Standard Operating Procedures • Facility Level • Updated Edition • December 2016_ 1

FOREWORD BY THE DIRECTOR-GENERAL

In July 2011, I approved the District Health Management Information Systems (DHMIS)
Policy for South Africa, which is aimed at ensuring uniformity in the implementation of the
DHMIS across the country. I also indicated then, that a need exists for the development of
Standard Operating Procedures (SOPs), to guide the implementation of the policy.

Since the first edition of the SOPs for Health Facilities IN 2012, a number of developments
have taken place and new policy decisions were taken. In 2015, we took a decision to
implement a policy on rationalisation of registers. We then embarked on the national roll-
out of PHC Comprehensive registers in all PHC facilities. During the same period, we intro-
duced a new electronic system called Health Patient Registration System (HPRS) together
with a standardised filing system. The HPRS has been fully rolled-out in the National Health
Insurance pilot districts and the current roll-out is being scaled up in the remaining dis-
tricts. We are also embarking on a phased implementation of Web-DHIS.

It is for the above developments that there was a need to update the Standard Operating Procedures for the DHMIS Policy. Partic-
ularly, we have revised the data flow timelines and stipulated additional procedures to strengthen the quality of the routine health
data. The data submission timelines have now been reduced from 60 to 25 days in the updated SOPs.

This updated edition sets out SOPs for the DHMIS policy, for use by health facilities, which are the first level of interaction between
community members and health services. Health facilities are therefore the first point of data collection and the level at which data
quality must first be improved. Health facility SOPs have thus been prioritised for publication. These SOPs seek to achieve standard-
isation in data collection, capturing, collation, storage, analysis and transmission to other levels of the health system. Related SOPs
have been produced for other levels of the public health sector namely: Health sub-districts; districts; provinces and the National
Department of Health.

These SOPs present basic and practical steps to be followed by health care providers and health information management personnel
to ensure that data is appropriately handled and used to improve service delivery at local level, prior to submission to the next level
of the health system, within the specified time frames.

The long-term vision of the National Department of Health is the creation of a national integrated patient-based information system,
which will require implementation of electronic systems for data management at all levels of the health system. In this regard, in
April 2014, the Department published the National Health Normative Standards Framework for Interoperability in eHealth in South
Africa through a Gazette Notice. This was followed by an assessment of all Primary Health Care (PHC) Patient Health Information
Systems by the Centre for Scientific and Industrial Research (CSIR). CSIR is now busy conducting an assessment of all Hospital-based
Patient Information Systems.

All health facility managers in the public health sector should ensure implementation of these SOPs. They must be assisted in this
role by information officers from health sub-districts; districts; provinces and the National Department of Health.

I wish to acknowledge and appreciate the pivotal role played by Health Information Systems Programme, Health Systems Trust and
MEASURE Evaluation Strategic Information for South Africa in assisting the Department with the revision of these SOPs.

MS MP MATSOSO
DIRECTOR-GENERAL
NATIONAL DEPARTMENT OF HEALTH
DECEMBER 2016

2 _Standard Operating Procedures • Facility Level • Updated Edition • December 2016

LIST OF ABBREVIATIONS

ART Antiretroviral Therapy

CHC Community Health Centre
DG Director-General
DHER District Health Expenditure Review
DHIS District Health Information System
DHMIS District Health Management Information System
DHP District Health Plan
DoH Department of Health
ETR Electronic Tuberculosis Register
HIS Health Information System
HOD Head of Department
ICT Information and Communication Technology
IT Information Technology
M&E Monitoring and Evaluation
NCS National Core Standards
NDD National Data Dictionary
NDoH National Department of Health
NHISSA National Health Information Systems Committee of South Africa
NIDS National Indicator Data Set
OPD Outpatient Department
Org unit Organisational Unit
PEC Patient Experience of Care
PHC Primary Health Care
PIDS Provincial Indicator Data Set
PQRS Provincial Quarterly Reporting System
QRS Quarterly Reporting System
SOP Standard Operating Procedure

Standard Operating Procedures • Facility Level • Updated Edition • December 2016_ 3

