acce
ssib
ility
to
the
guid
elin
es)
Yes
No
Faci
lity
refe
rral
SO
Ps a
vaila
ble
and
acce
ssib
le to
staf
f (M
OV-
SOP
avai
labl
e)
Yes
No
8.2.
The
hea
lth fa
cilit
y sh
all e
nsur
e th
at p
atie
nts
are
refe
rred
in a
tim
ely
man
ner
to th
e ap
prop
riat
e he
alth
faci
lity
or sp
ecia
list,
whi
le
ensu
ring
con
tinui
ty o
f ca
re a
nd p
atie
nt sa
fety
.
Patie
nts r
efer
red
with
in th
e tim
e se
t in
the
serv
ice
char
ter
(MO
V- In
terv
iew
resp
onsi
ble
staff,
file
s of
last
5 re
ferr
als)
Yes
No
P
The
faci
lity
has a
cces
s to
stan
dard
am
bula
nce
serv
ices
at a
ll tim
es (M
OV-
Obs
erve
for
avai
labi
lity
of a
mbu
lanc
es/ s
ervi
ce c
ontr
acts
)
Yes
No
Faci
lity
ensu
res a
com
pete
nt st
aff m
embe
r ac
com
pani
es p
atie
nt d
urin
g re
ferr
al (M
OV-
Refe
rral
sche
dule
/SO
Ps c
lear
ly d
ispla
yed
at
serv
ice
deliv
ery
area
s)
Yes
No
Ther
e is
evi
denc
e th
at p
atie
nts a
re re
ferr
ed to
th
e ap
prop
riate
hea
lth fa
cilit
y/sp
ecia
list
(MO
V- r
efer
ral r
egis
ter)
Yes
No
Ther
e is
con
tinui
ty o
f car
e/ li
fe su
ppor
t for
th
e pa
tient
whi
le in
tran
sit
(MO
V- S
OPs
/ Int
ervi
ew re
spon
sibl
e sta
ff)
Yes
No
43 |
Pa
ge
St
anda
rd
Requ
irem
ents
Sc
ore
(tick
app
ropr
iate
bo
x)
Rem
arks
8.3
The
refe
rrin
g fa
cilit
y ef
fect
ivel
y co
mm
unic
ates
w
ith th
e re
ceiv
ing
faci
lity.
The
faci
lity
prov
ides
roun
d-th
e-cl
ock
func
tiona
l and
eff
ectiv
e ho
tline
serv
ice
man
aged
by
com
pete
nt p
erso
nnel
con
vers
ant
with
the
man
agem
ent o
f ref
erra
ls. (
MO
V-ca
ll th
e ho
tline
to c
onfir
m fu
nctio
nalit
y)
Yes
No
Refe
rred
pat
ient
s are
acc
ompa
nied
with
dul
y fil
led
refe
rral
doc
umen
ts c
onta
inin
g at
a
min
imum
wor
king
dia
gnos
is, i
nves
tigat
ions
do
ne, a
ny o
ther
car
e pr
ovid
ed (M
OV-
sam
ple
refe
rral
doc
umen
ts)
Yes
No
P
Faci
lity
keep
s ref
erra
l rec
ords
as p
er th
e N
atio
nal R
efer
ral S
trate
gy (M
OV-
refe
rral
re
gist
er)
Yes
No
Feed
back
is p
rovi
ded
to th
e re
ferr
ing
faci
lity
(MO
V-Q
uart
erly
refe
rral
repo
rts)
Y
es
N
o
Cont
acts
deta
ils o
f fac
ilitie
s and
spec
ialis
ts to
w
hich
pat
ient
s are
refe
rred
are
ava
ilabl
e
(MO
V- D
ocum
ent w
ith e
mai
ls ad
dres
ses,
tele
phon
e an
d ph
ysic
al a
ddre
sses
)
Yes
No
8.4
The
heal
th fa
cilit
y sh
all f
ollo
w a
doc
umen
ted
proc
edur
e fo
r ha
ndov
er
of r
efer
red
patie
nts
The
heal
th fa
cilit
y ha
s a d
ocum
ente
d pr
oced
ure
for r
ecei
ving
refe
rred
pat
ient
s. Th
is in
clud
es b
ut is
not
lim
ited
to:
(MO
V-D
ocum
ente
d pr
otoc
ols a
nd
obse
rvat
ion
)
Loca
tion
for r
ecei
ving
refe
rred
pat
ient
s
Yes
No
44 |
Pa
ge
St
anda
rd
Requ
irem
ents
Sc
ore
(tick
app
ropr
iate
bo
x)
Rem
arks
Patie
nt a
dmis
sion
to th
e re
leva
nt u
nit a
nd
atte
ndan
ce b
y ap
prop
riate
spec
ialis
t
Y
es
N
o
Invo
lvem
ent o
f pat
ient
s and
thei
r esc
orts
in
hand
over
pro
cess
es
Yes
No
P
8.5
Dat
a on
re
ferr
als/
tran
sfer
s is
colle
cted
and
use
d to
co
ntin
uous
ly im
prov
e pa
tient
car
e an
d st
reng
then
the
refe
rral
sy
stem
.
The
faci
lity
colle
cts,
anal
yses
and
use
s the
da
ta to
con
tinuo
usly
impr
ove
patie
nt c
are
and
stren
gthe
n th
e re
ferr
al sy
stem
(M
OV-
refe
rral
aud
it, a
nd m
inut
es fr
om
HM
T di
scus
sing
refe
rral
dat
a)
Yes
No
45 |
Pa
ge
D
imen
sion
9: H
ealth
Rec
ords
and
Hea
lth M
anag
emen
t Inf
orm
atio
n Sy
stem
s
Stan
dard
R
equi
rem
ents
Sc
ore
(tick
app
ropr
iate
bo
x)
Rem
arks
9.1
The
heal
th fa
cilit
y sh
all
have
a sy
stem
for
data
m
anag
emen
t
The
heal
th fa
cilit
y ha
s dat
a co
llect
ion
tool
s (M
OV-
Obs
erve
at t
he re
cord
s uni
t and
on
e se
rvic
e de
liver
y ar
ea)
Yes
No
The
heal
th fa
cilit
y ha
s per
iodi
c da
ta
anal
ysis
repo
rts (M
OV-
File
d re
port
s)
Yes
No
Res
ults
of a
naly
sis a
re d
isse
min
ated
to
faci
lity
staf
f for
dec
ision
-mak
ing
(MO
V-Fi
led
repo
rts)
Yes
No
Faci
lity
has a
dequ
ate
data
stor
age
equi
pmen
t (Cl
oud,
com
pute
rs,
hard
copy
file
s) (M
OV-
obs
erva
tion
and
disc
ussio
n wi
th re
spon
sibl
e st
aff)
Yes
No
The
heal
th fa
cilit
y ha
s def
ined
acc
ess
right
s for
ele
ctro
nic
data
man
agem
ent
syst
ems (
adm
inist
rativ
e pa
ssw
ords
) (M
OV-
Doc
umen
ted
prot
ocol
s)
Yes
No
The
heal
th fa
cilit
y ha
s a sy
stem
for o
ff-si
te b
acku
p an
d se
curit
y
(MO
V- F
eedb
ack
from
reco
rds
depa
rtmen
t)
Yes
No
46 |
Pa
ge
St
anda
rd
Req
uire
men
ts
Scor
e (ti
ck a
ppro
pria
te
box)
Re
mar
ks
9.
2 Th
e he
alth
faci
lity
shal
l up
load
dat
a on
the
DH
IS
as p
er le
gal r
equi
rem
ents
.
The
faci
lity
has m
ore
than
one
staf
f m
embe
r with
acc
ess r
ight
s to
uplo
ad
data
ont
o D
HIS
(M
OV-
user
nam
es a
nd p
assw
ords
of
HM
T m
embe
rs)
Yes
No
P
N
A
The
faci
lity
uplo
ads s
ervi
ce d
eliv
ery
repo
rts d
efin
ed in
the
natio
nal D
HIS
m
anua
l (M
OV-
con
firm
dat
a up
load
ont
o D
HIS
)
Yes
No
P
9.3
Patie
nt m
anag
emen
t an
d in
terv
entio
ns sh
all b
e do
cum
ente
d an
d si
gned
by
rele
vant
per
sonn
el.
The
heal
th fa
cilit
y ha
s a a
def
ined
m
inim
um c
riter
ia o
f pat
ient
his
tory
and
ex
amin
atio
n (M
OV-
docu
men
ted
crite
ria)
Yes
No
All
treat
men
ts ar
e do
cum
ente
d an
d si
gned
by
rele
vant
per
sonn
el
(MO
V- sa
mpl
e 5
patie
nt fi
les)
Yes
No
P
Patie
nts’
reco
rds c
onta
in in
form
atio
n on
dia
gnos
is, t
reat
men
t, an
d fo
llow
-up
step
s (M
OV-
sam
ple
5 pa
tient
file
s)
Yes
No
9.4
Patie
nts r
ecor
ds sh
all
have
min
imum
id
entif
icat
ion
data
.
Patie
nts i
dent
ifica
tion
data
inc
lude
at
leas
t the
fol
low
ing:
(M
OV-
Sam
ple
5 pa
tient
s rec
ords
)
N
ame
Yes
No
47 |
Pa
ge
St
anda
rd
Req
uire
men
ts
Scor
e (ti
ck a
ppro
pria
te
box)
Re
mar
ks
U
niqu
e pa
tient
iden
tific
atio
n
Y
es
N
o
Pa
tient
s ID
num
ber (
whe
re
appl
icab
le)
Yes
No
D
ate
of b
irth/
age
Y
es
N
o
Se
x
Y
es
N
o
R
esid
ence
Y
es
N
o
C
onta
cts
Yes
No
N
ext o
f kin
Y
es
N
o
9.5
Med
ical
rec
ords
shal
l co
ntai
n co
mpl
ete,
legi
ble
and
easi
ly tr
acea
ble
info
rmat
ion.
All
med
ical
reco
rds a
re c
ompl
ete
and
legi
ble
(MO
V-Sa
mpl
e 5
patie
nt re
cord
s fro
m
outp
atie
nt a
nd in
patie
nt)
Yes
No
P
Med
ical
reco
rds a
re re
triev
able
with
in
the
timef
ram
e st
ipul
ated
in th
e se
rvic
e ch
arte
r (M
OV-
Feed
back
from
HR
depa
rtmen
t/ ob
serv
atio
n)
Yes
No
48 |
Pa
ge
St
anda
rd
Req
uire
men
ts
Scor
e (ti
ck a
ppro
pria
te
box)
Re
mar
ks
9.
6 R
ecor
ds a
nd
info
rmat
ion
shal
l be
prot
ecte
d fr
om lo
ss,
dest
ruct
ion,
tam
peri
ng a
nd
unau
thor
ized
acc
ess o
r us
e.
Ther
e ar
e gu
idel
ines
/SO
Ps fo
r op
erat
ing
the
regi
stry
to e
nsur
e th
ere
is no
loss
, des
truct
ion,
tam
perin
g an
d un
auth
oriz
ed a
cces
s to
reco
rds a
nd
info
rmat
ion
(MO
V- S
OP,
file
mov
emen
t reg
ister
)
Yes
No
P
Faci
lity
has a
secu
re re
gistr
y
(MO
V-lo
ckab
le d
oors
, gril
ls, f
irep
roof
ca
bine
ts, p
assw
ords
for e
lect
roni
c sy
stem
s)
Yes
No
Patie
nt re
cord
s are
han
dled
in a
co
nfid
entia
l man
ner
(MO
V- a
ll sta
ff ha
ve fi
lled
conf
iden
tialit
y fo
rms)
Yes
No
P
9.7
All
birt
hs a
nd d
eath
s oc
curr
ing
in h
ealth
faci
lity
are
reco
rded
and
rel
evan
t au
thor
ities
not
ified
.
Ther
e is
an u
p to
dat
e bi
rth re
giste
r/ (M
OV-
regi
ster/
notif
icat
ion
book
)
Y
es
N
o
Ther
e is
an u
p to
dat
e de
ath
regi
ster
(MO
V-re
giste
r, no
tific
atio
n bo
ok/
buria
l per
mit)
Yes
No
49 |
Pa
ge
D
imen
sion
10:
Fin
anci
al M
anag
emen
t
Stan
dard
Re
quir
emen
ts
Scor
e (ti
ck a
ppro
pria
te
box)
R
emar
ks
10
.1 T
he fa
cilit
y sh
all
man
age
its fi
nanc
es b
ased
on
pol
icie
s and
/or
stan
dard
op
erat
ing
proc
edur
es
The
heal
th fa
cilit
y ha
s sta
ndar
d op
erat
ing
proc
edur
es to
gui
de fi
nanc
ial m
anag
emen
t (M
OV-
Doc
umen
t)
☐Y
es
☐
No
Dut
ies a
re a
ppro
pria
tely
segr
egat
ed so
that
no
tran
sact
ion
is ha
ndle
d by
one
fina
nce
team
mem
ber f
rom
star
t to
com
plet
ion
(MO
V-Fi
nanc
ial m
anag
emen
t pro
toco
ls)
☐Y
es
☐
No
☐
P
Bank
acc
ount
s man
aged
onl
y on
the
stren
gth
of m
anag
emen
t boa
rd/c
omm
ittee
re
solu
tion
(MO
V-Fi
nanc
ial m
anag
emen
t pr
otoc
ols)
☐Y
es
☐
No
☐
P
The
faci
lity
carr
ies o
ut a
nnua
l int
erna
l au
dits
(MO
V- a
udit
repo
rts)
☐Y
es
☐
No
☐
P
The
faci
lity
carr
ies o
ut a
nnua
l ext
erna
l au
dits
(MO
V- a
udit
repo
rts)
☐Y
es
☐
No
☐
P
10.2
The
faci
lity
shal
l bu
dget
for
finan
ces i
n lin
e w
ith th
e st
rate
gic
and
annu
al w
ork
plan
s.
Budg
ets a
ligne
d to
the
faci
lity’
s ann
ual
wor
k pl
an a
nd st
rate
gic
plan
(M
OV-
Faci
lity’
s ope
ratio
nal p
lan
with
bu
dget
)
☐Y
es
☐
No
☐
P
Budg
ets a
ppro
ved
by th
e m
anag
emen
t boa
rd
(MO
V- R
elev
ant m
inut
es o
f boa
rd m
eetin
g)
Yes
No
50 |
Pa
ge
St
anda
rd
Requ
irem
ents
Sc
ore
(tick
app
ropr
iate
bo
x)
Rem
arks
The
heal
th fa
cilit
y ha
s a d
esig
nate
d bu
dget
fo
r im
plem
entin
g qu
ality
impr
ovem
ent
inte
rven
tions
with
in th
e an
nual
wor
k pl
an
(MO
V- B
udge
t)
Yes
No
P
10.3
The
faci
lity
shal
l m
aint
ain
finan
cial
rec
ords
to
allo
w fo
r co
ntin
uous
m
onito
ring
of i
ncom
e an
d ex
pend
iture
in r
elat
ion
to
perf
orm
ance
dat
a
The
faci
lity
mon
itors
its i
ncom
e an
d ex
pend
iture
in re
latio
n to
per
form
ance
dat
a (M
OV-
min
utes
of m
eetin
gs w
here
m
onito
ring
info
rmat
ion
is di
scus
sed)
Yes
No
10.4
The
hea
lth fa
cilit
y sh
all h
ave
mec
hani
sms f
or
cred
it m
anag
emen
t/wai
ver
and
exem
ptio
n fr
om
paym
ent f
or p
atie
nts w
ho
are
not a
ble
to p
ay fo
r se
rvic
es
Ther
e is
a do
cum
ente
d pr
oced
ure
for c
redi
t m
onito
ring/
wai
ver
(MO
V- a
vaila
bilit
y of
wai
ver d
ocum
ent)
Yes
No
Ther
e is
a do
cum
ente
d pr
oced
ure
for
exem
ptio
ns
(MO
V- a
vaila
bilit
y of
exe
mpt
ions
doc
umen
t)
Yes
No
51 |
Pa
ge
D
IMEN
SIO
N 1
1: P
RO
CES
SES
Each
faci
lity
impl
emen
ting
the
KQ
MH
stan
dard
s will
end
eavo
ur to
impr
ove
all p
roce
sses
with
in it
s ope
ratio
ns in
the
spiri
t of c
ontin
uous
qua
lity
impr
ovem
ent.
This
shal
l inv
olve
syst
emat
ic id
entif
icat
ion
of p
roce
ss(s
) or a
rea(
s) fo
r im
prov
emen
t; pl
anni
ng a
nd ta
rget
setti
ng fo
r im
prov
emen
t; im
plem
enta
tion
of im
prov
emen
t ini
tiativ
e; m
onito
ring
of im
prov
emen
t; an
d ev
alua
tion
of in
itiat
ives
. Thi
s sec
tion
iden
tifie
s the
cor
e ar
eas r
equi
red
to
addr
ess c
urre
nt p
ress
ing
chal
leng
es in
qua
lity
of c
are
with
in K
enya
n he
alth
faci
litie
s.
