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Quality Series 2
MINISTRY OF HEALTHDEMOCRATIC SOCIALIST REPUBLIC OF SRI LANKA
1ST EDITION OCTOBER 2010
IMPROVEMENT OF QUALITY ANDSAFETY OF HEALTHCARE INSTITUTIONS
NATIONAL GUIDELINES FOR
(FOR PRIMARY MEDICAL CARE UNITS)
Quality Series No.2
National Guidelines for Improvement of Quality and Safety of Healthcare Institutions
(For Primary Medical Care Units)
First Edition
Editors: Dr. Wimal Jayantha
Deputy Director General/Planning, Ministry of Health
Dr. S. Sridharan
Director Organization Development, Ministry of Health
Dr. C.J. Aluthweera
Coordinator for National Quality Assurance Programme, Ministry of Health
Mr. Shogo Kanamori
JICA Expert on Medical Services Administration
October 2010
COPYRIGHT © Management Development & Planning Unit Ministry of Health 385 Baddegama Wimalawansa Thero Mawatha., Colombo 10, Sri Lanka October 2010 National Library of Sri Lanka Cataloguing in Publication Data Quality Series No.2 National Guidelines for Improvement of Quality and Safety of Healthcare Institutions (for Primary Medical Care Units) ISBN: 978-955-0505-03-6 Printed in Sri Lanka This Publication is sponsored by: Japan International Cooperation Agency (JICA)
Preface
Sri Lanka provides free healthcare services to all the citizens irrespective of their status, income or geographic location, and has achieved remarkable health outcomes, particularly relative to neighbouring countries with a similar income range. Nevertheless, there are certain drawbacks in the service delivery system at the primary level which have affected the quality and efficiency of its services as demonstrated by overcrowding in the higher level institutions, deficiencies of amenities and patient dissatisfaction.
The National Guidelines for Improvement of Quality and Safety of Healthcare Institutions provide a comprehensive set of quality and safety standards and affordable measures to improve the curative services at the primary level. All the Primary Medical Care Units in Sri Lanka are therefore expected to be fully oriented on these Guidelines and prepared to improve their service delivery structure and process. Needless to say, the strong commitment of heads of institutions, PDHSs and RDHSs is critical in achieving the goals aimed by these Guidelines.
I wish to thank all the stakeholders involved in the development of this document as well as Japan International Cooperation Agency (JICA) for its technical assistance. In particular, I am grateful to Dr. Wimal Jayantha, DDG/Planning, who supervised the whole developmental process, Dr. S. Sridharan, Director OD, who led and facilitated the drafting work, and Mr. Shogo Kanamori, JICA Expert on Medical Services Administration, who provided coordinative and technical assistance.
Dr. Ravindra Ruberu Secretary Ministry of Health
1 October 2010
TABLE OF CONTENTS
1. Introduction ……………………………………………………………………………….. 1
1.1. Target Institutions of the Guidelines ………………………………………………… 1
1.2. The Guidelines in the Context of Quality Assurance Programme ………………... 2
1.3. Institutional arrangements for improvement of quality and safety of Primary Medical Care Units ……………………………………………………………………. 3
2. Quality and Safety Standards of Primary Medical Care Units ……...…………….. 3
I. Internal and External Customer Environment (5S) ………………………………. 4 1. Seiri (Sorting)
2. Seiton (Organisation) 3. Seiso (Cleaning with Meaning and for Beautifying) 4. Seiketsu (Standardisation) 5. Shitsuke (Training & Self-Discipline)
II. Services involving Patient Contacts ……………………………………………….. 10 6. Reception area
7. Immediate service points and frontline services 8. Responsiveness 9. Medical/pharmaceutical supplies and equipment management
III. Overall Quality and Safety Improvement ………………………………………….. 14 10. Waste management
11. Health education activities 12. Leadership and management 13. Productivity and quality improvement programme
ANNEXES ……………………………………………………………………………………….. 17 ANNEX 1: Isles for Stationeries ………………………………………………………….. 17 ANNEX 2: Standardised Colour Codes ………………………………………………….. 18 ANNEX 3: Emergency Tray Items for Primary Medical Care Units (Sample) ……….. 19 ANNEX 4: Patient Satisfaction Survey Form (Sample) …………………….………….. 20
APPENDIX: General Circular on National Quality Assurance Programme in Health 27
1. Introduction
These Guidelines will provide guidance to the staff working at Primary Medical Care Units in strengthening the organisational and individual preparedness for improvement of the quality and safety of patient care services. It is assumed that these Guidelines will be used for the following purposes.
As a handbook for Primary Medical Care Units in implementing quality improvement programmes and related activities
As a guiding document for orientation programmes to the staff at Primary Medical Care Units conducted by the National Quality Secretariat of the Ministry of Health and the Provincial Quality Secretariats
1.1. Target institutions of the Guidelines
The target institutions of these Guidelines are Primary Medical Care Units (MH & CD and Central Dispensaries under the old categorization).
New Categorization Old Categorization
Teaching Hospital (TH) Teaching Hospital (TH)
Provincial General Hospital (PGH) General Hospital (GH)
District General Hospital (DGH)
Base Hospital (Type A & Type B) Base Hospital (BH)
Divisional Hospital District Hospital (DH)
Peripheral Unit (PU)
Rural Hospital (RH)
Primary Medical Care Unit Maternity Homes (MH) & CD
Central Dispensary (CD)
According to the official circular on “Re-categorization of Hospitals” issued by the Ministry of Health, the Primary Medical Care Units are to be equipped with the following facilities/services.
Outpatient care
Limited emergency care: facilities for stabilization of patients before referring to secondary or tertiary care medical institutions.
Facilities for a poly-clinic including Ante-Natal & Post-Natal, Family Planning, Child Health, Well Women, etc.
Target Institutions of these Guidelines
1
1.2. The Guidelines in the context of Quality Assurance Programme
Two separate guidelines will be used to implement the National Quality Assurance Programme. One serves to provide guidance to Primary Medical Care Units in quality and safety improvement, and the other to provide protocols for external monitoring and evaluation of the services provided by the Primary Medical Care Units.
(1) Guideline for External Monitoring and Evaluation of Primary Medical Care Units
(2) Guideline for Improvement of Quality and Safety of Services at Primary Medical Care Units
The present Guideline mainly focuses on the improvement of the quality and safety at the Primary Medical Care Units.
Primary Medical Care Unit
PDHS/RDHS
Guidance & Monitoring
Guidance & Monitoring
1. Guidelines for External Monitoring and Evaluation
- External monitoring system
- National quality award system
2. Guidelines for Improvement of Quality and Safety
- Organizational arrangements
- Quality and safety standards & checklist
DDG/Planning
This Guideline Document
Director Organisational Development
2
1.3. Institutional arrangements for improvement of quality and safety of Primary Medical Care Units
All Primary Medical Care Units (Central Dispensary & Maternity Home and Central Dispensary) are expected to conduct their Quality Management Programme under a designated officer who will be guided by the Quality Management Unit of RDHS, according to the “General Circular No.01-29/2009” of the Ministry of Healthcare & Nutrition dated 22 September 2009 (attached as APPENDIX).
