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Urban Primary Health Care Standards:

A Manual for Quality Services in Urban Primary Health Care Facilities

Multi-Disciplinary HIV/AIDS Programme (MDHAP)

BANGLADESH URBAN PRIMARY HEALTH CARE QUALITY IMPROVEMENT PROGRAMME

Urban Primary Health Care Standards: A Manual for Quality Services in Urban Primary Health Care Facilities

Multi-Disciplinary HIV/AIDS Programme (MDHAP) - Bangladesh

Date: February 2010By: Dr. Kai Stietenroth

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URBAN PRIMARY HEALTH CARE STANDARDS BANGLADESH 2010

Urban PHC Standards Bangladesh Page 2 of 43 February 2010

CONTENTS Page

INTRODUCTION 3

SECTION A: SERVICE MANAGEMENT 6

1.0 Governance, Management and Planning 6

2.0 Client and Family Rights 8

3.0 Quality Improvement 10

4.0 Information Management 12

5.0 Human Resource Management 16

6.0 Safe and Appropriate Environment 17

7.0 Safe Practice 22

SECTION B: SERVICE PROVISION 25

8.0 Service Access 25

9.0 Client Care and Treatment 26

10.0 Medication and Vaccination Management 28

SECTION C: ADDITIONAL CLINICAL STANDARDS 31

11.0 Maternity Services 31

12.0 Laboratory Services 33

GLOSSARY 36



INTRODUCTION

Purpose of the Standards

This manual of standards for quality services in Urban Primary Health Care facilities in

Bangladesh has been developed for a pilot project in Sylhet. A set of draft standards has

been reviewed by working groups of stakeholders to ensure the standards were

applicable, important, understandable, measureable and achievable in urban primary

health care centres in Bangladesh. The pilot project is part of the second phase of the

Multidisciplinary HIV/AIDS Programme (MDP) funded by the German Ministry for

Economic Cooperation and Development (BMZ) in the form of technical cooperation

through the Gesellschaft für Technische Zusammenarbeit (GTZ). One of the themes of

this phase is for Urban PHC services to raise their standards of prevention/treatment of

infectious diseases, e.g. HIV/TB/STI) with a focus on Quality Management (QM). A

situational analysis of the activities of key stakeholders in the four cities of Chittagong,

Rajshahi, Khulna and Sylhet found a lack of coordination between the organisations

delivering urban primary health care, a lack of uniform standards as a referral point for the

City Corporations and a lack of consistent monitoring and evaluation mechanisms. The

aim now is to run a pilot to strengthen uniform QM mechanisms and tools in selected

facilities in Sylhet, leading to a future rollout of the QM initiative in the remaining Urban

PHC facilities of all four cities. The development of a set of uniform standards is an

essential first step. They will then be incorporated into an assessment tool that will be

used as part of the pilot assessment of the chosen sample of Urban PHCs and later for

assessments in other Urban PHC facilities.

Development of the Standards

The draft Urban PHC standards are based on primary healthcare standards developed in

similar contexts, including Egypt, South Africa, Himachel Pradesh, and other South Asian

countries. Standards, standard operating procedures, guidelines and checklists being

used by different healthcare organisations in Bangladesh were consulted and where

possible relevant provisions incorporated within these standards. Documents referenced

included:

I. Standards and other relevant documents for developing Urban PHC

standards (available in Bangladesh)

A. Government

1. Standards for District Hospital, covering SOPs for emergency, IPD, OPD, and house

keeping

2. Guideline for Accreditation of Women Friendly Hospital

3. Protocol for Women Friendly Hospital

B. Primary Health Care (Government)

1. Essential Services Delivery Package

C. Urban Primary Health Care Project (UPHCP II)

1. Integrated Supervisory Instrument (ISI) for regular monitoring

D. Smiling Sun Franchise Program (SSFP) (USAID funded)

1. Quality Monitoring & Supervision – Observation Job Aid



2. Quality Monitoring & Supervision – Facilitator Guide

E. Bangladesh AIDS Program (BAP) (USAID funded)

1. QA/QI Checklist (Implemented by Family Health International)

F. Marie Stopes Clinic Society

1. Checklist for facilities

2. Checklist for services

3. Checklist for service providers

4. Quality Strategy

G. FHI

1. Minimum Standards: Targeted STI Services

H. JICA

1. QA Checklist JICA

2. Proposal Quality Improvement

II. International, Regional and National Standards from other countries

1. Joint Commission International Primary Health Care Standards

2. AJK Primary Health Care Standards

3. NWFP Primary Care Standards

4. COHSASA Primary Health Care Standards

5. COHSASA HIV Management Standards

6. Egyptian HealthCare Accreditation Programme Primary Care Standards

7. WHO Framework for Monitoring the Health Sector Response to HIV/AIDS

The best international guide for assessing the adequacy of healthcare standards and

whether they meet international best practice requirements is the International Society for

Quality in Health Care‟s (ISQua‟s) International Principles for Healthcare Standards.

These Principles have been used by ISQua to assess and accredit over 30 sets of

standards of national and regional healthcare organisations. These Principles were used

to guide what should be included in the new standards.

Weaknesses of the Current System

The list above shows there are a number of standards, guidelines and other documents

being used by different agencies and organisations within Bangladesh urban primary

health care to monitor and evaluate the quality of services being provided. However,

none of them provide an overall framework for assessing and improving quality.

Standards need to address the different dimensions of quality access, appropriateness,

capacity, continuity, effectiveness, efficiency, responsiveness or client focus and safety,

Most local documents cover mainly the quantity of service delivered rather than the

quality, focusing on the adequacy of inputs or the measurement of outputs rather than the

implementation of processes which are the single most effective way for improving the

quality and consistency of services across the range of clinical and non-clinical functions

of any health care organisation or facility.

During the course of the development of this set of draft standards, four of the main

standards/guidelines currently in use in different urban PHC facilities in Bangladesh

(Family Health International Minimum Standards, Smiling Sun QMS Observation Job Aid,



Marie Stopes Rapid Clinic Assessment Observation Checklists, Accreditation Guideline of

Women Friendly Hospital) and the new Urban PHC draft standards were assessed

against the ISQua Principles for healthcare Standards and their criteria to identify the

strengths and gaps. The local standards/guidelines/checklists were found to be limited in

their coverage of governance, management, client focus and involvement and

organisational planning and performance. Their main focus was on facilities and

equipment, and specific clinical procedures. A number of the available operating

procedures and checklists would be useful adjuncts to a uniform set of organisation-wide

standards but are insufficient in themselves to measure or improve quality in a structured

and consistent way. Similarly, the Standards for District Hospitals are not standards but

standard operating procedures for emergency, OPD, IPD and Housekeeping, with

monitoring checklists.

These UPHC standards addressed most of the requirements of the ISQua Principles

although in a limited way in some areas. Many criteria in the standards are included

because they reflect good practice and have been demonstrated in other areas as useful

guidance for organisations. They provide a comprehensive framework for assessing the

quality of Urban PHC facilities.

Structure of the Urban PHC Standards

The UPHC standards consist of three major sections:

Section A: Service Management

Section B: Service Provision

Section C: Additional Clinical Standards

Glossary

Each section consists of “standards” and “measurable criteria”. Whereas “standards” are

broad statements of the expected level of performance, the “measurable criteria” make

the standards operational and provide details on structures and processes necessary to

ensure high quality of care, service and management.

Future Use of the Standards

It is intended that the UPHC Standards will provide a framework for self-assessments and

external assessments of the quality of care, service and management of Urban PHC

facilities in Bangladesh, whether they be public, private or part of a NGO. For this

purpose the standards will be incorporated into an assessment tool which will also be

able to be used for planning purposes. Based on an assessment of the strengths and

areas for improvement in the health care facility, priority areas for improvement can be

identified, an action plan can be developed and quality improvement activities can be

initiated. The standards also provide guidance when problems and questions about

quality arise in the daily management of the facility and serve as a basis for

communication with the clients.



No. Standards and Measurable Criteria

SECTION A: SERVICE MANAGEMENT

1.0 GOVERNANCE, MANAGEMENT AND PLANNING

1.1 The organisation’s vision, mission, values and codes of ethics give it direction

and guide its decision-making.

1.1.1 The organisation has a vision and mission statement that provides the basis for planning and

direction.

Guidance

A vision generally describes what the organisation would like to be in the future and the mission

generally cover who the organisation is, what it is, why it exists and whom it serves. Sometimes

the mission is called a statement of purpose or similar. They should be easy to understand and

written simply.

1.1.2 The vision and mission are developed based on best practice by the governing body, with input

from staff, clients and other stakeholders and are communicated to all relevant stakeholders in

the community.

1.1.3 The organisation develops a defined set of values that reflect the desired behaviour of the staff

and management of the UPHC Centre and guide the decision-making and service delivery.

1.1.4 The organisation has a written code of ethics or ethical guidelines for business and professional

behaviour, consistent with recognised codes of ethics.

1.1.5 There are documented processes to deal with ethical issues such as but not limited to conflict of

interest, confidentiality, advertising, resource allocation, consent, palliative care, death and

research.

