Allot 2 if the practice is carried out always, 1 if carried out occasionally and 0 if the practice is not adhered to usually. QC09. Majority of providers wear gloves during minor procedures (e.g. stitching, its removal, IV cannulation, blood sampling) Allot 2 if the practice is followed always, 1 if followed occasionally and 0 if the practice is not adhered to usually. Sterilization/disinfection QC10. Autoclave of surgical (OT) instruments (for FRU/RH/BPHC) Please check the autoclave and see that it is functioning. Allot 2 if the autoclave exists and is used as per direction, 1 if used but there are some gaps in its utilisation and 0 if not existing or is out of order. QC11. Log book for autoclave (for FRU/RH/BPHC) A log book should be maintained to show the date, duration, pressure reached, colour change of the monitoring strip and the signature of the person responsible of the autoclaving of instruments, linen etc. Allot 2 if the log book is maintained as per guidelines, 1 if there are some gaps are observed and 0 if the practice is not adhered to. QC12. Steam sterilizer Please check the steam steriliser and its functionality. Allot 2 if the steam sterilizer is used as per direction, 1 if used but there are some gaps in its utilisation and 0 if the guidelines are not followed at all. QC13.Alochol/chloroxynol/cresol based disinfectants for general antiseptics/disinfection. Check for availability. Allot 2 if used as per direction, 1 if used but there are some gaps in its utilisation and 0 if the guidelines are not followed at all. QC14. Povidone iodine liquid for high level disinfection during procedures Check for availability of povidone iodine. Allot 2 if used as per direction, 1 if used but there are some gaps in its utilisation and 0 if the guidelines are not followed at all. QC15. Phenolic disinfectant (Phenyl)/Sodium hypochlorite (Bleach) or wet mopping Check for availability. Allot 2 if used as per direction, 1 if used but there are some gaps in its utilisation and 0 if the guidelines are not followed at all. QC16 Bleaching power for disinfection of facility and surrounding. Check for availability. Allot 2 if bleaching powder is used for disinfecting the facility and its surrounding, 1 if the disinfection is not done satisfactorily and 0 if not done at all. Waste segregation at source QC17. Staff awareness regarding waste segregation at source guidelines All the providers should be oriented on segregation of the bio-medical waste generated in the facility. Coloured bins and bags should be provided to enable the providers segregate the waste generated. Allot 2 if the staffs are aware of the guidelines and are segregating the bio-medical waste correctly, 1 if the knowledge is inadequate however there is an effort to segregate the bio-medical waste and 0 if the procedure is neither known nor practiced. QC18. Colour coded bags/bins are placed at appropriate locations.
Transcript
Allot 2 if the practice is carried out always, 1 if carried out occasionally and 0 if the practice is not adhered to usually.
QC09. Majority of providers wear gloves during minor procedures (e.g. stitching, its removal, IV cannulation, blood sampling)Allot 2 if the practice is followed always, 1 if followed occasionally and 0 if the practice is not adhered to usually.
Sterilization/disinfectionQC10. Autoclave of surgical (OT) instruments (for FRU/RH/BPHC)Please check the autoclave and see that it is functioning. Allot 2 if the autoclave exists and is used as per direction, 1 if used but there are some gaps in its utilisation and 0 if not existing or is out of order.
QC11. Log book for autoclave (for FRU/RH/BPHC)A log book should be maintained to show the date, duration, pressure reached, colour change of the monitoring strip and the signature of the person responsible of the autoclaving of instruments, linen etc.Allot 2 if the log book is maintained as per guidelines, 1 if there are some gaps are observed and 0 if the practice is not adhered to.
QC12. Steam sterilizerPlease check the steam steriliser and its functionality.Allot 2 if the steam sterilizer is used as per direction, 1 if used but there are some gaps in its utilisation and 0 if the guidelines are not followed at all.
QC13.Alochol/chloroxynol/cresol based disinfectants for general antiseptics/disinfection.Check for availability. Allot 2 if used as per direction, 1 if used but there are some gaps in its utilisation and 0 if the guidelines are not followed at all.
QC14. Povidone iodine liquid for high level disinfection during proceduresCheck for availability of povidone iodine. Allot 2 if used as per direction, 1 if used but there are some gaps in its utilisation and 0 if the guidelines are not followed at all.
QC15. Phenolic disinfectant (Phenyl)/Sodium hypochlorite (Bleach) or wet moppingCheck for availability. Allot 2 if used as per direction, 1 if used but there are some gaps in its utilisation and 0 if the guidelines are not followed at all.
QC16 Bleaching power for disinfection of facility and surrounding.Check for availability.Allot 2 if bleaching powder is used for disinfecting the facility and its surrounding, 1 if the disinfection is not done satisfactorily and 0 if not done at all.
Waste segregation at source
QC17. Staff awareness regarding waste segregation at source guidelinesAll the providers should be oriented on segregation of the bio-medical waste generated in the facility. Coloured bins and bags should be provided to enable the providers segregate the waste generated.Allot 2 if the staffs are aware of the guidelines and are segregating the bio-medical waste correctly, 1 if the knowledge is inadequate however there is an effort to segregate the bio-medical waste and 0 if the procedure is neither known nor practiced.
QC18. Colour coded bags/bins are placed at appropriate locations.
Allot 2 if colour coded bags and bins are placed as per guidelines, 1 if there is effort to do the same but there are gaps and 0 if no colour coded bins and bags are not supplied.
QC19. Hub-cutters for destroying needle-syringe at appropriate locationsNeedle/hub cutter should be used to cut/separate the needle from the syringe by cutting the hub/adopter of the syringe. The syringe is rendered unusable after this process. The cut needle is kept in a puncture proof box for disposal. The syringe is kept in the blue bag for autoclaving and recycling.Allot 2 if the hub cutters are placed at appropriate locations and used as per guidelines, 1 if there is effort to do the same but there are gaps and 0 if no effort has been made towards this.