2. Quality and Safety Standards of Primary Medical Care Units
This chapter provides the quality and safety standards to which all the Primary Medical Care Units shall adhere. They are divided into three aspects and 13 areas as follows:
I. Internal and External Customer Environment (5S) 1. Seiri (Sorting) 2. Seiton (Organisation) 3. Seiso (Cleaning with Meaning and for Beautifying) 4. Seiketsu (Standardisation) 5. Shitsuke (Training & Self-Discipline)
II. Services involving Patient Contacts 6. Reception area 7. Immediate service points and frontline services 8. Responsiveness 9. Medical/pharmaceutical supplies and equipment management
III. Overall Quality and Safety Improvement 10. Waste management 11. Health education activities 12. Leadership and management 13. Productivity and quality improvement programme
These standards will be referred to whenever a Primary Medical Care Unit conducts quality and safety improvement activities. They are also in line with the criteria for external audits and for selection of the National Health Excellency Award recipients.
3
I. In
tern
al a
nd E
xter
nal C
usto
mer
Env
ironm
ent (
5S)
Are
a of
Con
cern
St
anda
rds
Mea
sura
ble
Elem
ents
1 Se
iri (S
ortin
g)
Elim
inat
ing
unne
cess
ary
item
s fro
m th
e w
orkp
lace
that
are
not
nee
ded
for c
urre
nt p
roce
ss in
the
inst
itutio
n.
1.1
Outsi
de an
d ins
ide pr
emise
s 1.1
.1 Un
wante
d item
s rem
oved
fro
m the
wor
kplac
e -
An es
tablis
hed p
roce
ss in
sortin
g wan
ted an
d unw
anted
items
is pr
esen
t. -
A pr
oper
proc
ess f
or co
ndem
ning i
tems i
s pre
sent.
-
Unwa
nted i
tems a
re no
t left i
n the
wor
kplac
e or m
arke
d with
tags
.
Red t
ags f
or th
ose i
tems t
o be d
ispos
ed
Or
ange
tags
for t
hose
items
unde
r con
sider
ation
. -
Tops
and i
nside
s of a
ll cup
boar
ds, s
helve
s, tab
les an
d dra
wers
are f
ree o
f unw
anted
/irre
levan
t item
s. 1.1
.2 Th
e floo
rs an
d pa
ssag
eway
s in t
he pu
blic
area
s equ
ipped
with
ga
rbag
e bins
for g
ener
al wa
ste an
d kep
t free
of
litter
s
- Ga
rbag
e bins
for g
ener
al wa
ste ar
e in p
lace a
nd co
lour c
oded
. -
The t
ime f
or re
movin
g litte
rs fro
m the
garb
age b
ins ar
e ind
icated
. -
The p
lace i
s fre
e of li
tter.
1.1.3
Unwa
nted t
rees
and
bran
ches
remo
ved
- Tr
ees w
hich a
re ob
struc
ting t
he dr
ainag
e are
remo
ved.
- Tr
ee br
anch
es ab
ove t
he ro
of an
d ove
r the
elec
tric an
d tele
phon
e wire
s are
trim
med.
1.2
Wall
s and
notic
e bo
ards
1.2
.1 W
alls b
eing f
ree o
f old
poste
rs, pi
cture
s or
calen
dars.
- Po
sters/
pictur
es ar
e not
fading
or to
rn.
- Inf
orma
tion o
n pos
ters/p
ictur
es is
not o
bsole
te.
-Ca
lenda
rs ar
e upd
ated.
1.2.2
Notic
e boa
rds b
eing f
ree
of ob
solet
e noti
ces
- Re
mova
l instr
uctio
ns ar
e in p
lace.
- Th
e rem
oval
instru
ction
is co
mplie
d. -
Notic
e boa
rds a
re ca
tegor
ized a
ccor
ding t
o the
need
s. -
Resp
onsib
le pe
rsons
for e
ach n
otice
boar
d are
iden
tified
. -
The a
lignm
ent a
nd an
X-Y
axis
tool a
re m
aintai
ned i
n the
notic
e boa
rd.
4
I. In
tern
al a
nd E
xter
nal C
usto
mer
Env
ironm
ent (
5S)
Are
a of
Con
cern
St
anda
rds
Mea
sura
ble
Elem
ents
2 Se
iton
(Org
anis
atio
n)
Ens
urin
g al
l the
item
s th
at h
ave
been
sor
ted
are
arra
nged
and
pla
ced
in p
re-a
ssig
ned
posi
tions
in o
rder
to fa
cilit
ate
effic
ienc
y at
wor
k.
2.1
The i
nstitu
tion
and s
ervic
e unit
ide
ntific
ation
2.1.1
A na
me bo
ard o
f the
institu
tion a
nd a
site m
ap
avail
able
- A
name
boar
d of th
e ins
titutio
n is d
isplay
ed ou
tside
in al
l thre
e lan
guag
es.
- A
site m
ap is
disp
layed
at th
e entr
ance
/ rec
eptio
n are
a in a
ll thr
ee la
ngua
ges.
2.2
Dire
ction
al ind
icatio
ns
2.2.1
Dire
ction
al bo
ards
av
ailab
le at
ever
y jun
ction
-
Dire
ction
al bo
ards
are d
isplay
ed at
ever
y jun
ction
outsi
de an
d ins
ide of
the i
nstitu
tion t
o all f
acilit
ies fr
om
the en
tranc
e in a
ll thr
ee la
ngua
ges.
2.2.2
Corri
dors
clear
ly ma
rked
with
entra
nces
and e
xit
lines
, cur
ved d
oor
open
ings,
and d
irecti
on of
tra
vel
- En
tranc
e and
exit l
ines a
re pl
aced
for O
PD/cl
inics
. -
Curve
d doo
r ope
nings
are m
arke
d at e
ntran
ce do
ors t
o roo
ms.
- Th
e dire
ction
of tr
avel
is ind
icated
on th
e cor
ridor
s. -
The s
liding
door
s are
prov
ided w
ith di
recti
onal
arro
ws.
2.3
Labe
lling a
nd
marki
ng
2.3.1
Room
s and
toile
ts cle
arly
identi
fied w
ith la
bels
- Al
l room
s and
toile
ts ar
e ide
ntifie
d with
labe
ls, na
me bo
ards
or nu
mber
s.
2.3.2
Stor
es an
d stor
age a
reas
pr
oper
ly or
ganis
ed
- Ite
ms in
stor
es an
d stor
age a
reas
are k
ept in
shelv
es, r
acks
or bi
ns an
d clea
rly m
arke
d. -
Shelf
grids
are m
arke
d with
refer
ence
numb
ers/n
ames
for e
asy r
etriev
al of
items
. -
All s
tation
eries
in th
e cup
boar
d are
kept
in pla
ces i
denti
fied w
ith sy
mbols
and m
arks
(visu
al co
ntrol
of sta
tione
ries).
-
Items
are s
tored
in an
alph
abeti
cal o
rder
and i
n a lo
gical
mann
er (le
ft to r
ight /
top to
botto
m).
- A
mech
anism
to re
plenis
h item
s is o
rgan
ized w
ith co
lour c
odes
:
Maxim
um st
ock l
evel:
Gre
en
Re
orde
r stoc
k lev
el: O
rang
e
Minim
um st
ock l
evel:
Red
2.3
.3 Sw
itche
s and
fans
easil
y ide
ntifie
d -
All s
witch
es an
d fan
regu
lator
s are
labe
lled a
ccor
dingly
. -
A se
para
te ele
ctrica
l poin
t plan
is in
plac
e for
each
room
at en
tranc
e.
