Quarterly District Hospital Performance Review. Volet I: Fonctionnement; Activités du Comite de Gestion (46)

Transcription

1 Page 1 of 25 6/22/29 Quarterly District Hospital Performance Review Review period: to Review date: Hospital Name: Hospital Evaluation Team Leader Name: District: District Function: Hospital Director: Address: Volet I: Fonctionnement; Activités du Comite de Gestion (46) 1.1 Activités du Comite de Gestion Code Topic Indicator Composite Criteria 1.1 Comite de Gestion Activities Peer review Code Topic Indicator Composite Criteria Activity Evaluation (including follow-up of activities related to community and health centers) Report on the quarterly action plan follow-up A report on a quarterly action plan follow-up contains: (1) Activities; level of achievement; realized, ongoing or not realized and observations (2) Based on a quarterly action plan which on its turn is based on an annual action plan A Report in which both criteria have been met = 6; one or two missing criteria = Coordination of activities Report on the monthly coordination meetings A report on the monthly activity coordination contains: (including follow-up of activities related to community and health centers) (1) date, hour of start and finish of the meeting (2) Agenda (3) A signed participants list (4) Approval of minutes of the previous meeting (5) Follow up of the recommendations or actions decided in the previous meeting (6) Each topic contains a description of the issue (7) Each topic lists recommendations or decisions

2 Page 2 of 25 6/22/29 taken (8) Each topic has a deadline to solve the issue (9) Each topic has a person responsible for followup (1) Each topic has a comments section (11) The minutes are signed by the Chairperson A report in which all above criteria have been met = 3; if one or more criteria are missing = (max 3 reports) Analysis of HIS data Reports on monthly analysis of Hospital HIS data Monthly reports analyzing Hospital SIS data contain: (1) Analysis using graphs with trend lines (2) Minutes of monthly meetings with heads of departments in which feedback is provided on the results One report with both elements = 4; one element or both lacking = (max 3 reports) Transmission of SIS reports Reports on monthly Hospital SIS data and Health Center SIS data have been entered in a database and passed on to central level Proof of reception of documents/data that indicate (proof of reception can be an ): (1) Timeliness all data from the preceding quarter have been received latest 1th of the 5th month. (2) Completeness: all data are complete One proof of reception with both criteria met = 3; one or more criteria not met = (maximum 3 reports) Management of HR, finances, equipment and buildings Monthly Comite de Gestion meeting Reports/minutes Monthly reports/minutes on activities which contain: (1) date, hour of start and finish of the meeting (2) Agenda (3) A signed participants list (4) Approval of minutes of the previous meeting (5) Follow up of the recommendations or actions decided in the previous meeting (6) Each topic contains a description of the issue (7) Each topic lists recommendations or decisions taken (8) Each topic has a deadline to solve the issue

3 Page 3 of 25 6/22/29 (9) Each topic has a person responsible for followup (1) Each topic has a comments section (11) The minutes are signed by the Chairperson Internal Rules and Regulations Internal Rules and Regulations A report with all the above 11 criteria met = 2; if one or more criteria have not been met = for that report (max 3 reports) Internal Rules and Regs exist and: Oui n (1) Is signed by the president of the governing board or the legal representative (of the governing board), or the president of the comite de gestion and is accessible for all staff from all services (2) Contains functional description of all services (3) Contains the organogram of all personnel (4) Contains regs on internal mutations, benefits, staff benefits, disciplinary regime, performance evaluation, leave and working hours All four criteria met = 4; one or more not met = Final Score 1.1 Comite de Gestion Activities Volet I: Fonctionnement; Gestion des Médicaments, Consommables et Vaccins (3) 1.2 Gestion des Médicaments, Consommables et Vaccins Code Topic Indicator Composite Criteria 1.2 Gestion des Médicaments, Consommables et Vaccins Peer review Code Topic Indicator Composite Criteria Stock management Management of vaccines stock Stock control cards for EPI vaccines filled according to MOH norms and updated, and: (1) Threshold defined and adhered to (2) Security stock defined and adhered to (3) Theoretical and real stock coincide