DEFINITIONS
TERMINOLOGY OPERATIONAL DEFINITION
Also known as validity. Data is measured against a referenced source and found
Accuracy to be correct. Accurate data minimize error (e.g. transcription error) to a point of
being negligible
Data is present and usable and represent the complete list of eligible sources and
Completeness
not just a fraction of it
Assurance that data will not be disclosed inappropriately and treated with
Confidentiality
appropriate levels of security
Data Raw, unprocessed numbers
The process where data for a data element from various service points are added
Data collation
together. It is very important to ensure that during this process the responsible
person add the data correctly together and avoid arithmetic errors
Data input forms This refers to the final form which will be used to enter the data into the relevant
database
Data sign off refers to the process where the person with the required authority
Data sign off
agrees to the correctness and validity of the data and commits him or herself to
submit data in accordance with data flow guidelines
A quantitative or qualitative variable that provides a simple and reliable
Indicator measurement of one aspect of performance, achievement or change in a
program or project
Processed or analysed data that adds context through relationships between
Information
data to allow for interpretation and use
System used to generate data is protected from deliberate bias or manipulation
Integrity
or loss of
A line manager has several management responsibilities, including direct
management of employees, administrative management and functional
Line manager
management. For an example, a person who directly manages a health facility
reports to an area manager.
Organisational Unit (Org Organisational Unit refers to reporting levels used in South African public health
Unit) system (e.g. org unit 5 is a facility level)
The facility in the organisation unit which takes responsibility for one or more
Parent facility
facilities.
Data has sufficient detail and is free as far as possible of error in terms of under
Precision
and/or over reporting
Manager responsible for a specific health programme/s e.g. (HIV and AIDS,
Programme manager
Nutrition etc.)
Rapid data quality assess- Eyeballing or visual checking of data to check for completeness, correctness, gaps
ment and outliers
Data generated by an information system is based on protocols and procedures
Reliability that do not change according to who is using them or how often they are used.
Data is measured and collected consistently
Reporting units within a facility e.g. consultation rooms, services within facility,
Service point
hospital wards (OrgU6)
Source point Facility level e.g. hospital, PHC clinic, delivery facility (OrgU5 levels)
Data and information is available on time for meeting budgeting, monitoring,
Timeliness
decision making and reporting requirements
Stakeholders who are authorised to access and use data in DHIS for monitoring,
Users of data
evaluation, research and reporting purposes

4 _Standard Operating Procedures • Facility Level • Updated Edition • December 2016

TABLE OF CONTENTS
LIST OF ABBREVIATIONS 3
DEFINITIONS 4
1. INTRODUCTION 6
1.1 Purpose 6
1.2 Scope 6
1.3 Training 6
1.4 Background 7
1.5 Principles 7
2. DATA/INFORMATION MANAGEMENT 8
2.1 Responsibility 8
2.1.1 Health Facility Receptionist/Patient Registration Staff
(PHC facilities and hospitals and non-facility based services) Responsibilities 8
2.1.1.1 Procedure: Health Facility Receptionist/Patient Registration Staff 9
2.1.2 Health Care Provider Responsibilities 9
2.1.2.1 Procedure: Health Care Provider 10
2.1.3 Data Capturers Responsibilities 11
2.1.3.1 Procedure: Data Capturer 11
2.1.4 Health Information Officer Responsibilities 14
2.1.4.1 Procedure: Health Information Officer 14
2.1.5 Facility Manager’s Responsibilities 19
2.1.5.1 Procedure: Facility Manager 20
3. REFERENCE DOCUMENTS 25

Standard Operating Procedures • Facility Level • Updated Edition • December 2016_ 5

1. INTRODUCTION

1.1 Purpose
This document provides SOPS to ensure appropriate data and information management at health facilities. These SOPs are an updated
version of the 2013 SOPs. These SOPs aim to clarify the responsibilities and procedures for effective management of aggregated routine
health service data.

1.2 Scope

These Standard Operating Procedures are mandatory and should be implemented by all employees and contractors when engaging in
health information related activities for DoH.. System and non-facility based services’ specific SOPs must be aligned to the DHMIS SOPs.
These SOPs must be used in conjunction with the following:
• DHMIS Policy 2011
• National Indicator Dataset (NIDS)
• System and Service Specific SOPs
• Reference Documents listed in Section 3

1.3 Training
The Facility Manager must ensure that team members (facility based and non-facility based staff reporting to facility) who follow these
procedures understand these SOPs’ objectives and other inter-related activities.

The Facility Manager must ensure that team members sign that they have read and understood these SOPs. Records of training provided
on the SOPs must be retained within the facility.