1.2 The organisation is effectively and efficiently governed.

1.2.1 The governing body provides leadership and is responsible for

a) establishing and reviewing the vision, mission, values, codes of ethics and strategic

directions of the organisation

b) facilitating resourcing of the organisation to enable objectives to be met and monitor

proper utilisation of these resources

c) undertaking research and other studies on such topics as community needs

d) monitoring, supervision, and evaluation against organisational management documents

e) identifying and managing risks

f) overseeing the design and implementation of programmes, achievement of results and

monitoring of quality performance

g) supporting and promoting the involvement of the organisation with the community to

identify and respond to the community‟s health needs

h) routinely communicating with and supporting the management and staff.




1.2.2 The governing body operates according to a deed, constitution, bylaws, legislation or articles of

association and works within its scope of authority.

1.2.3 All members of the governing body are oriented in the Bangladesh healthcare system and in

basic management skills.

1.2.4 The governing body meets regularly, preferably monthly but at least quarterly, according to a set

agenda that includes follow-up from the last meeting.

1.2.5 The governing body receives useful, timely and accurate written information from management so

it can identify issues, monitor the quality of services provided and plan and take actions.

1.2.6 Minutes of meetings are recorded, are kept for at least three years and are available at the

management/head office.

1.2.7 Provision is made for emergency meetings to deal with significant issues as they arise.

1.2.8 Governing body meeting minutes show key decisions to be implemented at facility level and

timeframes for communicating them to relevant persons in the organisation.

1.3 The organisation is effectively and efficiently managed.

1.3.1 The governing body appoints a manager, e.g. Director, Chief Health Officer, with appropriate

training and experience in health management to be responsible for operational management and

overseeing of service delivery centres.

1.3.2 The manager‟s role, responsibility and authority are clearly defined in a job description and job

specification which include but are not limited to:

a) type of qualifications and professional experience

b) efficient use of resources

c) the development of strategies to achieve the strategic goals or objectives

d) establishing and monitoring quality improvement processes

e) establishing and monitoring knowledge and information management systems

f) implementation of programmes and monitoring of achievement of results and quality

performance

g) management and development of staff

h) compliance with relevant laws and regulation

i) regular reporting and submission of management documents including budgets to the

governing body

j) ensuring appropriate response to reports from any inspecting or regulatory agencies and

k) advocating at different levels with relevant stakeholders to identify and respond to the

community‟s health needs.

1.3.3 The management style is participatory and transparent and managers coordinate and

communicate clearly with each other and with staff.

1.3.4 The governance and management structures and reporting lines are clearly defined in an

organogram which is displayed in the Centre.




1.4 Services are planned and coordinated to meet the needs of the organisation and

the community and achieve desired results.

1.4.1 The governing body carries out a strategic planning process to

a) determine measurable goals/objectives for the UPHC Centre

b) select indicators to measure whether goals/objectives are being achieved and

c) monitor progress in achievement.

1.4.2 Planning considers data or information from policy documents, research or other studies, UPHC

Centres, community health needs, finances and financial mechanisms, environmental factors,

human and other resources, risk and service user feedback.

1.4.3 The planning of services, functions and activities includes coordination within the organisation and

with other relevant service providers/organisations in order to identify gaps, promote

harmonisation and avoid duplication of services.

1.4.4 An annual planning process involves staff, stakeholders and clients and results in an annual plan

which is implemented and reviewed on a regular basis.

1.4.5 The annual plan specifies the planned actions and targets for meeting the strategic

goals/objectives and includes defined responsibilities for the actions and human, financial and

physical resources to implement the planned actions.

1.4.6 The annual plan is communicated throughout the UPHC Centre and any outreach services.

1.4.7 The annual plan includes a feedback mechanism to disseminate and share annual achievements

and results of quality assessments with staff, stakeholders and the community.

1.4.8 The governing body regularly reviews programme reports and monitors progress against the

annual plan, identifies problems and makes recommendations.

1.4.9 The governing body has a disaster management plan to respond to emergency situations, e.g.

epidemics and natural disasters.

2.0 CLIENT AND FAMILY RIGHTS

2.1 The facility protects and promotes the rights of its clients and their families.

2.1.1 The rights and responsibilities of clients, and their families are defined in a charter which is

displayed prominently throughout the UPHC and reflected in policies and procedures.

2.1.2 The UPHC Centre uses a documented process for clients not able to understand written information

to inform them of their rights.

2.1.3 Staff are familiar with the charter and there are processes in place to:

a) monitor its implementation

b) as soon as possible investigate any claims about violation of client‟s rights and resolve

the claims promptly.




2.1.4 The charter includes the right of clients to:

a) be treated with respect, taking into account their needs, values and beliefs, and to have

their privacy respected

b) be free from discrimination, coercion, harassment and exploitation

c) dignity and independence

d) services of an appropriate standard that comply with legal, professional, ethical, safety

and other relevant standards

e) effective, open and honest communication

f) be fully informed

g) make informed choices and actively participate in the service

h) make a complaint about the service (see 3.2 for details).

2.1.5 The Charter includes the responsibilities of clients to :

a) seek prompt attention for health problems

b) share information about their health with the service provider

c) follow the treatment plan

d) respect other clients, the environment and service providers.

2.1.6 Clients‟ privacy and confidentiality are protected by:

a) training staff about their responsibility to protect confidentiality

b) limiting access to information about clients to authorised individuals

c) obtaining consent to share personal information with families and other organisations that

need to know for the continuing care of treatment of the client and

d) ensuring they receive consultation and services in privacy.

2.1.7 Clients can choose to be examined or treated by a healthcare provider of the same sex or of the

client‟s choice, if they are available.

2.2 Staff give clients and their families relevant and understandable information about

proposed care or treatment and obtain informed consent.

2.2.1 Accurate and appropriate information is provided to clients and their families in the language they

desire or through other supporting materials, on:

a) the proposed care or treatment

b) the costs

c) the risks and benefits of the proposed treatment or investigation and

d) the alternatives available.

2.2.2 After the provision of information, consent from clients is obtained for all relevant care and

documented in the client record. (Refer Client Records 4.2)

2.2.3 The UPHC Centre has a list of procedures and treatment for which specific written consent is

required, including invasive treatments and family planning interventions, and written consents

are filed in the client record.

2.3 The facility and the services provided are easily accessible to the population

within their defined area of responsibility.




2.3.1 The range and location of services and availability of outreach or community services are

appropriate to the needs of the client groups served and the type of services offered.

2.3.2 Buildings in which services are provided are signed, physically accessible and appropriate to the

needs of the client groups served and the type of services offered.

2.3.3 The governing body identifies and removes or minimises barriers, including cost and hours of

opening, which prevent clients, their families and providers from accessing services.

2.3.4 Cultural barriers are addressed by such things as the separate waiting areas and toilets for males

and females.

2.3.5 The location of the facility and its outreach and other services is identified on a map of the

catchment area and displayed at prominent locations of the catchment area.

2.4 Information on services and applicable fees are provided for clients.

2.4.1 A poster or board listing: i. services provided

ii. opening and closing times, and

iii. emergency contacts during closing times

is displayed in a prominent place outside, near the main entrance where clients can see it. The

text is in an understandable format, e.g. local or national language or pictorial.

2.4.2 Lists using an understandable format, e.g. local or national language or pictorial, of:

i. all free services, registration fee and exemption criteria and

ii. available services and applicable fees

are posted in a prominent area where the clients can see them.

2.4.4 The layout of the UPHC Centre and an operational flow chart for the passage of clients through

the Centre are displayed at the entrance point, where the clients can easily see it. The text is in

an understandable format, e.g. local or national language, or pictorials are used.

2.4.5 Guidance and advice are provided to clients and their families by trained staff at the registration

counter.

3.0 QUALITY IMPROVEMENT

3.1 Client feedback is collected and used to improve services.

3.1.1 Clients have access to a culturally appropriate feedback mechanism, e.g. suggestion box,

questionnaires, comment books or regular interviews with clients by independent persons.

designated by the UPHC or another external agency.

3.1.2 Data collected on client satisfaction with services and treatment is analysed regularly by the clinic

manager or any other designated person and used to improve services.

3.2 Clients have the right to complain about services and treatment and their

complaints are investigated in a fair and timely manner.




3.2.1 Clients are informed in a culturally appropriate manner of their right to express their concerns or

complaints either verbally or in writing and are encouraged regularly to share these with the

designated person(s).

3.2.2 The complaint process is made simple and easy by making available a complaint form for clients

to complete, or staff to complete when they receive a verbal complaint. The forms are displayed in

prominent locations.

3.2.3 A documented process is made available to all which is fair and timely and is used for collecting,

reporting, investigating and resolving complaints, giving all parties an opportunity to be heard.

3.2.4 A register is kept of all complaints and their outcomes, and documented in client or staff files

where relevant.

3.3 The facility identifies opportunities to continuously improve its processes and

services, manages its risks, makes improvements and evaluates their

effectiveness and efficiency.

3.3.1 A planned and functioning quality improvement system, led by management and involving all

staff, covers all services and functions.

3.3.2 The quality improvement system coordinates all quality improvement and risk management

activities through various tools and techniques and includes the monitoring of:

i. staff and client satisfaction

ii. record keeping and data management

iii. medication and other errors and adverse events

iv. incidents and accidents

v. complaints

vi. staff performance

vii. utilisation management

viii. financial management

ix. high risk processes and procedures and other risks identified as significant and the

planned methods for managing them.

3.3.3 Staff receive training on quality improvement and risk management so they understand their role

and how they can contribute to improving safety and quality.