4 Page 4 of 25 6/22/29 (4) Command passed when threshold reached (command form filled) (5) Absence of a stock-out during the past three months and during the evaluation visit All stock control cards with all the 5 above elements = 7; a stock-out of one or more vaccines during the past quarter: - 7 penalty (bar when stock-out is due to central level stockouts) Cold Chain management Management of the Cold Chain The following composite criteria need to be met: (1) Refrigerator temperature between the official limits of +2 and + (2) interrupted cold chain during the past three months (3) Cold chain guaranteed in case of power failure (kerosene fridge with a kerosene stock of at least 5 liters, or a functioning generator All three criteria have been met = 9; criteria (1) or (2) not met = -9 penalty Stock management Management of drugs and consumable stock Stock control cards filled according to MOH norms and updated, and: (1) Threshold defined and adhered to (2) Security stock defined and adhered to (3) Theoretical and real stock coincide (4) Command passed when threshold reached (command form filled (5) Adequate storage system available to store products that need special storage (6) Absence of a stock-out for tracer drugs during the past quarter and the current evaluation All above criteria have been met = 8; one or more criteria not met = Stock management for the emergency cupboard Management of drugs and consumables in the emergency stock The following criteria have to be met: (1) Stock control cards or register with stock in and stock out (2) Absence of a stock-out during the past quarter and during the current evaluation (3) Theoretical and real stock coincide All above criteria have been met = 6;

5 Page 5 of 25 6/22/29 one or more criteria not met = Final Score 1.2 Gestion des Medicaments, Consommables et Vaccins Volet I: Fonctionnement; Gestion des Equipements (2) 1.3 Gestion des Equipements Code Topic Indicator Composite Criteria 1.3 Gestion des Equipements Peer review Code Topic Indicator Composite Criteria Communication equipment Telephone (mobile) and/or radio phone functioning The following criteria have to be met: (1) Radio phone and or telephone (mobile) accessible and functioning (tested in the presence of an evaluator) (2) Telephone (mobile) number recognized by three randomly selected health centers Both criteria have been met = 6; on or more criteria not met = Maintenance of equipment Preventive maintenance assured The following criteria should be met: (1) A preventive maintenance plan is made each quarter in which equipment is listed; services recorded; activities are planned and time and date are noted (2) Register for preventive maintenance activities available in which is noted type; location; planned date of maintenance; date of maintenance; first and second names of responsible and signature. The two above criteria have been met = 7; one or both not met = Management of the ambulance (s) Use of the log book(s) or ambulance register (s) The log book(s) or the ambulance register(s) contain the following elements: (1) First name and second name and complete address of all transported patients (2) Name of the nurse accompanying the ambulance (3) Signatures of the in-charge authorizing the use of the car and the one who has called for the ambulance (4) Information on the maintenance of the ambulance

6 Page 6 of 25 6/22/29 All log books or ambulance registers available and all four criteria met = 7; one or more criteria lacking = Final Score 1.3 Gestion des Equipements Volet I: Fonctionnement: Assurance Qualité (32) 1.4 Assurance Qualité Code Topic Indicator Composite Criteria 1.4 Assurance Qualité Peer review Code Topic Indicator Composite Criteria Central QA cell Monthly reports from this central QA cell Monthly reports of the central QA cell contain: (1) Report on the past month's activities (2) Conclusions, decisions and instructions aiming at improving quality (3) Specific feedback for each service (4) Analysis of feed back from the suggestions box (date; type of suggestions; identified problems; decisions taken; responsible for follow up, timeline and additional remarks) (5) These monthly QA reports are based on a quarterly action plan founded on SIS data, hospital evaluation results, department meetings or suggestion box One report respecting all above criteria = 5; one or more criteria not met = (max 3 reports) QA cell in each department Monthly reports from departmental QA cells Monthly reports of three randomly selected departmental QA cell meetings contain: (1) Description of activities carried out during the previous month which document the quality improvements brought about by these activities (2) Evaluation of the quality improvements (3) Conclusions; decisions and instructions related to quality improvements (4) Written proof of transmission to the central QA cell of the conclusions, decisions and instructions related to quality improvements (5) These monthly QA reports are based on a quarterly action plan of the departmental QA cell which are extracted from the quarterly action plan of the central QA cell

