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Quality Series No.4
National Guidelines for Improvement of Quality and Safety of Healthcare Institutions
(For Specialised Public Health Units and Campaigns)
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.4 National Guidelines for Improvement of Quality and Safety of Healthcare Institutions (for Specialised Public Health Units and Campaigns) ISBN: 978-955-0505-07-4 Printed in Sri Lanka This Publication is sponsored by: Japan International Cooperation Agency (JICA)
Preface
Sri Lanka has reached a high level of health status amongst its population in comparison with the countries in the neighbourhood. Alongside the preventive care service network which has evolved since 1920s, the Specialised Public Health Units and Campaigns under the Ministry of Health have played significant roles in improvement of the health outcomes, particularly of those represented by the MDG indicators. Nevertheless, there is still room for further improvement of the quality of the work undertaken by them.
The National Guidelines for Improvement of Quality and Safety of Healthcare Institutions provide a comprehensive set of quality standards and affordable measures to improve the work undertaken by the Specialised Public Health Units and Campaigns. They are therefore expected to be fully oriented on these Guidelines and prepared to improve their working environment and process, as well as the service delivery in the specialised areas. Needless to say, the strong commitment of heads of units 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, Dr. C. J. Aluthweera, Coordinator for National Quality Assurance Programme, who provided technical inputs in development of the quality standards, and Mr. Shogo Kanamori, JICA Expert on Medical Services Administration, who provided coordinative and technical assistance.
Dr. Ravindra Ruberu Secretary Ministry of Health
20 October 2010
List of Contributors
Dr. Aluthweera, Champa; Coordinator for National Quality Assurance Programme, Ministry of Health
Dr. Ambagahage, Thushara; Medical Officer, National Programme for Tuberculosis Control and Chest Diseases, Ministry of Health
Dr. Balasooriya, B.A.P.R.; Senior Registrar, MDPU, Ministry of Health
Dr. Batuwanthudawa, B.K.R., Consultant Epidemiologist, Epidemiology Unit, Ministry of Health
Dr. Deniyage, Sarath; Director, Malaria Control Programme, Ministry of Health
Mr. Dissanayake, Chaturanga; Project Assistant, JICA Advisor’s Office
Dr. Dolamulla, Suranga; Deputy Director; TH North Colombo (Ragama)
Dr. Fernando, Rani; Director, Castle Street Hospital for Women
Dr. Gamage, G.L.N.D.; DMO, DH Polpithigama
Dr. Gamage, Rehan; Research Assistant, JICA Advisor’s Office
Dr. Gamlath, G.; MS, DGH Kegalle
Dr. Jayanath, B.L.D.; MOIC, PU Madampe
Dr. Jayantha, Wimal; DDG (Planning), Ministry of Health
Dr. Jayasooriya, Usha; MO, National Programme for Tuberculosis Control and Chest Diseases, Ministry of Health
Mr. Kanamori, Shogo; JICA Expert on Medical Services Administration
Dr. Karawita, D.A.; Assistant Venereologist, National STD/AIDS Prevention Programme
Dr. Perera, Dilum; Medical Officer, Health Education Bureau, Ministry of Health
Dr. Pranagama, N.; Director, Cancer Control Programme, Ministry of Health
Dr. Rajamanthri, M.D.S.; Director, TH Kurunegala
Dr. Ruwanpathirana, T.; Reg/Community Physician, Family Health Bureau, Ministry of Health
Dr. Sridharan, S.; Director Organization Development, Ministry of Health
Dr. Wedamulla, Asanka; MO Planning, MDPU, Ministry of Health
Dr. Wijerathne, Lalitha; MO/QMU, DGH Gampaha
Dr. Wijesinghe, W.A.K.; RDHS, Kegalle District
TABLE OF CONTENTS
1. Introduction ……………………………………………………………………………….. 1
1.1. Target Institutions of the Guidelines ..……………………………………………..… 1
1.2. Institutional Arrangements for Quality Improvement of Specialised Public Health Units and Campaigns ……….....…………………………………………………...… 1
2. Quality Standards of Specialised Public Health Units and Campaigns …..…….. 2
I. Working Environment (5S) ………………………………….………………….…. 3 1. Seiri (Sorting)
