Quality Series No - JICA · Wimal Jayantha, DDG/Planning, who supervised the whole developmental...
Transcript of Quality Series No - JICA · Wimal Jayantha, DDG/Planning, who supervised the whole developmental...
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
Entrance, reception & passageways
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
Entrance, reception & passageways
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
Entrance, reception & passageways
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
Entrance, reception & passageways
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
Entrance, reception & passageways
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
Entrance, reception & passageways
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
Entrance, reception & passageways
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
Entrance, reception & passageways
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
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
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
ANNEX 9: Patient and Employee Satisfaction Survey Forms (Sample)
13. Nurses’ attention on you
14. The consistency of your doctor’s care
15. The consistency of your nurse’s care
16. Support of other 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
ANNEX 9: Patient and Employee Satisfaction Survey Forms (Sample)
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
ANNEX 9: Patient and Employee Satisfaction Survey Forms (Sample)
43. Would you recommend the hospital to others? Yes No
If not, Comments
…………………………………………………………………..…………………………………………………
………………..……………………………………………………………………………………………………
………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………
50
ANNEX 9: Patient and Employee Satisfaction Survey Forms (Sample)
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
ANNEX 9: Patient and Employee Satisfaction Survey Forms (Sample)
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
ANNEX 9: Patient and Employee Satisfaction Survey Forms (Sample)
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
ANNEX 9: Patient and Employee Satisfaction Survey Forms (Sample)
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
APPENDIX: General Circular on National Quality Assurance Programme in Health
General Circular Letter No. 01-29/ 2009 My No. HPI/ OD/ 06/ 2009. Ministry of Healthcare & Nutrition
“Suwasiripaya”, 385, Rev. Baddegama Wimalawansa Thero Mawatha, Colombo 10. 22, September 2009.
To : Addl. Secretaries All Provincial Secretaries of Health, Director General of Health Services, All Deputy Director Generals and Directors, All Provincial Directors of Health Services, All Regional Directors of Health Services, and All Heads of Health Institutions.
National Quality Assurance Programme in Health We are pleased to note that some of our hospitals and other health institutions have initiated
productivity and quality improvement programmes as per instruction given by the General
Circular No 02-109/2003 and dated 08th October 2003.
The Ministry of Healthcare and Nutrition has decided to expand the Quality Assurance
Programme to all health institutions in Sri Lanka, in order to improve the quality and safety of
health care services. It aims at establishing a continuous quality improvement process by setting up
organizational structures and mechanisms at all health care institutions.
1. Quality Secretariat (QS)
Ministry of Healthcare & Nutrition has established a Quality Secretariat (QS) to direct
management of the Quality Assurance Programme.
2. Quality Management Units (QMU)
All health institutions should establish a Quality Management Unit (QMU) to create quality
and safety culture towards improving Quality of Healthcare. This unit will undertake planning
the implementation and monitoring of the National Quality Assurance Programme with the
57
APPENDIX: General Circular on National Quality Assurance Programme in Health
guidance of the Quality Secretariat, Ministry of Healthcare & Nutrition. Please see the
Organizational Structure in annexure.
3. Roles and Functions
I. Quality Secretariat
i. To facilitate the implementation of national policies related to quality and safety.
ii. Prepare and disseminate standards, guidelines and procedures.
iii. Development of training packages in order to strengthen capacity building of staff.
iv. Coordination with relevant health and health related sectors for quality assessment and
improvement.
v. Facilitate the development of a shared learning environment and continued achievement
of best practices.
vi. Develop and implement a continuous monitoring & evaluation system.
vii. Mobilize resources for the continuous improvement of quality and safety in the health
system.
viii. To facilitate the development of the legal and regulatory framework for the
implementation of quality and safety policy.