7 Page 7 of 25 6/22/29 One monthly report with all above criteria met = 4; one or more criteria not met = (max 3 monthly reports) Suggestions management system Management of the suggestions boxes The following criteria have to be met: (1) Each hospital department which provides services has one suggestion box (2) Suggestions are stored by month (3) Monthly analysis of suggestions by the central QA cell All three criteria have been met = 5; one or more criteria not met = Final Score 1.4 Assurance Qualite Volet I: Fonctionnement: Activités d'évaluation (18) 1.5 Activités d'évaluation Code Topic Indicator Composite Criteria 1.5 Activités d'évaluation Peer review Code Topic Indicator Composite Criteria Quarterly selfevaluation Availability of the evaluation documents Report of the quarterly selfevaluation Availability of the evaluation documents The following criteria have to be met: (1) A report on the quarterly self-evaluation available and filled correctly and completely (either paper form or electronic form) (2) Difference between self-evaluation score and peer-evaluation score should be less than 1% (3) Submission of the self- report to the evaluation team on their arrival All three above criteria met = 11; one or more criteria not met = All below criteria should be met: 1) Promptness: all required documents will be presented within 5 minutes Promptness complied with in all instances = 7; when there is a delay of more than 5 minutes in the submission of one or more sets of

8 Page 8 of 25 6/22/29 documents = Final Score 1.5 Activites d'evaluation Volet I: Fonctionnement: Renforcement des Capacités (3) 1.6 Renforcement des Capacités Code Topic Indicator Composite Criteria 1.6 Renforcement des Capacités Peer review Code Topic Indicator Composite Criteria Medical Library Library and medical journals A medical library exists and has the following criteria: (1) It contains at least one book on medical emergencies, and one book on surgical emergencies and one book on obstetric emergencies (2) A document proving current subscription status to a medical journal (which can be an internet based subscription) (3) The above medical journal or copies from articles printed from the internet are available (at the least one copy) in the library (4) Inventory of books and journals available, upto-date and is verifiable through the physical presence of these items (5) A register for lending books is available and upto-date Each criterion which is present = 1; maximum is Training Clinical round The following criteria need to be met: 1) Clinical round presented by a medical doctor and/or another provider for medical and nursing staff (2) This clinical round should refer to a medical journal article or a medical case (3) List of participants available and signed by the participants One clinical round which meets the above criteria = Training Quarterly training report on training organized by the Hospital for its staff The following criteria need to be met: (1) A training duration is at least 3 days (2) The training report contains a justification for the type of training carried out (based on internal supervisory visits; PBF evaluation findings or

9 Page 9 of 25 6/22/29 recommendations; SIS analysis; other current topics or feed-back on trainings received) (3) The training report contains the training module/content (4) The training report contains the results from the pre-and the post-tests (5) The training report contains the list of participants signed by the participants One training report which meets the above 5 criteria = 15, one element missing = Final Score 1.6 Renforcement des Capacites Volet I: Fonctionnement: Hygiène (24) 1.7 Hygiène Code Topic Indicator Composite Criteria 1.7 Hygiène Peer review Code Topic Indicator Composite Criteria Wards Cleanliness of Wards and uniforms of the providers The below criteria need to be met: (1) Signed valid contract between the hospital and professional cleaning firm(s) or stock control cards showing stock-in and stock-out which correlate with the physical stock of these items (soaps, products based on chlorine) (2) All in-patients beds have plasticized mattresses and a insecticide impregnated bed net and sheets and blankets (or bed covers) (3) Presence of waste buckets in each room (4) Absence of garbage on the floors (5) Presence of safe disposal boxes for needles in treatment rooms (6) Presence of piped water in each patient ward (7) Decontamination fluid (for use for medical instruments and sharps) present in the wards (8) Uniforms are proper and in good condition and worn by all personnel Each one criterion met =.75 (maximum 8 criteria) Environment Cleanliness of the surrounding courts The below criteria need to be met:

10 Page 1 of 25 6/22/29 (1) Presence of waste disposal buckets (in the corridors and waiting rooms) (2) Absence of garbage on the floors and spaces (3) Space around the hospital cleaned of growth (4) Draining of stagnant water (5) Absence of organic debris Each one criterion met = 1 (maximum 5 criteria) Waste disposal Incinerator and placenta pit The below criteria need to be met: (1) Incinerator is functional and used according to norms (triage and destruction) (2) Protection and maintenance of the placenta pit according to the norms Each criterion = Toilets and showers Clean toilets and showers Presence of showers and latrines with the following criteria: Oui n (1) Functional (2) Absence of organic debris around the facilities (3) Doors than can be locked from the inside (4) Hole in VIP/Latrine covered (5) Water point close to the latrines Latrines with all above criteria = 3 and showers with all above criteria = 3, one criterion missing = Final Score 1.7 Hygiene Volet II: Encadrement des Centres de Sante (295) 2. Encadrement des Centres de Sante Code Topic Indicator Composite Criteria 2. Encadrement des Centres de Sante Peer review

