Ministry of Health

CHECKLIST FOR ASSESSING

QUALITY OF HEALTHCARE

Kenya Quality Model for Health

HOSPITALS
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CONTENTS
CONTENTS ......................................................................................................................... 2
FOREWORD ........................................................................................................................ 4
ACKNOWLEDGEMENTS .................................................................................................. 5
LIST OF CONTRIBUTORS ................................................................................................. 6
ABBREVIATIONS .............................................................................................................. 7
INTRODUCTION ................................................................................................................ 8
Background ....................................................................................................................... 8
Rationale for the Review of KQMH .................................................................................. 8
Review Objective .............................................................................................................. 9
Principles of the KQMH and Dimensions of Quality ......................................................... 9
Requirement .................................................................................................................... 10
Documents required during assessment............................................................................ 12
Facility profile ................................................................................................................. 13
STRUCTURE ..................................................................................................................... 15
Dimension 1: Leadership ................................................................................................. 15
Dimension 2: Human Resources Management and Development ..................................... 20
Dimension 3: Policies, Standards and Guidelines ............................................................. 25
Dimension 4: Facilities and Infrastructure........................................................................ 27
Dimension 5: Supplies Management ................................................................................ 38
Dimension 6: Equipment Management ............................................................................ 40
Dimension 7: Transport and Fleet Management ............................................................... 44
Dimension 8: Referral System ......................................................................................... 45
Dimension 9: Health Records and Health Management Information Systems .................. 48
Dimension 10: Financial Management ............................................................................. 52
DIMENSION 11: PROCESSES .......................................................................................... 54
11.1 Outpatient Services .................................................................................................. 54
11.2 Patient Centred Care ................................................................................................ 60
11.3 Infection Prevention and Control ............................................................................. 64
11.4 Inpatient Care .......................................................................................................... 67
11.5 Accidents and Emergency ........................................................................................ 72
11.6 Surgical Emergencies............................................................................................... 75
11.7 Anaesthesia.............................................................................................................. 78
11.8 Safe delivery ............................................................................................................ 83
11.9 Neonatal Care .......................................................................................................... 88
11. Dialysis services ........................................................................................................ 93
11.11 Laboratory ........................................................................................................... 110
11.12 Pharmacy ............................................................................................................. 119
11.13 Radiology ............................................................................................................ 122
11.14 Mortuary .............................................................................................................. 125
DIMENSION 12: RESULTS ............................................................................................ 127
APPENDICES .................................................................................................................. 134
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 Appendix 1: A&E Equipment ........................................................................................ 134
Appendix 2: Essential Medicines ................................................................................... 136
Appendix 3: List of Tracer Non-pharmaceutical products .............................................. 137
Appendix 4: Assessment for critical intra-partum care ................................................... 138
Appendix 5: List of equipment for maternal care ........................................................... 139
Appendix 6: List of laboratory Equipment ..................................................................... 140
Appendix 8: Surgical Safety Checklist ........................................................................... 142
Appendix 9: Anaesthesia Record ................................................................................. 144
TERMINOLOGY ............................................................................................................. 148

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LIST OF CONTRIBUTORS

Dr. Annah Wamae Department of Health Standards Quality Assurance and Regulation
Dr. Charles Kandie Department of Health Standards Quality Assurance and Regulation
Manasseh Bocha Department of Health Standards Quality Assurance and Regulation
Idah Ombura Department of Health Standards Quality Assurance and Regulation
Dr. Jamlick Karumbi Department of Health Standards Quality Assurance and Regulation
Dr. Judy Awinja Department of Health Standards Quality Assurance and Regulation
Francis Muma Department of Health Standards Quality Assurance and Regulation
Gaudencia Mokaya Department of Health Standards Quality Assurance and Regulation
John Towett Department of Health Standards Quality Assurance and Regulation
Agnes Mutinda Department of Curative and Rehabilitative Services
Florence Opiyo Nairobi City County Health Services
Joseph Githinji National Hospital Insurance Fund
Titus Oyoo Kenya Bureau of Standards
Doris Mueni Mengo Kenya Accreditation Service
Michael Talam Kenya Accreditation Service
Rebekka Oetz Christian Health Association of Kenya
Dr. Frank Wafula World Bank
Kasmil Masheti PharmAccess
Dr. Maureen Nafula Institute of Health Policy, Management and Research
Dr. Subiri Obwogo USAID-ASSIST
Peter Mutanda USAID-ASSIST
Dr. Kirsteen Awori Surgical Society of Kenya
Dr. Lydia Okutoyi Kenya Obstetrics and Gynaecology Society
Dr. Anne Kihara Kenya Obstetrics and Gynaecology Society
Dr. Ahmed Twahir Kenya Renal Association
Dr. Jonathan Wala Kenya Renal Association
Dr. P. Onyancha Mathari National Referral Hospital
Dr. Alice Maingi Kenyatta National Hospital
Anne Karume Kenyatta National Hospital
Abby Muembu Kenyatta National Hospital
David Were Kenyatta National Hospital
Dr. B. Wachira Aga Khan University Hospital
Lawrence Wamiti Association of Kenya Medical Laboratory Scientific Officers
Valentine Magero Association of Kenya Medical Laboratory Scientific Officers
Dr. Caroline Wafula Pharmaceutical Society of Kenya
Dr. Brian Maugo Paediatric Association of Kenya
Carolyne Kawira National Nurses Association of Kenya
Elijah Kinyangi Japan International Cooperation Agency
Prof. Rolf Korte Deutsche Gesellschaft für Internationale Zusammenarbeit.
Irene Omogi Deutsche Gesellschaft für Internationale Zusammenarbeit.

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ABBREVIATIONS
District Health Information System
DHIS

HMIS Health Management Information System

HRH Human Resources for Health

KHSSP Kenya Health Sector Strategic Plan

KQMH Kenya Quality Model for Health

KPI Key Performance Indicator

IQC Internal Quality Control

MCH Maternal and Child Health

MOH Ministry of Health

MOV Mode of Verification

QMS Quality Management System

SOP Standard Operating Procedure

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INTRODUCTION
Background
Improving the quality of healthcare is a key priority in Kenya as reflected in a number of
policy and strategy documents. According to Vision 2030, Kenya’s economic blueprint, the
country aims to have an equitable and affordable healthcare system of the highest possible
quality by the year 2030. The overarching goal of the Kenya Health Policy (Ministry of
Health, 2014) is ‘attaining the highest possible health standards in a manner responsive to the
population needs’. The policy aims to achieve this goal through supporting the provision of
equitable, affordable and quality health and related services at the highest attainable standards
to all Kenyans.

Rationale for the Review of KQMH

The KQMH is a conceptual framework for an integrated approach to improved quality of
healthcare in Kenya. In 2001, the Kenya Quality Model (KQM) was developed and
introduced by the Ministry of Health (MOH), to guide the organisation of health services to
deliver positive health impacts by addressing quality issues. The KQM consisted of standards
and a master checklist. In 2008, the KQM was revised to customise it for the various levels
of the healthcare system as described in the Kenya Essential Package of Health (KEPH).
However, the 2008 review did not consider the clinical content of the quality model. Further,
since 2008, there have been changes in the health sector, which needed to be reflected in a
new model. These changes include the enactment of a new constitution in 2010; the
development of the Kenya Health Policy 2014-2030; the adaption of the World Health
Organisation Health Systems Building in the Kenya Health Sector Strategic and Investment
Plan (KHSSP) 2014-2018; and the development of various clinical standards and guidelines
among others.

The first National Quality Policy Seminar held in Nairobi in 2013 recommended a review of
the KQMH, to make it a national quality improvement tool and one that could be legitimized
through regulation requiring all providers to use it. The seminar recognized that even though
multiple approaches allow implementers to innovate, to be creative and to experiment, there
is need to have a common national framework to guide all quality improvement initiatives. In
addition, the MOH has identified the KQMH as the vehicle for improving quality of care in
the health sector, therefore there is need to review and update it as a prelude for the
development of national standards to be used in the national accreditation framework.
The goal of the model is to improve adherence to standards and guidelines based on
evidence-based medicine, as well as applying quality principles and tools and satisfying
patient / client’s needs in a culturally appropriate way. The model uses Standards and
Guidelines that are evidence-based and proven to be effective, efficient, affordable and
acceptable. It also integrates patient partnership in the healthcare process.

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Review Objective
To ensure that the KQMH is comprehensive and reflects current national policies and
strategies, as well as international developments and best practices in the delivery of health
services.

Principles of the KQMH and Dimensions of Quality

The KQMH integrates evidence-based medicine through wide dissemination of public health
and clinical standards and guidelines embedded with total quality management and patient
partnership. The eight principles underlying KQMH are:

 Leadership
 Customer orientation
 Involvement of people and stakeholders
 Systems approach to management
 Process orientation
 Continuous quality improvement
 Evidence-based decision making
The 12 dimensions of the KQMH implemented through the standards described in this
document are organised around structure, processes and results, as follows:
I. Structure:
a) Leadership
b) Human Resources
c) Policies, Standards and Guidelines
d) Facility and Infrastructure
e) Supplies Management
f) Equipment
g) Transport
h) Referral Systems
i) Health Records and Health Management Information Systems
j) Financial Management
II. Processes:

a) Outpatient services
b) Patient-centred care
c) Infection prevention and control
d) Outpatient services
e) Accidents and emergencies
f) Surgical emergencies
g) Anaesthesia
h) Safe delivery
i) Neonatal care
j) Dialysis services
k) Laboratory services
l) Pharmacy services
m) Radiology services

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 n) Mortuary services
III. Results, measured against set key performance indicators.

Requirement
This checklist is intended for use in all levels of health facilities, in line with the services
provided. It should be used for facility self-assessment, peer assessment of network of
facilities and by external assessors such as regulator or certification bodies. All facilities shall
carry out self-assessment. The role of the assessor will be to validate the assessment results.

The classification of levels of healthcare delivery is as defined by the Health ACT 2017 as
shown in the table below

Level of healthcare Roles

delivery
Level 2: Dispensary/clinic  Treatment of minor ailments
 Rehabilitative services
 Preventive and promotive services.
 Does not provide in-patient services
Level 3: Health Centre  Out-patient care
 Limited emergency care
 Maternity for normal deliveries
 Laboratories, oral health and referral services;
 Preventive and promotive services;
 In-patient observations
Level 4: Primary Hospital  Clinical supportive supervision to lower level
facilities
 Referral level out-patient care
 In-patient services
 Emergency obstetric care and oral health services
 Surgery on inpatient basis
 Client health education
 Specialized laboratory tests
 Radiology services
 Proper case management of referral cases
 Proper counter referral
 Provision of logistical support to the lower facilities
in the catchment area;
 Coordination of information flow from facilities in
the catchment area.
Level 5: Secondary  Provision of specialized services
Hospital  Training facilities for cadres of health workers who
function at the primary care level
 Serve as an internship centre for all staff, up to
medical officers
 Serves as a research centre, that provides research
services for issues of county importance

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 Level of healthcare Roles
delivery

Level 6: Tertiary Hospital  Provides highly specialized services. These include

general specialization; discipline specialization; and
geographical/regional specialization including highly
specialized healthcare for area/regional
specialization;
 Research centre, provides training and research
services for issues of national importance.

Scoring system
Dimension 1-11
Score Notes
0 No documented/observable effort of compliance. (This is denoted
NO in the scoring sheet)
1 Partial. (Standard is not fully met, there is need for improvement.
State areas for improvement under remarks). This is denoted P in
the scoring sheet
3 Fully compliant. This is denoted YES in the scoring sheet

Dimension 12
Score Notes

0 - More than 75% off target

1 - 75 to 50% off target

2 - 49 to 25% off target
3 - 25 to 1% off target
4 - Met Target

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Documents required during assessment
The following documents (where applicable) should be available at the beginning of the
assessment process. Availability of a full self-assessment report prepared during the previous
12 months is highly desirable.
Health facility strategic plan or annual work Patient satisfaction survey reports

plans IPC audit report

Facility risk assessment report HAI surveillance report

Facility license and lease certificate Quarterly reports on turn-around-time at the

Quality improvement implementation A&E

reports Mortality audit reports

KQMH self-assessment reports Quarterly resuscitation drills reports for all

Human resource records clinical areas

Staff satisfaction survey report Internal audit report for the laboratory

Infrastructure maintenance report

5S audit & implementation report

Equipment maintenance report

Quarterly referral reports

Data analysis and dissemination report

Financial audit report

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Facility profile

Facility Name:
Facility Contacts:
Kenya Master Health
Facility List
coordinates:
Level:
County:
Sub-county:
Population of
catchment area:
Type of facility:
a) Public facility
b) Private facility
c) FBOs/CBOs
Range of services offered
(Fill in the services offered by the facility in the space provided below):

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STRUCTURE

Dimension 1: Leadership
Score (tick appropriate
Quality Standard Requirement Remarks
box)

1.1 Leadership and Management Responsibilities

1.1.1 The health facility Facility has a valid licence or is gazetted to offer
management shall ensure healthcare services  Yes
compliance with (MOV- Gazette notice /licence)  No
regulatory requirements.
The facility is licensed for provision of  Yes
laboratory, radiology and other relevant services  No
(MOV- relevant licenses)  P1
 N/A
1.1.2 The facility shall Organogram in place
 Yes
have in place governance (MOV-Observation)  No
structures in line with
relevant legislation (10) Facility has a management unit constituted as per
legislation
(MOV-In Public facilities- Gazette notice, list of  Yes
 No
board members
In Private facilities- letters of appointment for
board members, list of board members)

1
P – Partially; N/A – Not Applicable

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 Score (tick appropriate
Quality Standard Requirement Remarks
box)
Facility management unit has terms of reference
 Yes
(MOV- TORs available)
 No

1.1.3 The health facility Facility has a strategic plan/ business plan  Yes
leadership shall identify (MOV-availability of current plan)  No
and plan for the services
it offers
Annual work plan with a budget (MOV-  Yes
availability of current plan)  No
Departmental work plans in place (MOV-
 Yes
availability of current plan)
 No
 P
1.1.4 The health facility Management allocates resources for  Yes
management shall implementation of quality improvement  No
commit to the initiatives(MOV- report on capacity development  P
of staff on KQMH, budget, staffing)
implementation of the
Kenya Quality Model for Mission and vision statements are aligned to the
Health (KQMH) (9) county/national health sector's mission and vision  Yes
(MOV- confirm alignment with Kenya Health  No
Policy)  P

1.1.5 The health facility Quality improvement team appointed with terms  Yes
management shall have a of reference  No
designated quality (MOV- HR records)
improvement team
(QIT). QIT coordinator appointed with terms of  Yes
reference  No
(MOV-HR records)

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 Score (tick appropriate
Quality Standard Requirement Remarks
box)
QIT meets at least once every quarter.  Yes
(MOV-minutes)  No

All Work Improvement Teams (WITs) meet

monthly  Yes
(MOV-minutes)  No

1.1.6 The health facility Documented procedure for administrative

shall comply with ethical consent for undertaking of health interventions  Yes
principles. and research (MOV-Documented procedure)  No

Documented procedure for monitoring adverse

effect of health interventions and research  Yes
(MOV-Documented procedure)  No

1.2 Management Review and Continuous Improvement

1.2.1 Management shall Facility management team meets on a monthly
continually review the basis  Yes
facility operations (MOV- Minutes)  No

Facility holds monthly clinical meetings

 Yes
(MOV-Minutes)  No
Quality management review meetings are held
 Yes
on a quarterly basis. (MOV-Minutes)  No

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 Score (tick appropriate
Quality Standard Requirement Remarks
box)
Clear quality improvement agenda for the  Yes
meetings (to include among others results of  No
self-assessment; Customer satisfaction  P
feedback; Process performance; Status of
preventive and corrective actions; Risk
management; Follow-up actions from
previous management reviews;
Recommendations for improvement)
(MOV-Minutes for management review
meetings)
1.2.2 Management shall Areas for improvement are identified through  Yes
support staff to engage in biannual quality assessments (MOV- report on  No
a continuous quality identified areas for improvement).  P
improvement process. Facility implementation of quality
improvement plans  Yes
 No
(MOV- reports on quality improvement  P
projects)
1.2.3 The facility shall Self-assessment carried out biannually
carry out regular quality (MOV- assessment reports)
review and assessment of  Yes
the effectiveness of its  No
quality improvement  P
initiatives

1.2.4 The facility shall The facility evaluates benefits of improvement  Yes
evaluate benefits of interventions at least once annually  No
improvement (MOV- evaluation report)  P
interventions at least The facility disseminates success stories and  Yes
lessons learnt at least once annually.  No

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 Score (tick appropriate
Quality Standard Requirement Remarks
box)
once annually and (MOV- minutes/report of dissemination  P
success stories and meetings/ brochures/ social media/ internet
lessons learnt links )
communicated

1.3 Risk Management

The facility has in place The facility conducts risk assessment for all
clinical services (MOV- risk assessment  Yes
measures to reduce or
 No
eliminate clinical risks report)

The facility has put in place measures to

mitigate the identified risks  Yes
 No
(MOV- mitigation plan/report)

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Dimension 2: Human Resources Management and Development
Requirements Score (tick Remarks
Standard
appropriate box)
2.1 The health facility is Facility is staffed as per established HRH
 Yes
adequately staffed as per norms (MOV-HR records)
 No
the established HRH
norms and standards. Facility has a documented procedure for task
shifting or responsibility sharing between  Yes
different professional cadres (MOV-  No
documented protocol)

2.2 The health facility

Facility has an up to date personnel file that
maintains an updated
record of all staff. contains the following at a minimum:

 Registration with relevant professional  Yes

bodies.  No
(MOV-personnel file with listed documents.  P
Sample 5 files)
 Yes
 Relevant academic certificates
 No
(MOV-personnel file with listed documents.
 P
Sample 5 files)
 Yes
 Current curriculum vitae
 No
(MOV-personnel file with listed documents.
 P
Sample 5 files)
 Yes
 Letters of appointment
 No
(MOV-personnel file with listed documents.
 P
Sample 5 files)