5
I. In
tern
al a
nd E
xter
nal C
usto
mer
Env
ironm
ent (
5S)
Are
a of
Con
cern
St
anda
rds
Mea
sura
ble
Elem
ents
2.4
Pl
acing
and
parki
ng ru
les
2.4.1
Equip
ment
and t
ools
being
ke
pt in
origi
nal p
laces
after
us
e
- ‘Is
les’ a
re id
entifi
ed fo
r eac
h equ
ipmen
t and
tool
to be
kept
after
use w
ith th
e stra
ight li
ne m
ethod
and
shad
ow dr
awing
s disp
layed
. -
A me
chan
ism to
iden
tify pe
rsons
remo
ving i
tems f
rom
‘isles
’ Item
s is i
n plac
e.
An ex
ampl
e of ‘
Isles
’ is sh
own
in “A
NNEX
1: Is
les fo
r Sta
tione
ries”
.
2.4.2
Files
and f
older
s arra
nged
us
ing th
e mist
ake p
roofi
ng
conc
ept
- Fil
es an
d box
folde
rs ar
e arra
nged
using
the m
istak
e pro
ofing
conc
ept to
facil
itate
identi
ficati
on of
pa
rticula
r file
s (wi
thin 3
0 sec
onds
) and
stor
ing in
origi
nal p
laces
.
2.4.3
Parki
ng ar
eas f
or m
obile
eq
uipme
nt sp
ecifie
d and
ma
rked
- Pa
rking
area
s are
spec
ificall
y mar
ked f
or:
W
heelc
hairs
Garb
age b
ins
Su
cker
s and
oxyg
en tr
olley
s 2.4
.4 Pa
rking
area
s for
vehic
les
spec
ified a
nd m
arke
d -
Desig
nated
parki
ng pl
aces
are a
vaila
ble fo
r amb
ulanc
es (if
avail
able)
. -
Vehic
le flo
ws in
the p
remi
ses a
re id
entifi
ed an
d mar
ked.
-Si
gn bo
ards
for v
ehicl
es of
diffe
rentl
y-able
d per
sons
are i
n plac
e.
3 Se
iso
(Cle
anin
g w
ith M
eani
ng a
nd fo
r Bea
utify
ing)
Cle
anin
g up
one
’s w
orkp
lace
com
plet
ely
to e
limin
ate
dust
on
floor
s, m
achi
nes
or e
quip
men
t.
3.1
Gene
ral
appe
aran
ce of
cle
anlin
ess
3.1.1
The p
remi
ses m
aintai
ned
with
healt
hy an
d safe
en
viron
ment
for in
terna
l an
d exte
rnal
custo
mers
- Th
e gar
den i
s pro
perly
main
taine
d and
land
scap
ing is
done
by a
gard
ener
. -
Drain
s are
not le
aking
or ov
erflo
wing
. -
Stag
natio
n of w
ater is
avoid
ed in
all d
rains
. -
Unple
asan
t odo
ur is
not p
rodu
ced f
rom
the w
aste
site o
r othe
r plac
es.
-Th
e visi
ble pa
rts of
the r
oof a
re fr
ee of
unwa
nted i
tems.
6
I. In
tern
al a
nd E
xter
nal C
usto
mer
Env
ironm
ent (
5S)
Are
a of
Con
cern
St
anda
rds
Mea
sura
ble
Elem
ents
3.1
.2 Flo
ors,
walls
, wind
ows a
nd
curta
in &
other
fittin
gs
being
kept
clean
- Th
e clea
nline
ss is
main
taine
d at:
Flo
ors
W
alls
W
indow
s
Curta
ins
Ot
her f
itting
s
Gu
tters
-
A cle
aning
chec
klist
is av
ailab
le an
d upd
ated.
3.1.3
Toile
ts ar
e clea
n and
in
worki
ng or
der
- Un
pleas
ant o
dour
is no
t exp
erien
ced i
n toil
ets.
- To
ilet fa
cilitie
s are
kept
read
y for
use.
- A
clean
ing ch
eckli
st is
avail
able
and u
pdate
d. -
Adeq
uate
venti
lation
is pr
ovide
d in a
ll the
toile
ts.
3.2
Clea
ning o
f ma
chine
s, eq
uipme
nt, to
ols
and f
urnit
ure
3.2.1
The c
leanli
ness
of
build
ings,
mach
ines,
equip
ment,
tools
and
furnit
ure m
aintai
ned
- Th
e high
leve
l of c
leanli
ness
is m
aintai
ned w
ith no
visib
le dir
t:
Build
ings
Am
bulan
ces (
if ava
ilable
)
Medic
al eq
uipme
nt Fu
rnitu
re (t
ables
, des
ks, c
hairs
, etc.
) 3.3
Cl
eanin
g pra
ctice
3.3
.1 An
orga
nised
clea
ning
syste
m in
place
-
The f
ollow
ing to
ols an
d doc
umen
ts ar
e disp
layed
/avail
able:
Clea
ning r
espo
nsibi
lity ch
art
Cl
eanin
g sch
edule
s
Clea
ning g
uideli
nes
-Th
e abo
ve to
ols an
d doc
umen
ts ar
e upd
ated m
onthl
y. 3.3
.2 Cl
eanin
g too
ls an
d de
terge
nts pr
oper
ly sto
red
- Pr
oper
stor
age f
acilit
ies fo
r clea
ning t
ools
and d
eterg
ents
are a
vaila
ble.
- Ap
prop
riate
and n
eces
sary
chem
icals
are u
sed f
or m
anag
emen
t of b
ody f
luid s
pills.
-
Clea
ning t
ools
for ou
tside
area
s/toil
ets an
d ins
ide ar
eas a
re se
para
ted.
7
I. In
tern
al a
nd E
xter
nal C
usto
mer
Env
ironm
ent (
5S)
Are
a of
Con
cern
St
anda
rds
Mea
sura
ble
Elem
ents
4 Se
iket
su (S
tand
ardi
zatio
n)
Gen
erat
ing
mec
hani
sms
to m
aint
ain
the
thre
e Ss
(Sei
ri, S
eito
n an
d S
eiso
) by
deve
lopi
ng p
roce
dure
s, s
ched
ules
and
tool
s fo
r con
tinuo
us a
sses
smen
t and
re
gula
r aud
it.
4.1
Stan
dard
ized
visua
ls
4.1.1
Sign
boar
ds an
d dir
ectio
nal b
oard
s sta
ndar
dised
- Al
l sign
boar
ds an
d dire
ction
al bo
ards
are s
tanda
rdise
d with
prop
er al
ignme
nt an
d con
sisten
t fonts
, and
by
colou
r cod
es.
4.1.2
Drug
cupb
oard
s sta
ndar
dised
in al
l unit
s -
Drug
s are
sorte
d in a
logic
al ma
nner
.
vital,
esse
ntial
or no
rmal
ac
coun
table,
non-
acco
untab
le, or
spec
ial &
extra
-
Drug
s are
arra
nged
in al
phab
etica
l ord
er an
d left
-to-ri
ght in
all u
nits.
4.1.3
Arra
ngem
ents
of su
rgica
l su
pplie
s stan
dard
ised i
n all
units
- Th
e ster
ilisati
on st
atus i
s ind
icated
for s
urgic
al su
pplie
s. -
Surg
ical s
uppli
es ar
e arra
nged
logic
ally (
e.g. g
loves
acco
rding
to si
zes a
nd in
the l
eft-to
-righ
t ord
er)
4.1.4
Identi
ficati
on la
bels
place
d on
all m
achin
es an
d eq
uipme
nt
All m
achin
es an
d equ
ipmen
t hav
e ide
ntific
ation
labe
ls wi
th the
follo
wing
infor
matio
n:
Name
of th
e item
s
Identi
ficati
on an
d batc
h num
bers
Da
te of
acqu
isitio
n
Conta
ct de
tails
of ma
inten
ance
comp
any
Re
spon
sible
perso
n for
main
tenan
ce
Co
st of
equip
ment
4.1.5
Cauti
on si
gns d
isplay
ed at
ap
prop
riate
place
s -
“Dan
ger”
signs
are d
isplay
ed at
elec
tric sw
itchb
oard
s and
tran
sform
ers.
