Health sextor

2. 1.Provision of Safe Water
2.Notification of communicable diseases
3.Sanitation (General)
4.Sanitation (Specific)
5.Maternal Care
6.Examination of in-patients by a House Officer / Senior House
Officer
7.Efficiency of sterilization of instruments
8.Diet Services
9.Nursing care
10.Disaster preparedness

3. 11.Patient safety
12.Patients’ waiting time in OPD
13.Monitoring quality improvement progrramme (Quality of Care)
14.Community participation in Hospital management
15.In-service training
16.Intensive Care
17.Neonatal Care
18. Operating Theatre Services
19.Responsiveness to specialized groups
20.Standardized visuals

4. 1. PROVITION OF SAFE WATER
Adequate Supply of boiled cool or filtered safe
water to in-patients and staff
Adequate Supply of boiled cool/ /filtered safe
water to out-patients and visitors
Safety of source of water to the institution
1
2
3

5. Provision of boiled cool /filtered safe water throughout the
day for in-patients and staff
1.1. Adequate supply of boiled cool or
filtered safe water to
in- patients and staff

7. Provision of boiled cool /filtered safe water throughout
the day for out-patients and visitors
1.2.Adequate Supply of boiled cool/
/filtered safe water to out-patients and
visitors

8. Availability of chlorinated water throughout the year.
Testing biologically quality of water monthly (water
sample tested at least once a month and report received)
1.3.Safety of source of water to
the institution

9. 2.Notification of communicable diseases
2.1.Notification
of communicable
diseases
2.2.Maintenances
of morbidity and
mortality register
2.3. Diagnosis of
out-patient cases
100% notification
(Recommendation
of Epidemiology
Unit)
Maintenances of
morbidity
and mortality
register
We collecting
data from OPD
PHARMACY.

10. HOW TO MONITORING THE SANITATION
GENARAL
3.Sanitation (General

11. Cleanliness of
Toilets
Cleaning at least 4 times a day
Cleanliness of wards To be cleaned 02 times a day
Cleanliness of drains To be cleaned 02 times a day
Cleanliness of
gardens
To be cleaned once a day
Visits of PHI Fortnightly (once in two weeks)
100% correction of breeding sites
records in sanitation register

12. Refuse disposal Availability of waste segregation
system at site of waste generation
Availability of waste segregation system
at transportation of waste
Availability of waste segregation system
at final disposal
Waste bins to be emptied whenever full
Identification and
correction of
mosquito breeding
sites
Availability of a system to identify
mosquito breeding sites weekly

13. ම කසළ කලමණාකරනෙ බැහැර කරන රාප ෙනාවන අප ව / අප ව
ෙමටාම සරය හරහා ගම ෙම ප ව ඉ වන ඩා කැබ බැහැර ම සඳහා
ටැං ය මාණය ම.(Tank for Metamizer Waste)

14. ම අපජල වහන ප ධ ෙය බැහැර කර ලබන අවසාන ජල ෙකාටස භා ර
ප සරයට දා හැ මට ෙපර රඳවා තබන තටාකය(Lagoon).
Releasing water
to environment,
After UV
treating.
UV
Treatmen
t

15. 4.Sanitation (Specific
Cleanliness of floor
Ward floor to be mopped at least twice a day
OT floor to be mopped after each routine/ casualty/
case with antiseptic MAJOR , MINOR
ICU to be mopped at least twice a day
cleaning weekly on same day for wards
Labour room to be at least cleaned twice a
day, OT to be cleaned every day in the night
ICU floor to be comprehensively cleaned at
least once a week
OPD floor to be comprehensively cleaned
once a week

17. 5.Maternal Care
5.1.Checking of
hemoglobin
percentage, urine
5.2.Natal Care
5.3.Post natal care
100% of admission
Recording of FHS,
pulse at labour every 15
minutes
Recording or pulse, bleeding PV,
state of uterus every 15 minutes
for 02 hours
Recording or pulse, bleeding PV,
state of uterus every 15 minutes
for 02 hours

18. 5.4.Asepsis of labor
room
Availability of hand
washing facilities with
hand washing
instruction in the LR
Availability of hand rub
at the site of LR