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 Requirements Score (tick Remarks
Standard
appropriate box)
 Yes
 Signed job description
 No
(MOV-personnel file with listed documents.
 P
Sample 5 files)
2.3 The health facility
Management staff have signed their annual  Yes
implements staff
performance appraisal. performance contracts (MOV- HR records for  No
updated performance contracts)  P

Staff appraised at least once in a year (MOV-  Yes

personnel file with appraisal documents)  No
 P

Recommendations of the appraisals  Yes

implemented by the HR (MOV-documented  No
actions on recommendations)  P

2.4 Facility staff engages in

Facility implements a continuous medical
continuous medical  Yes
education. education programme (MOV- HR records and
schedule and file with minutes on CME  No
sessions)
All staff who provide direct patient care have
received training in basic cardiopulmonary
 Yes
resuscitation and the training is repeated at least
 No
every two years
 P
(MOV- HR records)

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 Requirements Score (tick Remarks
Standard
appropriate box)
2.5 Facility has staff Facility has a system for recognition and/or
motivation programme rewards of high achievers  Yes
(MOV-Administration records)  No
Team building activity carried out at least once
per year  Yes
(MOV-Administration records)  No
Motivation plan communicated to all staff
 Yes
(MOV- HR records)
 No

2.6 There shall be an

There is an induction schedule for all the new
induction into service
programme for all new staff. Induction to include but not limited to
 Yes
staff. the organizational structure, work area, staff
 No
facilities, health & safety requirements and
 P
occupational hazards
(MOV-documented schedule)

Induction report countersigned by new staff

and by the designated staff in the various  Yes
departments within the health facility (MOV-  No
Induction reports filed in the staff files)  P

2.7 The health facility shall

Annual training needs assessment conducted
allocate funds for training
of staff as informed by and documented
 Yes
capacity needs (MOV-Training needs assessment for the
 No
current calendar or financial year)

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 Requirements Score (tick Remarks
Standard
appropriate box)
Costed training schedule in place  Yes
(MOV-training schedule)  No

Budget allocated for training (MOV-  Yes

administration records)  No

2.8 The health facility has

The facility has a documented procedure for
in place a mechanism for
knowledge management. sharing of new knowledge which includes
 Yes
schedule of knowledge management activities
 No
including feedback from training, conference
 P
reports, learning sessions
(MOV-documented procedure)

2.9 The facility provides

There is evidence of approval of the health  Yes
internship programme in
accordance to MOH and facility to act as an internship centre  No
other relevant guidelines (MOV-Documented approval)  NA

There is a documented MoU between the health

 Yes
facility and training institution on internship
 No
programs
 NA
(MOV-Documented approval)

There are documented guidelines for interns,

 Yes
students and registrars on attachment
 No
(MOV- HR records)
 NA

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 Requirements Score (tick Remarks
Standard
appropriate box)
There is an up to date register for interns and  Yes
students  No
(MOV- HR records)  NA

2.10 Staff satisfaction shall

The facility assess and monitor job satisfaction  Yes
be assessed and monitored.
(MOV- Staff satisfaction report)  No

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Dimension 3: Policies, Standards and Guidelines
Requirements Score (tick Remarks
Standard
appropriate box)
3.1 Health care facility The operation plan for the health facility is
 Yes
shall align their operations aligned to the current Health Act, Kenya Health
 No
with current Health Act, Policy and KHSSP (MOV-Current annual
Kenya Health Policy and operational plan and objectives)
the Kenya Health Sector
Strategic Plan.

3.2 Health facilities shall, The facility has in place all key policy
at the minimum, have the documents and strategic plan including but not
relevant policy and limited to the following:
strategic documents
available on site (MOV- confirm availability of documents or
internet access)
 Yes
 Current Kenya Health Policy
 No

 Yes
 Current Kenya Health Sector Strategic and
 No
Investment Plan
 Yes
 Human Resources Norms and Standards
 No

 Yes
 Infrastructure Norms and Standards
 No

 Yes
 Previous year’s annual performance
 No
report(s)

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 Requirements Score (tick Remarks
Standard
appropriate box)
3.3 A management system SOPs strategically displayed
 Yes
shall be in place for the (MOV-SOPs in each service delivery area)
implementation and  No
regular review of standard  P
operating procedures
Evidence that standard operating procedures  Yes
and are reviewed at least once a year  No
(MOV- SOP with date of update displayed)  P

3.4 Staff members are

There is a documented plan for updating staff
regularly updated on the  Yes
current policies, standards on the current policies, standards and guideline
 No
and guidelines (MOV-documented plan )

3.5 Facility shall ensure the

The facility has relevant standard clinical
availability of standard  Yes
clinical treatment treatment guidelines.
 No
guidelines. (MOV- confirm physical or virtual access)

Use and adherence to guidelines is monitored.  Yes

(MOV-monitoring report)  No

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Dimension 4: Facilities and Infrastructure
Requirements Score (tick appropriate Remarks
Standard
box)
4.1 The health facility
The design of the facility is approved by  Yes
shall be planned, managed,
the relevant authorities.  No
and comply with the
(MOV-Approval of design)
applicable guidelines,
policies, gazette notices
The design of the facility complies with  Yes
and regulations.
the infrastructure norms and standards.  No
(MOV- Checklist for assessing and
monitoring infrastructure)

4.2 Physical facilities and Environmental conditions

4.2.1 The health facility
layout shall provide
adequate space for quality -The facility layout is appropriate for  Yes
health service delivery, delivering health services.  No
while ensuring safety of (MOV- sample 1 outpatient and 2 inpatient  P
personnel, patients and service areas)
visitors.
The service delivery rooms are well  Yes
ventilated.  No
(MOV- sample 1 outpatient and 2 inpatient
service area)

The service delivery rooms are well lit.  Yes

(MOV- sample 1 outpatient and 2 inpatient  No
service area)

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 Requirements Score (tick appropriate Remarks
Standard
box)
The service delivery rooms have the  Yes
required equipment  No
(MOV- sample 1 outpatient and 2 inpatient
service area)

The service delivery rooms have hand  Yes

hygiene facilities  No
(MOV- sample 1 outpatient and 2 inpatient  p
service area)

The facility has an accessibility ramp for  Yes

disabled/wheelchair patients  No
(MOV-observation)

4.2.2 Environment
Environmental monitoring done in all
monitoring shall be done
in all relevant areas. relevant areas for the following (MOV-
Monitoring log sheets, observation)

 Yes
 Humidity
 No
 P

 Yes
 Light
 No
 P

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 Requirements Score (tick appropriate Remarks
Standard
box)
 Yes
 Electrical supply
 No
 P

 Yes
 Temperature
 No
 P

 Yes
 Sound
 No
 P

 Yes
 Vibrations
 No
 P

There is evidence of corrective action on

opportunities identified for improvement
in the following areas (MOV-Documented
plans for corrective measures)
 Yes
 Humidity
 No
 P

 Yes
 Light
 No
 P

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 Requirements Score (tick appropriate Remarks
Standard
box)
 Yes
 Electrical supply
 No
 P
 Yes
 Temperature
 No
 P

 Yes
 Sound
 No
 P

 Yes
 Vibrations
 No
 P

4. 3 Sanitation and Hygiene

4.3.1 The health facility
The facility maintains smooth surfaces  Yes
infrastructure shall be
designed, constructed and throughout to facilitate cleaning  No
maintained to facilitate (MOV-observation of evidence of smooth  P
proper cleaning and surfaces)
drainage, infection
prevention and control and Design, construction and maintenance of  Yes
pest, rodents and
the health facility allows fast drainage of  No
scavenger control
water in sinks, wash basins, ablution and  P
laundry area (MOV-- interview
maintenance staff and observation )

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 Requirements Score (tick appropriate Remarks
Standard
box)
Maintenance of the health facility aids  Yes
control of pests, rodents and scavengers  No
(MOV- interview public health staff and
observation)

4.3.2 Facility shall ensure

Reliable sources of safe running water  Yes
there is adequate safe
running water at all times (MOV- observation)  No

4.4 Management of waste and hazardous materials

4.4.1 The health facility
Safe location for hazardous materials and  Yes
shall implement measures
on use, handling, storage wastes  No
and disposal of hazardous (MOV-physical facility or contract for
materials and waste. outsourced services)

Labelling of hazardous materials and  Yes

wastes  No
(MOV-observation)

Access to certified incinerator  Yes

(MOV-Interview with staff)  No

Disposal protocols in place  Yes

(MOV- disposal protocls)  No

31 | P a g e
 Requirements Score (tick appropriate Remarks
Standard
box)
Facility reports incidents to allow  Yes
corrective actions (MOV- periodic reports)  No

The facility has competent personnel  Yes

responsible for waste disposal  No
(MOV-designated officer with terms of
reference or contract in case of outsourced
services)

4.5 Lighting and security

4.5.1 The health facility
The facility has a reliable and stable power  Yes
shall have a reliable and
supply (MOV-observation )  No
stable power supply.

The facility has a power back-up  Yes

(MOV-evidence of functional and  No
serviceable power back-up equipment)

4.5.2 The health facility The facility has a documented security

 Yes
shall have adequate plan (MOV-Documented security plan
precautions to ensure the  No
security of its premises, Facility implements the security plan  Yes
staff, patients and visitors (MOV- fencing, security guards, metallic  No
grills in relevant areas, secure locks)

32 | P a g e
 Requirements Score (tick appropriate Remarks
Standard
box)

4.6 Disaster Management, Emergency preparedness, and risk

reduction
4.6.1 The health facility
Training programs on emergency  Yes
shall have in place
preparedness, disaster management and  No
measures to facilitate
risk reduction
emergency preparedness,
(MOV-HR records)
disaster management and
risk reduction. Standard operating procedures on  Yes
emergency preparedness, disaster  No
management and risk reduction
(MOV-SOP)

Fire, safety and security drills  Yes

(MOV- drills schedule and report)  No

Emergency exits and fire assembly points  Yes

(MOV-Observation)  No

Firefighting equipment  Yes

(MOV-Observation)  No

First aid kits  Yes

(MOV-Observation)  No

The facility has personnel responsible for  Yes

emergency preparedness, disaster  No
management and risk reduction
(MOV-HR records)

33 | P a g e
 Requirements Score (tick appropriate Remarks
Standard
box)

4.7 Storage facilities

The health facility shall
The health facility has adequate storage  Yes
provide for adequate
storage space and space (MOV-observation)  No
conditions that maintain
the quality of material The storage space is organized to allow for  Yes
stored therein. first expiry first out  No
(MOV-Bin cards and observation)

The storage space has the right  Yes

environmental conditions (temperature and  No
humidity)
(MOV-temperature and humidity
monitoring charts as applicable)

4.8 Amenities
4.8 The health facility has Availability of changing rooms for staff
 Yes
amenities for staff and (MOV-observation)
 No
clients
Availability of staff lounge
 Yes
(MOV-observation)
 No

Adequate storage for staff's personal

 Yes
possessions
 No
(MOV-observation)

34 | P a g e
 Requirements Score (tick appropriate Remarks
Standard
box)
Availability of safe drinking water
 Yes
(MOV-interview staff)
 No

Clean and functional toilets are available

 Yes
for staff and clients
 No
(MOV-observation)

The facility has ablution services for the

 Yes
disabled (MOV-observation)
 No

4.9 Linen and laundry services

4.9 The facility linen and The facility has a protocol for laundry and
 Yes
laundry services are linen services which covers:
 No
operated according to
 Collection and storage of
documented procedure. contaminated linen
 Cleaning of contaminated linen
 Storage and distribution of clean linen
(MOV-Linen and laundry protocol)
There is at least one functioning, fully
 Yes
automatic washing machine (MOV-
 No
Observation)

All laundry workers are trained

 Yes
(MOV- HR records)
 No

The space in the laundry is

 Yes
adequate to deal with the
 No
calculated or estimated dry

35 | P a g e
 Requirements Score (tick appropriate Remarks
Standard
box)
weight of articles to be
processed and the type of
washing equipment.
(MOV-observation)

4.10 Health facility maintenance

4.10 The healthcare facility The facility has a maintenance unit with
 Yes
infrastructure shall be trained staff/ access to maintenance
 No
maintained in a functional services
condition. (MOV-HR records)

The facility has a costed routine and  Yes

periodic maintenance plan (MOV-  No
Maintenance plan)

The facility implements the routine and  Yes

periodic maintenance plans (MOV-Reports  No
of corrective actions, up to date service or
service contracts for outsourced services)

4.11 Implementation of 5S
The facility shall
All staff have been trained on 5S (MOV-  Yes
implement 5S in all its
departments Training log sheet)  No
 P

36 | P a g e
 Requirements Score (tick appropriate Remarks
Standard
box)
Facility implements 5S in all its  Yes
departments (MOV-Observation,  No
implementation reports)  P

Implementation of 5S monitored and

 Yes
evaluated (MOV- 5S audit reports)
 No

37 | P a g e
Dimension 5: Supplies Management
Requirements Score (tick Remarks
Standard
appropriate box)

5.1 Planning for procurement

Approved plans for
The facility has an approved procurement  Yes
procurement of goods and
plan (MOV-Documented plan for current  No
services are available and
financial/calendar year, minutes)
incorporated in the facility
budget.
The procurement plan is incorporated in  Yes
the facility budget.  No
(MOV-Approved budget)

5.2 Prequalification of suppliers

Prequalification of
The facility carries out the prequalification  Yes
suppliers shall be done in
of suppliers  No
line with guidelines and
(MOV-List of pre-qualified
regulations.
suppliers/vendors, licences of supplies)

The facility evaluates performance of  Yes

suppliers annually (MOV- Minutes of  No
evaluation meetings)

5.3 Procedure for procurement

There shall be a
The facility has qualified personnel  Yes
documented procedure for
designated to handle procurement  No
ordering, reception and
(MOV-HR records)

38 | P a g e
 Requirements Score (tick Remarks
Standard
appropriate box)
storage of goods and
An inventory management system is in  Yes
services.
place  No
(MOV-confirm for paper based or
electronic system)

Specifications for all products and  Yes

services to be procured are in place  No
(MOV-List/log sheet of specifications)  P

The inventory records are up to date  Yes

(MOV-Inventory book)  No
 P

Goods stored according to manufacturer’s  Yes

specification (MOV-sample 3 items each  No
from pharmacy stores, laboratory,  P
general store and food store)

39 | P a g e
Dimension 6: Equipment Management
Requirements Score (tick appropriate Remarks
Standard
box)
6.1 The health facility shall
The facility has a defined list of equipment  Yes
have adequate equipment
as per scope of service. and quantities required to provide each of  No
the services offered
(MOV-File with list of equipment)

The facility has adequate number of  Yes

functional equipment as per the scope of  No
service
(MOV-Sample three service delivery areas
one for routine outpatient care, support
services and inpatient care)

The facility verifies that upon installation  Yes

and before use, equipment is capable of  No
achieving the necessary performance and
complies with relevant requirements.
(MOV- Records of installation, records of
validation and verification)

6.2 There shall be an

The facility has an updated inventory of all
updated inventory for all
equipment in the facility. equipment which should include:
(MOV-Equipment inventory book or log
sheet)

 Yes
 Identity of equipment
 No

40 | P a g e
 Requirements Score (tick appropriate Remarks
Standard
box)
 Yes
 Manufacturer ‘s name, model and
 No
serial number or other unique number
 Yes
 Contact information for the supplier or
 No
manufacturer
 Yes
 Date of receiving and installation at
 No
facility
 Yes
 Location
 No

 Yes
 Condition when received
 No

 Yes
 Acceptance testing reports
 No

 Yes
 Preventive maintenance records
 No

 Yes
 Service records
 No

41 | P a g e
 Standard Requirements Score (tick appropriate Remarks
box)
6.3.Donated equipment The facility has access to National Policy on  Yes
received by the facility handling of donated equipment  No
shall meet the national (MOV-availability of the policy)
policy, standards and
facility specifications The facility has standard operation procedures  Yes
for receiving donated equipment aligned to  No
national policy, standards and facility
specification
(MOV- availability of SOP)

6.4 All equipment shall be The facility equipment is operated by trained  Yes
operated by trained and and authorised personnel  No
authorized personnel. (MOV-HR records)  P

6.5 Operation manuals on All equipment have operation manuals/SOPs  Yes

the use, safety and for use, safety and maintenance.  No
maintenance of equipment (MOV – manuals available on site)  p
are available.
Equipment operation manuals are in a  Yes
language that is understood by users  No
(MOV – observation of manuals)  P

There is a preventive and periodic  Yes

6.6 All equipment shall be maintenance plan for all equipment in the  No
maintained in a functional facility (MOV-Maintenance plan)
condition. All equipment monitored in accordance with  Yes
the manufacturers’ specifications and  No
applicable standards (MOV-Sample one  P
equipment from the support services)

42 | P a g e
 Standard Requirements Score (tick appropriate Remarks
box)
The facility has designated personnel for  Yes
equipment maintenance or service contracts  No
for maintenance with suppliers/manufacturers
(MOV- evidence of designation or contract
for out sourced services)

There is a system for calibration and  Yes

validation of equipment  No
(MOV-Quality assurance log sheets/reports)

6.7 Disposal of equipment

6.7 There shall be a The facility has a procedure for the disposal  Yes
procedure for disposal of of obsolete equipment  No
obsolete equipment in line (MOV-SOPs)
with current regulation
The disposal is done in accordance with the  Yes
guidelines and regulations (MOV-Interview  No
staff responsible equipment disposal)

43 | P a g e
 Dimension 7: Transport and Fleet Management
Requirements Score (tick Remarks
Standard
appropriate box)

7.1 The health facility shall have

The facility has access to adequate number of  Yes
access to adequate and reliable
utility vehicles  No
transport facilities to support safe
(MOV-feedback from administration)
and effective service provision.

