(Insert logo)

CHECKLIST FOR ASSESSING

QUALITY OF HEALTHCARE

Le Germain Model for Health

CONTENTS (page no. not final)

CONTENTS ......................................................................................................................... 2

ABBREVIATIONS .............................................................................................................. 7

INTRODUCTION ................................................................................................................ 8

Background ....................................................................................................................... 8

Review Objective .............................................................................................................. 9

Principles of the Le Germain and Dimensions of Quality .........................................................

Documents required during assessment ............................................................................ 12

Facility profile ................................................................................................................. 13

STRUCTURE ..................................................................................................................... 15

Dimension 1: Leadership ................................................................................................. 15

Dimension 2: Human Resources Management and Development ..................................... 20

Dimension 3: Policies, Standards and Guidelines ............................................................. 25

Dimension 4: Facilities and Infrastructure ........................................................................ 27

Dimension 5: Supplies Management ................................................................................ 38

Dimension 6: Equipment Management ............................................................................ 40

Dimension 7: Financial Management ............................................................................. 52

DIMENSION 11: PROCESSES .......................................................................................... 54

11.1 Outpatient Services .................................................................................................. 54

11.4 Inpatient Care .......................................................................................................... 67

11.5 Accidents and Emergency ........................................................................................ 72

11.6 Surgical Emergencies ............................................................................................... 75

11.11 Laboratory ........................................................................................................... 110

11.12 Pharmacy ............................................................................................................. 119

11.13 Radiology ............................................................................................................ 122

11.14 Mortuary .............................................................................................................. 125

DIMENSION 12: RESULTS ............................................................................................ 127

APPENDICES .................................................................................................................. 1343

Appendix 1: A&E Equipment ........................................................................................ 134

Appendix 2: Essential Medicines ................................................................................... 136

Appendix 3: List of Tracer Non-pharmaceutical products .............................................. 137

TERMINOLOGY ............................................................................................................. 148

 INTRODUCTION

Background

The field of emergency medicine evolved out of the necessity of caring for a rapidly

growing population of patients seeking immediate and unscheduled medical care for

emergency conditions. It became clear that the number of emergency department visits was

rising across the United States. Improving the quality of healthcare in the Emergency

Department is the priority in Saint Germain Le Pres Teaching Hospital as reflected in several

policy and strategy documents. The overarching goal of the Saint Germain Hospital is to

attain the highest possible health standards in a manner responsive to the patient needs.

Emergency departments (ED) are an integral part of hospitals and medical practices and

provide the best medical or surgical care to patients arriving in need of immediate care.

Emergency Departments serve as the first point of contact, and people of nearly every age are

given medical care based on their injury or illness; it is the most crucial and intensive

department within a hospital as many times, the question of life and death hangs on a thin

line. Emergency departments are supposed to be equipped with all the modern and essential

equipment and accessories to render timely acute, emergency, trauma care services. The

policy aims to achieve this goal through supporting the provision of equitable, affordable, and

quality health and related services at the highest attainable standards to all the patients who

are in ambulatory and crucial condition.

As evidenced by a variety of policy and strategy documents, improving the quality of

healthcare is a top focus for Saint Germain Le Pres Teaching Hospital. Saint Germain Le Pres

Teaching Hospital consists of a completely integrated network of public and private

hospitals, doctors, and other medical service providers. It is a universal service that provides

health care to all citizens, regardless of their socioeconomic status, wealth, or age. The Saint
Germain Le Pres Teaching Hospital's overriding purpose is to combine low costs with patient

choice and autonomy for clinicians. The policy intends to achieve this goal by encouraging

all patients to have access to equitable, affordable, and high-quality health and related

services. It has a mix of public and private services, a high level of spending, high patient

success rates and low mortality rates, and high consumer satisfaction.

Emergency departments (ED) are an integral part of hospitals and medical practices

and provide the best medical or surgical care to patients arriving in need of immediate care.

The policy aims to achieve this goal through supporting the provision of equitable,

affordable, and quality health and related services at the highest attainable standards to all the

patients who are in ambulatory and crucial condition. Emergency Departments serve as the

first point of contact, and people of nearly every age are given medical care based on their

injury or illness; it is the most crucial and intensive department within a hospital as many

times, the question of life and death hangs on a thin line. The policy intends to achieve this

goal by encouraging all patients to have access to equitable, affordable, and high-quality

health and related services. The field of emergency medicine evolved out of the necessity of

caring for a rapidly growing population of patients seeking immediate and unscheduled

medical care for emergency conditions. It has a mix of public and private services, a high

level of spending, high patient success rates and low mortality rates, and high consumer

satisfaction.
Review of Objective

Saint Germain Le Pres Teaching Hospital aims to:

● Provide the best life-changing services

● Provide a safe and therapeutic environment to the patients and staffs

● Maintain high standards of quality care

● Increase satisfaction rates of patients, employees, and visiting medical officers

Principles of the Saint Germain Le Pres Teaching Hospital and Dimensions of Quality

The Saint Germain Le Pres Teaching Hospital incorporates evidence-based medicine

by widely disseminating public health and clinical standards and guidelines, which are

embedded in total quality management and patient partnership. The six guiding principles of

Saint Germain Le Pres Teaching Hospital are as follows:

1. Leadership

2. Patient centered

3. Systems approach to management

4. Process-oriented

5. Continuous quality improvement

6. Making decisions based on evidence

The Saint Germain Le Pres Teaching Hospital's 12 dimensions, as implemented through

the standards described in this document, are organized around structure, processes, and

results, as follows:

I. Structure:

a. Leadership
 b. Human Resources

c. Policies, Standards and Guidelines

d. Facility and Infrastructure

e. Supplies Management

f. Equipment

g. Financial Management

II. Processes:

a. Outpatient services

b. Infection prevention and control

c. Inpatient services

d. Accidents and emergencies

e. Surgical emergencies

f. Laboratory services

g. Pharmacy services

h. Radiology services

i. Mortuary services

III. Results, measured against set key performance indicators.

Documents required during assessment

Documents required during assessment

To achieve these objectives, the organization employs a range of methods. Its goal is
to create clinical care processes and make clinical care decisions based on the
greatest scientific information available. Clinical practice guidelines can help you
comprehend and apply the most up-to-date information to a specific diagnosis or
condition. The goal of the organization is to standardize the care procedure. Clinical
care pathways (protocols, algorithms, etc.) are useful tools in ensuring optimal
integration and coordination of treatment, as well as efficient use of available
resources.

Health facility strategic plan or annual Patient satisfaction survey report

• surveillance report
● Facility risk assessment report • Quarterly reports
● Facility license and lease certificate • Mortality audit reports
● Quality improvement implementation • Quarterly resuscitation drills reports
reports for all
● Human resource records • clinical areas
● Staff satisfaction survey report • Internal audit report for the
● Infrastructure maintenance laboratory
requirements
● Equipment maintenance report
● Quarterly referral reports
● Data analysis and dissemination
report
● Financial audit report
● Governance documents
● Management responsibility for
operations
● Oversight of contracts
● Departmental scope of services and
policies and procedures
● Space and equipment planning
● Staff recruitment, retention and
development
● Internal audit report for the
laboratory
Facility Profile

Facility Name:
Facility Contacts: (082)299-1234; (082)299-7890
Saint Germain Le
Pres Teaching
Hospital List
coordinates:
Level: Level 3
County:
Sub-county:
Population of 45
catchment area:
Type of facility:
a) Public facility
b) Private facility Private Emergency Room
c) FBOs/CBOs
Range of services offered
(Fill in the services offered by the facility in the space provided below):
1. Outpatient
2. Radiology/X-Ray
3. MRI
4. ECG
5. Dental
6. Physiotherapy
7. Pharmacy
8. Laboratory (CBC, Platelet, Urine, Stool)
9. Minor Surgeries
10. Major Surgeries
11. Psychiatric Care
12. Trauma Care
13. Ambulance

STRUCTURE
Dimension 1: Leadership
Dimension 2: Human Resources Management and Development

Human resource management in the health-care industry necessitates human resource

experts navigating the industry's ever-changing landscape. HR managers are primarily in

charge of ensuring that administrative personnel, clinicians, and patients receive high-quality

services. To solve all of these issues, HR managers must look at the larger picture and

possess the organizational abilities needed to manage these various sectors. In Le Germain

they follow protocols and standards that would be a basis in achieving quality care by

providing the best medical staff to cater the needs of the clients.
Dimension 3: Policies, Standards and Guidelines

To provide quality of care and have a collegial atmosphere and environment in Le

Germain Hospital policies and procedures hold personnel accountable for following the

proper processes when caring for patients. They ensure that every patient receives the same

level of treatment by standardizing practices across the organization. Patients are kept safe by

standardized procedures across the institution.

Dimension 4: Facilities and Infrastructure

● OPD (Allopathy & Homeopathy)

○ Patients are registered at the reception and are seen on a first come, first serve

basis, however out of turn consultation may be provided in case of emergency

and senior citizens. Patients have the right to consult any doctor. In OPD,
 clinical consultation is provided to patients which includes history taking,

clinical examination, diagnosis and providing prescription to patients besides

advising laboratory tests in some cases. OPD has a waiting hall with chairs, a

TV, public utilities like drinking water and toilets. Sub waiting areas are

available in front of individual consultation rooms. Wheel chairs, trolleys and

attendants are there to help very sick patients.