3.3.4 When problems or errors are identified, timely action is taken to address them as process or

training issues without blaming individuals.

3.3.5 Performance indicators for priority diseases and key processes are measured and reported to the

relevant managers and authorities.

3.3.6 Performance targets are well defined and monitored and used for continuous improvement, e.g.

targets for immunisation, family planning and T.B.

3.3.7 All relevant legal requirements are identified, compliance is regularly monitored and improvement

action is taken when breaches are found.

3.3.8 From monitoring and other quality measurement

a) data are analysed,




b) trends are identified,

c) results are evaluated

d) results are shared with relevant stakeholders and

e) results are used for planned quality improvement and innovation.

4.0 INFORMATION MANAGEMENT

4.1 The organisation has a management information system (MIS) which provides a

mechanism to plan, monitor and make decisions for providing better health

services.

4.1.1 The organisation‟s management information system is consistent with the central, city/local level

data management system.

4.1.2 Data and information

a) are collected using processes that are consistent across UPHC Centres and

b) can be integrated into the district and national information management systems.

4.1.3 There is a coordinated data collection system that includes data and information on, for example,

disease surveillance, clinical performance, family planning, financial management and quality of

services and which assists improvement in the quality of care and service.

4.1.4 The organisation:

a) defines in the annual plan the indicators it plans to measure, which may include national,

district level, service and health indicators

b) collects data to enable the measurement of the indicators and their benchmarking

c) analyses the indicator data to determine results and trends

d) communicates these in an understandable form to staff and other key stakeholders and

seeks their feedback.

4.1.5 The capacity of the organisation‟s management information system (MIS), such as for finances,

human resources and logistics, supports planning, monitoring and decision-making.

4.1.6 A designated person is responsible for the information management system in the facility and for

monitoring the information management processes.

4.1.7 Documented processes exist and are used to monitor the accuracy, timeliness and utilisation of

data.

4.2 Client information is registered, coded, analysed and used as a mechanism for

planning, monitoring and evaluation and decision-making for the organisation.

Note: While registers and health cards are currently used, the long term aim is to transition to

individual client records which are one of the most important ways to improve client health. They

facilitate continuity of care over time and between providers, ensure all information related to the

client is always available for the use of health professionals and help prevent omissions and

errors.




4.2.1 Client registers are used by the UPHC to collect data for management and statistical purposes

and are:

i. available

ii. kept up to date

iii. complete and

iv. accurate.

4.2.2 Basic written information in the registers is in line with operating procedures and includes:

i. dates

ii. ID number

iii. client demographic data

iv. diagnosis

v. treatment

vi. follow-up and

vii. referral.

4.2.3 Cards may be used to document client information and inform clients about their care, including

i. Health card (mother and child/family)

ii. Immunisation card

iii. TB card and

iv. STI card.

Guidance: Cards do not replace individual client records as a way for the UPHC Centre to

document a client’s care and treatment over time.

4.2.4 A disease coding system which is consistent with the city and national HMIS is used and

monitored.

4.3 The organisation protects the confidentiality, security and integrity of data and

information.

4.3.1 Staff work in accordance with documented policies and procedures for protecting the

confidentiality, security and integrity of information that cover at least:

a) designation of who may have access to client records to protect the confidentiality of

client information

a) processes for protection of highly sensitive client information that could lead to stigma,

discrimination or harm for the client, such as HIV or STI status

b) the circumstances and processes for granting access to data or information, for example

for research and legal purposes

c) processes guiding who can have access to what type of data for decision-making. The

process for the client to get access to his/her records

4.3.2 Client records are protected from destruction, loss, tampering and unauthorised access and use.

4.3.3 There is a policy on the retention time for financial and client records and how they should be

destroyed.

4.4 Client records are current, accurate, comprehensive and secure.




4.4.1 There is a single record for each client assessed and treated, including separate records for

mothers and babies, maintained in chronological order.

4.4.2 Client records contain sufficient information to:

a) identify the client, including unique ID number, name, address, contact details and date

of birth

b) promote continuity of care over time and between providers and services

c) support the diagnosis

d) substantiate the treatment (as per guideline if available)

e) document the course and results of treatment and

f) enable follow-up visits and referrals.

4.4.3 Entries in the client record:

a) are made only by authorised persons

b) are legible, dated and timely

c) are signed with name and designation

d) include the time of relevant events.

4.4.4 The client record includes at least the following:

i. client history

ii. reason for each visit

iii. any provisional or actual diagnosis made

iv. investigations

v. significant findings

vi. procedures performed

vii. medications or treatments prescribed

viii. follow-up instructions and referrals

ix. the name of the healthcare providers.

4.4.5 Inpatient client records are continuously updated according to defined timeframes and reflect any

changes in condition or treatment.

4.4.6 The contents of client records are filed in a chronological order, with the client‟s name and

identification on the outside of the record.

4.4.7 Client records are secured inside a cardboard folder, filed alphabetically, stored safely and

securely in accessible cabinets or shelves and available when needed by staff and others.

4.4.8 The UPHC Centre undertakes a review of a representative sample (batch check) of client records

for completeness and legibility of entries and contents at least quarterly.

4.5 Notifiable diseases are accurately recorded, reported promptly and appropriate

action is taken to minimise the spread of the disease.

4.5.1 A list of notifiable diseases is available and used within the organisation.

4.5.2 Notifiable diseases are reported to the relevant legal authority, e.g. IEDCR, within a specified time

period, but no longer than 24 hours.




4.5.3 Required reports for polio and other diseases as relevant are completed and submitted within

required timeframes.

4.5.4 There is recorded evidence of prompt investigations of all clusters of epidemic diseases and

actions taken by all levels participating in the outbreak control.

4.5.5 Procedures for managing notifiable diseases

a) are based on infection control principles and national protocols/guidelines

b) are used and

c) include clearly defined roles and responsibilities.

4.6 Information on causes of all maternal and neonatal deaths are recorded in those

facilities that provide obstetric delivery services.

4.6.1 A register of maternal and neonatal deaths within the facility is maintained and indicates whether

the death has been investigated for the probable cause of death.

4.6.2 Verbal autopsies and forms are completed by the facility for all maternal and child deaths that

occur in the facility.

4.6.3 Information on maternal and neonatal deaths are analysed and the results used by the UPHC

Centres to improve services.

4.7 Staff work in accordance with written policies and Standard Operating Procedures

(SOPs) for managing services and clients and to written guidelines and protocols

for common illnesses.

4.7.1 Policies and SOPs are documented and used for managing the facility, programmes and key

processes and functions and are reviewed at least every two years and revised as necessary.

4.7.2 Provision is made for more frequent review of policies and SOPs impacted by social, economic,

political or environmental changes within the nation.

4.7.3 Policies and SOPs are developed with the input of relevant staff and clients and

a) reflect contemporary UPHC best practice, citing references where used

b) are clear, easy to use and recorded in policy manuals or the equivalent

c) are subject to an effective document control system, for authorising, updating and

distributing

d) are readily accessible to staff for reference

e) are dated and authorised.

4.7.4 Written SOPs are used for the management of clients e.g. confidentiality, privacy, registration,

recording and coding.

4.7.5 Written treatment guidelines and protocols are available and used by service providers for the

treatment and management of common illnesses.




5.0 HUMAN RESOURCE MANAGEMENT

5.1 The organisation uses a human resource management system to manage, develop and

communicate with staff in accordance with the organisation’s vision, mission and strategic

plan.

5.1.1 Staff are informed about the HR management system such as job descriptions, orientation and

staff terms and conditions.

5.1.2 There is a transparent system in place for feedback from employees which ensures the

confidentiality of the person and the feedback.

See also 3.3.2 re regular monitoring of staff satisfaction

5.1.3 The HR management system processes for recruitment and selection, rostering, performance

evaluation, promotion and training are transparent, equitable and unbiased.

5.2 UPHC Centre staff are available for service delivery during all official times and are

actively engaged in service provision.

5.2.1 There are sufficient staff (as per the organogram and planning and monitoring mechanisms) to fill

all designated positions.

5.2.2 A roster of who is on duty, at what time and in what location is kept current and is displayed.

5.2.3 A qualified healthcare provider is available whenever the facility is open.

5.2.4 A record of daily staff attendance (including duty start and finish times) and a schedule of staff

activities are maintained.

5.2.5 Staff are available to respond to emergencies at all hours for inpatient maternity services.

5.2.6 Staff are easily identifiable by appropriate dress and name badges or similar.

5.3 Staff are recruited, appointed and oriented in accordance with documented

procedures, job descriptions and service needs.

5.3.1 Staff appointments are made in line with a written job description which specifies qualifications.

5.3.2 Qualifications and professional training and registration or license for professional staff are

verified before appointment and practising certificates, where relevant, are validated annually.

5.3.3 All staff are oriented to the UPHC programmes and their specific job description through a

documented orientation programme.

5.3.4 The orientation includes:

i. The UPHC Centre‟s vision, mission, values, goals and relevant planned actions for the

year

ii. Services provided

iii. Roles and responsibilities




iv. Relevant policies and procedures, including confidentiality

v. Client Charter

vi. Use of equipment

vii. Safety

viii. Emergency preparedness

ix. Quality improvement.

x. Other relevant topics specific to the position.