There is sufficient budget allocation for transport  Yes

(MOV-Facility plan with approved budget for  No
transport, interview with staff)
7.2 The facility shall maintain all
The facility has protocols for the maintenance of  Yes
means of transport in a serviceable
means of transport (where applicable)  No
condition
(MOV-availability of protocols)  N/A
Service schedules and maintenance records are  Yes
available and up-to-date  No
(MOV- services schedules and maintenance  P
records)  NA
7.3 There is a documented
There is documented SOP for the handover of all  Yes
handover process for all vehicles.
means of transport  No
(MOV-SOP available)  NA
Evidence of implementation of handover SOPs  Yes
(MOV- handover records)  No
 NA

44 | P a g e
Dimension 8: Referral System
Requirements Score (tick Remarks
Standard appropriate box)
8.1 The facility shall National Referral Guidelines are available and  Yes
ensure that referral accessible to relevant staff  No
guidelines and SOPs are (MOV- confirm availability/accessibility to the
available and guidelines)
communicated to the
relevant staff Facility referral SOPs available and accessible to  Yes
staff  No
(MOV-SOP available)

8.2. The health facility Patients referred within the time set in the service  Yes
shall ensure that patients charter  No
are referred in a timely (MOV- Interview responsible staff, files of last 5  P
manner to the referrals)
appropriate health facility
or specialist, while The facility has access to standard ambulance  Yes
ensuring continuity of services at all times (MOV-Observe for  No
care and patient safety. availability of ambulances/ service contracts)

Facility ensures a competent staff member  Yes

accompanies patient during referral (MOV-  No
Referral schedule/SOPs clearly displayed at
service delivery areas)

There is evidence that patients are referred to the  Yes

appropriate health facility/specialist  No
(MOV- referral register)

There is continuity of care/ life support for the  Yes

patient while in transit  No

45 | P a g e
 Requirements Score (tick Remarks
Standard appropriate box)
(MOV- SOPs/ Interview responsible staff)

8.3 The referring facility The facility provides round-the-clock functional  Yes
effectively communicates and effective hotline service managed by  No
with the receiving facility. competent personnel conversant with the
management of referrals.
(MOV-call the hotline to confirm functionality)

Referred patients are accompanied with duly filled  Yes

referral documents containing at a minimum  No
working diagnosis, investigations done, any other  P
care provided (MOV- sample referral documents)
Facility keeps referral records as per the National
Referral Strategy (MOV- referral register)  Yes
 No

Feedback is provided to the referring facility  Yes

(MOV-Quarterly referral reports)  No

Contacts details of facilities and specialists to  Yes

which patients are referred are available  No
(MOV- Document with emails addresses,
telephone and physical addresses)

8.4 The health facility The health facility has a documented procedure for
shall follow a documented receiving referred patients. This includes but is not
procedure for handover limited to:
of referred patients (MOV-Documented protocols and observation )
Location for receiving referred patients  Yes
 No

46 | P a g e
 Requirements Score (tick Remarks
Standard appropriate box)
Patient admission to the relevant unit and  Yes
attendance by appropriate specialist  No
(MOV-Sample 5 patient files)

Involvement of patients and their escorts in  Yes

handover processes  No
(MOV-Interview 5 patients)  P

8.5 Data on The facility collects, analyses and uses the data to  Yes
referrals/transfers is continuously improve patient care and strengthen  No
collected and used to the referral system
continuously improve (MOV- referral audit, and minutes from HMT
patient care and discussing referral data)
strengthen the referral
system.

47 | P a g e
Dimension 9: Health Records and Health Management Information Systems
Requirements Score (tick appropriate Remarks
Standard
box)
9.1 The health facility shall
The health facility has data collection  Yes
have a system for data
management tools  No
(MOV-Observe at the records unit and
one service delivery area)

The health facility has periodic data  Yes

analysis reports (MOV-Filed reports)  No

Results of analysis are disseminated to  Yes

facility staff for decision-making  No
(MOV-Filed reports)

Facility has adequate data storage  Yes

equipment (Cloud, computers,  No
hardcopy files) (MOV- observation and
discussion with responsible staff)

The health facility has defined access  Yes

rights for electronic data management  No
systems (administrative passwords)
(MOV-Documented protocols)

The health facility has a system for off-  Yes

site backup and security  No

48 | P a g e
 Requirements Score (tick appropriate Remarks
Standard
box)
(MOV- Feedback from records
department)

9.2 The health facility shall The facility has more than one staff
 Yes
upload data on the DHIS member with access rights to upload
as per legal requirements. data onto DHIS  No
(MOV-user names and passwords of  P
HMT members)  NA

The facility uploads service delivery

 Yes
reports defined in the national DHIS
manual  No
(MOV- confirm data upload onto  P
DHIS)
9.3 Patient management
The health facility has a defined  Yes
and interventions shall be
documented and signed by minimum criteria of patient history and  No
relevant personnel. examination
(MOV-documented criteria)

All treatments are documented and  Yes

signed by relevant personnel  No
(MOV- sample 5 patient files)  P

Patients’ records contain information  Yes

on diagnosis, treatment, and follow-up  No
steps
(MOV-sample 5 patient files)

Patients identification data include at

least the following:

49 | P a g e
 Requirements Score (tick appropriate Remarks
Standard
box)
9.4 Patients records shall (MOV-Sample 5 patients records)
have minimum  Yes
 Name
identification data.  No

 Yes
 Unique patient identification
 No

 Yes
 Patients ID number (where
 No
applicable)
 Yes
 Date of birth/ age
 No

 Yes
 Sex
 No

 Yes
 Residence
 No

 Yes
 Contacts
 No

 Yes
 Next of kin
 No

9.5 Medical records shall

All medical records are complete and  Yes
contain complete, legible
legible  No
and easily traceable
(MOV-Sample 5 patient records from  P
information.
outpatient and inpatient)

50 | P a g e
 Requirements Score (tick appropriate Remarks
Standard
box)
 Yes
Medical records are retrievable within
 No
the timeframe stipulated in the service
charter (MOV-Feedback from HR
department/ observation)

9.6 Records and

There are guidelines/SOPs for  Yes
information shall be
operating the registry to ensure there is  No
protected from loss,
no loss, destruction, tampering and  P
destruction, tampering and
unauthorized access to records and
unauthorized access or
information
use.
(MOV- SOP, file movement register)

Facility has a secure registry  Yes

(MOV-lockable doors, grills, fireproof  No
cabinets, passwords for electronic
systems)

Patient records are handled in a  Yes

confidential manner  No
(MOV- all staff have filled  P
confidentiality forms)

9.7 All births and deaths

There is an up to date birth register/  Yes
occurring in health facility
(MOV-register/ notification book)  No
are recorded and relevant
authorities notified.
There is an up to date death register  Yes
(MOV-register, notification book/  No
burial permit)

51 | P a g e
Dimension 10: Financial Management
Requirements Score (tick appropriate Remarks
Standard
box)
10.1 The facility shall The health facility has standard operating ☐Yes
manage its finances based procedures to guide financial management ☐No
on policies and/or standard (MOV-confirm for availability of SOPs)
operating procedures Duties are appropriately segregated so that ☐Yes
no transaction is handled by one finance ☐No
team member from start to completion
☐P
(MOV-Financial management protocols)
Bank accounts managed only on the ☐Yes
strength of management board/committee ☐No
resolution (MOV-Financial management
☐P
protocols)
The facility carries out annual internal ☐Yes
audits (MOV- audit reports) ☐No
☐P
The facility carries out annual external ☐Yes
audits (MOV- audit reports) ☐No
☐P
10.2 The facility shall Budgets aligned to the facility’s annual ☐Yes
budget for finances in line work plan and strategic plan ☐No
with the strategic and (MOV-Facility’s operational plan with
☐P
annual work plans. budget)
Budgets approved by the management board
 Yes
(MOV- Relevant minutes of board meeting)
 No

52 | P a g e
 Requirements Score (tick appropriate Remarks
Standard
box)
The health facility has a designated budget
 Yes
for implementing quality improvement
 No
interventions within the annual work plan
 P
(MOV- Budget)

10.3 The facility shall The facility monitors its income and
 Yes
maintain financial records expenditure in relation to performance data
 No
to allow for continuous (MOV- minutes of meetings where
monitoring of income and monitoring information is discussed)
expenditure in relation to
performance data
10.4 The health facility There is a documented procedure for credit
 Yes
shall have mechanisms for monitoring/waiver
 No
credit management/waiver (MOV- availability of waiver document)
and exemption from
payment for patients who There is a documented procedure for
 Yes
are not able to pay for exemptions
 No
services (MOV- availability of exemptions document)

53 | P a g e
DIMENSION 11: PROCESSES
Each facility implementing the KQMH standards will endeavour to improve all processes within its operations in the spirit of continuous quality
improvement. This shall involve systematic identification of process(s) or area(s) for improvement; planning and target setting for improvement;
implementation of improvement initiative; monitoring of improvement; and evaluation of initiatives. This section identifies the core areas required to
address current pressing challenges in quality of care within Kenyan health facilities.

11.1 Outpatient Services

Score (tick off the
Standard Requirements Remarks
appropriate box)

11.1.1 The facility shall plan and implement outpatient services in line with MOH policies and strategies

11.1.1.1 All patients cared The minimum requirements of history taking and  Yes
for by the health facilities physical examination of patients is defined for each  No
have their health care needs clinical discipline(MOV- SOPs)  P
identified through an
assessment process that has
been defined by the hospital Availability of vital signs observation tools, at  Yes
minimum, thermometer and blood pressure  No
machines  P
(MOV-observation)
Availability of patient examination tools, at  Yes
minimum, stethoscope and diagnostic kits  No
(MOV-observation)  P

Facility takes vital signs for all patients  Yes

(MOV-Sample 5 patient case files)  No
 P

11.1.1.2 The facility provides The hospital plans education consistent with its  Yes
health education that mission, services, and patient population.

54 | P a g e
 Score (tick off the
Standard Requirements Remarks
appropriate box)
supports patient and family (MOV-Schedule with topics)  No
participation in their care  P
decisions and care processes.
 Yes
There is an established structure for health  No
education throughout the hospital.  P
(MOV-Schedule with topics)

11.1.1.3 The facility shall Nutrition assessment carried out for all patients  Yes
establish nutrition plans and (MOV-Sample 5 patient files)  No
procedures to ensure the  P
provision of comprehensive
nutrition services. Nutrition assessment tools available, at a minimum,  Yes
MUAC tapes, BMI calculator, weight/height board  No
(MOV-Observation)  P
Nutrition counselling services offered to all patients  Yes
(MOV-Sample 5 patient files)  No
 P
Availability of supplementary and therapeutic feeds  Yes
e.g. FM 75, 100 and Plumpy Nut  No
(MOV- Observation)  P

Micronutrient supplements provided as per patient  Yes

categorization e.g. iron, folate, Vitamin A, Zinc  No
(MOV-Sample 5 patient case files)  P
Nutrition services provided by qualified staff  Yes
(MOV- HR records)  No
 P

Availability of all KEPI vaccines  Yes

55 | P a g e
 Score (tick off the
Standard Requirements Remarks
appropriate box)
11.1.1.4 The facility shall (MOV- Observation of inventory; stock-outs of any  No
establish procedures to antigens in the preceding 90 days)  P
ensure the provision of Cold chain facilities are available
primary immunization  Yes
(MOV- Observe monitoring charts and vaccine vial  No
services. monitor)  P

Immunization services provided on a daily basis  Yes

from Monday to Friday  No
(MOV-Check immunization register)  P

11.1.1.5 The facility shall Availability of emergency tray with essential  Yes
establish procedures to resuscitation drugs  No
ensure the provision of (MOV- observation)  P
comprehensive emergency
services.
Availability of resuscitation equipment, at a  Yes
minimum, ambubag, suture pack  No
(MOV- observation)  P

Availability of staff trained on basic life support  Yes

(MOV-HR Records)  No
 P

Response time for all emergency cases is defined  Yes

and adhered to  No
(MOV- emergency response protocol; sample  P
5patient files)

Resuscitation drills carried out for all clinical staff,  Yes

at least once every quarter

56 | P a g e
 Score (tick off the
Standard Requirements Remarks
appropriate box)
(MOV-Drills plan and report)  No
 P

11.1.1.6 The facility shall Facility operates daily at designated times in  Yes
provide comprehensive accordance with level of care (MOV-patient service  No
management of locally charter)  P
endemic conditions

Facility follows protocols and guidelines for  Yes

diagnosis of endemic conditions  No
(MOV- SOP; Sample 5 patient case files)  P

Facility follows protocols and guidelines for  Yes

treatment of endemic conditions  No
(MOV- SOP; Sample 5 patient case files  P
considering disease profile of the area where
facility is located)
Referral protocols available  Yes
(MOV- Observation)  No
 P

11.1.1.7 The facility shall Complete physical examination is carried out for all  Yes
provide high quality maternal pregnant women seeking ANC services.  No
health and family planning (MOV-ANC register)  P
services.
ANC profile for all antenatal mothers performed  Yes
and reviewed. (MOV- Sample 5 patient records)  No
 P

57 | P a g e
 Score (tick off the
Standard Requirements Remarks
appropriate box)
The facility provides individualized care to all  Yes
antenatal mothers based on physical, laboratory and  No
other diagnostic examinations.  P
(MOV- Sample 5 patient records)

Availability of both short and long acting methods  Yes

of family planning  No
(MOV-FP register; inventory)  P

Postnatal care provided to all mothers and newborns  Yes

for at least 24 hours before discharge  No
(MOV-Postnatal service register)  P

Availability of cervical cancer screening services  Yes

(MOV-Cervical cancer screening register)  No
 P

11.1.2 The facility has a Facility includes community participants in relevant  Yes
mechanism in place to committees  No
involve the community in (MOV-Minutes, management files for committee  P
service provision constitution)
There is a feedback mechanism to address  Yes
complaints and suggestions from the community  No
(MOV-reports)  P
11.1.3 The facility has a The facility conducts surveillance of diseases of  Yes
system for prevention, public health importance according to MOH  No
control and surveillance of recommendations (MOV- monthly surveillance  P
locally endemic conditions reports)

58 | P a g e
 Score (tick off the
Standard Requirements Remarks
appropriate box)
Protocols for management of disease outbreaks are  Yes
available and in use  No
(MOV-Protocols)  P
Water samples are collected from community water  Yes
sources periodically for bacteriological and  No
chemical analysis, analysed and reports given to  P
authorities and the community.
(MOV- Reports)

59 | P a g e
11.2 Patient Centred Care
Standard Requirements Score (tick appropriate Remarks
box)
11.2.1.The facility shall Patient rights charter displayed  Yes
have a mechanism to conspicuously in waiting areas.  No
protect the patient’s rights (MOV-Observation)
Regular sensitization of patients on their  Yes
rights  No
(MOV- schedule/record)
Patients sign consent forms for medical  Yes
procedures where required  No
(MOV- Sample 5 patient files)  P
Facility assures that patients get full range  Yes
of services regardless of their religious,  No
economic or social status  P
(MOV- protocol in place)
11.2.2 Health care All service providers wear tags with name  Yes
providers in the facility and designation visible to patients at all  No
shall empower and enable times  P
patients/clients to actively (MOV- observation name and designation
participate in their care tags)
processes. Cost of services and any insurance rebates  Yes
that apply to the patient are displayed or  No
available to the patient.  P
(MOV-observation)
Patients are fully informed on risks and  Yes
benefits of care given and a written consent  No
obtained from the patient  P
(MOV- Consent forms)

60 | P a g e
 Standard Requirements Score (tick appropriate Remarks
box)
The patient and next of kin are supported to  Yes
cope with debilitating effects of  No
illness/disability  P
(MOV-Counselling facilities, prayer rooms,
referral options to appropriate facilities)
Dignity and privacy in relation to patients’  Yes
care and support is provided (MOV- patient  No
screens, lockable doors)  P
There is linkage to social and community  Yes
networks for patient support and care  No
(MOV- List/inventory of support  P
groups/networks)
11.2.3 The views of The facility assesses clients’ views and level  Yes
patients/clients and their of satisfaction at least once every four  No
level of satisfaction shall be months  P
assessed (MOV- client satisfaction report)
Recommendations are acted upon in  Yes
improvement plans.  No
(MOV- progress report)  P
11.2.4 The facility shall The facility provides a complaint and  Yes
provide a mechanism for compliments box/ book  No
client/patient feedback (MOV-evidence of analysis of feedback
results)

A telephone number for patients to provide  Yes

feedback through is displayed.  No
(MOV-Observation)
Client feedback analysed and acted upon  Yes
(MOV- progress/status report)  No

61 | P a g e
 Standard Requirements Score (tick appropriate Remarks
box)
11.2.5 The facility shall The facility has protocols to follow when  Yes
provide amenities for dealing with patients with visual and  No
patients and visitors with hearing impairments  P
disabilities (MOV-Documented protocols, availability
of trained personnel, signage)
The facility has provision for ease of  Yes
movement for the physically handicapped  No
 P
11.2.6 The facility Patients are identified using at least two  Yes
implements a mechanism identifiers  No
to improve accuracy of (MOV-Protocol in place; sample 5 patient  P
patient identification. files)
Each patient is provided a hospital bracelet
 Yes
with unique identifier
 No
(MOV- Observe for armband with unique
 P
identifier)
The same identification is consistently used
 Yes
throughout the care process
 No
(MOV-Sample 5 patient files)  P

Patients are identified before providing

 Yes
treatments and procedures
 No
(MOV-Protocol in place; sample 5 patient
 P
files)
Patients are identified before undergoing
 Yes
any diagnostic procedures
 No
(MOV-Protocol in place)
 P

The facility is implementing a  Yes

system of reporting, investigation  No

62 | P a g e
 Standard Requirements Score (tick appropriate Remarks
box)
and change management to respond to
any patient care mismatching events
(MOV- Documentation of this system,
relevant reports)
11.2.7 There shall be a Pain management protocols are available  Yes
pain management protocol (MOV- Observation)  No
as per level of patient care
The facility implements  Yes
processes for addressing the  No
patient's needs for appropriate assessment  P
and management of pain.
(MOV- sample clinical notes)
11.2.8 The facility shall Facility provides individualized plan for  Yes
have a procedure for the palliative care of the terminally ill patient  No
care of terminally ill (MOV- Availability of palliative care plan)  P
patients

There is use of written procedures for  Yes

11.2.9 The facility shall handling cases of bereavement, performing  No
provide for respectful care culturally appropriate last offices, handling  P
of the deceased of the body and handover to funeral services
or last rites as appropriate
(MOV-SOP)
There is debriefing and support supervision  Yes
for care providers to cope with stressful  No
encounters/situations (MOV- SOP, interview  P
with health providers)
Facility provides for standardized,  Yes
documented procedures on embalming,  No
autopsies, issuance of burial permit as  P
appropriate (MOV- documented procedure)

63 | P a g e
11.3 Infection Prevention and Control
Requirements Score (tick appropriate Remarks
Standard
box)
11.3.1 The health facility A multidisciplinary IPC committee/ unit in
 Yes
shall have in place an place, with terms of reference (MOV-
 No
infection prevention and Minutes of monthly meetings, clinical reports,
control governance appointment letters for committee members)
structure as per the
national IPC policy and
guidelines
11.3.2 The health facility A plan in place to continuously update staff
 Yes
shall ensure infection knowledge on infection prevention and
control practices (MOV- Work plans, training  No
prevention and control
schedules, clinical audit schedule)  P
practice is in accordance
with the approved national
IPC guidelines and policies The facility carries out quarterly audits on
IPC to support implementation and adherence
to IPC standard precautions. The report
should include the following areas: (MOV-
Audit reports)
 Yes
 Hand hygiene
 No
 P
 Yes
 Waste management
 No
 P
 Yes
 Respiratory hygiene
 No
 P

64 | P a g e
 Requirements Score (tick appropriate Remarks
Standard
box)
 Yes
 Occupational exposure management
 No
 P

 Yes
 Personal protective equipment
 No
 P

 Yes
 Care of linen
 No
 P

 Yes
 Isolation
 No
 P

 Yes
 Food handling
 No
 P

 Yes
 Management of care equipment
 No
 P

 Yes
 Control of environment
 No
 P

11.3.3The health facility There facility carries out quarterly healthcare

 Yes
shall periodically conduct associated infections surveillance.