1.4 Background
In terms of the National Health Act (Act 61 of 2003) the National Department of Health (NDoH) is required to facilitate and coordinate
the establishment, implementation and maintenance of health information systems at all levels. The District Health Management In-
formation System (DHMIS) Policy 2011 defines the requirements and expectations to provide comprehensive, timely, reliable and good
quality routine evidence for tracking and improving health service delivery. The strategic objectives of the policy are to strengthen mon-
itoring and evaluation (M&E) through standardization of data management activities and to clarify the main roles and responsibilities
at each level for each category of staff to optimize completeness, quality, use, ownership, security and integrity of data.
Since 2000 the NDoH has been using various systems to collect and manage routine health service based information. These include the
DHIS, TIER.net and ETR.net. In 2015, a Health Patient Registration System (HPRS) was rolled out in Primary Health Care Facilities and the
webDHIS will be gradually phased in. There is progressively more focus on implementing electronic systems that are meeting the criteria
of Health Normative Standards Framework for Interoperability in eHealth in South Africa.

6 _Standard Operating Procedures • Facility Level • Updated Edition • December 2016

1.5 Principles
1. Principles for implementing SOPs:
Health service data elements are collected by means of a standardised set of rationalised registers. Those registers used for
recording data elements are updated in line with the relevant policies and guidelines. Data collection tools should provide
for the following:

• Facility name and facility code (as in Master Facility List), year and register number

• Start date of register

• End date of register

• Register pages must be pre-numbered

2.Data collection tools and processes for mobile and satellite clinics as well as health posts and outreach teams must be
managed in the same manner as those for fixed facilities. Summary forms must be submitted to the manager of the
‘parent’ fixed facility to be captured into the DHIS.
3. Service points should be allocated appropriate Organisational units.
4. Facilities employ data capturers/ward clerks to enter data into the various systems. Specific SOPs have been developed to
guide data capturing into each of these systems and are therefore not covered in this document. Facilities capturing data
into these systems must have copies of these SOPs and adhere to them.
5. The following are crucial for monitoring and optimising data quality:
• Standardised activation of relevant data elements of each health care facility
• S tandardised use of 0 (zero) reporting irrespective of the DHIS capturing level (facility or sub-district)
or frequency (daily or monthly)
• Facility must always be ready for an audit
6. Each health care user should have a facility retained clinical record in which all services are recorded in line with the
guidelines of statutory body.
7. All clinical records, data collection and collation tools must be stored safely and access to them controlled at all times.
8. Data management to provide quality routine data that would be used for clinical auditing purposes in initiatives such
as Perinatal Problem Identification Program (PPIP), Child Healthcare Problem Identification Programmes (ChildPIP) and
Confidential Inquiry into Maternal Mortality.

Standard Operating Procedures • Facility Level • Updated Edition • December 2016_ 7

2. DATA/INFORMATION MANAGEMENT
With the transitioning to a web-based information system and full implementation, the timeframe for data flow from facility to
national level should progressively decrease to 20 days. To achieve that target, timelines for submission of routine data and feedback
on data quality and performance, are outlined.

8 _Standard Operating Procedures • Facility Level • Updated Edition • December 2016

2.1 Responsibility

2.1.1  ealth Facility Receptionist/Patient Registration Staff (PHC facilities and hospitals and non-facility based services) Respon-
H
sibilities
Some large facilities have dedicated reception staff, but all staff providing a service to patients are responsible for the proce-
dures relevant to patient files and headcounts.

2.1.1.1 Procedure: Health Facility Receptionist/Patient Registration Staff

Step Action

ON A DAILY BASIS

1 PATIENT ADMINISTRATION

Register the patient visit in the system in use

1.1 Double check whether a patient file is available before a patient is registered as a new patient to prevent
duplicates being issued
Retrieve patient file from the filing cabinet or issue new patient file
1.2 Issue and record all folders issued per day

No patient should be seen by a health care provider without a file except in emergencies
1.3
The patient file must be issued as soon as possible in these exceptional cases

Record the visit as a headcount each time a patient presents to the facility for any service in the Reception/
1.4
OPD/Emergency Headcount register before the patient file is handed to health care provider

Count each patient as a headcount once each day, regardless of the number of services provided to the
1.5
individual at the facility on that day
Start each day with a new page of the Headcount Register
In small facilities where not many patients are seen, one line in the Headcount Register can be left open
1.6
after totalling that day’s headcount
The new date can be written in the middle of the next row
Ensure that no patient files leave the facility
If a patient is transferred to another facility a letter of transfer and copies of relevant records should accom-
pany the patient to the referred facility
1.7
Monitor return records and track outstanding records

The original file remains in the referring facility

1.8 Make follow up appointments for patients and provide appointment cards or dates

Ensure access control of medical records and the confidentiality of patient information is maintained at all
1.9 times

1.10 Non-facility based services should use the prescribed data collection tool for headcounts

Submit the register to the data capturer/ward clerk for capturing/summarising once it has been checked
1.11
and verified by the facility/operational manager or designated staff member

Standard Operating Procedures • Facility Level • Updated Edition • December 2016_ 9