- “S
lopes
” sign
s are
disp
layed
at w
here
ver t
here
is a
slope
. -
“Slip
pery”
sign
s with
zebr
a cod
e are
plac
ed at
wet
floor
after
clea
ning.
4.1.6
Open
and s
hut d
irecti
onal
labels
avail
able
on va
lves
and d
oors
- Th
e dire
ction
al lab
els ar
e put
on:
Do
or ha
ndles
of cu
pboa
rds
Al
l othe
r doo
r han
dles
4.1.7
Was
te bin
s sep
arate
d, lab
elled
and c
olour
-code
d -
All th
e was
te bin
s are
sepa
rated
, labe
lled a
nd co
lour-c
oded
.
The c
olou
r-cod
es ar
e elab
orat
ed in
“ANN
EX 2:
Sta
ndar
dise
d Co
lour
Cod
es”
8
I. In
tern
al a
nd E
xter
nal C
usto
mer
Env
ironm
ent (
5S)
Are
a of
Con
cern
St
anda
rds
Mea
sura
ble
Elem
ents
4.1
.8 Ox
ygen
cylin
ders
identi
fied
by st
anda
rdise
d visu
als
- Th
e stat
us of
oxyg
en cy
linde
rs (e
mpty
or fu
ll) ca
n be i
denti
fied b
y colo
urs o
r tag
s:
Empty
: Red
Fu
ll: Bl
ue
4.2
Maint
enan
ce of
ve
hicles
, ma
chine
s and
eq
uipme
nt
4.2.1
Vehic
les, m
achin
es an
d eq
uipme
nt pr
oper
ly ma
intain
ed
- Ma
inten
ance
sche
dules
and r
ecor
ds ar
e ava
ilable
and u
pdate
d for
the f
ollow
ing ite
ms:
Ve
hicles
Medic
al eq
uipme
nt -
Oper
ation
al ins
tructi
ons a
re m
ade a
vaila
ble fo
r equ
ipmen
t. 4.3
Sa
fety a
nd
secu
rity
meas
ures
4.3.1
Safet
y mea
sure
s are
in
place
for e
lectric
al ca
bles
and d
evice
s
- El
ectric
al wi
res a
re se
aled o
r bun
dled t
o pre
vent
accid
ental
conta
cts w
ith hu
man b
eings
. -
All s
witch
es ar
e pro
perly
fixed
with
out a
ny el
ectric
ally-c
ondu
ctive
parts
expo
sed.
- Al
l elec
tric de
vices
and b
oiler
s are
plac
ed in
a sa
fety m
anne
r. -
Dang
er si
gns (
Zebr
a cod
e or T
iger s
tripes
) are
appli
ed
4.3.2
Secu
rity m
easu
res i
n pla
ce fo
r a fir
e eve
nt -
Func
tiona
l fire
extin
guish
ers o
r san
d buc
kets
are a
vaila
ble.
- Th
e guid
eline
s or a
proto
col fo
r the
fire e
vent
is av
ailab
le.
5 Sh
itsuk
e (T
rain
ing
& S
elf-D
isci
plin
e)
Wor
king
on
5S a
s da
ily ro
utin
es a
nd e
nsur
ing
that
it b
ecom
es a
n in
tegr
al p
art o
f the
wor
kpla
ce fa
bric
.
5.1
Train
ing an
d ra
ising
aw
aren
ess
5.1.1
The s
taff tr
ained
on 5S
-
All th
e staf
f are
train
ed on
5S.
- A
prog
ramm
e to t
rain
new
staff o
n 5S
is av
ailab
le.
5.1.2
A 5S
Cor
ner a
vaila
ble in
the
insti
tution
-
A 5S
Cor
ner is
orga
nised
whe
re th
e staf
f hav
e fre
quen
t acc
ess.
- Th
e 5S
Corn
er is
upda
ted m
onthl
y.
9
II.
Serv
ices
invo
lvin
g Pa
tient
Con
tact
s A
reas
of C
once
rnSt
anda
rds
M
easu
rabl
e El
emen
ts
6 R
ecep
tion
area
6.1
Rece
ption
area
6.1
.1 An
orga
nised
rece
ption
av
ailab
le -
A re
cepti
on de
sk is
avail
able.
-
A tra
ined p
erso
n is i
n plac
e all t
he tim
e dur
ing th
e ope
ratio
nal h
ours.
-
Accu
rate
infor
matio
n abo
ut se
rvice
s is d
ispen
sed.
6.2
Wait
ing ar
ea
6.2.1
A sp
aciou
s and
venti
lated
wa
iting a
rea a
vaila
ble
- Ve
ntilat
ed en
viron
ment
is ev
ident
in the
wait
ing ar
ea..
-Th
e lay
out o
f the w
aiting
area
is w
ell or
ganiz
ed.
6.2.2
Adeq
uate
seati
ng fa
cilitie
s av
ailab
le wi
th pr
oper
se
ating
orde
rs
- A
suffic
ient n
umbe
r of s
eatin
g fac
ilities
(mini
mum
of 1/4
of th
e dail
y atte
ndan
ce) is
avail
able
at the
wa
iting a
rea.
-Se
ating
facil
ities a
re ar
rang
ed in
orde
r.
7 Im
med
iate
ser
vice
poi
nts
and
fron
tline
ser
vice
s
7.1
OPD
servi
ces
7.1.1
OPD
oper
ated d
aily w
ith
quali
fied s
taff
- OP
D is
oper
ated f
rom
8:00 t
o 12:0
0 and
14:00
to 16
:00 du
ring t
he w
eekd
ays,
from
8:00 t
o 12:0
0 on
Satur
days
, and
from
8:00
to 10
:00 on
Sun
days
. -
Quali
fied m
edica
l staf
f is st
ation
ed at
OPD
at al
l the t
ime d
uring
the o
pera
ting h
ours.
7.1
.2 A
regis
ter av
ailab
le -
A re
gister
of O
PD pa
tients
is av
ailab
le an
d upd
ated.
7.1.3
Exam
inatio
n bed
s ap
prop
riatel
y arra
nged
-
Exam
inatio
n bed
s are
scre
ened
for p
rivac
y. -
Exam
inatio
n bed
s hav
e clea
n matt
ress
es an
d line
n. 7.1
.4 Th
e ster
ility m
aintai
ned i
n dr
essin
g roo
ms, in
jectio
n ro
oms,
etc.
- A
hand
was
hing s
ink is
avail
able
with
clean
towe
ls an
d soa
p, an
d use
d. -
Surg
ical g
loves
are a
vaila
ble, a
rrang
ed ac
cord
ing to
their
size
s, an
d use
d to u
nder
take w
ound
dres
sing.
-St
erilis
ed in
strum
ents,
pack
ets an
d dre
ssing
s are
kept
in a c
upbo
ard w
ith a
writte
n ind
icatio
n of s
terilit
y. 7.1
.5 A
surve
y to m
easu
re
waitin
g tim
e of p
atien
ts at
OPD
cond
ucted
regu
larly
- A
surve
y for
m to
meas
ure w
aiting
time o
f pati
ents
is av
ailab
le.
