Quality statement Quality measure score Remark/ verification
criteria
SERGICAL SERVICE STANDARD 1: The health facility has an appropriate working system AND physical environment with adequate working
guidelines, utilities, medicines, supplies and equipment for providing quality surgical services
SS 1.1 Water, energy, sanitation, continuous electric supply with backup generator is available 1
hand-washing and waste-disposal
In case of power cut, generator is automatic or can be started 1
facilities are functional, reliable, safe
within 5 minute
and sufficient to meet the needs of
continuous water supply is available 1
staff, clients and their families
adequate backup water source is available when there is 1 Tankers, rotos
interruption from the main source
functional telephone is available in Liaison office 1
Telephone service is available for internal communication 1 Central operator or separate lines in
laboratory, pharmacy etc
leak-proof covered and labelled waste bins and impermeable 1 Verify in all wards for surgical
sharps containers available to segregate waste into 3 service 0 if missed / nonfunctional
categories even in one roo
at least one functioning hand hygiene station per 10 beds with 3 Verify in all wards for surgical
soap and water or alcohol based hand rubs in all surgical wards service 0 if missed / nonfunctional
even in one roo
Health-care staff demonstrate cleaning their hands correctly as 8 STAFFINTERVIW /Check the skills of
per the WHO 5 moments for hand hygiene (audit tool exists.) 4 HCWs
written, up-to-date protocols and awareness raising materials 1 Verify in all wards/rooms 0 if missed
(posters) on cleaning and / nonfunctional even in one room
disinfection, hand hygiene, operating and maintaining water,
sanitation and hygiene facilities, safe waste management are
available at all areas and are visibly posted
sanitation facilities are appropriately illuminated at night 6 1 for each bullet
accessible to people with limited mobility gender separated
for staff and patients include at least one toilet that meets
menstrual hygiene management needs hand washing stations
with soap and water adequate number (at least 1 latrine per 20
users for inpatient settings)
sufficient funds is allocated to support rehabilitation, 3 Document review
improvements and ongoing operation and maintenance of
water, sanitation, hygiene and health-care waste services
Curative and preventative risk-management plan exists for 1
managing and improving water, sanitation and hygiene services
suggestion box, register, complaint handling office is available 1
for handling compliant of clients and their families
suggestions and complaints are reviewed in the day to day 5
HDA and appropriate measures are taken when needed
Clients and families attending the health facility were satisfied 10 CLIENT INTERVIEW
with the water, sanitation and energy services and would
recommend the health facility to friends and family
all health-care staff are satisfied with the water, sanitation and 8 STAFF INTERVIW; 2 HCW and 2
energy services and believed that such services contribute Support staffs
positively to providing quality care
Clients and their families attending the health facility were 10 CLIENT INTERVIEW
satisfied with the power and lighting source and would
recommend the health facility to friends and family
rooms are well ventilated , illuminated, regularly cleaned and 1
maintained
SS1.2 The operation room has Adequate number of OR tables are present 4 , 4 if 100% 3 if 2 for Primary H. 4 for General H. (1
adequate rooms for provision of 50-100%, 0 if < septic) 7 for specialized H. (1 septic)
essential and emergency surgical 50%
services Demarcated 4 zones present (restricted, semi restricted, 1
transitional, non-restricted
CSR present with a minimum of 2 functional autoclaves 1
Changing Rooms with lockers present 1
Scrub area present 1
Recovery room is present 1
Toilet and showers present 1
clean and dirty utility rooms present 1
Duty room present 1
Mini-store present 1
SS 1.3 The facility ensures the safety of electrical establishment ensured - no temporary 1
physical safety of the infrastructure connections and loosely hanging wires
Floors of the ward are non-slippery and even 1
Windows/ ventilators if any in the OR are intact and sealed 1
SS1.4 financial protection given from Overall cost of care is not expensive 10 CLIENT INTERVIEW
cost of care Prescribed investigations are available at the facility 10 CHART REVIEW
The facility ensures that drugs prescribed are available at 10 CHART REVIEW
Pharmacy and wards
Surgical Service Standard 2: For every surgical patient , competent and motivated staff are consistently available to provide routine care and
manage complications
SS2.1 Every surgical patient has Adequate number of surgeons are available based on level of 5, 5 if 100% 3 if Primary H. – 1 IESO General H. – 2
access at all times to at least one hospital 50-100%; 2 if 25- General surgeon, 2 OB-GY and 1
skilled provider 50%; 0 if < 25% orthopedician Specialized H. – 3
General surgeon (1 subspecialist), 2
orthopedic surgeon, 3 obstetricians,
1 anesthesiologist, 10 anesthetist
A clear communication channels is present to reach staff on 1
duty at all times
a roster is used which is accessibly displayed in all areas, 1
detailing the names of staff on duty, the times of their shift and
their specific roles and responsibilities
All surgical patients were satisfied with the health-care 10 CLIENT INTERVIEW
received
SS2.2 surgical staff working in OR Staffs know how to prepare 0.5% Chlorine solution 8 (STAFF INTERVIW) Select 4 HCWs
and surgical ward have appropriate randomly and verify if they have the
