Quality Series No - JICA - 国際協力機構 Series No.1 National Guidelines for Improvement of Quality and Safety of Healthcare Institutions (For Line Ministry and Provincial Hospitals)

Quality Series No.1

National Guidelines for Improvement of Quality and Safety of Healthcare Institutions

(For Line Ministry and Provincial Hospitals)

First Edition

Edited by: Dr. Wimal Jayantha

DDG/Planning, Ministry of Health

Dr. S. Sridharan

Director OD, Ministry of Health

Mr. Shogo Kanamori

JICA Expert on Medical Services Administration

September 2010

COPYRIGHT © Management Development & Planning Unit Ministry of Health 385 Baddegama Wimalawansa Thero Mawatha., Colombo 10, Sri Lanka September 2010 National Library of Sri Lanka Cataloguing in Publication Data Quality Series No.1 National Guidelines for Improvement of Quality and Safety of Healthcare Institutions (for Line Ministry and Provincial Hospitals) ISBN: 978-955-9093-99-2 Printed in Sri Lanka This Publication is sponsored by: Japan International Cooperation Agency (JICA)

Preface

Sri Lanka provides free healthcare services to all the citizens irrespective of their status, income or geographic location, and has achieved remarkable health outcomes, particularly relative to neighbouring countries with a similar income range. Nevertheless, there are certain drawbacks in the hospital-based healthcare delivery system which have affected the quality and efficiency of its services as demonstrated by overcrowding in the higher level institutions, deficiencies of amenities and patient dissatisfaction.

The National Guidelines for Improvement of Quality and Safety of Healthcare Institutions provide a comprehensive set of quality and safety standards and affordable measures to improve the hospital services. All the hospitals in Sri Lanka are therefore expected to be fully oriented on these Guidelines and prepared to improve their service delivery structure and process. Needless to say, the strong commitment of heads of institutions, PDHSs and RDHSs is critical in achieving the goals aimed by these Guidelines.

I wish to thank all the stakeholders involved in the development of this document as well as Japan International Cooperation Agency (JICA) for its technical assistance. In particular, I am grateful to Dr Wimal Jayantha, DDG/Planning, who supervised the whole developmental process, Dr S. Sridharan, Director OD, who led and facilitated the drafting work, and Mr. Shogo Kanamori, JICA Expert on Medical Services Administration, who provided coordinative and technical assistance.

Dr. Ravindra Ruberu Secretary Ministry of Health

20 September 2010

Acknowledgement

The Ministry of Health acknowledges the following members for their technical inputs and logistic support through a series of the workshops to develop the content of this document.

Dr. Aluthweera, Champa; Coordinator for National Quality Assurance Programme, Ministry of Health Mrs. Amarasinghe, K.S.N.; Matron, National Hospital Sri Lanka Dr. Ariyadasa, Hirantha; Research Assistant, JICA Advisor’s Office Dr. De Silva, Susantha; Public Health Consultant Ms. Devashanthini, V.P.; Chief Pharmacist, Medical Supplies Department, Ministry of Health Mr. Dissanayake, Chaturanga; Project Assistant, JICA Advisor’s Office Dr. Fernando, Rani; Director, Castle Street Hospital for Women Dr. Gamage, Rehan; Research Assistant, JICA Advisor’s Office Dr. Gamage, S.A.K.; Director MS, Ministry of Health Dr. Gamlath, G.; MS, DGH Kegalle Dr. Gunasekera, S.C.; SMO, Castle Street Hospital for Women Dr. Gunasekara, Vijith; Deputy Director, Lady Ridgeway Hospital Dr. Hewageeganage, Neelamanie Rajapakse; PDHS Uva Province Dr. Jayanath, B.L.D.; MOIC, PU Madampe Dr. Jayantha, Wimal; DDG (Planning), Ministry of Health Dr. Jayasinghe, Lanka; MS, DGH Ampara Mr. Kanamori, Shogo; JICA Expert on Medical Services Administration Dr. Karandagoda, Wimal; Director (Medical services), Lanka Hospitals Ltd. Dr. Pannila, V.S.P.; Director Laboratory Services, Ministry of Health Dr. Perera, Susie; Director Policy Analysis & Development, Ministry of Health Dr. Rajamanthrie, M.; Director, Lady Ridgeway Hospital Dr. Samarage, Sarath; Consultant, WHO Sri Lanka Mrs. Samaranayake, S.G.; Director Nursing Education, Ministry of Health Dr. Senanayake, Lakshman; Consultant, Hospital Efficiency and Quality, HSDP / WB Project Mr. Shantha, M.P.S.; Chief Radiographer, Lady Ridgeway Hospital Dr. Sridharan, S.; Director Organizational Development, Ministry of Health Mr. Thilakasiri, M.; Senior Consultant, SLIDA Dr. Tissera, W.A.A.; Director, Training, Ministry of Health Dr. Wickramanayake, Kapila; Director TCS, Ministry of Health Dr. Wijerathne, Lalitha; MO/QMU, DGH Gampaha Dr. Wijesinghe, W.A.K.; RDHS, Kegalle District Mr. Withanage, Kithsiri; Superintendent MLT, National Hospital Sri Lanka

This document has been field tested at 7 hospitals including DGH Nawalapitiya, PU Thiththapajjala, DGH Nuwara Eliya, BH Dickoya, DGH Matale, BH Dambulla and DH Galewela in Central Province, and finalized by incorporating feedbacks from those pilot hospitals. The Ministry of Health appreciates the heads of these hospitals for their cooperation throughout the field testing process, the authorities in the Central Province including Dr. Shanthi Samarasinghe, PDHS Central Province; Dr. P.M.A. Samarakkody, Deputy-PDHS Central Province, Dr. V.S.K. Subasinghe, RDHS Nuwara Eliya; Dr. W.G.A. Dissanayake, RDHS Kandy; and Dr. L. Dissyanayake, RDHS Matale for their leadership and supervision of the work, and Dr. Sameera Athapattu, Medical Officer, PDHS Office, Central Province for the coordination of the overall activities.

In addition, the Ministry of Health extends special thanks to Japan International Cooperation Agency (JICA) for its technical and financial assistance in development of this document under “Project on Improvement of Quality and Safety of Healthcare Institutions in Sri Lanka”.

TABLE OF CONTENTS

1. Introduction ……………………………………………………………………………….. 1

1.1. Target Institutions ……………………………………………………………………… 1

1.2. The Guidelines in the Context of Quality Assurance Programme ………………... 1

2. Arrangements for Improvement of Quality and Safety in Hospitals …………….. 3

2.1. Establishment of Quality Management Unit (QMU) ……………………………….. 3

3. Hospital Quality and Safety Standards ……………………………………………….. 4

I. Internal and External Customer Environment (5S) ………………………………. 6 1. Seiri (Sorting)

2. Seiton (Organisation) 3. Seiso (Cleaning with Meaning and for Beautifying) 4. Seiketsu (Standardisation) 5. Shitsuke (Training & Self-Discipline)

II. Services involving Patient Contacts ……………………………………………….. 16 6. Reception area

7. Immediate service points and frontline services 8. Responsiveness 9. Inpatient care services 10. Diagnostic services 11. Medical/pharmaceutical supplies and equipment management 12. Mortuary service

III. Overall Quality and Safety Improvement ………………………………………….. 30 13. Infection control

14. Waste management 15. Medical record 16. Health education activities 17. Leadership and management 18. Productivity and quality improvement programme

ANNEXES ……………………………………………………………………………………….. 37 ANNEX 1: Isles for Stationeries ………………………………………………………….. 37 ANNEX 2: Standardised Colour Codes ………………………………………………….. 38 ANNEX 3: Emergency Tray Checklist (Sample) …….……………………………….…. 39 ANNEX 4: Discharge Checklist (Sample) …….………………….……………………... 41 ANNEX 5: Cleaning Checklist (Sample) …...……………………………………………. 42 ANNEX 6: CSSD Service Flowchart …………………………………………………….. 43 ANNEX 7: Visual Control Scheme for CSSD …………………………………………… 44 ANNEX 8: Protocol for Hazardous Waste Management ………………………………. 45 ANNEX 9: Patient and Employee Satisfaction Survey Forms (Sample) …………….. 47

APPENDIX: General Circular on National Quality Assurance Programme in Health 57

1. Introduction

These Guidelines will provide guidance to hospital staff in strengthening the organisational and individual preparedness for improvement of the quality and safety of patient care services at hospital. It is assumed that these Guidelines will be used for the following purposes.

As a handbook for hospitals in implementing quality improvement programmes and related activities

As a guiding document for orientation programmes to hospital staff conducted by the National Quality Secretariat of the Ministry of Health and the Provincial Quality Secretariats

1.1. Target institutions

The target institutions include Teaching Hospitals, Provincial General Hospitals, District General Hospitals, Base Hospitals and Divisional Hospitals.

New Categorization Old Categorization

Teaching Hospital (TH) Teaching Hospital (TH)

Provincial General Hospital (PGH) General Hospital (GH)

District General Hospital (DGH)

Base Hospital (Type A & Type B) Base Hospital (BH)

Divisional Hospital District Hospital (DH)

Peripheral Unit (PU)

Rural Hospital (RH)

Primary Medical Care Unit Maternity Homes (MH) & CD

Central Dispensary (CD)

1.2. The Guidelines in the context of Quality Assurance Programme

Two separate guidelines will be used to implement the National Quality Assurance Programme. One serves to provide guidance to hospitals in quality and safety improvement, and the other to provide protocols for external monitoring and evaluation of hospital services.

(1) Guideline for External Monitoring and Evaluation of Hospital Services

(2) Guideline for Improvement of Quality and Safety of Hospital Services

The present Guideline mainly focuses on the improvement of the quality and safety at the hospital level.

Target Institutions of these Guidelines

1

Line Ministry Hospitals Provincial Hospitals

PDHS/RDHS Guidance & Monitoring

Guidance & Monitoring

Guidance & Monitoring

1. Guidelines for External Monitoring and Evaluation

- External monitoring system

- National quality award system

2. Guidelines for Improvement of Quality and Safety

- Organizational arrangements

- Quality and safety standards & checklist

DDG/Planning

This Guideline Document

Director Organisational Development

2

2. Arrangements for Improvement of Quality and Safety in Hospitals

In order to initiate the quality and safety improvement programme, organizational arrangements within hospitals need to be modified. The critical step in this respect is to establish a Quality Management Unit within each hospital. The Quality Management Unit (QMU) serves as the secretariat for organizing training activities on quality and safety improvements as well as implementation, monitoring and evaluation of the programme in the hospital. In addition, at the ward/unit level, Work Improvement Teams (WITs) are to be formed to implement the programme. The Quality Management Team, consisting of the Hospital Director, QMU staff and the leaders of the WITs will serve as the decision making body. Suggestive organizational arrangements are provided in the table below.

Quality Management Team Quality Management Unit (QMU)

Work Improvement Teams (WIT)

Unit QMU Respective wards and other units

Members - Hospital Director - QMU staff - Leaders of WITs

- 1-3 full-time staff - All staff members of the relevant units

Leader Hospital Director MO or NO A committed staff member

2.1. Establishment of Quality Management Unit (QMU)

All hospitals need to have a dedicated QMU. According to the “General Circular No.01-29/2009” of the Ministry of Healthcare & Nutrition dated 22 September 2009, QMU is to coordinate the quality assurance and client safety program of hospitals. Its functions described in the Circular are summarized below. The original Circular document is attached as APPENDIX.

(1) Strengthening institutional setup and staff participation in the quality programme Facilitating management leadership in the quality programme Establishing Work Improvement Teams (WIT)/Quality Circles Training Work Improvement Teams (WIT) Facilitating involvement of medical consultants in the quality improvement process

(2) Building staff capacity and awareness Conducting quality and safety improvement workshops for staff members Facilitating in-service training programmes Maintaining database of staff training Promoting a quality culture by introducing 5S concept leading towards Total Quality

Management (TQM) Promoting environmental friendly hospitals

3

(3) Streamlining management of equipment and supplies Developing annual procurement plans for different variety of purchases Ensuring quality of supplies by encouraging maintenance contract agreements for support

services Organizing and updating supplier and maintenance information system

(4) Management of the quality programme Assisting the preparation of strategic plans of the hospital with the focus on quality and

safety improvement aspects (e.g. reduction of waiting times, instituting a smooth patient flow, infection control and proper waste disposal)

Facilitating adherence to standards, guidelines and protocols relevant to customer/patient care including clinical pathways

Maintaining computer based data on quality and safety (e.g. 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.)

Conducting customer satisfaction surveys and employee satisfaction surveys Encouraging “suggesting scheme” in the hospital Preparing half yearly/quarterly bulletins and annual performance reports Conducting performance reviews Monitoring the progress of the quality programme referring to the Quality and Safety

Standards in these Guidelines Promoting studies, research and medical audits in the hospitals

3. Hospital Quality and Safety Standards

This chapter provides hospital quality and safety standards to which all the hospitals shall adhere. They are divided into three aspects and 18 areas as follows:

I. Internal and External Customer Environment (5S) 1. Seiri (Sorting) 2. Seiton (Organisation) 3. Seiso (Cleaning with Meaning and for Beautifying) 4. Seiketsu (Standardisation) 5. Shitsuke (Training & Self-Discipline)

II. Services involving Patient Contacts 6. Reception area 7. Immediate service points and frontline services 8. Responsiveness 9. Inpatient care services 10. Diagnostic services

4

11. Medical/pharmaceutical supplies and equipment management 12. Mortuary service

III. Overall Quality and Safety Improvement 13. Infection control 14. Waste management 15. Medical record 16. Health education activities 17. Leadership and management 18. Productivity and quality improvement programme

These standards will be referred to whenever a hospital conducts quality and safety improvement activities as well as internal audit. They are also in line with the criteria for external audits and for selection of the National Quality Award recipients.

5

I. In

tern

al a

nd E

xter

nal C

usto

mer

Env

ironm

ent (

5S)

Area

of C

once

rn

Stan

dard

s Me

asur

able

Elem

ents

Wards

OPD/Clinics

Laboratory

Entrance, reception & passageways

Office

Stores

Record Room

Outside

Others

1 Se

iri (S

ortin

g)

Elim

inat

ing

unne

cess

ary

item

s fro

m th

e w

orkp

lace

that

are

not

nee

ded

for c

urre

nt p

roce

ss in

the

hosp

ital.

1.1

Outsi

de an

d ins

ide pr

emise

s 1.1

.1 Un

wante

d item

s re

move

d fro

m the

wo

rkplac

e

- An

estab

lishe

d pro

cess

in so

rting w

anted

and u

nwan

ted

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 wi

th tag

s.

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 dr

awer

s are

free

of un

wante

d /irr

eleva

nt ite

ms.

X X

X X

X X

X X

1.1.2

The f

loors

and

pass

agew

ays i

n the

pu

blic a

reas

equip

ped

with

garb

age b

ins fo

r ge

nera

l was

te an

d kep

t fre

e of li

tters

- Ga

rbag

e bins

for g

ener

al wa

ste ar

e in p

lace a

nd co

lour

code

d. -

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.