11.1
Out
patie
nt S
ervi
ces
Stan
dard
Re
quire
men
t Sc
ore
(tic
k of
f the
ap
prop
riat
e bo
x)
Rem
arks
11.1
.1 T
he fa
cilit
y sh
all p
lan
and
impl
emen
t out
patie
nt se
rvic
es in
line
with
MO
H p
olic
ies a
nd st
rate
gies
11
.1.1
.1 A
ll pa
tient
s car
ed
for b
y th
e he
alth
faci
litie
s ha
ve th
eir h
ealth
car
e ne
eds
iden
tifie
d th
roug
h an
as
sess
men
t pro
cess
that
has
be
en d
efin
ed b
y th
e ho
spita
l
The
min
imum
requ
irem
ents
of h
istor
y ta
king
and
phy
sica
l exa
min
atio
n of
pat
ient
s is
defin
ed fo
r eac
h cl
inic
al
disc
iplin
e(M
OV
- SO
Ps)
Yes
No
P
Ava
ilabi
lity
of v
ital s
igns
obs
erva
tion
tool
s, at
min
imum
, the
rmom
eter
and
blo
od
pres
sure
mac
hine
s
Yes
No
P
Ava
ilabi
lity
of p
atie
nt e
xam
inat
ion
tool
s, at
m
inim
um, s
teth
osco
pe a
nd d
iagn
ostic
kits
Y
es
N
o
P
Faci
lity
take
s vita
l sig
ns fo
r all
patie
nts
(M
OV-
Sam
ple
5 pa
tient
cas
e fil
es)
Yes
No
P
11.1
.1.2
The
faci
lity
prov
ides
he
alth
edu
catio
n th
at
The
hosp
ital p
lans
edu
catio
n co
nsist
ent
with
its m
issio
n, se
rvic
es, a
nd p
atie
nt
Yes
No
52 |
Pa
ge
St
anda
rd
Requ
irem
ent
Scor
e (t
ick
off t
he
appr
opri
ate
box)
R
emar
ks
supp
orts
patie
nt a
nd fa
mily
pa
rtici
patio
n in
thei
r car
e de
cisio
ns a
nd c
are
proc
esse
s.
popu
latio
n.
(MO
V-Sc
hedu
le w
ith to
pics
)
P
Ther
e is
an e
stabl
ishe
d st
ruct
ure
for h
ealth
ed
ucat
ion
thro
ugho
ut th
e ho
spita
l. (M
OV-
Sche
dule
with
topi
cs)
Yes
No
P
11.1
.1.3
The
faci
lity
shal
l es
tabl
ish n
utrit
ion
plan
s and
pr
oced
ures
to e
nsur
e th
e pr
ovisi
on o
f com
preh
ensi
ve
nutri
tion
serv
ices
.
Nut
ritio
n as
sess
men
t car
ried
out f
or a
ll pa
tient
s (M
OV-
Sam
ple
5 pa
tient
file
s)
Yes
No
P
Nut
ritio
n as
sess
men
t too
ls av
aila
ble,
at a
m
inim
um, M
UA
C ta
pes,
BM
I cal
cula
tor,
wei
ght/h
eigh
t boa
rd
(MO
V-O
bser
vatio
n)
Yes
No
P
Nut
ritio
n co
unse
lling
serv
ices
off
ered
to a
ll pa
tient
s (M
OV-
Sam
ple
5 pa
tient
file
s)
Yes
No
P
Ava
ilabi
lity
of su
pple
men
tary
and
th
erap
eutic
feed
s e.g
. FM
75,
100
and
Pl
umpy
Nut
(MO
V- O
bser
vatio
n)
Yes
No
P
Mic
ronu
trien
t sup
plem
ents
pro
vide
d as
per
pa
tient
cat
egor
izat
ion
e.g.
iron
, fol
ate,
V
itam
in A
, Zin
c
(MO
V-Sa
mpl
e 5
patie
nt c
ase
files
)
Yes
No
P
N
utrit
ion
serv
ices
pro
vide
d by
qua
lifie
d sta
ff (
MO
V- H
R re
cord
s)
Yes
No
P
53 |
Pa
ge
St
anda
rd
Requ
irem
ent
Scor
e (t
ick
off t
he
appr
opri
ate
box)
R
emar
ks
11.1
.1.4
The
faci
lity
shal
l es
tabl
ish p
roce
dure
s to
ensu
re th
e pr
ovisi
on o
f pr
imar
y im
mun
izat
ion
serv
ices
.
Ava
ilabi
lity
of a
ll K
EPI v
acci
nes
(MO
V- O
bser
vatio
n of
inve
ntor
y; st
ock-
outs
of a
ny a
ntig
ens i
n th
e pr
eced
ing
90
days
)
Yes
No
P
Cold
cha
in fa
cilit
ies a
re a
vaila
ble
(M
OV-
Obs
erve
mon
itorin
g ch
arts
and
vacc
ine
vial
mon
itor)
Yes
No
P
Imm
uniz
atio
n se
rvic
es p
rovi
ded
on a
dai
ly
basis
from
Mon
day
to F
riday
(M
OV-
Che
ck im
mun
izat
ion
regi
ster
)
Yes
No
P
11.1
.1.5
The
faci
lity
shal
l es
tabl
ish p
roce
dure
s to
ensu
re th
e pr
ovisi
on o
f co
mpr
ehen
sive
em
erge
ncy
se
rvic
es.
Ava
ilabi
lity
of e
mer
genc
y tra
y w
ith
esse
ntia
l res
usci
tatio
n dr
ugs
(MO
V- o
bser
vatio
n)
Yes
No
P
Ava
ilabi
lity
of re
susc
itatio
n eq
uipm
ent,
at a
m
inim
um, a
mbu
bag,
sutu
re p
ack
(MO
V- o
bser
vatio
n)
Yes
No
P
Ava
ilabi
lity
of st
aff t
rain
ed o
n ba
sic li
fe
supp
ort
(MO
V-H
R Re
cord
s)
Yes
No
P
Resp
onse
tim
e fo
r all
emer
genc
y ca
ses i
s de
fined
and
adh
ered
to
(MO
V- e
mer
genc
y re
spon
se p
roto
col;
sam
ple
5pat
ient
file
s)
Yes
No
P
54 |
Pa
ge
St
anda
rd
Requ
irem
ent
Scor
e (t
ick
off t
he
appr
opri
ate
box)
R
emar
ks
Resu
scita
tion
drill
s car
ried
out f
or a
ll cl
inic
al st
aff,
at le
ast o
nce
ever
y qu
arte
r (M
OV-
Dril
ls p
lan
and
repo
rt)
Yes
No
P
11.1
.1.6
The
faci
lity
shal
l pr
ovid
e co
mpr
ehen
sive
m
anag
emen
t of l
ocal
ly
ende
mic
con
ditio
ns
Faci
lity
oper
ates
dai
ly a
t des
igna
ted
times
in
acc
orda
nce
with
leve
l of c
are
(MO
V-pa
tient
serv
ice
char
ter)
Yes
No
P
Faci
lity
follo
ws p
roto
cols
and
gui
delin
es
for d
iagn
osis
of e
ndem
ic c
ondi
tions
(M
OV-
SO
P; S
ampl
e 5
patie
nt c
ase
files
)
Yes
No
P
Faci
lity
follo
ws p
roto
cols
and
gui
delin
es
for t
reat
men
t of e
ndem
ic c
ondi
tions
(M
OV-
SO
P; S
ampl
e 5
patie
nt c
ase
files
co
nsid
erin
g di
seas
e pr
ofile
of t
he a
rea
wher
e fa
cilit
y is
loca
ted)
Yes
No
P
Refe
rral
pro
toco
ls av
aila
ble
(M
OV-
Obs
erva
tion)
Y
es
N
o
P
11.1
.1.7
The
faci
lity
shal
l pr
ovid
e hi
gh q
ualit
y m
ater
nal
heal
th a
nd fa
mily
pla
nnin
g se
rvic
es.
Com
plet
e ph
ysic
al e
xam
inat
ion
is ca
rrie
d ou
t for
all
preg
nant
wom
en se
ekin
g A
NC
serv
ices
. (M
OV-
ANC
regi
ster
)
Yes
No
P
AN
C pr
ofile
for a
ll an
tena
tal m
othe
rs
perf
orm
ed a
nd re
view
ed.
(MO
V- S
ampl
e 5
patie
nt re
cord
s)
Yes
No
P
55 |
Pa
ge
St
anda
rd
Requ
irem
ent
Scor
e (t
ick
off t
he
appr
opri
ate
box)
R
emar
ks
The
faci
lity
prov
ides
indi
vidu
aliz
ed c
are
to
all a
nten
atal
mot
hers
bas
ed o
n ph
ysic
al,
labo
rato
ry a
nd o
ther
dia
gnos
tic
exam
inat
ions
. (M
OV-
Sam
ple
5 pa
tient
reco
rds)
Yes
No
P
Ava
ilabi
lity
of b
oth
shor
t and
long
act
ing
met
hods
of f
amily
pla
nnin
g
(MO
V-FP
regi
ster
; inv
ento
ry)
Yes
No
P
Post
nata
l car
e pr
ovid
ed to
all
mot
hers
and
ne
w-b
orns
for a
t lea
st 24
hou
rs b
efor
e di
scha
rge
(M
OV-
Post
nata
l ser
vice
regi
ster
)
Yes
No
P
Ava
ilabi
lity
of c
ervi
cal c
ance
r scr
eeni
ng
serv
ices
(M
OV-
Cer
vica
l can
cer s
cree
ning
regi
ster
)
Yes
No
P
11.1
.2 T
he fa
cilit
y ha
s a
mec
hani
sm in
pla
ce to
in
volv
e th
e co
mm
unity
in
serv
ice
prov
isio
n
Faci
lity
incl
udes
com
mun
ity p
artic
ipan
ts in
re
leva
nt c
omm
ittee
s (M
OV-
Min
utes
, man
agem
ent f
iles f
or
com
mitt
ee c
onsti
tutio
n)
Yes
No
P
Ther
e is
a fe
edba
ck m
echa
nism
to a
ddre
ss
com
plai
nts a
nd su
gges
tions
from
the
com
mun
ity
(MO
V-re
port
s)
Yes
No
P
11.1
.3 T
he fa
cilit
y ha
s a
syst
em fo
r pr
even
tion,
co
ntro
l and
surv
eilla
nce
of
loca
lly e
ndem
ic c
ondi
tions
The
faci
lity
cond
ucts
surv
eilla
nce
of
dise
ases
of p
ublic
hea
lth im
porta
nce
acco
rdin
g to
MO
H re
com
men
datio
ns
(MO
V- m
onth
ly su
rvei
llanc
e re
ports
)
Yes
No
P
56 |
Pa
ge
St
anda
rd
Requ
irem
ent
Scor
e (t
ick
off t
he
appr
opri
ate
box)
R
emar
ks
Prot
ocol
s for
man
agem
ent o
f dise
ase
outb
reak
s are
ava
ilabl
e an
d in
use
(M
OV-
Prot
ocol
s)
Yes
No
P
Wat
er sa
mpl
es a
re c
olle
cted
from
co
mm
unity
wat
er so
urce
s per
iodi
cally
for
bact
erio
logi
cal a
nd c
hem
ical
ana
lysis
, an
alys
ed a
nd re
ports
giv
en to
aut
horit
ies
and
the
com
mun
ity.
(MO
V- R
epor
ts)
Yes
No
P
57 |
Pa
ge
11
.2 P
atie
nt C
entr
ed C
are
Stan
dard
Re
quir
emen
ts
Scor
e (t
ick
appr
opri
ate
box)
R
emar
ks
11.2
.1.T
he fa
cilit
y sh
all
have
a m
echa
nism
to
prot
ect t
he p
atie
nt’s
rig
hts
Patie
nt ri
ghts
char
ter d
ispl
ayed
co
nspi
cuou
sly
in w
aitin
g ar
eas.
(M
OV-
Obs
erva
tion)
Yes
No
Regu
lar s
ensi
tizat
ion
of p
atie
nts o
n th
eir
right
s (M
OV-
sche
dule
/rec
ord)
Y
es
N
o
Patie
nts s
ign
cons
ent f
orm
s for
med
ical
pr
oced
ures
whe
re re
quire
d (M
OV-
Sam
ple
5 pa
tient
file
s)
Yes
No
P
Faci
lity
assu
res t
hat p
atie
nts g
et fu
ll ra
nge
of se
rvic
es re
gard
less
of t
heir
relig
ious
, ec
onom
ic o
r soc
ial s
tatu
s (M
OV-
pro
toco
l in
plac
e)
Yes
No
P
11.2
.2 H
ealth
car
e pr
ovid
ers i
n th
e fa
cilit
y sh
all e
mpo
wer
and
ena
ble
patie
nts/
clie
nts t
o ac
tivel
y pa
rtic
ipat
e in
thei
r ca
re
proc
esse
s.
All
serv
ice
prov
ider
s wea
r tag
s with
nam
e an
d de
sign
atio
n vi
sible
to p
atie
nts a
t all
times
(MO
V- o
bser
vatio
n n
ame
and
desig
natio
n ta
gs)
Yes
No
P
Cost
of se
rvic
es a
nd a
ny in
sura
nce
reba
tes
that
app
ly to
the
patie
nt a
re d
ispla
yed
or
avai
labl
e to
the
patie
nt.
(MO
V-ob
serv
atio
n)
Yes
No
P
Patie
nts a
re fu
lly in
form
ed o
n ris
ks a
nd
bene
fits o
f car
e gi
ven
and
a w
ritte
n co
nsen
t ob
tain
ed fr
om th
e pa
tient
(M
OV-
Con
sent
form
s)
Yes
No
P
58 |
Pa
ge
St
anda
rd
Requ
irem
ents
Sc
ore
(tic
k ap
prop
riat
e bo
x)
Rem
arks
The
patie
nt a
nd n
ext o
f kin
are
supp
orte
d to
co
pe w
ith d
ebili
tatin
g ef
fect
s of
illne
ss/d
isabi
lity
(MO
V-Co
unse
lling
faci
litie
s, pr
ayer
room
s, re
ferr
al o
ptio
ns to
app
ropr
iate
faci
litie
s)
Yes
No
P
Dig
nity
and
priv
acy
in re
latio
n to
pat
ient
s’
care
and
supp
ort i
s pro
vide
d (M
OV-
pat
ient
sc
reen
s, lo
ckab
le d
oors
)
Yes
No
P
Ther
e is
linka
ge to
soci
al a
nd c
omm
unity
ne
twor
ks fo
r pat
ient
supp
ort a
nd c
are
(M
OV-
List
/inve
ntor
y of
supp
ort
grou
ps/n
etwo
rks)
Yes
No
P
11.2
.3 T
he v
iew
s of
patie
nts/
clie
nts a
nd th
eir
leve
l of s
atisf
actio
n sh
all b
e as
sess
ed
The
faci
lity
asse
sses
clie
nts’
vie
ws a
nd le
vel
of sa
tisfa
ctio
n at
leas
t onc
e ev
ery
four
m
onth
s (M
OV-
clie
nt sa
tisfa
ctio
n re
port)
Yes
No
P
Reco
mm
enda
tions
are
act
ed u
pon
in
impr
ovem
ent p
lans
. (M
OV-
pro
gres
s rep
ort)
Yes
No
P
11.2
.4 T
he fa
cilit
y sh
all
prov
ide
a m
echa
nism
for
clie
nt/p
atie
nt fe
edba
ck
The
faci
lity
prov
ides
a c
ompl
aint
and
co
mpl
imen
ts b
ox/ b
ook
(MO
V-ev
iden
ce o
f ana
lysis
of f
eedb
ack
resu
lts)
Yes
No
A te
leph
one
num
ber f
or p
atie
nts t
o pr
ovid
e fe
edba
ck th
roug
h is
disp
laye
d.
(MO
V-O
bser
vatio
n)
Yes
No
Clie
nt fe
edba
ck a
naly
sed
and
acte
d up
on
(MO
V- p
rogr
ess/
stat
us re
port)
Y
es
N
o
59 |
Pa
ge
St
anda
rd
Requ
irem
ents
Sc
ore
(tic
k ap
prop
riat
e bo
x)
Rem
arks
11.2
.5 T
he fa
cilit
y sh
all
prov
ide
amen
ities
for
patie
nts a
nd v
isito
rs w
ith
disa
bilit
ies
The
faci
lity
has p
roto
cols
to fo
llow
whe
n de
alin
g w
ith p
atie
nts w
ith v
isual
and
he
arin
g im
pairm
ents
(M
OV-
Doc
umen
ted
prot
ocol
s, av
aila
bilit
y of
trai
ned
pers
onne
l, sig
nage
)
Yes
No
P
The
faci
lity
has p
rovi
sion
for e
ase
of
mov
emen
t for
the
phys
ical
ly h
andi
capp
ed
Yes
N
o
P
11.2
.6 T
he fa
cilit
y im
plem
ents
a m
echa
nism
to
impr
ove
accu
racy
of
patie
nt id
entif
icat
ion.
Patie
nts a
re id
entif
ied
usin
g at
leas
t tw
o id
entif
iers
(M
OV-
Prot
ocol
in p
lace
; sam
ple
5 pa
tient
fil
es)
Yes
No
P
Each
pat
ient
is p
rovi
ded
a w
ristb
and
with
un
ique
iden
tifie
r (M
OV-
Obs
erve
for a
rmba
nd w
ith u
niqu
e id
entif
ier)
Yes
No
P
The
sam
e id
entif
icat
ion
is c
onsis
tent
ly u
sed
thro
ugho
ut th
e ca
re p
roce
ss
(MO
V-Sa
mpl
e 5
patie
nt fi
les)
Yes
No
P
Patie
nts a
re id
entif
ied
befo
re p
rovi
ding
tre
atm
ents
and
proc
edur
es
(MO
V-Pr
otoc
ol in
pla
ce; s
ampl
e 5
patie
nt
files
)
Yes
No
P
Patie
nts a
re id
entif
ied
befo
re a
ny d
iagn
ostic
pr
oced
ures
(M
OV-
Prot
ocol
in p
lace
)
Yes
No
P
The
faci
lity
is im
plem
entin
g a
syst
em o
f rep
ortin
g, in
vest
igat
ion
Yes
No
60 |
Pa
ge
St
anda
rd
Requ
irem
ents
Sc
ore
(tic
k ap
prop
riat
e bo
x)
Rem
arks
and
chan
ge m
anag
emen
t to
resp
ond
to
any
patie
nt c
are
mis
mat
chin
g ev
ents
(M
OV-
Doc
umen
tatio
n of
this
syste
m,
rele
vant
repo
rts)
P
11.2
.7 T
here
shal
l be
a pa
in m
anag
emen
t pro
toco
l as
per
leve
l of p
atie
nt c
are
Pain
man
agem
ent p
roto
cols
are
avai
labl
e (M
OV-
Obs
erva
tion)
Y
es
N
o
The
faci
lity
impl
emen
ts
proc
esse
s for
add
ress
ing
the
patie
nt's
need
s for
ap
prop
riate
ass
essm
ent a
nd
man
agem
ent o
f pai
n.