11 Page 11 of 25 6/22/29 Code Topic Indicator Composite Criteria Quarterly Quality Supervisory visits Timeliness of the submission of the quarterly quality supervisory checklists The following criteria should be met: (1) Written proof of submission of all required quarterly quality supervisory checklists for the previous quarter, to the president of the district PBF steering committee (2) This submission should be prior to the 28th day of the first month after the quarter All above criteria met = 37; one or both criteria not met = Quarterly Quality Supervisory visits Number of evaluated health centers The following criteria should be met: (1) Availability of a copy of the quarterly quality supervisory checklist (2) One health center one quarterly quality supervisory checklist completely filled (3) Each checklist contains an evaluation of all services offered at these health centers Number of available and timely and completely and well-filled quarterly quality supervisory checklists/number of health centers = 1% 1% done = 52; % done = 39; 5-74% done = 26; 25-49% done = 13; <25% done = Supervision of health centers Reports on health center supervisory visits The following criteria should be met: (1) Need for formative supervision is identified during the application of the quarterly quality supervisory checklist or through analysis of the SIS (2) Supervisory reports signed by both the supervisor and the supervisee Number of available and timely and completely and well-filled health center supervisory reports (one narrative summary per health center)/number of health centers = 1% 1% done = 52; % done = 39; 5-74% done = 26; 25-49% done = 13; <25% done = Analysis of GESIS/HIS data Monthly reports analyzing GESIS/HIS data from Health Centers Each monthly report contains: (1) An analysis of all HIS data with (a) trend lines for indicators for the current year and (b) comments (2) Presentation of these HIS data made during the meeting with the heads of health centers, hospital supervisors and a representative of the USF/district health department One report with all the above elements = 15, maximum three such reports. When one or more elements in one report missing =

12 Page 12 of 25 6/22/ Training Quarterly training organized by Hospital staff for Health Center staff A training report of a training of at least three days which contains: (1) A reason for the training based on results of the quarterly quality supervisory checklist or supervisory visit reports or on analysis of SIS data (2) The training module (3) Results from the pre and the post-test (4) List of participants signed by the participants One such report in which all four above criteria have been met = 41; one or more criteria not met = Quality control of BS and Sputum exam results Supervision of health centers by medical doctors Quarterly Report on the quality control for BS and Sputum results for health centers Supervisory visits by medical doctors in health centers The following criteria should be met: (1) Copies of the quarterly quality control reports for BS and sputum exams are available for each health center (which offers such services). One report on BS and one report on sputum results per health center (2) Written proof of having received such report by health centers is available (for each health center which offers such services) All above criteria have been met for all health centers that offer such services (1%) = 38; 75-99% = 28.5; 5-74% = 19; 25-49% = 9.5; <25% = The following criteria should be met: (1) One weekly visit per health center that has ART services with submission of signed travel approval (2) At least one weekly formative supervisory visit per health center with submission of signed travel approval All the above criteria have been met for all eligible health centers (those that have ART services and all health centers) (1%) = 3; 75-99% = 22.5; 5-74% = 15; 25-49% = 7.5; <25% =. It is recommended to count 12 such visits per quarter for those health centers that offer ART services and 3 such visits per quarter per any other health center. Final Score 2. Encadrement des Centres de Sante Volet III: Activités Cliniques 3.1 Consultations de Référence par le Médecin R