- A
waitin
g tim
e sur
vey i
s con
ducte
d and
analy
zed m
onthl
y. -
A re
port
on ap
prop
riate
actio
ns ta
ken t
o red
uce t
he w
aiting
time i
s ava
ilable
. 7.1
.6 A
prop
er re
ferra
l sys
tem
avail
able
- A
list o
f spe
cializ
ed ho
spita
ls an
d con
tact d
etails
is av
ailab
le on
the w
all.
- Tr
ansfe
r in-a
nd-o
ut re
cord
is av
ailab
le an
d upd
ated.
-Th
e tra
nsfer
in-a
nd-o
ut sta
tistic
s are
comp
iled a
nd re
viewe
d ann
ually
.
10
II.
Serv
ices
invo
lvin
g Pa
tient
Con
tact
s A
reas
of C
once
rnSt
anda
rds
M
easu
rabl
e El
emen
ts
7.2
Clini
c ser
vices
7.2
.1 Po
ly-cli
nic se
rvice
s av
ailab
le -
Facil
ities f
or po
ly-cli
nic se
rvice
s are
avail
able,
inclu
ding:
An
te-na
tal &
post-
natal
clini
c
Fami
ly pla
nning
clini
c
Child
healt
h clin
ic
Well
wom
en cl
inic
7.2.2
Spec
ial cl
inics
avail
able
-Sp
ecial
clini
cs (e
.g. m
edica
l clin
ic) ar
e ava
ilable
with
quali
fied m
edica
l staf
f. 7.3
Em
erge
ncy c
are
servi
ces
7.3.1
An em
erge
ncy c
are
servi
ce fu
nctio
ning w
ith
esse
ntial
equip
ment
and
drug
s
- Th
e ess
entia
l equ
ipmen
t is ke
pt in
acce
ssibl
e plac
es an
d in w
orkin
g ord
er:
Ne
bulis
ing m
achin
e
Suck
er m
achin
e
Ambu
bag
La
ryngo
scop
e
ET T
ubes
and T
rach
aeoto
my tu
bes (
arra
nged
logic
ally a
ccor
ding t
o the
ir size
s) -
An em
erge
ncy t
ray i
s ava
ilable
with
esse
ntial
supp
lies,
solut
ions a
nd dr
ugs.
- A
chec
klist
for th
e eme
rgen
cy tr
ay ite
ms is
avail
able
and c
heck
ed at
daily
. -
A re
spon
sible
office
r is in
dicate
d for
the m
ainten
ance
of th
e eme
rgen
cy tr
ay.
- Em
erge
ncy c
are g
uideli
nes a
re pr
epar
ed an
d disp
layed
(at le
ast fo
r Ana
phyla
ctic S
hock
and C
ardia
c Ar
rest)
.
A lis
t of t
he em
erge
ncy t
ray i
tem
s are
pro
vided
in “A
NNEX
3: E
mer
genc
y Tra
y Ite
ms f
or P
rimar
y Me
dica
l Car
e Uni
ts (S
ampl
e)”
8 R
espo
nsiv
enes
s
8.1
Over
all
resp
onsiv
enes
s 8.1
.1 An
appo
intme
nt sy
stem
avail
able
for cl
inics
-
A me
chan
ism to
give
appo
intme
nts to
clini
c pati
ents
is av
ailab
le.
- Th
e app
ointm
ent s
ystem
is pr
oper
ly pr
actic
ed at
clini
cs.
8.1.2
Clea
n drin
king w
ater
prov
ided a
t all t
imes
to
patie
nts
- Cl
ean d
rinkin
g wate
r is av
ailab
le for
patie
nts w
ith a
water
filter
/conta
iner.
8.1.3
A su
gges
tion b
ox an
d a
proc
edur
e to t
ake
reme
dial a
ction
s ava
ilable
- A
sugg
estio
n box
is av
ailab
le wi
th a p
en an
d a de
signe
d for
m/wr
iting p
ad.
- Su
gges
tions
are b
eing r
eview
ed at
mon
thly f
orum
s/mee
tings
invo
lving
relev
ant d
ecisi
on m
aker
s. -
A re
cord
book
of ac
tions
take
n res
pond
ing to
the s
ugge
stion
s is a
vaila
ble an
d upd
ated.
11
II.
Serv
ices
invo
lvin
g Pa
tient
Con
tact
s A
reas
of C
once
rnSt
anda
rds
M
easu
rabl
e El
emen
ts
8.2
Resp
onsiv
enes
s to
spec
ialise
d gr
oups
8.2.1
Secu
re ac
cess
prov
ided
for th
e disa
bled a
nd se
nior
citize
ns
- Se
para
te toi
lets a
re av
ailab
le for
the d
isable
d per
sons
. -
Spec
ial ac
cess
at st
airwa
ys an
d toil
ets is
avail
able
for th
e disa
bled p
erso
ns.
- Pr
iority
coun
ters f
or th
e disa
bled p
erso
ns an
d sen
ior ci
tizen
s are
avail
able.
9 M
edic
al/p
harm
aceu
tical
sup
plie
s, e
quip
men
t and
con
sum
able
s m
anag
emen
t
9.1
Annu
al es
timate
of me
dical/
phar
mac
eutic
al su
pplie
s
9.1.1
Annu
al es
timate
s of
medic
al an
d ph
arma
ceuti
cal s
uppli
es
prep
ared
on tim
e
- An
annu
al es
timate
of m
edica
l and
phar
mace
utica
l sup
plies
is pr
epar
ed an
d sen
t to re
levan
t auth
oritie
s by
Sep
tembe
r eve
ry ye
ar.
9.2
Stoc
k ma
inten
ance
of
medic
al/ph
arma
ceu
tical
supp
lies
9.2.1
Drug
s and
vacc
ines s
tored
ac
cord
ing to
the
manu
factur
er’s
stand
ards
- A
refrig
erato
r with
a fun
ction
ing an
alogu
e the
rmom
eter is
avail
able
and k
ept a
t opti
mum
tempe
ratur
e. -
Drug
s and
vacc
ines (
tetan
us to
xoid)
are s
tored
in th
eir op
timum
temp
eratu
res.
- Th
e tem
pera
tures
of th
e refr
igera
tor ar
e mea
sure
d and
reco
rded
in a
regis
ter in
the m
ornin
g and
the
even
ing.
9.2.2
Stoc
ks of
me
dical/
phar
mace
utica
l su
pplie
s app
ropr
iately
ma
nage
d
- Dr
ugs a
re la
belle
d and
arra
nged
in a
sorte
d and
orga
nized
man
ner.
- Dr
ug in
vento
ries (
surg
ical a
nd ge
nera
l) are
avail
able
and u
pdate
d. -
Infor
matio
n on d
aily s
tock i
tems i
s ava
ilable
to O
PD/cl
inic d
octor
s. -
‘First
in -
first o
ut sy
stem’
is m
aintai
ned.
- Inf
orma
tion i
s upd
ated o
n sur
plus i
tems.
9.2.3
Expir
ing ite
ms
appr
opria
tely m
anag
ed
- Pe
riodic
chec
ks ar
e don
e for
expir
ing ite
ms re
gular
ly.
- A
regis
ter bo
ok of
perio
dic ch
ecks
for e
xpirin
g item
s is a
vaila
ble an
d upd
ated.