QC20. Puncture proof containers for disposal of sharps at appropriate locations.Puncture proof boxes are supplied under the BMWM scheme. If not supplied, puncture proof boxes can be made from empty card board boxes in which medicines come packed.Allot 2 if the puncture proof containers are supplied/prepared and placed at appropriate locations and used as per guidelines, 1 if there is an effort to do the same but there are gaps and 0 if no effort has been made towards this.
Pollution clearanceQC21. Valid clearance certificate from pollution control board.The in-charge of the facility is the producer of the BMW and is responsible for its proper disposal. He must obtain permission to handle and dispose of from the State Pollution Control Board (PCB). Necessary guidelines are issued by the Department. Please go through the Chapter on BMWM in the STG for details.Allot 2 if steps have been taken and the certificate has been obtained from the state PCB, 1 if steps have been initiated but the certificate is yet to be received 0 if no effort has been made to obtain the certificate.
Form D-Equipment, drugs and other supplies
To be looked for in Emergency Room /OT/Labour Room/post-operative room/pharmacy and other work station. The purpose of questions in this section is to know the availability of equipment and supplies, whether they are in working condition and whether they are in use. In the routinely provided RCH kits most of the essential equipment has been supplied. However, it is important to find out if specific instruments are available and drugs/consumables are in adequate supply. The monitors/assessors will check and confirm the availability and condition of the equipment and instruments. The emphasis is on functionality of the whole unit in conformity with set standards–for example, in order to take blood pressure of a pregnant woman it is essential to have a BP apparatus and stethoscope, both in working order. Equipment
Check the equipment from Sl.No. QD10 to QD18 for their availability, working status and use. Allot 2 if the equipment are in working condition, well maintained and are in use, allot 1 if the equipment are available but not maintained well and 0 if either they are not available or are out or order due to poor maintenance.
QD01. BP apparatus and stethoscope
QD02. Weighing scales for adults
QD03. Weighing scales for infants
QD04. IV stands and drip sets
QD05. Working oxygen cylinders with accessories (gauge, humidifier, wrench, tubing)
QD06. Working sucker machine. At least 3 (one each for OT, Delivery room, Observation room) at least 1
for PHC2
QD07. Emergency injection tray. Please see annexure for contents (Annexure 6).
QD08. Dressing and bandaging set up
QD09. Suturing tray (with sterile needles, needle holder, scissors, forceps and sutures). Please see
annexure for details on “Suturing kit”-Annexyre-12
QD10. Delivery kit for facility where delivery is conducted. Please see annexure on the contents of “Delivery
kit”-Annexure-5.
QD11. Baby (neonatal) resuscitation kit. Please see annexure on “Neonatal resuscitation kit” for details-
Annexure-7.
QD12. Baby warmer for facility conducting delivery
QD13. At least two bed side screens. (At least one for PHC)
QD14. Mercury containment kit to contain mercury spillage. Please see annexure on “Mercury containment
kit” for details.-Annexure-8.
QD15. Nebulizer (compressed air type) with Salbutamol nebulizing solution.
QD16. Glucometer with adequate number glucometer strips
QD17. Microscope with binocular lamp attachment and oil-immersion lens (for facility offering sputum
microscopy).
QD18. Haemoglobinometer
Devices and supplies
The purpose of questions in this section is to know the availability of equipment and supplies, whether they are in working condition and whether they are in use The monitoring officers/assessors will check and confirm the availability and condition of the equipment and instruments. If the quantity is adequate allot 2, allot 1 if the quantity is inadequate and 0, if item is not available. The supplies are mentioned in serial number from QD19 to QD 30.
QD19. Surgical glove at least 2 sizes (sterile).Specify sizes available.
QD20. Surgical glove at least 2 sizes (sterilisable).Specify sizes available.
QD21. Disposable syringe-needle at lease 5ml and 2ml capacity. At least 50 pieces should be available.
QD22. At least 2 sets of other personal protection items (caps, mask, apron)
QD23. Surgical attire (gown and trouser set) for facility with OT
QD24. OT slippers (for facilities with OT)
QD25. Items for wet mopping of floors (bucket, mop, mug).
QD26. Utility glove and gum boots for waste disposal.
QD27. Condoms
QD28. Pregnancy test cards.
QD29. Urine test strips for glucose (for RH, BPHC)
QD30. Kit for ABO grouping and cross matching (for RH)
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Drugs:Drugs are enlisted under serial number QD31 to QD72. Allot 1 if the drugs under consideration are available for at least 20 patients. Do not stock check main stock but the drugs that are being dispensed/available at providers’ end. If availability is less than the quantity desired, allot “0”.
Form - E: OUTPUT INDICATORS FOR QUALITY ASSESSMENT
Instructions: To assess this section, review records and calculate the data as required in the questions. Also write the total number of the information data required for the corresponding period in the last year. Compare the current data with that of the last year for the corresponding three months by subtracting last year’s data from the current data. Also calculate the required percentage change of utilization of services and the score percentage of change, as indicated. The formula to calculate the two percentages is given in the respective columns.
QE. 01 Total number of OPD patients (new and old) seen during the last three months
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Check the OPD register and write the total number of the patients who were treated in the last three months in column ‘1’. Check the OPD register for the last year for the same/corresponding three months and write the number of OPD cases treated during that period in column ’2’. Note the difference in the two numbers as per the formula given in column ‘3’. Calculate the percent change as per the formula and write in column ‘4’. Finally write the score % as per the formula provided in column ‘5’.The same formula is used for all other areas/items mentioned under serial no.QE02 to QE05.
QE02.Total number of indoor cases treated (Not applicable for non-bedded PHCs) QE.03 Total numbers of deliveries conducted. (Not applicable for non-bedded PHCs)
QE04.Total number of AFB smear examined. (Not applicable for centres without microscopy facilities.) QE05.Total number of low birth weight babies who stayed 24 hours for observationLow birth babies tend to die easily during the neonatal period especially within the first week after birth. Hence they require special attention and care at the institution to be safe. FRU/RH/BPHC/ PHC are provided with the equipment and training to MOs to take care of low birth weight babies. The measure of number of such babies being cared for indicates the level of specialised newborn and infant care being provided at the facility. Complete the rest of the information by comparing with the previous year’s records.