13 Page 13 of 25 6/22/29 Code Topic Indicator Composite Criteria 3.1 Consultations de Référence par le Médecin Peer review Code Topic Indicator Composite Criteria Referrals for pregnant women Quality of the consultation for the referred pregnant women A sample of 1 will be drawn from all referred pregnant women the past quarter, from the register for referred pregnant women, using a standard random sampling methodology. All the below conditions have to be met: (1) Proof of existence of a register in which all referred pregnant women are registered (2) Consultation form (selected at random from the register) contains identification of the patient; name, first name, age, sex, sector, and cell (3) As (2) date of the consultation (4) Name and signature of the medical doctor (5) History of the patient (symptoms and past history) (6) Clinical exam; vital signs (BP; pulse; temperature, weight, length), inspection, appropriate clinical exam) (7) Diagnosis and differential diagnosis (8) Complementary exams with results, and exams requested are in line with the working diagnosis, differential diagnoses and existing protocols (9) Treatment according to protocol or referral to a higher level of care (1) Referral slips of the pregnant women available (11) Written feedback on the referral signed by the medical doctor, and with a written proof of reception of this feedback by the health center, which contains: results and main observations/conclusions; diagnosis; treatment and interventions and follow up treatment if necessary. Each of the ten sampled consultations =.1. Click 'no' in areas that have errors in these 1 consultations Actual production this Quarter Referrals for Family Planning Quality of the consultation for the referred Family Planning client Total value for Random sampling as under 3.1.1; for each of the randomly selected clients, the following criteria need to be met: (1) Family Planning register correctly filled (2) Referral note and feedback to health center note signed by the medical doctor with proof of counter-referral or consultation notes from a hospital service filled by the medical doctor who advised FP or other method which does not figure in the health center package (PMA) (3) Justification on the consultation note of the recommended FP methods which are based on the consultation with the client, history, physical exam

14 Page 14 of 25 6/22/29 Each of the ten sampled consultation =.1. Click 'no' in areas that have errors in these 1 consultations Actual production this Quarter Total value for FP surgery BTL and Vasectomies Random sampling as under 3.1.1; for each of the randomly selected clients, the following criteria need to be met: (1) Detailed report of the operation, signed by the MD in the patient file (2) Consent letter signed by the client and his or her partner Each of the ten sampled consultations =.1 Click 'no' in areas that have errors in these 1 consultations. If less than 1: take proportion. E.g. if only 5 done, sample all five, and if all five is ok then put '1'. If 1 not ok, then put '.8' etc Referrals for other conditions (other than pregnancy and FP) Number of referrals (other than pregnancy and FP) Actual production this Quarter Total value for Random sampling as under 3.1.1; for each of the randomly selected clients, the following criteria need to be met: (1) Proof of existence of a register in which all referred pregnant women are registered (2) Consultation form (selected at random from the register) contains identification of the patient; name, first name, age, sex, sector, and cell (3) As (2) date of the consultation (4) Name and signature of the medical doctor (5) History of the patient (symptoms and past history) (6) Clinical exam; vital signs (BP; pulse; temperature, weight, length), inspection, appropriate clinical exam) (7) Diagnosis and differential diagnosis (8) Complementary exams with results, and exams requested are in line with the working diagnosis, differential diagnoses and existing protocols (9) Treatment according to protocol or referral to a higher level of care (1) Referral slips of the pregnant women available (11) Written feedback on the referral signed by the medical doctor, and with a written proof of reception of this feedback by the health center, which contains: results and main observations/conclusions; diagnosis; treatment and

15 Page 15 of 25 6/22/29 interventions and follow up treatment if necessary. Each of the ten sampled consultation =.1. Click 'no' in areas that have errors in these 1 consultations Actual production this Quarter Total value for Final Score 3.1 Consultations de Reference par le Medecin. Volet III: Activités Cliniques 3.2 Consultations Ordinaires R Code Topic Indicator Composite Criteria 3.2 Consultations Ordinaires Peer review Code Topic Indicator Composite Criteria Physiotherapy Quality of the physiotherapy consultation A sample of 1 will be drawn from all patients that had physiotherapy the past quarter, from the physiotherapy register, using a standard random sampling methodology. All the below conditions have to be met: (1) A physiotherapy register exists in which are registered all new cases and which contains: date, serial number, name and first name of patient, district, sector, cell, diagnosis and treatment (2) Consultation card for new cases with an indication for physiotherapy which is clearly formulated (3) as (2) and which has a description of the treatment provided by the physiotherapist Each of the ten sampled consultations =.1. Click 'no' in areas that have errors in these 1 consultations Actual production this Quarter Total value for Dentistry Quality of the dentistry consultation Selection of files as for dentistry, the following conditions have to be met: (1) A dentistry register exists in which are registered all new cases and which contains: date, serial number, name and first name of patient, district, sector, cell, diagnosis and treatment (2) Consultation card for new cases with an