 ON A WEEKLY BASIS

1.12 Complete and double check the weekly Reception/OPD/Emergency/WBOT Headcount summary

Enter the daily totals of the Headcount Register into the weekly Reception/OPD/Emergency/WBOT Head-
1.13 count summary sheet. Add and double check the weekly Reception/OPD/Emergency/WBOT Headcount
summary sheet

ON A MONTHLY BASIS

Enter the weekly totals of the weekly Reception/OPD/Emergency/WBOT Headcount Summary Sheet into
the monthly Reception/OPD/Emergency/WBOT Headcount summary sheet. Add and double check the
1.14
monthly Reception/OPD/Emergency/WBOT Headcount summary sheet and submit to the facility manager
on the 1st day of each month

Filing should be done on the same day that input forms have been completed to avoid loss of information –
1.15
file chronologically with the latest documents at the top in a lever arch file

2.1.2  ealth Care Provider Responsibilities

H
Health care providers (nurses, doctors and other health professionals) are responsible and accountable for ensuring high
quality data in individual patient files and on their own routine data collection and collation tools. These data collection tools
should be standardised registers.

It is essential that all health care providers write clearly and legibly on all data collection tools and limit the use of abbrevia-
tions.

Data collection tools and processes for mobile clinics, outreach teams and other community based platforms, e.g. school
health services must be managed in the same manner as those for fixed facilities and submitted to the manager of the ‘par-
ent’ fixed facility to be captured into the routine health information system.
It is essential that all health care providers write clearly and legibly on all data collection tools and limit the use of abbrevia-
tions.

2.1.2.1 Procedure: Health Care Provider

Step Action

ON A DAILY BASIS

1 RECORDING OF DATA ON DATA COLLECTION TOOLS

Record individual patient data in the facility retained patient file and if relevant, in the patient retained re-
1.1 cords (e.g. Antenatal cards and Road to Health charts) during or directly after each patient contact. A copy of
patient retained records must be retained in the health facility
Capture the required data in eTick register or standardised paper register during or directly after each pa-
1.2
tient contact. Ensure that the recording of data is in line with current standardised data element definitions
Indicate the patient file number clearly on the eTick register/paper register for patient follow- up and audit-
1.3
ing purposes
Double check that all the correct data elements and the correct columns relating to health care interventions
1.4
provided to patient were ticked

1.5 Ensure that the register guidelines are followed during the recording of the patient encounters

Save the eTick register per the guidelines of the webDHIS system
1.6
Any data quality issues in the eTick register will be managed in line with the guidelines

10 _Standard Operating Procedures • Facility Level • Updated Edition • December 2016

 Calculate, capture and sign daily totals clearly in standardised registers (electronic or paper) and submit for
1.7
verification by facility manager

1.8 Submit checked and verified register to health information staff for capturing in webDHIS/eSummary sheets

ON A WEEKLY BASIS

Complete and sign the weekly Tick Register summary form

1.9
File and store weekly Tick Register summary in a safe facility where access can be controlled

ON A MONTHLY BASIS

The manager/team leader of the service point (facility or non-facility based) or a designated person must
1.10 add the totals for each data element in the standard Tick Registers on the first day of each month to get a
monthly total for the previous month
1.11 A line must be drawn after the totals for the month to indicate clearly when it was totalled
Copy the totals in the registers onto the Tick Register summary form to be submitted to the facility manager
1.12
on the 1st day of each month

2.1.3  ata Capturers Responsibilities

D
Data capturers, also referred to as data officers, are responsible for capturing data and then forwarding the data to the next
level.

Data capturers must spend 100% of their work time on the data-related responsibilities stipulated below.

2.1.3.1 Procedure: Data Capturer

Step Action

PHC FACILITIES

ON A DAILY BASIS

1 COLLATION OF DATA

1.1 Collect Reception Headcount register from reception

1.2 Check and verify the Reception Headcount register before capturing

1.3 Report problems found in the headcount register to the information manager/facility manager

1.4 Capture verified data for reception in webDHIS DDC if available – indicate capturing date and sign

1.5 Capture headcount data in HPRS and headcount register in the absence of health facility receptionist

1.6 Check for outliers, add comment. Mark record for follow up if applicable

1.7 Check for missing data, add comment and mark record for follow up

Standard Operating Procedures • Facility Level • Updated Edition • December 2016_ 11

1.8 Run absolute validation checks

Follow up on incorrect daily data and provide feedback to clinicians to correct the eTick /paper tick
1.9
register