2. Seiton (Organisation) 3. Seiso (Cleaning with Meaning and for Beautifying) 4. Seiketsu (Standardisation) 5. Shitsuke (Training & Self-Discipline)
II. Overall Management of the Unit ……………………………………………....…. 8 6. Leadership quality
7. Health information system and performance review 8. Human resource management 9. Office management 10. Financial management 11. Responsiveness 12. Productivity and quality improvement programme 13. Inter-sectoral coordination, public relations and community mobilisation
ANNEXES ……………………………………………………………………………………….. 12 ANNEX 1: Isles for Stationeries ………………………………………………………….. 12 ANNEX 2: Cleaning Checklist (Sample) …...……………………………………………. 13 ANNEX 3: Standardised Colour Codes ………………………………………………….. 14
APPENDIX: General Circular on National Quality Assurance Programme in Health 17
1. Introduction
These Guidelines will provide guidance to those working at Specialised Public Health Units and Campaigns under the Ministry of Health in strengthening the organisational and individual preparedness for improvement of the quality of their work. It is assumed that these Guidelines will be used for the following purposes.
As a handbook for the Specialised Public Health Unit and Campaign staff in implementing quality improvement programmes and related activities
As a guiding document for orientation programmes to the Specialised Public Health Unit and Campaign staff conducted by the National Quality Secretariat
1.1. Target institutions of the Guidelines
The target institutions of these Guidelines include all Specialised Public Health Units and Campaigns under the Ministry of Health.
Epidemiology Unit
Family Health Bureau
Health Education Bureau
Mental Health Unit
Non-communicable Disease Control Unit
Environmental and Occupational Health Unit
Estate and Urban Health Unit
Quarantine Services Unit
Care for Youth, Elderly, Displaced and Disabled Persons
Nutrition Coordination Unit
Anti Leprosy Campaign
Anti Filariasis Campaign
Public Health Veterinary Services Unit
Anti Malaria Campaign
National Programme for Tuberculosis Control and Chest Diseases
National Cancer Control Programme
National STD/AIDS Prevention Programme
Dengue Coordinator Unit
Blood Transfusion Service
1.2. Institutional Arrangements for Quality Improvement of Specialised Public Health Units and Campaigns
All Specialised Public Health Units and Campaigns under the Ministry of Health are expected to establish Quality Management Unit and to implement Quality Management Programme under the
1
guidance of the National Quality Secretariat, according to the “General Circular No.01-29/2009” of the Ministry of Healthcare & Nutrition dated 22 September 2009 (attached as APPENDIX).
2. Quality Standards of Specialised Public Health Units and Campaigns
This chapter provides the quality standards of the Specialised Public Health Units and Campaigns. They are divided into two aspects and 13 areas.
I. Working 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. Overall Management of the Unit 6. Leadership quality 7. Health information system and performance review 8. Human resource management 9. Office management 10. Financial management 11. Responsiveness 12. Productivity and quality improvement programme 13. Inter-sectoral coordination, public relations and community mobilisation
These standards will be referred to whenever a Specialised Public Health Unit/Campaign conducts quality improvement activities as well as internal audit. They are also in line with the criteria for external audits and for selection of the National Health Excellency Award recipients.
2
I. W
orki
ng E
nviro
nmen
t (5S
)
Area
of C
once
rn
Stan
dard
s Me
asur
able
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 a
t wor
k
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 ite
ms.
1.1.2
The f
loors
and p
assa
gewa
ys
in the
publi
c are
as eq
uippe
d wi
th ga
rbag
e bins
for g
ener
al wa
ste an
d kep
t free
of lit
ters
- 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 b
ranc
hes
remo
ved
(if ap
plica
ble)
- 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 c
alend
ars.
- 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 o
f 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.