X

X

1.1.3

Unwa

nted t

rees

and

bran

ches

remo

ved

- Tr

ees w

hich a

re ob

struc

ting t

he dr

ainag

e are

remo

ved.

- Tr

ee br

anch

es ab

ove t

he ro

of an

d ove

r the

elec

tric an

d tel

epho

ne w

ires a

re tr

imme

d.

X

1.2

Wall

s and

no

tice b

oard

s 1.2

.1 W

alls b

eing f

ree o

f old

poste

rs, pi

cture

s or

calen

dars.

- Po

sters/

pictur

es ar

e not

fading

or to

rn.

- Inf

orma

tion o

n pos

ters/p

ictur

es is

not o

bsole

te.

- Ca

lenda

rs ar

e upd

ated.

X X

X X

X X

X X

6

I. In

tern

al a

nd E

xter

nal C

usto

mer

Env

ironm

ent (

5S)

Area

of C

once

rn

Stan

dard

s Me

asur

able

Elem

ents

Wards

OPD/Clinics

Laboratory


Office

Stores

Record Room

Outside

Others

1.2.2

Notic

e boa

rds b

eing f

ree

of ob

solet

e noti

ces

- Re

mova

l instr

uctio

ns ar

e in p

lace.

- Th

e rem

oval

instru

ction

is co

mplie

d. -

Notic

e boa

rds a

re ca

tegor

ized a

ccor

ding t

o the

staff

me

mber

s/nee

ds.

- Re

spon

sible

perso

ns fo

r eac

h noti

ce bo

ard a

re

identi

fied.

- Th

e alig

nmen

t and

an X

-Y ax

is too

l are

main

taine

d in

the no

tice b

oard

.

X X

X X

X X

X X

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

Hosp

ital a

nd

servi

ce un

it ide

ntific

ation

2.1.1

A ho

spita

l nam

e boa

rd

and a

site

map a

vaila

ble

- A

hosp

ital 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

all th

ree l

angu

ages

.

X

X

2.2

Dire

ction

al ind

icatio

ns

2.2.1

Dire

ction

al bo

ards

av

ailab

le at

ever

y jun

ction

- Di

recti

onal

boar

ds ar

e disp

layed

at ev

ery j

uncti

on

outsi

de an

d ins

ide of

the h

ospit

al to

all fa

cilitie

s fro

m the

en

tranc

e in a

ll thr

ee la

ngua

ges.

X

2.2.2

Corri

dors

clear

ly ma

rked

with

entra

nces

and e

xit

lines

, cur

ved d

oor

open

ings,

and d

irecti

on

of tra

vel

- En

tranc

e and

exit l

ines a

re pl

aced

for O

PD/cl

inics

. -

Curve

d doo

r ope

nings

are m

arke

d at e

ntran

ce do

ors t

o ro

oms.

- Th

e dire

ction

of tr

avel

is ind

icated

on th

e cor

ridor

s. -

The s

liding

door

s are

prov

ided w

ith di

recti

onal

arro

ws.

X

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

boar

ds or

numb

ers.

X X

X X

X X

X X

7

I. In

tern

al a

nd E

xter

nal C

usto

mer

Env

ironm

ent (

5S)

Area

of C

once

rn

Stan

dard

s Me

asur

able

Elem

ents

Wards

OPD/Clinics

Laboratory


Office

Stores

Record Room

Outside

Others

2.3.2

Stor

es an

d stor

age

area

s pro

perly

orga

nised

-

Items

in st

ores

and s

torag

e are

as ar

e kep

t in sh

elves

, ra

cks o

r bins

and c

learly

mar

ked.

- Sh

elf gr

ids ar

e mar

ked w

ith re

feren

ce nu

mber

s/nam

es

for ea

sy re

trieva

l of it

ems.

- Al

l stat

ioner

ies in

the c

upbo

ard a

re ke

pt in

place

s ide

ntifie

d with

symb

ols an

d mar

ks (v

isual

contr

ol of

statio

nerie

s).

- Ite

ms ar

e stor

ed in

an al

phab

etica

l ord

er an

d in a

logic

al ma

nner

(left t

o righ

t / top

to bo

ttom)

. -

A me

chan

ism to

reple

nish i

tems i

s org

anize

d with

colou

r co

des:

Ma

ximum

stoc

k lev

el: G

reen

Reor

der s

tock l

evel:

Ora

nge

Minim

um st

ock l

evel:

Red

X X

X

X X

X

2.3.3

Switc

hes a

nd fa

ns ea

sily

identi

fied

- Al

l swi

tches

and f

an re

gulat

ors a

re la

belle

d acc

ordin

gly.

- A

sepa

rate

electr

ical p

oint p

lan is

in pl

ace f

or ea

ch ro

om

at en

tranc

e. X

X X

X X

X X

2.4

Plac

ing an

d pa

rking

rules

2.4

.1 Eq

uipme

nt an

d too

ls be

ing ke

pt in

origi

nal

place

s afte

r use

- ‘Is

les’ a

re id

entifi

ed fo

r eac

h equ

ipmen

t and

tool

to be

ke

pt aft

er us

e with

the s

traigh

t line

meth

od an

d sha

dow

draw

ings d

isplay

ed.

- A

mech

anism

to id

entify

perso

ns re

movin

g item

s fro

m ‘is

les’ It

ems i

s in p

lace.

An ex

ampl

e of ‘

Isles

’ is sh

own

in “A

NNEX

1: Is

les fo

r St

atio

nerie

s”.

X X

X

X X

X X

8

I. In

tern

al a

nd E

xter

nal C

usto

mer

Env

ironm

ent (

5S)

Area

of C

once

rn

Stan

dard

s Me

asur

able

Elem

ents

Wards

OPD/Clinics

Laboratory


Office

Stores

Record Room

Outside

Others

2.4.2

Files

and f

older

s ar

rang

ed us

ing th

e mi

stake

proo

fing c

once

pt

- Fil

es an

d box

folde

rs ar

e arra

nged

using

the m

istak

e pr

oofin

g con

cept

to fac

ilitate

iden

tifica

tion o

f par

ticula

r file

s (wi

thin 3

0 sec

onds

) and

stor

ing in

origi

nal p

laces

. X

X X

X

X

2.4.3

Parki

ng ar

eas f

or m

obile

eq

uipme

nt sp

ecifie

d and

ma

rked

- Pa

rking

area

s are

spec

ificall

y mar

ked f

or:

Pa

llets/

trolle

ys

W

heelc

hairs

Stre

tcher

s

Garb

age b

ins

Su

cker

s and

oxyg

en tr

olley

s

X X

X

2.4.4

Parki

ng ar

eas f

or

vehic

les sp

ecifie

d and

ma

rked

- De

signa

ted pa

rking

plac

es ar

e ava

ilable

for

ambu

lance

s. -

Vehic

le flo

ws in

the h

ospit

al ar

eas a

re id

entifi

ed an

d ma

rked.

- Si

gn bo

ards

for v

ehicl

es of

diffe

rentl

y-able

d per

sons

are

in pla

ce.

- An

illum

inated

sign

boar

d (e.g

. with

“P” s

ign) f

or th

e ve

hicle

park

is av

ailab

le at

night.

X

9

I. In

tern

al a

nd E

xter

nal C

usto

mer

Env

ironm

ent (

5S)

Area

of C

once

rn

Stan

dard

s Me

asur

able

Elem

ents

Wards

OPD/Clinics

Laboratory


Office

Stores

Record Room

Outside

Others

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

Hosp

ital p

remi

ses

maint

ained

with

healt

hy

and s

afe en

viron

ment

for

inter

nal a

nd ex

terna

l cu

stome

rs

- Th

e gar

den i

s pro

perly

main

taine

d and

land

scap

ing is

do

ne by

a ga

rden

er.

- Dr

ains a

re no

t leak

ing or

over

flowi

ng.

- St

agna

tion o

f wate

r is av

oided

in al

l dra

ins.

- Un

pleas

ant o

dour

is no

t pro

duce

d fro

m the

hosp

ital

waste

site

or ot

her p

laces

. -

The v

isible

parts

of th

e roo

f are

free

of un

wante

d item

s.

X

3.1.2

Floor

s, wa

lls, w

indow

s an

d cur

tain &

othe

r fitt

ings b

eing k

ept c

lean

- Th

e clea

nline

ss is

main

taine

d at:

Flo

ors

W

alls

W

indow

s

Curta

ins

Ot

her f

itting

s

Gu

tters

-

A cle

aning

chec

klist

is av

ailab

le an

d upd

ated.

X X

X X

X X

X

3.1.3

Toile

ts ar

e clea

n and

in

worki

ng or

der

- Un

pleas

ant o

dour

is no

t exp

erien

ced i

n toil

ets.

- To

ilet fa

cilitie

s are

kept

read

y for

use.

- A

clean

ing ch

eckli

st is

avail

able

and u

pdate

d. -

Adeq

uate

venti

lation

is pr

ovide

d in a

ll the

toile

ts.

X X

X X

X

3.1.4

Chan

ging r

ooms

for

patie

nts be

ing ke

pt cle

an

and i

n wor

king o

rder

- A

clean

ing ch

eckli

st is

avail

able

and u

pdate

d. X

X

Th

eatre

10

I. In

tern

al a

nd E

xter

nal C

usto

mer

Env

ironm

ent (

5S)

Area

of C

once

rn

Stan

dard

s Me

asur

able

Elem

ents

Wards

OPD/Clinics

Laboratory


Office

Stores

Record Room

Outside

Others

3.2

Clea

ning o

f ma

chine

s, eq

uipme

nt,

tools

and

furnit

ure

3.2.1

The c

leanli

ness

of

build

ings,

mach

ines,

equip

ment,

tools

and

furnit

ure m

aintai

ned

- Th

e high

leve

l of c

leanli

ness

is m

aintai

ned w

ith no

vis

ible d

irt:

Bu

ilding

s

Ambu

lance

s

Othe

r hos

pital

vehic

les

Me

dical

equip

ment

Fu

rnitu

re (t

ables

, des

ks, c

hairs

, etc.

)

X X

X

X

3.3

Clea

ning

prac

tice

3.3.1

An or

ganis

ed cl

eanin

g sy

stem

in pla

ce

- Th

e foll

owing

tools

and d

ocum

ents

are

displa

yed/a

vaila

ble:

Cl

eanin

g res

pons

ibility

char

t

Clea

ning s

ched

ules

Cl

eanin

g guid

eline

s -

The a

bove

tools

and d

ocum

ents

are u

pdate

d mon

thly.

X X

X X

X X

X X

3.3.2

Clea

ning t

ools

and

deter

gents

prop

erly

store

d

- Pr

oper

stor

age f

acilit

ies fo

r clea

ning t

ools

and

deter

gents

are a

vaila

ble.

- Ap

prop

riate

and n

eces

sary

chem

icals

are u

sed f

or

mana

geme

nt of

body

fluid

spills

. -

Clea

ning t

ools

for ou

tside

area

s/toil

ets an

d ins

ide ar

eas

are s

epar

ated.

X X

X X

X X

X X

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 dir

ectio

nal b

oard

s sta

ndar

dised

- Al

l sign

boar

ds an

d dire

ction

al bo

ards

are s

tanda

rdise

d wi

th pr

oper

align

ment

and c

onsis

tent fo

nts, a

nd by

co

lour c

odes

. X

X X

X

X X

11

I. In

tern

al a

nd E

xter

nal C

usto

mer

Env

ironm

ent (

5S)

Area

of C

once

rn

Stan

dard

s Me

asur

able

Elem

ents

Wards

OPD/Clinics

Laboratory


Office

Stores

Record Room

Outside

Others

4.1.2

Drug

cupb

oard

s sta

ndar

dised

in al

l unit

s -

Drug

s are

sorte

d in a

logic

al ma

nner

.

vital,

esse

ntial

and n

orma

l

acco

untab

le, no

n-ac

coun

table,

and s

pecia

l & ex

tra

- Dr

ugs a

re ar

rang

ed in

alph

abeti

cal o

rder

and l

eft-to

-righ

t in

all un

its.

X X

4.1.3

Arra

ngem

ents

of su

rgica

l su

pplie

s stan

dard

ised i

n all

units

- Th

e ster

ilisati

on st

atus i

s ind

icated

for s

urgic

al su

pplie

s. -

Surg

ical s

uppli

es ar

e arra

nged

logic

ally (

e.g. g

loves

ac

cord

ing to

size

s and

in th

e left

-to-ri

ght o

rder

) X

X X

4.1.4

Identi

ficati

on la

bels

place

d on a

ll mac

hines

an

d equ

ipmen

t

All m

achin

es an

d equ

ipmen

t hav

e ide

ntific

ation

labe

ls wi

th the

follo

wing

infor

matio

n:

Name

of th

e item

s

Identi

ficati

on an

d batc

h num

bers

Da

te of

acqu

isitio

n

Conta

ct de

tails

of ma

inten

ance

comp

any

Re

spon

sible

perso

n for

main

tenan

ce

Co

st of

equip

ment

X X

X

X X

X

4.1.5

Cauti

on si

gns d

isplay

ed

at ap

prop

riate

place

s -

“Dan

ger”

signs

are d

isplay

ed at

:

Elec

tric sw

itchb

oard

s and

tran

sform

ers

Ra

diolog

y/X-ra

y

Liquid

oxyg

en ta

nks

- “B

iohaz

ard”

sign

s are

disp

layed

at:

La

bora

tories

hand

ling c

ontag

ious i

tems

- “S

lopes

” sing

s are

disp

layed

at:

W

here

ver t

here

is a

slope

. -

“Slip

pery”

sign

s with

zebr

a cod

e are

plac

ed at

:

Wet

floor

after

clea

ning.

X X

X X

X

12

I. In

tern

al a

nd E

xter

nal C

usto

mer

Env

ironm

ent (

5S)

Area

of C

once

rn

Stan

dard

s Me

asur

able

Elem

ents

Wards

OPD/Clinics

Laboratory


Office

Stores

Record Room

Outside

Others

4.1.6

Open

and s

hut

direc

tiona

l labe

ls av

ailab

le on

valve

s and

do

ors

- Th

e dire

ction

al lab

els ar

e put

on:

Ox

ygen

tank

s

Door

hand

les of

cupb

oard

s

Thea

tre ta

ps

All o

ther d

oor h

andle

s

X X

X X

X X

X

4.1.7

Was

te bin

s sep

arate

d, lab

elled

and

colou

r-cod

ed

- Al

l the w

aste

bins a

re se

para

ted, la

belle

d and

co

lour-c

oded

.