16 Page 16 of 25 6/22/29 indication for dentistry which is clearly formulated Each of the ten sampled consultations =.1. Click 'no' in areas that have errors in these 1 consultations Actual production this Quarter Total value for Final Score 3.2 Consultations Ordinaires. Volet III: Activités Cliniques 3.3 Imagerie et Examens Complémentaires R Code Topic Indicator Composite Criteria 3.3 Imagerie et Examens Complémentaires Peer review Code Topic Indicator Composite Criteria Medical Imagery Number of X rays For the number of X rays taken of in-patients, which are produced by the Hospital during the past quarter, sample in the X-ray register randomly 1 X-rays and examine whether the following composite criteria are met: (1) Registry entry contains number, date, given name and family name, sex, age, address (sector, cell and district), type of X-ray requested and requesting Doctor (2) X-ray contains: Contrast ok; proper ok; name of patient, L or R indicated Each of the ten X-rays which is conform both criteria =.1 Click 'no' in areas that have errors in these 1 X- rays Actual production this Quarter Total value for Ultrasound Number of Ultrasounds For each ultrasound exam randomly sampled from the patient register during the past quarter, the following criteria should be met: (1) Number, date, given name and family name, age, sex, address (district, sector, cell), type of exam requested, requesting Doctor, results of the exam Each of the ten sampled consultations

17 Page 17 of 25 6/22/29 =.1. Click 'no' in areas that have errors in these 1 consultations Actual production this Quarter Total value for Lab exams: blood slides Number of blood slides Quality control effectuated by the national reference laboratory during the past month in which: (1) There is at least 95% concordance When the quality control is at least 95%, one exam is worth.14; when quality is less than 95% or results are not in: nil blood slide will be remunerated. Nil results Actual production this quarter Total value for Lab exams: AAFBs Number of diagnostic or control AAFB exams A series of three AAFB sputum exams for diagnostics or 1 AAFB sputum exam for a control exam (1) Quality control effectuated by the national reference laboratory during the past month in which there is at least 95% concordance When the quality control is at least 95%, one exam (series of three for diagnosis or one exam in case of control ) is worth.12; when quality is less than 95% or results are not in: nil blood slide will be remunerated. Oui n <95% Actual production this quarter Total value for Final Score 3.3 Imagerie et Examens Complementaires. Volet III: Activités Cliniques 3.4 Hospitalisation R Code Topic Indicator Composite Criteria 3.4 Hospitalisation Peer review Code Topic Indicator Composite Criteria Documentation Number of available The following criteria need to be met:

18 Page 18 of 25 6/22/29 of in-patient care clinical protocols and therapeutic guidelines (1) Availability of national treatment protocols for Malaria, Meningitis, Diarrheal diseases, TBC, and Malnutrition Discharged from the Internal Medicine Department Number of discharged patients (2) Therapeutic protocols for conditions for which there are not national protocols (yet): High blood pressure, Medical emergencies, Typhoid fever, Pneumonia, Diabetes Maximum Number of Medical protocols available, maximum 12, with each valid protocol.1 Ten discharged patients are randomly selected from the inpatient register. The below criteria need to be met for each of the randomly selected files (1) Personal patient details (Name, first name, age, sex, sector, cell) (2) Date and hour of admission (3) Date and hour of the first exam done by the medical doctor, within one hour after admission (4) Name and signature of the medical doctor (5) History taken (complaints and past medical history) (6) Clinical exam done; (a) BP, pulse, temperature, Respiratory Rate (b) physical exam; physical exam of the affected body system (7) Provisory diagnosis and differential diagnoses made (8) Complementary exams, with results, which are in line with the provisory/working diagnosis, differential diagnoses and prevailing medical protocols (9) Diagnosis is according to the protocols that have been applied (1) Treatment according to protocol or referral to an existing protocol (11) Nursing follow-up (vital signs; Temp; BP; Pulse, Weight) done (12) Daily follow-up by the MD (13) Counter-referral slip with a confirmation of receipt by the health center, available Each of the ten sampled discharges =.1 Click 'no' in areas that have errors in any one of these 1 files Actual production this Quarter Total value for Discharged from the Pediatric Department Number of discharged patients Ten discharged patients are randomly selected from the inpatient register. The below criteria need to be met for each of the randomly selected files (1) Personal patient details (Name, first name, age, sex, sector, cell, name of the parent or caretaker) (2) Date and hour of admission