(MO
V- sa
mpl
e cl
inic
al n
otes
)
Yes
No
P
11.2
.8 T
he fa
cilit
y sh
all
have
a p
roce
dure
for
the
care
of t
erm
inal
ly il
l pa
tient
s
Faci
lity
prov
ides
indi
vidu
aliz
ed p
lan
for
palli
ativ
e ca
re o
f the
term
inal
ly il
l pat
ient
(M
OV-
Ava
ilabi
lity
of p
allia
tive
care
pla
n)
Yes
No
P
11.2
.9 T
he fa
cilit
y sh
all
prov
ide
for
resp
ectf
ul c
are
of th
e de
ceas
ed
Ther
e is
use
of w
ritte
n pr
oced
ures
for
hand
ling
case
s of b
erea
vem
ent,
per
form
ing
cultu
rally
app
ropr
iate
last
off
ices
, han
dlin
g of
the
body
and
han
dove
r to
fune
ral s
ervi
ces
or la
st ri
tes a
s app
ropr
iate
(MO
V-SO
P)
Yes
No
P
Ther
e is
debr
iefin
g an
d su
ppor
t sup
ervi
sion
for c
are
prov
ider
s to
cope
with
stre
ssfu
l en
coun
ters
/situ
atio
ns (M
OV-
SO
P, in
terv
iew
with
hea
lth p
rovi
ders
)
Yes
No
P
Faci
lity
prov
ides
for s
tand
ardi
zed,
do
cum
ente
d pr
oced
ures
on
emba
lmin
g,
auto
psie
s, is
suan
ce o
f bur
ial p
erm
it as
ap
prop
riate
(MO
V- d
ocum
ente
d pr
oced
ure)
Yes
No
P
61 |
Pa
ge
11
.3 In
fect
ion
Prev
entio
n an
d C
ontr
ol
Stan
dard
Re
quir
emen
ts
Scor
e (t
ick
appr
opria
te
box)
Re
mar
ks
11.3
.1 T
he h
ealth
faci
lity
shal
l hav
e in
pla
ce a
n in
fect
ion
prev
entio
n an
d co
ntro
l gov
erna
nce
stru
ctur
e as
per
the
natio
nal p
olic
y an
d gu
idel
ines
A m
ultid
isci
plin
ary
IPC
com
mitt
ee/ u
nit i
n pl
ace,
with
term
s of r
efer
ence
(M
OV-
M
inut
es o
f mon
thly
mee
tings
, clin
ical
repo
rts,
appo
intm
ent l
ette
rs fo
r com
mitt
ee m
embe
rs)
Yes
No
11.3
.2 T
he h
ealth
faci
lity
shal
l ens
ure
infe
ctio
n pr
even
tion
and
cont
rol
prac
tice
is in
acc
orda
nce
with
the
appr
oved
gu
idel
ines
and
pol
icie
s
A p
lan
in p
lace
to c
ontin
uous
ly u
pdat
e st
aff
know
ledg
e on
infe
ctio
n pr
even
tion
and
cont
rol p
ract
ices
(MO
V- W
ork
plan
s, tr
aini
ng
sche
dule
s, cl
inic
al a
udit
sche
dule
)
Yes
No
P
The
faci
lity
carr
ies o
ut q
uarte
rly a
udits
on
IPC
to su
ppor
t im
plem
enta
tion
and
adhe
renc
e to
IPC
stan
dard
pre
caut
ions
. The
repo
rt sh
ould
incl
ude
the
follo
win
g ar
eas:
(MO
V-
Audi
t rep
orts)
Han
d hy
gien
e
Y
es
N
o
P
Was
te m
anag
emen
t
Y
es
N
o
P
Resp
irato
ry h
ygie
ne
Yes
No
P
62 |
Pa
ge
St
anda
rd
Requ
irem
ents
Sc
ore
(tic
k ap
prop
riate
bo
x)
Rem
arks
Occ
upat
iona
l exp
osur
e m
anag
emen
t
Y
es
N
o
P
Pers
onal
pro
tect
ive
equi
pmen
t
Y
es
N
o
P
Care
of l
inen
Y
es
N
o
P
Isol
atio
n
Yes
No
P
Food
han
dlin
g
Yes
No
P
Man
agem
ent o
f car
e eq
uipm
ent
Yes
No
P
Cont
rol o
f env
ironm
ent
Yes
No
P
63 |
Pa
ge
St
anda
rd
Req
uire
men
ts
Scor
e (t
ick
appr
opri
ate
box)
R
emar
ks
11.3
.3 T
he h
ealth
faci
lity
shal
l hav
e a
plan
for
m
anag
emen
t of
haz
ardo
us
occu
patio
nal e
xpos
ure
of
heal
th st
aff
Ther
e is
a pl
an fo
r occ
upat
iona
l exp
osur
e m
anag
emen
t of s
taff
hea
lth.
(MO
V- st
aff i
mm
uniz
atio
n sc
hedu
les,
pre
and
post-
expo
sure
pro
phyl
axis
guid
elin
es, n
eedl
e sti
ck in
jurie
s rec
ord
book
)
Yes
No
P
11.3
.4 T
he h
ealth
faci
lity
shal
l ens
ure
adeq
uate
IPC
su
pplie
s at a
ll tim
es
Ther
e is
mec
hani
sm to
ens
ure
adeq
uate
IPC
su
pplie
s at a
ll tim
es (M
OV-
inve
ntor
y o
f IPC
su
pplie
s las
ting
at le
ast 6
mon
ths)
Yes
No
P
64 |
Pa
ge
11
.4 In
patie
nt C
are
Stan
dard
Re
quire
men
ts
Scor
e (ti
ck a
ppro
pria
te
box)
Re
mar
ks
11.4
.1 T
he m
anag
emen
t sha
ll en
sure
that
the
faci
lity
has
adeq
uate
res
ourc
es a
nd sk
ills
to p
rovi
de q
ualit
y in
patie
nt
care
Ade
quat
e be
ds a
re a
vaila
ble
and
Func
tiona
l. Th
ere
are
no p
atie
nts s
harin
g be
ds.
(MO
V-O
bser
vatio
n)
Yes
No
P
Each
pat
ient
has
acc
ess t
o a
nurs
e ca
ll sy
stem
at a
ll tim
es.
(MO
V-O
bser
vatio
n)
Yes
No
P
Ther
e ar
e w
ard
scre
ens
(MO
V-O
bser
vatio
n)
Yes
No
P
Mat
tress
es, b
ed li
nen,
tow
els a
nd g
owns
for
patie
nts a
re a
vaila
ble
and
in g
ood
cond
ition
. (M
OV-
Obs
erva
tion)
Yes
No
P
Equi
pmen
t for
faci
litat
ing
patie
nts'
mob
ility
ar
e av
aila
ble
and
in g
ood
cond
ition
. (M
OV-
Obs
erva
tion)
Yes
No
P
Equi
pmen
t and
mat
eria
ls fo
r mon
itorin
g pa
tient
s' vi
tal s
igns
are
pro
vide
d.
(MO
V-O
bser
vatio
n)
Yes
No
P
11.4
.2 T
he fa
cilit
y sh
all
ensu
re tr
iagi
ng o
f pat
ient
s is
cond
ucte
d ba
sed
on th
e pa
tient
’s/c
lient
s con
ditio
n
Faci
lity
deve
lops
and
use
s pro
toco
ls fo
r tri
agin
g of
pat
ient
s (M
OV-
Tri
age
prot
ocol
AND
Tag
ging
of
Patie
nts o
r pat
ent f
iles)
Yes
No
P
65 |
Pa
ge
St
anda
rd
Requ
irem
ents
Sc
ore
(tick
app
ropr
iate
bo
x)
Rem
arks
11.4
.3 T
he h
ealth
faci
lity
shal
l ens
ure
that
co
mpr
ehen
sive
patie
nt
asse
ssm
ent i
s con
duct
ed
The
faci
lity
carr
ies o
ut c
ompr
ehen
sive
asse
ssm
ent o
f the
pat
ient
, whi
ch in
clud
es
patie
nts’
bio
data
, his
tory
of p
rese
nt il
lnes
s, pa
st m
edic
al h
istor
y, fa
mily
hist
ory
and
soci
al h
istor
y
(MO
V- o
utpa
tient
form
, pat
ient
’s c
arde
x,
adm
issio
ns re
giste
r)
Yes
No
P
The
faci
lity
docu
men
ts ba
selin
e vi
tal s
igns
(M
OV-
obs
erva
tions
cha
rt, fl
uid
char
ts,
nurs
ing
care
pla
n, c
arde
x)
Yes
No
P
11.4
.4 T
he h
ealth
faci
lity
shal
l cat
egor
ize
patie
nts i
nto
the
pres
crib
ed le
vel o
f car
e
The
heal
th fa
cilit
y ha
s a d
ispl
ayed
pro
toco
l fo
r cat
egor
izat
ion
of p
atie
nts f
or p
resc
ribed
le
vels
of c
are:
Ca
tego
ry “
A”
criti
cal ,
Ca
tego
ry “
B” u
nsta
ble
Ca
tego
ry “
C” st
able
(M
OV-
Arr
ange
men
t of p
atie
nts a
ccor
ding
to
thei
r cat
egor
ized
leve
l of c
are,
do
cum
ente
d pr
otoc
ol o
f car
e of
fere
d to
the
patie
nt)
Yes
No
P
11.4
.5 T
he h
ealth
faci
lity
shal
l con
tinuo
usly
car
ry o
ut
epis
odic
pat
ient
ass
essm
ent
The
faci
lity
carr
ies o
ut e
piso
dic
patie
nt
asse
ssm
ent a
nd re
cord
s vi
tals
in th
e ap
prop
riate
cha
rts o
f car
e
(MO
V- O
bser
vatio
ns c
hart,
flui
d ch
arts,
nu
rsin
g ca
re p
lan,
Car
dex)
Yes
No
P
11.4
.6 T
he fa
cilit
y sh
all h
ave
in p
lace
stan
dard
ized
di
agno
stic
s and
trea
tmen
t pr
oces
ses
Faci
lity
follo
ws p
roto
cols
and
guid
elin
es
for d
iagn
ostic
s and
trea
tmen
t (M
OV-
SO
P; S
ampl
e 5
patie
nt c
ase
files
)
Yes
No
P
66 |
Pa
ge
St
anda
rd
Requ
irem
ents
Sc
ore
(tick
app
ropr
iate
bo
x)
Rem
arks
Faci
lity
follo
ws s
tand
ardi
zed
proc
edur
e fo
r ha
ndov
er o
f pat
ient
s bet
wee
n un
its (M
OV-
SOP,
clin
ical
not
es)
Yes
No
P
11.4
.7 T
he h
ealth
faci
lity
shal
l adm
inis
ter
and
docu
men
t pre
scri
bed
med
icat
ion
usin
g th
e 5R
pr
inci
ple
The
faci
lity
adm
inis
ters
pre
scrib
ed
med
icat
ion
usin
g th
e 5R
prin
cipl
e -
right
pa
tient
, rig
ht d
rug,
righ
t dos
age,
righ
t rou
te,
right
tim
e - a
nd d
ocum
enta
tion
done
in th
e tre
atm
ent s
heet
and
pat
ient
’s c
arde
x (M
OV-
pro
toco
l of d
rug
adm
inis
tratio
n,
card
ex, 5
trea
tmen
t she
ets)
Yes
No
P
11.4
.8 T
he h
ealth
faci
lity
shal
l ens
ure
full
docu
men
tatio
n of
all
proc
edur
es is
cor
rect
ly d
one
Doc
umen
tatio
n of
all
proc
edur
es is
don
e in
th
e re
leva
nt c
harts
/ she
ets
(MO
V- c
arde
x, fl
uid/
feed
ing
char
ts,
treat
men
t she
et,
turn
ing
shee
t, ob
serv
atio
n ch
arts,
nur
sing
car
e pl
an)
Yes
No
P
11.4
.9 T
he fa
cilit
y sh
all h
ave
a do
cum
ente
d st
anda
rdiz
ed
proc
ess f
or c
ondu
ctin
g w
ard
roun
ds
Faci
lity
prov
ides
for d
aily
sche
dule
d w
ard
roun
ds a
nd o
ther
clin
ical
revi
ews o
f pa
tient
s (M
OV-
Sch
edul
es fo
r war
d ro
unds
)
Yes
No
P
Faci
lity
staf
f fol
low
gui
delin
es a
nd
proc
edur
es fo
r int
er-p
rofe
ssio
nal
cons
ulta
tion
mee
tings
and
cas
e co
nfer
ence
s (M
OV-
Sche
dule
s)
Yes
No
P
11.4
.10
The
faci
lity
shal
l ca
tego
rize
nut
ritio
n st
atus
of
all i
npat
ient
s and
pro
vide
cu
ltura
lly se
nsiti
ve fo
od a
nd
drin
ks fo
r in
patie
nt c
are
Ass
essm
ent o
f nut
ritio
nal s
tatu
s of a
ll pa
tient
s is d
one
on a
dmiss
ion
and
cont
inuo
usly
mon
itore
d (M
OV-
Sam
ple
5 pa
tient
file
s)
Yes
No
P
67 |
Pa
ge
St
anda
rd
Requ
irem
ents
Sc
ore
(tick
app
ropr
iate
bo
x)
Rem
arks
Die
tary
cou
nsel
ling
and
feed
ing
supp
ort i
s pr
ovid
ed b
y nu
tritio
nist
s or o
ther
com
pete
nt
staff
(M
OV-
Sch
edul
es fo
r nut
ritio
nists
)
Yes
No
P
A su
itabl
y qu
alifi
ed a
nd/o
r ex
perie
nced
per
son
advi
ses
on m
eal d
evel
opm
ent
(MO
V-H
R Re
cord
s)
Yes
No
P
Ther
e is
a p
lann
ed w
eekl
y m
enu
that
is a
dher
ed to
(M
OV-
Upd
ated
faci
lity
patie
nt m
enu
)
Yes
No
P
Faci
lity
prov
ides
inpa
tient
s with
cul
tura
lly
sens
itive
food
(M
OV-
Inte
rvie
w 5
inpa
tient
s)
Yes
No
P
11.4
.11
The
faci
lity
shal
l put
in
pla
ce m
easu
res f
or
prev
entio
n of
falls
and
pa
tient
mob
iliza
tion
to
prev
ent b
ed so
res,
stre
ss
ulce
rs, t
hrom
bosis
Faci
lity
prov
ides
pro
toco
ls fo
r pre
vent
ion
of fa
lls (M
OV-
ava
ilabi
lity
of p
roto
cols)
Yes
No
P
Faci
lity
prov
ides
pro
toco
ls fo
r pat
ient
m
obili
zatio
n to
pre
vent
bed
sore
s, st
ress
ul
cers
, thr
ombo
sis
(MO
V- a
vaila
bilit
y of
pro
toco
ls)
Yes
No
P
Mea
sure
s are
in p
lace
to p
reve
nt im
mob
ility
an
d pr
even
t the
com
plic
atio
ns o
f im
mob
ility
. (M
OV-
SOPs
)
Yes
No
P
68 |
Pa
ge
St
anda
rd
Requ
irem
ents
Sc
ore
(tick
app
ropr
iate
bo
x)
Rem
arks
Ther
e is
evi
denc
e th
at th
e pa
tient
, whe
n co
nfin
ed to
bed
or i
mm
obile
, rec
eive
s as
sista
nce
with
lifti
ng, m
ovin
g, p
ositi
onin
g,
turn
ing
in b
ed a
nd tr
ansf
errin
g fr
om a
nd
back
to b
ed.
(MO
V-O
bser
vatio
n; in
terv
iew
5 pa
tient
s)
Yes
No
P
Ther
e is
evi
denc
e th
at p
ress
ure
relie
ving
te
chni
ques
(car
e of
skin
, tur
ning
in b
ed o
n sc
hedu
le, o
bser
ving
and
pre
vent
ing
pote
ntia
l bed
sore
s) a
re im
plem
ente
d an
d do
cum
ente
d.
(MO
V-SO
Ps: S
ampl
e 5
patie
nt fi
les)
Yes
No
P
Patie
nts r
ecei
ve p
rofe
ssio
nal p
hysio
ther
apy
care
and
ass
istan
ce w
ith re
habi
litat
ion
if re
quire
d.