The c

olou

r-cod

es ar

e elab

orat

ed in

“ANN

EX 2:

St

anda

rdise

d Co

lour

Cod

es”

X X

X X

4.1.8

Pipe

s and

oxyg

en/ga

s tan

ks id

entifi

ed by

sta

ndar

dised

visu

als

- Ty

pes o

f pipe

s can

be id

entifi

ed by

diffe

rent

colou

rs:

Ox

ygen

Comp

ress

ed ai

r

Vacu

um

- Ty

pes o

f tank

s can

be id

entifi

ed by

colou

rs:

Ox

ygen

(O2; W

hite)

Carb

on D

ioxide

(CO 2

; Gra

y)

Nitro

us O

xide (

N 2O;

Blue

)

LP G

as

- Th

e stat

us of

tank

s (em

pty or

full)

can b

e ide

ntifie

d by

colou

rs or

tags

:

Empty

: Red

Fu

ll: Bl

ue

Thea

tre

13

I. In

tern

al a

nd E

xter

nal C

usto

mer

Env

ironm

ent (

5S)

Area

of C

once

rn

Stan

dard

s Me

asur

able

Elem

ents

Wards

OPD/Clinics

Laboratory


Office

Stores

Record Room

Outside

Others

4.2

Maint

enan

ce of

ve

hicles

, ma

chine

s and

eq

uipme

nt

4.2.1

Vehic

les, m

achin

es an

d eq

uipme

nt pr

oper

ly ma

intain

ed

- Ma

inten

ance

sche

dules

and r

ecor

ds ar

e ava

ilable

and

upda

ted fo

r the

follo

wing

items

:

Vehic

les

Ma

chine

s

Hosp

ital e

quipm

ent

- Op

erati

onal

instru

ction

s are

mad

e ava

ilable

for

mach

ines a

nd eq

uipme

nt.

X X

X

X

X

4.3

Safet

y and

se

curity

me

asur

es

4.3.1

Safet

y mea

sure

s are

in

place

for e

lectric

al ca

bles a

nd de

vices

- El

ectric

al wi

res a

re se

aled o

r bun

dled t

o pre

vent

accid

ental

conta

cts w

ith hu

man b

eings

. -

All s

witch

es ar

e pro

perly

fixed

with

out a

ny

electr

ically

-cond

uctiv

e par

ts ex

pose

d. -

All e

lectric

devic

es an

d boil

ers a

re pl

aced

in a

safet

y ma

nner

. -

Dang

er si

gns (

Zebr

a cod

e or T

iger s

tripes

) are

appli

ed

X X

X X

X X

X X

4.3.2

Secu

rity m

easu

res i

n pla

ce fo

r a fir

e eve

nt -

Func

tiona

l fire

extin

guish

ers o

r san

d buc

kets

are

avail

able.

-

The g

uideli

nes o

r a pr

otoco

l for t

he fir

e eve

nt is

avail

able.

X

X X

X X

X X

X Ki

tchen

14

I. In

tern

al a

nd E

xter

nal C

usto

mer

Env

ironm

ent (

5S)

Area

of C

once

rn

Stan

dard

s Me

asur

able

Elem

ents

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 ho

spita

l qua

lity

impr

ovem

ent c

ondu

cted

with

the ch

eckli

st

- An

inter

nal a

udit s

heet

on th

e hos

pital

quali

ty im

prov

emen

t is av

ailab

le.

- 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

Train

ing an

d ra

ising

aw

aren

ess

5.2.1

The h

ospit

al sta

ff tra

ined

on 5S

-

All th

e hos

pital

staff a

re tr

ained

on 5S

. -

A pr

ogra

mme t

o tra

in ne

w sta

ff on 5

S is

avail

able.

5.2

.2 A

reso

urce

centr

e on

hosp

ital q

uality

im

prov

emen

t ava

ilable

- A

reso

urce

centr

e on 5

S, K

aizen

and C

QI re

lated

mate

rials

is av

ailab

le for

the h

ospit

al sta

ff.

5.2.3

A 5S

Cor

ner a

vaila

ble in

the

hosp

ital

- A

5S C

orne

r is or

ganis

ed w

here

the s

taff h

ave f

requ

ent a

cces

s. -

The 5

S Co

rner

is up

dated

mon

thly.

5.2.4

5S pr

omoti

ng co

mpeti

tions

am

ong e

mploy

ees

orga

nised

- As

sess

ment

criter

ia for

5S co

mpeti

tions

are p

repa

red a

nd pr

actic

ed.

- An

even

t to ap

prec

iate b

est e

mploy

ers i

s car

ried o

ut an

nuall

y.

5.2.5

A sy

stem

to giv

e awa

rds t

o we

ll-per

forme

d wor

k unit

s av

ailab

le

- As

sess

ment

criter

ia to

meas

ure t

he pe

rform

ance

is pr

epar

ed to

selec

t bes

t unit

s and

best

teams

. -

An ev

ent to

appr

eciat

e bes

t per

formi

ng un

its an

d tea

ms is

carri

ed ou

t ann

ually

.

15

II.

Serv

ices

invo

lvin

g Pa

tient

Con

tact

s Ar

eas o

f Con

cern

St

anda

rds

Me

asur

able

Elem

ents

6 R

ecep

tion

area

6.1

Rece

ption

area

6.1

.1 An

orga

nised

rece

ption

av

ailab

le -

A re

cepti

on de

sk is

avail

able.

-

A tra

ined p

erso

n is i

n plac

e all t

he tim

e dur

ing th

e ope

ratio

nal h

ours.

-

Accu

rate

infor

matio

n abo

ut the

hosp

ital s

ervic

es is

disp

ense

d. 6.2

W

aiting

area

6.2

.1 Sp

aciou

s and

venti

lated

wa

iting a

rea a

vaila

ble

- Ve

ntilat

ed en

viron

ment

is ev

ident

in the

wait

ing ar

ea..

-Th

e lay

out o

f the w

aiting

area

is w

ell or

ganiz

ed.

6.2.2

Adeq

uate

seati

ng fa

cilitie

s av

ailab

le wi

th pr

oper

se

ating

orde

rs

- A

suffic

ient n

umbe

r of s

eatin

g fac

ilities

(mini

mum

of 1/4

of th

e dail

y atte

ndan

ce) is

avail

able

at the

wa

iting a

rea..

-

Seati

ng fa

cilitie

s are

arra

nged

in or

der.

7 Im

med

iate

ser

vice

poi

nts

and

fron

tline

ser

vice

s

7.1

Out P

atien

t De

partm

ent &

Cl

inics

7.1.1

Exam

inatio

n bed

s ap

prop

riatel

y arra

nged

-

Exam

inatio

n bed

s are

scre

ened

for p

rivac

y. -

Exam

inatio

n bed

s hav

e clea

n matt

ress

and l

inen.

7.1.2

The s

terilit

y main

taine

d in

dres

sing r

ooms

, injec

tion

room

s, etc

.

- A

hand

was

hing s

ink is

avail

able

with

clean

towe

ls an

d soa

p, an

d use

d. -

Surg

ical g

loves

are a

vaila

ble, a

rrang

ed ac

cord

ing to

their

size

s, an

d use

d to u

nder

take w

ound

dres

sing.

-St

erilis

ed in

strum

ents,

pack

ets an

d dre

ssing

s are

kept

in a c

upbo

ard w

ith a

writte

n ind

icatio

n of s

terilit

y. 7.1

.3 Re

friger

ated d

rugs

and

vacc

ines m

aintai

ned a

t an

optim

um te

mper

ature

- A

refrig

erato

r with

a fun

ction

ing A

nalog

ther

mome

ter is

avail

able

and k

ept a

t opti

mum

tempe

ratur

e. -

Drug

s and

vacc

ines a

re st

ored

in th

eir op

timum

temp

eratu

res.

- Th

e tem

pera

ture(

s) of

the re

friger

ator is

mea

sure

d dail

y two

times

a da

y (8.0

0am

& 4.0

0 pm)

and

reco

rded

in a

book

/shee

t by a

resp

onsib

le off

icer.

7.1.4

Drug

s pro

perly

arra

nged

an

d the

ir ava

ilabil

ity

strea

mline

d

- Dr

ugs a

re la

belle

d and

arra

nged

in a

sorte

d and

orga

nized

man

ner.

- A

drug

avail

abilit

y reg

ister

is m

ade a

vaila

ble to

OPD

/clini

c doc

tors a

nd up

dated

wee

kly.

7.1.5

A su

rvey t

o mea

sure

wa

iting t

ime o

f pati

ents

at OP

D co

nduc

ted re

gular

ly

- A

surve

y for

m to

meas

ure w

aiting

time o

f pati

ents

is av

ailab

le.

- A

waitin

g tim

e sur

vey i

s con

ducte

d and

analy

zed m

onthl

y. -

A re

port

on ap

prop

riate

actio

ns ta

ken t

o red

uce t

he w

aiting

time i

s ava

ilable

. 7.1

.6 A

prop

er re

ferra

l sys

tem

avail

able

- A

list o

f spe

cializ

ed ho

spita

ls an

d con

tact d

etails

is av

ailab

le on

the w

all.

- Tr

ansfe

r in-a

nd-o

ut re

cord

is av

ailab

le an

d upd

ated.

-Th

e tra

nsfer

in-a

nd-o

ut sta

tistic

s are

comp

iled a

nd re

viewe

d ann

ually

.

16

II.

Serv

ices

invo

lvin

g Pa

tient

Con

tact

s Ar

eas o

f Con

cern

St

anda

rds

Me

asur

able

Elem

ents

7.2

Em

erge

ncy c

are

unit

7.2.1

An em

erge

ncy c

are u

nit

functi

oning

24 ho

urs w

ith

esse

ntial

equip

ment

and

drug

s

- Th

e ess

entia

l equ

ipmen

t is ke

pt in

acce

ssibl

e plac

e and

in w

orkin

g ord

er:

EC

G an

d defi

brilla

tor

Ne

bulis

ing m

achin

e

Suck

er m

achin

e

Ambu

bag

La

ryngo

scop

e

ET T

ubes

and T

rach

aeoto

my tu

bes (

arra

nged

logic

ally a

ccor

ding t

o the

ir size

s) -

Emer

genc

y car

e guid

eline

s are

prep

ared

and d

isplay

ed (a

t leas

t for A

naph

ylacti

c Sho

ck an

d Car

diac

Arre

st).

- A

chec

klist

for dr

ugs a

nd su

pplie

s is a

vaila

ble.

- Th

e che

cklis

t is m

aintai

ned d

aily a

nd th

ere i

s no e

xpire

d dru

g in s

tock.

7.2.2

A dis

aster

prep

ared

ness

pr

otoco

l and

equip

ment

avail

able

- A

disas

ter m

anag

emen

t plan

is up

dated

annu

ally.

- A

disas

ter m

anag

emen

t cup

boar

d is a

vaila

ble w

ith ap

prop

riate

items

and u

pdate

d mon

thly.

-Fil

es w

ith nu

mber

ed B

HTs,

forms

and t

ags a

re ke

pt for

disa

ster s

ituati

on.

7.2.3

A tria

ge sy

stem

avail

able

- Ex

isting

staff

in em

erge

ncy c

are u

nit ar

e tra

ined o

n tria

ge.

- Tr

iage p

rotoc

ols ar

e ava

ilable

and p

racti

ced.

- Re

susc

itatio

n fac

ilities

are a

vaila

ble at

triag

e site

s in t

he ho

spita

l. -

Sites

for P

1, P 2

, P3 &

P4 a

re id

entifi

ed in

the h

ospit

al.

7.2.4

A pr

oper

refer

ral s

ystem

av

ailab

le -

Tran

sfer in

-and

-out

reco

rd is

avail

able

and u

pdate

d. -

The t

rans

fer in

-and

-out

statis

tics a

re co

mpile

d and

revie

wed a

nnua

lly.

8 R

espo

nsiv

enes

s

8.1

Over

all

resp

onsiv

enes

s 8.1

.1 An

appo

intme

nt sy

stem

avail

able

for cl

inics

-

A me

chan

ism to

give

appo

intme

nts to

clini

c pati

ents

is av

ailab

le.

-Th

e app

ointm

ent s

ystem

is pr

oper

ly pr

actic

ed at

clini

cs.

Clini

c

8.1.2

Clea

n drin

king w

ater

prov

ided a

t all t

imes

to

patie

nts

- Cl

ean d

rinkin

g wate

r is av

ailab

le for

patie

nts w

ith a

water

filter

/conta

iner.

War

ds/ O

PD/

Clini

cs

8.1.3

An in

forma

tion d

esk

avail

able

for re

lative

s of

inpati

ents.

- An

infor

matio

n des

k is a

vaila

ble w

ith a

traine

d hos

pital

staff.

- Inf

orma

tion i

s disp

ense

d in a

n app

ropr

iate w

ay.

Rece

ption

/

War

ds

17

II.

Serv

ices

invo

lvin

g Pa

tient

Con

tact

s Ar

eas o

f Con

cern

St

anda

rds

Me

asur

able

Elem

ents

8.1

.4 A

sugg

estio

n box

and a

pr

oced

ure t

o tak

e re

media

l acti

ons a

vaila

ble

- A

sugg

estio

n box

is av

ailab

le wi

th a p

en an

d a de

signe

d for

m/wr

iting p

ad.

- Su

gges

tions

are b

eing r

eview

ed at

mon

thly f

orum

s/mee

tings

invo

lving

relev

ant

decis

ion m

aker

s. -

A re

cord

book

of ac

tions

take

n res

pond

ing to

the s

ugge

stion

s is a

vaila

ble an

d upd

ated.

Entra

nce,

rece

ption

&

pass

agew

ays

8.2

Resp

onsiv

enes

s to

in-pa

tients

8.2

.1 Se

para

te din

ing ar

eas

avail

able

for in

patie

nts

- Se

para

te din

ing ar

eas a

re av

ailab

le for

in-p

atien

ts.

War

ds

8.2.2

Bed l

inen c

hang

ed

prop

erly

- Be

d line

n is c

hang

ed on

the f

ollow

ing oc

casio

ns:

At

ever

y disc

harg

e of p

atien

ts.

W

hen t

here

is a

blood

spot

or bo

dy se

cretio

n on t

he lin

en.

Whe

n a re

ason

able

requ

est is

mad

e by t

he pa

tients

.

War

ds

8.2.3

A ch

angin

g roo

m av

ailab

le for

inpa

tients

-

A pr

oper

ly co

vere

d cha

nging

room

is av

ailab

le for

the i

npati

ents.

W

ards

8.2.4

Food

prov

ided i

n a pr

oper

ma

nner

-

Food

to th

e pati

ents

are t

rans

porte

d and

kept

in the

war

d in c

losed

conta

iners.

-

Food

is di

stribu

ted to

the p

atien

ts in

a clea

n env

ironm

ent w

hich i

s not

acce

ssibl

e to

flies.

War

ds

8.2.5

Patie

nt tro

lleys

prov

ided

with

mattr

esse

s -

All th

e pati

ent tr

olley

s are

prov

ided w

ith m

attre

sses

. W

ard

Entra

nce,

rece

ption

&

pass

agew

ays

8.3

Resp

onsiv

enes

s to

spec

ialise

d gr

oups

8.3.1

Secu

re ac

cess

prov

ided

for th

e diffe

rentl

y-able

d an

d sen

ior ci

tizen

s

- Se

para

te toi

lets a

re av

ailab

le for

the d

iffere

ntly-a

bled.

- Sp

ecial

acce

ss at

stair

ways

is av

ailab

le for

the d

iffere

ntly-a

bled.

- Pr

iority

coun

ters f

or di

ffere

ntly-a

bled a

nd se

nior c

itizen

s are

avail

able.