65 | P a g e
 Requirements Score (tick appropriate Remarks
Standard
box)
healthcare associated (MOV-Surveillance reports)  No
infections surveillance in
accordance with the
National IPC guidelines.
11.3.4 The health facility There is a plan for occupational exposure
 Yes
shall have a plan for management of staff health.
 No
management of hazardous (MOV- staff immunization schedules, pre and
 P
occupational exposure of post-exposure prophylaxis guidelines, needle
health staff stick injuries record book)

11.3.5 The health facility There is mechanism to ensure adequate IPC

 Yes
shall ensure adequate IPC supplies at all times (MOV- inventory of IPC
 No
supplies at all times supplies lasting at least 6 months)
 P

66 | P a g e
11.4 Inpatient Care
Requirements Score (tick Remarks
Standard
appropriate box)
11.4.1 The management shall Adequate beds are available and
 Yes
ensure that the facility has Functional. There are no patients sharing beds.
adequate resources and skills (MOV-Observation)  No
to provide quality inpatient  P
care
Each patient has access to a nurse call system at
 Yes
all times.
(MOV-Observation)  No
 P

There are ward screens

 Yes
(MOV-Observation)
 No
 P

Mattresses, bed linen, towels and gowns for

 Yes
patients are available, in good condition and in use
 No
(MOV-Observation)
 P

Equipment for facilitating patients' mobility are

 Yes
available and in good condition.
 No
(MOV-Observation)
 P

Equipment and materials for monitoring patients'

 Yes
vital signs are provided.
 No
(MOV-Observation)
 P

11.4.2 The facility shall Facility develops and uses protocols for triaging of
 Yes
ensure triaging of patients is patients
 No
conducted based on the (MOV- Triage protocol AND Tagging of Patients
 P
patient’s/clients condition or patent files)

67 | P a g e
 Requirements Score (tick Remarks
Standard
appropriate box)
11.4.3 The health facility The facility carries out comprehensive assessment
shall ensure that of the patient, which includes patients’ biodata,  Yes
comprehensive patient history of present illness, past medical history,  No
assessment is conducted family history and social history upon admission  P
(MOV- outpatient form, patient’s cardex,
admissions register)
The facility documents baseline vital signs
 Yes
(MOV- observations chart, fluid charts, nursing
care plan, cardex)  No
 P

11.4.4 The health facility The health facility has a displayed protocol for
shall categorize patients into categorization of patients for prescribed levels of
the prescribed level of care care:
Category “A” critical ,  Yes
Category “B” unstable  No
Category “C” stable  P
(MOV- Arrangement of patients according to their
categorized level of care, documented protocol of
care offered to the patient)
11.4.5 The health facility
The facility carries out episodic patient assessment  Yes
shall continuously carry out
episodic patient assessment and records vitals in the appropriate charts of care  No
(MOV- Observations chart, fluid charts, nursing  P
care plan, Cardex)
11.4.6 The facility shall have Facility follows protocols and guidelines for  Yes
in place standardized diagnostics and treatment  No
diagnostics and treatment (MOV- SOP; Sample 5 patient case files)  P
processes
Facility follows standardized procedure for  Yes
handover of patients between units  No
(MOV-SOP, clinical notes)  P

68 | P a g e
 Requirements Score (tick Remarks
Standard
appropriate box)
11.4.7 The health facility The facility administers prescribed medication
shall administer and using the 5R principle - right patient, right drug,
document prescribed right dosage, right route, right time - and  Yes
medication using the 5R documentation done in the treatment sheet and  No
principle patient’s cardex  P
(MOV- protocol of drug administration, cardex, 5
treatment sheets)
11.4.8 The health facility
Documentation of all procedures is done in the
shall ensure full  Yes
documentation of all relevant charts/ sheets
 No
procedures is correctly done
(MOV- cardex, fluid/feeding charts, treatment  P
sheet, turning sheet, observation charts, nursing
care plan)
11.4.9 The facility shall have  Yes
Facility provides for daily scheduled ward rounds
a documented standardized  No
process for conducting ward and other clinical reviews of patients (MOV-
Schedules for ward rounds)  P
rounds

Facility staff follow guidelines and procedures for  Yes

inter-professional consultation meetings and case  No
conferences (MOV-Schedules)  P

11.4.10 The facility shall

Assessment of nutritional status of all patients is  Yes
categorize nutrition status of
all inpatients and provide done on admission and continuously monitored  No
culturally sensitive food and (MOV-Sample 5 patient files)  P
drinks for inpatient care
Dietary counselling and feeding support is  Yes
provided by nutritionists or other competent staff  No
(MOV- Schedules for nutritionists)  P

69 | P a g e
 Requirements Score (tick Remarks
Standard
appropriate box)
A suitably qualified and/or  Yes
experienced person advises  No
on meal development  P
(MOV-HR Records)

There is a planned weekly  Yes

menu that is adhered to  No
(MOV- Updated facility patient menu )  P

Facility provides inpatients with culturally  Yes

sensitive food  No
(MOV-Interview 5 inpatients)  P

11.4.11 The facility shall put Facility provides protocols for prevention of falls  Yes
in place measures for (MOV- availability of protocols)  No
prevention of falls and
 P
patient mobilization to
prevent bed sores, stress
ulcers, thrombosis Facility provides protocols for patient  Yes
mobilization to prevent bed sores, stress ulcers,  No
thrombosis  P
(MOV- availability of protocols)

Measures are in place to prevent immobility and  Yes

prevent the complications of immobility.  No
(MOV-SOPs)  P

There is evidence that the patient, when confined  Yes

to bed or immobile, receives assistance with  No
lifting, moving, positioning, turning in bed and  P
transferring from and back to bed.
(MOV-Observation; interview 5 patients)

70 | P a g e
 Requirements Score (tick Remarks
Standard
appropriate box)
There is evidence that pressure relieving  Yes
techniques (care of skin, turning in bed on  No
schedule, observing and preventing potential  P
bedsores) are implemented and documented.
(MOV-SOPs: Sample 5 patient files)

Patients receive professional physiotherapy care  Yes

and assistance with rehabilitation if required.  No
(MOV-SOPs)  P

11.4.12 The facility shall Facility has a documented discharge protocol

 Yes
have a documented patient (MOV- availability of protocol)
discharge mechanism  No

There is documentation of discharge of patient

 Yes
against medical advice
 No
(MOV-Discharge Against medical advice forms)
 P

71 | P a g e
11.5 Accidents and Emergency
Requirements Score (tick Remarks
Standard
appropriate box)
11.5.1 The health facility shall Facility has adequate number of licensed
 Yes
ensure that the accident and skilled staff
 No
emergency department has (MOV- HR records)
adequate resources and skills to
provide quality emergency care Healthcare workers involved in adult
 Yes
emergency care have additional training on
 No
Basic Life Support and Advanced Life Support
 P
(MOV-HR records)

Healthcare workers involved in paediatric

 Yes
emergency care have additional training on
 No
Basic Life Support and Pediatric Advanced
 P
Life Support

(MOV-HR records)

Facility has adequate emergency equipment

 Yes
and Supplies, fully stocked resuscitation trolley
 No
(MOV-inventory of emergency equipment and
 P
supplies)

11.5.2 The facility shall ensure Triage guidelines in place

 Yes
that triaging is conducted (MOV-Observation)
 No
according to current guidelines
Triage turn-around time is defined (MOV-
 Yes
quarterly report on assessment of turn-around-
 No
time)

72 | P a g e
 Requirements Score (tick Remarks
Standard
appropriate box)
A record of patient volumes based on the
 Yes
different triage categories is maintained
 No
(MOV- triaging register)

11.5.3 The health facility shall Algorithms for trauma and medical
 Yes
ensure that evidence-based emergencies are available
 No
emergency care guidelines are (MOV- availability of algorithms)
 P
available and effectively applied
within the Emergency
Department
11.5.4 The facility shall ensure The following turn-around time is monitored:
that turn-around times for
emergencies is monitored and  Yes
 Door to Triage
reviewed.  No

 Yes
 Door to Doctor/clinicians
 No

 Yes
 Laboratory Services
 No

 Yes
 Radiological Services
 No

 Yes
 Decision to Senior Review
 No
 Decision to referral
 Door to Disposition/Length of Stay in  Yes
A&E  No
(MOV-Discharge, Admission, Referral)

73 | P a g e
 Requirements Score (tick Remarks
Standard
appropriate box)
Evidence that patients are seen within the time
 Yes
limits set by the triage guidelines
 No
(MOV- quarterly report on assessment of turn-
around time)

11.5.5 The facility shall evaluate Facility maintains records of patients who
 Yes
morbidity and mortality data return to the Emergency Department within 24
 No
within the A&E department. hours after being seen. (MOV- A&E register)

Review of all mortalities conducted within 24

 Yes
hours of admission (MOV- mortality audit
 No
report)

11.5.6 The facility shall provide Availability and use of protocols for service
 Yes
emergency care, regardless of fee waiver and exemption. (MOV-protocols;
waiver and exemptions register )  No
the ability to pay for service.
 P

11.5.7 The facility shall be All staff are assessed quarterly on their
 Yes
prepared to handle mass knowledge of mass casualty management skills
 No
casualties at all times and the institutional procedures
 P
(MOV-assessment report)

Facility conducts demo drills twice a year to

 Yes
test the facility’s preparedness to manage mass
 No
casualties (MOV-drills report)
 P

74 | P a g e
11.6 Surgical Emergencies
Requirements Score (tick the Remarks
Standard
appropriate box)
11.6.1 The surgical Availability of surgical emergency response
 Yes
departments shall have guidelines/protocols.
 No
adequate resources to (MOV-accessible guidelines/ protocols)
provide quality emergency
surgical care Adequate number of formally licenced clinical
 Yes
staff as per HRH norms and standards.
 No
(MOV- Norms and standards and HR records)

All surgical staff should have certification in

 Yes
trauma care and life support.
 No
(MOV- HR records)

Availability of adequate theatre equipment and

 Yes
supplies
 No
(MOV- Observation and equipment inventory)

Availability of adequate resuscitation

 Yes
equipment in all surgical clinical areas
 No
(MOV- Observation and equipment inventory)

Access to adequate blood supply

 Yes
(MOV-interview clinical and laboratory staff)
 No

Two operating rooms available for elective and

 Yes
emergency surgery
 No
(MOV-Observation)
 NA

75 | P a g e
 Requirements Score (tick the Remarks
Standard
appropriate box)
Access to functioning support facilities (ICU,
 Yes
laboratory and rehabilitation services).
 No
(MOV-interview clinical staff and observation)

11.6.2 The facility shall Categorization of patients based on their illness

 Yes
make provision for status.
priority care of critically ill (MOV-Protocol)  No
surgical patients
The time from decision to operate to actual
 Yes
time of surgery is recorded in the patient notes.
(MOV-Sample 5 patient files)  No

Application of escalation protocols to deal with

 Yes
deteriorating patients.
(MOV-Interview clinical staff)  No

Daily scheduled ward rounds attended by a

 Yes
surgeon.(MOV-Procedure manual, duty rota)
 No

11.6.3 The health facility All surgical patients’ files have a filled-in safe
 Yes
shall assure the safety of surgical checklist (based on WHO prototype)
 No
surgical patients. and is signed by both the nurse and the
surgeon. (MOV- confirm with 5 patient files.
See Appendix 8 for WHO prototype)

11.6.4 Non-operative
All emergency patients are discussed with the  Yes
patients shall be reviewed
within no more than 24 consultant surgeon.  No
hours after admission. (MOV- Confirm with patient notes for
documentation of the decision)

76 | P a g e
 Requirements Score (tick the Remarks
Standard
appropriate box)
11.6.5 There shall be a
Senior surgeon delegates responsibility for  Yes
structured delegation and
emergency surgical cases to appropriate staff  No
handing-over process of
(MOV- documented procedure)
emergency surgical cases.

All emergency cases undergo peer discussion  Yes

(MOV-Protocol)  No

Documented handing over procedure available  Yes

(MOV-handing over procedure)  No

The surgical unit carries out scheduled  Yes

handover rounds with names of participants  No
clearly documented.
(MOV- ward-round register)

11.6.6 The facility shall

The surgical unit has a structured discharge  Yes
give each patient clear
summary with information on presenting  No
information on discharge
complaints, clinical findings, investigation  P
and explain how to make
findings and treatment and discharge
contact with a healthcare
instructions.
professional if the need
(MOV-Sample 5 discharge notes)
arises.

77 | P a g e
11.7 Anaesthesia
Areas for assessment Score (tick the Remarks
Standard
appropriate box)
11.7.1 The management shall
Each theatre in the hospital has one  Yes
ensure that the facility has
adequate resources and skills anaesthesia care provider attending to one  No
to provide quality anesthesia patient per unit time.
care (MOV- observation)

Each theatre has at least one theatre technician  Yes

adequately trained in assisting both the  No
surgical and anaesthesia teams.
(MOV-HR records)

Responsibilities for monitoring and reviewing  Yes

anaesthesia services are defined and carried  No
out
(MOV-SOP)
All staff in clinical contact with patients under  Yes
anaesthesia are appropriately trained in  No
resuscitation skills.  P
(MOV-HR records)
Presence of theatre users committee to  Yes
facilitate implementation of work plans. This  No
committee has, at bare minimum, the theatre
nurse in charge, the resident anaesthesia care
provider, the resident surgeon/gynaecologist

78 | P a g e
 Areas for assessment Score (tick the Remarks
Standard
appropriate box)
and a member of the hospital administrative
team. (MOV- Documentation)

The theatre committee meets at least quarterly  Yes

and chart out theatre work plans as well as  No
serve to review any critical incidents/outcomes
 P
in perioperative care. (MOV-Minutes of
meetings)

Availability of adequate anaesthesia equipment  Yes

and supplies as outlined in the appendix  No
(MOV- Observation and equipment inventory)  P

11.7.2 The facility management There is standard anaesthetic chart enabling  Yes
shall ensure that there is contemporaneous documentation on  No
adequate space and recording perioperative care
material for peri-operative (MOV-observation)
care
The facility has adequate perioperative  Yes
monitoring devices  No
(MOV- Observation and equipment inventory)  P
11.7.3 The facility shall have inPre-anaesthesia assessment is performed for  Yes
place a mechanism to ensure patients scheduled to undergo surgery.  No
that pre-anaesthesia (MOV- clinical notes from patient records)  P
assessment is carried out for all
patients scheduled to undergo Separate pre-induction assessment is  Yes
surgery. performed to re-evaluate patients immediately  No
before the induction of anaesthesia  P
(MOV- SOP, patient clinical notes)

79 | P a g e
 Areas for assessment Score (tick the Remarks
Standard
appropriate box)
The patient, family, and/or decision makers are  Yes
educated on the risks, benefits, and alternatives  No
of anaesthesia.  P
(MOV-SOP)
11.7.4 The facility shall ensure The anaesthesia care of each patient is planned  Yes
that each patient’s anaesthesia and documented in the patient’s record.  No
care is planned and (MOV-SOP; Patient clinical records)  P
documented
The anaesthesia agent, dose and anaesthetic  Yes
technique are documented in the patient’s  No
record.  P
(MOV-SOP; patient clinical records)
11.7.5 The facility shall have All patients undergoing anaesthesia are  Yes
procedures to ensure each monitored for circulation, ventilation and  No
patient is monitored during oxygenation on the minimum  P
anaesthesia (MOV- patient clinical records, SOP)
A medical practitioner whose sole  Yes
responsibility is the provision of anaesthetic  No
care for patients is constantly present from  P
induction of anaesthesia until safe transfer to
Recovery Room staff or Intensive Care Unit.
(MOV-SOP)
11.7.6 The facility shall have Presence of a dedicated Post Anaesthesia Care  Yes
adequate post-anaesthesia care Unit  No
unit facilities (MOV-observation)  P

80 | P a g e
 Areas for assessment Score (tick the Remarks
Standard
appropriate box)
Presence of adequate staffing  Yes
(MOV-HR records)  No
 P
Presence of adequate monitoring and  Yes
emergency care equipment and drugs.  No
(MOV-observation; equipment inventory)  P

Availability of post anaesthesia to theatre bed  Yes

ratio of at least 1:1.5  No
(MOV-HR records)  P

11.7.7 Each patient’s post- All patients are monitored during the post-  Yes
anaesthesia status shall be anaesthesia recovery period. Particular  No
monitored and documented attention is given to monitoring oxygenation,  P
ventilation, circulation and temperature.
(MOV-SOP; patient clinical notes)
Observations are documented in the patient’s  Yes
clinical record. This should include at least,  No
state of consciousness, colour, respiratory rate,  P
oxygen saturation, pulse and blood pressure
and level of pain.
(MOV-SOP; patient clinical notes)
Patients are discharged from the post-  Yes
anaesthesia care unit in accordance with  No
national guidelines (MOV-SOP; patient  P
clinical notes)

81 | P a g e
 Areas for assessment Score (tick the Remarks
Standard
appropriate box)
Staff record, for each patient, time recovery is  Yes
started and time recovery phase is complete  No
(MOV-Patient’s records; SOP)  P

All post anaesthesia patients are accompanied  Yes

to the recovery room and adequately handed  No
over to the nursing staff by the anaesthesia  P
care provider.