● Dental facility

○ An experienced Dental surgeon provides procedures like Dental Extractions,

RCT, Scaling /Cleaning, Fillings, Local curettage.

● Ward/ Indoor facility

○ Ward facilities for observation and management of medical problems like

typhoid, acute gastroenteritis, COPD, bronchial asthma, malaria, viral fever,

pneumonias etc. There are 3 wards, one special room and one well equipped

emergency.

● Minor OT/ Dressing Room

○ Provides services for minor surgical procedures like dressing of lacerated

wounds, suturing of minor lacerations & resuturing.

● Physiotherapy

○ Range of physiotherapy services to assist the patients to recover from a wide

range of musculoskeletal pain-ful disorders. Available modalities are MWD,

SWD, U/S, TENS, IFC laser therapy traction unit, magnolia.

● Laboratory services

○ Trained laboratory staff are providing best services which includes painless

blood withdrawal Services of one NABL accredited laboratory are also

available for carrying out specialized tests, they collect samples from 8 AM to
 12 noon. In IIT Hospital. Sample collection time for IIT laboratory is 8 am to

10.30 am and upto 11:00 am for students while emergency tests like Blood

sugar, platelet count & blood grouping are done in emergent cases throughout

OPD hours.

● ECG Services

○ 24hours ECG services including machine report, done by trained staff.

● Pharmacy

○ Free reliable quality medicines are available to beneficiaries on doctor

prescription during OPD hours. Medicines not available are provided by S.O.

signed by prescribing Doctor and Head and collected from on campus chemist

shop.

● Radiology/X-ray facility

○ X-Ray pleophos-D, 300 MA Siemens available, X-rays done on all working

days during OPD hour. Sonoline G-50 U/S machine, Siemens. Ultrasounds are

done once a week.

● Ambulance Services

○ 24 hours patient transport vehicle available. Patients are transported from

home (on campus) to IIT hospital and patients referred by emergency duty

doctor to empanelled hospital for specialized care.

Dimension 5: Supplies Management

 Standard Requirement Score Remarks

5.1 Planning for

procurement

Improve all
aspects of supplier
year over year

Improve the
efficiency of the
supply
management

Acquire new value-

adding
technologies and
innovation from
supply

Ensure continuity
of supply

Dimension 6: Equipment Management

Dimension 7: Financial Management

Establish operational goals for their work and figure out how much funds they'll need

to meet them. They must be able to account for the money's use, assess whether it was wisely

spent, and report on their financial condition. It must also assess how well it is performing all

of these activities and determine if the objectives have been met or if changes are necessary.

The budget is the financial equivalent of the operational plan. The financial resources needed

to carry out the operating plan must be considered by the hospital. They calculate the costs of

their planned equipment management operations and determine how much money they'll

need. The hospital's budget is its primary instrument for financial planning.

DIMENSIONS 11: PROCESSES

 Each facility implementing the Le Germain standards will endeavor to improve all

processes within its operations in the spirit of continuous quality improvement. This shall

involve systematic identification of process(s) or area(s) for improvement; planning and

target setting for improvement; implementation of improvement initiative; monitoring of

improvement; and evaluation of initiatives. This section identifies the core areas required to

address current pressing challenges in quality of care within Le Germain health facilities.

11.1 Outpatient Services

11.2 Inpatient Care
11.3 Accidents and Emergency
11.4 Surgical Emergencies

Surgical Emergencies

Standard Requirements Scorre ( check the Remarks

appropriate box )

Access to Yes
The surgical functioning support No
department shall facilities ( ICU,
have adequate Laboratory and
resources to provide rehabilitation
quality emergency services.)
surgical care.

Categorization of Yes
patients based on No
their illnesses status.

The time from the Yes

decision to operate No
to actual time of
surgery is recorded
in the patient chart.

Application of Yes
escalation protocols No
 to deal with
deteriorating
patients.

Daily schedule ward Yes

rounds attended by No
a surgeon.

All surgical patients’ Yes

have a filled in safe No
surgical checklist
and is signed by
both the nurse and
the surgeon.

11.5 Laboratory

11.6 Pharmacy

11.7 Radiology

11.8 Mortuary

Comments:

Pls align the page numbers, paragraphs and titles.

Do not copy what was wriitten on the guide. Make your own.

Pls take note of the items I marked with red.

There are missing pages: appendices