Clini

c, En

tranc

e, re

cepti

on &

pa

ssag

eway

s

18

II.

Serv

ices

invo

lvin

g Pa

tient

Con

tact

s Ar

eas o

f Con

cern

St

anda

rds

Me

asur

able

Elem

ents

9 In

patie

nt c

are

serv

ices

9.1

Gene

ral W

ard

9.1.1

An up

dated

summ

ary o

f the

stati

stics

disp

layed

in

the w

ard

- Th

e stat

istica

l sum

marie

s of th

e las

t yea

r, the

last

month

and y

ester

day a

re di

splay

ed in

the w

ard a

nd

upda

ted on

:

Numb

er of

beds

Numb

er of

admi

ssion

s

Numb

er of

disc

harg

es

Be

d occ

upan

cy ra

te

Numb

er of

tran

sfers

(in an

d out)

Numb

er of

deliv

eries

(Pos

t-nata

l war

ds on

ly)

9.1.2

Inpati

ents

atten

ded

appr

opria

tely o

n ad

miss

ion to

war

ds

- St

ampin

g on B

HTs o

f pati

ents

who r

equir

e urg

ent m

edica

l atte

ntion

is do

ne at

OPD

. -

The g

ener

al sta

tus an

d vita

l sign

s are

mea

sure

d and

reco

rded

on ad

miss

ion to

war

ds fo

r all t

he pa

tients

. -

Patie

nts w

ith “H

O to

See S

tat” a

re co

nsult

ed by

docto

rs wi

thin r

easo

nable

time.

- Al

locati

on of

nurse

s to p

atien

ts is

clear

ly ind

icated

in th

e war

d. 9.1

.3 An

emer

genc

y tra

y sy

stema

ticall

y arra

nged

an

d fun

ction

ing

- An

emer

genc

y tra

y is a

vaila

ble w

ith es

senti

al su

pplie

s, eq

uipme

nts, s

olutio

ns an

d dru

gs.

- A

chec

k list

for t

he em

erge

ncy t

ray i

tems i

s ava

ilable

and c

heck

ed at

leas

t onc

e a da

y. -

A re

spon

sible

office

r is in

dicate

d for

the m

ainten

ance

of th

e eme

rgen

cy tr

ay.

A sa

mpl

e em

erge

ncy t

ray i

tem

chec

klist

is at

tach

ed in

“ANN

EX 3:

Em

erge

ncy T

ray C

heck

list

(Sam

ple)

”.

9.1.4

Nursi

ng st

ation

s arra

nged

to

resp

ond t

o eme

rgen

cy

occa

sions

- Nu

rses c

an ob

serve

acute

patie

nts an

d tho

se w

ho re

quire

clos

e mon

itorin

g fro

m the

nursi

ng st

ation

all

the tim

e. -

Patie

nts ar

e eas

ily ac

cess

ible f

rom

the nu

rsing

stati

on in

emer

genc

y occ

asion

s. 9.1

.5 A

sepa

rate

exam

inatio

n ar

ea av

ailab

le -

An ex

amina

tion b

ed is

avail

able.

-

The e

xami

natio

n are

a is s

creen

ed fo

r priv

acy.

9.1.6

BHTs

prop

erly

writte

n -

Date

and t

ime a

re w

ritten

at ev

ery e

ntry t

o BHT

s. -

BHTs

are p

age-

numb

ered

. -

All th

e entr

ies to

BHT

s are

clea

rly w

ritten

. -

Drug

char

ts an

d flui

d bala

nce c

harts

are m

ade u

p to d

ate on

BHT

s. -

Comp

lete d

iagno

sis is

writt

en on

the B

HTs u

pon d

ischa

rge o

f pati

ents.

19

II.

Serv

ices

invo

lvin

g Pa

tient

Con

tact

s Ar

eas o

f Con

cern

St

anda

rds

Me

asur

able

Elem

ents

9.1

.7 W

ard r

ound

s con

ducte

d tw

ice a

day

- W

ard r

ound

s are

cond

ucted

twice

a da

y (mo

rning

and e

venin

g).

-Ob

serva

tions

durin

g the

war

d rou

nds a

nd th

e tim

e are

enter

ed in

the B

HTs.

9.1.8

Hand

ing-o

ver a

nd

taking

-ove

r of p

atien

ts pr

oper

ly do

ne up

on sh

ift ch

ange

s

- A

hand

ing-o

ver/t

aking

-ove

r reg

ister

is av

ailab

le.

- Pa

tient

detai

ls ar

e writt

en on

the r

egist

er an

d han

ded o

ver w

ith si

gnatu

re to

the l

eade

r of th

e nex

t shif

t.

9.1.9

Arra

ngem

ents

to inf

orm

Medic

al Of

ficer

s dur

ing

emer

genc

ies be

ing

satis

factor

y at a

ll tim

es

- A

list o

f the o

n-ca

ll doc

tors i

s upd

ated a

nd co

ntact

numb

ers a

re m

ade a

vaila

ble fo

r nur

ses a

nd

displa

yed.

- An

Inter

com

and/o

r a co

mmun

icatio

n boo

k are

avail

able

and f

uncti

oning

.

9.1.10

Av

ailab

ility o

f dru

gs

infor

med t

o all c

linici

ans

- A

drug

avail

abilit

y reg

ister

is m

ade a

vaila

ble fo

r doc

tors a

nd up

dated

wee

kly.

9.1.11

Ar

rang

emen

ts to

disch

arge

patie

nts be

ing

adeq

uate

- A

print

ed di

scha

rge c

heck

list is

avail

able

and f

illed f

or ea

ch pa

tient

and a

ttach

ed to

the B

HT at

ever

y dis

char

ge.

- Vi

tal in

forma

tion i

s inc

luded

in th

e che

cklis

t. -

Patie

nt dis

char

ge in

forma

tion i

nclud

ing da

te, tim

e and

sign

ature

is w

ritten

on B

HTs.

A sa

mpl

e disc

harg

e che

cklis

t is a

ttach

ed in

“ANN

EX 4:

Disc

harg

e Che

cklis

t (Sa

mpl

e)”.

20

II.

Serv

ices

invo

lvin

g Pa

tient

Con

tact

s Ar

eas o

f Con

cern

St

anda

rds

Me

asur

able

Elem

ents

9.1

.12

Relev

ant r

egist

ers

maint

ained

and u

pdate

d. -

The f

ollow

ing re

gister

s are

avail

able

and u

pdate

d:

War

d Adm

ission

Boo

k

Call B

ook

De

ath re

gister

Healt

h edu

catio

n boo

k

Infec

tion c

ontro

l boo

k and

infec

tion c

ontro

l aud

it che

cklis

t

Brok

en an

d con

demn

ing ite

m bo

ok (H

ealth

500 a

nd 50

3)

Ac

ciden

t and

incid

ent r

egist

er

Re

admi

ssion

book

Drug

s boo

k

Comm

unica

ble di

seas

es no

tifica

tion r

egist

er

Di

scha

rge r

egist

er

Co

rresp

onde

nce b

ook

Ch

eckli

st for

spec

ial an

d ess

entia

l app

aratu

s

Tran

sfer in

and o

ut bo

ok

Mi

dnigh

t rep

ort b

ook

Staff

roste

r by c

atego

ry 9.1

.13

A de

ath re

cord

main

taine

d -

A de

ath re

cord

is co

mplet

ed w

ith ca

use o

f dea

th, un

derly

ing ca

use a

nd pr

obab

le ca

use.

9.1.14

An

upda

ted cl

eanin

g ch

eckli

st 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 5:

Clea

ning

Che

cklis

t (Sa

mpl

e)”.

21

II.

Serv

ices

invo

lvin

g Pa

tient

Con

tact

s Ar

eas o

f Con

cern

St

anda

rds

Me

asur

able

Elem

ents

9.2

Int

ensiv

e car

e un

it 9.2

.1 A

functi

oning

inten

sive

care

unit a

vaila

ble w

ith

esse

ntial

equip

ment

- A

24 ho

ur co

nsult

ant c

over

age i

s ava

ilable

. -

Medic

al Of

ficer

s and

Nur

sing O

fficer

s are

assig

ned a

ccor

dingly

. -

The I

CU is

equip

ped w

ith th

e foll

owing

equip

ment:

ECG

and d

efibr

illator

Nebu

lising

mac

hine

Pu

lse ox

ymete

r

Suck

er m

achin

e

Ambu

bag

La

ryngo

scop

e

Tube

s

Venti

lator

s

Bloo

d gas

analy

zer

IC

U be

ds

Me

dical

Gase

s -

An em

erge

ncy t

ray i

s ava

ilable

with

esse

ntial

supp

lies,

solut

ions a

nd dr

ugs f

or ev

ery b

ed.

- A

comm

unica

tion m

echa

nism

to co

ntact

all re

levan

t hea

lth pe

rsonn

el an

d ser

vices

is in

plac

e in a

n em

erge

ncy s

ituati

on.

- A

chec

klist

for th

e eme

rgen

cy tr

ay ite

ms is

avail

able

and m

aintai

ned o

nce a

day.

- Ad

miss

ion an

d disc

harg

e crite

ria to

and f

rom

the in

tensiv

e car

e unit

is av

ailab

le.

9.2.2

Hand

ing-o

ver a

nd

taking

-ove

r of p

atien

ts pr

oper

ly do

ne up

on sh

ift ch

ange

s

- A

hand

ing-o

ver/t

aking

-ove

r reg

ister

is av

ailab

le.

- Pa

tient

detai

ls ar

e writt

en on

the r

egist

er an

d han

ded o

ver w

ith si

gnatu

re to

the l

eade

r of th

e nex

t shif

t.

9.3

Oper

ating

thea

tre

9.3.1

An up

dated

summ

ary o

f the

stati

stics

disp

layed

in

the op

erati

ng th

eatre

- Th

e stat

istica

l sum

marie

s of th

e las

t yea

r, the

last

month

and y

ester

day a

re di

splay

ed in

the o

pera

ting

theatr

e and

upda

ted on

:

Numb

er of

oper

ating

beds

Numb

er of

majo

r sur

gerie

s acc

ordin

g to s

pecia

lity (S

urge

ry, O

bs, G

ynae

, ENT

, EYE

etc.,

)

Numb

er of

mino

r sur

gerie

s

22

II.

Serv

ices

invo

lvin

g Pa

tient

Con

tact

s Ar

eas o

f Con

cern

St

anda

rds

Me

asur

able

Elem

ents

9.3

.2 Inf

ectio

n con

trol p

rotoc

ols

adhe

red t

o -

A co

py of

the “

Hosp

ital In

fectio

n Con

trol M

anua

l, Sri L

anka

Coll

ege o

f Micr

obiol

ogist

s” is

avail

able

and

the in

fectio

n con

trol p

rotoc

ols in

Cha

pter 9

are a

dher

ed to

. -

Ster

ile ar

eas a

re av

ailab

le for

instr

umen

ts, lin

en, s

hoes

etc.

and i

denti

fied w

ith th

e visu

al co

ntrol

metho

d. -

A ste

riliza

tion c

hart

is av

ailab

le in

the IC

U.

- Di

rty ut

ility a

reas

are a

vaila

ble fo

r instr

umen

ts, lin

en, s

hoes

etc.

and i

denti

fied w

ith th

e visu

al co

ntrol

metho

d. -

A pr

oper

was

te se

greg

ation

mec

hanis

m ba

sed o

n the

colou

r cod

ing is

avail

able.

9.3

.3 An

effec

tive p

re-o

pera

tive

care

avail

able

- Pa

tients

from

the w

ard a

re ta

ken o

ver b

y ope

ratin

g the

atre n

urse

s with

coun

tersig

natur

es.

- A

pre-

oper

ative

chec

klist

is av

ailab

le an

d adh

ered

to.

A

print

ed pr

e-op

erati

ve ch

eck l

ist is

avail

able

in the

war

d.

The c

heck

list is

filled

and a

ttach

ed to

the B

HT at

the w

ard.

Th

e che

cklis

t is co

mplet

ed w

hen a

patie

nt is

brou

ght to

the o

pera

ting t

heatr

e.

The c

heck

list is

coun

terch

ecke

d at th

e the

atre r

ecep

tion a

s well

as by

an an

aesth

etist.

-

A pa

tient

identi

ficati

on pr

oced

ure a

nd a

mech

anism

to pr

even

t sur

gical

misa

dven

tures

are i

n plac

e.

The p

atien

t iden

tifica

tion t

ag co

nsist

ing of

patie

nt na

me, B

HT N

o. an

d sur

gical

proc

edur

es to

be

unde

rtake

n is a

vaila

ble.

Th

e pati

ent id

entifi

catio

n tag

s are

prop

erly

filled

and p

laced

on al

l the p

atien

ts on

the d

ay of

the

surg

ery.

Th

e sur

gical

theatr

e list

inclu

ding p

atien

t infor

matio

n (pa

tient

name

, BHT

No.

and s

urgic

al pr

oced

ure)

for a

partic

ular d

ay is

deve

loped

in th

e war

d and

sent

to the

oper

ating

thea

tre.

9.3.4

An ef

fectiv

e ope

rativ

e car

e av

ailab

le -

A me

chan

ism to

iden

tify di

ffere

nt typ

es of

gase

s use

d dur

ing an

aesth

esia

is av

ailab

le.

- An

anae

stheti

c dru

g tra

y is a

vaila

ble an

d che

cked

with

a ch

eckli

st by

MO

Anae

sthes

ia be

fore e

very

shift.

-

An em

erge

ncy d

rug t

ray i

s ava

ilable

and c

heck

ed w

ith a

chec

klist

by M

O An

aesth

esia

befor

e eve

ry sh

ift.

- Th

e foll

owing

mec

hanis

ms ar

e ava

ilable

.

Estab

lishe

d pac

k cou

nt me

chan

ism

Es

tablis

hed e

quipm

ent c

ount

mech

anism

Mech

anism

to as

sess

bloo

d los

s

A fun

ction

ing ve

ntilat

ion m

echa

nism

9.3.5

An ef

fectiv

e pos

t ope

rativ

e ca

re av

ailab

le -

A re

cove

ry ar

ea is

avail

able

with

desig

nated

staff

. -

Esse

ntial

equip

ment

and d

rugs

are a

vaila

ble in

the r

ecov

ery a

rea.

- Po

st op

erati

ve no

tes ar

e pro

vided

in th

e BHT

s. -

Patie

nts ar

e han

ded o

ver t

o the

war

d with

coun

tersig

natur

es of

the w

ard s

taff.

23

II.

Serv

ices

invo

lvin

g Pa

tient

Con

tact

s Ar

eas o

f Con

cern

St

anda

rds

Me

asur

able

Elem

ents

9.3

.6 Th

e the

atre s

ched

ule

prop

erly

mana

ged

- Th

e the

atre s

ched

ule fo

r a w

eek i

s mad

e ava

ilable

to ho

spita

l staf

f. -

Guide

lines

for e

merg

ency

surg

eries

are a

vaila

ble an

d pra

ctice

d. 9.3

.7 Re

levan

t reg

ister

s ma

intain

ed

- An

oper

ating

thea

tre re

gister

men

tionin

g mino

r and

majo

r sur

gerie

s acc

ordin

g to t

he sp

ecial

ity is

av

ailab

le an

d upd

ated.

