Routine Data Quality Assessment - TB DOTS

Facility Name/LG
Date of Revie
Reporting Period Verifi
Component of the M&E System

Part 1: Data Verifications

A - Documentation Review:

2
B - Recounting reported Results:

8
C - Cross-check reported results with other data sources:

9
10
 9
10

Part 2. Systems Assessment

I - M&E Structure, Functions and Capabilities
1
2
3
4

II- Indicator Definitions and Reporting Guidelines

4

III - Data-collection and Reporting Forms and Tools

5

Part 3: Recommendations for the Service Site

1
2
3
4
 Routine Data Quality Assessment - TB DOTS Faci
Facility Name/LGU:
Date of Review:
Reporting Period Verified:
Component of the M&E System

Part 1: Data Verifications

A - Documentation Review:
Review availability and completeness of all indicator source documents for the selected reporting period.
Check for the applicable source documents: Presumptive TB Masterlist, Laboratory Register, TB Register,
TPT Register, TB treatment cards, TPT treatment cards, inventory and stock cards
Review available source documents for the reporting period being verified. Is there any indication that source
documents are missing? Which documents are missing? (Check for the Presumptive Masterlist, TB Register,
TPT Register)
Are all available source documents complete and updated?
B - Recounting reported Results:
Recount results (number of individuals screened, presumptives identified, number of presumptive TB tested
per type of case finding) from the Presumptive TB Masterlist, compare the verified numbers to the site
reported numbers in ITIS and explain discrepancies (if any).
Recount the number of individuas screened, presumptives identified and presumptive TB tested during the
reporting period by reviewing the source documents.
Enter the number of individuas screened, presumptives identified and presumptive TB tested reported by the
site during the reporting period from the site summary report.
Are there discrepancies in the numbers? What are the reasons for the discrepancy (if any) observed (i.e.,
data entry errors, arithmetic errors, missing source documents, other)?

Recount results (number of individuals examined and number of positive test) from TB Laboratory Register
and compare the verified numbers to the site reported numbers in ITIS and explain discrepancies (if any).

Recount the number of individuals examined and number of positive test during the reporting period by
reviewing the source documents.
Enter the number of individuals examined and number of positive test reported by the site during the
reporting period from the site summary report.
Are there discrepancies in the number? What are the reasons for the discrepancy (if any) observed (i.e., data
entry errors, arithmetic errors, missing source documents, other)?
C - Cross-check reported results with other data sources:
Cross check patient TB treatment cards and ITIS. Randomly select 5 treatment cards and verify if these patients we
same information is noted in the treatment cards and ITIS. Randomly select 5 patients in the ITIS and verify if these
whether the same information is noted in ITIS and treatment cards. (check for the contacts listed in the treatment ca
indicated in ITIS as well )
Describe the cross-checks performed.
What are the reasons for the discrepancy (if any) observed?
Cross check patient TPT treatment cards and ITIS. Randomly select 5 treatment cards and verify if these patients w
same information is noted in the treatment cards and ITIS. Randomly select 5 patients in the ITIS and verify if these
whether the same information is noted in ITIS and treatment cards.
 Describe the cross-checks performed.
What are the reasons for the discrepancy (if any) observed?

Part 2. Systems Assessment

I - M&E Structure, Functions and Capabilities
There is/are designated staff responsible for recording data on the paper-based records and ITIS.
There is/are designated staff responsible for reviewing reports in ITIS prior to submission to higher level.
All relevant staff have received training on the the recording and reporting forms (MOP) and ITIS
Facilities have provision for internet or communication allowance and computers or devices to record data
electronically in ITIS.
II- Indicator Definitions and Reporting Guidelines
The facility has been provided guidelines on what they are supposed to report on, the reports to be submitted
and when reports are due.
III - Data-collection and Reporting Forms and Tools
Standard NTP forms/tools are used for data-collection and reporting.
###