Check that the incorrect record has been properly corrected

1.10

In line with the SOPs/guidelines for other systems (e.g. TIER.net or TB Register), collate and capture data
1.11
as required

ON A WEEKLY BASIS

Monitor daily data entry for each service point

1.12
For eRegisters monitor that submissions were processed

ON A MONTHLY BASIS

Obtain validated data input forms from the facility manager on all monthly data sets on the 3rd day of
1.13
each month if data is provided on hard copies (paper based):

Conduct a rapid data quality assessment of data on data input forms – must be 100% complete and
1.14
should contain no gaps or outliers without comments

1.15 Capture monthly data into the webDHIS

1.16 Indicate date of capturing on each monthly data input form and sign

1.17 Check for outliers, add comment. Mark record for follow up if applicable

1.18 Check for missing data, add comment and mark record for follow up

1.19 Run absolute validation checks

1.20 Follow up on incorrect monthly data and do edits once the source documents have been corrected.

1.21 Mark record as completed after editing completed - by 5th of next month

1.22 File records and store safely in a facility with controlled access

In line with the SOPs/guidelines for other systems (e.g. TIER.net or TB Register), collate and capture data
1.23
as required

12 _Standard Operating Procedures • Facility Level • Updated Edition • December 2016

HOSPITALS

ON A DAILY BASIS

1. COLLATION OF DATA

Collect the signed midnight census report from the night supervisor and perform checks for completeness,
correctness, consistency and currency by checking the form and comparing with the midnight census data
1.1
collection tools as well as other data collection tools in the ward. Report any discrepancies found to the
Operational manager for follow-up
Collect data collection tools (e.g. OPD tick registers, headcount registers, theatre and delivery registers) from
1.2
service points/wards
Perform data quality checks on signed and verified data to ensure completeness, correctness, consistency
1.3
and currency

1.4 Report any problems found

Capture data directly from the data collection tools into webDHIS (if doing daily data capturing to avoid
1.5
collation of data
1.6 Run routine data quality checks in webDHIS that are appropriate for daily capturing

1.7 Follow up on incorrect daily data

1.8 File records and store safely in a facility with controlled access

1.9 Provide in house mentoring on completion of registers

ON MONTHLY BASIS

1.10 Collect data collation forms from wards/sections

Perform data quality checks on signed and verified data to ensure completeness, correctness, consistency
1.11
and currency
1.12 Report any problems found

1.13 Capture data into webDHIS

1.14 Run webDHIS data quality checks

1.15 Follow up on incorrect data

File records needed to meet monitoring and audit requirements and store safely in a facility with controlled
1.16
access

ON A QUARTERLY BASIS

1.17 Capture National Core Standards (NCS) data

ON AN ANNUAL BASIS

1.18 Capture Patient Experience of Care data

Standard Operating Procedures • Facility Level • Updated Edition • December 2016_ 13

2.1.4 Health information officer responsibilities

Health Information officers should be progressively appointed at fixed facilities (clinics, community health centres and hospi-
tals). They are responsible for data quality assurance and encouraging local use of information.

If there are no data capturers at the facility the health information officer is responsible for the same procedures as relevant
for data capturers.

Information officers/managers must spend 100% of their time on the data/information-related activities stipulated below.

2.1.4.1 Procedure: Health Information Officer

Step Action

1 MANAGEMENT AND SUPERVISION

Develop a health information plan specifying:

1.1 • Information needs of all stakeholders at service points

• Reporting processes
• Areas for improvement
Provide staff who collect data with training on data elements to be collected and tools to be used to
1.2
collect data as well on how to analyse their own data
Keep submission logs for monitoring adherence to reporting timeframes and identification of bot-
1.3
tlenecks for remedial action

Ensure that all documents required for monitoring and auditing are filed correctly and stored in a
1.4
facility with controlled access

14 _Standard Operating Procedures • Facility Level • Updated Edition • December 2016

PRIMARY HEALTH CARE FACILITIES

ON A DAILY BASIS

2 DATA MANAGEMENT

If the facility has a Local Area Network (LAN) set up between reception/facility manager computer
2.1 and consulting room computers check the main server computer daily to ensure that backups from
each consulting room have been saved to the server computer
If eTick register is used ensure that there is a register saved for each consulting room in the health
2.2 facility to ensure that all clinicians submitted their daily register. Report to the facility manager if
any consulting room register is missing for the day
Copy all backed up registers from the server computer onto a removable drive and ensure that it is
2.3
locked up in a safe location in the health facility (preferably a safe)
Ensure that these backups remain properly saved in folders which can be retrieved for auditing
2.4
purposes
2.5 Monitor whether daily data capture for reception/service points has been done
Check that all service points’ eTick Registers have uploaded to webDHIS/summaries have been re-
ceived
• Run validation checks on service points
2.6
• Check for outliers and missing data