competencies and skills mix to meet knowledge
needs during labor, childbirth and Staffs know how to process used instruments (instrumental 8 (STAFF INTERVIW) Select 4 HCWs
the early postnatal period processing) randomly and verify if they have the
knowledge
all Surgical patients were satisfied with the care and support 10 CLIENT INTERVIEW
from the facility staff
≥ 80% of OR and Sugical ward Staffs had a satisfactory 5 STAFF INTERVIEW Select 4 HCWs
performance appraisal on the previous month appraisal randomly and verify
all OR and surgical ward staffs reported to be “highly satisfied” 8 STAFF INTERVIEW Select 4 HCWs
with their job in relation to the working environment and randomly and verify
support of hospital management
No staff in OR and surgical ward is actively considering looking 8
for a new job because of poor working environment and poor
hospital management support
a written, up-to-date quality-of-care improvement plan and 1
patient-safety programme is present in OR and surgical ward
a written, up-to-date, leadership structure, indicating roles and 1
responsibilities with reporting lines of accountability is present
in OR and surgical ward
a mechanism is in place for regular collection of information on 1
patient satisfaction (monthly ) and provider satisfaction
(quarterly ) in OR and surgical ward
Surgical staff efficiency is monitored Major surgeries per FTE surgeon in the facility (last month) 10 10 if more than 45 or less than 45
but 0 surgical waiting list 7 if 30-45
5 if 20-30 2 if 10-20 0 if less than 10
Delay for elective surgery (last month) 10 10 if less than 1 month 7 if b/n 1-3
month 5 if b/n 3-6 month 2 if b/n 6-
9month 0 if more than 9 month
SS2.3 Every health facility has Monthly meeting is conducted to review data, monitor QI 5
managerial and clinical leadership performance and make recommendations to address Problems
that is collectively responsible for identified, and to celebrate those who have performed and
creating and implementing encourage staff who are struggling to improve.
appropriate policies and fosters an
environment that supports facility
staff to undertake continuous
quality improvement all OR and surgical ward leaders are trained in QI and leading 5
change (use of information, enabling behavior, continuous
learning)
Action plan is developed and implemented / implementation in 10
progress for the gaps identified from clients feedbacks, staff
feedbacks, data review, clinical audit feedbacks etc
Health facility leaders and front line workers are 5 See last month’s report and
communicated through established mechanisms (e.g. a management meeting minute
dashboard of key metrics) that track the performance of the
department
Surgical service standard 3: Evidence based care is provided for all surgical patients
SS3.1 The facility has defined and Pre-Operative Assessment is done for all surgical patients (P/E , 10 CHART REVIEW
established procedures for clinical results of lab investigation, diagnosis and proposed surgery
assessment and reassessment of the
patients.
Minimum preoperatively needed lab tests are done 10 CHART REVIEW
All lab tests were done in the same facility 10 CHART REVIEW
SS3.2 Facility has defined and Protocol for hand-overing and consultation mechanisms are 1 CHART REVIEW
established procedures for present
continuity of care of patient and Established procedure of handing over is present while 10 CHART REVIEW
referral receiving patient from OR to Wards and ICU (transfer form
documented)
Interdepartmental or inter professional consultations are 10 CHART REVIEW
effected not more than 2 hours
SS3.3Rational use of drugs is Antibiotics used for surgical prophylaxis are as per STG 10 CHART REVIEW
practiced recommendation
Drugs are prescribed under generic name only 10 CHART REVIEW
Antibiotics used for surgical prophylaxis - Dose, frequency, 10 CHART REVIEW
route and number of doses, timing of administration are as per
STG recommendations
SS3.4 All the necessary preoperative Anesthetic evaluation was done 10 CHART REVIEW
preparation are done before surgery Cross matched Blood prepared 10 CLIENT INTERVIW
Written consent taken 10 CHART REVIEW
Patient informed of the clinical condition, treatment plan and 10 CHART REVIEW and CLIENT
possible outcomes INTERVIEW
Date of surgery was preplanned at admission and informed to 10 CLIENT INTERVIW
the patient
No delay from the preplanned procedure day 10 CLIENT INTERVIW
Surgical safety checklist is used 10 CHART REVIEW
SS3.5 Facility has defined and There is procedure OT schedule 1
established procedures of Surgical
Surgical Site is marked before entering into OT to prevent 10 CLIENT INTERVIEW
Services
wrong site and wrong surgery
Sponge and Instrument Count Practice is implemented 10 CHART REVIEW
Post-operative monitoring is done before discharging to ward 10 CHART REVIEW
SS3.6 Facility has established Anesthesia plan is documented before entering into OT 10 CHART REVIEW
procedures for monitoring during
anesthesia Food intake status of Patient is checked 10 CHART REVIEW
Patients vitals are recorded during anesthesia 10 CHART REVIEW
Post anesthesia status is monitored and documented 10 CHART REVIEW
Surgical service Standard 4: The health information system enables the use of data for early and appropriate action to
improve care for surgical patients
SS 4.1 All surgical patients have a The health facility has registers, data collection forms, clinical 1 Observation
complete and accurate standardized and observation charts in place at all times, designed to
medical record routinely record and track all key care processes for surgical
patients (see annex)