(MO
V-SO
Ps)
Yes
No
P
11.4
.12
The
faci
lity
shal
l ha
ve a
doc
umen
ted
patie
nt
disc
harg
e m
echa
nism
Faci
lity
has a
doc
umen
ted
disc
harg
e pr
otoc
ol
(MO
V- a
vaila
bilit
y of
pro
toco
l)
Yes
No
Ther
e is
doc
umen
tatio
n of
dis
char
ge o
f pa
tient
aga
inst
med
ical
adv
ice
(M
OV-
Disc
harg
e Ag
ains
t med
ical
adv
ice
form
s)
Yes
No
P
69 |
Pa
ge
11
.5 A
ccid
ents
and
Em
erge
ncy
Stan
dard
R
equi
rem
ents
Sc
ore
(tic
k ap
prop
riate
bo
x)
Rem
arks
11.5
.1 T
he h
ealth
faci
lity
shal
l en
sure
that
the
acci
dent
and
em
erge
ncy
depa
rtm
ent h
as
adeq
uate
res
ourc
es a
nd sk
ills t
o pr
ovid
e qu
ality
em
erge
ncy
care
Faci
lity
has a
dequ
ate
num
ber o
f lic
ense
d sk
illed
staf
f (M
OV-
HR
reco
rds)
Yes
No
Hea
lthca
re w
orke
rs in
volv
ed in
adu
lt em
erge
ncy
care
hav
e ad
ditio
nal t
rain
ing
on B
asic
Life
Sup
port
and
Adv
ance
d Li
fe S
uppo
rt (M
OV-
HR
reco
rds)
Yes
No
P
Hea
lthca
re w
orke
rs in
volv
ed in
pa
edia
tric
emer
genc
y ca
re h
ave
addi
tiona
l tra
inin
g on
Bas
ic L
ife S
uppo
rt an
d Pe
diat
ric A
dvan
ced
Life
Sup
port
(MO
V-H
R re
cord
s)
Yes
No
P
Faci
lity
has a
dequ
ate
emer
genc
y eq
uipm
ent a
nd S
uppl
ies,
fully
stoc
ked
resu
scita
tion
trolle
y (M
OV-
inve
ntor
y of
em
erge
ncy
equi
pmen
t and
supp
lies)
Yes
No
P
11.5
.2 T
he fa
cilit
y sh
all e
nsur
e th
at tr
iagi
ng is
con
duct
ed
acco
rdin
g to
cur
rent
gui
delin
es
Tria
ge g
uide
lines
in p
lace
Y
es
No
Tria
ge tu
rn-a
roun
d tim
e is
defin
ed
(MO
V- q
uarte
rly re
port
on a
sses
smen
t of
turn
-aro
und-
time)
Yes
No
A re
cord
of p
atie
nt v
olum
es b
ased
on
the
diffe
rent
tria
ge c
ateg
orie
s is
mai
ntai
ned
Yes
No
70 |
Pa
ge
St
anda
rd
Req
uire
men
ts
Scor
e (t
ick
appr
opria
te
box)
Re
mar
ks
(MO
V- tr
iagi
ng re
gist
er)
11.5
.3 T
he h
ealth
faci
lity
shal
l en
sure
that
evi
denc
e-ba
sed
emer
genc
y ca
re g
uide
lines
are
av
aila
ble
and
effe
ctiv
ely
appl
ied
with
in th
e E
mer
genc
y D
epar
tmen
t
Alg
orith
ms f
or tr
aum
a an
d m
edic
al
emer
genc
ies a
re a
vaila
ble
(M
OV-
ava
ilabi
lity
of a
lgor
ithm
s)
Yes
No
P
11.5
.4 T
he fa
cilit
y sh
all e
nsur
e th
at tu
rn-a
roun
d tim
es fo
r em
erge
ncie
s is m
onito
red
and
revi
ewed
.
The
follo
win
g tu
rn-a
roun
d tim
e is
m
onito
red:
D
oor t
o Tr
iage
Y
es
N
o
D
oor t
o D
octo
r/clin
icia
ns
Yes
No
La
bora
tory
Ser
vice
s
Y
es
N
o
D
ecisi
on to
refe
rral
(lev
el 2
&3)
Y
es
N
o
D
oor t
o D
ispos
ition
/Len
gth
of
Stay
in A
&E
(MO
V-D
ischa
rge,
Adm
issio
n,
Refe
rral
)
Yes
No
Evid
ence
that
pat
ient
s are
seen
with
in
the
time
limits
set b
y th
e tri
age
guid
elin
es
(MO
V- q
uarte
rly re
port
on a
sses
smen
t
Yes
No
71 |
Pa
ge
St
anda
rd
Req
uire
men
ts
Scor
e (t
ick
appr
opria
te
box)
Re
mar
ks
of tu
rn-a
roun
d tim
e)
11.5
.5 T
he fa
cilit
y sh
all e
valu
ate
mor
bidi
ty a
nd m
orta
lity
data
w
ithin
the
A&
E de
part
men
t.
Faci
lity
mai
ntai
ns re
cord
s of p
atie
nts
who
retu
rn to
the
Emer
genc
y D
epar
tmen
t with
in 2
4 ho
urs a
fter b
eing
se
en. (
MO
V- A
&E
regi
ster)
Yes
No
Rev
iew
of a
ll m
orta
litie
s con
duct
ed
with
in 2
4 ho
urs o
f adm
issio
n.
(MO
V- m
orta
lity
audi
t rep
ort)
Yes
No
11.5
.6 T
he fa
cilit
y sh
all p
rovi
de
emer
genc
y ca
re, r
egar
dles
s of
the
abili
ty to
pay
for
serv
ice.
Ava
ilabi
lity
and
use
of p
roto
cols
for
serv
ice
fee
wai
ver a
nd e
xem
ptio
n.
(MO
V-pr
otoc
ols;
wai
ver a
nd e
xem
ptio
ns
regi
ster
)
Yes
No
P
11.5
.7 T
he fa
cilit
y sh
all b
e pr
epar
ed to
han
dle
mas
s ca
sual
ties a
t all
times
All
staff
are
ass
esse
d qu
arte
rly o
n th
eir
know
ledg
e of
mas
s cas
ualty
m
anag
emen
t ski
lls a
nd th
e in
stitu
tiona
l pr
oced
ures
(M
OV-
asse
ssm
ent r
epor
t)
Yes
No
P
Faci
lity
cond
ucts
dem
o dr
ills
twic
e a
year
to te
st th
e fa
cilit
y’s p
repa
redn
ess
to
man
age
mas
s cas
ualti
es
(MO
V-dr
ills r
epor
t)
Yes
No
P
72 |
Pa
ge
11
.8 S
afe
deliv
ery
Stan
dard
Ar
eas f
or a
sses
smen
t Sc
ore
(tick
the
appr
opri
ate
box)
Re
mar
ks
11.8
.1 T
he h
ealth
faci
lity
man
agem
ent s
hall
avai
l sk
illed
per
sonn
el,
infr
astr
uctu
re a
nd
equi
pmen
t to
offe
r lif
e-sa
ving
em
erge
ncy
and
qual
ity m
ater
nal c
are
The
staff
esta
blish
men
t for
mat
erni
ty se
rvic
es
is as
per
the
hum
an re
sour
ces n
orm
s and
sta
ndar
ds (
MO
V- H
R re
cord
s)
Yes
No
Mat
erni
ty d
epar
tmen
t has
ade
quat
e eq
uipm
ent
(See
app
endi
x fo
r list
of e
quip
men
t) (M
OV-
fun
ctio
nal e
quip
men
t)
Yes
No
P
Labo
ur w
ard
is c
lean
, has
ade
quat
e lig
htin
g an
d is
optim
ally
aer
ated
(MO
V- O
bser
vatio
n)
Yes
No
P
11.8
.2 T
he h
ealth
faci
lity
shal
l ens
ure
that
all
deliv
ery
unit
staf
f pro
vide
re
spec
tful
mat
erni
ty c
are
Clie
nt ri
ghts
pro
toco
l stra
tegi
cally
pla
ced
(MO
V-ob
serv
atio
n)
Yes
No
Clie
nt e
xper
ienc
e qu
estio
nnai
re a
dmin
iste
red
at d
ischa
rge
(MO
V-m
onth
ly re
port
s)
Que
stion
naire
in A
nnex
Yes
No
Mec
hani
sm o
f res
pond
ing
to c
lient
com
plai
nts
in p
lace
(M
OV-
Com
plai
nt a
nd c
ompl
imen
ts bo
x/ b
ook,
ev
iden
ce o
f ana
lysis
of f
eedb
ack
resu
lts)
Yes
No
Ther
e is
prov
ision
for p
rivac
y fo
r pat
ient
s (M
OV-
Obs
erva
tion
for s
cree
ns)
Yes
No
11.8
.3 T
he h
ealth
faci
lity
shal
l ens
ure
that
ris
k as
sess
men
t is c
ondu
cted
an
d th
at in
trap
artu
m c
are
Ass
essm
ent o
f the
pat
ient
s don
e w
ithin
15
min
utes
of a
dmiss
ion
by a
skill
ed h
ealth
pr
ovid
er (M
OV-
Sam
ple
5 pa
tient
file
s)
Yes
No
P
73 |
Pa
ge
St
anda
rd
Area
s for
ass
essm
ent
Scor
e (ti
ck th
e ap
prop
riat
e bo
x)
Rem
arks
is pr
ovid
ed a
ppro
pria
tely
W
HO
che
cklis
t on
risk
asse
ssm
ent o
f mot
her
and
baby
fille
d fo
r all
deliv
erie
s (M
OV-
sam
ple
5 pa
tient
file
s for
com
plet
enes
s)
Yes
No
p
MEO
W (M
odifi
ed E
arly
Obs
tetri
c W
arni
ng
Scor
e) f
illed
for e
very
pat
ient
(M
OV-
sam
ple
5 pa
tient
file
s fo
r co
mpl
eten
ess)
Yes
No
P
Parto
grap
h av
aila
ble
on si
te, a
nd th
ere
is
evid
ence
of i
ts pr
oper
use
(M
OV-
sam
ple
5 pa
tient
file
s for
com
plet
enes
s)
Yes
N
o
P
Foet
al su
rvei
llanc
e co
nduc
ted
for e
very
mot
her
in la
bour
, in
line
with
nat
iona
l gui
delin
es
(MO
V-Re
leva
nt c
harts
)
Yes
N
o
P
11.8
.4 T
he h
ealth
faci
lity
shal
l ens
ure
that
em
erge
ncy
mat
erni
ty c
are
is su
ppor
ted
by ti
mel
y di
agno
stic
s and
labo
rato
ry
serv
ices
Tim
ely
diag
nosti
cs a
nd la
bora
tory
serv
ices
pr
ovid
ed fo
r em
erge
ncy
mat
erna
l car
e
incl
udin
g bu
t not
lim
ited
to: M
alar
ia, b
lood
su
gar,
HB,
urin
alys
is, b
lood
typi
ng, r
hesu
s co
mpa
tibili
ty
(MO
V- re
ports
on
turn
-aro
und-
time
for
labo
rato
ry se
rvic
es)
Yes
No
P
11.8
.5 T
he h
ealth
faci
lity
shal
l ens
ure
that
ther
e is
imm
edia
te p
ost-
deliv
ery
reas
sess
men
t of t
he m
othe
r
All
clie
nts a
re a
sses
sed
for t
he fo
llow
ing:
(
MO
V- sa
mpl
e 5
patie
nt fi
les)
Co
ntra
ctio
n of
the
uter
us
Yes
No
74 |
Pa
ge
St
anda
rd
Area
s for
ass
essm
ent
Scor
e (ti
ck th
e ap
prop
riat
e bo
x)
Rem
arks
and
the
neon
ate
with
in 1
5 m
inut
es o
f del
iver
y
P
Te
ars i
n th
e bi
rth c
anal
Y
es
N
o
P
Br
eath
ing
of th
e ne
w b
orn
Yes
No
P
N
ewbo
rn A
pgar
scor
e
Y
es
N
o
P
Re
chec
k th
e um
bilic
al c
ord
Yes
No
P
11.8
.6 T
he h
ealth
faci
lity
shal
l ens
ure
that
em
erge
ncy
vagi
nal d
eliv
ery
is ex
pedi
ted
Prot
ocol
s for
ass
iste
d va
gina
l
del
iver
y di
spla
yed
(MO
V-O
bser
vatio
n)
Yes
No
Ava
ilabi
lity
of fu
nctio
nal i
nstru
men
ts fo
r as
siste
d va
gina
l del
iver
y e.
g. fo
rcep
s, va
cuum
se
t (M
OV-
Obs
erva
tion)
Yes
No
Tim
ely
docu
men
tatio
n of
the
proc
edur
es fo
r as
siste
d va
gina
l del
iver
ies
(MO
V- sa
mpl
e 5
patie
nt fi
les)
Yes
No
P
11.8
.7 T
he h
ealth
serv
ice
prov
ider
shal
l con
tinua
lly
mon
itor
the
vita
l sig
ns o
f a
patie
nt w
ho h
as p
ost-
part
um h
aem
orrh
age
Cont
inuo
us m
onito
ring
of v
ital s
igns
and
do
cum
enta
tion
done
eve
ry 1
5 m
inut
es fo
r the
fir
st tw
o ho
urs t
hen
half
hour
ly in
the
3rd h
our
(MO
V- S
ampl
e 5
patie
nt fi
les)
Yes
No
P
PPH
esc
alat
ion
prot
ocol
s disp
laye
d
Yes
No
75 |
Pa
ge
St
anda
rd
Area
s for
ass
essm
ent
Scor
e (ti
ck th
e ap
prop
riat
e bo
x)
Rem
arks
(MO
V- o
bser
vatio
n)
P
11.8
.8 T
he h
ealth
faci
lity
shal
l ens
ure
that
its s
taff
of
fer
baby
frie
ndly
pr
actic
es
Baby
-frie
ndly
serv
ices
off
ered
(M
OV-
obs
erva
tion
for r
oom
ing
in)
Yes
No
P
11.8
.9 T
he h
ealth
faci
lity
shal
l ens
ure
that
the
serv
ice
prov
ider
s con
duct
war
d ha
nd-o
ver
roun
ds
War
d ha
nd-o
ver r
ound
s con
duct
ed
(MO
V- S
ampl
e 5
patie
nt fi
les)
Y
es
N
o
76 |
Pa
ge
11
.9 N
eona
tal C
are
Stan
dard
Re
quire
men
ts
Sc
ore
(tick
the
appr
opri
ate
box)
Re
mar
ks
11.9
.1 T
he h
ealth
faci
lity
shal
l ens
ure
that
skill
ed
pers
onne
l, in
fras
truc
ture
an
d eq
uipm
ent a
re
avai
labl
e to
off
er li
fe-s
avin
g em
erge
ncy
and
qual
ity
new
born
car
e
Hea
lthca
re p
rovi
der a
vaila
ble
24 h
ours
a d
ay, 7
da
ys a
wee
k.
(MO
V-H
R re
cord
s; st
aff r
ota)
Yes
No
At l
east
2 sk
illed
hea
lth w
orke
rs tr
aine
d in
goa
l-or
ient
ed A
NC
and
Esse
ntia
l New
born
Car
e
(MO
V-H
R re
cord
s)
Yes
No
Faci
lity
has a
dequ
ate
infr
astru
ctur
e an
d eq
uipm
ent
to o
ffer l
ife-s
avin
g em
erge
ncy
and
qual
ity
new
born
car
e (M
OV-
Obs
erve
and
rev
iew
inve
ntor
y as
per
leve
l of
faci
lity)
Yes
No
P
Resu
scita
tion
spac
e/ta
ble
avai
labl
e in
labo
ur w
ard,
th
eatre
, pos
tnat
al w
ard
and
paed
iatri
c w
ard.
(M
OV-
Obs
erva
tion)
Yes
No
P
Nur
sery
spac
e ad
jace
nt to
labo
ur w
ard
(M
OV-
Obs
erva
tion)
Y
es
N
o
Beds
ass
igne
d fo
r Kan
garo
o M
othe
r Car
e (K
MC)
in
pos
tnat
al w
ards
(M
OV-
Obs
erva
tion)
Yes
No
77 |
Pa
ge
St
anda
rd
Requ
irem
ents
Scor
e (ti
ck th
e ap
prop
riat
e bo
x)
Rem
arks
11.9
.2 T
he h
ealth
faci
lity
shal
l man
age
all n
ewbo
rns
as p
resc
ribe
d in
the
Es
sent
ial N
ewbo
rn C
are
guid
elin
es
Faci
lity
uses
bab
y w
raps
to k
eep
new
born
s war
m
at a
ll tim
es
(MO
V-
obse
rvat
ion,
inte
rvie
w sta
ff)
Yes
No
P
Brea
stfee
ding
with
in o
ne h
our o
f del
iver
y fo
r wel
l ba
bies
(MO
V- S
OPs
dis
play
ed,
inte
rvie
w sta
ff an
d cl
ient
s)
Yes
No
P
Adm
inist
ratio
n of
Vita
min
K a
fter d
eliv
ery
(MO
V- c
heck
pat
ient
file
s on
the
last
5 de
liver
ies)
Y
es
N
o
P
Use
of 4
% c
hlor
hexi
dine
form
ulat
ion
for c
ord
care
(M
OV-
che
ck p
atie
nt fi
les f
or th
e la
st 5
deliv
erie
s)
Yes
No
P
Adm
inist
ratio
n of
tetra
cycl
ine
eye
oint
men
t to
baby
imm
edia
tely
afte
r birt
h (M
OV-
che
ck p
atie
nt fi
les f
or th
e la
st fiv
e de
liver
ies)
Yes
No
P
Imm
edia
te sk
in-to
-ski
n co
ntac
t bet
wee
n m
othe
r/par
ent a
nd b
aby
is p
ract
iced
at t
he fa
cilit
y (K
anga
roo
Mot
her C
are
for b
abie
s <2,
500g
ms)
(M
OV-
int
ervi
ew st
aff a
nd c
lient
s)
Yes
No
P
11.9
.3 T
he fa
cilit
y sh
all b
e ad
equa
tely
pre
pare
d fo
r re
suci
tatio
n of
new
born
ba
bies
with
in o
ne m
inut
e of
The
faci
lity
has a
com
plet
e se
t of
resu
scita
tion
equi
pmen
t (su
ctio
n ba
ll, fu
nctio
nal p
aedi
atric
am
bu-b
ag a
nd m
ask,
resu
scita
re) (
MO
V-
Obs
erva
tion/
che
ck in
vent
ory
as p
er le
vel o
f
Yes
No
78 |
Pa
ge
St
anda
rd
Requ
irem
ents
Scor
e (ti
ck th
e ap
prop
riat
e bo
x)
Rem
arks
birt
h
faci
lity)
The
faci
lity
cond
ucts
resu
scita
tion
drill
s (M
OV-
quar
terly
repo
rt)
Yes
No
Babi
es v
ital s
igns
obs
erve
d w
ithin
two
hour
s of
deliv
ery
(MO
V- sa
mpl
e pa
tient
not
es fo
r the
last
5 de
liver
ies)
Yes
No
P
11.9
.4 T
he fa
cilit
y sh
all
have
a m
echa
nism
for
dete
ctin
g an
d re
ferr
al o
f ba
bies
with
dan
ger
signs
or
criti
cally
ill b
abie
s
The
faci
lity
has S
OPs
for d
etec
tion
of b
abie
s with
da
nger
sign
s dis
play
ed
(MO
V-ob
serv
atio
n)
Yes
No
The
faci
lity
has d
rug
form
ulat
ions
for m
anag
ing
neon
atal
infe
ctio
ns
(MO
V-ch
eck
drug
inve
ntor
y)
Yes
No
P
The
faci
lity
uses
refe
rral
pro
toco
ls fo
r the
cr
itica
lly il
l bab
ies o
r bab
ies w
ith d
ange
r sig
ns
(MO
V-fa
cilit
y pr
otoc
ol a
vaila
ble/
disp
laye
d)
Yes
No
11.9
.5 T
he fa
cilit
y sh
all
man
age
neon
atal
seps
is ac
cord
ing
to n
atio
nal
guid
elin
es
Ava
ilabi
lity
of s
tand
ard
prot
ocol
for t
he
man
agem
ent o
f neo
nata
l sep
sis (
MO
V-Ac
cess
to
guid
elin
es)
Yes
No
11.9
.6 T
he fa
cilit
y sh
all u
se
the
curr
ent t
reat
men
t gu
idel
ines
for
the
care
of
HIV
-exp
osed
infa
nts
Faci
lity
prov
ides
app
ropr
iate
pro
phyl
axis
for
HIV
-exp
osed
new
born
with
in o
ne h
our a
fter
deliv
ery
(MO
V- sa
mpl
e fil
es o
f HEI
r)
Yes
No
P
79 |
Pa
ge
St
anda
rd
Requ
irem
ents
Scor
e (ti
ck th
e ap
prop
riat
e bo
x)
Rem
arks
11.9
.7 T
he h
ealth
faci
lity
shal
l ens
ure
infe
ctio
n pr
even
tion
mea
sure
s are
pu
t in
plac
e in
the
neon
atal
un
it.