19. Directorate of Healthcare Quality & Safety -
Version 7 (Last updated on 07.11.2018)
ACTIVITIES FOR
IMPROVING
ANTENATAL CARE

20. Directorate of Healthcare Quality & Safety -
Version 7 (Last updated on 07.11.2018)
Activities for improving postnatal care

21. 6.Examination of in-patients by a House Officer / Senior
House Officer
Ward rounds
6.1.Ward rounds
6.2.New
admissions
6.3.Referral to
SHOs by HO
Morning - completed before 9 am,
Evening - completed between 2pm
to 4 pm
night - completed before 10pm
Stamped cases to be seen immediately not
later than 15 minutes.
Any other admission to be seen within
1/2 an hours
Referred cases seen by SHO

22. 7.Efficiency of sterilization of instruments
7.1.Maintenance of sterilization
charts
7.2.Supervision
Maintaining
sterilization charts for
all instrument sterilizers
Maintaining
sterilization charts for
every batch of
sterilization
Daily checks by officer-
in-charge/Matron

23. 8.Diet Services
8.1.Provision
of adequate
hygienic food
 Availability of Storing raw food item in a
hygienic manner
 A cleaning check list available and used in
kitchen
 No visible dirt in kitchen
 Water, soap and other basic requirement are
freely available
 All the kitchen staff are provided with caps
and apron and those working in kitchen always
wear the properly
 All the staff working in the kitchen are given
basic education on health and sanitation
 Medical examinations are done for all the
kitchen staff at least once a year
Containers are maintained in hygienic manner

24. 8.2.In patient diet  Availability diet schedules in
the wards
 Distribution under
supervision in the ward

25. 9.Nursing care
9.1.Midnight
reports
Daily
9.2Handing
over and
taking over of
patients
properly done
upon shift
changes
A handing over/taking over register is
available in ICU
A handing over/taking over register is
available in ETU
A handing over/taking over register is
available in all wards
Patients details are written on the register
and handed over with the signature to the
leader of the next shift
9.3.An emergency tray is
systematically arranged
and functioning
An emergency tray is available with essential
supplies, equipment, solutions and drugs,
A check list for the emergency tray items is
available and check at least once a day
A responsible officer is indicated for the
maintenance of the emergency tray

26. 9.4.Changing patients'
bed linen
For every new patient
Once in two days
9.5.Drug management Accountable drug
registers are updated up
to previous day
9.6.Pressure area
care
0% patients with
hospital acquired bed
sores.

27. 10.Disaster preparedness
10.1.Written plan of all
components
10.2.Buffer stock of drugs,
equipment
10.3.Disaster drill
Availability
Availability
Once a year

28. DISASTER PLANE

29. Directorate of Healthcare Quality & Safety -
Version 7 (Last updated on 07.11.2018)
Disaster Management - 2019
Table top drill

30. Directorate of Healthcare Quality & Safety -
Version 7 (Last updated on 07.11.2018)
Disaster drill – 06th November 2019

31. 11.Patient safety
A mechanism
to collect data
on patient
safety in place
Safety signs are displayed in accident
prone areas.
Registry is available to record
accidents and incidents on patient fall .
Registry is available to record accidents
and incidents on drug reaction.
Registry is available to record accidents
and incidents such on blood reaction.
A meeting or forum to discuss accidents
and adverse events takes place monthly.
A report with analysis of accident and
adverse events is produced monthly

34. WE DOING SO MANY SURVEYS
THOSE ARE CUSTOMER SATISFACTION SURVEYS,WAITING TIME,STAFE
SATISFACTION SURVEY.WE TRY TO DELIVER DELLIGHTE CUSTEMER
CARE IN OUR HOSPITAL.WE ANNALYZED SUJJETION AND COMPLAINS OF
THEM.WE ARRANGE SOME ACTION FOR THEM.
12.Patients’ waiting time
Registration Within 05 minutes
Examination by
Medical Officer
Within 01 hour
Issue of drugs at
dispensary
Within 30 minutes