5.3.5 All staff have a copy of their job description that is kept current. The job description includes the

job specifications, responsibilities, accountabilities, tasks, performance measures and reporting

relationships.

5.3.6 All staff are given

a) a signed copy of their appointment letter and/or contract which covers their conditions of

employment including but not limited to benefits, salary, notice period, probationary

period, hours of work,

b) a confidentiality agreement signed by the staff member and

c) staff policies.

5.3.7 All health service providers practise only within the scope of client treatment and types of

procedures defined in their job description or similar document.

5.4 Staff are trained and their performance evaluated on a planned and systematic

basis.

5.4.1 Staff performance is evaluated annually with the staff member against their job description and

agreed targets, and is used to identify strengths, areas for improvement and training needs.

5.4.2 An annual staff training plan based on a needs assessment is developed, covering at least areas

such as recent health priorities, health and safety, quality improvement and client rights.

5.4.3 Staff receive periodic in-service/on-the job training relevant to their job and the healthcare service

as identified by the staff member or the organisation.

5.4.4 Records of all staff training are maintained.

5.4.5 The performance management system includes a rewards and recognition programme.

6.0 SAFE AND APPROPRIATE ENVIRONMENT

6.1 The UPHC Centre has sufficient space and appropriate layout for the services

provided.

6.1.1 There are defined and properly labelled rooms or spaces for the following activities:

i. client waiting

ii. central registration

iii. examination, treatment and counselling of clients that provide privacy

iv. client education

v. instrument sterilising

vi. drug storage




vii. dispensary

viii. EPI

ix. labour and delivery

x. mini-laboratory

xi. staff administration and meeting.

6.1.2 There is sufficient space for staff to move around, sit and undertake clinical and administrative

tasks.

6.1.3 There is a sluice area equipped in accordance with a documented checklist.

6.2 Store rooms enable items to be stored safely and securely

6.2.1 Storage facilities are dry, dust free and clean with adequate lighting and ventilation and controlled

for vermin such as rodents and insects.

6.2.2 Materials are labelled and properly stacked on shelves that are at least 6 inches off the ground

and off the wall.

6.2.3 Store rooms are kept locked with a key available to staff needing access.

6.3 Utilities are managed to ensure they are functional and risk is minimised.

6.3.1 The facility has a functioning power supply, adequate lighting and ventilation, with an adequate

number of fans in working order in all the rooms of the facility.

6.3.2 A backup generator, or alternative power source

a) is available in working condition and

b) has an adequate budget for its operation, maintenance and fuel.

6.3.3 All electrical wiring is concealed.

6.3.4 There is a functioning connection with a land phone.

6.4 There is a reliable, clean and safe supply of water from a protected water source

and an efficient sewerage system.

6.4.1 Running water (pipe) is available within the facility and sufficient water storage containers are in

place OR

there is a protected water source within 200 yards of the facility: tube well, water tank (with tubing

of water for outflow, concrete slab, drainage) and temporary storage containers.

6.4.2 A supply line and storage system keeps water clean and free from contamination by

regular cleaning of storage tanks and periodical check-up of internal supply lines.

6.4.3 There is an adequate supply of drinking water, including in waiting rooms, and:

a) water is bought from a reliable source

b) regularly maintained filter is available




c) water is boiled for 10 minutes.

6.4.4 An efficient sewerage system is maintained within and outside the close proximity of the boundary

of the facility.

6.5 The facility has clean latrines or toilets

6.5.1 Well maintained latrines or toilets exist within the facility or facility compound in adequate

numbers for staff and clients.

6.5.2 Staff and clients have access to separate functional latrines or toilets which are clearly signed and

are lockable from the inside.

6.5.3 Where possible, there is at least one well maintained male toilet and female toilet within the

compound.

6.5.4 Toilet bowls and latrine slabs are clean, toilet areas are clean and dry and well ventilated, and

separate toilet cleaning materials are available (brush, mop, toilet cleanser).

6.5.5 Soap and a regular water supply are available at a hand-washing point in or near the

toilet(s)/latrine(s), with toilet paper and a clean towel or equivalent such as paper towel.

6.5.6 Covered containers for waste are provided inside the toilets and emptied regularly.

6.6 The waiting area is clean and provides for the comfort and protection of clients.

6.6.1 Clean waiting areas protect clients from the sun, rain and extremes of temperature and are well

ventilated.

6.6.2 There are designated separate male and female waiting areas.

6.6.3 The waiting areas have adequate chairs or other sitting arrangements.

6.7 The facility is clean.

6.7.1 All areas of the facility are clean and free from dust, cobwebs, blood, trash, needles and syringes.

6.7.2 Signs are put requesting clients not to spit or smoke.

6.7.3 Interior and exterior walls, windows, doors and floors are intact and well maintained.

6.7.4 Walls are decorated with pictures and posters promoting health.

6.8 The facility compound and its surroundings are clean and use rubbish bins or pits

for disposal of refuse and medical waste.

6.8.1 The compound, the area immediately outside the boundary and the approach road are free from

litter such as plastic bags, refuse and medical waste.




6.8.2 Sufficient rubbish bins are provided for general waste to avoid littering.

6.8.3 There are separate rubbish bins or pits within the compound for different kinds of waste. For

medical waste, the bins or pits are covered.

See also 7.6.1

6.8.4 The bins/pits are not overflowing and are properly used, i.e. rubbish is not disposed of anywhere

else.

6.9 Consumables and other supplies are monitored and managed to ensure

availability when needed.

6.9.1 There is a system for ensuring consumables and other supplies sufficient for three months of

Centre operation are available.

6.9.2 The facility has a functioning stock control system for consumables and other supplies and usage

is monitored against a stock register.

6.9.3 Clean supplies are available in client treatment areas and ready to use in clean, labelled

containers.

Note: Type of supplies are listed in the National Guideline for Infection Control.

6.10 Equipment and furniture are functional, meet the defined needs of planned

services, are properly maintained and used and equipment is operational.

6.10.1 Equipment is supplied based on:

a) the level and type of services provided

b) whether staff have the knowledge and skills to operate the equipment and

c) recognised checklists.

Refer 6.10.6 – 6.10.11

6.10.2 Equipment is stored safely, securely and efficiently, including gas cylinders being appropriately

restrained.

6.10.3 Documented procedures for the safe use of equipment and medical devices are available, used

and include:

a) setting up equipment appropriately.

b) having equipment and supplies used only as intended by the manufacturer

c) orienting the users on information from the manufacturer

d) acting on available information about hazards, defects and recalls and

e) reporting compromises to safety to management.

6.10.4 The UPHC Centre educates and trains staff on:

a) safely operating and maintaining equipment and medical devices

b) available backup if equipment fails

c) getting repair services

d) carrying out emergency procedures




e) reporting problems and incidents involving equipment and

f) keeping records of equipment servicing.

6.10.5 Equipment is registered and routinely tested and inspected.

6.10.6 An equipment maintenance and replacement schedule is available for:

i. maintenance

ii. repair and

iii. safe disposal.

6.10.6 General equipment is available in sufficient numbers for the range of services provided at the

UPHC Centre, is in working condition and ready to use and includes:

i. Thermometer

ii. Stethoscope

iii. BP apparatus

iv. Weighing scale, baby weighing scale

v. Measuring tape/scale to measure height

vi. Snell‟s chart

vii. Torch

viii. ARI timer or watch

ix. Hammer

x. Tongue depressor

xi. Needle safety box

xii. X-ray viewer

xiii. Gloves, masks, apron.

6.10.7 Service-specific equipment is available as per the checklists for the range of services provided at

the UPHC Centre, is in working condition and ready to use.

Guidance: Guidelines/Checklists include Family Planning Guideline, National Immunisation

Guideline, National EOC Guideline, IMCI Protocol, Malaria Guideline, Dengue Guideline, STI

Guideline, HIV policy and strategy, Infection Prevention Guideline, Asthma Guideline, National

Tuberculosis Guideline, TB/HIV Co-infection Guideline.

6.10.8 Equipment for boiling/sterilising instruments is available for the range of services provided at the

UPHC Centre, is in working condition and ready to use.

Note: Infection Prevention GOB Guidelines

6.10.9 Emergency equipment is available as necessary for the range of services provided at the UPHC

Centre, is in working condition and ready to use and includes:

i. a stretcher

ii. ambu bag and airway tube

iii. oxygen therapy unit

iv. suction unit

v. plain/Foley‟s catheter,

vi. atraumatic catgut

vii. suture set,

viii. medical supplies for dressing

ix. spot light

x. nebuliser




xi. resuscitation kit.

6.10.10 Furniture/logistics in the examination room/s include:

i. Examination couch that is clean and covered with a plastic sheet

ii. Functioning washbasin with faucet or bucket with tap and lid

iii. Desk

iv. Chairs or bench for staff, client and their companion

v. Two-step ladder

vi. Screen for privacy

vii. Cabinet for storing materials

viii. Container for general waste and medical waste

ix. Stationery

x. Refrigerator

xi. Logbook/Register.

7.0 SAFE PRACTICE

7.1 The health and safety of clients, staff and visitors are protected.

7.1.1 All staff are trained and aware of how to reduce risk, including:

a) identifying, assessing and reporting risk situations

b) reducing unsafe behaviour or situations

c) preventing and controlling infection and

d) using equipment and supplies safely.