II. Quality Management Unit (QMU)
i. Quality Management Units (QMU) will be established in National Hospital of Sri Lanka,
Teaching Hospitals, Provincial General Hospitals, District General Hospitals and Base
Hospitals and specialised hospitals.
ii. All campaigns, decentralized units and special units under the Ministry of Healthcare &
Nutrition are expected to establish Quality Management Unit.
iii. Divisional Hospitals (District Hospitals, Peripheral Units and Rural Hospitals), and
Primary Medical Care Units (Central Dispensary & Maternity Home and Central
Dispensary) are expected to conduct their Quality Management Programme under a
designated officer who will be guided by the Quality Management Unit of RDHS.
iv. All MOOH are expected to plan and implement the Quality Management Programme,
under the guidance of the Quality Management Unit of RDHS.
58
APPENDIX: General Circular on National Quality Assurance Programme in Health
v. To facilitate development of a shared learning environment and continued achievement
of best practices.
III. Functions of QMU
QMU would coordinate the quality assurance and client safety program of the healthcare institutions through following functions.
i. Promote employee participation in management of quality by establishing Work Improvement
Teams (WIT) /Quality Circles (QC) in for the different departments/units within the health
institution.
ii. Conduct training of Work Improvement Teams (WIT).
iii. Maintain a database in staff training and conduct a planned In-service Training Programme.
iv. Conduct programs and workshops on quality improvement and patient safety focussing on
problem solving approaches and measurements.
v. Initiate a quality culture in health institutions by introducing 5S concepts leading towards Total
Quality Improvement (TQI).
vi. Ensure management leadership and involvement of medical consultants in the quality
improvement process.
vii. Assist in preparing strategic plans for the institutions with focus on reduction of waiting times,
instituting a smooth patient flow, infection control and waste disposal.
viii. Implementation of standards, guidelines and protocols relevant to customer/ patient care
including clinical pathways.
ix. Maintain a computer based data system by collecting and analysing data related to quality
improvement of services (eg. Patient accidents and adverse events, near misses re-admissions,
case fatality rates, complication arising from medical and surgical procedures, referrals, adverse
events following immunization and transfers, etc).
x. Prepare and distribute half yearly / quarterly bulletins and annual performance reports with
the assistance of Medical Record Unit (MRU) and other relevant units.
xi. Promote an environment friendly healthcare institution.
xii. Conduct customer satisfaction surveys, and employee satisfaction surveys, maintain and take
corrective action for public complaints. Encourage suggestion scheme in healthcare
institutions.
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APPENDIX: General Circular on National Quality Assurance Programme in Health
xiii. Ensure quality of supplies by encouraging maintenance contract agreements for support
services in order to impalement Total Productivity Maintenance of the supplies.
xiv. Develop Annual Procurement plans for different variety of purchases.
xv. Organize and update supplier and maintenance information system and disseminate to the
relevant Units.
xvi. Facilitate assessment and improvement of performance through regular monitoring of the
programme using quality measurement indicators (Guidelines will be sent).
xvii. Assist and conduct performance reviews and maintain records of such reviews.
xviii. Promote studies, research and medical audits in the institutions.
xix. Assist Non Health Sectors to implement Productivity and Quality Assurance Programmes.
Contact Details
Quality Secretariat is located at;
Castle Street Hospital Complex, Colombo 08.
Tele: 011 2678598, 011 2678599, Fax 011 - 2695244
e- mail: Quality Secretariat" <[email protected]>. Dr. Athula Kahadaliyanage Dr. Ajith Mendis Secretary Director General of Health Service Ministry of Healthcare & Nutrition
60
APPENDIX: General Circular on National Quality Assurance Programme in Health
Annexure
Organizational Structure
Quality Secretariat Ministry of Healthcare &
Nutrition
Quality Management Unit
TH & Other Special hospitals under MoH
Quality Management Unit All Campaigns & Specialized Units
Quality Management Unit
PH, DGH, BH
Divisional Hospitals & Primary Medical Care
Units
MOH Office
Quality Management Unit
PDHS (Planning Unit)
Quality Management Unit RDHS
(Planning Unit)
61
APPENDIX: General Circular on National Quality Assurance Programme in Health
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