3
I. W
orki
ng E
nviro
nmen
t (5S
)
Area
of C
once
rn
Stan
dard
s Me
asur
able
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
Offic
e ide
ntific
ation
2.1
.1 An
offic
e nam
e boa
rd an
d a
site m
ap av
ailab
le -
An of
fice n
ame b
oard
is di
splay
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
avail
able
at ev
ery j
uncti
on
- Di
recti
onal
boar
ds ar
e disp
layed
at ev
ery j
uncti
on ou
tside
and i
nside
of th
e offic
e to a
ll fac
ilities
from
the
entra
nce i
n all t
hree
lang
uage
s. 2.2
.2 Co
rrido
rs cle
arly
marke
d with
en
tranc
es an
d exit
lines
, cu
rved d
oor o
penin
gs, a
nd
direc
tion o
f trav
el
- Cu
rved d
oor o
penin
gs ar
e mar
ked a
t entr
ance
door
s to r
ooms
. -
The d
irecti
on of
trav
el is
indica
ted on
the c
orrid
ors.
- Th
e slid
ing do
ors a
re pr
ovide
d with
dire
ction
al ar
rows
.
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. 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”
.
4
I. W
orki
ng E
nviro
nmen
t (5S
)
Area
of C
once
rn
Stan
dard
s Me
asur
able
Elem
ents
2.4
.2 Fil
es an
d fold
ers a
rrang
ed
using
the m
istak
e pro
ofing
co
ncep
t
- 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
Table
s and
chair
s plac
ed in
or
der
- Ta
bles a
nd ch
airs i
n the
offic
e are
arra
nged
acco
rding
to X
Y ax
is.
2.4.4
Parki
ng ar
eas f
or ve
hicles
sp
ecifie
d and
mar
ked
(If ap
plica
ble)
- Pa
rking
area
s for
vehic
les ar
e spe
cified
and m
arke
d. -
Vehic
le flo
ws ar
e ide
ntifie
d and
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
Offic
e pre
mise
s main
taine
d wi
th he
althy
and s
afe
envir
onme
nt (if
appli
cable
)
- 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
. -
The v
isible
parts
of th
e roo
f are
free
of un
wante
d item
s. 3.1
.2 Flo
ors,
walls
, wind
ows a
nd
curta
in &
other
fittin
gs be
ing
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
clean
ing ch
eckli
st is
avail
able
and u
pdate
d. 3.1
.3 To
ilets
are c
lean a
nd in
wo
rking
orde
r -
Unple
asan
t odo
ur is
not e
xper
ience
d in t
oilets
. -
Toile
t facil
ities a
re ke
pt re
ady f
or us
e. -
A cle
aning
chec
klist
is av
ailab
le an
d upd
ated.
-Ad
equa
te ve
ntilat
ion is
prov
ided i
n all t
he to
ilets.
5
I. W
orki
ng E
nviro
nmen
t (5S
)
Area
of C
once
rn
Stan
dard
s Me
asur
able
Elem
ents
3.2
Cl
eanin
g of
mach
ines,
equip
ment,
tools
an
d fur
nitur
e
3.2.1
The c
leanli
ness
of
build
ings,
mach
ines,
equip
ment,
tools
an
d fur
nitur
e main
taine
d
- Th
e high
leve
l of c
leanli
ness
is m
aintai
ned w
ith no
visib
le dir
t:
Build
ings
Of
fice v
ehicl
es
Of
fice e
quipm
ent
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 s
ystem
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 dete
rgen
ts 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.
- Cl
eanin
g too
ls for
outsi
de ar
eas/t
oilets
and i
nside
area
s are
sepa
rated
. 3.3
.3 An
upda
ted cl
eanin
g che
cklis
t av
ailab
le -
A cle
aning
chec
klist
is dis
playe
d and
mad
e visi
ble to
the s
taff m
embe
rs.
- Re
spon
sible
perso
nnel
for cl
eanin
g is i
denti
fied a
nd m
entio
ned i
n the
clea
ning c
heck
list.