- An

accid

ent a

nd ad

verse

even

t reg

ister

is av

ailab

le an

d upd

ated.

9.4

Bloo

d ban

k 9.4

.1 A

24-h

our b

lood b

ank

servi

ce av

ailab

le -

A blo

od ba

nk is

open

ed an

d fun

ction

ing fo

r 24 h

ours.

-

Urge

nt gr

oupin

g and

DT

are p

erfor

med 2

4 hou

rs.

9.4.2

Train

ed st

aff av

ailab

le ac

cord

ing to

the N

ation

al Bl

ood T

rans

fusion

Ser

vice

(NBT

S) st

anda

rds

- Al

l the d

octor

s, nu

rses a

nd M

LTs w

orkin

g at th

e bloo

d ban

k atte

nded

the 4

wee

k tra

ining

cour

se

orga

nized

by N

BTS.

9.4.3

A me

chan

ism to

ensu

re

suffic

ient s

tocks

of bl

ood

and b

lood r

elated

prod

uct

in pla

ce

- Av

ailab

ility o

f the b

lood s

tocks

is di

splay

ed.

- A

calen

dar o

r rec

ord i

ndica

ting e

xpirin

g RCC

stoc

ks is

mad

e ava

ilable

. -

A mi

nimum

stoc

k lev

el for

RCC

is cl

early

defin

ed.

9.4.4

A va

lidati

on m

echa

nism

in pla

ce fo

r cro

ss m

atchin

g, an

d iss

uing a

nd

trans

fusing

bloo

d in a

ll un

its

- A

stand

ardiz

ed cr

oss m

atchin

g req

uest

form

is av

ailab

le an

d fille

d pro

perly

at th

e war

d. -

A sta

ndar

dized

comp

atibil

ity re

port

is av

ailab

le, fil

led pr

oper

ly at

the cr

oss m

atchin

g lab

orato

ry an

d re

turne

d to t

he w

ard.

9.4.5

The t

empe

ratur

e of th

e re

friger

ators

prop

erly

maint

ained

- Th

e tem

pera

ture o

f refr

igera

tors i

s mea

sure

d and

reco

rded

in a

regis

ter tw

ice a

day.

- A

tempe

ratur

e cha

rt is

maint

ained

and d

isplay

ed.

9.5

Labo

ur ro

om

9.5.1

The s

terilit

y main

taine

d in

the la

bour

room

at al

l tim

es

- Th

orou

gh cl

eanin

g othe

r tha

n dail

y clea

ning p

racti

ce is

cond

ucted

wee

kly us

ing ap

prop

riate

disinf

ectan

ts.

- Th

e dail

y and

wee

kly cl

eanin

g pra

ctice

s are

reco

rded

in a

regis

ter.

- A

perso

n res

pons

ible f

or cl

eanin

g is i

denti

fied.

- St

erile

area

s are

avail

able

for in

strum

ents,

linen

, sho

es et

c. wi

th the

visu

al co

ntrol

metho

d. -

A ste

riliza

tion c

hart

is av

ailab

le in

the la

bour

room

. -

Dirty

utilit

y are

as ar

e ava

ilable

for in

strum

ents,

linen

, sho

es et

c. wi

th the

visu

al co

ntrol

metho

d. -

A pr

oper

was

te se

greg

ation

mec

hanis

m ba

sed o

n the

colou

r cod

ing is

avail

able.

24

II.

Serv

ices

invo

lvin

g Pa

tient

Con

tact

s Ar

eas o

f Con

cern

St

anda

rds

Me

asur

able

Elem

ents

9.5

.2 An

te-na

tal an

d pos

t-nata

l mo

thers

effec

tively

mo

nitor

ed an

d man

aged

- Th

e Guid

eline

s give

n by t

he C

olleg

e of O

bstet

rician

s and

Gyn

aeco

logist

s are

avail

able.

-

Parto

gram

is st

arted

at on

set o

f deli

very

and m

aintai

ned p

rope

rly un

til de

liver

y and

kept

near

ever

y bed

. -

Vital

sign

s and

clini

cal d

ata ar

e reg

ularly

mea

sure

d and

reco

rded

on B

HTs a

fter d

elive

ry un

til the

pa

tients

are t

rans

ferre

d to t

he po

st-na

tal w

ard.

- A

mech

anism

to as

sess

bloo

d los

s is i

n plac

e. -

An em

erge

ncy t

ray i

s ava

ilable

with

a ch

eckli

st an

d che

cked

on ev

ery s

hift.

- Ep

isioto

my an

d all t

he la

cera

tions

are s

uture

d with

in on

e hou

r on u

rgen

cy of

requ

ireme

nt (b

ased

on B

HT

reco

rds a

nd in

tervie

ws ab

out th

e las

t five

deliv

eries

). -

Hand

ing-o

ver a

nd ta

king-

over

of m

other

s to a

nd fr

om th

e war

d is d

one w

ith es

senti

al inf

orma

tion

conv

eyed

with

coun

tersig

natur

e. 9.5

.3 Es

senti

al fac

ilities

for

resu

scita

tion o

f new

born

s av

ailab

le

- A

chec

klist

of es

senti

al ite

ms fo

r res

uscit

ation

of ne

wbor

ns is

avail

able

and u

pdate

d onc

e a da

y. -

A fun

ction

al wa

rmer

is av

ailab

le to

resu

scita

te the

newb

orns

. -

A lis

t of th

e on-

call P

aedia

tric H

ouse

Offic

ers i

s upd

ated a

nd co

ntact

detai

ls ar

e mad

e ava

ilable

for

nurse

s at th

e lab

our r

oom.

10

Dia

gnos

tic s

ervi

ces

10.1

Labo

rator

y 10

.1.1

A 24

hour

labo

rator

y se

rvice

avail

able

- A

24 ho

ur la

bora

tory s

ervic

e is a

vaila

ble fo

r inpa

tients

. -

The f

ollow

ing te

sts ar

e pro

vided

at th

e nigh

t on-

call l

abor

atory.

Bloo

d sug

ar

Se

rum

Elec

trolyt

es (S

odium

& P

otass

ium)

Se

rum

Amyla

se

Bl

ood U

rea

Se

rum

Biliru

bin (t

otal &

dire

ct)

CS

F su

gar

CS

F Fu

ll Rep

ort

Ur

ine de

posit

s (on

ly fro

m ca

sualt

y war

ds)

Ur

ine K

etone

bodie

s

Full B

lood C

ount

Proth

romb

in Tim

e

25

II.

Serv

ices

invo

lvin

g Pa

tient

Con

tact

s Ar

eas o

f Con

cern

St

anda

rds

Me

asur

able

Elem

ents

10

.1.2

Esse

ntial

equip

ment

functi

onal

and i

n ord

er at

all

times

- At

leas

t one

train

ing pr

ogra

mme i

s con

ducte

d for

diffe

rent

categ

ories

of la

bora

tory s

taff in

ratio

nal u

se of

lab

orato

ry eq

uipme

nt.

- A

back

-up s

ystem

or an

alter

nativ

e arra

ngem

ent to

cove

r bre

akdo

wns o

f labo

rator

y equ

ipmen

t is in

pla

ce.

- Re

gister

s ind

icatin

g ‘br

eakd

own p

eriod

s’ of

labor

atory

equip

ment

are a

vaila

ble.

- Gu

idelin

es ar

e ava

ilable

to en

sure

‘ade

quate

site

requ

ireme

nts’ in

insta

llatio

n of e

quipm

ent.

- Se

rvice

main

tenan

ce ag

reem

ents

are m

ade f

or ex

pens

ive la

bora

tory e

quipm

ent.

- SO

Ps ar

e ava

ilable

for a

ll majo

r labo

rator

y equ

ipmen

t and

proc

edur

es.

- Se

rvicin

g, cle

aning

and m

ainten

ance

instr

uctio

ns fo

r labo

rator

y equ

ipmen

t are

read

ily av

ailab

le for

us

ers.

- Se

rvicin

g rec

ords

are r

eadil

y ava

ilable

(e.g.

to no

tice w

hen t

o hav

e the

next

servi

ce).

-Cl

eanin

g res

pons

ibility

char

ts for

equip

ment

are a

vaila

ble an

d upd

ated.

10

.1.3

A Me

chan

ism to

ensu

re

‘mini

mal ti

me ga

p betw

een

orde

ring o

f inve

stiga

tions

an

d deli

very

of re

ports

at

the w

ards

’ in pl

ace

- Re

gister

s/for

ms ar

e ava

ilable

to in

dicate

the t

ime o

f ord

ering

of in

vesti

gatio

ns, th

e tim

e of h

andin

g-ov

er

samp

les an

d the

time o

f deli

verin

g rep

orts

at the

war

ds.

- A

sepa

rate

coun

ter is

avail

able

in the

labo

rator

y with

the M

LT in

-char

ge to

sort

out s

ample

s and

dire

ct the

m to

relev

ant M

LTs/d

ivisio

ns.

- Th

e tim

e for

acce

pting

routi

ne sa

mples

is se

t at o

r befo

re 10

.00am

. -

The t

ime f

or de

liver

ing ro

utine

repo

rts is

set a

t or b

efore

3.00

pm.

- A

mech

anism

to in

form

alarm

ing re

sults

to re

levan

t unit

s is i

n plac

e. -

A re

gister

to en

ter un

acce

ptable

samp

les is

avail

able.

-

A bo

ok to

infor

m co

mplai

nts/su

gges

tions

on an

y dela

ys is

avail

able

and r

eview

ed m

onthl

y. 10

.1.4

Urge

nt re

ques

ts en

tertai

ned w

ithin

an

acce

ptable

time d

urati

on

- “U

rgen

t”, da

te an

d tim

e are

men

tione

d in r

eque

st for

ms fo

r tho

se re

quirin

g urg

ent a

ttenti

on.

- A

mech

anism

to at

tend u

rgen

t req

uests

is in

plac

e. -

Repo

rts fo

r urg

ent r

eque

sts ar

e retu

rned

to th

e war

ds as

soon

as po

ssibl

e. -

A re

gister

to in

dicate

the t

ime d

urati

on re

quire

d to r

eturn

urge

nt re

ques

ts to

the w

ards

is av

ailab

le.

26

II.

Serv

ices

invo

lvin

g Pa

tient

Con

tact

s Ar

eas o

f Con

cern

St

anda

rds

Me

asur

able

Elem

ents

10

.1.5

Inter

nal a

nd ex

terna

l qu

ality

contr

ol me

asur

es

adop

ted

- A

copy

of th

e “Ma

nual

on La

bora

tory S

ervic

es (J

anua

ry 20

07),

The L

abor

atory

Secto

r of th

e Mini

stry o

f He

althc

are a

nd N

utritio

n” is

avail

able.

-

A me

chan

ism to

ensu

re in

terna

l qua

lity is

avail

able

and l

og bo

oks a

nd/or

mac

hine p

rintou

ts ar

e kep

t for

all th

e foll

owing

tests

.

Bioc

hemi

stry

Ha

emato

logy

Mi

crobio

logy (

ABST

) -

SOPs

are a

vaila

ble fo

r all t

he la

bora

tory p

roce

dure

s. -

A sta

ndar

dised

proto

col fo

r reu

se of

spec

imen

bottle

s (e.g

. was

hing,

sterili

zing a

nd re

using

) is av

ailab

le an

d adh

ered

to.

- An

exter

nal q

uality

contr

ol re

gister

is av

ailab

le an

d pro

vides

evide

nce t

hat r

esult

s of Q

uality

Ass

uran

ce

samp

les se

nt by

MRI

unde

r NEQ

AS ar

e retu

rned

in tim

e. -

Actio

ns ta

ken o

n NEQ

AS ‘e

rrors

repo

rts’ a

re du

ly do

cume

nted f

or th

e refe

renc

e of u

sers.

-

Month

ly lab

orato

ry me

dicine

mee

tings

are h

eld an

d minu

tes ar

e main

taine

d. 10

.2 Ra

diolog

y 10

.2.1

A 24

hour

Rad

iolog

y Se

rvice

avail

able

for

inpati

ents

- An

in-h

ospit

al ra

diolog

y ser

vice/

on-ca

ll ser

vice f

rom

the sa

me ho

spita

l or o

utside

the h

ospit

al is

avail

able.

-

A ba

ck-u

p sys

tem/ a

ltern

ative

arra

ngem

ents

to co

ver b

reak

down

s of e

quipm

ent a

re av

ailab

le.

10.2.

2 Es

senti

al eq

uipme

nt fun

ction

al an

d in o

rder

at

all tim

es

- Al

l the r

adiol

ogy e

quipm

ent is

func

tionin

g and

main

taine

d reg

ularly

. -

A ma

inten

ance

reco

rd fo

r rad

iolog

y equ

ipmen

t is av

ailab

le an

d upd

ated.

- A

resp

onsib

le off

icer is

avail

able

to ma

intain

majo

r equ

ipmen

t. 10

.2.3

The R

adiol

ogy S

ervic

e pr

otoco

ls ad

here

d to

- A

copy

of th

e Nati

onal

Guide

line o

n Rad

iolog

y Ser

vices

is av

ailab

le an

d adh

ered

to.

10.2.

4 Ra

diatio

n pro

tectio

n me

asur

es ta

ken a

ccor

ding

to the

Nati

onal

Atom

ic En

ergy

Auth

ority

(AEA

) sta

ndar

ds

- A

docu

ment

issue

d by A

EA to

certif

y tha

t insta

llatio

n site

s of r

adiat

ing eq

uipme

nt me

et the

AEA

stan

dard

is

avail

able.

-

Licen

ces a

re ob

taine

d for

each

radia

ting e

quipm

ent fr

om A

EA an

d ren

ewed

ever

y yea

r. -

The c

riteria

for t

he us

e of p

rotec

tive g

ears

are a

dher

ed to

in ac

cord

ance

with

the T

herm

o Lum

inesc

ent

Dosim

eter (

TLD)

disp

lay.

10.3

Othe

r diag

nosti

c se

rvice

s 10

.3.1

A 24

hour

ECG

servi

ce

avail

able

for in

patie

nts

- An

in-h

ospit

al EC

G se

rvice

/ on-

call s

ervic

e is a

vaila

ble fr

om th

e sam

e hos

pital.

27

II.

Serv

ices

invo

lvin

g Pa

tient

Con

tact

s Ar

eas o

f Con

cern

St

anda

rds

Me

asur

able

Elem

ents

11

Med

ical

/pha

rmac

eutic

al s

uppl

ies

and

equi

pmen

t man

agem

ent

11.1

Mana

geme

nt of

phar

mace

utica

l un

it

11.1.

1 An

nual

estim

ates o

f me

dical

and

phar

mace

utica

l sup

plies

pr

epar

ed on

time

- An

annu

al es

timate

of m

edica

l and

phar

mace

utica

l sup

plies

is pr

epar

ed an

d sen

t to M

SD by

Sep

tembe

r ev

ery y

ear.