- A
mech
anism
to pr
even
t mix-
up of
expir
ed an
d non
-exp
ired d
rugs
and t
o disp
ose t
he ex
pired
items
on
time i
s in p
lace.
9.2.4
Emer
genc
y buff
er st
ocks
for
vital
and e
ssen
tial
drug
s main
taine
d
- A
list o
f vita
l and
esse
ntial
drug
s with
a bu
ffer s
tock l
evel
is av
ailab
le.
- Th
e buff
er st
ock l
evel
of all
vital
and e
ssen
tial d
rugs
is m
aintai
ned.
9.3
Disp
ensin
g and
dr
ug
admi
nistra
tion
9.3.1
A me
chan
ism to
prov
ide
esse
ntial
infor
matio
n to
patie
nts on
usag
e of d
rugs
in
place
- Dr
ugs a
re di
spen
sed i
n pac
kets
with
writte
n ins
tructi
ons i
nclud
ing do
sage
, freq
uenc
y and
dura
tion.
12
II.
Serv
ices
invo
lvin
g Pa
tient
Con
tact
s A
reas
of C
once
rnSt
anda
rds
M
easu
rabl
e El
emen
ts
9.4
Medic
al eq
uipme
nt ma
nage
ment
9.4.1
A ge
nera
l inve
ntory
and a
dis
tributi
on re
gister
of
differ
ent c
atego
ries o
f eq
uipme
nt ma
intain
ed
- A
regis
ter on
gene
ral in
vento
ry is
avail
able
and u
pdate
d. -
A dis
tributi
on re
gister
of di
ffere
nt ca
tegor
ies of
equip
ment
is av
ailab
le an
d upd
ated.
9.4.2
Sepa
rate
files a
nd st
ock
card
s for
indiv
idual
equip
ment
avail
able
with
nece
ssar
y deta
ils
- Ea
ch eq
uipme
nt ha
s a se
para
te file
with
all th
e deta
ils of
the e
quipm
ent.
- Th
e file
s of th
e equ
ipmen
t con
tain a
summ
ary s
heet
indica
ting s
ervic
e and
repa
ir rec
ords
of th
e eq
uipme
nt an
d upd
ated.
9.5
Cons
umab
les
mana
geme
nt 9.5
.1 Co
nsum
ables
othe
r tha
n me
dical/
phar
mace
utica
l su
pplie
s man
aged
pr
oper
ly
- A
cons
umab
le inv
entor
y is a
vaila
ble an
d upd
ated.
- Co
nsum
ables
are r
eplen
ished
in a
timely
man
ner.
13
III.
Ove
rall
Qua
lity
and
Safe
ty Im
prov
emen
t A
reas
of C
once
rnSt
anda
rds
Mea
sura
ble
Elem
ents
10 W
aste
man
agem
ent
10.1
Was
te ma
nage
ment
10.1.
1 W
astes
adeq
uatel
y dis
pose
d -
Five t
ypes
of w
astes
are s
egre
gated
by th
e colo
ur co
des:
Ge
nera
l was
tes
Sh
arps
Infec
ted w
astes
Plas
tics
Gl
asse
s -
A co
lour c
oding
char
t for t
he w
aste
segr
egati
on is
disp
layed
. -
The w
aste
segr
egati
on is
orga
nised
at th
e was
te dis
posa
l are
a acc
ordin
g to t
he co
lour c
odes
. -
An in
ciner
ator o
r a pr
oper
mec
hanis
m for
the f
inal d
ispos
al of
waste
s is a
vaila
ble an
d fun
ction
ing.
10.1.
2 Ha
zard
ous w
astes
dis
pose
d pro
perly
-
Disp
osal
bins f
or sh
arps
inclu
ding n
eedle
s are
in pl
ace a
ccor
dingly
. -
A pr
otoco
l for d
ispos
al of
waste
body
fluid
and b
lood c
ompo
nents
are a
vaila
ble an
d adh
ered
to.
11 H
ealth
edu
catio
n ac
tiviti
es
11.1
Healt
h edu
catio
n ac
tivitie
s 11
.1.1
Healt
h edu
catio
n acti
vities
co
nduc
ted
- An
adva
nce p
rogr
amme
regis
ter fo
r hea
lth ed
ucati
on ac
tivitie
s is a
vaila
ble an
d upd
ated.
-A
perfo
rman
ce re
port
on he
alth e
duca
tion a
ctivit
ies is
avail
able
and u
pdate
d.
12 L
eade
rshi
p an
d m
anag
emen
t
12.1
Lead
ersh
ip qu
ality
12.1.
1 Vi
sion a
nd M
ission
of th
e ins
titutio
n ava
ilable
-
The V
ision
and M
ission
of th
e hos
pital
are d
isplay
ed in
a vis
ible p
lace.
-Th
e staf
f are
awar
e of th
e Visi
on an
d Miss
ion, a
nd un
derst
and t
hem.
12
.1.2
A str
ategic
plan
and/o
r a
mediu
m-ter
m pla
n of th
e ins
titutio
n ava
ilable
- A
docu
ment
on st
rateg
ic pla
n and
/or a
mediu
m-ter
m pla
n of th
e ins
titutio
n is a
vaila
ble.
- An
activ
ity pl
an of
the i
nstitu
tion i
s ava
ilable
and u
pdate
d.
12.2
Publi
c rela
tions
an
d com
munit
y mo
biliza
tion
12.2.
1 A
mech
anism
to im
prov
e co
mmun
ity pa
rticipa
tion
and c
ommu
nity
mobil
izatio
n in p
lace
- An
annu
al pla
n for
comm
unity
activ
ities i
s ava
ilable
. -
All th
e com
munit
y acti
vities
are r
ecor
ded a
nd fil
ed.
14
III.
Ove
rall
Qua
lity
and
Safe
ty Im
prov
emen
t A
reas
of C
once
rnSt
anda
rds
Mea
sura
ble
Elem
ents
12
.3 Hu
man r
esou
rce
mana
geme
nt 12
.3.1
Staff
atten
danc
e pro
perly
ma
nage
d -
A lea
ve re
gister
of th
e staf
f is av
ailab
le an
d upd
ated p
rope
rly.
12.3.
2 Du
ty lis
ts for
all c
atego
ries
of sta
ff ava
ilable
-
Duty
lists
for al
l cate
gorie
s of s
taff a
re av
ailab
le.
12.3.
3 St
aff tr
aining
cond
ucted
re
gular
ly -
A sta
ff tra
ining
annu
al pla
n is a
vaila
ble.
-A
staff t
raini
ng re
cord
book
is av
ailab
le an
d upd
ated.
12.3.
4 Gr
ievan
ce ha
ndlin
g me
chan
isms i
n plac
e -
A wa
y of r
epor
ting g
rieva
nces
(in ve
rbal
or w
ritten
form
) to a
uthor
ities i
s ava
ilable
for s
taff a
nd pa
tients
. -
All th
e grie
vanc
es of
the s
taff a
re re
cord
ed se
para
tely a
nd fil
ed.
- Th
e grie
vanc
es ar
e rev
iewed
at re
gular
mee
tings
. 12
.4 Ut
ility S
ervic
es
12.4.
1 Am
bulan
ces m
aintai
ned
prop
erly
(if av
ailab
le)
- Th
e foll
owing
form
s and
files
are m
aintai
ned f
or am
bulan
ces (
if ava
ilable
) and
upda
ted ac
cord
ing to
the
Guide
lines
.