- Th
e clea
ning c
heck
list is
upda
ted w
eekly
.
A sa
mpl
e clea
ning
chec
klist
is p
rovid
ed in
“ANN
EX 2:
Clea
ning
Che
cklis
t (Sa
mpl
e)”.
4 Se
iket
su (S
tand
ardi
zatio
n)
Gen
erat
ing
mec
hani
sms
to m
aint
ain
the
thre
e S
s (S
eiri,
Sei
ton
and
Sei
so) b
y de
velo
ping
pro
cedu
res,
sch
edul
es a
nd to
ols
for c
ontin
uous
ass
essm
ent a
nd
regu
lar a
udit.
4.1
Stan
dard
ized
visua
ls
4.1.1
Sign
boar
ds an
d dire
ction
al bo
ards
stan
dard
ised
- 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
, an
d by c
olour
code
s. 4.1
.2 Ide
ntific
ation
labe
ls pla
ced o
n all
mac
hines
and e
quipm
ent
- Al
l mac
hines
and e
quipm
ent h
ave i
denti
ficati
on la
bels
with
the fo
llowi
ng in
forma
tion:
Na
me of
the i
tems
Ide
ntific
ation
and b
atch n
umbe
rs
Date
of ac
quisi
tion
Co
ntact
detai
ls of
maint
enan
ce co
mpan
y
Resp
onsib
le pe
rson f
or m
ainten
ance
Co
st of
equip
ment
6
I. W
orki
ng E
nviro
nmen
t (5S
)
Area
of C
once
rn
Stan
dard
s Me
asur
able
Elem
ents
4.1
.3 Ca
ution
sign
s disp
layed
at
appr
opria
te pla
ces
- “D
ange
r” sig
ns ar
e disp
layed
at el
ectric
switc
hboa
rds a
nd tr
ansfo
rmer
s. -
“Slop
es” s
ings a
re di
splay
ed at
whe
reve
r the
re is
a slo
pe.
- “S
lippe
ry” si
gns w
ith ze
bra c
ode a
re pl
aced
at w
et flo
or af
ter cl
eanin
g. 4.1
.4 Op
en an
d shu
t dire
ction
al lab
els av
ailab
le on
door
s -
The d
irecti
onal
labels
are p
ut on
door
hand
les of
cupb
oard
s.
4.1.5
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 3:
Sta
ndar
dise
d Co
lour
Cod
es”
4.2
Maint
enan
ce of
ve
hicles
and
equip
ment
4.2.1
Vehic
les an
d equ
ipmen
t 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
Offic
e equ
ipmen
t -
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
Secu
rity m
easu
res i
n plac
e for
a f
ire ev
ent
- Fu
nctio
nal fi
re ex
tingu
isher
s or s
and b
ucke
ts ar
e ava
ilable
. -
The g
uideli
nes o
r a pr
otoco
l for t
he fir
e eve
nt is
avail
able.
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
Inter
nal a
udit
5.1.1
Inter
nal a
udits
on th
e qua
lity
and s
afety
impr
ovem
ent
cond
ucted
with
the c
heck
list
- An
inter
nal a
udit s
heet
on th
e qua
lity im
prov
emen
t of th
e ins
titutio
n is a
vaila
ble.
- A
team
has b
een a
ppoin
ted to
cond
uct th
e inte
rnal
audit
. -
The i
ntern
al au
dit is
cond
ucted
at le
ast o
nce i
n thr
ee m
onths
. 5.2
Tr
aining
and
raisi
ng
awar
enes
s
5.2.1
The s
taff tr
ained
on 5S
, pr
oduc
tivity
and q
uality
-
All th
e staf
f are
train
ed on
5S, p
rodu
ctivit
y and
quali
ty.
-A
prog
ramm
e to t
rain
new
staff o
n 5S,
prod
uctiv
ity an
d qua
lity is
avail
able.
5.2
.2 A
syste
m to
give a
ward
s to
well-p
erfor
med s
taff a
nd un
its
avail
able
- An
even
t to ap
prec
iate b
est p
erfor
ming
emplo
yees
is ca
rried
out a
nnua
lly.