11.1.

2 A

functi

oning

drug

revie

w co

mmitte

e ava

ilable

-

A dr

ug re

view

comm

ittee i

s ava

ilable

and m

onthl

y mee

tings

are c

ondu

cted.

- Mi

nutes

of th

e dru

g rev

iew co

mmitte

e mee

tings

with

lists

of att

ende

es an

d dec

ision

s mad

e are

avail

able

and c

ircula

ted.

11.1.

3 A

mech

anism

to

strea

mline

loca

l pur

chas

es

of dr

ugs i

n plac

e

- Inf

orma

tion o

n day

to da

y ava

ilabil

ity of

loca

l pur

chas

e dru

gs is

circu

lated

from

MSD

to th

e hos

pital,

and

from

the ph

arma

cy to

cons

ultan

ts in

an fu

nctio

ning o

rder

. -

A loc

al dr

ug pu

rchas

e for

mat is

avail

able

and u

tilize

d. -

A loc

al dr

ug pu

rchas

e reg

ister

is m

aintai

ned.

-Th

e utili

zatio

n stat

us of

loca

l pur

chas

e allo

catio

n is c

ircula

ted m

onthl

y to c

onsu

ltants

. 11

.2 St

orag

e and

sto

ck

maint

enan

ce of

me

dical/

phar

mac

eutic

al su

pplie

s

11.2.

1 Ph

arma

ceuti

cal it

ems

store

d acc

ordin

g to t

he

manu

factur

er’s

stand

ards

- Ph

arma

ceuti

cal it

ems a

re st

ored

at op

timum

temp

eratu

res.

- Te

mper

ature

s of c

old ro

oms a

re m

easu

red a

nd re

cord

ed in

a re

gister

in th

e mor

ning a

nd th

e eve

ning.

11.2.

2 St

ock i

tems o

f ph

arma

ceuti

cal s

uppli

es

appr

opria

tely m

anag

ed

- Inf

orma

tion o

n dail

y stoc

k item

s is a

vaila

ble.

- ‘Fi

rst ex

piry f

irst o

ut sy

stem’

is m

aintai

ned.

- Inf

orma

tion i

s upd

ated o

n SUR

PLUS

items

. 11

.2.3

Expir

ing ite

ms

appr

opria

tely m

anag

ed

- Pe

riodic

chec

ks ar

e don

e for

expir

ing ite

ms re

gular

ly.

- A

regis

ter bo

ok of

perio

dic ch

ecks

for e

xpirin

g item

s is a

vaila

ble an

d upd

ated.

- A

mech

anism

to pr

even

t mix-

up of

expir

ed an

d non

-exp

ired d

rugs

and t

o disp

ose t

he ex

pired

items

on

time i

s in p

lace.

11.2.

4 Pe

riodic

test

chec

ks

cond

ucted

perio

dicall

y -

Test

chec

ks ar

e con

ducte

d at s

ervic

e unit

s per

iodica

lly.

- A

regis

ter bo

ok of

test

chec

ks is

avail

able

and u

pdate

d. 11

.2.5

Emer

genc

y buff

er st

ocks

for

vital

and e

ssen

tial

drug

s main

taine

d

- A

list o

f vita

l and

esse

ntial

drug

s with

a bu

ffer s

tock l

evel

is av

ailab

le.

- Th

e buff

er st

ock l

evel

of all

vital

and e

ssen

tial d

rugs

is m

aintai

ned.

28

II.

Serv

ices

invo

lvin

g Pa

tient

Con

tact

s Ar

eas o

f Con

cern

St

anda

rds

Me

asur

able

Elem

ents

11

.3 Di

spen

sing a

nd

drug

ad

minis

tratio

n

11.3.

1 A

mech

anism

to pr

ovide

es

senti

al inf

orma

tion t

o pa

tients

on us

age o

f dru

gs

in pla

ce

- Dr

ugs a

re di

spen

sed i

n pac

kets

with

writte

n ins

tructi

ons i

nclud

ing do

sage

, freq

uenc

y and

dura

tion.

11.4

Medic

al eq

uipme

nt 11

.4.1

A ge

nera

l inve

ntory

and a

dis

tributi

on re

gister

of

differ

ent c

atego

ries o

f eq

uipme

nt ma

intain

ed

- A

regis

ter on

gene

ral in

vento

ry is

avail

able

and u

pdate

d. -

A dis

tributi

on re

gister

of di

ffere

nt ca

tegor

ies of

equip

ment

is av

ailab

le an

d upd

ated.

11.4.

2 Ma

inten

ance

mec

hanis

m for

equip

ment

avail

able

- A

functi

oning

biom

edica

l wor

ksho

p for

equip

ment

maint

enan

ce is

at th

e hos

pital

or al

terna

tively

such

se

rvice

is ac

cess

ible.

-Pr

even

tive m

ainten

ance

train

ing fo

r med

ical e

quipm

ent is

cond

ucted

annu

ally f

or ho

spita

l staf

f. 11

.4.3

Sepa

rate

files a

nd st

ock

card

s for

indiv

idual

equip

ment

avail

able

with

nece

ssar

y deta

ils

- Ea

ch eq

uipme

nt ha

s a se

para

te file

with

all th

e deta

ils of

the e

quipm

ent.

- Th

e file

s of th

e equ

ipmen

t con

tain a

summ

ary s

heet

indica

ting s

ervic

e and

repa

ir rec

ords

of th

e eq

uipme

nt an

d upd

ated.

12

Mor

tuar

y se

rvic

e

12.1

Mortu

ary

12

.1.1

A fun

ction

al mo

rtuar

y av

ailab

le -

Adeq

uate

and t

raine

d staf

f (JM

O an

d tra

ined m

inor s

taff)

are a

vaila

ble at

the m

ortua

ry du

ring t

he da

y tim

e. -

Func

tiona

l mor

tuary

coole

rs ar

e ava

ilable

. -

A ch

eckli

st for

esse

ntial

equip

ment

for th

e mor

tuary

is av

ailab

le an

d use

d. -

The m

ortua

ry is

equip

ped w

ith:

Ru

nning

wate

r

Adeq

uate

lighti

ng fa

cilitie

s

Venti

lation

facil

ities

- A

clean

ing ch

eckli

st is

avail

able

for cl

eanin

g at th

e end

of ea

ch po

st mo

rtem

sess

ion an

d at th

e end

of

the da

y.

29

III.

Ove

rall

Qua

lity

and

Safe

ty Im

prov

emen

t A

reas

of C

once

rnSt

anda

rds

Mea

sura

ble

Elem

ents

13

Infe

ctio

n co

ntro

l

13.1

Infec

tion c

ontro

l ma

nage

ment

13.1.

1 Inf

ectio

n Con

trol

Prog

ramm

e ava

ilable

and

functi

onal

in the

hosp

ital

- A

functi

oning

Infec

tion C

ontro

l Unit

is av

ailab

le.

- A

Medic

al Of

ficer

and/o

r a tr

ained

nurse

is av

ailab

le for

infec

tion c

ontro

l acti

vities

. -

Infec

tion i

denti

ficati

on re

gister

s are

avail

able

and u

pdate

d. 13

.1.2

Infec

tion r

isk co

ntrol

proc

edur

es an

d pro

tocols

de

velop

ed

- Th

e infe

ction

contr

ol co

mmitte

e is e

stabli

shed

. -

The i

nfecti

on co

ntrol

comm

ittee c

ondu

cts m

eetin

gs on

ce in

thre

e mon

ths an

d minu

tes of

the m

eetin

gs

are a

vaila

ble.

- An

infec

tious

dise

ase r

egist

er is

main

taine

d at th

e Infe

ction

Con

trol U

nit.

- A

writte

n pro

cedu

re w

ith in

struc

tions

on pr

oper

hand

was

hing i

s ava

ilable

. -

Train

ing pr

ogra

mmes

are c

ondu

cted t

o staf

f in re

lation

to in

fectio

n con

trol.

13.1.

3 Pr

otecti

ve ge

ars a

vaila

ble

and u

sed

- Pr

otecti

ve ge

ars a

re av

ailab

le in

all th

e unit

s and

read

y to u

se.

-Pr

otecti

ve ge

ars a

re us

ed w

hene

ver n

eces

sary.

13

.1.4

A sy

stem

to pr

epar

e and

dis

tribute

ster

ile

instru

ments

and d

ress

ings

to re

levan

t unit

s in p

lace

- St

eps a

nd ro

utes o

f ster

ile ite

ms fr

om C

SSD

to ea

ch se

rvice

unit a

re cl

early

defin

ed (e

.g. by

mea

ns of

a flo

wcha

rt).

- A

stand

ardis

ed vi

sual

contr

ol me

thod t

o ide

ntify

sterile

and u

nster

ile ite

ms is

in pl

ace.

- A

sepa

rate

place

is av

ailab

le to

rece

ive un

sterili

zed i

nstru

ments

and l

inen.

- A

sterile

plac

e is a

vaila

ble to

issu

e ster

ile in

strum

ents

and l

inen.

A st

anda

rd fl

owch

art o

f CSS

D is

prov

ided

in “A

NNEX

6: C

SSD

Serv

ice F

lowc

hart”

.

A vis

ual c

ontro

l sch

eme f

or C

SSD

is pr

ovid

ed in

“ANN

EX 7:

Visu

al Co

ntro

l Sch

eme f

or C

SSD”

13.1.

5 A

mech

anism

to en

sure

ha

nd w

ashin

g ava

ilable

in

all un

its

- Ha

nd w

ashin

g ins

tructi

ons a

re di

splay

ed at

all th

e sink

s use

d by h

ealth

care

perso

nnel.

-

All th

e sink

s use

d for

hand

was

hing a

re in

wor

king c

ondit

ion.

- Ha

nd w

ashin

g liqu

id/ so

ap ar

e ava

ilable

for h

and w

ashin

g. 13

.1.6

Noso

comi

al Inf

ectio

n pr

even

tion a

nd re

ducti

on

meas

ures

in pl

ace

- Th

e ide

ntifie

d site

s whic

h are

at ris

k for

noso

comi

al inf

ectio

n are

defin

ed an

d ind

icated

. -

Swab

s are

take

n and

sent

once

a mo

nth to

MRI

from

the i

denti

fied s

ites (

oper

ating

thea

tre, th

e lab

our

room

, ICU,

SCB

U an

d PBU

) for

cultu

re in

vesti

gatio

n.

30

III.

Ove

rall

Qua

lity

and

Safe

ty Im

prov

emen

t A

reas

of C

once

rnSt

anda

rds

Mea

sura

ble

Elem

ents

13

.1.7

Nece

ssar

y imm

uniza

tion

carri

ed ou

t for h

ealth

staff

at

risk

- Th

e Hep

atitis

B va

ccina

tion i

s don

e for

all th

e hea

lth st

aff th

ree t

imes

.

13.2

Isolat

ion un

it 13

.2.1

An is

olatio

n unit

avail

able

- An

isola

tion u

nit is

avail

able

and s

et up

acco

rding

to th

e Hos

pital

Infec

tion C

ontro

l Man

ual, S

ri Lan

ka

Colle

ge of

Micr

obiol

ogist

(Pag

e 26)

. -

An ad

miss

ion an

d disc

harg

e poli

cy to

and f

rom

the is

olatio

n unit

is av

ailab

le.

- Pr

otecti

ve ge

ars a

re av

ailab

le an

d use

d in t

he is

olatio

n unit

. -

All th

e staf

f wor

king i

n the

isola

tion u

nit ar

e pro

tected

by va

ccine

s (He

patiti

s B, H

1N1 a

nd T

ypho

id).

14 W

aste

man

agem

ent

14.1

Was

te ma

nage

ment

14.1.

1 W

astes

adeq

uatel

y dis

pose

d -

Five t

ypes

of w

astes

are s

egre

gated

by th

e colo

ur co

des i

n the

war

ds:

Ge

nera

l was

tes

Sh

arps

Infec

ted w

astes

Plas

tics

Gl

asse

s -

A co

lour c

oding

char

t for t

he w

aste

segr

egati

on is

disp

layed

in th

e war

ds.

- Th

e was

te se

greg

ation

is or

ganis

ed at

the w

aste

dispo

sal a

rea a

ccor

ding t

o the

colou

r cod

es.

- An

incin

erato

r is av

ailab

le an

d fun

ction

ing.

14.1.

2 Ha

zard

ous w

astes

dis

pose

d acc

ordin

g to t

he

natio

nal s

tanda

rds

- Pr

otoco

ls for

hand

ling t

he fo

llowi

ng ha

zard

ous w

astes

are a

dher

ed to

:

Shar

ps

Pa

tholog

ical W

aste

Ef

fluen

ts

Radio

activ

e Was

te

Phar

mace

utica

l Was

te

Chem

ical W

aste

La

bora

tory W

aste

- Di

spos

al bin

s for

shar

ps in

cludin

g nee

dles a

re in

plac

e acc

ordin

g. -

A pr

otoco

l for d

ispos

al of

waste

body

fluid

and b

lood c

ompo

nents

are a

vaila

ble an

d adh

ered

to.

A pr

otoc

ol fo

r haz

ardo

us w

aste

man

agem

ent i

s atta

ched

in A

NNEX

8: P

roto

col f

or H

azar

dous

Was

te

Mana

gem

ent”.

31

III.

Ove

rall

Qua

lity

and

Safe

ty Im

prov

emen

t A

reas

of C

once

rnSt

anda

rds

Mea

sura

ble

Elem

ents

15 M

edic

al re

cord

15.1

Medic

al re

cord

/stati

stics

ro

om

15.1.

1 BH

Ts ha

nded

over

to th

e me

dical

reco

rd ro

om on

tim

e

- Co

mplet

ed B

HTs w

ith di

agno

sis ar

e han

ded o

ver f

rom

the w

ard t

o the

med

ical re

cord

room

with

in 24

ho

urs.

15.1.

2 An

nual

statis

tics b

ulleti

ns

conta

ining

mon

thly a

nd

quar

terly

data

publi

shed

- Qu

arter

ly sta

tistic

s bull

etins

are p

ublis

hed o

n tim

e (e.g

. the 1

st qua

rterly

bulle

tin by

end o

f May

each

ye

ar).

-An

nual

statis

tical

bulle

tins a

re pu

blish

ed be

fore M

arch

of ea

ch ye

ar.

15.1.

3 IM

MR m

aintai

ned

appr

opria

tely

- Di

seas

es ar

e clas

sified

acco

rding

to th

e ICD

-10 c

lassif

icatio

n at th

e Med

ical R

ecor

d roo

m.

- IM

MR is

main

taine

d acc

ordin

g to t

he IC

D-10

clas

sifica

tion.

- IM

MR is

upda

ted up

to th

e las

t qua

rter.

15.1.

4 Ho

spita

l retur

ns su

bmitte

d on

time

- Re

turns

are s

ent to

RDH

S (p

rovin

cial in

stitut

ions)

or S

tatist

ics U

nit of

MOH

N (lin

e mini

stry h

ospit

als) o

n tim

e: IM

MR

Ma

terna

l Stat

istics

Ins

titutio

nal d

ata

15.1.