7.1.2 Security measures are taken to ensure the protection of clients, especially of those identified by

the UPHC Centre as being vulnerable, from assault, loss of property and other harm in the facility.

7.1.3 Security measures are taken to ensure the protection of staff, especially of those identified by the

UPHC Centre as being vulnerable, from assault, loss of property and other harm, in all

workplaces including outreach facilities or in the community. .

7.1.4 Security measures are taken to protect facilities and assets from damage and loss.

7.1.5 Guidelines for major risks and hazards are available and known by staff.

Note: ILO Occupational Health and Safety (OHS), UN safety and security guideline

7.1.6 Hazards are identified by staff and recorded in a hazard register.

7.1.7 Hazards are assessed for significance in terms of the likelihood of them happening and the

consequences of harm if they do.

7.1.8 Appropriate hazard controls are put in place for hazards assessed as significant

by:

a) eliminating them or

b) isolating them to reduce exposure to harm or

c) minimising their impact, e.g. by using barriers or warning notices.




7.1.9 Incidents, accidents, near misses and adverse events are managed using a set procedure which

includes:

a) reporting them on the appropriate form

b) investigating them promptly

c) dealing with them appropriately

d) using them to make improvements in line with any findings and

e) communicating results to staff and clients, where necessary.

7.1.10 Incident, accident, near miss and adverse event data are collated centrally into a central record,

analysed and reported to the appropriate committee or management team for information and action

as required.

7.1.11 Staff understand their responsibilities to report workplace injuries, e.g. needle stick injuries, and

illnesses, e.g. MRSA, that have or might have harmed anyone in the workplace.

7.1.12 Staff are provided with, and trained in the use of protective equipment, e.g. gloves, aprons, masks

and use the equipment in accordance with a relevant guideline.

Note: National Universal Precaution Guideline by UNICEF

7.1.13 Information about fire safety, gas leakage, earthquake response and other necessary emergency

procedures are posted on the facility wall, and staff understand their responsibilities in carrying

out these procedures.

7.1.14 Fire drills are practised on a regular basis, e.g. six monthly.

7.1.15 Staff at risk are protected by the provision of immunisation for infections such as Hepatitis B and

tetanus.

7.2 Staff follow correct aseptic techniques and wash their hands between clients.

7.2.1 Healthcare providers wash their hands or disinfect them with antiseptic gel between clients and

between procedures.

Note: Universal Precautions Guideline, Chapter on Handwashing, WHO/Unicef

7.2.2 Soap (where possible liquid soap) and water or antiseptic gel/solution are available at the

handwashing point(s) inside the consulting/examination room(s) and a clean hand towel or

alternative is available.

7.2.3 Hand washing instructions are posted above the handwashing point(s).

7.2.4 Health workers perform procedures using aseptic techniques in line with SOPs or guidelines, e.g.

wound dressing, suturing, injections and immunisations.

Note: Universal Precautions Guideline, WHO/Unicef

7.3 Instruments and other articles are decontaminated, cleaned, sterilised, packed and

stored to prevent contamination.

7.3.1 Staff are trained in decontamination, cleaning, HLD, sterilisation and safe handling of instruments




and other items and follow established guidelines.

Note: Universal Precaution Guideline, WHO/Unicef

7.3.2 There is a specified area for instrument processing to prevent contamination of clean, HLD and

sterile items.

7.3.3 Instructions for instrument processing are displayed on the wall.

7.3.4 A shelf-life system (first in, first out) to store sterile or HLD items is in place, with no sterilised

instruments being stored for more than 24 hours.

7.4 Sharps, needles and single use items are used and disposed of safely.

7.4.1 Processes and disposal systems for single-use items, e.g. gloves and disposable syringes, are

available and used.

7.4.2 Labelled puncture-proof safety boxes with only a small opening for disposing of syringes with

needles and other sharp objects are available at point of use.

7.4.3 Instructions for safe disposal of sharps and needles are displayed on the walls.

7.5 Soiled linen and general laundry are separately collected and cleaned to avoid

contamination and infection.

7.5.1 Staff follow written procedures for handling and cleaning soiled linen.

7.5.2 Staff follow written procedures for handling and cleaning general laundry.

7.6 Waste is segregated at the source, collected, handled and disposed of properly to

avoid injuries and contamination.

7.6.1 Medical waste, e.g. sharps, placenta, dressings, are disposed of in a accordance with a

documented procedure which includes use of a separate covered bin.

Note: National Guideline on Universal Precautions, WHO/Unicef

7.6.2 Staff are trained in documented SOPs for segregation, collection, handling and disposal of waste

and implement these processes.

See also 6.8.for facility compound rubbish management.

7.6.3 Instructions for waste segregation, collection, handling and disposal of waste are displayed on the

walls.




SECTION B: SERVICE PROVISION

8.0 SERVICE ACCESS

8.1 Clients and their attendants are received and registered promptly and in a respectful

manner.

8.1.1 Clients are received and treated in a kind, courteous and non-judgmental manner irrespective of

their sex, age, race, occupation, religion or physical appearance.

8.1.2 The registration is completed promptly for all clients and a token number/registration chit is given

to all clients.

8.1.3 The time the client arrives is documented during registration process and put on the registration

chit/token and monitored.

8.2 Clients are seen in order of priority.

8.2.1 A system using the time of arrival recorded during registration process is used to prioritise clients.

8.2.2 A system is in place for documenting the time of treatment of each client.

8.2.3 The order prioritises extremely sick clients/emergencies first, those of extreme ages (elderly and

babies) second and then others.

8.2.4 Emergency cases are seen by the healthcare provider immediately (at least within ten minutes),

and those of extreme ages within 30 minutes.

8.2.5 Non-priority clients are seen on a first-come first-serve basis.

8.2.6 Waiting times are no more than one hour and are monitored.

8.2.7 Waiting times are analysed and results used to improve services.

8.3 Providers use a defined process for referring cases (emergencies and others).

8.3.1 A referral directory and active referral network is in place and documented.

8.3.2 Standard Operating Procedures (SOPs) exist for referrals, including identification of types of

clients who need to be referred and client transport.

8.3.3 Referral forms provide sufficient information to allow continuity of care and are available in the

facility

8.3.4 The facility identifies various emergency transport options for referral of emergency cases, e.g.

telephone number of taxi drivers, community ambulance services, stretcher bearers.




8.3.5 The facility provides some type of assistance for moving a sick client to a referral facility such as

communication to the next level or helping client or client caretakers arranging community

transport.

9.0 CLIENT CARE AND TREATMENT

9.1 The privacy and confidentiality of clients is ensured during consultation and

examination.

9.1.1 Consultations and examinations are done one by one in privacy, e.g. behind closed doors, in

rooms with curtained windows, and behind screens.

9.1.2 Healthcare providers ensure confidentiality at all times including during consultation and

examination.

See also HRM 5.2.6

9.1.3 Examinations and any interventions are carried out only in the presence of those persons who are

necessary for the examination or intervention unless the client consents or requests otherwise.

9.2 All clients receive appropriate assessment and diagnosis.

9.2.1 Basic assessment is undertaken and includes temperature, pulse, blood pressure, and symptom

identification including weight and height if needed, e.g. ANC, and is recorded appropriately.

9.2.2 Basic assessment for children under five includes weight, height, immunisation status,

temperature, level of consciousness and symptom identification.

9.2.3 A client history is taken and documented, together with the clinical examination results and the

diagnosis, and allocated space for the client`s history is included in the relevant documents.

9.2.4 Diagnostic tests are ordered to support a provisional diagnosis if found necessary during initial

assessment.

9.2.5 Other checks and examinations are carried out in accordance with approved checklists and

results are documented accordingly.

9.2.6 A process is used for assessing and relieving pain according to the current state of knowledge.

9.2.7 A process is used for assessing clinical risks, e.g. allergies, antibiotic resistance, risks associated

with long term conditions, and the findings are documented together with the client`s history.

9.2.8 Clients are given an opportunity to express their concerns and the healthcare provider listens

carefully to what they say, using open ended questions (why, who, what, when, how) to obtain

information.

9.3 Care and treatment are planned, managed and followed up.

9.3.1 Treatment and care management are planned with the client in accordance with the assessment,

test results, diagnosis and care management guidelines.




9.3.2 The healthcare provider explains to the client the diagnosis, desired results, care management,

and follow-up.

9.3.3 The healthcare provider takes feedback from the client to ensure the client understands the

message communicated.

9.3.4 The timeliness of delivering treatment and care, how often they are delivered, and the methods

used are in accordance with the agreed plan of treatment and care and approved guidelines.

9.3.5 The healthcare provider gives specific advice and counselling about ongoing treatment and care

as needed and key points are given in writing to the client or other appropriate health information

material is provided. .

9.3.6 Referrals to other services are made when required and documented accordingly.

9.3.7 Appointments for future care are made if applicable in accordance with approved protocols and

are documented.

9.3.8 A system is used to remind clients of their next appointment for all ANC, PNC, EPI, FP/DEPO,

DOTS clients.

9.3.9 Outreach services, where they exist, are used to motivate clients to attend appointments and to

help them to ensure compliance with their treatment and activities are documented.

9.3.10 Results of previous care are used in follow-up visits (if records are available), clients re-assessed

when results indicate the need and care and treatment revised as necessary.