Vehic
le Lo
g Boo
k (Fo
rm G
ener
al 26
7)
Da
ily R
unnin
g Cha
rt (F
orm
Gene
ral 2
68)
Th
e Veh
icle I
nven
tory i
ndica
ting t
he R
egist
ratio
n No.,
the d
ata of
regis
tratio
n, the
mak
er an
d mo
del, C
hass
is No
., Eng
ine N
o., an
d deta
ils of
all a
cces
sorie
s.
Vehic
le file
s -
Guide
lines
are a
vaila
ble an
d adh
ered
to on
clea
ning o
f amb
ulanc
es w
ith di
sinfec
tants
after
tran
spor
ting
a pati
ent w
ith co
mmun
icable
dise
ase.
- Fu
el co
nsum
ption
tests
are d
one a
t leas
t onc
e a ye
ar.
12.4.
2 A
mech
anism
for
maint
enan
ce of
build
ing,
water
supp
ly an
d elec
trical
facilit
ies in
plac
e
- Th
e buil
ding p
lan an
d the
wate
r and
elec
tricity
supp
ly lay
out a
re av
ailab
le.
- A
syste
m to
chec
k the
pipe
lines
and t
aps f
or le
aking
and t
o rep
air th
em is
in pl
ace.
- A
comp
lete i
nspe
ction
of th
e elec
trical
netw
ork i
s car
ried o
ut ev
ery 6
mon
ths.
12.5
Perfo
rman
ce
revie
w 12
.5.1
Staff
mee
tings
held
regu
larly
- St
aff m
eetin
gs ar
e held
mon
thly.
- Mi
nutes
of st
aff m
eetin
gs ar
e ava
ilable
. 12
.5.2
Stati
stics
comp
iled
regu
larly
- St
atisti
cs re
lated
to th
e ser
vices
are c
ompil
ed m
onthl
y and
mad
e ava
ilable
.
15
III.
Ove
rall
Qua
lity
and
Safe
ty Im
prov
emen
t A
reas
of C
once
rnSt
anda
rds
Mea
sura
ble
Elem
ents
13 P
rodu
ctiv
ity a
nd q
ualit
y im
prov
emen
t pro
gram
me
13.1
Prod
uctiv
ity an
d qu
ality
impr
ovem
ent
prog
ramm
e
13.1.
1 Th
e ins
titutio
nal q
uality
ma
nage
ment
syste
m mo
nitor
ed re
gular
ly
- A
pre-
desig
ned p
erfor
manc
e che
cklis
t with
indic
ators
is av
ailab
le.
- Al
l the u
nits a
re m
onito
red a
t leas
t onc
e in t
wo m
onths
. -
Reco
rds o
n mon
itorin
g visi
ts an
d the
ir fee
dbac
ks ar
e kep
t. 13
.1.2
Patie
nt su
rveys
regu
larly
cond
ucted
-
Simp
le pa
tient
satis
factio
n for
mats
are a
vaila
ble in
all u
nits.
- A
regis
ter on
the s
imple
patie
nt sa
tisfac
tion s
urve
y res
ults i
s ava
ilable
. -
Detai
led pa
tient
satis
factio
n sur
veys
are c
ondu
cted o
nce i
n thr
ee m
onths
. -
Repo
rts on
the p
atien
t sati
sfacti
on su
rveys
are a
vaila
ble.
- A
regis
ter to
reco
rd pa
tient
comp
laints
and n
eces
sary
actio
n tak
en is
avail
able.
Patie
nt sa
tisfa
ctio
n su
rvey
form
s are
pro
vided
in “A
NNEX
4: P
atien
t Sat
isfac
tion
Surv
ey F
orm
(S
ampl
e)”.
16
AN
NEX
1: I
sles
for S
tatio
nerie
s
Sh
adow
dra
win
g
17
AN
NEX
2: S
tand
ardi
sed
Col
our C
odes
(Info
rmat
ion
prov
ided
by
cour
tesy
of C
astle
Stre
et H
ospi
tal f
or W
omen
)
Stan
dard
ised
Col
our C
odes
Red
:
Un-
ster
ile
Em
pty
N
egat
ive
Blu
e:
Ster
ile
Fu
ll
Posi
tive
Gre
en:
Saf
e
Qua
lity
& S
afet
y
Yello
w:
Infe
ctio
n
Bla
ck:
Gen
eral
18
ANNEX 3: Emergency Tray Items for Primary Medical Care Units (Sample)
Item Quantity (of one set) Disposable syringe 5cc 5
Disposable syringe 10cc 5
Disposable syringe 1cc 5
Disposable Needle 24G 10
Disposable I.V. Cannula 22G 5
Butterfly Cannula 23G 5
0.9% NaCl 1
Water for injection 1
Disposable IV sets 3
25% Glucose solution 1
Adrenaline (S/D) 1:1000 3
Atropine Sulphate injection 5
Hydrocortisone injection 10
Chlorpheniramine 10mg injection 3
Piriton 4mg tablets 13
Prednisolone 5mg tablets 50
Cotton wool 50g 1
Surgical tape 3” roll 1
Plastic carrier with lid 1
19
ANNEX 4: Patient Satisfaction Survey Form (Sample)
Patient Satisfaction Survey (OPD/Clinics) OPD
Clinics
I. About you
1. Are you Male Female
2. How old are you? -18 19-34 35-54 54-74 74+
3. Is this your first visit to this institution?
Yes No
4. How did you select this institution?
Recommendation from a doctor
From the previous visit
According to my knowledge
Close to house
5. How far are you living from the institution?
1-10 kms 11-20 kms 21-30 kms 31-50 kms 50+ kms
II. How do you feel about the institution?
Exce
llent
Very
Goo
d
Good
Fair
Poor
N/A
or D
K
6. Information given prior to arrival
7. Easiness of coming to the institution
8. Arrangement of the institution
9. Your welcome by reception
10. The registration process
III. Patients’ Care
Exce
llent
Very
Goo
d
Good
Fair
Poor
N/A
or D
K
11. The way we explained about Clinics and OPD
12. Doctors attention
20
ANNEX 4: Patient Satisfaction Survey Form (Sample)
13. Nurses’ attention on you
14. The consistency of your doctor’s care
15. The consistency of your nurse’s care
16. Support of other staff
17. The way staff made you feel confident in them
18. Were you given an opportunity to ask questions?
19. Drug issuing procedure at the pharmacy
20. Did they issue the medicine according to the doctor’s prescription?
21. If you had questions to ask, did you get answers you could understand?
22. Did your consultant explain about your illness
23. Instructions you received from the doctor
IV. Time spent at OPD & Clinics
Exce
llent
Very
Goo
d
Good
Fair
Poor
N/A
or D
K 24. Time spent for registration
25. Time waited to meet the doctor
26. Time spent with the doctor
27. Time spent to get the medicine
28. Overall time you spent at the institution
21
ANNEX 4: Patient Satisfaction Survey Form (Sample)
V. Facilities provided from the Institution
Exce
llent
Very
Goo
d
Good
Fair
Poor
N/A
or D
K
29. Directions given to you
30. Promptness of attention on you
31. Seating facilities
32. Waiting room privacy
33. Waiting room comfort
34. Waiting room décor
35. Toilet facilities
36. Support and caring of the staff
37. Overall cleanliness
38. Overall amenities
VI. Comments on Overall Quality of the Service
Exce
llent
Very
Goo
d
Good
Fair
Poor
N/A
or D
K
39. Overall rating on quality of care
40. Overall rating on quality of facilities
41. Total time spent at the institution
42. Did you get the treatments and care as you expected?
22
ANNEX 4: Patient Satisfaction Survey Form (Sample)
43. Would you recommend the institution to others? Yes No
If not, Comments
…………………………………………………………………..…………………………………………………
………………..……………………………………………………………………………………………………
………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………
23
24
APPENDIX
25
APPENDIX: General Circular on National Quality Assurance Programme in Health
26
APPENDIX: General Circular on National Quality Assurance Programme in Health
General Circular Letter No. 01-29/ 2009 My No. HPI/ OD/ 06/ 2009. Ministry of Healthcare & Nutrition
“Suwasiripaya”, 385, Rev. Baddegama Wimalawansa Thero Mawatha, Colombo 10. 22, September 2009.