Form E- Out put indicators for service quality assessment
Parameters to assess change in service provision:
1
No. of clients served duringLast 3 moths:B
2
No served during corresponding period last year: B
Guidelines on filling up of the forms in the Revised Operational Manual
There are 10 forms from A to J as follows that are used for the facility assessment and follow up actions at the facility, district and state level.Form A: Providers’ Availability and PracticesForm B: InfrastructureFrom C: Infection Prevention PracticesForm D: Equipment drugs and other suppliesForm E: Output indicators for service quality assessmentForm F: Assessment Results of three consecutive visitsForm G. Action plan prepared at facility level at the end of the facility visitForm H: Actions to be taken at facility level (Consolidated) prepared by DNOForm I: Actions to be taken at district level (DNO)Form: J: Actions to be taken at state level (Prepared by SNO)
The visits are pre announced. However, the district administrators may decide to carry out surprise visits as per need. Efforts should be made to visit each facility at lease once in two months. On reaching the facility the assessor or the team leader meets the in-charge and tells him about the assistance he/she will require for the assessment. On completion of the assessment i.e. filling up of the forms from A to E the assessor fills up Form F which helps him to compare the result of the present visit with previous visits. This is not applicable for the first visit. He fills up the Form G: Action plan prepared at facility level at the end of the facility visit in consultation with the facility head and his colleagues.This report is jointly signed by the assessor/monitoring officer/leader of the team and the facility in-charge. The facility head initiates corrective activities at the facility level soon after the visit.. The assessor/monitoring officer /team leader hands over copies of the filled up Forms A to G to the District Nodal Officer (DNO). The DNO prepares a consolidated report of all the Forms Gs in Form H i.e. actions to be taken at facility level (Consolidated).This report is shared with all the facility heads during the MIES meeting for review/discussion. The district nodal officer will prepare a District Action Plan in Form I from the facility level action plans and will take remedial measures as required. The state nodal officer will prepare a consolidated State Action Plan from the reports he receives from the district in Form J. and will take remedial actions as per need.
Further, all data in forms A to G, as generated during the facility visits, will be entered at the district level and transmitted electronically to the state level. This process has been introduced during the pilot and will continue.
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DEPARTMENT OF HEALTH & FAMILY WELFAREGOVERNMENT OF WEST BENGAL
STANDARD TREATMENT GUIDELINES IMPLEMENTATION MONITORING
Facility identifiers:-
Name of the Health Facility …………………………………………….…….. PHC / BPHC / RH / FRU
Postal Address ……………………………………………………………………….……………………….……
Block ………………………………… District …………………………………... Pin code ………………
Distance from district headquarters (Km) ……………………………………………………………
Respondents (Facility staff):-
Sl.no. Name Designation
1. …………………………………………… ………………………………………..
2. …………………………………………… ………………………………………..
3. …………………………………………… ………………………………………..
4. …………………………………………… ………………………………………..
5. …………………………………………… ………………………………………..
Monitoring team members:-
Sl.no. Name Designation
1. ………………………………………… ………………………………………..
2. ………………………………………… ………………………………………..
3. ………………………………………… ………………………………………..
Other information:-
Date of assessment ……………………….. Date of last monitoring visit ………………………..
Monitoring started at ………..……. Monitoring concluded at ……..…..……Duration ……..…..……
Signature of the Team Leader: _________________________________________________
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FORM A – PROVIDERS’ AVAILABILITY AND PRACTICES
Q. No. Medical, paramedical and support staff availability Performing adequately
Not performing adequately
Not available
QA01 Medical Officer trained in use of STG – at least one 2 0QA02 Pediatrician / Medical Officer trained in RCH / IMNCI – at least one 2 0QA03 Medical Officer trained in BEmOC or CEmOC – at least one 2 0QA04 Medical Officer trained in MTP services – at least one 2 0
QA05 Medical Officer included in the district list of doctors empanelled for conducting sterilization procedures – at least one 2 0
QA06 Medical Officer trained in RNTCP – at least one
QA07 Medical Officer available round the clock – at least one [for RH, BPHC, 24X7 PHC] 2 0
QA08 Surgeon / Medical Officer offering male or female sterilization services – at least one [for RH, BPHC] 2 1 0
QA09 Surgeon / Medical Officer capable of Caesarian section – at least one [for FRU] 2 1 0
QA10 Anesthetist / Medical Officer capable of undertaking general anesthesia – at least one [for FRU] 2 1 0
QA11 Dentist/dental surgeon – at least one [for RH] 2 1 0QA12 Ophthalmologist / Ophthalmic Assistant – at least one [for RH, BPHC] 2 1 0
QA13 Nursing staff (GNM / ANM) – at least 80% of sanctioned strength * 24 X 72
OPD hours1 0
QA14 Nursing staff with HIV/AIDS training – at least one 2 1 0QA15 Pharmacist to look after medical stores and run dispensing services 2 1 0QA16 Lab technician trained in sputum microscopy 2 1 0QA17 Lab technician trained in basic blood, urine and stool tests 2 1 0
QA18 Lab technician trained in blood grouping and blood storage procedures [for FRU] 2 1 0
QA19 Technician trained in ECG – at least one [for RH, BPHC] 2 1 0QA20 Technician trained in basic X-ray techniques – at least one [for RH, BPHC] 2 1 0
QA21 Office staff capable of computerized data management – at least one [for RH, BPHC] 2 1 0
QA22 Group D staff – at least 80% of sanctioned strength 2 1 0
Activities performed ** Yes Partly No
QA23 OPD run by one or more medical officers on _____ in a week All 6 days2
4-5 days1
< 4 days0
QA24 Medical Officer / Staff nurse / HA (F) undertaking STI screening with per speculum examination 2 1 0
QA25 Pharmacist maintaining stock ledgers and undertaking stock checks 2 1 0QA26 Dispenser explaining use of medicines to clients 2 1 0QA27 Copy of Standard Treatment Guidelines available at working station 2 0QA28 New OPD / Emergency ticket being used 2 0QA29 Referral register is being maintained 2 0QA30 Normal delivery is being conducted 2 0QA31 Low birth weight babies are being kept 24 hours for observation 2 0QA32 Partograph is being used [for facility where delivery is conducted] 2 1 0QA33 Facility offering access to condoms 2 1 0QA34 Facility offering immunization services 2 1 0
Prescription quality ** Yes Partly NoQA35 Patient identification particulars being noted 2 1 0QA36 Stamp on prescriber’s name being used 2 1 0QA37 Chief complaints with duration noted 2 1 0QA38 Diagnosis / Provisional diagnosis / Injury noted 2 1 0QA39 Investigations, if applicable, being advised 2 1 0QA40 Medicines are being prescribed as per STG (from essential medicines list) 2 1 0QA41 Prescriber can justify use of medicines outside essential medicines list 2 1 0QA42 Generic drug names being used 2 1 0QA43 Dosing regimens specified are complete 2 1 0QA44 Non-standard abbreviations are being avoided 2 1 0QA45 Prescriptions are legible 2 1 0
Score Obtain = Total Score = Percentage =
* Ask for category-wise list of sanctioned posts and vacancies.