82 | P a g e
11.8 Safe delivery
Areas for assessment Score (tick the Remarks
Standard
appropriate box)
11.8.1 The health facility
The staff establishment for maternity services  Yes
management shall avail
is as per the human resources norms and  No
skilled personnel,
standards (MOV- HR records)
infrastructure and
equipment to offer life- Maternity department has adequate equipment
 Yes
saving emergency and (See appendix for list of equipment)
 No
quality maternal care (MOV- functional equipment)
 P

Labour ward is clean, has adequate lighting

 Yes
and is optimally aerated
 No
(MOV- Observation)  P

11.8.2 The health facility Client rights protocol strategically placed

 Yes
shall ensure that all (MOV-observation)
 No
delivery unit staff provide Client experience questionnaire administered
 Yes
respectful maternity care at discharge
 No
(MOV-monthly reports)

Mechanism of responding to client complaints

 Yes
in place
 No
(MOV- Complaint and compliments box/ book,
evidence of analysis of feedback results)
There is provision for privacy for patients
 Yes
(MOV- Observation)
 No
11.8.3 The health facility Assessment of the patients done within 15
 Yes
shall ensure that risk minutes of admission by a skilled health
provider  No

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 Areas for assessment Score (tick the Remarks
Standard
appropriate box)
assessment is conducted  p
(MOV-Sample 5 patient files)
and that intrapartum care
is provided appropriately
WHO checklist on risk assessment of mother
 Yes
and baby filled for all deliveries
 No
(MOV- sample 5 patient files for completeness)
 p

MEOW (Modified Early Obstetric Warning

 Yes
Score) filled for every patient
 No
(MOV- sample 5 patient files for
 P
completeness)

Partograph available on site, and there is

 Yes
evidence of its proper use
 No
(MOV- sample 5 patient files for completeness)
 P

Foetal surveillance conducted for every mother

 Yes
in labour, in line with national guidelines
(MOV-Relevant charts)  No
 P

11.8.4 The health facility Timely diagnostics and laboratory services

 Yes
shall ensure that provided for emergency maternal care
 No
emergency maternity care including but not limited to:
 P
is supported by timely
 Malaria, blood sugar, HB, urinalysis,
diagnostics and laboratory
blood typing, rhesus compatibility
services
(MOV- reports on turn-around-time for
laboratory services)

84 | P a g e
 Areas for assessment Score (tick the Remarks
Standard
appropriate box)
11.8.5 The health facility All clients are assessed for the following:
shall ensure that there is (MOV- sample 5 patient files)
immediate post-delivery  Contraction of the uterus
reassessment of the mother  Yes
and the neonate within 15  No
minutes of delivery  P

 Tears in the birth canal  Yes

 No
 P

 Breathing of the new born  Yes

 No
 P

 Newborn Apgar score  Yes

 No
 P

 Recheck the umbilical cord  Yes

 No
 P

11.8.6 The health facility

Protocols for assisted vaginal  Yes
shall ensure that
delivery displayed  No
emergency vaginal delivery
(MOV-Observation)
is expedited

Availability of functional instruments for  Yes

assisted vaginal delivery e.g. forceps, vacuum  No
set (MOV-Observation)

85 | P a g e
 Areas for assessment Score (tick the Remarks
Standard
appropriate box)
Timely documentation of the procedures for  Yes
assisted vaginal deliveries  No
(MOV- sample 5 patient files)  P

11.8.7 The health facility

Emergency Caesarean Section carried out  Yes
shall ensure that
within 30 minutes of decision-making.  No
emergency Caesarean
 P
Section is performed within MOV-Preoperative checklist, documentation
30 minutes of decision- indicating time action taken, sample 5 patient
making. files)
Relevant laboratory investigations done within  Yes
30 minutes of decision-making  No
(MOV- Lab requests, clinical notes)  P

Voluntary informed consent secured for all  Yes

patients scheduled to undergo surgical  No
obstetrics procedures  P
(MOV- Signed consent form, -documented
procedure for obtaining consent)

Pre-operative checklist available in the  Yes

patient’s file, signed by the nurse and the  No
surgeon (MOV- Sample 5 patient files)  P

Pre-operative anaesthetic review is made prior  Yes

to conducting the emergency Caesarean  No
Section  P
(MOV- Sample 5 patient files)

86 | P a g e
 Areas for assessment Score (tick the Remarks
Standard
appropriate box)
11.8.8 The health service
Continuous monitoring of vital signs and  Yes
provider shall continually
documentation done every 15 minutes for the  No
monitor the vital signs of a
first two hours then half hourly in the 3rd hour  P
patient who has post-
(MOV- Sample 5 patient files)
partum haemorrhage

PPH escalation protocols displayed  Yes

(MOV- observation)  No
 P
11.8.9 The health facility
Baby-friendly services offered  Yes
shall ensure that its staff
(MOV- observation for rooming in)  No
offer baby friendly
 P
practices
11.8.10 The health facility
Ward hand-over rounds conducted  Yes
shall ensure that the service
(MOV- Sample 5 patient files)  No
providers conduct ward
hand-over rounds

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11.9 Neonatal Care
Requirements Score (tick the Remarks
Standard
appropriate box)
11.9.1 The health facility
Healthcare provider available 24 hours a day, 7  Yes
shall ensure that skilled
personnel, infrastructure days a week.  No
and equipment are (MOV-HR records; staff rota)
available to offer life-saving
emergency and quality At least 2 skilled health workers trained in goal-  Yes
newborn care oriented ANC and Essential Newborn Care  No
(MOV-HR records)

Facility has adequate infrastructure and equipment

 Yes
to offer life-saving emergency and quality
 No
newborn care
 P
(MOV-Observe and review inventory as per level
of facility)

Resuscitation space/table available in labour ward,

 Yes
theatre, postnatal ward and paediatric ward.
 No
(MOV-Observation)
 P

Nursery space adjacent to labour ward

 Yes
(MOV-Observation)
 No

Beds assigned for Kangaroo Mother Care (KMC)

 Yes
in postnatal wards
 No
(MOV-Observation)

11.9.2 The health facility Facility uses baby wraps to keep newborns warm
 Yes
shall manage all newborns at all times
 No
as prescribed in the (MOV- observation, interview staff)
 P

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 Requirements Score (tick the Remarks
Standard
appropriate box)
Essential Newborn Care Breastfeeding within one hour of delivery for well
 Yes
guidelines babies
 No
(MOV- SOPs displayed, interview staff and
 P
clients)

Administration of Vitamin K after delivery

 Yes
(MOV- check patient files on the last 5 deliveries)
 No
 P

Use of 4% chlorhexidine formulation for cord

 Yes
care
 No
(MOV- check patient files for the last 5 deliveries)
 P

Administration of tetracycline eye ointment to

 Yes
baby immediately after birth
 No
(MOV- check patient files for the last 5 deliveries)
 P

Immediate skin-to-skin contact between

 Yes
mother/parent and baby is practiced at the facility
 No
(Kangaroo Mother Care for babies <2,500gms)
 P
(MOV- interview staff and clients)

11.9.3 The facility shall be The facility has a complete set of resuscitation
 Yes
adequately prepared for equipment (suction ball, functional paediatric
 No
resucitation of newborn ambu-bag and mask, resuscitare)
babies within one minute of (MOV- Observation/ check inventory as per level
birth of facility)

The facility conducts resuscitation drills

 Yes

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 Requirements Score (tick the Remarks
Standard
appropriate box)
(MOV-quarterly report)  No

Babies vital signs observed within two hours of

 Yes
delivery (MOV- sample patient notes for the last
 No
5 deliveries)
 P

11.9.4 The facility shall The facility has SOPs for detection of babies with
 Yes
have a mechanism for danger signs displayed
 No
detecting and referral of (MOV-observation)
babies with danger signs or
critically ill babies The facility has drug formulations for managing
 Yes
neonatal infections
 No
(MOV-check drug inventory)
 P

The facility uses referral protocols for the

 Yes
critically ill babies or babies with danger signs
 No
(MOV-facility protocol available/ displayed)

11.9.5 The facility shall Availability of standard protocol for the

 Yes
manage neonatal sepsis management of neonatal sepsis
 No
according to national (MOV-Access to guidelines)
guidelines
11.9.6 The facility shall use Facility provides appropriate prophylaxis for
 Yes
the current treatment HIV-exposed newborn within one hour after
 No
guidelines for the care of delivery
 P
HIV-exposed infants (MOV- sample files of HEIr)

90 | P a g e
 Requirements Score (tick the Remarks
Standard
appropriate box)
11.9.7 The health facility Hand hygiene facilities in or near the examination
 Yes
shall ensure infection room, labour ward, theatre, postnatal, nursery and
 No
prevention measures are paediatric wards.
 P
put in place in the neonatal (MOV- Observation )
unit.
Hand washing with soap and water between
 Yes
examining babies, before and after procedures;
 No
availability of hand sanitizer on site
 P
(MOV-SOP)

The newborn unit has disinfection facilities

 Yes
(MOV- Observe for correct disinfection
 No
processes)
 P

Staff safely dispose-off sharp objects and waste in

 Yes
well-labelled containers.
 No
(MOV- Check availability of safety boxes and
colour-coded waste bins )

11.9.8 The facility shall All newborns stay with the mother in the health
 Yes
discharge the newborn facility for a minimum of 24 hours
 No
appropriately in not less (MOV-5 Patient files/exit interviews)
 P
than 24 hours after birth.
All mothers receives education on clean chain,
 Yes
cord care, warm chain and breastfeeding.
 No
(MOV- Patient exit interviews)
 P

All mothers informed on danger signs to watch

 Yes
out for at home
 No

91 | P a g e
 Requirements Score (tick the Remarks
Standard
appropriate box)
(MOV-Patient exit interviews)  P

All mothers given postnatal appointments

 Yes
(MOV-5 Patient files)
 No
 P

11. 9. 9 The facility shall Health facility conducts group health education
 Yes
provide comprehensive sessions including: (1) HIV, (2) Danger signs, (3)
 No
health education and Infant and young child feeding, (4) KMC, (5)
 P
service information to the Cord care, (6) Extra care for small babies, (7)
clients Personal Hygiene
(MOV- Observation of Health education
schedule materials and actual health education
sessions)

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11. Dialysis services
Requirements Score (tick Remarks
Standard
appropriate box)
11. 10.1 The dialysis centre The person in charge of a haemodialysis centre is a
 Yes
shall ensure availability of nephrologist, assisted by other personnel of at least the
qualified staff to provide following qualification:  No
dialysis services to patients. · A Nephrologist
· A Physician who has completed recognized
training in haemodialysis treatment and
maintains an affiliation with Kenya Renal
Association (KRA)
· Any other Registered Medical Practitioner who
has completed recognized training in
haemodialysis treatment and maintains an
affiliation with KRA
(MOV-HR records, duty roster)
For every five (5) dialysis patients, there is at least one
 Yes
(1) registered nurse with at least six months training in
haemodialysis treatment and care in each shift.  No
(MOV-HR records, duty roster)
All dialysis treatment is provided under the order of:
 Yes
(a) A nephrologist
 No
(b) A physician with requisite training under the
supervision of a nephrologist.  P
(MOV- SOP)

11.10.2 Haemodialysis

11. 10.2.1 The dialysis The dialysis treatment is monitored closely, with
 Yes
centres shall have particular attention to:
- Any intra-dialytic complications

93 | P a g e
 Requirements Score (tick Remarks
Standard
appropriate box)
mechanisms to ensure - Vital signs during dialysis: Blood Pressure,  No
stringent monitoring of pulse & temperature, blood sugar
- Vascular access adequacy achieving blood flow  P
dialysis patient
>300, signs of infection

(MOV-SOP; Sample 5 patient case files)

Each dialysis treatment is recorded in the patient files
 Yes
(MOV- Sample 5 patient files)  No
 P
Blood investigations are done at regular predetermined
 Yes
intervals
(MOV- SOPs, sample 5 patient files)  No
 P

Dialysis adequacy is monitored at least every three (3)

 Yes
monthly using urea reduction ratio (URR) or Kt/V
(MOV- Sample 5 patient files)  No
 P
Nutrition status of all patients is routinely monitored
 Yes
(MOV- Sample 5 patient files)
 No
 P

11. 10.2.2 All haemodialysis All staff working in haemodialysis unit must be tested
 Yes
centres shall ensure for Hepatitis B and treated accordingly.
implementation of, and (MOV- SOPs; HR records)  No

94 | P a g e
 Requirements Score (tick Remarks
Standard
appropriate box)
adherence to strict infection  P
control procedures designed
All patients are tested for Hepatitis B and C before
to prevent cross-infection  Yes
initiating the first haemodialysis treatment and after
returning from another haemodialysis facility  No
(MOV- SOPs, sample 5 patient files)
 P

All Hepatitis B positive persons are considered

 Yes
infectious, and thus dialyzed using separate machines,
equipment and instruments.  No
(MOV- SOPs; observation)

Serology testing is carried out every 6 months for

 Yes
patients who are Hepatitis B and C negative.
(MOV- SOPs, sample 5 patient files)  No
 P

Patients who are Hepatitis B negative are vaccinated

 Yes
(MOV- SOPs, sample 5 patient files)  No
 P
Haemodialysis staff caring for Hepatitis B positive
 Yes
patients do not care for Hepatitis B susceptible patients
at the same shift.  No
(MOV- SOPs; duty roster)

95 | P a g e
 Requirements Score (tick Remarks
Standard
appropriate box)
 P
Combined Hepatitis B and Hepatitis C infected patients
 Yes
are isolated. If the isolation facility for combined
Hepatitis B and C is not available, the facility makes a  No
provision to have the patient dialyzed in a Hepatitis B
isolation unit. For all patients single use of dialyser is  P
mandatory.
(MOV- SOPs; observation)
All patients are tested for HIV antibody before initiating
 Yes
first haemodialysis treatment and after returning from
another haemodialysis facility.  No
(MOV- SOPs, sample 5 patient files)

In HIV negative patients, serologic test is performed

 Yes
every 6 months
(MOV- SOPs, sample 5 patient files)  No
 P

11. 10.2.3 There shall be Availability of a storeroom with adequate space for
 Yes
adequate space and facilities supplies, consumables and equipment
for all haemodialysis  No
activities to be performed in (MOV-Observation; inventory)
 P
the haemodialysis centres
and for the required volume A suitable and secure area for clinical waste
 Yes
of work
(MOV-Observation)  No

Dialysis room/area with adequate space for dialysis

 Yes
machine and bed/couch/dialysis

96 | P a g e
 Requirements Score (tick Remarks
Standard
appropriate box)
Chair. It should have provision for segregation of  No
patients who are Hepatitis B
(MOV-Observation)
Treatment/ consultation room with facilities and
 Yes
equipment for the treatment and care of end stage renal
failure patients. If facility is providing minor procedures  No
to haemodialysis patients then a treatment room, which
is located separate from the dialysis room/area is
required (MOV-Observation)
Resuscitation facilities including, but not limited to,
 Yes
cardiac monitoring device with defibrillator, bag-valve-
mask, suction apparatus, a functioning laryngoscope,  No
endotracheal tube, drugs commonly used in medical
 P
emergency and oxygen supply and all should be easily
accessible.
(MOV-Observation; equipment inventory)
Appropriately sized water treatment room separated
 Yes
from the dialysis room and all other rooms. There should
be provision for the treated water to be delivered to  No
individual haemodialysis machines through pipes made
of acrylonitrile butadiene styrene (ABS), cross-linked
polyethylene (PEX) or equivalent material.
(MOV-Observation)
Reprocessing room only to be used strictly for dialyser
 Yes
reprocessing, storing of reprocessed dialysers and
sterilant. The room should have adequate ventilation to  No
reduce inhalation risk.
(MOV-Observation)
Conveniently located toilet and washbasins for the staff
 Yes
and patients

97 | P a g e
 Requirements Score (tick Remarks
Standard
appropriate box)
(MOV-Observation)  No
Adequate ventilation by windows, ducts or mechanical
 Yes
means
(MOV-Observation)  No
Waiting area
 Yes
(MOV-Observation)  No

11. 10.2.4 The facility shall The haemodialysis machines are capable of performing
 Yes
ensure that there are conventional (diffusive) haemodialysis and preferably
adequate and functional convective therapy.  No
haemodialysis machines
(MOV-Observation; interview of health providers)
The machines meet specifications set by the Ministry of
 Yes
Health.
(compare machine properties with MOH specifications)  No

There is a mechanism to ensure uninterrupted power

 Yes
supply to return blood from the extra-corporeal circuit in
the event of power failure  No
(MOV-SOP)
A minimum of one back-up machine is available for
 Yes
every ten (10) haemodialysis machines.
(MOV-Observation)  No
Endotoxin retention filter for the dialysate is used when
 Yes
performing high flux haemodialysis
(MOV-SOP)

98 | P a g e
 Requirements Score (tick Remarks
Standard
appropriate box)
 No
External surfaces of the haemodialysis machines are
 Yes
disinfected after each dialysis session.
 No
(MOV-SOP; cleaning logs)
All machines have a documented planned preventive
 Yes
maintenance and technical safety check according to
manufacturer recommendations.  No