35. Flow Chart for Average Waiting
Time -OPD
Arrival to OPD
Registration
Consultation
Room
Pharmacy
Exit from OPD
a
b c
f g
h
Laboratory
d1
e
Entry
Exit
Entry
Entry
Exit
Exit
Directorate of Healthcare Quality & Safety -
Version 7 (Last updated on 07.11.2018)
d2

36. 13.Monitoring quality improvement programme (Quality of Care)
13.1.Meetings Monthly WIT meetings in all the
units
Quarterly QIT meetings (Quality
Improvement Committee)
Availability of minutes of all
these meetings
13.1.Patient
satisfaction
surveys
At least 01 patient satisfactory survey
carried out per year

39. ාථ ක ස කාර ඒකකෙ සකස් කර ආර ෂක ඇ ආ ත රදවනය
අෙන වා හා ඒකකවල ද මාණය කර ගැ ම
Kizen, Suggestion
New Creation
of PPE Box

40. Best Kaizen Suggestions / Innovative ideas / Process
improvements 2019
Use one autoclaved
cot sheet for each
baby (prepaid by
labour room).
Made file boxes to
keep BHTs in Ward 03

41. Prepared a drugs rack (stepwise
arrangement to visualize all
containers in alphabetical order)
in ward 09 & Ward 11
Best Kaizen Suggestions / Innovative ideas / Process
improvement 2018

42. භා ර ෙර අංශය
අසල
මැ ඒකකය ල

44. Monthly
14.Community participation in Hospital
management
Institutional meetings of hospital
development committee

45. 15.In-service training
Number of in-service training
At least 01 per identified category annually

46. IN-SERVICE TRAINING PROGRAMME OF FINANCIAL MANAGEMENT & HOME
PRODUCTIVITY 2018.08.16
Quality Management Unit - District General Hospital Monaragala.

47. IN-SERVICE TRAINING PROGRAMME OF
PRODUCTIVITY, PRODUCTIVITY CONCEPTS, 5S AND QUALITY — 18.09.2019
Quality Management Unit — District General Hospital Monaragala.

48. 16.Intensive Care
16.1.A functioning intensive
care unit available with
essential equipment's
16.2.Infection Control
ECG and defibrillator
Nebulising machine
Pulse oxymeter
Sucker machine
AMBU bag
Laryngoscope
ET Tubes
Ventilators
Blood gas analyzer
ICU beds
Medical Gases
Centrally supplied Oxygen
100% of cleaning of hands
between patients with hand rub
0% MRSA patients
0% urinary catheter
infection rate
The functional ICU is available

49. 17.Neonatal Care
MORBIDITY
AND
MORTALITY
APGAR SCORE
RECORD AT BIRTH
NEONATAL
EXAMINATION BY MO
RESUCITATION OF NEW
BORN BY TRAINED MO

50. 18.3.An
effective
post
operative
care
available
18.2.An
effective
operative care
available
18.1.Efficiency
18.Operating Theatre Services

51. 18.1.Efficiency
100% of routine
lists start at
scheduled time
100% of routine
lists run without
interruption

52. Established
mechanism to
count
instruments
A mechanism to identify
different type of gases
used during anesthesia is
available An anesthetic
drug tray is
available and
checked with a
checklist by
MO
An emergency
drug tray is
available and
checked with
checklist by MO -
Anesthesia before
every shift
Established
mechanism
to count the
packs
18.2.An effective
operative care
available
Established
mechanism
to assess the
blood loss
Functioning
ventilation
mechanism
Available

53. 18.3.An effective
post operative
care available
Essential drugs
are available in
the recovery area
Essential
equipments are
available in the
recovery area
A recovery
area is
available with
designated staff
Patients are handed
over to the ward with
counter signatures of
the ward staff
Post operative
notes are
provided in the
BHTs

54. Secure access provided for
the differently- abled and
senior citizens
Separate toilets
are available for
the differently
Special access at
stairways is
available for the
differently-abled
Priority counter
for differently -
abled and senior
citizens are
available

56. Sign boards and
directional boards
standardized
Sign boards and directional
boards in all 03 languages
All sign boards and
directional boards are
standardized with proper
alignment and consistent
fonts and by color codes.
20.Standardized visuals

57. Signs and boards displayed in the hospital