9.4 Treatment guidelines and protocols (including existing national guidelines and

protocols) are available at the facility, form the basis of regular training for

relevant staff and are followed in providing care to the clients.

9.4.1 Health care providers have access to guidelines for all ESD components as listed below but not

limited to them:

i. First Aid and Emergency Care, injury management, minor surgical procedures

ii. IMCI, ANC, PNC, Family planning

iii. Disease Early Warning System (DEWS) case definitions and investigation

iv. Malaria, TB & DOTS, HIV and AIDS, VCT, PMTCT, STI/RTI, Diarrhoea, Polio, Hepatitis,

Dengue fever, Avian Influenza, Measles, ARI, Hypertension, Diabetes, Anaemia,

Common skin problems, EPI

v. Dental care

vi. Mental health and psychosocial support.

9.4.2 Staff are regularly trained to follow these guidelines, according to a documented schedule.

9.4.3 Healthcare providers provide services according to these guidelines.

9.4.3 Justification is available for variations from the guidelines and documented.

9.5 All children who attend the facility have their weight plotted correctly on their

growth monitoring chart or in their individual client record and have their




immunisation status checked.

9.5.1 All children aged under five attending the facility are weighed.

9.5.2 Weight is accurately plotted on the child‟s growth monitoring chart or in their individual client

record and follow-up action taken based on the plot.

9.5.3 Immunisation status is checked according to the EPI card or register/record and missing

immunisations are given as needed.

9.5.4 Weight and vaccination information is given to the parent/carer.

9.6 Healthcare providers regularly educate their clients on health issues in a way that

is easy to understand.

9.6.1 There is a designated area, e.g. waiting area or examination room, for health education for groups

of clients.

9.6.2 Healthcare providers are assigned to conduct group health education sessions which are held at

least four times a month and the session roster is displayed in the facility.

9.6.3 Healthcare providers use the following materials during client counselling/education sessions:

posters, family planning material, brochures, leaflets, flipcharts and cue cards.

9.6.4 Health education messages (posters and charts with pictures and minimal text) are visibly posted

in prominent areas within the facility.

9.6.5 Health education written material is available for clients to read and take home.

Note: Client records are covered in 4.4

10.0 MEDICATION AND VACCINATION MANAGEMENT

10.1 Prescribing of medications is safe, efficient and effective and promotes best

possible treatment outcomes.

10.1.1 An essential drug list:

a) is available in the facility

b) staff are trained and

c) the essential drug list is followed.

10.1.2 Good prescribing practice guidelines (including contraindications) for drugs:

a) are available in the facility

b) staff are trained and

c) guidelines are followed.

10.1.3 Policies for antibiotic prescribing are established, followed by medical practitioners and include:

a) minimal use of broad-spectrum agents to minimise the development of resistant bacteria

b) using prophylactic antibiotics only where their efficacy has been established.




10.1.4 All prescriptions are legible and duly signed by a doctor, clearly stating the doctor`s name, and

include the following:

i. Name

ii. Age

iii. Sex

iv. Diagnosis, provisional or confirmed

v. Dose, frequency, duration and timing, e.g. before/after/with meal

vi. Dosage form

vii. Strength of medications.

10.1.5 The client is provided with written and verbal information on the prescribed medicine including:

i. the costs if applicable

ii. the potential benefits and adverse effects and

iii. the risks of ignoring instructions, including not completing the prescribed course of

medicine.

10.1.6 The healthcare provider/dispenser instructs the client about the medication, the amount of

medication to take, what time of the day it should be taken and for how long it should be taken.

10.1.7 The healthcare provider/dispenser checks that the client understands the instructions.

10.2 Essential drugs and supplies are available at all times during open hours.

10.2.1 Stock keeping is clearly assigned to one or more responsible staff members.

10.2.2 Stock cards are up to date and correspond to physical stock.

10.2.3 There is a stock for at least two months of the essential drugs and emergency drugs in

accordance with government approved lists.

10.2.4 There is a documented process for checking dates of expiry and for using earliest expiring drugs

first.

10.2.5 No expired drugs are in stock and there is a documented process in place for separating,

discarding and disposing of expired drugs.

10.2.6 Monthly utilisation rates of essential drugs are calculated and an appropriate system is in place to

prevent stock-outs.

10.2.7 Staff responsible for stock management and storage are trained and refresher courses are

conducted annually in effective drug management.

10.3 Stock is stored to ensure that medications are kept safe.

10.3.1 Medicines are stored on shelves enabling:

a) protection from the adverse effects of light, e.g. glass windows painted white, dampness

and temperature extremes

b) freedom from vermin such as rodents and insects

c) adequate ventilation.




10.3.2 Adequate and secure storage facilities provided include:

i. lockable storage facilities, e.g. in a separate room

ii. a suitable metal cupboard or container for the storage of flammable and/or hazardous

material

iii. a functioning refrigerator which can be used by the pharmacy and has a sealed

compartment for drugs

iv. a separate metal cupboard, securely fixed to the wall or floor, for storage of controlled drugs

in compliance with drugs regulations.

10.4 Vaccines are properly stored in a temperature controlled refrigerator to maintain

the cold chain.

10.4.1 A Cold Chain procedure for vaccines is documented, staff are trained and the procedure is used

and includes clear directions on the following practices1:

i. Vaccine stock management including vaccine storage, potency, stock quantities, stock

records, and arrival report

ii. Equipment for vaccine transport and storage

iii. Maintenance of equipment

iv. Control and monitoring of temperature, e.g. temperature graph

v. Cold chain during immunisation sessions

vi. Syringes and needles and

vii. Breakdown of equipment and emergency actions to minimise risks.

10.4.2 There is evidence of refrigerator temperatures being recorded twice a day and action taken when

temperatures are outside the required level.

10.4.3 A vaccines and syringes stock register is maintained with vaccine expiry dates.

10.4.4 Instructions for cold chain maintenance and safety of vaccines during power break down and cold

chain failure are displayed.

1 Based on Safe Vaccine Handling, Cold Chain and Immunization: A manual for Newly Independent States,

EPI, WHO, Geneva, 1998




- SECTION C: ADDITIONAL CLINICAL STANDARDS

- 11.0 - MATERNITY SERVICES

11.1 Maternity Service staff are qualified, trained and available to provide safe, timely and

efficient services for mothers and their babies.

11.1.1 The maternity service is managed by a suitably qualified, registered and experienced Woman

Medical Officer, nurse or midwife.

See 5.3.2 re validation of credentials

11.1.2 Each woman accessing the maternity service is cared for by a suitably qualified, registered and

experienced nurse, doctor, senior midwife or lady health worker who she can contact for advice and

help throughout her pregnancy.

11.1.3 A trained mid-wife/nurse midwife is present at every birth.

11.1.4 Maternity centres that provide birthing services have 24 hour on-call cover from qualified medical

doctors.

11.1.5 A guideline on obtaining medical assistance at anytime during labour is used by nurses and

midwives.

11.1.6 An agreement exists with a referral hospital offering more comprehensive services for the provision

of necessary emergency maternity services not available in the UPHC Centre.

11.1.7 Regular training in maternal and neonatal resuscitation is carried out for medical and nursing staff

attending deliveries

11.1.8 A record of resuscitation training is kept in the UPHC

11.2 The work of the Maternity Services is guided by written policies and procedures

for key processes.

11.2.1 Written procedures and guidelines are consistent with the UPHC Centre‟s policies and functions

and are used for:

a) ante natal care

i. registration

ii. first visit check up

iii. birth planning

iv. identifying high risk pregnancy

v. tetanus immunization

b) care during delivery

i. planning, treatment and mode of delivery

ii. plan for managing pain during labour and delivery

iii. monitoring of labour and use of partograph

iv. active management of labour

c) post-natal care




i. breastfeeding post natal check for mother and baby

ii. counselling for parenthood, and the use of relevant educational material, for areas

such as family planning, congenital problems.

iii. immunization for mother (whenever applicable) and baby including vitamin-A

supplementation.

11.2.2 Referral guidelines for conditions such as multiple pregnancies, instrumental deliveries, C-

sections and congenital abnormalities exist and are followed by the staff

11.3 Accurate records are maintained and data is made available for analysis and to

improve services.

See also 4.4 re Client Records

11.3.1 Separate records are initiated and used for every mother and each baby.

11.3.2 After discharge, records are kept for each client and include:

i. Admission register

ii. Maternity notes (including birth/care plans) and partograph

iii. Delivery register

iv. Birth certificate(s)

v. Discharge summary.

11.3.3 Data is collected and available for analysis and quality improvement activities and includes:

i) Number of women attending ante-natal clinics

ii) Number of women with complications attending ante-natal clinics stratified by type and

whether pregnancy related

iii) Number of women referred to higher-level care during pregnancy

iv) Number of women referred to higher-level care during labour

v) Number of women referred to higher-level care after labour

vi) Number of deliveries (live and still births)

vii) Number of complicated deliveries

viii) Birth weight of infants and percentage of low birth weight (LBW) and very low birth weight

ix) Number of maternal deaths

x) Number of neonatal deaths.

11.4 Facilities and equipment are safe and adequate for the maternity services

provided.

11.4.1 Facilities and equipment specific to level of care are:

i. OB First Aid

Oxytocics, injectable antibiotics, anticonvulsants

ii. Basic EOC

OB First Aid + Assisted vaginal delivery, manual removal of placenta

iii. Comprehensive EOC

Basic EOC + Caesarean sections, blood transfusion.