Part 3: Recommendations for the Service Site

Based on the findings of the review and data verification at the service site, please describe any challenges to data q
strengthening measures, with an estimate of the length of time the improvement measure could take. These will be
Description of Action Point
OTS Facility
Gabaldon RHU
February 3, 2023
October - December 2022
Yes or
REVIEWER COMMENTS
No

Yes

Yes

Pres: 48 Tested: 48
Detected:12 Enrolled: 17
Pres: 46, Tested: 46,
Detected: 12 Enrolled: 12
Reporting/Counting error

Tested 48, Detected: 12

Tested 46, Detected: 12

No

ese patients were recorded in IT IS. Check whether the

d verify if these patients have their treatment cards. Check
he treatment card and check whether the HH contacts are

Yes
No
hese patients were recorded in IT IS. Check whether the
d verify if these patients have their treatment cards. Check
 Yes TPT card to IT IS
No

Yes
Yes
Yes
Yes

Yes

Yes aside from Lab registry

lenges to data quality identified and recommended

. These will bePerson(s)
discussed with the facility staff.
Time Line
Responsible
FAST Plus Facility Implementation

I.   QUICK CHECK. Please check the appropriate box. Under comments, write additional details including challenges the facility may have for
each item asked.
Guide Questions Yes/No/NA Comments
Are all clients entering the facility screened for TB?
Indicate entry points where screening is done within Yes
the facility.
Are the health care workers correctly and
Yes
completely filling out the screening forms?
Are all clients at the triage/OPD/admission who
were screened positive (symptom and/or Chest X- Yes
ray) requested for TB testing?
Are all identified presumptive TB referred for
No Unable to expectorate
sputum testing on the same day?
Is sputum specimen collected onsite? Is your facility Onsite: Yes
supported by STRIDER? Strider: No
Are doctors initiating treatment the same day a
Yes
confirmed diagnosis is made?

For non-providing facilities, do they have difficulties

in referring clients to DOTS facilities for:

·       Bacteriologic confirmation

·       Initiation of treatment
Are all referred clients by the FAST plus site received
by the referral facility?
Do you receive feedback for each client referred? If No feedback from the receiving facility
not, how do you ensure patients are received by the
referral facility?
Do you have regular communication with the TB
No
facilities where you refer your clients?

Does the facility practice “separation” of clients

once a client has been identified as presumptive TB
Yes
(symptom and/or CXR)? Do you have well-ventilated
area where you can place these patients?

Are there staff trained on FAST Plus, MOP? How

Yes: MHO, Medical Officer, TB Coor, MedTech
many?
Are FAST Plus related paper-based and/or ITIS
records updated and completed correctly?
·       Presumptive Masterlist/Hospital Referral
Logbook
No With minimal errors for correction
·       Screening Logbook
·       If with TML/RTDL: Laboratory Register
·       If with TB clinic: DS and/or DR-TB register
If with ITIS accounts, they do encode their data and
patients?
For non-TB DOTS providing facility: Do all doctors Yes
notify their diagnosed TB clients? (mandatory N/A
notification)
Is there a hospital policy on FAST Plus? Infection
Prevention and Control?

For FAST Plus facilities where baseline assessment has not been done, kindly please administer the FAST Baseline Assessment. Here is the link: https://forms.gle/LdQ

For FAST Plus sites implementing for 6 months or more, please administer the FAST Implementation Monitoring for more detailed monitoring. Please use the link: h

II. Random Check on Turn-Around Time. Please select 5 patients who were initiated treatment and review the date patients were screened,
diagnosed, and initiated treatment. Count the number of days for each patient and get the average for all clients included in the review.