Han
d hy
gien
e fa
cilit
ies i
n or
nea
r the
exa
min
atio
n ro
om, l
abou
r war
d, th
eatre
, pos
tnat
al, n
urse
ry a
nd
paed
iatri
c w
ards
. (M
OV-
Obs
erva
tion
)
Yes
No
P
Han
d w
ashi
ng w
ith so
ap a
nd w
ater
bet
wee
n ex
amin
ing
babi
es, b
efor
e an
d af
ter p
roce
dure
s;
avai
labi
lity
of h
and
sani
tizer
on
site
(MO
V-SO
P)
Yes
No
P
The
new
-bor
n un
it ha
s dis
infe
ctio
n fa
cilit
ies
(MO
V- O
bser
ve fo
r cor
rect
disi
nfec
tion
proc
esse
s)
Yes
No
P
Staf
f saf
ely
disp
ose
off s
harp
obj
ects
and
was
te in
w
ell-l
abel
led
cont
aine
rs. (
MO
V- C
heck
av
aila
bilit
y of
safe
ty b
oxes
and
col
our-
code
d wa
ste b
ins )
Yes
No
11.9
.8 T
he fa
cilit
y sh
all
disc
harg
e th
e ne
w-b
orn
appr
opri
atel
y in
not
less
th
an 2
4 ho
urs a
fter
bir
th.
All
new
-bor
ns st
ay w
ith th
e m
othe
r in
the
heal
th
faci
lity
for a
min
imum
of 2
4 ho
urs
(MO
V-5
Patie
nt fi
les/e
xit i
nter
view
s)
Yes
No
P
All
mot
hers
rece
ives
edu
catio
n on
cle
an c
hain
, co
rd c
are,
war
m c
hain
and
bre
astfe
edin
g.
(MO
V- P
atie
nt e
xit i
nter
view
s)
Yes
No
P
All
mot
hers
info
rmed
on
dang
er si
gns t
o w
atch
ou
t for
at h
ome
(M
OV-
Patie
nt e
xit i
nter
view
s)
Yes
No
P
80 |
Pa
ge
St
anda
rd
Requ
irem
ents
Scor
e (ti
ck th
e ap
prop
riat
e bo
x)
Rem
arks
All
mot
hers
giv
en p
ostn
atal
app
oint
men
ts (M
OV-
5 Pa
tient
file
s)
Yes
No
P
11. 9
. 9 T
he fa
cilit
y sh
all
prov
ide
com
preh
ensi
ve
heal
th e
duca
tion
and
serv
ice
info
rmat
ion
to th
e cl
ient
s
Hea
lth fa
cilit
y co
nduc
ts g
roup
hea
lth e
duca
tion
sess
ions
incl
udin
g: (1
) HIV
, (2)
Dan
ger s
igns
, (3)
In
fant
and
you
ng c
hild
feed
ing,
(4) K
MC,
(5)
Cord
car
e, (6
) Ext
ra c
are
for s
mal
l bab
ies,
(7)
Pers
onal
Hyg
iene
(M
OV-
Obs
erva
tion
of H
ealth
edu
catio
n sc
hedu
le m
ater
ials
and
act
ual h
ealth
edu
catio
n se
ssio
ns)
Yes
No
P
81 |
Pa
ge
11
.11
Labo
rato
ry
Stan
dard
Re
quire
men
ts
Scor
e (t
ick
appr
opri
ate
box)
Re
mar
ks
11.1
1.1
The
hea
lth fa
cilit
y sh
all e
nsur
e th
ere
are
adeq
uate
res
ourc
es to
pr
ovid
e qu
ality
labo
rato
ry
serv
ices
Staf
fing
is in
line
with
the
HR
norm
s and
stan
dard
s (M
OV-
HR
reco
rds)
Yes
No
P
Faci
lity
has a
dequ
ate
labo
rato
ry in
fras
truct
ure
and
equi
pmen
t as p
er ti
er o
f car
e ( S
ee a
ppen
dix)
(M
OV-
Ade
quat
e eq
uipm
ent a
s per
the
scop
e of
wor
k an
d tie
r of t
he h
ealth
faci
lity)
Yes
No
P
Labo
rato
ry ro
om is
air
cond
ition
ed, c
lean
, unc
lutte
red
and
wel
l ven
tilat
ed.
(M
OV-
obs
erva
tions
)
Yes
No
P
Ther
e is
an
inve
ntor
y st
ore
with
con
trolle
d te
mpe
ratu
res
(MO
V- o
bser
vatio
ns)
Yes
No
P
Benc
hes,
wel
l fitt
ed w
ith re
com
men
ded
labo
rato
ry
chai
rs
(MO
V- o
bser
vatio
ns)
Yes
No
P
Labo
rato
ry h
as p
rope
r lig
htin
g an
d ac
cess
con
trol
serv
ices
(M
OV-
obs
erva
tions
)
Yes
No
P
Safe
ty c
abin
ets a
vaila
ble
(M
OV-
obs
erva
tions
)
Y
es
N
o
P
The
labo
rato
ry m
onito
rs e
nviro
nmen
tal c
ondi
tions
that
af
fect
testi
ng
(MO
V-M
onito
ring
logs
)
Yes
No
P
82 |
Pa
ge
St
anda
rd
Requ
irem
ents
Sc
ore
(tic
k ap
prop
riat
e bo
x)
Rem
arks
11.
11.2
Gen
eral
Lab
orat
ory
Qua
lity
Man
agem
ent S
yste
m
11.1
1.2.
1 Th
e he
alth
faci
lity
shal
l dev
elop
and
mak
e av
aila
ble
a qu
ality
man
ual
that
sum
mar
izes
the
labo
rato
ry’s
qua
lity
man
agem
ent s
yste
m (Q
MS)
.
Ther
e is
an
upda
ted
labo
rato
ry q
ualit
y m
anua
l tha
t has
be
en c
omm
unic
ated
to a
ll re
leva
nt st
aff
(MO
V-av
aila
bilit
y of
cur
rent
labo
rato
ry m
anua
l)
Yes
No
Ther
e is
a la
bora
tory
mas
ter l
ist w
ith a
ll do
cum
ents.
(M
OV-
ava
ilabi
lity
of m
aste
r list
)
Y
es
N
o
P
The
labo
rato
ry h
as d
efin
ed it
s sco
pe o
f ser
vice
and
pr
ovid
es m
inim
um e
ssen
tial t
ests
as re
quire
d pe
r its
le
vel (
MO
V- a
vaila
bilit
y of
Qua
lity
man
ual i
n lin
e w
ith
ISO
151
89, c
ompl
ete
docu
men
t mas
ter l
ist)
Yes
No
P
11.1
1.2.
2 Th
e he
alth
faci
lity
shal
l pro
vide
spec
ifica
tions
fo
r su
pplie
s and
co
nsum
able
s
The
labo
rato
ry p
rovi
des s
peci
ficat
ions
for i
ts su
pplie
s an
d co
nsum
able
s (M
OV-
list w
ith sp
ecifi
catio
n fo
r su
pplie
s and
con
sum
able
s)
Yes
No
P
The
labo
rato
ry m
aint
ains
reco
rds f
or e
ach
reag
ent a
nd
cons
umab
le u
sed
in th
e pe
rfor
man
ce o
f exa
min
atio
ns,
with
acc
urat
e in
vent
ory
of it
s sto
ck. (
MO
V-in
vent
ory)
Yes
No
P
The
labo
rato
ry h
as a
ppro
pria
te st
orag
e ar
eas,
whi
ch a
re
rout
inel
y m
onito
red
(MO
V-ob
serv
atio
n)
Yes
No
P
The
labo
rato
ry e
mpl
oys F
irst-E
xpira
tion-
Firs
t-Out
(F
EFO
) pra
ctic
e to
all
reag
ents/
test
kits
in u
se. (
MO
V-ob
serv
atio
n/ b
in c
ards
)
Yes
No
83 |
Pa
ge
St
anda
rd
Requ
irem
ents
Sc
ore
(tic
k ap
prop
riat
e bo
x)
Rem
arks
All
expi
red
prod
ucts
labe
lled
and
disp
osed
pro
perly
. (M
OV-
SOPs
and
reco
rds/h
oldi
ng g
roun
ds/ o
bser
ved)
Y
es
N
o
11.1
1.2.
3 Th
e he
alth
faci
lity
shal
l con
duct
its i
nter
nal
audi
ts a
t int
erva
ls a
s def
ined
in
the
qual
ity m
anua
l and
ad
dres
s are
as im
port
ant t
o pa
tient
car
e
Inte
rnal
aud
its c
ondu
cted
as d
escr
ibed
in in
tern
al a
udit
proc
edur
e.
(MO
V-au
dit r
epor
ts)
Yes
No
P
Inte
rnal
aud
it ac
tion
plan
dev
elop
ed w
ith c
lear
tim
elin
es,
assig
ned
pers
onne
l and
doc
umen
ted
follo
w-u
p.
(MO
V- e
vide
nce
of tr
aine
d in
tern
al a
udito
rs, S
OP
on
inte
rnal
aud
it, n
on-c
onfo
rmiti
es id
entif
ied,
cor
rect
ive
actio
ns ta
ken)
Yes
No
11.1
1.3
Pre
-exa
min
atio
n pr
oces
ses
11.
11.3
.1 T
he h
ealth
faci
lity
shal
l use
stan
dard
ized
la
bora
tory
req
uest
form
s
The
labo
rato
ry h
as st
anda
rdiz
ed a
req
uest
form
, with
sp
ace
for i
nclu
sion
of, b
ut n
ot li
mite
d to
the
follo
win
g:
patie
nt id
entif
icat
ion
incl
udin
g ag
e, g
ende
r, da
te o
f birt
h an
d lo
catio
n/co
ntac
ts, n
ame
or u
niqu
e id
entif
ier o
f the
re
ques
ting
clin
icia
n, d
ate
and
time
of p
rimar
y sa
mpl
e co
llect
ion
(MO
V- O
bser
ve fo
r use
of a
stan
dard
ized
requ
est f
orm
ac
ross
the
faci
lity)
Yes
No
P
11.1
1.3.
2 Th
e la
bora
tory
sh
all
have
gui
delin
es fo
r sp
ecim
en c
olle
ctio
n an
d tr
ansp
orta
tion
The
labo
rato
ry h
as g
uide
lines
for s
peci
men
col
lect
ion
(incl
udin
g sta
ff a
nd c
lient
safe
ty),
labe
lling
, and
tra
nspo
rtatio
n to
per
sons
resp
onsib
le fo
r prim
ary
sam
ple
colle
ctio
n
(MO
V- sa
mpl
e co
llect
ion
guid
elin
es a
t sam
ple
colle
ctio
n ar
eas)
Yes
No
84 |
Pa
ge
St
anda
rd
Requ
irem
ents
Sc
ore
(tic
k ap
prop
riat
e bo
x)
Rem
arks
11.1
1.3.
3 Th
e la
bora
tory
sh
all d
ocum
ent,
revi
ew a
nd
eval
uate
ref
erra
ls to
la
bora
tori
es a
nd c
onsu
ltant
s’
clin
ics a
s def
ined
by
the
labo
rato
ry
The
labo
rato
ry d
ocum
ents
, rev
iew
s and
eva
luat
es
refe
rral
s to
labo
rato
ries a
nd c
onsu
ltant
clin
ics
(MO
V- re
ferr
al re
gist
er/ r
ecor
d)
Yes
No
P
The
labo
rato
ry m
aint
ains
a re
gist
er o
f ref
erra
l la
bora
torie
s and
con
sulta
nts c
linic
s, an
d al
l ref
erre
d sp
ecim
ens a
re tr
acke
d pr
oper
ly u
sing
a lo
gboo
k,
track
ing
form
or e
lect
roni
cally
. (M
OV-
crit
eria
for s
elec
tion
and
eval
uatio
n of
refe
rral
la
bora
torie
s and
con
sulta
nts c
linic
s, lis
t of r
efer
ral
labo
rato
ries,
reco
rds o
f ref
erre
d sa
mpl
es,
evid
ence
of
the
refe
rrin
g la
bora
tory
pro
vidi
ng re
sults
to th
e re
ques
ting
entit
y)
Yes
No
11.1
1.3.
4 Th
ere
shal
l be
a m
echa
nism
for
refe
rral
of
sam
ples
to a
ppro
pria
te
faci
litie
s
A p
roce
dure
for r
efer
ral o
f sam
ples
is in
pla
ce
(MO
V- S
OP)
.
Y
es
N
o
11.1
1.4
Exa
min
atio
n pr
oces
ses
11.1
1.4
.1 T
he la
bora
tory
sh
all d
evel
op S
tand
ard
Ope
ratin
g Pr
oced
ures
(SO
P)
for
all i
ts p
roce
sses
The
labo
rato
ry h
as S
tand
ard
Ope
ratin
g Pr
oced
ures
(S
OP)
for a
ll its
pro
cess
es
(MO
V- S
OP
deve
lope
d an
d av
aila
ble
at p
oint
of u
se)
Yes
No
P
11.1
1.4
.2 O
nly
trai
ned,
qu
alifi
ed a
nd a
utho
rize
d pe
rson
nel s
hall
be a
llow
ed to
co
llect
ana
lyse
and
rel
ease
th
e re
sults
of p
atie
nts.
The
labo
rato
ry is
run
and
man
aged
by
qual
ified
and
au
thor
ized
pro
fess
iona
ls
(MO
V- H
R Re
cord
s/Dat
a ba
se –
def
ined
qua
lific
atio
ns
of st
aff)
Yes
No
P
85 |
Pa
ge
St
anda
rd
Requ
irem
ents
Sc
ore
(tic
k ap
prop
riat
e bo
x)
Rem
arks
11.1
1.4
.3 A
ll la
bora
tory
eq
uipm
ent s
hall
be
mai
ntai
ned
in a
func
tiona
l co
nditi
on.
Ther
e is
evi
denc
e of
rout
ine
calib
ratio
n of
equ
ipm
ent
(incl
udin
g pi
pette
s, ce
ntrif
uges
, bal
ance
s, an
d th
erm
omet
ers)
sche
dule
d, a
t min
imum
, fol
low
ing
man
ufac
ture
r rec
omm
enda
tions
and
ver
ified
(M
OV-
Calib
ratio
n re
cord
s, sc
hedu
le o
f cal
ibra
tion,
m
aint
enan
ce o
f equ
ipm
ent,
evid
ence
of c
alib
ratio
n ce
rtific
ates
,)
Yes
No
Prev
entiv
e m
aint
enan
ce p
erfo
rmed
on
all e
quip
men
t and
re
cord
ed
(MO
V- M
aint
enan
ce re
cord
s)
Yes
No
P
Man
ufac
ture
r’s o
pera
tor m
anua
ls re
adily
ava
ilabl
e to
te
sting
staf
f in
a la
ngua
ge u
nder
stood
by
the
staff
. (M
OV-
SO
Ps a
nd m
anuf
actu
rers
ope
ratin
g m
anua
ls)
Yes
No
P
11.1
1.4.
4 Ex
amin
atio
n pr
oced
ures
shal
l be
veri
fied/
valid
ated
for
the
labo
rato
ry b
efor
e be
ing
intr
oduc
ed in
to r
outin
e us
e
Exam
inat
ion
met
hods
and
pro
cedu
res s
hall
be v
alid
ated
an
d ve
rifie
d be
fore
bei
ng in
trodu
ced
into
rout
ine
use
(*
Not
e: S
tand
ard
met
hods
do
not n
eed
to b
e va
lidat
ed,
but s
hall
be v
erifi
ed) (
See
ISO
151
89 a
nd C
LSI
guid
elin
es)
(MO
V- S
OP
on v
alid
atio
n an
d ve
rific
atio
n,
evid
ence
of v
alid
atio
n/ v
erifi
catio
n of
met
hods
. St
atem
ent o
f acc
epta
bilit
y of
the
met
hod)
Yes
No
Each
new
reag
ent p
repa
ratio
n, n
ew lo
t num
ber,
new
sh
ipm
ent o
f rea
gent
s or c
onsu
mab
les s
hall
be v
erifi
ed
befo
re u
se a
nd d
ocum
ente
d (M
OV-
Evi
denc
e of
ver
ifica
tion
of re
agen
ts an
d co
nsum
able
s bef
ore
use
in la
bora
tory
e.g
. lot
to lo
t ve
rific
atio
n)
Yes
No
P
86 |
Pa
ge
St
anda
rd
Requ
irem
ents
Sc
ore
(tic
k ap
prop
riat
e bo
x)
Rem
arks
11.1
1.4
.5 In
tern
al Q
ualit
y C
ontr
ol (I
QC
) sha
ll be
pe
rfor
med
, doc
umen
ted,
and
ve
rifie
d fo
r al
l te
sts/p
roce
dure
s bef
ore
rele
asin
g pa
tient
s’ r
esul
ts
IQC
resu
lts a
re m
onito
red
and
revi
ewed
(inc
ludi
ng
bias
es a
nd L
evy-
Jenn
ings
cha
rts fo
r qua
ntita
tive
tests
) an
d co
rrec
tive
actio
ns ta
ken
whe
n qu
ality
con
trol r
esul
ts ex
ceed
the
acce
ptab
le ra
nge.
