checklist for assessing · 2020-01-21 · 1 | page ministry of health checklist for assessing...
TRANSCRIPT
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Ministry of Health
CHECKLIST FOR ASSESSING QUALITY OF HEALTHCARE
Kenya Quality Model for Health
LEVEL 2 FACILITIES
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CONTENTS CONTENTS ............................................................................................................................ 2 FOREWORD ........................................................................................................................... 3 ACKNOWLEDGEMENTS ..................................................................................................... 4 LIST OF CONTRIBUTORS .................................................................................................... 5 ABBREVIATIONS ................................................................................................................. 6 INTRODUCTION ................................................................................................................... 7
Background ........................................................................................................................... 7 Rationale for the Review of KQMH ...................................................................................... 7 Review Objective .................................................................................................................. 8 Principles of the KQMH and Dimensions of Quality ............................................................. 8 Requirement .......................................................................................................................... 9 Scoring system .................................................................................................................... 10 Documents required during assessment ................................................................................ 11 Facility profile ..................................................................................................................... 12
STRUCTURE ........................................................................................................................ 13
Dimension 1: Leadership ..................................................................................................... 13 Dimension 2: Human Resources Management and Development ......................................... 17 Dimension 3: Policies, Standards and Guidelines ................................................................. 22 Dimension 4: Facilities and Infrastructure ............................................................................ 24 Dimension 5: Supplies Management .................................................................................... 33 Dimension 6: Equipment Management ................................................................................ 35 Dimension 7: Transport and Fleet Management ................................................................... 39 Dimension 8: Referral System ............................................................................................. 40 Dimension 9: Health Records and Health Management Information Systems ...................... 43 Dimension 10: Financial Management ................................................................................. 47
DIMENSION 11: PROCESSES ............................................................................................. 49
11.1 Outpatient Services ...................................................................................................... 49 11.2 Patient Centred Care .................................................................................................... 55 11.3 Infection Prevention and Control ................................................................................. 59 11.4 Accidents and Emergency ............................................................................................ 62
DIMENSION 12: RESULTS ................................................................................................. 65 APPENDICES ....................................................................................................................... 67
Appendix 1: A&E Equipment .............................................................................................. 67 Appendix 2: Essential Medicines ......................................................................................... 69 Appendix 3: List of Tracer Non-pharmaceutical products .................................................... 70
TERMINOLOGY .................................................................................................................. 71
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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. 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 Simon Gitau 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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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 geographical/regional specialization including highly
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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 (where applicable) 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 report/s
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):
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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
14 |
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
15 |
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
)
Y
es
No
1.1.
6 T
he h
ealth
faci
lity
shal
l co
mpl
y w
ith e
thic
al
prin
cipl
es.
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
Qua
lity
Stan
dard
Re
quire
men
t Sc
ore
(tick
ap
prop
riat
e bo
x)
Rem
arks
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
(MO
V- M
inut
es)
Yes
N
o
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
16 |
Pa
ge
Q
ualit
y St
anda
rd
Requ
irem
ent
Scor
e (ti
ck
appr
opri
ate
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)
Yes
N
o
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
on
ce a
nnua
lly a
nd
succ
ess s
tori
es a
nd
less
ons l
earn
t co
mm
unic
ated
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.