7
II.
Ove
rall
Man
agem
ent o
f the
Uni
t Ar
eas o
f Con
cern
St
anda
rds
Me
asur
able
Elem
ents
6 Le
ader
ship
qua
lity
6.1
Targ
et se
tting
and p
lannin
g 6.1
.1 Vi
sion,
Miss
ion an
d valu
es of
the
orga
nisati
on av
ailab
le -
The V
ision
, Miss
ion an
d valu
es of
the o
rgan
isatio
n are
disp
layed
in a
visibl
e plac
e. -
Offic
e staf
f are
awar
e of th
e Visi
on, M
ission
and v
alues
, and
unde
rstan
d the
m.
6.1.2
Prod
uctiv
ity ba
sed g
oals
and
objec
tives
avail
able
- Pr
oduc
tivity
base
d goa
ls an
d obje
ctive
s of th
e unit
are a
vaila
ble.
6.1.3
The m
anag
emen
t of th
e unit
ba
sed o
n plan
s -
The f
ollow
ing pl
ans a
re de
velop
ed an
d ava
ilable
.
Adva
nce p
rogr
amme
s for
all th
e key
staff
Annu
al pla
n of th
e ins
titutio
n
Mediu
m-ter
m pla
n of th
e ins
titutio
n -
Indica
tors t
o mea
sure
the o
rgan
izatio
nal p
erfor
manc
e are
avail
able,
inclu
ding:
Ke
y mea
sure
ment
area
s
Rates
/ratio
s to m
easu
re th
e per
forma
nce
Targ
ets w
ith tim
efram
e 6.2
Fo
llow-
up
activ
ities
6.2.1
Meas
ures
take
n to r
educ
e de
viatio
n of s
tanda
rds o
f gap
s -
Follo
w-up
activ
ities a
re ta
ken t
o add
ress
devia
tion o
f stan
dard
s of g
aps (
e.g. in
creas
e of in
ciden
ce)
by to
p man
agem
ent a
nd do
cume
nted.
- Ne
w or
inno
vativ
e mea
sure
s (e.g
. pilo
t pro
ject, r
esea
rch) a
re ta
ken t
o red
uce d
eviat
ion of
stan
dard
s of
gaps
by to
p man
agem
ent.
6.2.2
Monit
oring
and e
valua
tion o
f pr
oject
activ
ities
- A
monit
oring
mec
hanis
m is
avail
able
in im
pleme
nting
proje
ct ac
tivitie
s. -
Mid-
term
and f
inal e
valua
tion o
f the p
rojec
t acti
vities
are c
ondu
cted a
nd do
cume
nted.
7 H
ealth
info
rmat
ion
syst
em a
nd p
erfo
rman
ce re
view
7.1
Healt
h inf
orma
tion
syste
m
7.1.1
Colle
ction
of re
turns
and d
ata
adeq
uatel
y man
aged
-
Type
s of r
eturn
s and
data
to be
colle
cted b
y the
Unit
are c
learly
defin
ed.
- Al
l the m
onthl
y and
quar
terly
retur
ns ar
e coll
ected
in a
timely
man
ner.
7.1.2
Web
-bas
ed in
forma
tion
syste
m av
ailab
le -
A we
b-ba
sed i
nform
ation
syste
m is
avail
able
and f
uncti
oning
.
8
II.
Ove
rall
Man
agem
ent o
f the
Uni
t Ar
eas o
f Con
cern
St
anda
rds
Me
asur
able
Elem
ents
7.1
.3 Or
derly
healt
h info
rmati
on in
pla
ce
- Ac
cura
te, co
mplet
e and
upda
ted da
ta an
d stat
istics
are a
vaila
ble.