(MO
V- le
vy c
hart
s an
alys
ed a
nd c
orre
ctiv
e ac
tions
take
n in
cas
e of
non
-co
nfor
mity
)
Yes
No
P
11.1
1.4
.6 T
he la
bora
tory
sh
all p
artic
ipat
e in
inte
r-la
bora
tory
com
pari
son
prog
ram
s or
prof
icie
ncy
test
ing
or a
ltern
ativ
e as
sess
men
t sys
tem
s for
all
test
s
Inte
r-lab
orat
ory
com
paris
on p
rogr
amm
e(s)
hav
e cl
inic
ally
rele
vant
cha
lleng
es th
at m
imic
pat
ient
s’
sam
ples
and
hav
e th
e ef
fect
of c
heck
ing
the
entir
e ex
amin
atio
n pr
oces
ses i
nclu
ding
pre
-exa
min
atio
n,
exam
inat
ion
and
post
exam
inat
ion
proc
edur
es w
here
po
ssib
le
(MO
V- fe
edba
ck fr
om th
e Pr
ofic
ienc
y te
sting
pro
vide
r on
par
ticip
atio
n o
n P
rofic
ienc
y te
sting
, cor
rect
ive
actio
ns ta
ken
in c
ase
of fa
ilure
of
Prof
icie
ncy
testi
ng)
Yes
No
P
11.1
1.5
Pos
t exa
min
atio
n pr
oces
ses
11.1
1.5.
1 A
ll te
st r
esul
ts
repo
rts s
hall
be le
gibl
e,
tech
nica
lly
veri
fied/
valid
ated
, and
co
nfir
med
aga
inst
pat
ient
in
form
atio
n
Repo
rts o
f tes
t res
ults
are
legi
ble,
tech
nica
lly
verif
ied/
valid
ated
, and
con
firm
ed a
gain
st pa
tient
in
form
atio
n (M
OV-
Sam
ple
5 la
b re
sults
)
Yes
No
P
11.1
1.5.
2 R
esul
ts sh
all b
e in
terp
rete
d an
d re
leas
ed b
y au
thor
ized
per
sonn
el.
Resu
lts in
terp
rete
d an
d re
leas
ed b
y au
thor
ized
per
sonn
el
(MO
V- li
st o
f aut
hori
sed
pers
onne
l to
inte
rpre
t res
ults)
Y
es
N
o
P
87 |
Pa
ge
St
anda
rd
Requ
irem
ents
Sc
ore
(tic
k ap
prop
riat
e bo
x)
Rem
arks
11.1
1.5.
3 R
epor
ting
mec
hani
sm sh
all b
e in
pla
ce
for
criti
cal a
nd u
rgen
t re
sults
.
Labo
rato
ry h
as a
repo
rting
pro
cedu
re fo
r crit
ical
and
ur
gent
resu
lts (
MO
V- S
OP
on c
ritic
al re
port
ing,
pas
t re
cord
s on
criti
cal r
epor
ting)
Yes
No
P
11.1
1.5.
4 Th
e la
bora
tory
re
port
shal
l be
com
preh
ensiv
e an
d cl
ear
Labo
rato
ry re
ports
are
cle
ar a
nd in
clud
e:
- Ex
amin
atio
n pe
rfor
med
, -
Patie
nt id
entif
icat
ion,
-
Nam
e or
uni
que
iden
tifie
r of t
he re
ques
ting
pers
on ,
-
Exam
inat
ion
resu
lts re
porte
d in
SI u
nits,
or o
ther
ap
plic
able
uni
ts,
- Bi
olog
ical
refe
renc
e in
terv
als,
-
Inte
rpre
tatio
n of
resu
lts a
s app
ropr
iate
, -
Iden
tific
atio
n of
per
son
unde
rtaki
ng th
e ex
amin
atio
n an
d pe
rson
revi
ewin
g th
e re
sults
(MO
V- e
vide
nce
of a
stan
dard
ized
repo
rt )
Yes
No
P
11.1
1.5.
5 A
ll ar
chiv
ed r
esul
ts
shal
l be
prop
erly
labe
lled
and
stor
ed in
a se
cure
lo
catio
n, e
asily
ret
riev
able
an
d ac
cess
ible
onl
y to
au
thor
ized
per
sonn
el
Arc
hive
d re
sults
are
pro
perly
labe
lled
and
store
d in
a
secu
re lo
catio
n ac
cess
ible
onl
y to
aut
horiz
ed p
erso
nnel
(M
OV-
SO
P on
arc
hivi
ng, r
ecor
ds o
f arc
hive
d re
port)
Yes
No
11.1
1.5.
6 Th
e la
bora
tory
sh
all d
efin
e le
ngth
of t
ime
clin
ical
sam
ples
will
be
reta
ined
, whi
ch sh
all b
e
The
labo
rato
ry h
as a
def
ined
per
iod
for c
linic
al sa
mpl
es
rete
ntio
n, w
hich
dep
ends
on
the
natu
re o
f the
sam
ple,
the
exam
inat
ion
and
any
appl
icab
le re
quire
men
ts
(reg
ulat
ion)
Yes
No
88 |
Pa
ge
St
anda
rd
Requ
irem
ents
Sc
ore
(tic
k ap
prop
riat
e bo
x)
Rem
arks
alig
ned
to c
urre
nt
regu
latio
n.
(MO
V- re
tent
ion
guid
elin
es a
nd a
s per
app
licab
le
regu
latio
ns ,
rete
ntio
n re
cord
s)
11.1
1.5.
7 Sa
mpl
e di
spos
al
shal
l be
carr
ied
out i
n ac
cord
ance
with
was
te
man
agem
ent r
egul
atio
ns.
Sam
ple
disp
osal
car
ried
out i
n ac
cord
ance
with
was
te
man
agem
ent r
egul
atio
ns
(MO
V- R
ecor
ds o
f was
te d
ispos
al)
Yes
No
P
11.1
1.5.
8 W
here
the
labo
rato
ry u
ses i
nfor
mat
ion
man
agem
ent s
yste
ms,
the
labo
rato
ry sh
all d
efin
e le
vels
of a
cces
s aut
hori
zatio
n an
d re
spon
sibi
litie
s for
the
man
agem
ent a
nd u
se o
f the
la
bora
tory
info
rmat
ion
syst
em
The
labo
rato
ry d
efin
es le
vels
of a
cces
s aut
horiz
atio
n an
d re
spon
sibili
ties f
or th
e m
anag
emen
t and
use
of t
he
labo
rato
ry in
form
atio
n sy
stem
(M
OV-
reco
rds s
howi
ng le
vel a
nd a
utho
rity
for a
cces
s, us
e of
pas
swor
ds)
Yes
No
11.1
1.5.
9 A
ll re
sults
that
ha
ve b
een
tran
smitt
ed
elec
tron
ical
ly o
r re
prod
uced
ex
tern
ally
to th
e la
bora
tory
sh
all b
e ve
rifie
d
Resu
lts th
at h
ave
been
tran
smitt
ed e
lect
roni
cally
or
repr
oduc
ed e
xter
nally
to th
e la
bora
tory
(com
pute
rs, f
ax
mac
hine
s, em
ail a
nd w
ebsit
es a
nd p
erso
nal w
eb d
evic
es)
are
verif
ied
(MO
V- S
OP
on
verif
icat
ion
of th
e so
ftwar
e)
Yes
No
P
89 |
Pa
ge
St
anda
rd
Req
uire
men
ts
Scor
e (t
ick
appr
opri
ate
box)
R
emar
ks
11.1
1.6
Poi
nt o
f Car
e Te
sting
11.1
1.6.
1 Th
e he
alth
faci
lity
man
agem
ent s
hall
be
resp
onsi
ble
for
ensu
ring
th
at a
ppro
pria
te m
easu
res
are
put i
n pl
ace
to p
rovi
de
and
mon
itor
poin
t of c
are
test
ing
with
in th
e in
stitu
tion
Ther
e is
a q
ualif
ied
staf
f mem
ber r
espo
nsib
le fo
r de
velo
ping
and
impl
emen
ting
poi
nt o
f car
e te
sting
pro
cedu
res
(MO
V –
HR
reco
rds)
Yes
No
Trai
ning
pro
gram
in p
lace
for P
OCT
(M
OV-
trai
ning
pro
gram
)
Y
es
No
Faci
lity
proa
ctiv
ely
deal
with
non
conf
orm
ities
ar
isin
g fr
om P
OCT
. (M
OV-
faile
d qu
ality
con
trol
and
EQ
A re
port
s)
Yes
N
o
Faci
lity
impl
emen
ts p
roce
ss fo
r com
paris
on o
f eq
uipm
ent /
met
hods
(M
OV-
repo
rt)
Yes
N
o
Proc
edur
es fo
r ord
erin
g a
nd c
olle
ctio
n of
sa
mpl
es fo
r po
int o
f car
e te
st ar
e d
ocum
ente
d (M
OV
–obs
erva
tion
of d
ocum
ente
d pr
oced
ure)
Yes
N
o
90 |
Pa
ge
11
.12
Phar
mac
y
Stan
dard
Re
quir
emen
ts
Scor
e (t
ick
appr
opri
ate
box)
Re
mar
ks
11.1
2.1
The
hea
lth fa
cilit
y sh
all p
rovi
de a
dequ
ate
reso
urce
s to
supp
ort
prov
ision
of q
ualit
y ph
arm
aceu
tical
serv
ices
The
phar
mac
y is
app
ropr
iate
ly st
affe
d ba
sed
on th
e H
RH n
orm
s and
stan
dard
s (M
OV-
HR
Reco
rds)
Y
es
N
o
All
phar
mac
eutic
al st
aff a
re re
giste
red
by th
e Ph
arm
acy
and
Poiso
ns B
oard
(MO
V- H
R Re
cord
s)
Yes
No
The
faci
lity
has t
able
t cou
nter
s, di
spen
sing
so
ftwar
e, a
nd re
frig
erat
or a
s per
the
exist
ing
infr
astru
ctur
e no
rms a
nd st
anda
rds (
MO
V-O
bser
vatio
n)
Yes
No
P
The
faci
lity
has t
empe
ratu
re c
ontro
lled,
wel
l ve
ntila
ted
com
mod
ity st
orag
e ro
om w
ith ra
cks
(MO
V-O
bser
vatio
n, te
mpe
ratu
re c
hart
s)
Yes
No
11.1
2.2
The
heal
th fa
cilit
y sh
all e
nsur
e th
at
phar
mac
eutic
al se
rvic
es
are
prov
ided
bas
ed o
n th
e be
st p
harm
aceu
tical
pr
actic
es
Ther
e is
a sy
stem
in p
lace
in th
e ph
arm
acy
for
dete
ctio
n of
pre
scrip
tion
erro
rs (M
OV-
SOP)
Y
es
N
o
Ther
e is
a pr
oced
ure
in th
e ph
arm
acy
for r
ectif
ying
de
tect
ed p
harm
aceu
tical
err
ors
(MO
V-D
ocum
ente
d pr
oced
ure
)
Yes
No
Ther
e is
a pr
ovis
ion
in th
e ph
arm
acy
for
conf
iden
tial c
ouns
ellin
g of
clie
nts o
n th
e us
e of
m
edic
ines
and
oth
er p
rodu
cts d
ispe
nsed
by
the
phar
mac
y (M
OV-
Obs
erva
tion)
Yes
No
91 |
Pa
ge
St
anda
rd
Requ
irem
ents
Sc
ore
(tic
k ap
prop
riat
e bo
x)
Rem
arks
Phar
mac
y ad
here
s to
the
stand
ard
oper
atin
g pr
oced
ures
for e
xtem
pora
neou
s pre
para
tions
and
re
cons
titut
ions
(M
OV-
ava
ilabi
lity
of
clea
n wa
ter a
nd d
ispen
sing
co
ntai
ners
)
Yes
No
P
Ther
e is
evid
ence
of s
tora
ge a
nd u
se o
f pr
escr
iptio
n da
ta fo
r dec
ision
mak
ing
(MO
V- M
edic
ines
and
The
rape
utic
Com
mitt
ee
min
utes
)
Yes
No
P
11.1
2.3
The
faci
lity
shal
l es
tabl
ish m
echa
nism
s for
en
suri
ng th
e sa
fety
of
med
icin
al p
rodu
cts,
incl
udin
g va
ccin
es a
nd
herb
al m
edic
atio
ns
Ther
e is
a ch
eckl
ist
to d
eter
min
e th
at th
e m
edic
ines
are
of g
ood
qual
ity a
nd sa
fe to
use
(M
OV-
Chec
klis
t)
Yes
No
Nar
cotic
s and
psy
chot
ropi
c m
edic
ines
are
ac
coun
ted
for i
n ac
cord
ance
to th
e SO
Ps a
nd
spec
ified
regi
ster
s (M
OV-
Nar
cotic
s reg
ister
, DD
A)
Yes
No
Ther
e is
a sy
stem
for p
harm
aco-
vigi
lanc
e
(MO
V- p
harm
acov
igila
nce
regi
ster
/ for
ms)
Y
es
N
o
11.1
2.4
The
faci
lity
shal
l es
tabl
ish a
mec
hani
sm fo
r m
edic
atio
n th
erap
y m
anag
emen
t
Ther
e is
a ph
arm
aceu
tical
car
e pl
an, w
hich
is
com
mun
icat
ed to
the
pres
crib
er/p
rovi
der a
nd th
e cl
ient
. (M
OV-
List
of a
vaila
ble
drug
s)
Yes
No
Ther
e is
a tra
ckin
g ch
art f
or m
edic
ines
(M
OV-
ava
ilabi
lity
of tr
acki
ng c
hart
).
Y
es
N
o
92 |
Pa
ge
St
anda
rd
Requ
irem
ents
Sc
ore
(tic
k ap
prop
riat
e bo
x)
Rem
arks
Ther
e is
evid
ence
of d
ocum
enta
tion
of m
edic
ines
an
d th
erap
eutic
com
mitt
ee m
eetin
gs.
(MO
V- M
inut
es o
f MTC
)
Yes
No
11.1
2.5
The
heal
th fa
cilit
y sh
all e
nsur
e ph
arm
aceu
tical
staf
f un
derg
o re
gula
r tr
aini
ng, u
pdat
e th
eir
skill
s an
d ca
rry
out o
pera
tiona
l re
sear
ch
Ther
e is
evid
ence
of a
CM
E sc
hedu
le, r
egist
er a
nd
min
utes
by
the
phar
mac
y de
partm
ent a
t lea
st o
nce
ever
y m
onth
(M
OV-
CM
E re
port)
Yes
No
Ther
e is
a do
cum
ente
d pl
an o
f hea
lth e
duca
tion
for
clie
nts/
clin
icia
ns
(MO
V- S
ched
ules
)
Yes
No
Ther
e is
evid
ence
that
the
faci
lity
carr
ies o
ut
oper
atio
nal r
esea
rch
to in
form
pha
rmac
y de
cisio
ns.
(MO
V-Re
sear
ch re
port)
Yes
No
93 |
Pa
ge
D
IMEN
SIO
N 1
2: R
ESU
LTS
The
faci
lity
shal
l ass
ess i
ts p
erfo
rman
ce o
n a
quar
terly
bas
is us
ing
a se
t of d
efin
ed k
ey p
erfo
rman
ce in
dica
tors
. Tre
nds f
or th
e K
PIs s
hall
be a
naly
sed
and
docu
men
ted.
The
se in
dica
tors
hav
e be
en o
utlin
ed in
the
sect
ion
belo
w:
No.
In
dica
tor
Benc
hmar
k 0
1 2
3 4
1 Pa
tient
satis
fact
ion
inde
x 85
%
˂21%
21
-42%
43
-63%
64
-84%
≥8
5%
2 St
aff s
atis
fact
ion
inde
x 85
%
˂21%
21
-42%
43
-63s
%
64-8
4%
≥85%
3
Epis
odes
of s
tock
out
of a
ny o
f the
22
esse
ntia
l med
icin
es a
nd su
pplie
s la
sting
ove
r 7 d
ays i
n th
e la
st th
ree
mon
th
0 ≥7
epi
sode
s 5-
6 ep
isode
s 3-
4 ep
isode
s 1-
2 ep
isod
es
0
4 D
own
time
rate
s for
vac
cine
s frid
ge:
Num
ber o
f day
s the
vac
cine
frid
ge w
as
not f
unct
iona
l in
the
past
90 d
ays
0 ≥7
day
s 5-
6 da
ys
3-4
days
1-
2 da
ys
0 da
ys
5 Pr
opor
tion
of e
mer
genc
y pa
tient
s re
ferr
ed w
ithin
30
min
utes
of d
ecisi
on
mak
ing
Num
erat
or: N
umbe
r of e
mer
genc
y pa
tient
s ref
erre
d by
the
faci
lity
with
in
30 m
inut
es o
f dec
isio
n m
akin
g D
enom
inat
or: T
otal
num
ber o
f em
erge
ncy
patie
nts r
efer
red
by th
e fa
cilit
y
100%
˂
25%
25
-49%
50
-74%
75
-99%
10
0%
6 P
ropo
rtion
of u
nder
yea
r one
chi
ldre
n va
ccin
ated
aga
inst
Mea
sles a
nd
Rube
lla
Num
erat
or: N
o. o
f chi
ldre
n un
der 1
yr
imm
uniz
ed a
gain
st m
easl
es
Den
omin
ator
: Fac
ility
targ
et
popu
latio
n un
der 1
year
of a
ge
90%
˂
22
22-4
4%
45-6
7%
68-8
9%
≥90%
94 |
Pa
ge
N
o.
