Action plan
Stan Unmet Stand Current Action Responsible Time
d n. standards ard status Line
1.1 Continuous water 0 Continuity Facility mgt
supply is available 1 should be
maintained
Adequate backup 1 0 There should be Facility mgt
water source is tanker and
available when rotos
there is
interruption from
the main source
Telephone service 1 0 There should be Facility mgt
is available for common ICT Head
internal telephone
communication service
at least one 3 0 There is hand Facility mgt
functioning hand hygiene stations
hygiene station but it should
per 10 beds with have water,
soap and water or soda or alcohol
alcohol based
hand rubs in all
surgical wards
written, up-to-date 1 0 Written or up- S. Department
protocols and to-date posters head
awareness raising should have to Head Nurse
materials (posters) be visibly
on cleaning and posted
disinfection, hand
hygiene, operating
and maintaining
water, sanitation
and hygiene
facilities, safe
waste
management are
available at all
areas and are
visibly posted
sanitation 6 3 Sanitation
facilities are facility should
appropriately be
illuminated at appropriately
night separated for
accessible to
people with staff and
limited mobility patients also
gender separated based on
for staff and gender. There
patients should have
include at least adequate
one toilet that illuminated and
meets menstrual
with soap and
hygiene
water
management
needs
hand washing
stations with soap
and water
adequate number
(at least 1 latrine
per 20 users for
inpatient settings
sufficient funds is 3 0 Sufficient funds CEO
allocated to should be
support allocated….
rehabilitation,
improvements and
ongoing operation
and maintenance
of water,
sanitation,
hygiene and
health-care waste
services
suggestion box, 1 0 Suggestion box
register, and complaint
complaint office should be
handling office is available for
available for client complaint
handling
compliant of
clients and their
families
suggestions and 5 0 There should be
complaints are formal
reviewed in the complaint and
day to day HDA suggestions
and appropriate measure
measures are
taken when
needed
Clients and 10 7 Sanitation and Facility mgt
families attending energy services
the health facility should be
were satisfied continuously
with the water, available
sanitation and
energy services
and would
recommend the
health facility to
friends and family
all health-care 8 3 Water, Facility mgt
staff are satisfied sanitation and
with the water, energy service
sanitation and should be
energy services fulfilled
and believed that according to
such services their need as
contribute
much as
positively to
possible
providing quality
care
1.4 Prescribed 10 8 All prescribed Head Lab
investigations are investigation
available at the should be
facility availed at the
facility
2.2 Staffs know how 8 4 Skill gap on Department of
to prepare 0.5% head
Chlorine solution preparation of
senior
0.5% chlorine management
team
should be
Quality mgt
solved office
all OR and 8 2 Good working CEO of JUMC
surgical ward environment S. Department
staffs reported to should be head
be “highly created, smooth Head nurse
satisfied” with relationship and
their job in communication
relation to the among staff as
working
well as good
environment and
team sprit
support of
hospital
management
No staff in OR 8 2 Good working CEO of JUMC
and surgical ward environment S. Department
is actively should be head
considering created, smooth Head nurse
looking for a new relationship and
job because of communication
poor working among staff as
environment and well as good
poor hospital team sprit
management
support
a written, up-to- 1 0 There should be S. Department
date quality-of- a written, up-to- head
care improvement date quality-of- Quality mgt
plan and patient- care office
safety program is improvement
present in OR and plan and
surgical ward patient-safety
program is
present in OR
and surgical
ward
a written, up-to- 1 0 Maintaining a CEO
date, leadership written up to S. Department
structure, date leadership head
indicating roles structure,
and indicating roles
responsibilities and
with reporting responsibilities
lines of with reporting
accountability is lines of
present in OR and accountability is
surgical ward present in OR
and surgical
ward
Major surgeries 10 2 Productivity Human
per FTE surgeon issue in resource(HR)
in the facility (last association with S. Department
month) efficiency head
should be
improved
Delay for elective 10 7 Dalliance on Liaison
surgery (last elective surgery S. Department
month) should be head
improved
3.1 Pre-Operative 10 9 Almost all Head nurse
Assessment is patients shall
done for all get pre-
surgical patients operative
(P/E , results of assessment
lab
investigation,
diagnosis
and proposed
surgery)
All lab tests were 10 3 All lab tests Lab Head
done in the same must be done in
facility the same facility
3.2 Protocol for hand- 1 0 Protocol for S. department
overring and handing-over head
consultation and consultation
mechanisms are mechanisms are
present present should
be maintained
Established 10 0 Preparing S. department
procedure of handing over head
handing over is protocol
present while
receiving patient
from OR to
Wards and ICU
(transfer form
documented)
Interdepartmental 10 4 Reducing S. department
or inter duration of head
professional interdepartmen
consultations are tal or inter
affected not more professional
than 2 hours consultation
3.4 Anesthetic 10 8 Anesthetic S. department
evaluation was evaluation head
done should be done
for all clients
Cross matched 10 7 Always withhold Lab head
Blood prepared Cross matched
Blood
3.5 Surgical Site is 10 4 Mark surgical Head nurse
marked before site for all
entering into OT clients before
to prevent wrong entering to OT
site and wrong
surgery
Sponge and 10 7 Implement Head nurse
Instrument Count sponge and
Practice is instrument
implemented count practice
3.6 Anesthesia plan is 10 7 Document S. department
documented Anesthesia plan head
before entering before entering Head nurse
into OT into OT
3.6 Post anesthesia 10 7 Do Post S. department
status is anesthesia status head
monitored and monitoring and Head nurse
documented documentation
5.1 Surgical patients 10 4 Opportunity S. department
are given the should be given head
opportunity to to clients to Head nurse
discuss their discuss their
concerns and concerns and
preferences preferences
health-care staffs 10 7 Health care S. department
demonstrate the staffs correctly head
following skills: demonstrate Head nurse
active listening, expected skills Quality mgt
asking questions, office
responding to
questions,
verifying client’s
and their families
understanding,
and supporting
client’s in
problem- solving
surgical patients 10 6 Client S. department
and their families satisfaction head
cared in the must be Head nurse
facility expressed improved Quality mgt
overall office
satisfaction with
the health services
Surgical patients 10 7 Health Head nurse
and their families education
cared in the program should
facility reported be functional
that they were
satisfied with the
health education
and information
they received
from the care
providers.
Patient and / or 10 6 Patient and / or Head nurse
attendant attendant
is informed about is informed
clinical condition, about
surgical finding clinical
and treatment condition…..
been
provided
6.2 The health facility 1 0 Prepare written CEO
has written up to date S. Department
accountability policy for head
mechanisms for redress in an
redress in an event of
event of mistreatment
mistreatment
The health facility 4 0 Prepare written CEO
has a written, up- up to date
to-date policy and policy
protocols
outlining clients
right to make a