• Mark records for follow up where appropriate

2.7 Draw a follow up report from webDHIS and give to facility manager

Ensure that the corrections received from the facility manager are captured and that there is a clear
2.8
audit trail back to the source documents

2.9 Check that corrections to the eTick Registers have uploaded to webDHIS

Monitor that daily data capture has been done on eSummary sheet and that there is no backlog in
2.10
capturing eSummary sheets from all service points

Standard Operating Procedures • Facility Level • Updated Edition • December 2016_ 15

ON A MONTHLY BASIS

2.11 Monitor that monthly data capture has been done

2.12 Check that all data from outreach teams has been captured if relevant

2.13 Draw follow up reports from webDHIS and ensure that all the edits are done timeously

2.14 Do validation checks and ensure that edits are done timeously
Conduct pre-submission data validation on a monthly basis with facility staff and draft feedback
2.15
report
2.16 Discuss persistent data quality problems found in source documents with facility manager
Develop webDHIS customised pivot table, GIS and data visualizer favourites, customised dash-
2.17
boards for use in reports and facility data analysis
2.18 Compile a monthly information report for the facility

2.19 Provide customised reports to line/programme managers

2.20 Present information report at facility meetings

2.21 Provide information for facility review meetings

2.22 Attend sub-district meetings as required and report on facility information

ON A QUARTERLY BASIS

2.23 Submit ART quarterly data (zipped xml format) into webDHIS

16 _Standard Operating Procedures • Facility Level • Updated Edition • December 2016

ON AN AD HOC BASIS

3 DATABASE MANAGEMENT AND TRAINING

Ensure that all hardware and software is fully operational and report IT related problems to sub-dis-
3.1
trict IT
Run troubleshooting procedures as relevant to different information systems;
• Data bundles (if not uncapped)
3.2
• Connectivity

• DHMIS help desk

Ensure that zipped eTick register and all monthly data input forms are sent to the lowest level that
3.3
is online - hospital/sub-district or district for importing into webDHIS
Obtain report of analysed data with appropriate pivot tables and charts from sub-district/district
3.4
and use to generate facility feedback

3.5 Provide training to clinicians on use and maintenance of electronic registers

Assess training needs, provide and coordinate training for hospital staff on information related top-
3.6
ics including the use of dashboards, pivots, charts, maps for reporting

3.7 Contribute to orientation of all new staff on health information management system

Contribute to training on data elements, data quality assessment and data use for all staff responsi-
3.8
ble for data collection and collation and managing service points/wards

3.9 Guides with audit readiness activities

ON A QUARTERLY BASIS

3.10 Receive ART quarterly TIER.net export (zipped xml format) from data capturer

Submit TIER.net export (zipped xml format) to the lowest level that is online – hospital/sub-district
3.11
or district for importing into webDHIS

Standard Operating Procedures • Facility Level • Updated Edition • December 2016_ 17

HOSPITALS

ON A DAILY BASIS

4 DATA MANAGEMENT

Monitor that daily data capture for wards/sections has been done if data is captured daily/summa-
4.1
ries of paper based registers obtained

4.2 Draw a follow up report from webDHIS and give to operational managers

ON A MONTHLY BASIS

4.3 Monitor that monthly data capture has been done

4.4 Draw follow up reports from webDHIS and ensure that all the edits are done timeously

4.5 Do validation checks and ensure that edits are done timeously

4.6 Conduct pre-submission data validation monthly with hospital staff and draft feedback report

4.7 Develop and maintain customised pivot table, GIS and data visualizer favourites for the hospital

4.8 Develop and maintain customised dashboards for use in reports

4.9 Use the public dashboards and favourites as templates for hospital data analysis

4.10 Compile a monthly information report for the hospital

4.11 Provide customised reports to line/programme managers

Present information report at hospital meetings and discuss persistent data quality problems found
4.12
in source documents with hospital managers
4.13 Provide information for hospital information review meetings

ON A QUARTERLY BASIS

4.14 Supervise the capturing of National Core Standards and reporting

ON AN ANNUAL BASIS

Supervise the periodic capturing of the Patient Experience of Care and reporting and analysis of
4.15
findings

18 _Standard Operating Procedures • Facility Level • Updated Edition • December 2016