(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 )
Yes
N
o
P
17 |
Pa
ge
Q
ualit
y St
anda
rd
Requ
irem
ent
Scor
e (ti
ck
appr
opri
ate
box)
R
emar
ks
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
Dim
ensi
on 2
: Hum
an R
esou
rces
Man
agem
ent a
nd D
evel
opm
ent
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
:
Regi
strat
ion
with
rele
vant
pro
fess
iona
l bo
dies
. (M
OV-
pers
onne
l file
with
liste
d do
cum
ents
. Sam
ple
5 fil
es)
Y
es
N
o
P
18 |
Pa
ge
St
anda
rd
Requ
irem
ents
Sc
ore
(tic
k ap
prop
riat
e bo
x)
Rem
arks
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
docu
men
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
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
19 |
Pa
ge
St
anda
rd
Requ
irem
ents
Sc
ore
(tic
k ap
prop
riat
e bo
x)
Rem
arks
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
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
20 |
Pa
ge
St
anda
rd
Requ
irem
ents
Sc
ore
(tic
k ap
prop
riat
e bo
x)
Rem
arks
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
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
21 |
Pa
ge
St
anda
rd
Requ
irem
ents
Sc
ore
(tic
k ap
prop
riat
e bo
x)
Rem
arks
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
22 |
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
23 |
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
24 |
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
25 |
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
26 |
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
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
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
28 |
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
cls)
Y
es
N
o
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
29 |
Pa
ge
St
anda
rd
Req
uire
men
ts
Scor
e (ti
ck a
ppro
pria
te
box)
Re
mar
ks
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
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
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
Yes
30 |
Pa
ge
St
anda
rd
Req
uire
men
ts
Scor
e (ti
ck a
ppro
pria
te
box)
Re
mar
ks
man
agem
ent a
nd ri
sk re
duct
ion
(MO
V-SO
P)
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
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
31 |
Pa
ge
St
anda
rd
Req
uire
men
ts
Scor
e (ti
ck a
ppro
pria
te
box)
Re
mar
ks
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
(MO
V-ob
serv
atio
n)
Yes
No
Ava
ilabi
lity
of sa
fe d
rinki
ng w
ater
(M
OV-
inte
rvie
w sta
ff)
Yes
No
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
32 |
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
33 |
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
34 |
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
35 |
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
36 |
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
37 |
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
cond
ition
.
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
38 |
Pa
ge
St
anda
rd
Req
uire
men
ts
Scor
e (t
ick
appr
opria
te
box)
R
emar
ks
All
equi
pmen
t mon
itore
d in
acc
orda
nce
with
th
e m
anuf
actu
rers
’ spe
cific
atio
ns a
nd
appl
icab
le st
anda
rds (
MO
V-Sa
mpl
e on
e eq
uipm
ent f
rom
the
supp
ort s
ervi
ces)
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
39 |
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
40 |
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
Yes
No
41 |
Pa
ge
St
anda
rd
Requ
irem
ents
Sc
ore
(tick
app
ropr
iate
bo
x)
Rem
arks
(MO
V- S
OPs
/ Int
ervi
ew re
spon
sibl
e sta
ff)
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
Y
es
42 |
Pa
ge
St
anda
rd
Requ
irem
ents
Sc
ore
(tick
app
ropr
iate
bo
x)
Rem
arks
N
o
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
43 |
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
44 |
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
45 |
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
46 |
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
47 |
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
48 |
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
49 |
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
Ar
eas f
or a
sses
smen
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 fo
r by
the
heal
th fa
cilit
ies h
ave
thei
r hea
lth c
are
need
s id
entif
ied
thro
ugh
an
asse
ssm
ent p
roce
ss th
at h
as
been
def
ined
by
the
hosp
ital
The
min
imum
requ
irem
ents
of h
istor
y ta
king
and
phy
sica
l exa
min
atio
n of
pa
tient
s is d
efin
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
bl
ood
pres
sure
mac
hine
s
Yes
No
P
Ava
ilabi
lity
of p
atie
nt e
xam
inat
ion
tool
s, at
min
imum
, ste
thos
cope
and
dia
gnos
tic
kits
Yes
No
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
50 |
Pa
ge
St
anda
rd
Area
s for
ass
essm
ent
Scor
e (t
ick
off t
he
appr
opri
ate
box)
R
emar
ks
11.1
.1.2
The
faci
lity
prov
ides
he
alth
edu
catio
n th
at su
ppor
ts pa
tient
and
fam
ily p
artic
ipat
ion
in th
eir c
are
deci
sions
and
car
e pr
oces
ses.
The
hosp
ital p
lans
edu
catio
n co
nsist
ent
with
its m
issio
n, se
rvic
es, a
nd p
atie
nt
popu
latio
n.