(MOV- documented preventive maintenance plan)

11. 10.2.5 The facility shall The room that houses the water treatment system is
 Yes
have in place a water located in an area which minimizes disruption to
treatment system that haemodialysis treatment.  No
provides safe water for use in (MOV-Observation)
haemodialysis The room has adequate ventilation to prevent over-
 Yes
heating
(MOV-Observation)  No
Floor traps are available to drain excess water.
 Yes
(MOV-Observation)
 No
Flow diagram of the water treatment system is displayed
 Yes
in the water treatment room.
(MOV-Observation)  No

All water treatment components and equipment are  Yes

clearly labelled.
(MOV-Observation)  No

99 | P a g e
 Requirements Score (tick Remarks
Standard
appropriate box)
All columns in pre-treatment are opaque  Yes
(MOV-Observation)
 No

Pressure gauge is installed before and after each  Yes

component to monitor fouling of the components.
(MOV-Observation)  No

Daily recording of the parameters of water  Yes

treatment system is performed.
(MOV- check water treatment records; SOPs)  No

Daily testing for chlorine/chloramine and hardness  Yes

is done every morning prior to starting
haemodialysis treatment  No
(MOV- check water treatment records; SOPs)
The raw water tank is covered; has a low-level alarm
 Yes
sensor; is inspected for defects and cleaned every 6
months; appropriate capacity that is adequate to enable  No
at least one shift of treatment to be completed if water
supply is disrupted
(MOV- Observation; check water treatment
records; SOPs)
There are at least two raw water pumps, made of
 Yes
stainless steel
(MOV- Observation)  No

Backwash of the multimedia sediment filter is carried

 Yes
out at least 2 times per week
(MOV- check water treatment records; SOPs)  No

100 | P a g e
 Requirements Score (tick Remarks
Standard
appropriate box)
Empty Bed Contact Time (EBCT) for the carbon
 Yes
columns is ten (10) minutes in total, or five (5) minutes
for each filter stage, if two carbon filters are used to  No
optimise the chlorine and chloramines removal.
Backwash is carried out at least twice per week.
(MOV- check water treatment records; SOPs)
Softener Column is regenerated by sodium chloride from
 Yes
brine tank or equivalent
(MOV- SOPs)  No
The guard filter is replaced as necessary.
 Yes
(MOV- check water treatment records; SOPs)
 No
The recovery rate of reverse osmosis system is at least
 Yes
50%.
(MOV- check water treatment records; SOPs)  No
The water treatment system has the following
 Yes
parameters displayed:
 No
- Conductivity of permeate
- Permeate flow rate
- Reject flow rate
- Raw water pressure
- Guard-in & guard-out pressure
- Reverse osmosis membrane system-in &
system-out pressure

(MOV- check water treatment records; SOPs)

101 | P a g e
 Requirements Score (tick Remarks
Standard
appropriate box)
Water sample ports are available for sampling at the
 Yes
following points:
 No
- Post first carbon column
- Post second carbon column
- Post softener column/Pre-RO module
- Immediate post RO module
- First point in the distribution loop
- Last point in the distribution loop
- Last point of the dialyzer-reprocessing loop

(MOV- check water treatment records; SOPs)

The treated water storage tank is made of stainless steel
 Yes
or high density polyethylene; covered with a tight fitting
lid and fitted with ultraviolet irradiator for destruction of  No
bacteria with an air vent with a bacterial filter.
(MOV- observation; SOPs)
Water treatment system is distributed to the individual
 Yes
dialysis stations, and dialyser reprocessing stations using
distribution materials and designs which minimize or  No
stop microbiological contamination.
(MOV- check water treatment records; SOPs)
A minimum of six (6) monthly (or as specified by the
 Yes
manufacturer’s recommendation) chemical disinfection
of distribution loop including the connections to dialysis  No
machine is done, using peracetic acid 2-3% or chlorine
dioxide especially when materials of distribution loop
are not heat resistant. Weekly heat disinfection of the
tank and distribution loop is carried out for a system

102 | P a g e
 Requirements Score (tick Remarks
Standard
appropriate box)
which incorporates a heater and uses heat resistant
piping
(MOV- SOPs)
11. 10.2.6 The facility shall Dialysis water is produced by the process of reverse
 Yes
have in place measures to osmosis
ensure that water quality (MOV-SOP)  No
used for haemodialysis is of
Chlorine and chloramines and water hardness testing is
the right quality.  Yes
performed onsite using commercially available test kits
while full analysis for chemical contaminants is  No
performed by an accredited laboratory
(MOV-records for water analysis; SOPs)
Testing for contaminants is carried out daily using
 Yes
commercially available test kits for chlorine and
chloramines and every six months in an accredited  No
laboratory for chemical analysis.
(MOV-records for water analysis; SOPs)
Daily testing for chlorine and chloramines is done after
 Yes
each carbon column; testing for hardness after softener
column; while Six (6)-monthly full laboratories testing  No
for chemicals is done at raw water point, pre and post
reverse osmosis.
(MOV-records for water analysis; SOPs)
The facility takes action if limits are exceeded mainly by
 Yes
evaluating water treatment system and rectifying as
necessary  No
(MOV-records for water analysis; SOPs)
The facility carries out total viable counts using spread
 Yes
plate or membrane filtration technique using Trypton
Glucose Extract Agar (TGEA) or equivalent and  No

103 | P a g e
 Requirements Score (tick Remarks
Standard
appropriate box)
determines presence of pyrogen/endotoxin using
Limulus Amoebocyte Lysate (LAL) method.
(MOV-records for water analysis; SOPs)
The facility carries out monthly testing for bacterial
 Yes
count and endotoxin test
(MOV-records for water analysis; SOPs)  No
11. 10.2.7 The facility shall The reprocessing machine is fully automated integrated
 Yes
have a mechanism for unit capable to clean, test and fill the dialyser with
efficient reprocessing of disinfectant and is able to perform automatic dilution of  No
sterilant to specified strength.
dialyser
(MOV-Check machine specifications)

The dialyser reprocessing procedure includes:

- Calibration every morning  Yes

- Cleansing of residual blood and blood products
and rinsed with reverse osmosis water.  No
- Testing for residual membrane performance
(Total Cell Volume (TCV) and the presence of
leaks. Dialyzers with TCV <80% or failed the
leak test with TCV not be reused
- Filled with appropriate concentration of a
germicide.
- The machine is sanitized at the end of every day.
Every reused dialyser is tested for residual disinfectant
prior to use. (MOV-SOP; Cleaning records)
A separate machine is used for HBs Ag positive or anti
 Yes
HCV positive patients. Single use of dialyser ensured for
Hepatitis B & C co-infected patients.  No
(MOV-SOP; observation)

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 Requirements Score (tick Remarks
Standard
appropriate box)
11. 10.2.8 The facility shall Dialysate used is approved by Kenya Pharmacy and
 Yes
ensure consumables used in Poisons Board.
haemodialysis are of the (MOV-SOP; Observation)  No
right standard The dialysate packaging has the following information
 Yes
clearly labelled:
- Address of manufacturer  No
- Contents
- Concentration of electrolytes
- Dialysate concentration ratio
- Date of manufacture and expiry

(MOV-SOP; Observation)
Dialysers used by the facility are made from
 Yes
biocompatible membrane.
(MOV-SOP; Observation)  No

Bloodlines used for haemodialysis treatment meet MOH

 Yes
specifications
(MOV-SOP; Observation)  No

Arterio-venous needle used for haemodialysis treatment

 Yes
meets MOH specification
(MOV-SOP; Observation)  No

11.10.3 Peritoneal Dialysis (PD)

11.10.3.1 All equipment and Peritoneal dialysis insertion sets (including PD  Yes
supplies used in the delivery Catheters) available
and monitoring of PD (MOV-Observation)  No
therapies shall comply with
PD tubing sets with infection-preventing designs such as
the relevant standards.  Yes
the Y-connector and the use of disconnect systems

105 | P a g e
 Requirements Score (tick Remarks
Standard
appropriate box)
(MOV-Observation)  No
PD cycler for initiation and training in automated PD
 Yes
(MOV-Observation)
 No
PD fluids should satisfy current quality medical
 Yes
standards
(MOV-Supplies specifications)  No

11.10.3.2 The facility shall The PD training is carried out in a well-equipped PD

 Yes
have in place provisions for Training Room
educating of PD patients (MOV-Observation)  No
The PD Training will include the following:
 Yes
o Training schedule (topics, guidelines for trainer,
pre and post patient training assessment)  No
o Teaching aids
o Home environment assessment  P
o Family support assessment
(MOV-Training curriculum)

11.10.3.3 The facility shall All PD patients are monitored using the following
put in place measures to parameters
ensure each PD patient is Small-Solute Clearance measured at 4-6 weeks after PD
 Yes
monitored for compliance onset and when clinically indicated
with an adequate PD dose (MOV-SOPs; sample 5 patient files)  No

Residual Renal Function (RRF) measured every 3-6

 Yes
months or when clinically indicated
(MOV-SOPs; sample 5 patient files)  No

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 Requirements Score (tick Remarks
Standard
appropriate box)
Volume assessment and performance of 2.5% or 4.25%
 Yes
dextrose PET carried out no sooner than 4 weeks after
initiation of PD.  No
(MOV-SOPs; sample 5 patient files)

Nutrition assessment: using Predictive Indices of

 Yes
Nutrition e.g. body weight, lean body mass, serum
albumin and pre-albumin, blood urea, subjective global  No
assessment, protein equivalent of nitrogen appearance
(MOV-SOPs; sample 5 patient files)
11.10.3.4 The peritoneal The facility has physical or virtual access to the
 Yes
dialysis unit shall have in following SOPs:
place standard operating  No
procedures for its services  Nursing management of patients on PD Guidelines
for the PD training program  P
 Care of the peritoneal access (including peritoneal
catheter and exit site)
 Treatment of infection (peritonitis and PD catheter
exit site)
 Management of dialysis-related complications
 Peritoneal equilibration test
 PD adequacy assessment
 Patient education on fluid and dietary restrictions
(MOV- Observation)

11.10.4 The facility carries Audit of dialysis unit carried out

 Yes
out, documents and (MOV- Audit report)
disseminates to all relevant  No

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 Requirements Score (tick Remarks
Standard
appropriate box)
staff annual audit reports of
the dialysis unit
The audit covers at a minimum the following :

Patient to dialysis nursing staff ratio  Yes

(MOV-audit report)
 No

Functionality of medical equipment  Yes

(MOV-audit report)
 No

Audit of care pathway for dialysis preparation to  Yes

include information given (including proportion of
patients offered dialysis), when and who delivers it.  No
(MOV-audit report)
Audit of information on modality options provided  Yes
to patients presenting who urgently require renal
replacement therapy, and both initial and  No
subsequent modality of renal replacement therapy
selected by these patients.
(MOV-audit report)
Audit of care pathway for catheter insertion  Yes
(MOV-audit report)
 No

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 Requirements Score (tick Remarks
Standard
appropriate box)
Catheter complications and their resolution  Yes
(MOV-audit report)
 No

Frequency of solute clearance estimation  Yes

(MOV-audit report)
 No

Frequency of measurement of membrane function,  Yes

residual urine and peritoneal ultrafiltration volume
(MOV-audit report)  No

Number of patients regularly requiring hypertonic  Yes

(3.86% glucose) exchanges to maintain fluid
balance  No
(MOV-audit report)
Identify patients with a total fluid removal <750 ml  Yes
per day.
(MOV-audit report)  No

Functionality of infection prevention strategies  Yes

(MOV-audit report)
 No

Infection outcomes  Yes

(MOV-audit report)
 No

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11.11 Laboratory
Requirements Score (tick Remarks
Standard
appropriate box)
11.11.1 The health facility shall Staffing is in line with the HR norms and standards
 Yes
ensure there are adequate (MOV- HR records)
 No
resources to provide quality
 P
laboratory services
Facility has adequate laboratory infrastructure and
 Yes
equipment as per tier of care
(MOV- Adequate equipment as per the scope of work  No
and tier of the health facility)  P

Laboratory room is air conditioned, clean, uncluttered

 Yes
and well ventilated.
 No
(MOV- observations)
 P

There is an inventory store with controlled

 Yes
temperatures
 No
(MOV- observations)
 P

Benches, well fitted with recommended laboratory

 Yes
chairs
 No
(MOV- observations)
 P

Laboratory has proper lighting and access control

 Yes
services
 No
(MOV- observations)
 P

Safety cabinets available

 Yes
(MOV- observations)
 No
 P

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 Requirements Score (tick Remarks
Standard
appropriate box)
The laboratory monitors environmental conditions that
 Yes
affect testing
(MOV-Monitoring logs)  No
 P

11.11.2 General Laboratory Quality Management System

11.11.2.1 The health facility shall There is an updated laboratory quality manual that has
 Yes
develop and make available a been communicated to all relevant staff
 No
quality manual that summarizes (MOV-availability of current laboratory manual)
the laboratory’s quality There is a laboratory master list with all documents.
 Yes
management system (QMS). (MOV- availability of master list)
 No
 P

The laboratory has defined its scope of service and

 Yes
provides minimum essential tests as required per its
 No
level (MOV- availability of Quality manual in line with
 P
ISO 15189, complete document master list)

11.11.2.2 The health facility shall The laboratory provides specifications for its supplies
 Yes
provide specifications for and consumables
 No
supplies and consumables (MOV-list with specification for supplies and
 P
consumables)

The laboratory maintains records for each reagent and

 Yes
consumable used in the performance of examinations,
 No
with accurate inventory of its stock.
 P
(MOV-inventory)

The laboratory has appropriate storage areas, which are

 Yes
routinely monitored
 No
(MOV-observation)

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 Requirements Score (tick Remarks
Standard
appropriate box)
 P

The laboratory employs First-Expiration-First-Out

 Yes
(FEFO) practice to all reagents/test kits in use. (MOV-
 No
observation/ bin cards)

All expired products labelled and disposed properly.

 Yes
(MOV-SOPs and records/holding grounds/ observed)
 No

11.11.2.3 The health facility shall Internal audits conducted as described in internal audit
 Yes
conduct its internal audits at procedure.
 No
intervals as defined in the quality (MOV-audit reports)
 P
manual and address areas
important to patient care Internal audit action plan developed with clear
 Yes
timelines, assigned personnel and documented follow-
 No
up.
(MOV- evidence of trained internal auditors, SOP on
internal audit, non-conformities identified, corrective
actions taken)

11.11.3 Pre-examination processes

11.11.3.1 The health facility The laboratory has standardized a request form, with
 Yes
shall use standardized space for inclusion of, but not limited to the following:
 No
laboratory request forms patient identification including age, gender, date of
 P
birth and location/contacts, name or unique identifier of
the requesting clinician, date and time of primary
sample collection

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 Requirements Score (tick Remarks
Standard
appropriate box)
(MOV- Observe for use of a standardized request form
across the facility)

11.11.3.2 The laboratory shall The laboratory has guidelines for specimen collection
 Yes
have guidelines for specimen (including staff and client safety), labelling, and
 No
collection and transportation transportation to persons responsible for primary
sample collection
(MOV- sample collection guidelines at sample
collection areas)
11.11.3.3 The laboratory shall The laboratory documents, reviews and evaluates
 Yes
document, review and evaluate referrals to laboratories and consultant clinics
 No
referrals to laboratories and (MOV- referral register/ record)
 P
consultants’ clinics as defined by
the laboratory The laboratory maintains a register of referral
 Yes
laboratories and consultants clinics, and all referred
 No
specimens are tracked properly using a logbook,
tracking form or electronically.
(MOV- criteria for selection and evaluation of referral
laboratories and consultants clinics, list of referral
laboratories, records of referred samples, evidence of
the referring laboratory providing results to the
requesting entity)

11.11.3.4 There shall be a A procedure for referral of samples is in place

 Yes
mechanism for referral of (MOV- SOP).
 No
samples to appropriate facilities

11.11.4 Examination processes

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 Requirements Score (tick Remarks
Standard
appropriate box)
11.11.4 .1 The laboratory shall The laboratory has Standard Operating Procedures
 Yes
develop Standard Operating (SOP) for all its processes
 No
Procedures (SOP) for all its (MOV- SOP developed and available at point of use)
 P
processes
11.11.4 .2 Only trained, qualified The laboratory is run and managed by qualified and
 Yes
and authorized personnel shall authorized professionals
 No
be allowed to collect analyse and (MOV- HR Records/Data base – defined qualifications
 P
release the results of patients. of staff)

11.11.4 .3 All laboratory There is evidence of routine calibration of equipment

 Yes
equipment shall be maintained in (including pipettes, centrifuges, balances, and
 No
a functional condition. thermometers) scheduled, at minimum, following
manufacturer recommendations and verified
(MOV-Calibration records, schedule of calibration,
maintenance of equipment, evidence of calibration
certificates,)

Preventive maintenance performed on all equipment

 Yes
and recorded
 No
(MOV- Maintenance records)
 P

Manufacturer’s operator manuals readily available to

 Yes
testing staff in a language understood by the staff.
 No
(MOV- SOPs and manufacturers operating manuals)
 P
11.11.4.4 Examination Examination methods and procedures shall be validated
 Yes
procedures shall be and verified before being introduced into routine use
 No
verified/validated for the

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 Requirements Score (tick Remarks
Standard
appropriate box)
laboratory before being (*Note: Standard methods do not need to be validated,
introduced into routine use but shall be verified) (See ISO 15189 and CLSI
guidelines)
(MOV- SOP on validation and verification, evidence
of validation/ verification of methods. Statement of
acceptability of the method)
Each new reagent preparation, new lot number, new
 Yes
shipment of reagents or consumables shall be verified
 No
before use and documented
 P
(MOV- Evidence of verification of reagents and
consumables before use in laboratory e.g. lot to lot
verification)
11.11.4 .5 Internal Quality IQC results are monitored and reviewed (including
 Yes
Control (IQC) shall be biases and Levy-Jennings charts for quantitative tests)
 No
performed, documented, and and corrective actions taken when quality control
 P
verified for all tests/procedures results exceed the acceptable range.
before releasing patients’ results (MOV- levy charts analysed and corrective actions
taken in case of non-conformity)
11.11.4 .6 The laboratory shall Inter-laboratory comparison programme(s) have
 Yes
participate in inter-laboratory clinically relevant challenges that mimic patients’
 No
comparison programs or samples and have the effect of checking the entire
 P
proficiency testing or alternative examination processes including pre-examination,
assessment systems for all tests examination and post examination procedures where
possible
(MOV- feedback from the proficiency testing provider
on participation on Proficiency testing, corrective
actions taken in case of failure of Proficiency testing)