11.4.2 The delivery room is equipped with functioning, safe and well maintained equipment specific for

deliveries including but not limited to the following:

i) Delivery table which can be turned to the Trendelenburg position

ii) Delivery sets, baby weighing scale, fetoscope




iii) Resuscitation equipment, oxygen and drugs for infants and mothers

iv) Intravenous crystalloid and plasma expanders

v) Lighting which is versatile enough to provide a restful environment and allow birthing

procedures to be performed.

vi) Equipment to maintain the room temperature

vii) Washing and toilet facilities for the comfort of the mother.

Note: This equipment is in addition to the equipment specified in 6.10.

11.4.3 Other equipment available in the facility includes but is not limited to:

i) Ultrasound machine for which trained personnel are available

ii) An incubator, with temperature adjustable for infants in need

iii) Separate oxygen supply to the incubator

iv) Phototherapy unit.

11.4.4 Privacy for mothers is maintained, e.g. when breast-feeding.

11.4.5 A waiting area is provided for attendants

12.0 LABORATORY SERVICES

12.1 The medical testing laboratory is managed and organised to provide efficient and

effective laboratory service.

12.1.1 The UPHC Centre laboratory is managed by suitably qualified and experienced personnel.

12.1.2 A pamphlet and/or display board outlines

i. the list and prices of services offered

ii. types of samples required

iii. waiting times for sample collection and

iv. approximate reporting time for tests.

12.1.3 Pamphlets or other instruction material are available where the client is required to follow steps for

specific tests.

12.1.4 For any infection identified in client samples that could provide a risk to the UPHC Centre staff,

clients and/or the community according to the notifiable disease list, laboratory staff inform in writing

the designated staff member.

12.1.5 Staff follow written Standard Operating Procedures in compliance with legal requirements.

See also 12.2.9

12.1.6 Staff are involved on a regular basis in a quality management programme to monitor and improve the

laboratory quality.

12.2 Laboratory samples and tests are managed to maximise accuracy of testing and

minimise risks to clients and staff.

12.2.1 A requisition form is used and includes the following:

i. Client information - full name, age, sex, contact number

ii. UPHC registration number and provision for laboratory ID number




iii. Test required

iv. Type of sample

v. Relevant clinical findings

vi. Probable diagnosis

vii. Sample collection time

viii. Name of sample collector.

12.2.2 Staff follow and communicate to clients, verbally and in writing, procedures for the clients‟ preparation

for tests.

12.2.3 Samples collected are labelled with the client‟s name, UPHC Centre registration number plus

laboratory ID number, and date and time of collection.

12.2.4 Mechanisms are in place to identify urgent samples.

12.2.5 Sample containers are designed to enable safe transport.

12.2.6 A laboratory register contains the following:

i. Date and time of receipt by the laboratory

ii. UPHC registration number plus laboratory ID number

iii. Client full name

iv. Age and gender

v. Identification of sample source, e.g. blood, tissue, urine, fluids

vi. Name of the test(s)

vii. Test results

viii. Name of technologist who performed test

ix. Date and time of reporting result.

12.2.7 Laboratory registers are readily accessible to laboratory staff.

12.2.8 Results are recorded on the reporting/result form.

12.2.9 Staff follow written, dated and signed Standard Operating Procedures (SOPs) for:

i. Client preparation for tests

ii. Completion of test request forms

iii. Reporting of test results

iv. Disposal of laboratory result forms

v. Reporting results verbally

vi. Emergency and urgent requests

vii. Storage of samples and blood in the laboratory

viii. Acceptable parameters for test requests and reporting times

ix. Sample collection

x. Sample handling

xi. Sample labelling

xii. Sample transportation

xiii. Testing

xiv. Sample retention

xv. Sample storage

xvi. Disposal of samples, including blood and body fluids.




12.2.10 Signed and dated SOPs are readily available to staff in the laboratory.

12.2.11 Clearly labelled, separate containers are used for disposal of hazardous and infectious waste.

12.3 All persons are protected from potential hazards in the laboratory.

12.3.1 A mechanism is in place to restrict access to the laboratory to authorised personnel only.

12.3.2 Health and safety policies, current relevant hazard notices and safety action bulletins are displayed

as required or are readily available to staff.

12.3.3 Appropriate equipment is used for the safe handling of hazardous materials.

12.3.4 Action to be taken in the event of an accidental exposure and/or occupational illness is known to all

staff and is clearly documented.

12.3.5 Staff are offered immunisations relevant to their type of work and emergency immunisations where

required, based on written policies.

12.3.6 Mechanisms are documented and used for handling accidental spillage or other adverse events.

12.4 Safe and adequate facilities and equipment are provided to meet the needs of the

clients served by the laboratory.

12.4.1 Laboratory and office space are sufficient to enable staff to carry out their jobs safely.

12.4.2 The laboratory is well lit and ventilated.

12.4.3 Staff have adequate laboratory equipment to carry out their jobs safely.

12.4.4 There are safe and sufficient storage facilities for reagents, consumables and test kits.

12.4.5 There are safe and adequate storage facilities for sample preservation.

12.4.6 Functioning emergency electrical supply for refrigerators/freezers is available and regularly assessed

for readiness.

12.4.7 A system for regular inspection, calibration and maintenance is used for all laboratory equipment.



GLOSSARY

Term Definition

Acceptability The degree to which services, including care and treatment, reflect the needs and

preferences of clients and their families.

Access Ability of clients or potential clients to obtain required or available services when

needed within an appropriate time. Also accessibility.

Accident Something which happens unexpectedly and unintentionally and which often

damages something or injures someone

Accountability Responsibility and requirement to answer for tasks or activities. This responsibility

may not be delegated.

Admission The process by with a client commences an episode of care or treatment.

Adverse event Event with negative or unfavourable reactions or results that are unintended,

unexpected or unplanned. Includes unexpected or dangerous reaction to a drug.

Agenda List of items to be dealt with at a meeting.

Annual plan The current action plan for the year for achieving organisation goals and objectives,

which includes the processes, actions and resources needed for this. Also

operational plan.

Antiseptic gel Healthcare personal hand wash, hand alcohol or a hand antiseptic used as a

supplement or alternative to handwashing with soap and water.

Appropriateness The degree to which service is consistent with a client‟s expressed requirements

and is provided in accordance with current best practice. Also appropriate.

Aseptic Free from living pathogenic organisms.

Assessment Process by which the characteristics and needs of clients, groups or situations are

evaluated or determined so that they can be addressed. The assessment forms the

basis of a plan of care, treatment or action.

Assessor External reviewer, assessor of achievement of or compliance with agreed

standards, principles and/or criteria.

Atraumatic Non-cutting.

Autoclave Apparatus for sterilizing instruments by means of steam under pressure.

Barrier Anything that serves to obstruct access or prevents progress.

Belief Feeling of certainty that something exists or is true.

Benefit Something that improves or promotes health.

Best practice Approaches that have been shown to produce superior results, selected by a



Term Definition

evidence systematic process, and judges as „exemplary‟, „good‟ or „successfully

demonstrated‟. Also best practice, best practice guidelines, practice

guidelines.

Broad spectrum

agent

Antibiotic with activity against a wide range of disease-causing bacteria; overuse

can result in drug resistant bacteria.

Budget Financial plan for a period of time.

Calibration The comparison of a measurement instrument or system of unverified accuracy with

a measurement instrument or system of known accuracy, in order to detect any

variation from required measurement performance.

Care plan A document that outlines the care and treatment to be provided to a client, a set of

actions the healthcare provider will implement to resolve health problems identified

by assessment or to achieve the client‟s goals and needs. Also birth plan,

treatment plan.

Chief executive The person appointed by the governing body of an organisation to act on their

behalf in the overall management of the organisation. A range of other titles may be

used including general manager, manager, director or executive director.

Choice A decision to receive certain services, refuse services or withdraw consent to

services.

Clients Individuals being served or provided with care or treatment by the organisation. Also

patients, users, consumers.

Client groups Different categories or groupings of clients or potential clients.

Client record A record of all data from the multidisciplinary team, in chronological order, on a

given client. It includes information about the client‟s life and health history, needs,

interventions by providers and results.

Charter of client

rights

A clear statement of the rights of all clients of the organisation, which all personnel

are required to recognise and protect and which is supported by organisation and

service policies, procedures and resource levels.

Coercion The use of force to persuade someone to do something which they are unwilling to

do.

Cold chain Temperature-controlled supply chain, uninterrupted series of storage and

distribution activities which maintain a given temperature range. Used to protect the

safety and effectiveness of vaccines.

Community Collectivity of individuals, families, groups and organisations that interact with one

another, cooperate in common activities, solve mutual concerns, usually in a

geographic locality or environment.

Complaint Expression of a problem, an issue, or dissatisfaction with services that may be

verbal or in writing.



Term Definition

Conditions of

employment

Standard provisions such as leave entitlements, hours of work, pay, disciplinary and

grievance conditions.

Confidentiality Guaranteed limits on the use and distribution of information collected from

individuals or organisations.

Conflict of interest Occurs when an entrusted individual or organisation has an interest that might

compromise their actions.

Consent Voluntary agreement or approval given by a client.

Consumables Goods that are used regularly and need to be replaced often.