19 Page 19 of 25 6/22/29 (3) Date and hour of the first exam done by the medical doctor, within one hour after admission (4) Name and signature of the medical doctor (5) History taken (complaints and past medical history, including vaccination status) (6) Clinical exam done; (a) BP, pulse, temperature, weight, length, Respiratory Rate (b) physical exam; ENT exam; (d)physical exam of the affected body system (7) Provisory diagnosis and differential diagnoses made (8) Complementary exams, with results, which are in line with the provisory/working diagnosis, differential diagnoses and prevailing medical protocols (9) Diagnosis is according to the protocols that have been applied (1) Treatment according to protocol or referral to an existing protocol (11) Nursing follow-up (vital signs; Temp; BP; Pulse, Respiratory Rate) and drug intake done (12) Daily follow-up by the MD (13) Counter-referral slip with a confirmation of receipt by the health center, available Each of the ten sampled discharges =.1 Click 'no' in areas that have errors in any one of these 1 files Actual production this quarter Total value for Discharged from the Malnutrition Ward Number of discharged patients less than five years old Ten discharged patients are randomly selected from the inpatient register. The below criteria need to be met for each of the randomly selected files (1) Personal patient details (Name, first name, age, sex, sector, cell, name of the parent or caretaker) (2) Date and hour of admission (3) Date and hour of the first exam done by the medical doctor, within one hour after admission (4) Name and signature of the medical doctor (5) History taken (complaints and past medical history, including vaccination status) (6) Clinical exam done; (a) BP, pulse, temperature, weight, length, Respiratory Rate (b) physical exam; ENT exam; (d)physical exam of the affected body system (7) Provisory diagnosis and differential diagnoses made (8) Complementary exams, with results, which are in line with the provisory/working diagnosis, differential diagnoses and prevailing medical protocols

20 Page 2 of 25 6/22/29 (9) Diagnosis is according to the protocols that have been applied (1) Treatment according to protocol or referral to an existing protocol (11) Nursing follow-up (vital signs; Temp; BP; Pulse, Respiratory Rate, diarrhea, vomiting, edema) and drug intake done (12) Daily follow-up by the MD (13) Discharged with a weight/length > 8% (14) Counter-referral slip with a confirmation of receipt by the health center, available Each of the ten sampled discharges =.1 Click 'no' in areas that have errors in any one of these 1 files Actual production this quarter Total value for Discharged from the Surgical Ward Number of patients who benefited from a Major Surgical Intervention as defined in the Complementary Hospital Package (PCA) Ten discharged patients are randomly selected from the inpatient register. The below criteria need to be met for each of the randomly selected files (1) Personal patient details (Name, first name, age, sex, sector, cell, name of the parent or caretaker) (2) Date and hour of admission (3) Date and hour of the first exam done by the medical doctor, within one hour after admission (4) Name and signature of the medical doctor (5) History taken (complaints and past medical history, including vaccination status) (6) Clinical exam done; (a) BP, pulse, temperature, weight, length, Respiratory Rate (b) physical exam; ENT exam; (d)physical exam of the affected body system (7) Provisory diagnosis and differential diagnoses made (8) Complementary exams, with results, which are in line with the provisory/working diagnosis, differential diagnoses and prevailing medical protocols, and pre-operative laboratory results (9) Diagnosis is maintained (1) Report of the operation available (11) Anesthesia report completely filled (12) Post-operative guidelines and treatment followed as prescribed (13) Daily follow-up by the MD (14) post-operative wound infection Each of the ten sampled discharges

21 Page 21 of 25 6/22/29 =.1 Click 'no' in areas that have errors in any one of these 1 files Actual production this quarter Discharged from the Gyn/Obs ward (other than deliveries) Number of discharged patients from the Gyn/Obs ward (other than deliveries) Total value for Ten discharged patients are randomly selected from the inpatient register. The below criteria need to be met for each of the randomly selected files (1) Personal patient details (Name, first name, age, sex, sector, cell) (2) Date and hour of admission (3) Date and hour of the first exam done by the medical doctor, within one hour after admission (4) Name and signature of the medical doctor (5) History taken (complaints and past medical history) (6) Clinical exam done; (a) BP, pulse, temperature, weight, length, Respiratory Rate (b) physical exam; physical exam of the affected body system (7) Provisory diagnosis and differential diagnoses made (8) Complementary exams, with results, which are in line with the provisory/working diagnosis, differential diagnoses and prevailing medical protocols, and pre-operative laboratory results (9) Diagnosis is maintained according to the protocols (1) Treatment according to protocol or referral to an existing protocol (11) Nursing follow-up (vital signs; Temp; BP; Pulse, Respiratory Rate, diarrhea, vomiting, edema) and drug intake done (12) Daily follow-up by the MD (13) Counter-referral slip with a confirmation of receipt by the health center, available Each of the ten sampled discharges =.1 Click 'no' in areas that have errors in any one of these 1 files Actual production this quarter Total value for Final Score 3.4 Hospitalisation.