 ON AN AD HOC BASIS

5 DATABASE MANAGEMENT AND TRAINING

Assess training needs, provide and coordinate training for hospital staff on information related
5.1
topics including the use of dashboards, pivots, charts, maps for reporting
5.2 Contribute to orientation of all new staff on health information management system
Contribute to training on data elements, data quality assessment and data use for all staff respon-
5.3
sible for data collection and collation and managing service points/wards
5.4 Guide audit readiness activities
Ensure that all hardware and software is fully operational and report IT related problems to hospi-
5.5
tal/ sub-district IT

2.1.5 Facility Manager’s responsibilities

The provider-patient interaction at the health facility is the foundation for effective and efficient routine health information manage-
ment. If health facility data submitted for capturing into the RHIS is of poor quality, evidence-based management decisions are compro-
mised at all levels.
The health information management, monitoring and reporting responsibilities of health facility managers are similar at all types of
facilities and these focus on the management of high quality information that must be used to:

• optimise patient/client care

• optimise public health and the health status of the population

• optimise performance of health programs and the healthcare system

• improve data quality

• monitor, evaluate and report on performance against all legislated plans in the health sector

With regards to filing, archiving and disposal of patient records, the facility manager must

• Ensure that a health record is created and maintained at the facility for every user of the health service

• Set up control measures to prevent unauthorised access to those records and to the storage facility in which, or system by which,
records are kept.

• Take responsibility for the management of the records (filing, archiving and disposal) of the facility

• Assign administrative staff to manage records at reception and filing

• Arrange that an annual clean-up of the records storage room takes place by archiving and disposing of the eligible records

Standard Operating Procedures • Facility Level • Updated Edition • December 2016_ 19

2.1.5.1 Procedure: Facility Manager

Step Action1

All facilities

1 INFORMATION MANAGEMENT

1.1 Provide sufficient resources for routine health information management

Mobilise for further resources (staff, data collection tools, hardware and software, email and inter-
1.2
net connections) per national guidelines
Include data management, monitoring and reporting in performance contracts and job descriptions
1.3
of all managers
Ensure training on data elements, data quality assessment and data use for all staff responsible for
1.4
data collection and collation and managing service points

1.5 Ensure that all new staff are orientated on health information management system in the facility.

Compile a patient and data flow plan for the facility indicating where patient is received and head-
1.6
counts are done and where service points are

1.7 Ensure that staff concerned know how to use the eTick register

Conduct weekly spot checks – correlation of registers with what has been captured in systems,
filing practices for data verification and audits.
1.8
Conduct internal audits, data quality assessments and patient file reviews
Keep dated and signed records of spot checks

20 _Standard Operating Procedures • Facility Level • Updated Edition • December 2016

1.9 Verify all monthly data before it is captured in webDHIS

Follow up on feedback from the health information officer/data capturer and ensure that clinicians
1.10
correct the eTick Registers.

Ensure that updated data quality reports and pivot table of raw data are received from the health
1.11
information officer/data capturer after corrections were made in the DHIS

Oversee, lead and support effective and efficient data collection, management and use on:
•Patient visits and care/interventions provided
1.12
•Clinical work days and supervision visits
•Stock and equipment

1.13 Sign off eSummary registers and send to next level for importing into webDHIS

Ensure that data and information are part of the standing item in the management agenda of a
1.14
facility and promote an information culture.
Follow up on feedback from the health information officer/data capturer and make corrections.
1.15 Draw a line through the incorrect value in the source document, write in the new value. These
changes are to be initialled and dated. No correction fluid is to be used.
Ensure that updated data quality reports and pivot table of raw data are received from the health
1.16
information officer/data capturer after corrections were made in the DHIS

Approve/sign off data after verification. This process must be finalised by the 5th of the month fol-
1.17
lowing the reporting period.
Ensure that the validation rules that were violated are corrected or commented on and that feed-
1.18 back on violations are given to the sub-district/sub-structure/district office if these were only cor-
rected after 5th of the next month

1.19 Ensure that outliers are commented on

1.20 Attend sub-district and district meetings as required and report on hospital information

1.21 Ensure that the facility is ready for audit at any time

2 PROVIDE FEEDBACK

Standard Operating Procedures • Facility Level • Updated Edition • December 2016_ 21

2.1 Data quality – timeliness, completeness and accuracy of data

2.2 Program-related indicators highlighting good performance and service delivery shortcomings

2.3 Develop action plans with facility staff for indicators showing poor performance
Follow up on feedback from the health information officer/data capturer and make corrections.
2.4 Draw a line through the incorrect value in the source document, write in the new value. These
changes are to be initialled and dated. No correction fluid is to be used.
Ensure that the validation rules that were violated are corrected or commented on and that feed-
2.5
back on violations is given to the sub-district/sub-structure/district office