Continuity The provision of coordinated services within and across programs and

organisations, and over time.

Coordination The process of working together effectively with collaboration among providers,

organisations and services in and outside the organisation to avoid duplication,

gaps, or breaks.

Criteria Specific steps to be taken, or activities to be done, to reach a decision or a

standard, measurable elements of a standard.

Cultural

appropriateness

The design and delivery of services are consistent with the cultural values of clients

who use them.

Data Unorganised facts from which information can be generated.

Decontamination The removal of dangerous substances, rendering harmless by the removal or

neutralization of poisons or radioactivity.

Discrimination Unfair treatment of a person because of their racial group, gender, religion or

perceived difference, action based on prejudice.

Education Systematic instruction and learning activities to develop or bring about change in

knowledge, attitudes, values or skills.

Effectiveness The degree to which services, interventions or actions are provided in accordance

with current best practice in order to meet goals and achieve optimal results. Also

effective.

Efficiency The degree to which resources are brought together to achieve desired results most

cost effectively, with minimal waste, re-work and effort. Also efficient.

Ethics Acknowledged set of principles that are deemed morally correct and which guide

professional and moral conduct.

Evaluation Assessment of the degree of success in meeting the goals and expected results

(outcomes) of the organisation, services, programs or clients. Also evaluate.

Evidence Data and information used to made decisions. Evidence can be derived from



Term Definition

research, experiential learning, indicator data, and evaluations. Evidence is used in

a systematic way to evaluate options and make decisions.

Exploitation Any abuse of a position of trust or exercise of undue influence, taking advantage of

a person or situation for one‟s own ends.

Feedback Information or comment provided by clients in response to a service or query.

Flowchart Type of diagram representing the steps in a process.

Goals Broad statements that describe the outcomes that are being sought and provide

direction for day-to-day decisions and activities. Organisation goals support the

mission of the organisation.

Governance The function of determining the organisation‟s direction, setting objectives and

developing policy to guide the organisation in achieving its mission.

Governing Body Individuals, group or agency with ultimate authority and accountability for the overall

strategic directions and modes of operation of the organization. Also Management

Committee.

Guidelines Principles guiding or directing action.

Harassment Behaviour such as persistent questioning or attacks that upsets or annoys

someone. Also sexual harassment.

Hazard A situation which poses a level of threat to life, health, property or environment.

Also hazardous.

Healthcare provider A person who provides the health care for or on behalf of the organisation, group or

agency, e.g. a doctor, nurse, allied health professional.

Human resources The personnel requirements of the organisation.

Incidents Events that are unusual, unexpected, may have an element of risk, or that may have

a negative effect on clients, groups, staff, or the organisation.

Indicator Performance measurement tool that is used as a guide to monitor, evaluate, and

improve the quality of services. Indicators relate to structure, process, and

outcomes and are rate based, i.e. have a numerator and denominator so that they

can be compared and benchmarked.

Information Data that is organised, interpreted and used. Information may be in written, audio,

video or photograph form.

Information

management

Planning, organising, analysing and controlling data. Information management is an

organisation-wide function that includes clinical, financial and administrative

databases, documents and records and applies to both computer0based and

manual systems.

Informed consent Voluntary agreement or approval given by a client after being given full information



Term Definition

about the proposed intervention or plan of care.

Intervention Action taken to treat or provide care or other service designed to improve health

outcomes.

Leadership Ability to provide direction and cope with change. It involves establishing a vision,

developing strategies for producing the changes needed to implement the vision;

aligning people; and motivating and inspiring people to overcome obstacles.

Job description Description of a job including its nature and scope, duties and responsibilities,

general and specific accountabilities and the qualifications required to do it.

Management Setting targets or goals for the future through planning and budgeting, establishing

processes for achieving those targets and allocating resources to accomplish those

plans. Ensuring that plans are achieved by organising, staffing, controlling and

problem-solving.

Medical waste Waste products that cannot be considered general waste, produced from healthcare

premises, often consisting of infectious waste that could lead to the spread of

infectious diseases.

Mission A broad written statement in which the organisation states what it does and why it

exists. The mission sets apart one organisation from another.

Monitoring Being aware of the state of a system by observing a situation or process for any

changes which may occur over time, usually using a measuring tool or device.

Near miss Unplanned event that did not result in injury, illness or damage but had the potential

to do so and only a fortunate break in the chain of events prevented an injury,

fatality or damage.

Need Physical, mental, emotional, social or spiritual requirement for well-being. Needs

may or may not be perceived or expressed by those in need. They must be

distinguished from demands, which are expressed desires, not necessarily needs.

Objective A target that must be reached if the organisation is to achieve its goals. It is the

translation of the goals into specific, concrete terms against which results can be

measured.

Organogram A diagram that shows the structure of an organisation and the relationships and

relative ranks of its parts and positions/jobs. Also organisation chart.

Organisation Comprises all sites/locations under the governance of, and accountable to, the

governing body/owner(s).

Orientation The process by which staff become familiar with all aspects of the work environment

and their responsibilities.

Outreach services Services of the organisation provided in specific communities, not necessarily within

a facility.



Term Definition

Participatory

management

Practice of empowering employees to participate in organisation decision-making.

Partograph Tool that can be used by healthcare providers during the birthing process to assess

the progress of labour and identify when intervention is necessary.

Performance

evaluation

The continuous process by which a manager and a staff member review the staff

member‟s performance, set performance goals, and evaluate progress towards

these goals. Also performance appraisal, review.

Performance

targets

Expected levels of performance, used to assess performance achieved compared to

planned or expected performance.

Policies Written statements which act as guidelines and reflect the position and values of the

organisation on a given subject.

Prevention Activities designed to prevent the occurrence or progression of death, disease,

disability or dysfunction (WHO).

Procedures Written sets of instructions conveying the approved and recommended steps for a

particular act or series of acts.

Processes Series of interrelated activities and communications which accomplish services.

Protection Strategies to ensure an effective response to health risks.

Protocol A descriptive practice guideline, developed through research and expert opinion, on

management of a typical clinical case in a typical situation.

Qualified Having the credentials for, being professionally and legally prepared, responsible

and authorised to perform specific acts.

Quality The degree of excellence, extent to which an organisation meets clients‟ needs and

exceeds their expectations.

Quality activities Activities which measure performance, identify opportunities for improvement in the

delivery of services, and include action and follow-up.

Quality assessment Planned and systematic collection and analysis of data about a service, usually

focused on service content and delivery specifications and client outcomes

Quality

improvement

Ongoing response to quality assessment data about a service in ways that improve

the processes by which services are provided to clients.

Referral A direction from another provider or organisation to provide service for a client; or

direction to or on behalf of the client to obtain additional services from another

organisation or provider.

Register A book or document in which records of acts, events, names, etc. are kept

Registration The act of making an entry in a register or



Term Definition

Process by which a government authority grants permission to an individual

practitioner or healthcare organisation to operate or to engage in an occupation or

profession. Also registered.

Research Contribution to an existing body of knowledge through investigation, aimed at the

discovery and interpretation of facts.

Results (Outcomes) The consequences of a service or intervention.

Resources Inputs that determine the capacity of the organisation, e.g. personnel, finances,

equipment and supplies.

Rights Something that can be claimed as justly, fairly, legally, or morally one‟s own. A

formal description of the services that clients can expect and demand from an

organisation.

Risk Chance or possibility of danger, loss or injury. This can relate to the health and

well-being of staff and the public, property, reputation, environment, organisational

functioning, financial stability, market share and other things of value.

Safety The degree to which the potential risk and unintended results are avoided or

minimised.

Secure Certain to be safe, certain not to fail. Also security.

Services Products of the organisation delivered to clients, or units of the organisation that

deliver products to clients.

Sluice Usually sluice sink for rinsing contamination off linen.

Staff Employees of the organisation.

Stakeholder Individuals, organisations or groups that have an interest or share in services.

Standard A desired and achievable level of performance against which actual performance is

measured.

Standard Operating

Procedures

Set of detailed, written instructions, having the force of a directive, to achieve

uniformity or standardization of the performance of a specific function.

Sterilisation Act or process, physical or chemical, which destroys all micro-organisms, including

spores.

Stock control Process of maintaining inventory data on the quantity, location and condition of

supplies.

Strategic plan A formalised plan that establishes the organisation‟s overall goals and that seeks to

position the organisation in terms of its environment.

Strategies Methods for achieving the goals in the strategic plan.



Term Definition

Support The action of enabling, encouraging, making possible, assisting through various

means, physical, emotional, verbal, resources.

Surveillance The process of data collection, collation and analysis for the purpose of

characterizing groups of risks and identifying control strategies, and the timely

dissemination and feedback of data to those who need to know.

System Management of a group of separate activities or processes in an orderly fashion to

achieve a common goal, e.g. medication management system, quality management

system.

Trendelenburg

position

A position in which the body is laid flat on the back with the feet higher than the

head.

Utilisation review The examination and evaluation of the appropriateness of the use of an

organisation‟s or service‟s resources.

Values Principles, beliefs or statements of philosophy that guide behaviour and that may

involve social or ethical issues.

Verbal autopsy Method of finding out the cause of a death based on an interview with next of kin or

other caregivers.

Vermin Insects and rodents that cause problems or harm to people or animals.

Vision Description of what the organisation would like to be.

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