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 Requirements Score (tick Remarks
Standard
appropriate box)
11.11.5 Post examination
processes
11.11.5.1 All test results reports Reports of test results are legible, technically
 Yes
shall be legible, technically verified/validated, and confirmed against patient
 No
verified/validated, and information (MOV- Sample 5 lab results)
 P
confirmed against patient
information
11.11.5.2 Results shall be Results interpreted and released by authorized
 Yes
interpreted and released by personnel
 No
authorized personnel. (MOV- list of authorised personnel to interpret results)
 P

11.11.5.3 Reporting mechanism Laboratory has a reporting procedure for critical and
 Yes
shall be in place for critical and urgent results
 No
urgent results. (MOV- SOP on critical reporting, past records on
 P
critical reporting)

11.11.5.4 The laboratory report Laboratory reports are clear and include:
 Yes
shall be comprehensive and clear
- Examination performed,  No
- Patient identification,  P
- Name or unique identifier of the requesting
person ,
- Examination results reported in SI units, or
other applicable units,
- Biological reference intervals,
- Interpretation of results as appropriate,
- Identification of person undertaking the
examination and person reviewing the results

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 Requirements Score (tick Remarks
Standard
appropriate box)
(MOV- evidence of a standardized report )

11.11.5.5 All archived results Archived results are properly labelled and stored in a
 Yes
shall be properly labelled and secure location accessible only to authorized personnel
 No
stored in a secure location, easily (MOV- SOP on archiving, records of archived report)
retrievable and accessible only to
authorized personnel
11.11.5.6 The laboratory shall The laboratory has a defined period for clinical samples
 Yes
define length of time clinical retention, which depends on the nature of the sample,
 No
samples will be retained, which the examination and any applicable requirements
shall be aligned to current (regulation)
regulation. (MOV- retention guidelines and as per applicable
regulations , retention records)

11.11.5.7 Sample disposal shall Sample disposal carried out in accordance with waste
 Yes
be carried out in accordance management regulations
 No
with waste management (MOV- Records of waste disposal)
 P
regulations.
11.11.5.8 Where the laboratory The laboratory defines levels of access authorization
 Yes
uses information management and responsibilities for the management and use of the
 No
systems, the laboratory shall laboratory information system
define levels of access (MOV- records showing level and authority for access,
authorization and use of passwords)
responsibilities for the
management and use of the
laboratory information system

11.11.5.9 All results that have Results that have been transmitted electronically or
 Yes
been transmitted electronically reproduced externally to the laboratory (computers, fax

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 Requirements Score (tick Remarks
Standard
appropriate box)
or reproduced externally to the machines, email and websites and personal web  No
laboratory shall be verified devices) are verified  P
(MOV- SOP on verification of the software)

11.11.6 Point of Care Testing

11.11.6.1 The health facility There is a qualified staff member responsible for
 Yes
management shall be responsible developing and implementing point of care testing
 No
for ensuring that appropriate procedures
measures are put in place to (MOV – HR records)
provide and monitor point of
care testing within the institution Training program in place for POCT
 Yes
(MOV- training program)
 No

Facility proactively deal with nonconformities arising

 Yes
from POCT.
 No
(MOV-failed quality control and EQA reports)

Facility implements process for comparison of

 Yes
equipment / methods
 No
(MOV- report)

Procedures for ordering and collection of samples for

 Yes
point of care test are documented
 No
(MOV –observation of documented procedure)

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11.12 Pharmacy
Requirements Score (tick Remarks
Standard
appropriate box)
11.12.1 The health facility The pharmacy is appropriately staffed based on the
 Yes
shall provide adequate HRH norms and standards (MOV- HR Records)
 No
resources to support
provision of quality All pharmaceutical staff are registered by the
 Yes
pharmaceutical services Pharmacy and Poisons Board (MOV- HR
 No
Records)

The facility has tablet counters, dispensing

 Yes
software, and refrigerator as per the existing
 No
infrastructure norms and standards
 P
(MOV-Observation)

The facility has temperature controlled, well

 Yes
ventilated commodity storage room with racks
 No
(MOV-Observation, temperature charts)

11.12.2 The health facility There is a system in place in the pharmacy for
 Yes
shall ensure that detection of prescription errors (MOV-SOP)
 No
pharmaceutical services
are provided based on the There is a procedure in the pharmacy for rectifying
 Yes
best pharmaceutical detected pharmaceutical errors
 No
practices (MOV-Documented procedure )

There is a provision in the pharmacy for

 Yes
confidential counselling of clients on the use of
 No
medicines and other products dispensed by the
pharmacy (MOV-Observation)

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 Requirements Score (tick Remarks
Standard
appropriate box)
Pharmacy adheres to the standard operating
 Yes
procedures for extemporaneous preparations and
 No
reconstitutions
 P
(MOV- availability of clean water and dispensing
containers)

There is evidence of storage and use of

 Yes
prescription data for decision making
 No
(MOV- Medicines and Therapeutic Committee
 P
minutes)

11.12.3 The facility shall There is a checklist to determine that the

 Yes
establish mechanisms for medicines are of good quality and safe to use
 No
ensuring the safety of (MOV-Checklist)
medicinal products,
including vaccines and Narcotics and psychotropic medicines are
 Yes
herbal medications accounted for in accordance to the SOPs and
 No
specified registers
(MOV- Narcotics register, DDA)

There is a system for pharmaco-vigilance

 Yes
(MOV- pharmacovigilance register/ forms)
 No

11.12.4 The facility shall There is a pharmaceutical care plan, which is

 Yes
establish a mechanism for communicated to the prescriber/provider and the
 No
medication therapy client. (MOV-List of available drugs)
management
There is a tracking chart for medicines
 Yes
(MOV- availability of tracking chart).
 No

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 Requirements Score (tick Remarks
Standard
appropriate box)
There is evidence of documentation of medicines
 Yes
and therapeutic committee meetings.
 No
(MOV- Minutes of MTC)

11.12.5 The health facility There is evidence of a CME schedule, register and
 Yes
shall ensure minutes by the pharmacy department at least once
 No
pharmaceutical staff every month
undergo regular (MOV- CME report)
training, update their skills
and carry out operational There is a documented plan of health education for
 Yes
research clients/ clinicians
 No
(MOV- Schedules)

There is evidence that the facility carries out

 Yes
operational research to inform pharmacy
 No
decisions.
(MOV-Research report)

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11.13 Radiology
Requirements Score (tick Remarks
Standard
appropriate box)
11.13.1 The facility shall The wall thickness of x-ray rooms, window height,
 Yes
ensure that X-Ray ceiling height, doors and room size meet
 No
infrastructure is developed recommended international radiation protection
 P
according to regulation. specifications
(MOV- approved building plan)

X-ray room ceiling height allows room for ceiling

 Yes
suspended equipment
 No
(MOV- Observation against standards)

X-ray department is located adjacent to casualty

 Yes
department for ease of transfer of emergency cases.
 No
(MOV-Observation)

11.13.2 The facility Facility carries out radiation monitoring of all staff
 Yes
management will ensure working in radiation area on a monthly basis. This
 No
radiation safety for staff, should include submission of radiation doses.
patient and the public. (MOV-Radiation monitoring reports)

Radiation protection gear is available for all

 Yes
patients and staff
 No
(MOV-Observation)

Facility monitors radiation within the X-ray

 Yes
department
 No
(MOV- radiation monitoring report)
 P

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 Requirements Score (tick Remarks
Standard
appropriate box)
Facility has put in place measures to address
 Yes
identified areas of improvement based on results of
 No
radiation monitoring
 P
(MOV- Improvement plan)
 NA

11.13.3 Facility management Facility uses a standard request form that includes
 Yes
shall ensure that examination at least fields for:
 No
request forms are
- Patient details (Name, Age, Sex, IP/OP no)  P
standardised.
- Clinical details
- Clinical query to be answered
- Referral details
- Region and examination details
- Procedure priority (e.g. urgent, elective)
- Provisional diagnosis.
- Gravidity status for females of child bearing
age.
- History of reaction to iodine based contrast
media

(MOV- observe for the above in the request form)

11.13.4 Imaging departments Facility has a secure changing room

 Yes
will ensure patient dignity and (MOV-Observation)
 No
comfort is ensured during
imaging examinations. Facility has clean changing gowns
 Yes
(MOV-Observation)
 No

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 Requirements Score (tick Remarks
Standard
appropriate box)
Examination room offers privacy during
 Yes
procedures
 No
(MOV-Observation)

Facility displays ‘Examination in Progress’ sign at

 Yes
the entrance to the examination room
 No
(MOV-Observation)

11.13.5 Imaging departments The department provides 24 hour services, 7 days

 Yes
will ensure a mechanism is in a week
 No
place for immediate reporting
of urgent and critical
examination results.

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11.14 Mortuary
Requirements Score (tick appropriate Remarks
Standard
box)
11.14.1 The facility shall Staff working in the mortuary have relevant
 Yes
have adequate resources to training
 No
provide quality mortuary (MOV-HR records)
 P
services (8)
The mortuary has functional system for
 Yes
preservation of bodies (e.g. coolers or
 No
formalin technology)
(MOV-observation of the mortuary)

A body trolley is available

 Yes
(MOV-observation)
 No

A dissecting kit is available

 Yes
(MOV-observation and equipment list)
 No

11.14.2 The facility shall Bodies are received in line with standard
 Yes
have in place documented operating procedures
 No
standard operating (MOV- Availability of SOP)
procedures for body
processing Bodies are identified according to standard
 Yes
operating procedures
 No
(MOV- Availability of SOP)

Bodies are stored in line with standard

 Yes
operating procedures
 No
(MOV- Availability of SOP)

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 Requirements Score (tick appropriate Remarks
Standard
box)
Bodies are released in line with standard
 Yes
operating procedures
 No
(MOV- Availability of SOP)

11.14.3 The mortuary Mortuary has a working drainage system

 Yes
environment shall have a (MOV-Observation)
 No
functional drainage system
and be free from smells Odour from the mortuary does not reach
 Yes
patient areas and the public
 No
(MOV- Observation)

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DIMENSION 12: RESULTS
The facility shall assess its performance on a quarterly basis using a set of defined key performance indicators. Trends for the KPIs shall be analysed and
documented. These indicators have been outlined in the section below:

No. Indicator Benchmark 0 1 2 3 4

1 Patient satisfaction index 85% ˂21% 43-63% 64-84% ≥85%
21-42%
2 Staff satisfaction index 85% ˂21% 21-42% 43-63s% 64-84% ≥85%
3 Average length of hospital stay 4 ≥8 days 7 days 6 days 5 days ˂4 days
4 Episodes of stock out of any of the 22 0 ≥7 episodes 5-6 episodes 3-4 episodes 1-2 episodes 0
essential medicines and supplies
lasting over 7 days in the last three
month
5 Down time rates for vaccines fridge: 0 ≥7 days 5-6 days 3-4 days 1-2 days 0 days
Number of days the vaccine fridge was
not functional in the past 90 days
6 Proportion of emergency patients 100% ˂ 25% 25-49% 50-74% 75-99% 100%
referred within 30 minutes of decision
making
Numerator: Number of emergency
patients referred by the facility within
30 minutes of decision making
Denominator: Total number of
emergency patients referred by the
facility

7 Proportion of under year one children 90% ˂ 22 22-44% 45-67% 68-89% ≥90%
vaccinated against Measles and
Rubella

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 No. Indicator Benchmark 0 1 2 3 4
Numerator: No. of children under 1
yr immunized against measles
Denominator: Facility target
population under 1year of age
8 Proportion of patients developing 5% ˃8.8% 8.8-7.6% 7.5-6.4% 6.3-4.9% ≤5%
nosocomial infections
Numerator: Number of patients with
nosocomial infections
Denominator: Total number of
inpatients
9 Proportion of patients with bed sores 1% ˃ 1.75 1.75-1.6% 1.5-1.26% 1.25-1% ˂1
grade 1 & 2
Numerator: Number of patients with
bed sores grade 1 & 2
Denominator: Total number of
inpatients
10 Proportion of women with perineal 3 ˃ 5.3 5.3-4.4% 4.5-3.9% 3.8-3% ˂3
tears Grade 2-4
Numerator: Number of women with
perineal tears
Denominator: Total number of
vaginal deliveries
11 Caesarean Section rate 15% ˂ 3.8% 3.8-7.4% 7.5-11.3% 11.4-14.9% ≥15
Numerator: Number of CS
Denominator: Total number of births
12 Facility-based direct obstetric case 1% ˃ 1.75 1.75-1.6% 1.5-1.26% 1.25-1% ˂1
fatality rate
Numerator: Number of maternal
deaths at facility

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 No. Indicator Benchmark 0 1 2 3 4
Denominator: Number of obstetric
complications managed at facility
13 Proportion of maternal deaths audited 100% ˂ 25% 25-49% 50-74% 75-99% 100%
Numerator: Number of maternal
deaths audited
Denominator: Total number of
maternal deaths
14 Proportions of newborns successfully 100% ˂ 25% 25-49% 50-74% 75-99% 100%
resuscitated
Numerator: Number of newborns
successfully resuscitated
Denominator: Number of newborns
requiring resuscitation
15. Proportion of babies with confirmed or 5 ˃8.8% 8.8-7.6% 7.5-6.4% 6.3-4.9% ≤5%
suspected neonatal infection (including
readmissions within seven days of
discharge)
Numerator: Number of babies with
confirmed or suspected neonatal
infection (including readmissions
within seven days of discharge)
Denominator: Total number of live
births in the health facility
16. Proportion of babies born with low 5% ˃8.8% 8.8-7.6% 7.5-6.4% 6.3-4.9% ≤5%
birth weight
Numerator: Number of babies born
with weight ˂2500g
Denominator: Total number of live
births

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 No. Indicator Benchmark 0 1 2 3 4
17 Survival rate for babies born 90% ˂ 22 22-44% 45-67% 68-89% ≥90%
premature
Numerator: Number of premature
babies who are discharged alive
Denominator: Total number of babies
born premature
18 Facility-based perinatal mortality rate 1% ˃ 1.75 1.75-1.6% 1.5-1.26% 1.25-1% ˂1
Numerator: Number of perinatal
deaths (all stillbirths and early
neonatal deaths including
readmissions)
Denominator: Total number of births
19 Stillbirth rate 10 ˃17.5 still births 17.5-15.1 still 15.0-12.6 still 12.5-10.1 still ≤10 still births
Numerator: Number of babies with per 1000 live births per 1000 births per 1000 births per 1000 per 1000 live
no signs of life at birth (at or after 28 births live births live births live births births
weeks of gestation and weighting
≥1000 grams)
Denominator: Total # of births in the
facility
20 Facility-based neonatal mortality rate 12 mortalities ˃ 21 mortalities 21-18.1 18-15.1 15.0-12.1 ˂ 12 mortalities
Numerator: Number of neonatal per 1000 live per 1000 live mortalities per mortalities per mortalities per per 1000 live
deaths births births 1000 live births 1000 live births 1000 live births births
Denominator: Total number of
livebirths
21 Facility-based pneumonia case fatality 5% ˃8.8% 8.8-7.6% 7.5-6.4% 6.3-4.9% ≤5%
rate for children under 5yrs
Numerator: Number of deaths of
children under 5yrs from pneumonia

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 No. Indicator Benchmark 0 1 2 3 4
Denominator: Total number of
pneumonia cases of children under 5
yrs
22 Facility-based diarrhoea case fatality 1% ˃ 1.75 1.75-1.6% 1.5-1.26% 1.25-1% ˂1
rate in children under 5 years of age
Numerator: Number of deaths of
children below 5 years of age from
diarrhoea
Denominator: Total number of
inpatient diarrhoea cases in children
below 5years of age
23 Percentage of perinatal deaths audited 100% ˂ 25% 25-49% 50-74% 75-99% 100%
Numerator: Number of perinatal
deaths audited
Denominator: Total number of
perinatal deaths
24 Proportion of repeat surgeries 2% ˃3.5% 3.5-3.1% 3.0-2.6% 2.5-2% ˂2%
Numerator: Number of repeat
surgeries in a year
Denominator: Total number of
surgeries in a year
25 Surgical rate for cold cases 0.9 ˂0.2 0.2-0.49 0.5-0.69 0.7-0.9 ˃0.9
Numerator: Number of surgeries
conducted for cold cases
Denominator: Total number of
scheduled surgeries
26 Proportion of post-surgery 10% ˃17.5 % 17.5-15.1 % 15.0-12.6 % 12.5-10.1% ≤10 %
complications

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 No. Indicator Benchmark 0 1 2 3 4
Numerator: Number of patients with
post-surgery complications
Denominator: Total number of
surgeries
27 TB cure rate 90% ˂ 22 22-44% 45-67% 68-89% ≥90%
Numerator: Number of TB cases
cured
Denominator: Total number of TB
cases treated
28 HIV viral load suppression 90% ˂ 22 22-44% 45-67% 68-89% ≥90%
Numerator: Number of HIV patients
on treatment whose viral loads are
suppressed below 1000 copies/μl
Denominator: Total number of HIV
patients on treatment

29 Malaria inpatient case fatality rate 5% ˃8.8% 8.8-7.6% 7.5-6.4% 6.3-4.9% ≤5%
Numerator: Number of deaths due to
malaria
Denominator: Total number of
inpatient malaria cases
30 Percentage of dialysis patients with 100% ˂ 25% 25-49% 50-74% 75-99% 100%
most recent haemoglobin above 12g/dl
Numerator: Number of dialysis
patients whose haemoglobin level is
above 12g/dl
Denominator: Total number of
patients undergoing dialysis in the last
one year.