To : Addl. Secretaries All Provincial Secretaries of Health, Director General of Health Services, All Deputy Director Generals and Directors, All Provincial Directors of Health Services, All Regional Directors of Health Services, and All Heads of Health Institutions.
National Quality Assurance Programme in Health We are pleased to note that some of our hospitals and other health institutions have initiated
productivity and quality improvement programmes as per instruction given by the General
Circular No 02-109/2003 and dated 08th October 2003.
The Ministry of Healthcare and Nutrition has decided to expand the Quality Assurance
Programme to all health institutions in Sri Lanka, in order to improve the quality and safety of
health care services. It aims at establishing a continuous quality improvement process by setting up
organizational structures and mechanisms at all health care institutions.
1. Quality Secretariat (QS)
Ministry of Healthcare & Nutrition has established a Quality Secretariat (QS) to direct
management of the Quality Assurance Programme.
2. Quality Management Units (QMU)
All health institutions should establish a Quality Management Unit (QMU) to create quality
and safety culture towards improving Quality of Healthcare. This unit will undertake planning
the implementation and monitoring of the National Quality Assurance Programme with the
27
APPENDIX: General Circular on National Quality Assurance Programme in Health
guidance of the Quality Secretariat, Ministry of Healthcare & Nutrition. Please see the
Organizational Structure in annexure.
3. Roles and Functions
I. Quality Secretariat
i. To facilitate the implementation of national policies related to quality and safety.
ii. Prepare and disseminate standards, guidelines and procedures.
iii. Development of training packages in order to strengthen capacity building of staff.
iv. Coordination with relevant health and health related sectors for quality assessment and
improvement.
v. Facilitate the development of a shared learning environment and continued achievement
of best practices.
vi. Develop and implement a continuous monitoring & evaluation system.
vii. Mobilize resources for the continuous improvement of quality and safety in the health
system.
viii. To facilitate the development of the legal and regulatory framework for the
implementation of quality and safety policy.
II. Quality Management Unit (QMU)
i. Quality Management Units (QMU) will be established in National Hospital of Sri Lanka,
Teaching Hospitals, Provincial General Hospitals, District General Hospitals and Base
Hospitals and specialised hospitals.
ii. All campaigns, decentralized units and special units under the Ministry of Healthcare &
Nutrition are expected to establish Quality Management Unit.
iii. Divisional Hospitals (District Hospitals, Peripheral Units and Rural Hospitals), and
Primary Medical Care Units (Central Dispensary & Maternity Home and Central
Dispensary) are expected to conduct their Quality Management Programme under a
designated officer who will be guided by the Quality Management Unit of RDHS.
iv. All MOOH are expected to plan and implement the Quality Management Programme,
under the guidance of the Quality Management Unit of RDHS.
28
APPENDIX: General Circular on National Quality Assurance Programme in Health
v. To facilitate development of a shared learning environment and continued achievement
of best practices.
III. Functions of QMU
QMU would coordinate the quality assurance and client safety program of the healthcare institutions through following functions.
i. Promote employee participation in management of quality by establishing Work Improvement
Teams (WIT) /Quality Circles (QC) in for the different departments/units within the health
institution.
ii. Conduct training of Work Improvement Teams (WIT).
iii. Maintain a database in staff training and conduct a planned In-service Training Programme.
iv. Conduct programs and workshops on quality improvement and patient safety focussing on
problem solving approaches and measurements.
v. Initiate a quality culture in health institutions by introducing 5S concepts leading towards Total
Quality Improvement (TQI).
vi. Ensure management leadership and involvement of medical consultants in the quality
improvement process.
vii. Assist in preparing strategic plans for the institutions with focus on reduction of waiting times,
instituting a smooth patient flow, infection control and waste disposal.
viii. Implementation of standards, guidelines and protocols relevant to customer/ patient care
including clinical pathways.
ix. Maintain a computer based data system by collecting and analysing data related to quality
improvement of services (eg. Patient accidents and adverse events, near misses re-admissions,
case fatality rates, complication arising from medical and surgical procedures, referrals, adverse
events following immunization and transfers, etc).
x. Prepare and distribute half yearly / quarterly bulletins and annual performance reports with
the assistance of Medical Record Unit (MRU) and other relevant units.
xi. Promote an environment friendly healthcare institution.
xii. Conduct customer satisfaction surveys, and employee satisfaction surveys, maintain and take
corrective action for public complaints. Encourage suggestion scheme in healthcare
institutions.
29
APPENDIX: General Circular on National Quality Assurance Programme in Health
xiii. Ensure quality of supplies by encouraging maintenance contract agreements for support
services in order to impalement Total Productivity Maintenance of the supplies.
xiv. Develop Annual Procurement plans for different variety of purchases.
xv. Organize and update supplier and maintenance information system and disseminate to the
relevant Units.
xvi. Facilitate assessment and improvement of performance through regular monitoring of the
programme using quality measurement indicators (Guidelines will be sent).
xvii. Assist and conduct performance reviews and maintain records of such reviews.
xviii. Promote studies, research and medical audits in the institutions.
xix. Assist Non Health Sectors to implement Productivity and Quality Assurance Programmes.
Contact Details
Quality Secretariat is located at;
Castle Street Hospital Complex, Colombo 08.
Tele: 011 2678598, 011 2678599, Fax 011 - 2695244
e- mail: Quality Secretariat" <[email protected]>. Dr. Athula Kahadaliyanage Dr. Ajith Mendis Secretary Director General of Health Service Ministry of Healthcare & Nutrition
30
APPENDIX: General Circular on National Quality Assurance Programme in Health
Annexure
Organizational Structure
Quality Secretariat Ministry of Healthcare &
Nutrition
Quality Management Unit
TH & Other Special hospitals under MoH
Quality Management Unit All Campaigns & Specialized Units
Quality Management Unit
PH, DGH, BH
Divisional Hospitals & Primary Medical Care
Units
MOH Office
Quality Management Unit
PDHS (Planning Unit)
Quality Management Unit RDHS
(Planning Unit)
31
APPENDIX: General Circular on National Quality Assurance Programme in Health
32
Feedback Form National Guidelines for Improvement of Quality and Safety of Healthcare Institutions
(For Primary Medical Care Units)
Kindly provide feedback for improvement of this document. We will try our best to incorporate your views and opinions into the next edition of these Guidelines.
Name: Title: Institution: Address: Tel: E-mail: Please write your suggestions for improvement of these Guidelines below:
Kindly mail this form to:
Director Organization Development, Ministry of Health, 385 Baddegama Wimalawansa Thero Mw., Colombo 10, Sri Lanka
MINISTRY OF HEALTHDEMOCRATIC SOCIALIST REPUBLIC OF SRI LANKA
ISBN: 978-955-0505-03-6