Indi
cato
r Be
nchm
ark
0 1
2 3
4 70
Pr
opor
tion
of w
omen
with
per
inea
l te
ars G
rade
2-4
N
umer
ator
: Num
ber o
f wom
en w
ith
perin
eal t
ears
D
enom
inat
or: T
otal
num
ber o
f va
gina
l del
iver
ies
3 ˃
5.3
5.3-
4.4%
4.
5-3.
9%
3.8-
3%
˂3
8 Fa
cilit
y-ba
sed
dire
ct o
bste
tric
case
fa
talit
y ra
te
Num
erat
or: N
umbe
r of m
ater
nal
deat
hs a
t fac
ility
D
enom
inat
or: N
umbe
r of o
bste
tric
com
plic
atio
ns m
anag
ed a
t fac
ility
1%
˃ 1.
75
1.75
-1.6
%
1.5-
1.26
%
1.25
-1%
˂1
9 Pr
opor
tion
of m
ater
nal d
eath
s aud
ited
N
umer
ator
: Num
ber o
f mat
erna
l de
aths
aud
ited
Den
omin
ator
: Tot
al n
umbe
r of
mat
erna
l dea
ths
100%
˂
25%
25
-49%
50
-74%
75
-99%
10
0%
10
Prop
ortio
ns o
f new
born
s suc
cess
fully
re
susc
itate
d N
umer
ator
: Num
ber o
f new
born
s su
cces
sful
ly re
susc
itate
d D
enom
inat
or: N
umbe
r of n
ewbo
rns
requ
iring
resu
scita
tion
100%
˂
25%
25
-49%
50
-74%
75
-99%
10
0%
11
Prop
ortio
n of
bab
ies w
ith c
onfir
med
or
susp
ecte
d ne
onat
al in
fect
ion
(incl
udin
g re
adm
issio
ns w
ithin
seve
n da
ys o
f di
scha
rge)
N
umer
ator
: Num
ber o
f bab
ies w
ith
conf
irmed
or s
uspe
cted
neo
nata
l in
fect
ion
(incl
udin
g re
adm
issio
ns
with
in se
ven
days
of d
ischa
rge)
D
enom
inat
or: T
otal
num
ber o
f liv
e bi
rths i
n th
e he
alth
faci
lity
5 ˃8
.8%
8.
8-7.
6%
7.5-
6.4%
6.
3-4.
9%
≤5%
12.
Prop
ortio
n of
bab
ies b
orn
with
low
5%
˃8
.8%
8.
8-7.
6%
7.5-
6.4%
6.
3-4.
9%
≤5%
95 |
Pa
ge
N
o.
Indi
cato
r Be
nchm
ark
0 1
2 3
4 bi
rth w
eigh
t N
umer
ator
: Num
ber o
f bab
ies b
orn
with
wei
ght ˂
2500
g D
enom
inat
or: T
otal
num
ber o
f liv
e bi
rths
13
Faci
lity-
base
d pe
rinat
al m
orta
lity
rate
N
umer
ator
: Num
ber o
f per
inat
al
deat
hs (a
ll st
illbi
rths a
nd e
arly
ne
onat
al d
eath
s inc
ludi
ng
read
mis
sions
) D
enom
inat
or: T
otal
num
ber o
f birt
hs
1%
˃ 1.
75
1.75
-1.6
%
1.5-
1.26
%
1.25
-1%
˂1
14
Still
birth
rate
N
umer
ator
: Num
ber o
f bab
ies w
ith
no si
gns o
f life
at b
irth
(at o
r afte
r 28
wee
ks o
f ges
tatio
n an
d w
eigh
ting
≥100
0 gr
ams)
D
enom
inat
or: T
otal
# o
f birt
hs in
the
faci
lity
10
˃17.
5 st
ill b
irths
pe
r 100
0 liv
e bi
rths
17.5
-15.
1 st
ill
birth
s per
100
0 liv
e bi
rths
15.0
-12.
6 st
ill
birth
s per
100
0 liv
e bi
rths
12.5
-10.
1 sti
ll bi
rths p
er 1
000
live
birth
s
≤10
stil
l birt
hs
per 1
000
live
birth
s
15
Faci
lity-
base
d ne
onat
al m
orta
lity
rate
N
umer
ator
: Num
ber o
f neo
nata
l de
aths
D
enom
inat
or: T
otal
num
ber o
f liv
ebirt
hs
12 m
orta
litie
s pe
r 100
0 liv
e bi
rths
˃ 21
mor
talit
ies
per 1
000
live
birth
s
21-1
8.1
mor
talit
ies
per
1000
live
birt
hs
18-1
5.1
mor
talit
ies
per
1000
live
birt
hs
15.0
-12.
1 m
orta
litie
s pe
r 10
00 li
ve b
irths
˂ 12
mor
talit
ies
per 1
000
live
birth
s
16
Faci
lity-
base
d pn
eum
onia
cas
e fa
talit
y ra
te fo
r chi
ldre
n un
der 5
yrs
Num
erat
or: N
umbe
r of d
eath
s of
child
ren
unde
r 5yr
s fro
m p
neum
onia
D
enom
inat
or: T
otal
num
ber o
f pn
eum
onia
cas
es o
f chi
ldre
n un
der 5
yr
s
5%
˃8.8
%
8.8-
7.6%
7.
5-6.
4%
6.3-
4.9%
≤5
%
17
Faci
lity-
base
d di
arrh
oea
case
fata
lity
rate
in c
hild
ren
unde
r 5 y
ears
of a
ge
Num
erat
or: N
umbe
r of d
eath
s of
child
ren
belo
w 5
yea
rs o
f age
from
1%
˃ 1.
75
1.75
-1.6
%
1.5-
1.26
%
1.25
-1%
˂1
96 |
Pa
ge
N
o.
Indi
cato
r Be
nchm
ark
0 1
2 3
4 di
arrh
oea
Den
omin
ator
: Tot
al n
umbe
r of
inpa
tient
dia
rrho
ea c
ases
in c
hild
ren
belo
w 5
year
s of a
ge
18
Perc
enta
ge o
f per
inat
al d
eath
s aud
ited
Num
erat
or: N
umbe
r of p
erin
atal
de
aths
aud
ited
Den
omin
ator
: Tot
al n
umbe
r of
perin
atal
dea
ths
100%
˂
25%
25
-49%
50
-74%
75
-99%
10
0%
197
TB c
ure
rate
N
umer
ator
: Num
ber o
f TB
cas
es
cure
d D
enom
inat
or: T
otal
num
ber o
f TB
case
s tre
ated
90%
˂
22
22-4
4%
45-6
7%
68-8
9%
≥90%
20
HIV
vira
l loa
d su
ppre
ssio
n
Num
erat
or: N
umbe
r of H
IV p
atie
nts
on tr
eatm
ent w
hose
vira
l loa
ds a
re
supp
ress
ed b
elow
100
0 co
pies
/μl
Den
omin
ator
: Tot
al n
umbe
r of H
IV
patie
nts o
n tre
atm
ent
90%
˂
22
22-4
4%
45-6
7%
68-8
9%
≥90%
21
Mal
aria
inpa
tient
cas
e fa
talit
y ra
te
Num
erat
or: N
umbe
r of d
eath
s due
to
mal
aria
D
enom
inat
or: T
otal
num
ber o
f in
patie
nt m
alar
ia c
ases
5%
˃8.8
%
8.8-
7.6%
7.
5-6.
4%
6.3-
4.9%
≤5
%
22
Perc
enta
ge o
f dia
lysis
pat
ient
s with
m
ost r
ecen
t hae
mog
lobi
n ab
ove
12g/
dl
Num
erat
or: N
umbe
r of d
ialy
sis
patie
nts w
hose
hae
mog
lobi
n le
vel i
s ab
ove
12g/
dl
Den
omin
ator
: Tot
al n
umbe
r of
patie
nts u
nder
goin
g di
alys
is in
the
last
one
year
.
100%
˂
25%
25
-49%
50
-74%
75
-99%
10
0%
97 |
Pa
ge
N
o.
Indi
cato
r Be
nchm
ark
0 1
2 3
4 23
A
ll w
omen
of r
epro
duct
ive
age
acce
ssin
g ca
re a
t the
hea
lth fa
cilit
y ar
e sc
reen
ed fo
r cer
vica
l can
cer
Num
erat
or: N
umbe
r of w
omen
sc
reen
ed fo
r cer
vica
l can
cer
Den
omin
ator
: All
wom
en o
f re
prod
uctiv
e ag
e ac
cess
ing
care
at t
he
heal
th fa
cilit
y
75%
˂1
8%
18-3
7%
37-5
6%
57-7
4%
≥75%
24
Faci
lity
base
d in
patie
nt fa
talit
y ra
te
(%)
Num
erat
or: N
umbe
r of d
eath
s D
enom
inat
or: T
otal
num
ber o
f ad
mis
sion
s
2 ˃3
.5%
3.
5-3.
1%
3.0-
2.6%
2.
5-2%
˂2
%
25
Qua
rterly
dat
a qu
ality
aud
its c
arrie
d ou
t in
the
past
one
yea
r 4
0 1
2 3
4
98 |
Pa
ge
APP
END
ICES
A
ppen
dix
1: A
&E
Equi
pmen
t Th
e ba
sic e
quip
men
t and
supp
lies n
eede
d fo
r eff
ectiv
e ru
nnin
g of
the
A&
E ar
e lis
ted
belo
w:
Airw
ays/B
reat
hing
Bag
valv
e m
ask
Ch
est t
ube
/ und
erw
ater
seal
dra
inag
e
Co
mbi
tube
Elas
tic g
um b
ougi
es
En
dotra
chea
l tub
e
La
ryng
eal M
ask
Airw
ay
La
ryng
osco
pe, v
ario
us si
zes o
f bla
des
M
cGill
forc
eps
N
asal
pro
ngs
N
asop
hary
ngea
l airw
ays
N
ebul
izer
mac
hine
Oro
phar
ynge
al a
irway
s
Oxy
gen
cylin
der w
ith a
flow
met
re
Su
ctio
n m
achi
nes,
tube
s and
cat
hete
rs
Th
orac
otom
y se
t
Tong
ue d
epre
ssor
Trac
heos
tom
y se
t
Tran
spor
t Ven
tilat
ors
Oth
er A
&E
Equi
pmen
t
Barlo
ws t
ape
mea
sure
(for
chi
ldre
n)
W
eigh
ing
scal
e
Te
leph
one
and
dire
ctor
y
Pe
dal o
pera
ted
colo
ur-c
oded
was
te b
ins
Sa
fety
box
for s
harp
s
Bloo
d fri
dge
Cabi
nets
Com
pute
r (s)
and
acc
esso
ries a
nd a
ppro
pria
te so
ftwar
e
D
rug
cabi
net
Ex
amin
atio
n co
uch
Exam
inat
ion
lam
ps
H
oist
Instr
umen
t tra
ys
O
ffic
e fu
rnitu
re
EP
I Ref
riger
ator
Resu
scita
tion
trolle
y/tra
y
Ro
llers
Stre
tche
rs
Pr
oced
ure
trolle
ys
W
heel
cha
irs
Sp
lints
Band
ages
Cerv
ical
col
lar –
hard
col
lar
Pl
aste
r of
Paris
Spin
e bo
ard
Trac
tion
kit
Mon
itorin
g D
evic
es
Pu
lse o
xim
eter
Patie
nt M
onito
rs (i
nvas
ive*
** a
nd n
on in
vasi
ve)
G
luco
met
er
Bl
ood
gas e
lect
roly
te a
naly
ser
Sp
irom
eter
/ pea
k flo
w m
eter
Ther
mom
eter
99 |
Pa
ge
D
iagn
osis
set
St
etho
scop
e
Sp
hygm
oman
omet
er (D
igita
l & A
nero
id)
Circ
ulat
ion/
Hae
mod
ynam
ics
12
lead
ECG
mac
hine
Bloo
d an
d flu
id w
arm
er
Ce
ntra
l ven
ous c
athe
ters
Def
ibril
lato
r/ A
utom
ated
Ext
erna
l Def
ibril
lato
r (A
ED)
Fo
leys
cat
hete
r s
In
fusio
n pu
mps
Intra
oseo
us N
eedl
es
IV
can
nula
e 14
, 16
18 2
0 an
d 22
Syrin
ge p
umps
Dia
gnos
tic
M
obile
X-r
ay m
achi
ne
D
iagn
ostic
set
Sp
ecim
en b
ottle
s
Lum
bar p
unct
ure
set
Fo
etal
hea
rt m
onito
r
Ultr
asou
nd m
achi
ne
100
| Pa
ge
A
ppen
dix
2: E
ssen
tial M
edic
ines
M
edic
ine
D
escr
iptio
n
1.
Cap
A
mox
icill
in
250m
g 2.
Sy
r Am
oxic
illin
12
5mg/
5ml
3.
Tab
Para
ceta
mol
50
0mg
4.
Tab
Cot
rimox
azol
e
480m
g 5.
Ta
b A
lben
dazo
le
400m
g 6.
Ta
b C
hlor
phen
iram
ine
4m
g 7.
Ta
b A
rtem
isin
in lu
mef
antri
ne
20/1
20m
g 8.
Su
sp M
etro
nida
zole
20
0mg
/ 5m
l 9.
In
j Gen
tam
ycin
10.
Inj B
enzy
lpen
icill
in
11
In
j Adr
enal
ine
1m
g/m
l 12
. In
j Hyd
roco
rtiso
ne
100m
g/m
l 13
. O
ral r
ehyd
ratio
n sa
lt 50
0ML/
satc
het
14.
Tetra
cycl
ine
eye
oint
men
t 1%
15
. C
lotri
maz
ole
crea
m
1%
16.
Inj.
Oxy
toci
n
17.
Infu
sion
Nor
mal
Sal
ine
#
101
| Pa
ge
A
ppen
dix
3: L
ist o
f Tra
cer
Non
-pha
rmac
eutic
al p
rodu
cts
No.
Ite
m D
escr
iptio
n
Item
cat
egor
y U
nit o
f Iss
ue
1 Co
tton,
Gau
ze P
lain
36"
x 1
00yd
s - 1
500g
ms B
P w
eigh
t Whi
te c
olou
r, Lo
osel
y W
oven
and
abs
orbe
nt
Surg
ical
dre
ssin
g ro
lls
2 Co
tton
woo
l 400
gm
Surg
ical
dre
ssin
g ro
lls
3 G
ivin
g se
ts, B
lood
, Dou
ble
Cha
mbe
r
surg
ical
syrin
ges/
need
les /
cann
ulas
Bo
x of
25
4
Aut
ocla
ving
Tap
e
Surg
ical
dre
ssin
g pa
ck o
f 10
5 Co
rd C
lum
ps
Surg
ical
dre
ssin
g pa
ck o
f 100
6 G
love
s :
Gyn
aeco
logi
cal
glov
es
Surg
ical
glo
ves
pair
s Su
rgic
al L
atex
Glo
ves
(Ste
rile)
size
7.5
“
Surg
ical
glo
ves
Pack
of 5
0 pa
irs
Cl
ean
glov
es
Surg
ical
glo
ves
Pack
of 5
0 pa
irs
7 G
ivin
g se
ts, B
lood
, Dou
ble
Cha
mbe
r
surg
ical
syrin
ges/
need
les /
cann
ulas
8 G
ivin
g Se
ts, IV
Flu
id In
fusio
n, w
ith a
ir in
lets
surg
ical
syrin
ges/
need
les /
cann
ulas
9 Ca
thet
ers F
olle
y's 3
0ml s
ize
- 16
FG
Surg
ical
tube
s Pi
eces
10
I.V
. Can
nula
s : -
shor
t Tef
lon,
18G
- sho
rt Te
flon,
24G
Su
rgic
al tu
bes
Pack
of 5
0
11
Sa
fety
Box
es
Surg
ical
dre
ssin
g Pa
ck o
f 50
12
Su
ture
s:
Nyl
on N
o. 2
/0 1
/2" c
ircle
reve
rse,
Cutti
ng n
eedl
e, 2
6mm
, 75c
m N
on-
abso
rbab
le (s
teril
e)
Poly
glyc
olic
aci
d 2/
0 RB
N 3
0mm
x75c
m
Sutu
res
D
ozen
13
Syrin
ges:
2m
l with
G23
Nee
dle
(Reu
se P
reve
ntio
n Sy
ringe
s)
5ml w
ith o
ne G
21n
eedl
e (R
euse
Pre
vent
ion
Syrin
ges)
Surg
ical
syrin
ges/
need
les
/can
nula
s
Box
of 1
00
14
Zinc
Oxi
de st
rapp
ing
7.5c
m x
4.5
m B
PC
Surg
ical
dre
ssin
g bo
x of
6 p
c 15
Ba
ndag
es, C
otto
n, lo
ose
Wov
en, B
P,7.
5cm
x 4
.5m
Su
rgic
al d
ress
ing
Doz
en
16
Blad
es, S
urgi
cal,
size
23
Su
rgic
al tu
bes
pack
of 1
0
102
| Pa
ge
A
ppen
dix
4: A
sses
smen
t for
cri
tical
intr
a-pa
rtum
car
e Th
e pr
ovid
er sh
all c
ondu
ct a
risk
ass
essm
ent f
or th
e m
othe
r and
unb
orn
baby
, ide
ntify
, inv
estig
ate
and
take
act
ion
to re
duce
cha
nce
of b
ad o
utco
me
in
acco
rdan
ce w
ith T
able
s 1 to
9.