** To be judged on basis of performance in last 2-3 months.
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FORM B – INFRASTRUCTURE
Q.No. General cleanliness of facility Yes Partly NoQB01 Surroundings are clean with no spread of hospital (biomedical) waste 2 1 0QB02 No spreading also of kitchen and general waste 2 1 0QB03 Drains are not blocked and there is no water logging 2 1 0QB04 Floors and walls are clean 2 1 0QB05 No seepage affecting walls and ceilings 2 1 0QB06 No dust over window panes and sills, desks, trolleys, etc. 2 1 0
QB07 Clean dustbins are provided in corridors, patient waiting areas, OPD rooms and other rooms 2 1 0
QB08 No dust in OT (including over OT lamps) [Not applicable for PHC] 2 1 0
Amenities and privacy for clients Yes Partly NoQB09 Waiting area is covered / shaded with adequate chairs / benches 2 1 0
QB10 Functional piped water supply / tubewell / other potable water source on the premises 2 1 0
QB11 Dedicated drinking water facility for clients 2 1 0
QB12 At least one separate toilet for use by female patientsWith running
water2
Without running water
10
QB13 All occupied beds have clean mattresses and bedsheets [Not applicable for non-bedded PHC] 2 1 0
QB14 Kitchen arrangements for serving meals to admitted patients [Not applicable for PHC] 2 1 0
QB15 OPD / Examination room has curtains on doors and windows 2 1 0
QB16 OPD / Examination room has examination table / couch in separate cubicle / screened off area 2 1 0
QB17 Labor / Delivery room has curtains on doors and windows [Not applicable for non-bedded PHC] 2 1 0
Services and facilities Equipped & performing
Equipped only No
QB18 At least one observation bed with oxygen cylinder and sucker machineAll 3 items
2Bed ± 1 item
1 0QB19 Trolley / Stretcher for transporting critically ill / injured patient 2 1 0QB20 Facility for sterilization operations [Not applicable for non-bedded PHC] * 2 1 0QB21 Facility for vaginal deliveries [Not applicable for non-bedded PHC] * 2 1 0QB22 Facility for Caesarean sections [Not applicable for BPHC, PHC] * 2 1 0QB23 Refrigerator for storing heat labile drugs and vaccines 2 1 0
QB24 Functional inverter / generator (with adequate fuel-oil-lubricants) / solar powered system as back-up power source 2 1 0
QB25 Functional vehicle with driver / outsourced ambulance arrangement for transferring critically ill patients to another center [not applicable for PHC] 2 1 0
QB26 Sputum microscopy services following RNTCP guidelines 2 1 0
QB27 Basic laboratory services or outsourced arrangement (PPP) for same [Not applicable for PHC] 2 1 0
QB28 Separate ophthalmology services [Not applicable for PHC] 2 1 0QB29 Separate dental services [Not applicable for BPHC, PHC] 2 1 0
Information, education and communication facilities Yes Partly NoQB30 Citizen’s charter in a prominent place in local language indicating services 2 1 0QB31 Signage in local language indicating various service stations 2 1 0QB32 Complaint / Suggestion box in a prominent place 2 1 0QB33 Clear protocol for handling complaints / suggestions 2 1 0QB34 Official 24 X 7 phone
Fully functional2
Not functional1 0
Staff quarters Existing and utilized
Existing but not utilized Not existing
QB35 Adequately maintained quarters for at least one medical officer 3 1 0QB36 Adequately maintained quarters for at least one staff nurse 3 1 0QB37 Adequately maintained quarters for at least 1 GDA and 1 Sweeper 3 1 0
Score Obtain = Total Score = Percentage =
* Equipped denotes availability of separate room, all necessary instruments and trained manpower.