- Hu
man r
esou
rce da
tabas
e inc
luding
thos
e wor
king a
t per
ipher
al un
its is
avail
able
and u
pdate
d to
comp
ly wi
th the
bian
nual
staff c
ensu
s. -
Key s
tatist
ics ar
e disp
layed
in th
e unit
. 7.1
.4 De
cision
mak
ing ba
sed o
n he
alth i
nform
ation
-
The h
ealth
infor
matio
n is u
sed f
or pl
annin
g and
decis
ion m
aking
purp
oses
, as e
viden
t by:
Mi
nutes
of m
onthl
y and
perfo
rman
ce re
view
meeti
ngs
An
nual
and m
id-ter
m pla
ns
7.2
Perfo
rman
ce
revie
w 7.2
.1 A
functi
onal
supe
rviso
ry sy
stem
in pla
ce
- Th
e mon
thly m
eetin
g of th
e unit
is co
nduc
ted an
d minu
tes ar
e kep
t. -
A su
pervi
sory
staff c
hart
is av
ailab
le.
- Re
gular
insp
ectio
ns of
the p
eriph
eral
units
(if an
y) ar
e con
ducte
d by s
uper
vising
staff
at le
ast o
nce i
n thr
ee m
onths
. -
Repo
rts on
supe
rviso
ry vis
its ar
e ava
ilable
and u
pdate
d. 7.2
.2 Pe
rform
ance
comp
iled a
nd
revie
wed
- Re
gular
mee
tings
to re
view
key m
easu
reme
nts an
d the
orga
nisati
onal
perfo
rman
ce ar
e con
ducte
d wi
th int
erna
l and
exter
nal s
taff m
embe
rs an
d doc
umen
ted.
-An
nual
repo
rts on
the p
erfor
manc
e are
comp
iled a
nd di
stribu
ted.
8 H
uman
reso
urce
man
agem
ent
8.1
Huma
n res
ource
ma
nage
ment
8.1.1
Staff
train
ing co
nduc
ted
regu
larly
- A
staff t
raini
ng an
nual
plan i
s ava
ilable
. -
A sta
ff tra
ining
reco
rd bo
ok is
avail
able
and u
pdate
d. -
A co
ordin
ator f
or st
aff tr
aining
is as
signe
d. 8.1
.2 St
aff de
ploym
ent a
dequ
ately
mana
ged
- Th
e cad
re an
d the
curre
nt sta
tus of
the s
taff a
re di
splay
ed an
d upd
ated.
- St
aff de
ploym
ent r
ecor
d boo
ks ar
e ava
ilable
for a
ll cate
gorie
s of s
taff a
nd up
dated
. -
Perso
nal fi
les ar
e ava
ilable
for e
ach s
taff a
nd up
dated
. 8.1
.3 Jo
b des
cripti
ons f
or al
l ca
tegor
ies of
staff
avail
able
- Jo
b des
cripti
ons f
or al
l cate
gorie
s of s
taff a
re av
ailab
le.
8.1.4
Appr
aisal
syste
m in
place
-
A sta
ff app
raisa
l form
at is
avail
able.
-
Staff
appr
aisal
is co
nduc
ted on
a re
gular
basis
. 8.1
.5 St
aff w
elfar
e sch
emes
av
ailab
le -
Staff
welf
are s
chem
es (e
.g. an
nual
functi
ons,
loan s
chem
es, e
tc.) a
re av
ailab
le.
8.1.6
Huma
n dev
elopm
ent
mech
anism
in pl
ace
- A
plan o
r poli
cy on
huma
n dev
elopm
ent (
e.g. s
tress
free
envir
onme
nt, de
velop
ment
of so
cial
relat
ionsh
ip an
d pro
motio
n of p
hysic
al ac
tivitie
s) is
avail
able.
9
II.
Ove
rall
Man
agem
ent o
f the
Uni
t Ar
eas o
f Con
cern
St
anda
rds
Me
asur
able
Elem
ents
9 O
ffice
man
agem
ent
9.1
Offic
e ma
nage
ment
syste
m
9.1.1
A fun
ction
al off
ice
mana
geme
nt sy
stem
in pla
ce
- Th
e nam
e, de
signa
tion a
nd th
e sub
ject o
f eve
ry he
alth m
anag
emen
t ass
istan
t (HM
A) is
avail
able
at the
entra
nce o
f the o
ffice.