Ta
ble
1: C
riter
ia fo
r crit
ical
intra
-par
tum
car
e Cr
iteria
for c
ritic
al in
trapa
rtum
car
e Re
late
d cr
iteria
ava
ilabl
e th
roug
h hy
perli
nk
Initi
al a
sses
smen
t of a
pos
t-na
tal m
othe
r •M
anag
emen
t of P
RO
M
•man
agem
ent o
f pre
term
labo
ur
Part
ogra
m
Caes
aria
n se
ctio
n
Man
agem
ent o
f ecl
ampi
a, se
vere
PE
T
Act
ive
man
agem
ent o
f thi
rd st
age
of la
bour
M
anag
emen
t of P
PH a
nd m
anua
l rem
oval
of p
lace
nta
Intr
apar
tum
car
e fo
r po
sitiv
e m
othe
r
Tabl
e 2:
App
ropr
iate
stat
us o
f fac
ility
for a
dequ
ate
care
Le
vel (
as p
er th
e KH
SSP)
Le
vel (
WH
O)
Aste
rix
Leve
l 1-3
B
asic
em
erge
ncy
Obs
tetri
cs c
are
unit
EMO
C
٭
Leve
l 4
Com
preh
ensi
ve e
mer
genc
y O
bste
trics
uni
t (CE
MO
C)
٭٭
Leve
l 5-6
C
ompr
ehen
sive
em
erge
ncy
Obs
tetri
cs u
nit
٭٭ ٭
Ref
eren
ces
103
| Pa
ge
A
ppen
dix
5: L
ist o
f equ
ipm
ent f
or m
ater
nal c
are
All
faci
litie
s will
hav
e th
e fo
llow
ing
equi
pmen
t and
com
mod
ities
:
D
eliv
ery
beds
Func
tiona
l aut
ocla
ve
Ex
amin
atio
n co
ach
Tr
acer
dru
gs (o
xyto
cin,
dex
amet
haso
ne, g
enta
myc
in, m
agne
sium
sulp
hate
, mis
opro
stol
)
Oxy
gen
B
aby
war
mer
BP
mon
itor
Fe
tosc
ope/
Dop
pler
Ster
ile p
acks
Spec
ulum
pac
k
VE
pack
Del
iver
y pa
ck
D
eliv
ery
coac
h
MV
A k
its v
ento
se/v
accu
m e
xtra
ctor
Res
usci
taire
Emer
genc
y tra
y w
ith re
quis
ite d
rugs
Res
usci
tatio
n eq
uipm
ent s
uch
as A
mbu
bag
, oxy
gen
and
suct
ion
mac
hine
s,
In a
dditi
on to
abo
ve ti
er 3
faci
litie
s will
hav
e:
B
lood
pro
duct
s
Puls
e ox
imet
er
Fu
nctio
nal t
heat
re b
ed a
nd a
naes
thet
ics
Li
fe su
ppor
t mac
hine
(mon
itor,
vent
ilato
r, pu
lse o
xim
eter
)
104
| Pa
ge
A
ppen
dix
6: L
ist o
f lab
orat
ory
Equi
pmen
t Le
vel 2
and
3 fa
cilit
ies s
houl
d ha
ve a
t min
imum
the
follo
win
g eq
uipm
ent:
H
aem
oglo
bino
met
er
R
efrig
erat
or
Ti
mer
(sto
p w
atch
)
Pipe
tte
C
entri
fuge
Glu
com
eter
Bin
ocul
ar m
icro
scop
e x1
0, x
40, x
100,
Le
vel 4
hea
lth fa
cilit
ies s
houl
d ha
ve th
e fo
llow
ing
equi
pmen
t in
addi
tion
to w
hat l
evel
2 a
nd 3
faci
litie
s hav
e:
H
aem
atol
ogy
anal
yser
Aut
ocla
ve
W
eigh
ing
bala
nce
Ta
lly c
ount
er
C
hem
istry
ana
lyse
r
Blo
od m
ixer
Wat
er b
ath,
-20
degr
ees f
reez
er.
Leve
l 5 h
ealth
faci
litie
s sho
uld
have
the
follo
win
g eq
uipm
ent i
n ad
ditio
n to
wha
t lev
el 4
faci
litie
s hav
e:
Fu
lly a
utom
ated
ana
lyze
rs
Sa
fety
hoo
d/B
iosa
fety
cab
inet
Hot
air
oven
Elec
troph
ores
is eq
uipm
ent
A
naer
obic
jars
Flow
cyt
omet
ry
EL
ISA
equ
ipm
ent
A
utom
atic
pip
ette
-70
degr
ees f
reez
ers
105
| Pa
ge
P
ATIE
NT
HAS
CON
FIRM
ED:
o
I DEN
TITY
o
SI
TE
o
P RO
CEDU
RE
o
C ON
SEN
T
S
ITE
MAR
KED
/NA
A
NAE
STHE
SIA
SAFE
TY C
HEC
K CO
MPL
ETED
PU
LSE
OXI
MET
ER O
N P
ATIE
NT
AND
FUN
CTIO
NIN
G
D OES
PAT
IEN
T HA
VE:
K NO
WN
ALL
ERG
Y?
N
O
Y
ES
D IFF
ICU
LT A
IRW
AYS/
ASPI
RATI
ON
RIS
K?
N
O
Y
ES, A
ND
EQU
IPM
ENT/
ASSI
STAN
CE A
VAIL
ABLE
R ISK
OF
>500
ML
BLO
OD
LOSS
(7M
L/KG
IN C
HIL
DREN
)?
N
O
Y
ES, A
ND
ADEQ
UAT
E IN
TRAV
ENO
US
ACCE
SS A
ND
FLU
IDS
AVAI
LABL
E
NU
RSE
VERB
ALLY
CO
NFI
RMS
WIT
H TH
E TE
AM:
T
HE N
AME
OF
THE
PRO
CED
URE
REC
ORD
ED
T
HAT
INST
RUM
ENT,
SPO
NG
E AN
D N
EEDL
E AR
E
CORR
ECT
( OR
NO
T AP
PLIC
ABLE
)
HO
W T
HE
SPEC
IMEN
IS L
ABEL
LED
( INCL
UDI
NG
PATI
ENT
NAM
E)
W
HETH
ER T
HER
E AR
E AN
Y EQ
UIP
MEN
T
PRO
BLEM
S TO
BE
ADDR
ESSE
D
S
URG
EON
, AN
AEST
HES
IA P
ROFE
SSIO
NAL
AN
D
NU
RSE
REVI
EW T
HE
KEY
CON
CERN
S FO
R
RECO
VERY
AN
D M
ANAG
EMEN
T O
F TH
IS P
ATIE
NT
THIS
CHE
CKLI
ST IS
NO
T IN
TEN
DED
TO B
E
COM
PREH
ENSI
VE. A
DDIT
ION
S AN
D
MO
DIFI
CATI
ON
S TO
FIT
LO
CAL
PRAC
TICE
ARE
ENCO
URA
GED
SIG
N IN
CON
FIRM
ALL
TEA
M M
EMBE
RS H
AVE
INTR
ODU
CED
THEM
SELV
ES B
Y N
AME
AND
ROLE
SURG
EON
, AN
AEST
HESI
A PR
OFE
SSIO
NAL
AN
D N
URS
E VE
RBAL
LY C
ON
FIRM
: o
P A
TIEN
T o
SI
TE
o
PRO
CEDU
RE
ANTI
CIPA
TED
CRI
TICA
L EV
ENTS
:
SURG
EON
REV
IEW
S : W
HAT
ARE
THE
CRIT
ICAL
OR
UN
EXPE
CTED
STE
PS, O
PERA
TIVE
DU
RATI
ON
, AN
TICI
PATE
D BL
OO
D L
OSS
?
AN
AEST
HES
IA T
EAM
REV
IEW
S : A
RE T
HERE
AN
Y PA
TEN
T -SP
ECIF
IC C
ON
CERN
S ?
NU
RSIN
G T
EAM
REV
IEW
S : H
AS S
TERI
LITY
(IN
CLU
DIN
G
INDI
CATO
R RE
SULT
S ) B
EEN
CO
NFI
RMED
? AR
E TH
ERE
EQU
IPM
ENT
ISSU
ES O
R CO
NCE
RNS ?
HAS
ANY
ANTI
BIO
TIC
PRO
PHYL
AXIS
BEE
N G
IVEN
WIT
HIN
THE
LA
ST 6
0 M
INU
TES ?
YES
NO
T AP
PLIC
ABLE
IS ES
SEN
TIAL
IMAG
ING
DIS
PLAY
ED?
Y ES
NO
T AP
PLIC
ABLE
TIM
E O
UT
SIG
N O
UT
A
ppen
dix
7: S
urgi
cal S
afet
y C
heck
list
S URG
ICAL
SAF
ETY
C HEC
KLI
ST (F
IRST
EDI
TIO
N)
Be
fore
indu
ctio
n of
anae
sthes
ia Be
fore
skin
incis
ion
Befo
re p
atien
t lea
ves o
pera
ting r
oom
106 | P a g e
TERMINOLOGY Accreditation: Third party attestation related to a conformity assessment body
conveying formal demonstration of its competence to carry out specific conformity assessment tasks.
Advanced life support: The preservation or restoration of life by the establishment
and/or maintenance of airway, breathing and circulation using invasive techniques such as defibrillation, advanced airway management, intravenous access and drug therapy.
Adverse drug reaction: A drug response that is noxious and unintended, and which
occurs at doses normally used or tested in humans for the prophylaxis, diagnosis or therapy of disease, or for the modification of physiological function.
Annual plan: The current action plan for the year for achieving organization goals
and objectives, which includes the processes, actions and resources needed for this. Also operational plan.
Assessment: Process by which the characteristics and needs of clients, groups or
situations are evaluated or determined so that they can be addressed. The assessment forms the basis of a plan of care and treatment for patients or improvement for facilities.
Assessor: External reviewer, assessor of achievement of or compliance with
agreed standards, principles and/or criteria. Basic life support: The preservation of life by the initial establishment of, and/or
maintenance of, airway, breathing, circulation and related emergency care, including use of an automated external defibrillator.
Best practice: Approaches that have been shown to produce superior results, selected
by a systematic process, and judges as exemplary. Calibration: The comparison of a measurement instrument or system of unverified
accuracy with a measurement instrument or system of known accuracy, in order to detect any variation from required measurement performance.
Care plan: A document that outlines the care and treatment to be provided to a
client, a set of actions the healthcare provider will implement to resolve health problems identified by assessment or to achieve the client’s goals and needs.
107 | P a g e
Care-givers: People who provide unpaid care and support to family members and friends who have a disability, mental illness, chronic condition, terminal illness or general frailty.
Clients: Individuals being served or provided with care or treatment by the
organization. Complaint: Expression of a problem, an issue, or dissatisfaction with services that
may be verbal or in writing. Consent: Voluntary agreement or approval given by a client. Continuity: The provision of coordinated services within and across programs and
organizations, and over time. Continuous quality improvement: A systematic, ongoing effort to raise an organization’s
performance as measured against a set of standards or indicators. Criteria: Specific steps to be taken, or activities to be done, to reach a decision
or a standard, measurable elements of a standard. Cultural appropriateness: The design and delivery of services are consistent with the
cultural values of clients who use them. Data: Facts and statistics collected together for reference or analysis, from
which information can be generated. Decontamination: The removal of dangerous substances, rendering harmless by the
removal or neutralization of poisons or radioactivity. Effectiveness: The degree to which services, interventions or actions are provided in
accordance with current best practice in order to meet goals and achieve optimal results.
Efficiency: The degree to which resources are brought together to achieve desired
results most cost effectively, with minimal waste, re-work and effort Environment: The overall surroundings where health care is being delivered,
including the building, fixtures, fittings and services such as air and water supply. Environment can also include other patients, visitors and the workforce
Escalation protocol: The protocol that sets out the organizational response required for different levels of abnormal physiological measurements or other observed deterioration. The protocol applies to the care of all patients at all times
108 | P a g e
Ethics: Acknowledged set of principles that are deemed morally correct and
which guide professional and moral conduct. Evaluation: Assessment of the degree of success in meeting the goals and expected
results (outcomes) of the organization, services, programs or clients. Evidence: Data and information used to made decisions. Evidence can be derived
from research, experiential learning, indicator data, and evaluations. Evidence is used in a systematic way to evaluate options and make decisions.
Feedback: Information or comment provided by clients in response to a service or
query. Guidelines: Clinical practice guidelines are systematically developed statements to
assist practitioner and patient decisions about appropriate health care for specific circumstances
Hand hygiene: A general term referring to any action of hand cleansing. Health outcome: The health status of an individual, a group of people or a population
that is wholly or partially attributable to an action, agent or circumstance.
Healthcare provider: A person who provides the health care for or on behalf of the
organization, group or agency, e.g. a doctor, nurse, allied health professional.
Health record: Information about a patient held in hard or soft copy. The health
service record may comprise of clinical records, administrative records and financial records (e.g. invoices, payments and insurance information.
Incident: An event or circumstance that resulted, or could have resulted, in unintended and/or unnecessary harm to a person and/or a complaint, loss or damage.
Indicator: Performance measurement tool that is used as a guide to monitor,
evaluate, and improve the quality of services. Indicators relate to structure, process, and outcomes and are rate based, i.e. have a numerator and denominator so that they can be compared and benchmarked.
Infection control or infection control measures: Actions to prevent the spread of
pathogens between people in a healthcare setting. Examples of
109 | P a g e
infection control measures include targeted healthcare associated infection surveillance, infectious disease monitoring, hand hygiene and personal protective equipment.
Informed consent: A process of communication between a patient and their medical
officer that results in the patient’s authorization or agreement to undergo a specific medical intervention. This communication should ensure the patient has an understanding of all the available options and the expected outcomes such as the success rates and/or side effects for each option
Intervention: Action taken to treat or provide care or other service designed to
improve health outcomes. Leadership: Ability to provide direction and cope with change. It involves
establishing a vision, developing strategies for producing the changes needed to implement the vision; aligning people; and motivating and inspiring people to overcome obstacles.
Management: The organization and coordination of the activities of a facility or
organization in order to achieve defined objectives. It involves setting targets or goals for the future through planning and budgeting, establishing processes for achieving those targets and allocating resources to accomplish those plans.
Medication history: An accurate recording of a patient’s medicines. It comprises a list of all
current medicines including all current prescription and
non‑prescription medicines, complementary healthcare products and medicines used intermittently; recent changes to medicines; past history of adverse drug reactions including allergies; and recreational drug
Monitoring: Being aware of the state of a system by observing a situation or process for any changes which may occur over time, usually using a measuring tool or device.
Monitoring plan: A written plan that documents the type and frequency of observations
to be recorded. Objective: A target that must be reached if the organization is to achieve its goals.
It is the translation of the goals into specific, concrete terms against which results can be measured.
110 | P a g e
Orientation: A formal process of informing and training workforce upon entry into a position or organization, which covers the policies, processes and procedures applicable to the organization.
Partograph: Tool that can be used by healthcare providers during the birthing
process to assess the progress of labor and identify when intervention is necessary.
Patient: A person receiving care in a health facility. Also referred to as
consumer or client. Patient-centered care: The delivery of health care that is responsive to the needs and
preferences of patients. Patient-centered care is a dimension of safety and quality.
Patient identifiers: Items of information accepted for use in patient identification,
including patient name, date of birth, gender, address, medical record number etc. Health facility and clinicians are responsible for specifying the approved items for patient identification. Identifiers such as room or bed number are not to be used by facilities implementing the KQMH.
Patient rights charter: A clear statement of the rights of all clients of the organization,
which all personnel are required to recognize and protect and which is supported by health facility and service policies, procedures and resource levels.
Performance evaluation: The continuous process by which a manager and a staff member
review the staff member’s performance, set performance goals, and evaluate progress towards these goals.
Performance targets: Expected levels of performance, used to assess performance achieved
compared to planned or expected performance. Policy: A set of principles that reflect the organization’s mission and direction.
All procedures and protocols are linked to a policy statement. Procedures: Written sets of instructions conveying the approved and recommended
steps for a particular act or series of acts. Procedures make policies and protocols operational and are specific to an organization.
Protocol: An established set of rules used for the completion of tasks or a set of
tasks.
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Quality: The degree of excellence, extent to which an organization meets clients’ needs and exceeds their expectations.
Quality assessment: Planned and systematic collection and analysis of data about a service,
usually focused on service content and delivery specifications and client outcomes
Quality improvement: Ongoing response to quality assessment data about a service in ways
that improve the processes by which services are provided to clients. Referral: The act of a facility or provider directing a client/patient to the care of
another facility, or service provider; or giving direction to or on behalf of the client to obtain additional services from another organization or provider.
Rights: Something that can be claimed as justly, fairly, legally, or morally
one’s own. A formal description of the services that clients can expect and demand from an organization.
Risk: The chance of something happening that will have a negative impact. It
is measured by consequences and likelihood. Risk management: The design and implementation of a program to identify and avoid or
minimize risks to patients, employees, volunteers, visitors and the institution.
Safety: The degree to which the potential risk and unintended results are
avoided or minimized. Standard: A desired and achievable level of performance against which actual
performance is measured. Standard Operating Procedures: Set of detailed, written instructions, having the force of a
directive, to achieve uniformity or standardization of the performance of a specific function.
Strategic plan: A formalized plan that establishes the organization’s overall goals and
that seeks to position the organization in terms of its environment. Surveillance: The process of data collection, collation and analysis for the purpose of
characterizing groups of risks and identifying control strategies, and the timely dissemination and feedback of data to those who need to know.
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System: The organization of resources, policies, processes and procedures that are integrated, regulated and administered to accomplish the objective of the Standard.
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Ministry of Health, Afya House, Cathedral Road,
P.O. Box 30016–00100, Nairobi, Kenya. Telephone: +254-20-2717077
http://www.health.go.ke/