5 BH

Ts ar

rang

ed in

orde

r for

ea

sy re

trieva

l -

BHTs

are a

rrang

ed in

shelv

es ac

cord

ing to

the y

ear a

nd th

e BHT

numb

ers.

15.1.

6 A

traine

d staf

f (in

medic

al re

cord

s) av

ailab

le in

the

medic

al re

cord

s roo

m

- A

quali

fied M

RO is

assig

ned t

o the

med

ical re

cord

room

.

16 H

ealth

edu

catio

n ac

tiviti

es

16.1

Healt

h edu

catio

n ac

tivitie

s 16

.1.1

A fun

ction

al He

alth

Educ

ation

Unit

avail

able

- A

Healt

h Edu

catio

n Unit

is av

ailab

le an

d fun

ction

ing.

- At

leas

t a M

edica

l Offic

er or

a tra

ined n

urse

is av

ailab

le for

healt

h edu

catio

n acti

vities

. -

An ad

vanc

e pro

gram

me re

gister

for h

ealth

educ

ation

activ

ities i

s ava

ilable

and u

pdate

d. -

A pe

rform

ance

repo

rt on

healt

h edu

catio

n acti

vities

is av

ailab

le an

d upd

ated.

32

III.

Ove

rall

Qua

lity

and

Safe

ty Im

prov

emen

t A

reas

of C

once

rnSt

anda

rds

Mea

sura

ble

Elem

ents

17 L

eade

rshi

p an

d m

anag

emen

t

17.1

Lead

ersh

ip qu

ality

17.1.

1 Vi

sion a

nd M

ission

of th

e ho

spita

l ava

ilable

-

The V

ision

and M

ission

of th

e hos

pital

are d

isplay

ed in

a vis

ible p

lace.

-Ho

spita

l staf

f are

awar

e of th

e Visi

on an

d Miss

ion, a

nd un

derst

and t

hem.

17

.1.2

A str

ategic

plan

and/o

r a

mediu

m-ter

m pla

n of th

e ho

spita

l dev

elopm

ent

avail

able

- A

docu

ment

on st

rateg

ic pla

n and

/or a

mediu

m-ter

m pla

n of th

e hos

pital

is av

ailab

le.

- An

activ

ity pl

an of

the h

ospit

al is

avail

able

and u

pdate

d.

17.2

Publi

c rela

tions

an

d com

munit

y mo

biliza

tion

17.2.

1 An

mec

hanis

m to

impr

ove

comm

unity

partic

ipatio

n an

d com

munit

y mo

biliza

tion i

n plac

e

- An

annu

al pla

n for

comm

unity

activ

ities i

s ava

ilable

. -

All th

e com

munit

y acti

vities

are r

ecor

ded a

nd fil

ed.

17.3

Huma

n res

ource

ma

nage

ment

17.3.

1 St

aff tr

aining

cond

ucted

re

gular

ly -

A sta

ff tra

ining

annu

al pla

n is a

vaila

ble.

- A

staff t

raini

ng re

cord

book

is av

ailab

le an

d upd

ated.

- A

coor

dinato

r for

staff

train

ing is

assig

ned.

17.3.

2 St

aff de

ploym

ent

adeq

uatel

y man

aged

-

Staff

deplo

ymen

t rec

ord b

ooks

are a

vaila

ble fo

r all c

atego

ries o

f staf

f and

upda

ted.

- Th

e cad

re an

d the

curre

nt sta

tus of

the s

taff a

re di

splay

ed an

d upd

ated.

17.3.

3 Du

ty lis

ts for

all c

atego

ries

of sta

ff ava

ilable

-

Duty

lists

for al

l cate

gorie

s of s

taff a

re av

ailab

le.

17.3.

4 Gr

ievan

ce ha

ndlin

g me

chan

isms i

n plac

e -

A wa

y of r

epor

ting g

rieva

nces

(in ve

rbal

or w

ritten

form

) to h

ospit

al au

thoriti

es is

avail

able

for st

aff an

d pa

tients

. -

All th

e grie

vanc

es of

the s

taff a

re re

cord

ed se

para

tely a

nd fil

ed.

-Th

e grie

vanc

es ar

e rev

iewed

at re

gular

mee

tings

.

33

III.

Ove

rall

Qua

lity

and

Safe

ty Im

prov

emen

t A

reas

of C

once

rnSt

anda

rds

Mea

sura

ble

Elem

ents

17

.4 Of

fice

mana

geme

nt 17

.4.1

A fun

ction

al off

ice

mana

geme

nt sy

stem

in pla

ce.

- Of

fices

in th

e hos

pital

are c

atego

rized

into

the fo

llowi

ng th

ree:

Ge

nera

l reso

urce

man

agem

ent

Hu

man r

esou

rce m

anag

emen

t

Finan

cial m

anag

emen

t -

Healt

h man

agem

ent a

ssist

ants

(HMA

s) ar

e ass

igned

with

clea

rly de

fined

subje

cts.

- Th

e offic

e lay

out w

ith as

signe

d HMA

s and

their

subje

cts ar

e disp

layed

at th

e entr

ance

of th

e offic

e. -

A me

chan

ism to

resp

ond t

o the

requ

est fr

om th

e staf

f to se

e ann

ual s

alary

incre

ment

date

is in

place

. -

All th

e file

s hav

e ide

ntific

ation

numb

ers a

nd al

l pag

es ar

e num

bere

d. -

Reor

der le

vels

of pa

per f

orms

and s

tation

eries

are d

efine

d and

indic

ated,

and a

n ade

quate

numb

er of

pa

per f

orms

and s

tation

eries

are m

ade a

vaila

ble al

l the t

ime.

17.5

Kitch

en

mana

geme

nt 17

.5.1

The k

itche

n main

taine

d to

prov

ide hy

gienic

and

adeq

uate

food

- A

clean

ing ch

eckli

st is

avail

able

and u

sed i

n the

kitch

en.

- Th

ere i

s no v

isible

dirt

in the

kitch

en.

- W

ater,

soap

and o

ther b

asic

requ

ireme

nts ar

e fre

ely av

ailab

le.

- Al

l the k

itche

n staf

f are

prov

ided w

ith ca

ps an

d apr

ons,

and t

hose

wor

king i

n the

kitch

en al

ways

wea

r the

m pr

oper

ly.

- Al

l the s

taff w

orkin

g in t

he ki

tchen

are g

iven b

asic

educ

ation

on he

alth a

nd sa

nitati

on.

- Me

dical

exam

inatio

ns ar

e don

e for

all th

e kitc

hen s

taff a

t leas

t onc

e a ye

ar.

- Ch

arts

of dif

feren

t type

s of fo

od ar

e disp

layed

in th

e kitc

hen.

- A

mech

anism

to pr

even

t mix-

up of

cook

ed fo

od w

ith ra

w foo

d item

s is i

n plac

e. -

A log

book

to ke

ep co

mmen

ts giv

en du

ring s

uper

visor

y visi

ts by

the D

irecto

r/ MS

/ AO/

Matr

ons i

s av

ailab

le.

17.6

Utilit

y Ser

vices

17

.6.1

Comm

unica

tion s

ystem

s an

d fac

ilities

prop

erly

maint

ained

- A

telep

hone

exch

ange

is fu

nctio

nal a

nd w

ell m

aintai

ned.

- A

traine

d tele

phon

e ope

rator

is av

ailab

le for

24 ho

urs.

- Co

ntact

detai

ls (In

terco

m No

., Res

idenc

e No.,

Mob

ile N

o. etc

.) of

all em

ploye

es ar

e ava

ilable

and e

asily

re

feren

ced.

- A

regis

ter to

enter

the a

ll outg

oing c

alls a

re av

ailab

le an

d upd

ated.

34

III.

Ove

rall

Qua

lity

and

Safe

ty Im

prov

emen

t A

reas

of C

once

rnSt

anda

rds

Mea

sura

ble

Elem

ents

17

.6.2

Ambu

lance

s main

taine

d pr

oper

ly -

The f

ollow

ing fo

rms a

nd fil

es ar

e main

taine

d and

upda

ted ac

cord

ing to

the G

uideli

nes.

Ve

hicle

Log B

ook (

Form

Gen

eral

267)

Daily

Run

ning C

hart

(For

m Ge

nera

l 268

)

The V

ehicl

e Inv

entor

y ind

icatin

g the

Reg

istra

tion N

o., th

e data

of re

gistra

tion,

the m

aker

and

mode

l, Cha

ssis

No., E

ngine

No.,

and d

etails

of al

l acc

esso

ries.

Ve

hicle

files

- Gu

idelin

es ar

e ava

ilable

and a

dher

ed to

on cl

eanin

g of a

mbula

nces

with

disin

fectan

ts aft

er tr

ansp

ortin

g a p

atien

t with

comm

unica

ble di

seas

e. -

Fuel

cons

umpti

on te

sts ar

e don

e at le

ast o

nce a

year

. 17

.6.3

A me

chan

ism fo

r ma

inten

ance

of bu

ilding

, wa

ter su

pply

and e

lectric

al fac

ilities

in pl

ace

- Th

e buil

ding p

lan an

d the

wate

r and

elec

tricity

supp

ly lay

out a

re av

ailab

le.

- A

functi

onal

maint

enan

ce un

it for

mino

r rep

airs i

s ava

ilable

in th

e hos

pital.

-

A sy

stem

to ch

eck t

he pi

pelin

es an

d tap

s for

leak

ing an

d to r

epair

them

is in

plac

e. -

A co

mplet

e ins

pecti

on of

the e

lectric

al ne

twor

k is c

arrie

d out

ever

y 6 m

onths

. -

A fun

ction

al sta

nd-b

y gen

erato

r is av

ailab

le wi

th the

prior

ity of

powe

r sup

ply to

ICU,

Bloo

d Ban

k and

Op

erati

ng T

heatr

e. 17

.7 Pe

rform

ance

re

view

17.7.

1 St

aff m

eetin

gs he

ld mo

nthly

- Se

ction

al He

ad m

eetin

gs ar

e held

mon

thly.

- Mi

nutes

of st

aff m

eetin

gs ar

e ava

ilable

. 17

.7.2

Death

revie

ws co

nduc

ted

- De

ath re

view

meeti

ngs a

re co

nduc

ted m

onthl

y for

mate

rnal,

perin

atal a

nd ot

her d

eaths

. -

Minu

tes of

the r

eview

mee

tings

are a

vaila

ble.

- De

ath re

view

reco

rds a

re ke

pt in

a file

. -

Death

stati

stics

are c

ompil

ed an

d mad

e ava

ilable

. 17

.7.3

Supe

rvisio

n ins

pecti

ons

cond

ucted

-

Supe

rvisio

n ins

pecti

ons a

re co

nduc

ted pr

efera

bly da

ily by

:

Head

of th

e Ins

titutio

n

Admi

nistra

tive g

rade

offic

er

Sp

ecial

grad

e nur

sing o

fficer

Chief

phar

macis

t -

Supe

rvisio

n ins

pecti

on re

cord

s are

avail

able

and m

aintai

ned.

35

III.

Ove

rall

Qua

lity

and

Safe

ty Im

prov

emen

t A

reas

of C

once

rnSt

anda

rds

Mea

sura

ble

Elem

ents

18 P

rodu

ctiv

ity a

nd q

ualit

y im

prov

emen

t pro

gram

me

18.1

Prod

uctiv

ity an

d qu

ality

impr

ovem

ent

prog

ramm

e

18.1.

1 A

Quali

ty Ma

nage

ment

Unit e

stabli

shed

and

functi

oning

- A

Quali

ty Ma

nage

ment

Unit i

s ava

ilable

with

an of

ficer

in-ch

arge

. -

A St

eerin

g Com

mitte

e for

the q

uality

impr

ovem

ent p

rogr

amme

is av

ailab

le.

- Fil

es an

d fold

ers o

f the Q

uality

Man

agem

ent U

nit ar

e main

taine

d acc

ordin

g to t

he cr

iteria

give

n by t

he

Natio

nal Q

uality

Sec

retar

iat.

-Or

ganis

ation

al re

sults

inclu

ding k

ey st

atisti

cs ar

e disp

layed

in th

e Qua

lity M

anag

emen

t Unit

. 18

.1.2

Wor

k Imp

rove

ment

Team

s (W

ITs)

forme

d in a

ll un

its/w

ards

- W

IT m

eetin

gs ar

e con

ducte

d mon

thly i

n all t

he un

its.

- Mi

nutes

of W

IT m

eetin

gs ar

e ava

ilable

in al

l the u

nits.

18.1.

3 Th

e ins

titutio

nal q

uality

ma

nage

ment

syste

m mo

nitor

ed re

gular

ly

- A

pre-

desig

ned p

erfor

manc

e che

cklis

t with

indic

ators

is av

ailab

le.

- Al

l the u

nits a

re m

onito

red a

t leas

t onc

e in t

wo m

onths

. -

Reco

rds o

n mon

itorin

g visi

ts an

d the

ir fee

dbac

ks ar

e kep

t. 18

.1.4

Patie

nt an

d emp

loyee

sa

tisfac

tion s

urve

ys

regu

larly

cond

ucted

- Si

mple

patie

nt sa

tisfac

tion f

orma

ts ar

e ava

ilable

in al

l unit

s. -

A re

gister

on th

e sim

ple pa

tient

satis

factio

n sur

vey r

esult

s is a

vaila

ble.

- De

tailed

patie

nt sa

tisfac

tion s

urve

ys ar

e con

ducte

d onc

e in t

hree

mon

ths.

- Re

ports

on th

e pati

ent s

atisfa

ction

surve

ys ar

e ava

ilable

. -

A re

gister

to re

cord

patie

nt co

mplai

nts an

d nec

essa

ry ac

tion t

aken

is av

ailab

le.

- Em

ploye

e sati

sfacti

on su

rveys

are c

ondu

cted a

t leas

t onc

e a ye

ar.

- Pa

tient/

emplo

yee s

atisfa

ction

surve

y rep

orts

are d

issem

inated

to al

l the s

ectio

n hea

ds.

Patie

nt an

d em

ploy

ee sa

tisfa

ctio

n su

rvey

form

s are

pro

vided

in “A

NNEX

9: P

atien

t and

Em

ploy

ee

Satis

fact

ion

Surv

ey F

orm

s (Sa

mpl

e)”.

18.2

Patie

nt sa

fety

prog

ramm

e 18

.2.1

A me

chan

ism to

colle

ct da

ta on

patie

nt sa

fety i

n pla

ce

- A

regis

try is

avail

able

to re

cord

accid

ents

and i

ncide

nts su

ch as

patie

nt fal

l, dru

g rea

ction

and b

lood

reac

tion.

- A

meeti

ng or

a for

um to

disc

uss a

ccide

nts an

d adv

erse

even

ts tak

es pl

ace m

onthl

y. -

A re

port

with

analy

sis of

accid

ents

and a

dver

se ev

ents

is pr

oduc

ed m

onthl

y.