- Na
me an
d sub
ject o
f eac
h HMA
is di
splay
ed on
each
HMA
’s tab
le.
- Al
l the f
iles h
ave i
denti
ficati
on nu
mber
s and
docu
ments
in th
e file
s are
numb
ered
in a
stand
ard
mann
er.
- A
mech
anism
to co
ver u
p abs
ence
of of
fice s
taff is
in pl
ace.
-An
inbu
ilt me
chan
ism to
rece
ive an
d sen
d lett
ers a
nd fa
xes i
s in p
lace.
9.2
Offic
e equ
ipmen
t an
d con
suma
bles
9.2.1
Offic
e equ
ipmen
t pro
perly
ma
nage
d -
An in
vento
ry of
the of
fice e
quipm
ent is
avail
able
and u
pdate
d. -
Each
equip
ment
has a
sepa
rate
file w
ith m
ainten
ance
reco
rds a
nd al
l the o
ther d
etails
. 9.2
.2 Of
fice c
onsu
mable
s pro
perly
ma
nage
d -
Annu
al sto
ck re
quire
ment
is av
ailab
le for
each
cons
umab
le ite
m.
- Su
pplie
r infor
matio
n of th
e offic
e con
suma
bles i
s ava
ilable
. -
A pr
oper
proc
ess t
o iss
ue co
nsum
able
items
to th
e unit
on re
ques
t is in
plac
e.
10 F
inan
cial
man
agem
ent
10.1
Finan
cial
mana
geme
nt 10
.1.1
Salar
y she
ets/vo
uche
rs pr
oper
ly co
mplet
ed
- Th
e sala
ry sh
eets
and v
ouch
ers a
re co
mplet
ed pr
oper
ly.
10.1.
2 Ov
ertim
e/allo
wanc
e pay
ment
in tim
e -
Over
time a
nd al
lowan
ce pa
ymen
ts ar
e don
e in t
ime.
10.1.
3 Ca
sh an
d acc
ounts
man
aged
pr
oper
ly -
The a
ctual
cash
balan
ce co
mplie
s with
the r
ecor
d in t
he ca
sh bo
ok.
- Th
e acc
ounts
are m
aintai
ned p
rope
rly.
- Th
e retu
rns o
f pett
y cas
h rele
ased
to th
e ins
titutio
ns ar
e coll
ected
in tim
e. 10
.1.4
Stoc
k ver
ificati
on co
nduc
ted
prop
erly
(if ap
plica
ble)
- St
ock v
erific
ation
is co
nduc
ted pr
oper
ly.
10
II.
Ove
rall
Man
agem
ent o
f the
Uni
t Ar
eas o
f Con
cern
St
anda
rds
Me
asur
able
Elem
ents
11 R
espo
nsiv
enes
s
11.1
Resp
onsiv
enes
s to
visito
rs 11
.1.1
Infor
matio
n ava
ilable
for
visito
rs -
A re
cepti
on de
sk is
avail
able
with
a rele
vant
perso
n in c
harg
e. -
Esse
ntial
infor
matio
n is p
rovid
ed fo
r visi
tors.
-A
reso
urce
centr
e whic
h pro
vides
broc
hure
s, lea
flet a
nd ot
her m
ateria
ls is
avail
able
and f
uncti
oning
. 11
.1.2
Basic
facil
ities a
vaila
ble
- Se
ating
facil
ities a
re av
ailab
le for
visit
ors.
-Ba
sic fa
cilitie
s inc
luding
drink
ing w
ater a
nd a
clean
usab
le toi
let ar
e ava
ilable
. 11
.2 Re
spon
siven
ess
to sta
ff mem
bers
11.2.
1 St
aff m
embe
rs pr
ovide
d with
he
alth s
creen
ing
- St
aff m
embe
rs ar
e pro
vided
with
healt
h scre
ening
annu
ally.