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FORM C – INFECTION PREVENTION PRACTICES
Q. No. Immunization *All / Majority
*Some *Few / None
QC01 Key providers vaccinated against Tetanus 2 1 0
QC02 Key providers vaccinated against Hepatitis B 2 1 0
Handwashing Followed in practice
Only Knowledge / Equipment
availableNo
QC03 Washing hands (following 6 steps of hand washing) by any healthcare provider 2 1 0
QC04 Liquid soap / Disinfectant used for handwashing 2 1 0
QC05 Disposable napkins / regularly cleaned towels used for drying hands after washing 2 1 0
Gloves use Always Sometimes Usually no
QC06 Majority of providers wear gloves during genital examination 2 1 0
QC07 Majority of providers wear gloves during dressing / bandaging 2 1 0
QC08 Majority of providers wear gloves during suturing 2 1 0
QC09 Majority of providers wear gloves during minor procedures (e.g. stitch removal, IV cannulation, blood sampling) 2 1 0
QC18 Color coded bags / bins for waste disposal at appropriate locations 2 1 0
QC19 Hub cutters for destroying used needle-syringe at appropriate locations 2 1 0
QC20 Puncture proof container for disposal of sharps at appropriate locations 2 1 0
Pollution clearance Available In process No
QC21 Valid clearance certificate from pollution control board 2 1 0 Score Obtain = Total Score = Percentage =
*Could be quantified as follows: All/Majority-60-100% Some-59-10% Few or nobe-0-9%
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FORM D – EQUIPMENT, DRUGS & OTHER SUPPLIES
Q.No. Equipment Well maintained
Partly maintained
Not existing
QD01 BP apparatus and stethoscope 2 1 0QD02 Weighing scale for adults 2 1 0QD03 Weighing scale for infants 2 1 0QD04 IV stand and Drip sets 2 1 0QD05 Working O2 cylinder with accessories (gauge, humidifier, wrench, tubing) 2 1 0
QD06 Working sucker machines – At least 3 (OT, Delivery room, Observation room) [At least 1 for PHC] 2 1 0
QD07 Emergency injection tray 2 1 0QD08 Dressing and bandaging set-up 2 1 0QD09 Suturing tray (with sterile needles, needle holder, scissors, forceps and sutures) 2 1 0QD10 Delivery kit [for facility where delivery is conducted] 2 1 0QD11 Baby (neonatal) resuscitation kit 2 1 0QD12 Baby warmer [for facility where delivery is conducted] 2 1 0QD13 At least 2 bed side screens [At least 1 for PHC] 2 1 0QD14 Mercury containment kit for handling mercury spillage 2 1 0QD15 Nebulizer (compressed air type) with Salbutamol nebulizing solution 2 1 0QD16 Glucometer with adequate number of glucometer strips 2 1 0
QD17 Microscope (binocular, with lamp attachment and oil-immersion lens) [for facility offering sputum microscopy] 2 1 0
QD18 Hemoglobinometer 2 1 0
Devices and supplies Quantity adequate
Quantity inadequate
Not available
QD19 Surgical gloves of at least 2 sizes [sterile] Specify sizes available: 2 1 0QD20 Surgical gloves of at least 2 sizes [sterilizable] Specify sizes available: 2 1 0QD21 Disposable syringe-needle of at least 5 mL and 2 mL capacity 2 1 0QD22 At least 2 sets of other personal protection items (cap, mask, apron) 2 1 0QD23 Surgical attire (gown and trouser set) [for facility with OT] 2 1 0QD24 OT slippers [for facility with OT] 2 1 0QD25 Items for wet mopping of floors (buckets, mugs, mops) 2 1 0QD26 Utility gloves and gum boots for waste disposal 2 1 0QD27 Condoms 2 1 0QD28 Pregnancy test cards / strips 2 1 0QD29 Urine test strip for glucose [for RH, BPHC] 2 1 0QD30 Kit for ABO grouping and Cross-matching [for FRU] 2 1 0
FORM E – Output indicators for service quality assessment
Q.No.Parameters to assess change in service provision from the facility
No. of clients served during
last three months [A]
No. of clients served in
corresponding three months period of past
year [B]
Specify months Specify months
Change in no. of clients[A – B]
Percent Change in
no. of clients
( [A – B] / B X 100 )
Score
> +15% → 35 - 15% → 2
Less than 5% → 1No change or negative
→ 0
QE01 Total number of OPD patients (new, old, emergency) treated
QE02Total number of Indoor cases treated [Not applicable for non-bedded PHCs]
QE03Total number of deliveries conducted [Not applicable for non-bedded PHCs]
QE04Total number of AFB smears examined [Not applicable for centers without microscopy facility]
QE05Total number of low birth weight babies who stayed 24 hours for observation
Score Obtain =
Total Score =
Percentage =
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FORM F-STG MONITORING ASSESSMENT RESULTS
Name of the Health Facility …………………………………………….…….. PHC / BPHC / RH / FRU
Block ……………………………………. District ……………………... Date ………………
Scoring during three successive assessments
Component Indicators Total Points
Visit 1 Visit 2 Visit 3Score % Score % Score %
A. Providers’ availability and practices
QA 01 – 46
B. Infrastructure QB 01 – 37
C. Infection prevention practices
QC 01 – 21
D. Equipment, drugs & other supplies
QD 01 – 72
E. Output indicators for service quality assessment
QE 01 – 05
TOTAL
FACILITY GRADE
State score in the form N / D, where N is the score obtained out of the maximum possible score D.Facility gradation is as follows: A = above 75% B = 50 – 75% C = 25 – 50% D = Less than 25%
Signature of Medical Officer I/C ________________________________________________
Signature of Team leader ________________________________________________
14
Name and Signature of team leader: ________________________________________ Signature of MO I/C ___________________________________________
FORM-G FRU/RH/BPHC/PHC Quality Assessment ResultsFindings, Interpretation and Areas of Improvement - Action Plan
To be prepare at the end of the Facility visit
Name of facility: District: State: Date:S.
No. Element Sub Element
Problems SolutionAction Needed at: Due Date by when action
will be takenPerson responsible for action
Facility level
District Level
State Level
Facility Level
District Level
State Level
Primaryresponsibility
Secondaryresponsibility
Facility Level
District Level
StateLevel
Facility Level
District Level
State Level
1
2
3
4
Gen
eral
Fac
ility
Rea
dine
ss
A. Providers Availability & Practices
B. Infrastructure
C. Infection Prevention Practices
D. Availability of Equipment and supplies
5
E: Out put
indicators for
service quality
E. Out put Indicators
FORM-H: QA Summary Report of FRU/RH/BPHC/PHC Prepared by District Nodal OfficerBased on ALL Visits Made in the Month of --------------------Year----------------------------
Number of CHC/PHCs visited ----------------------------------------- Actions to be taken at Facility level
Form A:
Providers Availability & practices
Form B:
Infrastructure
Form C:
InfectionPrevention Practices
Form D :
Equipment & Supplies
Form E:
Output indicators
Recommended for All/Several FRU/RH/BPHC/
PHC
Recommended for facility (specify)
1. _______________________
2. _______________________
3. _______________________
4. _______________________
5. _______________________
6. _______________________
Signature of the State/District Nodal Officer __________________________________________Signature of CMOH _____________________________________________________________Note: This report is to be consolidated from Facility visit reports (Form-G) at District level by the DNO. Facilities to be informed in the MIES meeting for follow-up.