36

AN

NEX

1: I

sles

for S

tatio

nerie

s

Sh

adow

dra

win

g

37

AN

NEX

2: S

tand

ardi

sed

Col

our C

odes

(Info

rmat

ion

prov

ided

by

cour

tesy

of C

astle

Stre

et H

ospi

tal f

or W

omen

)

Stan

dard

ised

Col

our C

odes

Red

:

Un-

ster

ile

Em

pty

N

egat

ive

Blu

e:

Ster

ile

Fu

ll

Posi

tive

Gre

en:

Saf

e

Qua

lity

& S

afet

y

Yello

w:

Infe

ctio

n

Bla

ck:

Gen

eral

38

AN

NEX

3: E

mer

genc

y Tr

ay C

heck

list (

Sam

ple)

Emer

genc

y Tr

ay C

heck

list (

Sam

ple)

Mo

nth…

……

…Ye

ar…

……

……

UN

IT/W

D:

No

. 1

2 3

4 5

6 7

8 9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30

31

Drug

s

Adre

nalin

e Vial

10

Atro

pine v

ial

10

Di

azep

am V

ial

02

Do

butam

ine V

ial

02

Do

pami

ne V

ial

05

Fr

usem

ide V

ial

10

GT

N Vi

al 01

Hydr

ocor

tison

e Vial

10

Isopr

enali

ne V

ial

05

KC

I Vial

02

Metoc

lopra

mide

Vial

05

Mida

zolam

Vial

02

Nor-A

dren

aline

Vial

02

Pirito

n Vial

05

Thiop

ental

Sod

ium V

ial

01

Solu

tions

Norm

al Sa

line

04

5%

Dex

trose

02

50%

/ 25%

Dex

trose

02

Voluv

en (C

olloid

/Star

ch)

02

Othe

r Sup

plies

Ambu

Bag

s 01

Air W

ays

02

An

aesth

etic M

ask

01

Si

mple

face M

ask

01

La

ryngo

scop

e 01

Laryn

gosc

ope

01

39

AN

NEX

3: E

mer

genc

y Tr

ay C

heck

list (

Sam

ple)

No

. 1

2 3

4 5

6 7

8 9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30

31

ET Tu

be (S

ize 8.

5)

02

ET

Tube

(Size

8)

02

ET

Tube

(Size

7.5)

02

ET Tu

be (S

ize G

7)

02

ET

Tube

(Size

G6.5

) 02

ET Tu

be (S

ize G

6)

02

Lig

noca

ine Je

lly Tu

be

01

Gl

oves

Size

6 06

Glov

es S

ize 6

½

05

Gl

oves

Size

7 05

Syrin

ge (5

0cc)

05

Sy

ringe

(20c

c) 05

Syrin

ge (1

0cc)

05

Sy

ringe

(05c

c) 05

Syrin

ge (0

3cc)

05

Sy

ringe

(01c

c) 05

Need

le (G

20)

10

Ne

edle

(G22

) 10

Need

le (G

23)

10

IV

Can

ula (G

17)

05

IV

Can

ula (G

18)

05

IV

Can

ula (G

20)

05

IV

Can

ula (G

22)

05

El

ectro

Gel

01

EC

G El

ectro

des

20

IV

Set

05

10

0ml B

urett

e Set

05

NG

Tube

(Size

12)

05

NG

Tube

(Size

14)

05

NG

Tube

(Size

16)

05

Le

uco P

laster

Roll

01

Elas

to Pl

aster

Roll

01

(Info

rmat

ion

prov

ided

by

cour

tesy

of

DG

H A

mpa

ra)

40

ANNEX 4: Discharge Checklist (Sample)

Discharge Checklist (Sample)

Patient’s name:

BHT number: UNIT/WD:

Yes N/A N/O Signature Patient’s Signature 01 Diagnosis card given

02 OPD chits for drugs given

03 Private drugs chits given

04 Investigation chits given

05 Biopsy chits & Biopsy report note given

06 Catheter removed

07 N.G. tube removed

08 Canula removed

09 X-ray film & E.C.G. strips given

10 Review in clinics or ward instructed

11 Medico-legal examination form (M.L.E.F) given

12 Preventive medications given

13 Patient’s satisfaction and comments about care asked

14 If Patient is below 16years of age, name & address of the guardian asked

15 Clinics book given

16 Medical certificate given

Name of N/O: Signature: Date (D/M/Y): / /

(Information provided by courtesy of DGH Ampara)

41

ANNEX 5: Cleaning Checklist (Sample)

Cleaning Checklist (Sample)

Month/Year: September 2010

Item Responsible Person Time Week I II III IV

Wheel chair Mr. Fernando Sat. 3.00pm X

Trolley Mrs. Perera Sun. 10.00am X

42

ANNEX 6: CSSD Service Flowchart

(Information provided by courtesy of Castle Street Hospital for Women)

43

AN

NEX

7: V

isua

l Con

trol

Sch

eme

for C

SSD

(In

forma

tion p

rovid

ed by

cour

tesy o

f Cas

tle S

treet

Hosp

ital fo

r Wom

en)

44

ANNEX 8: Protocol for Hazardous Waste Management

1. Sharps

All used syringes, needles and broken glassware should be collected into a ‘sharp’ bin. This should be made of leak proof and puncture proof material. If standard sharp bins are not available, an improvised ‘sharp’ bin made of thick cardboard could be used. This bin should have an opening on top, sufficient only to dispose the used syringes and needles conveniently.

After the bin is ¾ full and transport to incinerator for burning. If an incinerator is not available, burn in a drum incinerator or deep pit. The residue should be buried at sufficient depth (>1m). The pit should be preferably lined with impervious material, e.g. clay or concrete lined

2. Pathological Waste

All anatomical waste from the theatre should be collected in a yellow bag and transported to the closest crematorium for incineration. If there is a delay, store at 1-5 degrees centigrade in the mortuary. Alternatively, bury at sufficient depth (>1m) in the hospital premises in a secure place more than 100m away from any underground water source, e.g. wells.

Placenta collected from the labour room should be buried or incinerated.

Contaminated dressing, cotton swabs and drip sets should be collected in yellow bags, sealed with appropriate adhesive tape and incinerated. If an incinerator is not available, burn in a concrete lined pit. If facilities are available autoclaving and shredding can be done.

3. Effluents

Untreated effluent should be discharged through a sanitary sewerage system to a treatment plant or closed drainage system if this facility is available. There should be a dedicated sink/commode for this purpose. Health care worker should wear personal protective equipment and should avoid splashing and aerosol formation.

If there is no closed drainage system, decontaminate with an equal volume of 1% hypochlorite solution of if tuberculosis is suspected 5% Lysol solution overnight, before discharging into the drainage system.

Radio active effluents of patients on radiotherapy should be discharged into a septic tank, after radioactivity has decayed to back-ground level in a retention tank.

4. Radioactive Waste

Radio active waste is collected in appropriate containers & stored as required by the appropriate nuclear authority for time periods suitable for complete radio active decay. Thereafter, dispose as non-hazardous waste.

5. Pharmaceutical Waste

Pharmaceutical waste should not be burnt of buried. It should be returned to the Medical Supplies Division for proper disposal. If this is not possible “inertisation” techniques should be used. This is to mix pharmaceutical waste with cement & lime before burying in a concrete lined pit.

6. Chemical Waste

Large quantities of these could be returned to the supplier. If not seek advise from Central Environmental Authority. Waste with high levels of cadmium and mercury should never be incinerated.

7. Laboratory Waste

Microbiology Specimens

Microbiology specimens should be rendered non-infectious by autoclaving or incineration. If these

45

ANNEX 8: Protocol for Hazardous Waste Management

facilities are not available:

• Pus, sputum and faeces may be immersed in 5% Lysol overnight. Once they are rendered non-infectious these specimens could be disposed via the general drainage system i.e. Poured into a sink. Alternatively these specimens may be burned in an open pit followed by covering with a layer of soil.

• Blood, serum or body fluids can be poured into a sink connected to a closed drainage system or these specimens can be rendered non-infectious by immersing in 1% hypochlorite solution overnight before disposal or washing for reuse.

Untreated samples should not be poured into a sink or drain unless it drains into a closed drainage system.

Histology Specimen/Anatomical Waste

These should be disposed by incineration or by burial. Burial should be done under supervision in a deep pit.

Specimen Containers

Disposable containers should be rendered non infectious by autoclaving or incineration. Once they are safe to handle, they maybe disposed together with non-infectious waste into a common garbage dump. Reusable containers should autoclaved and washed.

Laboratory Glassware

Reusable glassware (eg. Tubes, pipettes, universal and bijou bottles) contaminated with infective material should be rendered non-infectious by autoclaving. If an autoclave is not available, they may be boiled for 20 minutes or immersed overnight in 1% hypochlorite. Once rendered non-infectious they may be washed using a brush and a detergent in order to remove all organic material.

Bacteriological Media

All used bacteriological media should be rendered non infectious by autoclaving. After autoclaving they may be disposed via the general drainage system preferably with hot water to prevent clogging of pipe lines.

If an autoclave is not available media be immersed in 5% Lysol solution overnight and then collected in yellow bags.

(Excerpts from Hospital Infection Control Manual, Sri Lanka College of Microbiologists, 2005)

46

ANNEX 9: Patient and Employee Satisfaction Survey Forms (Sample)

Patient Satisfaction Survey (OPD/Clinics) OPD

Clinics

I. About you

1. Are you Male Female

2. How old are you? -18 19-34 35-54 54-74 74+

3. Is this your first visit to this hospital?

Yes No

4. How did you select this hospital?

Recommendation from a doctor

From the previous visit

According to my knowledge

Close to house

5. How far are you living from the hospital?

1-10 kms 11-20 kms 21-30 kms 31-50 kms 50+ kms

II. How do you feel about the hospital?

Exce

llent

Very

Goo

d

Good

Fair

Poor

N/A

or D

K

6. Information given prior to arrival

7. Easiness of coming to the hospital

8. Hospital arrangement

9. Your welcome by reception

10. The registration process

III. Patients’ Care

Exce

llent

Very

Goo

d

Good

Fair

Poor

N/A

or D

K

11. The way we explained about Clinics and OPD

12. Doctors attention

47


13. Nurses’ attention on you

14. The consistency of your doctor’s care

15. The consistency of your nurse’s care

16. Support of other hospital staff

17. The way staff made you feel confident in them

18. Were you given an opportunity to ask questions?

19. Drug issuing procedure at the pharmacy

20. Did they issue the medicine according to the doctor’s prescription?

21. If you had questions to ask, did you get answers you could understand?

22. Did your consultant explain about your illness

23. Instructions you received from the doctor

IV. Time spent at OPD & Clinics

Exce

llent

Very

Goo

d

Good

Fair

Poor

N/A

or D

K 24. Time spent for registration

25. Time waited to meet the doctor

26. Time spent with the doctor

27. Time spent to get the medicine

28. Overall time you spent at the hospital

48


V. Facilities provided from the Hospital

Exce

llent

Very

Goo

d

Good

Fair

Poor

N/A

or D

K

29. Directions given to you

30. Promptness of attention on you

31. Seating facilities

32. Waiting room privacy

33. Waiting room comfort

34. Waiting room décor

35. Toilet facilities

36. Support and caring of the hospital staff

37. Overall cleanliness

38. Overall amenities

VI. Comments on Overall Quality of the Service

Exce

llent

Very

Goo

d

Good

Fair

Poor

N/A

or D

K

39. Overall rating on quality of care

40. Overall rating on quality of facilities

41. Total time spent at the hospital

42. Did you get the treatments and care as you expected?

49


43. Would you recommend the hospital to others? Yes No

If not, Comments

…………………………………………………………………..…………………………………………………

………………..……………………………………………………………………………………………………

………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………

50


Patient Satisfaction Survey (In-patients)

I. About you

1. Are you Male Female

2. How old are you? -18 19-34 35-54 54-74 74+

3. Is this your first visit to this hospital?

Yes No

4. How did you select this hospital?

Recommendation from a doctor

From the previous visit

According to my knowledge

Close to house

5. How far are you living from the hospital?

1-10 kms 11-20 kms 21-30 kms 31-50 kms 50+ kms

II. How you feel about the hospital

Ex

celle

nt

Very

Goo

d

Good

Fair

Poor

N/A

or D

K

6. Information given prior to arrival

7. Easiness of coming to the hospital

8. Hospital arrangement

9. Your welcome by reception

10. Time taken for the admission process

11. Facilities in the ward

III. Patients’ Care

Exce

llent

Very

Goo

d

Good

Fair

Poor

N/A

or D

K

12. Courtesy & consideration of staff

13. Doctors’ attention

51


14. The consistency of your doctor’s care

15. The consistency of your nursing care

16. Support from the nurses

17. Support of other hospital staff

18. Getting medicine on time in the ward

19. Were you given an opportunity to ask questions?

20. If you had questions to ask, did you get answers you could understand?

21. Did your consultant explain about your illness?

22. The way staff made you feel confident in them

23. Instructions you received from the doctor

24. The effectiveness with which we managed your pain

IV. Consultant Care

Exce

llent

Very

Goo

d

Good

Fair

Poor

N/A

or D

K 25. Special treatments you received in the ward

26. How effective was the consultant care

V. During the stay in the Hospital

Exce

llent

Very

Goo

d

Good

Fair

Poor

N/A

or D

K

27. After admitting, time taken to do the necessary treatments

28. Time spent in the ward after the treatments

52


VI. Facilities provided from the Hospital

Exce

llent

Very

Goo

d

Good

Fair

Poor

N/A

or D

K

29. Ward corridors

30. Facilities in the ward

31. Privacy in the ward

32. Comfort in the ward

33. Décor

34. Bathroom cleanliness

35. Ward cleanliness

36. Care of visitors

37. Temperature control

38. Ability to select the food you are getting

39. Food quality

40. Your overall impression of accommodation

41. Securely storing of your goods within the ward

42. Overall facilities

VII. Comments on Overall Quality of the Service

Exce

llent

Very

Goo

d

Good

Fair

Poor

N/A

or D

K

43. Overall rating on quality of care

44. Overall rating on quality of facilities

53


45. Total time spent at the hospital

46. Did you get the treatments and care as you expected

VIII. Discharge

Exce

llent

Very

Goo

d

Good

Fair

Poor

N/A

or D

K

47. Instructions for aftercare

48. Assistance for planning your departure

49. Your overall opinion of the discharge process

50. Would you recommend the hospital to others? Yes No

If not, Comments

…………………………………………………………………..…………………………………………………

………………..……………………………………………………………………………………………………

………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………

(Information provided by courtesy of DGH Ampara)

54

APPENDIX

55

APPENDIX: General Circular on National Quality Assurance Programme in Health

56


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

57


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.

58


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.

59


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

60


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


PH, DGH, BH

Divisional Hospitals & Primary Medical Care

Units

MOH Office


PDHS (Planning Unit)

Quality Management Unit RDHS

(Planning Unit)

61


62

Feedback Form

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 Organizational Development, Ministry of Health, 385 Baddegama Wimalawansa Thero Mw., Colombo 10, Sri Lanka

Documents

Quality Series No - JICA - 国際協力機構 Series No.1 National Guidelines for Improvement of Quality and Safety of Healthcare Institutions (For Line Ministry and Provincial Hospitals)