(MO
V-Sc
hedu
le w
ith to
pics
)
Yes
No
P
Ther
e is
an e
stabl
ishe
d st
ruct
ure
for
heal
th e
duca
tion
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
all p
atie
nts
(MO
V-Sa
mpl
e 5
patie
nt fi
les)
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
(M
OV-
Obs
erva
tion)
Yes
No
P
Mic
ronu
trien
t sup
plem
ents
pro
vide
d as
pe
r pat
ient
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
51 |
Pa
ge
St
anda
rd
Area
s for
ass
essm
ent
Scor
e (t
ick
off t
he
appr
opri
ate
box)
R
emar
ks
11
.1.1
.4 T
he fa
cilit
y sh
all
esta
blish
pro
cedu
res t
o en
sure
th
e pr
ovisi
on o
f prim
ary
imm
uniz
atio
n se
rvic
es.
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
da
ily b
asis
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
the
prov
ision
of
com
preh
ensi
ve e
mer
genc
y 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
5 pa
tient
file
s)
Yes
No
P
52 |
Pa
ge
St
anda
rd
Area
s for
ass
essm
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 p
rofil
e fo
r all
ante
nata
l mot
hers
pe
rfor
med
and
revi
ewed
. (M
OV-
Sam
ple
5 pa
tient
reco
rds)
Yes
No
P
53 |
Pa
ge
St
anda
rd
Area
s for
ass
essm
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 a
ll an
tena
tal m
othe
rs b
ased
on
phys
ical
, la
bora
tory
and
oth
er d
iagn
ostic
ex
amin
atio
ns.
(MO
V- S
ampl
e 5
patie
nt re
cord
s)
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
re
gist
er)
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
rele
vant
com
mitt
ees
(MO
V-M
inut
es, m
anag
emen
t file
s for
co
mm
ittee
con
stitu
tion)
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
54 |
Pa
ge
St
anda
rd
Area
s for
ass
essm
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
55 |
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)
Yes
No
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
(M
OV-
obs
erva
tion
nam
e an
d de
sign
atio
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
56 |
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
57 |
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 sh
all
impl
emen
t 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 ho
spita
l bra
cele
t w
ith u
niqu
e id
entif
ier
(MO
V- O
bser
ve fo
r arm
band
with
uni
que
iden
tifie
r)
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
and
chan
ge m
anag
emen
t to
resp
ond
to
Yes
No
58 |
Pa
ge
St
anda
rd
Requ
irem
ents
Sc
ore
(tic
k ap
prop
riat
e bo
x)
Rem
arks
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
app
ropr
iate
ass
essm
ent
and
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
59 |
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
60 |
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
61 |
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
62 |
Pa
ge
11
.4 A
ccid
ents
and
Em
erge
ncy
Stan
dard
R
equi
rem
ents
Sc
ore
(tic
k ap
prop
riate
bo
x)
Rem
arks
11.4
.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)
Y
es
N
o
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
11.4
.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
Yes
63 |
Pa
ge
St
anda
rd
Req
uire
men
ts
Scor
e (t
ick
appr
opria
te
box)
Re
mar
ks
mai
ntai
ned
(MO
V- tr
iagi
ng re
gist
er)
No
11.4
.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
11.4
.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
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
64 |
Pa
ge
St
anda
rd
Req
uire
men
ts
Scor
e (t
ick
appr
opria
te
box)
Re
mar
ks
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 of
turn
-aro
und
time)
Yes
No
11.4
.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
11.4
.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
11.4
.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
65 |
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
90%
˂
22
22-4
4%
45-6
7%
68-8
9%
≥90%
66 |
Pa
ge
N
o.
Indi
cato
r Be
nchm
ark
0 1
2 3
4 D
enom
inat
or: F
acili
ty ta
rget
po
pula
tion
unde
r 1ye
ar o
f age
7
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%
8 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%
9 Q
uarte
rly d
ata
qual
ity a
udits
car
ried
out i
n th
e pa
st o
ne y
ear
4 0
1 2
3 4
67 |
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
68 |
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
69 |
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
70 |
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
lam
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
71 | 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.
72 | 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
73 | 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
74 | 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.
75 | 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.
76 | P a g e
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/