FORM- I: QA Summary Report of FRU/RH/BPHC/PHC Prepared by District Nodal OfficerBased on ALL Visits Made in the Month of --------------------Year----------------------------
16
Number of CHC/PHCs visited ----------------------------------------- Actions to be taken at District level
Form A:
Providers Availability & practices
Form B:
Infrastructure
Form C:
InfectionPrevention Practices
Form D :
Equipment & Supplies
Form E:
Output indicators
Recommended for All/Several FRU/RH/BPHC/PHC
Recommended for facility (specify)
1. _______________________
2. _______________________
3. _______________________
4. _______________________
5. _______________________
6. _______________________
Signature of the State/District Nodal Officer __________________________________________Signature of CMOH _____________________________________________________________
Note: This report to be prepared from the facility visit reports (Form-G) at District level by the DNO. Actions to be taken at District level.
FORM-J: QA Summary Report of FRU/RH/BPHC/PHC Prepared by State Nodal OfficerBased on ALL Visits Made in the Month of --------------------Year----------------------------
Number of CHC/PHCs visited ----------------------------------------- Actions to be taken at State level
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Form A:
Providers Availability & practices
Form B:
Infrastructure
Form C:
InfectionPrevention Practices
Form D :
Equipment & Supplies
Form E:
Output indicators
Recommended for All/Several FRU/RH/BPHC/PHC
Recommended for facility (specify)
1. _______________________
2. _______________________
3. _______________________
4. _______________________
5. _______________________
6. _______________________ Signature of the State Nodal Officer __________________________________________Note: This report is to be prepared from the facility visit reports (Form-G) by the SNO. He/She will enlist the activities to be taken up at the State level.
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Exit Interview for assessing client satisfaction with services
The Department of Health & Family Welfare, Government of West Bengal, is trying to standardize treatment offered in primary care by implementing Standard Treatment Guidelines (STG) that has been developed for this purpose. In addition the government is trying to improve the access to and quality of healthcare services. This programme has been piloted in North and South 24 Parganas district and has now been extended to this district. We have been appointed as monitors to oversee implementation of the STG Programme by visiting various primary health care facilities in this district.
Please help us in this endeavor by giving a few minutes to respond to the brief series of questions that we will ask. We will record these responses, and your age and sex but, in order to keep the responses confidential, will not record your name. Do not hesitate to give your frank comments and suggestions. Your inputs will ultimately help the system to rectify shortcomings and improve the quality of services that you and other patients will receive in future.
Name of the Health Facility ……………………………….……………………….…….. PHC / BPHC / RH / FRU
Age of the respondent …………. y Gender of the respondent ………… Date of interview …………………….
1. How far is this facility from your home Nearby
Some distance
Quite far
2. What is your opinion regarding the waiting time for services that you availed today
Did not have to wait
Usual waiting time
Waited too long
3. Did you face problems in getting the following services todaya) Registrationb) Consultation with doctor / nurse Did not availc) Obtaining medicines Did not availd) Obtaining laboratory services Did not avail
Not at all
To some extent
Definitely
4. How would you rate the overall quality of services received todaya) Registrationb) Consultation with doctor / nurse Did not availc) Medicine dispensing Did not availd) Laboratory services Did not avail
Very good
Satisfactory
Poor
5. How would you rate the behavior of the following staffa) Doctor Did not meetb) Nurse Did not meetc) Pharmacist Did not meetd) Laboratory technician Did not meet
Very good
Satisfactory
Poor
6. Was privacy maintained satisfactorily during your examination
Yes
No
Not relevant
7. How would you rate the overall cleanliness of this facility Undoubtedly clean
Acceptable
Dirty
8. Would you recommend to others to come here for primary care
Yes, always
Only if there is no alternative
Never
9. In your opinion, apart from the comments you have expressed so far, which other aspects do you think that need to be addressed in order to improve service from this facility.
Name and signature of the Interviewer / Monitor __________________________________________
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Good Prescription Writing, Guidelines on and Auditing of Prescriptions
Dr. Anjan Adhikari, Assistant Professor, Department of Pharmacology, R G Kar Medical College, Kolkata.
Good Prescription Writing Prescription is the physician’s written order to pharmacist for preparing and dispensing medicines and also direction to the patient for the proper use of medicines. Writing a good prescription is not only a good scientific practice but also involves arts of medical science. Good prescription is the first step for rational drug use. Rational drug use indicates right drug for the right patient in right dose at right time and at right cost. Good prescription or rational prescription or right prescription is one of the preconditions for use of right medicines by the society.
Once a patient with clinical problems has been evaluated and a diagnosis is reached, the physician can select any one of the variety of therapeutic approaches. Medication, surgery, radiation, physical therapy, health education, counseling, further consultation and no therapy are some of the options available. Of these options, drug therapy is by far the one most commonly chosen. Usually prescriptions of medications are the results of 67% cases of physician patient contact.
Prescription is an outcome of the interaction between the doctor and the patient. Writing a prescription rationally & correctly is the prime responsibility of any physician. It carries more importance in countries like ours where superstition and ignorance is still persisting in the society. Good prescription plays crucial role in dissemination of rational and scientific knowledge throughout in the society. A prescription should cover all the relevant information about patient, disease & medicine advised. In recent times, the trend has been to prescribe the medicines that are produced in mass and packaged in convenient formulations under brand names. Now the practice of writing complex prescription orders containing many active ingredients, adjutants, correctives and vehicle has been abandoned in favour of single drug compounded by pharmaceutical companies. The prescription in this case refers to the physician’s written order to the pharmacist or chemist for dispensing a medicine.
The followings important points should be remembered during prescription writing. These are –
● A prescription is an important medico-legal document.
● A prescription should be clear, legibly written in ink in English with good handwriting or computer printed. Local vernaculars can also be used for better understanding of the patients.
● Abbreviations of all type should be avoided as much as possible.
● A prescription must have a date. Date serves multiple purposes like legal aspect, maximum number & time of refilling, patient compliance etc.