- He
alth r
ecor
ds of
all th
e staf
f mem
bers
are a
vaila
ble.
11.3
Resp
onsiv
enes
s to
spec
ialise
d gr
oups
11.3.
1 Se
cure
acce
ss pr
ovide
d for
the
disa
bled a
nd se
nior
citize
ns.
- Sp
ecial
acce
ss at
stair
ways
and t
oilets
is av
ailab
le for
the d
isable
d per
sons
.
12
Prod
uctiv
ity a
nd q
ualit
y im
prov
emen
t pro
gram
me
12.1
Prod
uctiv
ity an
d qu
ality
impr
ovem
ent
prog
ramm
e
12.1.
1 Qu
ality
impr
ovem
ent s
ystem
in
place
-
Quali
ty cir
cles o
r wor
k imp
rove
ment
teams
are e
stabli
shed
and f
uncti
onal.
-
Prod
uctiv
ity an
d qua
lity im
prov
emen
t pro
gram
mes s
uch a
s 5S
imple
menta
tion a
t the u
nit ar
e co
nduc
ted re
gular
ly an
d doc
umen
ted.
12.1.
2 Se
nior m
anag
ers i
nvolv
ed in
qu
ality
impr
ovem
ent a
ctivit
ies
- Se
nior m
anag
ers i
nitiat
e and
atten
d mee
tings
to im
pleme
nt qu
ality
mana
geme
nt ac
tivitie
s. -
Reco
rds i
ndica
ting t
he pa
rticipa
tion o
f the s
enior
man
ager
s in t
he ab
ove a
ctivit
ies ar
e ava
ilable
. 12
.1.3
Publi
c com
plaint
s and
staff
su
gges
tions
hand
led pr
oper
ly -
A re
gister
for p
ublic
comp
laints
and a
ction
s tak
en is
avail
able
and m
aintai
ned.
-A
mech
anism
to re
ceive
and r
eview
staff
sugg
estio
ns is
in pl
ace.
13
Inte
r-se
ctor
al c
oord
inat
ion,
pub
lic re
latio
ns a
nd c
omm
unity
mob
ilisa
tion
13.1
Comm
unity
pa
rticipa
tion
13.1.
1 Co
mmun
ity pa
rticipa
tion
mech
anism
in pl
ace
- A
mech
anism
to ha
ndle
dona
tions
and o
ther a
ssist
ance
from
the c
ommu
nity i
s org
anise
d.
13.1.
2 Co
mmen
datio
n fro
m the
pu
blic r
eceiv
ed
- Co
mmen
datio
n fro
m the
publi
c are
reco
rded
. -
A me
chan
ism to
diss
emina
te co
mmen
datio
ns fr
om th
e pub
lic to
the s
taff m
embe
rs is
in pla
ce.
13.2
Inter
-secto
ral
coor
dinati
on
13.2.
1 Int
er-se
ctora
l mee
tings
att
ende
d -
Senio
r man
ager
s atte
nd in
ter-se
ctora
l mee
tings
(e.g.
HDC
, NHD
C, et
c.).
-Mi
nutes
or re
cord
s of th
ose m
eetin
gs ar
e kep
t in fil
es.
11
AN
NEX
1: I
sles
for S
tatio
nerie
s
Sh
adow
dra
win
g
12
ANNEX 2: Cleaning Checklist (Sample)
Cleaning Checklist (Sample)
Month/Year: September 2010
Item Responsible Person Time Week I II III IV
Fans Mr. Fernando Sat. 3.00pm X
Carpet Mrs. Perera Sun. 10.00am X
13
AN
NEX
3: 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
14
APPENDIX
15
APPENDIX: General Circular on National Quality Assurance Programme in Health
16
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
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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.
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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.
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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
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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)
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APPENDIX: General Circular on National Quality Assurance Programme in Health
22
Feedback Form National Guidelines for Improvement of Quality and Safety of Healthcare Institutions
(For Specialised Public Health Units and Campaigns)
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