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 No. Indicator Benchmark 0 1 2 3 4
31 Percentage of patients being managed 100% ˂ 25% 25-49% 50-74% 75-99% 100%
for high blood pressure with most
recent blood pressure <140/90 mmHg
Numerator: Number of patients with
most recent blood pressure <140/90
mmHg who have been managed for
hypertension in the last one year
Denominator: Total number of
patients undergoing treatment for
hypertension in the last one year.

32 All women of reproductive age 75% ˂18% 18-37% 37-56% 57-74% ≥75%
accessing care at the health facility are
screened for cervical cancer
Numerator: Number of women
screened for cervical cancer
Denominator: All women of
reproductive age accessing care at the
health facility

33 Facility based inpatient fatality rate 2 ˃3.5% 3.5-3.1% 3.0-2.6% 2.5-2% ˂2%
(%)
Numerator: Number of deaths
Denominator: Total number of
admissions
34 Quarterly data quality audits carried 4 0 1 2 3 4
out in the past one year

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APPENDICES
Appendix 1: A&E Equipment
The basic equipment and supplies needed for effective running of the A&E are listed below:
Airways/Breathing Other A&E Equipment
 Bag valve mask  Barlows tape measure (for children)
 Chest tube / underwater seal drainage  Weighing scale
 Combitube  Telephone and directory
 Elastic gum bougies  Pedal operated colour-coded waste bins
 Endotracheal tube  Safety box for sharps
 Laryngeal Mask Airway  Blood fridge
 Laryngoscope, various sizes of blades  Cabinets
 McGill forceps  Computer (s) and accessories and appropriate software
 Nasal prongs  Drug cabinet
 Nasopharyngeal airways  Examination couch
 Nebulizer machine  Examination lamps
 Oropharyngeal airways  Hoist
 Oxygen cylinder with a flow metre  Instrument trays
 Suction machines, tubes and catheters  Office furniture
 Thoracotomy set  EPI Refrigerator
 Tongue depressor  Resuscitation trolley/tray
 Tracheostomy set  Rollers
 Transport Ventilators  Stretchers
 Procedure trolleys
 Wheel chairs

Splints Monitoring Devices

 Bandages  Pulse oximeter
 Cervical collar –hard collar  Patient Monitors (invasive*** and non invasive)
 Plaster of Paris  Glucometer
 Spine board  Blood gas electrolyte analyser
 Traction kit  Spirometer/ peak flow meter
 Thermometer

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  Diagnosis set
 Stethoscope
 Sphygmomanometer (Digital & Aneroid)

Circulation/Haemodynamics Diagnostic
 12 lead ECG machine  Mobile X-ray machine
 Blood and fluid warmer  Diagnostic set
 Central venous catheters  Specimen bottles
 Defibrillator/ Automated External Defibrillator (AED)  Lumbar puncture set
 Foleys catheter s  Foetal heart monitor
 Infusion pumps  Ultrasound machine
 Intraoseous Needles
 IV cannulae 14, 16 18 20 and 22
 Syringe pumps

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Appendix 2: Essential Medicines
Medicine Description
1. Cap Amoxicillin 250mg
2. Syr Amoxicillin 125mg/5ml
3. Tab Paracetamol 500mg
4. Tab Cotrimoxazole 480mg
5. Tab Albendazole 400mg
6. Tab Chlorpheniramine 4mg
7. Tab Artemisinin lumefantrine 20/120mg
8. Susp Metronidazole 200mg / 5ml
9. Inj Gentamycin
10. Inj Benzylpenicillin
11 Inj Adrenaline 1mg/ml
12. Inj Hydrocortisone 100mg/ml
13. Oral rehydration salt 500ML/satchet
14. Tetracycline eye ointment 1%
15. Clotrimazole cream 1%
16. Inj. Oxytocin
17. Infusion Normal Saline
#

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Appendix 3: List of Tracer Non-pharmaceutical products
Item Description Item category Unit of Issue
No.
1 Cotton, Gauze Plain 36" x 100yds - 1500gms BP weight White colour, Surgical dressing rolls
Loosely Woven and absorbent
2 Cotton wool 400gm Surgical dressing rolls
3 Giving sets, Blood, Double Chamber surgical syringes/ needles Box of 25
/cannulas
4 Autoclaving Tape Surgical dressing pack of 10
5 Cord Clumps Surgical dressing pack of 100

6 Gloves :
Gynaecological gloves Surgical gloves pairs
Surgical Latex Gloves (Sterile) size 7.5 “ Surgical gloves Pack of 50 pairs
Clean gloves Surgical gloves Pack of 50 pairs
7 Giving sets, Blood, Double Chamber surgical syringes/ needles
/cannulas
8 Giving Sets, IV Fluid Infusion, with air inlets surgical syringes/ needles
/cannulas
9 Catheters Folley's 30ml size - 16 FG Surgical tubes Pieces
10 I.V. Cannulas : - short Teflon, 18G Surgical tubes Pack of 50
- short Teflon, 24G
11 Safety Boxes Surgical dressing Pack of 50
12 Sutures: Sutures Dozen
Nylon No. 2/0 1/2" circle reverse,Cutting needle, 26mm, 75cm Non-
absorbable (sterile)
Polyglycolic acid 2/0 RBN 30mmx75cm
13 Syringes: Surgical syringes/ needles Box of 100
2ml with G23 Needle (Reuse Prevention Syringes) /cannulas
5ml with one G 21needle (Reuse Prevention Syringes)
14 Zinc Oxide strapping 7.5cm x 4.5m BPC Surgical dressing box of 6 pc
15 Bandages, Cotton, loose Woven, BP,7.5cm x 4.5m Surgical dressing Dozen
16 Blades, Surgical, size 23 Surgical tubes pack of 10

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Appendix 4: Assessment for critical intra-partum care
The provider shall conduct a risk assessment for the mother and unborn baby, identify, investigate and take action to reduce chance of bad outcome in
accordance with Tables 1 to 9.

Table 1: Criteria for critical intra-partum care

Criteria for critical intrapartum care Related criteria available through hyperlink

•Management of PROM
Initial assessment of a post-natal mother
•management of preterm labour

Caesarian section
Partogram

Management of eclampia, severe PET

Management of PPH and manual removal of placenta
Active management of third stage of labour

Intrapartum care for positive mother

Table 2: Appropriate status of facility for adequate care

Level (as per the KHSSP) Level (WHO) Asterix
Level 1-3 Basic emergency Obstetrics care unit ‫٭‬
EMOC
Level 4 Comprehensive emergency ‫٭٭‬
Obstetrics unit (CEMOC)

Level 5-6 Comprehensive emergency ‫٭٭٭‬

Obstetrics unit
References

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Appendix 5: List of equipment for maternal care
All facilities will have the following equipment and commodities:

 Delivery beds
 Functional autoclave
 Examination coach
 Tracer drugs (oxytocin, dexamethasone, gentamycin, magnesium sulphate, misoprostol)
 Oxygen
 Baby warmer
 BP monitor
 Fetoscope/Doppler
 Sterile packs
 Speculum pack
 VE pack
 Delivery pack
 Delivery coach
 MVA kits ventose/vaccum extractor
 Resuscitaire
 Emergency tray with requisite drugs
 Resuscitation equipment such as Ambu bag, oxygen and suction machines,

In addition to above tier 3 facilities will have:

 Blood products
 Pulse oximeter
 Functional theatre bed and anaesthetics
 Life support machine (monitor, ventilator, pulse oximeter)

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Appendix 6: List of laboratory Equipment
Level 2 and 3 facilities should have at minimum the following equipment:
 Haemoglobinometer
 Refrigerator
 Timer (stop watch)
 Pipette
 Centrifuge
 Glucometer
 Binocular microscope x10, x40, x100,
Level 4 health facilities should have the following equipment in addition to what level 2 and 3 facilities have:
 Haematology analyser
 Autoclave
 Weighing balance
 Tally counter
 Chemistry analyser
 Blood mixer
 Water bath, -20 degrees freezer.
Level 5 health facilities should have the following equipment in addition to what level 4 facilities have:
 Fully automated analyzers
 Safety hood/Biosafety cabinet
 Hot air oven
 Electrophoresis equipment
 Anaerobic jars
 Flow cytometry
 ELISA equipment
 Automatic pipette
 -70 degrees freezers

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 blank

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 Appendix 8: Surgical Safety Checklist

SURGICAL SAFETY CHECKLIST (FIRST EDITION)

Before induction of anaesthesia Before skin incision Before patient leaves operating room

SIGN IN TIME OUT SIGN OUT

 CONFIRM ALL TEAM MEMBERS HAVE INTRODUCED

 PATIENT HAS CONFIRMED: NURSE VERBALLY CONFIRMS WITH THE TEAM:
THEMSELVES BY NAME AND ROLE
o IDENTITY
o SITE  SURGEON, ANAESTHESIA PROFESSIONAL AND NURSE  THE NAME OF THE PROCEDURE RECORDED
o PROCEDURE VERBALLY CONFIRM:  THAT INSTRUMENT, SPONGE AND NEEDLE ARE
o CONSENT o PATIENT CORRECT (OR NOT APPLICABLE)
 SITE MARKED/NA o SITE  HOW THE SPECIMEN IS LABELLED (INCLUDING
 ANAESTHESIA SAFETY CHECK COMPLETED o PROCEDURE
PATIENT NAME)
 PULSE OXIMETER ON PATIENT AND FUNCTIONING
ANTICIPATED CRITICAL EVENTS:  WHETHER THERE ARE ANY EQUIPMENT
DOES PATIENT HAVE: PROBLEMS TO BE ADDRESSED
 SURGEON REVIEWS: WHAT ARE THE CRITICAL OR
KNOWN ALLERGY? UNEXPECTED STEPS, OPERATIVE DURATION, ANTICIPATED
BLOOD LOSS?
 NO
 ANAESTHESIA TEAM REVIEWS: ARE THERE ANY PATENT-
 YES  SURGEON, ANAESTHESIA PROFESSIONAL AND
SPECIFIC CONCERNS?
 NURSING TEAM REVIEWS: HAS STERILITY (INCLUDING NURSE REVIEW THE KEY CONCERNS FOR
DIFFICULT AIRWAYS/ASPIRATION RISK?
INDICATOR RESULTS) BEEN CONFIRMED? ARE THERE RECOVERY AND MANAGEMENT OF THIS PATIENT
 NO EQUIPMENT ISSUES OR CONCERNS?
 YES, AND EQUIPMENT/ASSISTANCE AVAILABLE THIS CHECKLIST IS NOT INTENDED TO BE
HAS ANY ANTIBIOTIC PROPHYLAXIS BEEN GIVEN WITHIN THE
LAST 60 MINUTES? COMPREHENSIVE. ADDITIONS AND
RISK OF >500ML BLOOD LOSS (7ML/KG IN CHILDREN)?
 YES MODIFICATIONS TO FIT LOCAL PRACTICE ARE
 NO
 NOT APPLICABLE ENCOURAGED
 YES, AND ADEQUATE INTRAVENOUS ACCESS AND
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FLUIDS AVAILABLE IS ESSENTIAL IMAGING DISPLAYED?
 YES
 blank

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Appendix 9: Anaesthesia Record

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 CURRENT MEDICATION
1 4 STEROID USE
2 5 YES NO
3 6

ALLERGIES:

PRE-OPERATIVE ORDERS / INSTRUCTIONS

Name Signed Date Time

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 TERMINOLOGY
Accreditation: Third party attestation related to a conformity assessment body
conveying formal demonstration of its competence to carry out
specific conformity assessment tasks.

Advanced life support: The preservation or restoration of life by the

establishment and/or maintenance of airway, breathing and
circulation using invasive techniques such as defibrillation,
advanced airway management, intravenous access and drug
therapy.

Adverse drug reaction: A drug response that is noxious and unintended, and
which occurs at doses normally used or tested in humans for
the prophylaxis, diagnosis or therapy of disease, or for the
modification of physiological function.

Annual plan: The current action plan for the year for achieving organization
goals and objectives, which includes the processes, actions and
resources needed for this. Also operational plan.

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 and treatment for patients or improvement for facilities.

Assessor: External reviewer, assessor of achievement of or compliance

with agreed standards, principles and/or criteria.

Basic life support: The preservation of life by the initial establishment of, and/or
maintenance of, airway, breathing, circulation and related
emergency care, including use of an automated external
defibrillator.

Best practice: Approaches that have been shown to produce superior results,
selected by a systematic process, and judges as exemplary.

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.
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 Care-givers: People who provide unpaid care and support to family
members and friends who have a disability, mental illness,
chronic condition, terminal illness or general frailty.

Clients: Individuals being served or provided with care or treatment by

the organization.

Complaint: Expression of a problem, an issue, or dissatisfaction with

services that may be verbal or in writing.

Consent: Voluntary agreement or approval given by a client.

Continuity: The provision of coordinated services within and across

programs and organizations, and over time.

Continuous quality improvement: A systematic, ongoing effort to raise an

organization’s performance as measured against a set of
standards or indicators.

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: Facts and statistics collected together for reference or analysis,

from which information can be generated.

Decontamination: The removal of dangerous substances, rendering harmless by

the removal or neutralization of poisons or radioactivity.

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.

Efficiency: The degree to which resources are brought together to achieve

desired results most cost effectively, with minimal waste, re-
work and effort

Environment: The overall surroundings where health care is being delivered,

including the building, fixtures, fittings and services such as air
and water supply. Environment can also include other patients,
visitors and the workforce

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 Escalation protocol: The protocol that sets out the organizational response required
for different levels of abnormal physiological measurements or
other observed deterioration. The protocol applies to the care of
all patients at all times

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 organization, services,
programs or clients.

Evidence: Data and information used to made decisions. Evidence can be

derived from research, experiential learning, indicator data, and
evaluations. Evidence is used in a systematic way to evaluate
options and make decisions.

Feedback: Information or comment provided by clients in response to a

service or query.

Guidelines: Clinical practice guidelines are systematically developed

statements to assist practitioner and patient decisions about
appropriate health care for specific circumstances

Hand hygiene: A general term referring to any action of hand cleansing.

Health outcome: The health status of an individual, a group of people or a

population that is wholly or partially attributable to an action,
agent or circumstance.

Healthcare provider: A person who provides the health care for or on behalf of the
organization, group or agency, e.g. a doctor, nurse, allied health
professional.

Health record: Information about a patient held in hard or soft copy. The
health service record may comprise of clinical records,
administrative records and financial records (e.g. invoices,
payments and insurance information.
Incident: An event or circumstance that resulted, or could have resulted,
in unintended and/or unnecessary harm to a person and/or a
complaint, loss or damage.

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
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 rate based, i.e. have a numerator and denominator so that they
can be compared and benchmarked.

Infection control or infection control measures: Actions to prevent the spread of

pathogens between people in a healthcare setting. Examples of
infection control measures include targeted healthcare
associated infection surveillance, infectious disease monitoring,
hand hygiene and personal protective equipment.

Informed consent: A process of communication between a patient and their

medical officer that results in the patient’s authorization or
agreement to undergo a specific medical intervention. This
communication should ensure the patient has an understanding
of all the available options and the expected outcomes such as
the success rates and/or side effects for each option

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.

Management: The organization and coordination of the activities of a facility

or organization in order to achieve defined objectives. It
involves setting targets or goals for the future through planning
and budgeting, establishing processes for achieving those
targets and allocating resources to accomplish those plans.

Medication history: An accurate recording of a patient’s medicines. It comprises a

list of all current medicines including all current prescription
and non‑prescription medicines, complementary healthcare
products and medicines used intermittently; recent changes to
medicines; past history of adverse drug reactions including
allergies; and recreational drug
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.

Monitoring plan: A written plan that documents the type and frequency of
observations to be recorded.

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 Objective: A target that must be reached if the organization is to achieve
its goals. It is the translation of the goals into specific, concrete
terms against which results can be measured.

Orientation: A formal process of informing and training workforce upon

entry into a position or organization, which covers the policies,
processes and procedures applicable to the organization.

Partograph: Tool that can be used by healthcare providers during the

birthing process to assess the progress of labor and identify
when intervention is necessary.

Patient: A person receiving care in a health facility. Also referred to as

consumer or client.

Patient-centered care: The delivery of health care that is responsive to the needs and
preferences of patients. Patient-centered care is a dimension of
safety and quality.

Patient identifiers: Items of information accepted for use in patient identification,

including patient name, date of birth, gender, address, medical
record number etc. Health facility and clinicians are responsible
for specifying the approved items for patient identification.
Identifiers such as room or bed number are not to be used by
facilities implementing the KQMH.

Patient rights charter: A clear statement of the rights of all clients of the
organization, which all personnel are required to recognize and
protect and which is supported by health facility and service
policies, procedures and resource levels.

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.

Performance targets: Expected levels of performance, used to assess performance

achieved compared to planned or expected performance.

Policy: A set of principles that reflect the organization’s mission and

direction. All procedures and protocols are linked to a policy
statement.

Procedures: Written sets of instructions conveying the approved and

recommended steps for a particular act or series of acts.

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 Procedures make policies and protocols operational and are
specific to an organization.

Protocol: An established set of rules used for the completion of tasks or a

set of tasks.

Quality: The degree of excellence, extent to which an organization

meets clients’ needs and exceeds their expectations.

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: The act of a facility or provider directing a client/patient to the

care of another facility, or service provider; or giving direction
to or on behalf of the client to obtain additional services from
another organization or provider.

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 organization.

Risk: The chance of something happening that will have a negative

impact. It is measured by consequences and likelihood.

Risk management: The design and implementation of a program to identify and

avoid or minimize risks to patients, employees, volunteers,
visitors and the institution.

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

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.

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 Strategic plan: A formalized plan that establishes the organization’s overall
goals and that seeks to position the organization in terms of its
environment.

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: The organization of resources, policies, processes and

procedures that are integrated, regulated and administered to
accomplish the objective of the Standard.

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 Ministry of Health,
Afya House, Cathedral Road,
P.O. Box 30016–00100, Nairobi, Kenya.
Telephone: +254-20-2717077
http://www.health.go.ke/

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