● A prescription should contain prescriber details including the name, address and contact phone number. It serves proper identification of the physician and the doctor can be contacted if any clarification is needed, for unavailability of the prescribed branded drugs, for adverse drug reaction and emergency.
● Information regarding the patient should be complete. It should contain name, age, sex, address, body weight and body surface area if needed.
● Name of the drugs should be written correctly and clearly & in capital letter if possible. Use of Generic names should be preferred.
● Use leading zeros (0.125mg not .125mg) are always preferred, but never use trailing zeros (5mg not 5.0 mg).
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● Dosage form, Strength, Units, Dose, Duration and Route, Timing of drugs with meals should be clearly mentioned. The dose and duration of the therapy should be specified. This information must be ventilated to the patient or the relatives.
● If there is more than one dosage form by different routes in a prescription, the order should be as follows – ►Injections, followed by ►Oral preparations in this order – Capsules, Tablets, Liquids and finally ►Topical preparations
● If there is any special instruction for the pharmacist or chemist, it should be written clearly.
● The prescription should be explained to the patient or the relatives.
● All prescriptions must be signed by the competent authority, i.e., physician or registered medical practitioner. Registration number if required must be written.
Poor prescribing habits can lead to ineffective and unsafe treatment, exacerbation or prolongation of illness, distress and harm to the patient and higher costs of therapy. It may be a source of medication error.
In this modern era of scientific explosion, it is the right of common people to get right and appropriate information about health. It will be very difficult if the doctors are not able to prescribe good, rational, scientific, cost effective prescription, if the pharmacists & chemists are not able to follow the prescription and to ventilate the necessary information to the users and if the patients are not realizing the importance of rational use of medicines.
Guidelines on Prescription writing :-Doctors are requested to follow the following guidelines suggested by STG.
(1). There must be a standard format or proforma for both Out Patient Door (OPD) and Indoor/Emergency. STG developed a format for OPD/Emergency. This standard format is already used by different health facilities of North & South 24 parganas district. The physicians are requested to use this format while prescribing in OPD/Emergency. A copy of this format is given in this book (Annexure-3).
(2). Identity of the health facility must be clear.
(3). Identity of the patient must be clear.
(4). Identity of the prescriber/doctor must be clear.
(5). Prescription may be in hand written/typed/computer printed.
(6). It should be in easy language, preferably in local, in clear terms.
(7). It must be legible, if hand written.
(8). Date must be mentioned in every prescription and in each encounter.
(9). Signature in each encounter is an integral part of prescription.
(10). Name of the medicines should be in capital letter. But small letter legible name can also serve the purpose, if writing in capital letter is laborious due to patient overload.
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(11). Provisional diagnosis and important findings supporting the provisional diagnosis (PD) should be written.
(12). Relevant information related to provisional diagnosis (PD) or differential diagnosis (DD) should be written.
(13). Chronology of prescribing drugs/medicines- Core Drug
Complimentary DrugSupportive or Symptomatic Drugs.
(14). Each prescribed drug/medicine must be provided with—Dosage form
StrengthDose
FrequencyDuration
(15). Supportive advice following the provisional diagnosis or the drugs/medicines should be written. Important advice in the prescription indicates quality prescription.
(16). Advice of supportive investigation will strengthen the purpose of prescription.
(17). Try to avoid abbreviation as much as possible.
(18). Registration number should be written whenever necessary as per prescription.
Auditing of Prescriptions
Drug or medicine is any substance or product that is used or is intended to be used to explore the physiological system or to modify pathological states for the benefit of recipients (World Health Organization). Drugs or medicines can do good, can do harm & whenever a drug is taken a risk is taken. So doctors should be aware of its importance.
Medication error is defined as "any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer...related to professional practice, health care products, procedures and systems including prescribing; order communication; product labeling, packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use."
Statistics shows that 44,000 to 98,000 Americans die each year as a result of medical errors. This is associated with a cost of USD 17 to USD 29 billion and ranks medical error the eighth-leading cause of death in the US. Though in India, a proper reporting of medication errors in the hospital is not available still now, but out of all visits to the medical emergency department- six per cent are drug-related. Adverse Drug Reactions accounted for 45 per cent of all adverse drug events (ADE). Of all ADE-related visits, 52 per cent and of all ADE-related admissions, 55 per cent were considered preventable.
Several survey confirmed irrational drug use in India. Recent initiatives of regulatory authorities (MCI) warned that doctors found to be unethical and irrational prescribing would be punished. The fast growing rates of medication errors all over the world indicates the need for starting a routine prescription auditing in all health setup, this is more important in respect to India, where resources are limited. In this connection, Standard Treatment Guideline (STG) prepared and implemented by Institute of Health & Family Welfare, Department of Health & Family Welfare, Govt. of West Bengal, Swasthya Bhavan,(29 GN Block, Sector-V, Bidhan Nagar, Kolkata-700091) is a justified and timely approach.
What is prescription auditing? This is a process of auditing prescription in a particular health care system with the purpose of identifying the medication errors, finding out the way to prevent such errors and thus improving the overall health care system.
The process of prescription auditing in its broader sense include prescription monitoring, drug utilization studies, prescription pattern studies, study of prescription habits of doctors, adverse drug reaction monitoring, drug interaction monitoring, criteria based prescription auditing and many other activities. But the most important and basic activities include checking the prescription for drug name (brand name or generic), strength, formulation, dose, route of administration, frequency, duration of treatment and drug allergies.
The process of prescription auditing is a type of vigilance activity, which is very beneficial for the health system in terms of reducing the financial burden because of medication errors and increasing the rate of patient recovery and discharge from the hospital. Not only that, prescription audit ensures quality health service which is very much essential.
There is no routine auditing system of prescription audit in India. The method used for prescription auditing depends upon purpose for which it is carried out. Different studies audited prescription in different ways. Though there is no standard methodology, these studies are very helpful in collecting data regarding prescription habits of doctors, the comparison of efficacies of different drugs, etc.