Ensure that updated data quality reports and pivot table of raw data are received from the health
2.6
information officer/data capturer after corrections were made in the DHIS

Monthly approval and sign off data:

Sign off monthly summary report and supervise submission to next level for capturing in webDHIS if
2.7 not capturing in facility
Ensure that the eTick register data is zipped and that it is sent to the lowest level with connectivity
for importing into webDHIS

Ensure that the facility receives feedback from the sub-district/district on data submitted in the
2.8
form of reports/pivot tables/charts

2.9 Verify all data before it is sent to the next level for capturing/importing

Monthly approval and sign off data:

2.10 Sign off monthly summary report and supervise submission to next level for capturing in webDHIS.

Ensure that the facility receives feedback from the sub-district/district on data submitted in the form
2.11
of reports

Follow up on feedback from the sub-district and make corrections. Draw a line through the incorrect
value in the source document, write in the new value. These changes are to be initialled and dated.
2.12
No correction fluid is to be used. Ensure that the eSummary register is corrected, zipped and saved
to memory stick and submitted to next level for importing into webDHIS

Ensure that the validation rules that were violated are corrected or commented on and that feedback
2.13
on violations is given to the sub-district/district office

22 _Standard Operating Procedures • Facility Level • Updated Edition • December 2016

3. WBOT AND SCHOOL HEALTH SERVICES (IF APPLICABLE)

Weekly spot checks –OHH records/client clinical record reviews, filing practices for data verification
3.1 and audits.
Keep dated and signed records of spot checks

3.2 Verify data in registers /daily collection tools weekly and sign off

3.3 Verify monthly data in source documents and sign off

Collate and submit data to nearest facility/district/sub-district with connectivity/sub-district/district

3.4
for capturing in webDHIS

3.5 Ensure that data quality report and pivot table of raw data is received from sub-district/district

Ensure that the validation rules that were violated are corrected or commented on and that feedback
3.6
on violations are given to the sub-district /district office next month
Ensure that the validation rules that were violated are corrected or commented on and that feedback
3.7
on violations are given to the sub-district /district office
3.8 Ensure that valid outliers are commented on and that incorrect outliers are fixed

Ensure that updated data quality reports and pivot table of raw data are received from the sub-district
3.9
after corrections were made in the webDHIS

Standard Operating Procedures • Facility Level • Updated Edition • December 2016_ 23

A FACILITY IS READY FOR AN AUDIT WHEN:
• All internal policies and procedures documents are available and are implemented
• A ll staff are trained on all policies and procedures and there is evidence of this training
• Each
 patient has only one patient folder/clinical record and file is always available in the facility
(proper filing system)
• Information recorded on data collection tool (Tick Register, standard register or patient based
software application) are consistent with patient folder and supporting documentation
• All
 applicable patient records are captured on electronic databases, e.g.ETR.net, TIER.net, web-
DHIS
• Information recorded in DHIS is consistent with data input forms
• A ll data input forms applicable to the facility have data collected for and are captured in the DHIS
• A ll data collection tools used for collection of data by institution have been reviewed for quality
and have been signed off by the health care provider who collected the data
• A ll registers have been reviewed for quality and have been signed off by the facility manager
• All validation errors have been corrected or explained
• All outliers have been explained
• Processing of data updates has been completed correctly
• Sign off forms are properly completed and signed by the facility manager

24 _Standard Operating Procedures • Facility Level • Updated Edition • December 2016

3. REFERENCE DOCUMENTS
Individuals using these procedures should become familiar with the following documents:
3.1 DHMIS Policy, National Department of Health, 2011
3.2 Ideal Clinic Manual (October 2015)
3.3 National Health Act (Act 61 of 2003): Commencement Section 53 of the National Health Act,
2003
3.4 National Archives of South Africa Act (No. 43 of 1996)
3.5 Promotion of Access to Information Act (Act 2 of 2000): GN 585, Government Gazette
26332, 14 May 2004
3.6 Public Audit Act of 2004 (Act 25 of 2004): Government Gazette Vol 474, Cape Town, 20
December 2004 No. 27121
3.7 Public Finance Management Act (Act 1 of 1999): Public Finance Management Amendment
Act (Act No. 29 of 1999)
3.8 Statistics Act (Act 6 of 1999): Government Gazette Vol. 406, Cape Town 21 April 1999. No.
19957
3.9 Treasury Regulations: Government Gazette, Vol. 500, Pretoria, 20 February 2008, No.
29644

Standard Operating Procedures • Facility Level • Updated Edition • December 2016_ 25

26 _Standard Operating Procedures • Facility Level • Updated Edition • December 2016