22 Page 22 of 25 6/22/29 Volet III: Activités Cliniques 3.5 Activités de Maternité R Code Topic Indicator Composite Criteria 3.5 Activités de Maternité Peer review Code Topic Indicator Composite Criteria Deliveries, Eutocic, Referred Number of referred eutocic deliveries For each one of the ten randomly selected referred eutocic deliveries, randomly sampled from the admission register, the following criteria should be met as verified in the patient file: (1) Reason for the referral according to the health center partogramme, or noted on the referral slip in case of latency phase (2) Partogramme of the hospital correctly filled on both the front and the back sides (dilatation, descent, BP 4 hourly, pulse, BCF and contractions are noted half-hourly) (3) Exam by the MD, immediately, and name and signature available (4) Counter referral slip signed by the MD with a proof of counter-referral for referred cases Each of the ten sampled discharges =.1 Click 'no' in areas that have errors in any one of these 1 files Actual production this quarter Total value for Dystocic Deliveries Number of dystocic deliveries (forceps; vacuum extraction; breech delivery, twin pregnancy) Ten discharged patients are randomly selected from the inpatient register. The below criteria need to be met for each of the randomly selected files (1) Partogramme of the hospital correctly filled on both the front and the back sides (dilatation, descent, BP 4 hourly, pulse, BCF and contractions are noted half-hourly) (2) Exam by the MD, immediately, and name and signature available (3) Valid indication for the VE or Forceps delivery or manual manipulation (4) Counter referral slip signed by the MD with proof of reception for the referred cases Each of the ten sampled discharges =.1 Click 'no' in areas that have errors in any one of these 1 files Actual production this Quarter Total value for Caesarean Number of Caesarean Ten discharged patients are randomly selected

23 Page 23 of 25 6/22/29 Sections Sections from the inpatient register. The below criteria need to be met for each of the randomly selected files (1) Partogramme of the hospital correctly filled on both the front and the back sides (dilatation, descent, BP 4 hourly, pulse, BCF and contractions are noted half-hourly) (2) Physical exam by the MD within an hour after arrival in case of arrival with the alert line on the partogramme (3) Valid indication for a CS made by an MD (4) Detailed operation report, with information on the type of anesthesia used and name and signature of MD (5) Absence of post-operative wound infection (6) Counter referral slip signed by the MD with proof of reception for the referred cases Each of the ten sampled discharges =.1 Click 'no' in areas that have errors in any one of these 1 files Actual production this quarter Total value for Final Score 3.5 Activites de Maternite. Volet III: Activités Cliniques 3.6 Autres activités R Code Topic Indicator Composite Criteria

24 Page 24 of 25 6/22/ Autres Activités Peer review Code Topic Indicator Composite Criteria Daily staff meetings Number of reports of daily staff meetings Report of daily activities available in the staff meeting register book (either for the Hospital as a whole or per service) and has the following characteristics. 1 randomly sampled reports. (1) Name and signature of the MD on call (2) Presentation of new cases, severe cases, deaths and other problems that have occurred during the night (3) Recommendations and other decisions pertaining to the situations under (2) clearly discussed and documented in the daily handover reports One such report with all the above composite criteria =,1. Maximum of 9 such reports per quarter. When one composite criterion is not available = Actual production this quarter Total value for Final Score 3.6 Autres Activites. Final Score Volet 3 Activites Cliniques. Final Score Hospital Volet Points Max Trimestre Points Obtained FRW % Performance Volet 1 Administration 2 Volet 2 Supervision 295 Volet 3 Clinical Activities 1.2. R.. R.. R. FINAL PERFORMANCE.

25 Page 25 of 25 6/22/29 Total Earnings This Quarter (FRW) R Name Present