Standard treatment guidelines and its implementation in the primary health care evaluated and monitored the prescription habit of doctors. A standard method is developed for routine screening of some sample prescription (usually ten) and all the prescription drugs along with the prescribed information regarding the drug name (brand names), strength, formulation, doses, route of administration, frequency and duration of treatment. We also evaluate some other important aspects of prescriptions.
Standard procedure for collection of prescription
1. Doctor should prescribe medicines on the standardized OPD/Emergency tickets (STG). These prescriptions contain PD, symptoms, signs, drug name, strength, formulation, doses, route of administration, frequency & duration of treatment, necessary advices and investigations.
2. STG monitors/assessors will collect sample prescription randomly, carefully during the visit of health facilities for audit. Prescription containing more that one encounter should reflect better prescribing trends.
3. Collect only OPD/Emergency prescriptions. Try to avoid Eye, ENT, Dental, RNTCP, Antenatal Check up, Discharge Tickets.
4. If possible xerox or scan the prescriptions, if no such copying system available nearby then the monitors can copy the prescription by handwriting.
5. Properly preserve the prescription and hand over it to the respective authority for audit.
Prescription auditing methodology
Following the guidelines of World Health Organization (WHO) and under the guidance of our respected teachers we developed a methodology for prescription auditing. Some modification of WHO formula was done to make it simple and practical and compliant to our primary health care setup. This methodology was already tested and proved effective during the audit of prescription in piloting of STG (Number of prescription/encounters audited - 4867, North 24 pgs-2373 & South 24 pgs-2658).
Steps to be followed in prescription audit in STG-
1. All prescriptions collected should be numbered as ----------• Number the Prescription as 1,2,3………..etc.
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• &…………..→ Then• Number of Encounters as 1,2,3,4………
2. In audit we will evaluate the encounters.
3. Encounters without date will be cancelled and not evaluated.
4. If the prescription is ILLEGIBLE at any item then that item should not be considered and 0 (ZERO) points will be given.
5. The main Objectives for evaluation ---►Prescription should be understandable.
• Scheme & Flow Chart of Evaluation process of Prescription Audit-
6. Evaluation scoring system- Each encounter/prescription will be assessed on the following four facets, I. Completeness of Prescription (Diagnosis, Findings, Signature), II. Whether Prescription corroborates with Symptoms/Diagnosis (Selection of core drugs,
Selection of subsidiary/symptomatic drug, Relevant advices/instructions for patients), III. Prescribing Behavior (Generic Prescription, Essential drugs Prescription, Judicious
Investigations) IV. Dosage Schedule (Dose, Frequency of administration, Duration of therapy).
All the points/question/item scores 2 (two) marks.
Negative marking will be there depending on prescribing of vitamin / tonics / enzymes / poly pharmacy (antimicrobials) / parenterals for unnecessary indicators.
PRESCRIBING INDICATORS
Category: 4 (Each category comprises of three questions / items)
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Questions 12 (Each question / item carries 2 marks)Total marks: 24Marks obtained: 24 - to >18: Rational 18 - to >12: Semi Rational = or >12: Un acceptableI. Completeness of Prescription ►Diagnosis ►Findings ►Signature
II. Whether Prescription corroborates with Symptoms/Diagnosis ►Selection of core drugs ►Selection of subsidiary/symptomatic drug ►Relevant advices/instructions for patients
III. Prescribing Behavior ►Generic Prescription ►Essential drugs Prescription ►Judicious Investigations
IV. Dosage Schedule ►Dose ►Frequency of administration (Interval) ►Duration of therapy
There are twelve items to be evaluated in each encounter / prescription. Each item scores 2 (two) marks. So, total points are 24. Negative markings (2 marks for each item) will be given for tonics/enzymes/poly pharmacy (antimicrobials)/parenterals for unnecessary indicators. Now the total marks scored by each encounter will be converted into percentage and then graded into Rational (R), Semi Rational (SR), and Un Acceptable (UA).
Evaluation Scheme
Total Points = 24 = 100%
R = Rational = Points - >18- to 24: Rational = >75% to 100%
SR = Semi Rational = Points - >12- to 18 Semi Rational = > 51% or = or < 75%
UA =Un Acceptable=Points- < or = 12: Un Acceptable = = or < 50%
In prescription audit of STG, we will also take care of the following points during evaluation of prescription. These are-
●Prescription with identification- a). Identification of the health facility b). Prescribers identification c). Patient identification d). Stamp of the prescribers e). Signature of the prescriber
●Other points-• Prescription with provisional diagnosis/findings written • Illegible prescription • Percentage of prescription without abbreviation• Prescription with medicine written in capital
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• Prescription with drugs from Generic / EDL • Number of drugs prescribed per prescription • Percentage of prescription with an antibiotic • Percentage of prescription with an injection • Number of prescription without drugs (only advice)• Prescription written in local language
A zero medication error is an impossible thing to achieve because we are humans and not machine. So, the only way to get rid of irrational, unscientific prescription is a thorough screening all components of a prescription. That is why to ensure rational prescription auditing must be an integral component of the health system. This unique approach of prescription audit in Standard Treatment Guidelines at primary health care is a definite step for right medicine for right person at right time in right dose and at a right cost.
Some examples of good & bad prescriptions collected from the piloting of STG are given here. References –
Iain L. O, Buxton. Principles of Prescription Order Writing And Patient Compliance. Laurence L. Brunton, John S. Lazo, Keith L. Parker, Goodman & Gillman’s The Pharmacological Basis of Therapeutics; Eleventh Edition: 1777-17
Paul W. Lofholm., Bertram G. Katzung. Rational Prescribing and Prescription writing. Basic & Clinical Pharmacology., Eight Edition, 2000: 1091.
Tripathi K.D. Essentials of Medical Pharmacology., Fifth Edition, Jaypee Brothers, New Delhi, 2003: 60.
Prescription Writing, Teacher’s Manual, Department of Pharmacology & Therapeutics; Seth G. S. Medical College & K.E.M Hospital: Parel, Mumbai 400012: 13.
Sahin , F . Akcicek. A de novo model of rational pharmacotherapy training: the interns' perspective. European Journal of Internal Medicine; Volume 15: Issue 3; 201 - 204 H.