all surgical patients have complete record of all information in 10 CHART REVIEW (Verify if all
the client chart and registered on the HMIS register in information is recorded in the client
alignment with ICD code chart and if the diagnosis is
registered on the HMIS register in
alignment with ICD code)
The health facility has a system to classify diseases in 10 CHART REVIEW Verify if the
alignment with ICD codes at all times diagnosis written in the client chart
is documented in the HMIS register
in alignment with the ICD codes
SS4.2 Facility has defined and Records of intraoperative Monitoring maintained 10 CHART REVIEW
established procedures for Operative Notes are Recorded (date, identification of patient 10 CHART REVIEW
maintaining, updating of patients’ including MRN number, surgical and anesthesia team,
clinical records and their storage preoperative and postoperative diagnosis, type and description
of procedure, type of incisions and used suture materials,
postoperative plan)
Anesthesia Notes are Recorded & Registers and records are 10 REGISTER REVIEW
maintained
SS4.3 Every health facility has a OR and Surgical ward working HCWs regularly conducts reviews 40 40 ( 10 for each bulleted criteria) if
mechanism in place for data of surgical care and their data every month AND develops and the following were done in the
collection, analysis and feedback, as implements a QI project for all the gaps identified previous month surgical care
part of its monitoring and assessment was done the previous
performance improvement activities month Gaps were identified
QUALITY PLANNING (action plan)
for the gap Implementation and
follow up in progress
The health facility implements standard operating procedures 5 Check previous month minutes if
and protocols in place at all times for checking, validating and the OR and surgical ward staff
reporting data evaluated their data before
reporting
Surgical service Standard 5 : Communication with surgical patients and their families is effective and in response to their
needs and preferences
SS5.1 All surgical patients and their Surgical patients are given the opportunity to discuss their 10 CLIENT INTERVIEW
families receive information about concerns and preferences
their care and experience effective
interactions with staff health-care staffs demonstrate the following skills: active 10 CLIENT INTERVIEW
listening, asking questions, responding to questions, verifying
client’s and their families understanding, and supporting
client’s in problem- solving
surgical patients and their families cared in the facility felt they 10 CLIENT INTERVIEW
were adequately informed by the attending care provider(s)
regarding examinations, any actions and decisions taken about
their care
surgical patients and their families cared in the facility 10 CLIENT INTERVIEW
expressed overall satisfaction with the health services
surgical patients and their families cared in the facility reported 10 CLIENT INTERVIEW
that they were satisfied with the health education and
information they received from the care providers
SS5.2 There is established Written informed consent is taken before any surgical 10 CHART REVIEW
procedures for taking informed procedure and induction of anesthesia
consent before treatment and
procedures
SS5.3 Information about the surgical Patient and / or attendant is informed about clinical condition, 10 CLIENT INTERVIEW
finding and treatment is shared surgical finding and treatment been provided
with patients or attendants,
regularly
Surgical service Standard 6 : surgical patients receive care with respect and dignity
SS6.1 All surgical patients have The physical environment of the health facility facilitates 10 CLIENT INTERVIEW
privacy around the time of clinical privacy and provision of respectful care, confidential care
evaluation , and their confidentiality including the availability of curtains, screens
is respected
The health facility has written, up-to-date, protocols to ensure 1
privacy and confidentiality for all clients throughout all aspects
of care
SS6.2 No surgical patient is The health facility has accountability mechanisms for redress in 1
subjected to mistreatment such as the event of violations of privacy, confidentiality and consent
physical, sexual or verbal abuse,
discrimination, neglect, detainment,
extortion or denial of services The health facility has written, up-to-date, zero-tolerance, non- 1
discriminatory policies relating to the mistreatment of clients
Any client who reported physical, verbal or sexual abuse, to 20 Select and verify 5 clients exiting
themselves or their families during clinical evaluation from the OR register 4 for each
client if they are protected 0 for
each client if report of abuse
The health facility has written accountability mechanisms for 1
redress in an event of mistreatment
The health facility has a written, up-to-date policy and protocols 4 4 if present AND periodically
outlining clients right to make a complaint about the care emptied and reviewed 1 if only
received and has an easily accessible mechanism (box) for present
handing in complaints and is periodically emptied and reviewed
All clients were satisfied with the facility meeting their religious 10 CLIENT INTERVIEW
and cultural needs
All clients reported to be treated with respect and dignity 10 CLIENT INTERVIEW
SS6.3 All clients have informed The health facility has a written, up-to-date, policy in place to 1 Document review
choices in the services they receive, promote for obtaining informed consent from clients prior to
and the reasons for intervention or examinations and procedures
outcomes are clearly explained