Indicator Value Source of Data

Average time from screening to diagnosis Date of screening: Presumptive Masterlist
Diagnosis date refers to the date of DSSM or Xpert 1-3 days Date of Diagnosis: Presumptive Masterlist or Laboratory Register or
MTB/RIF test TB Register
Date of Diagnosis: Presumptive Masterlist or Laboratory Register or
TB Register
Average time from diagnosis to treatment 1-2 days
Average time from diagnosis to treatment 1-2 days
Data of Treatment: Presumptive Masterlist or TB Register

III.                Data on TB Cascade of Care. Please ensure data indicated here is encoded in the TBP tracker during the onsite visit. The table below
contains same information in the tracker, so this table serves as a guide.
Month: ___________

Indicator Data Source of Data Gaps

Facility Census, OPD/Admission

Number of OPD/admitted clients
Logbook
Presumptive Masterlist/Hospital
Referral Logbook, OR
Number of clients screened by symptoms or CXR
Screening Logbook if different from
the Presumptive Masterlist
Presumptive Masterlist/Hospital
Referral Logbook, OR
Number of clients screened by CXR
Screening Logbook if different from
the Presumptive Masterlist
Number with positive CXR Presumptive Masterlist/Hospital
Number of presumptive TB (sx and/or CXR) 48 Referral Logbook
Presumptive Masterlist/Hospital
Referral Logbook, OR
Number of presumptive TB tested by Xpert 46
Laboratory register (of FAST Pus
facility or referral facility)
Presumptive Masterlist/Hospital
Referral Logbook, OR
Number of presumptive TB tested by DSSM 0
Laboratory register (of FAST Pus
facility or referral facility)
Presumptive Masterlist/Hospital
Number of DSTB detected (MTB-Rif susceptible, Referral Logbook, OR
12
MTB-indeterminate) Laboratory register (of FAST Pus
facility or referral facility)
Presumptive Masterlist/Hospital
Referral Logbook, OR
Number of DRTB detected (MTB-Rif-resistant) 0
Laboratory register (of FAST Pus
facility or referral facility)
Presumptive Masterlist/Hospital
Number of DSTB-BC cases
Referral Logbook, OR
9
TB register (of FAST Pus facility or
initiated treatment
referral facility)
Presumptive Masterlist/Hospital
Referral Logbook, OR
Number of DSTB-CD cases initiated treatment 8
TB register (of FAST Pus facility or
referral facility)
Presumptive Masterlist/Hospital
Referral Logbook, OR
Number of DRTB-BC cases initiated treatment 0
TB register (of FAST Pus facility or
referral facility)
Presumptive Masterlist/Hospital
Referral Logbook, OR
Number of DRTB-CD cases initiated treatment 0
TB register (of FAST Pus facility or
referral facility)
Number of Index TB cases for whom contact 15
investigation is conducted
TB treatment card
Number of HH Contacts Investigated 60
Number HH contacts given TPT 4
TPT Register

IV.                Validation with Referral TB Facilities (TML, RTDL, DOTS, or STC).

Visit referral DOTS Facilities/STCs, TMLs and RTDLs to follow up referrals. It is recommended to visit the DOTS/STC/TML/RTDL where most of
the presumptive TB are referred. For FAST implementing hospitals which are also DOTS Providing facilities, visit the Hospital DOTS in addition
to the DOTS facilities in the catchment LGU.
Summary of Monitoring Findings and Key Action Points

Name of Facility/Province Gabaldon RHU

Date of Onsite Visit

Monitoring team (CHD/PHO/TBP)

Jonathan Yambao, Amiel Dionisio

I.   Summary of Findings

Activities Strengths Areas for Improvement

Recording/Reporting (Data quality checks)

All Registers are available.

Program Management The facility has a TSR of 97%.

ACF/ECF Implementation

TPT and Contact Investigation low uptake on CXR among contacts

The facility is actively performing contact investigation even with presence of CXR voucher.
and TPT enrolment.
(work, distance, transportation cost)
FAST Plus Implementation

TBCC

HSS

II.  Action Points

Description of Action Point/s Timeline Person Responsible

Recommended to update the presumptive TB masterlist

Mentored the PHN on how to encode in ITIS and perform

actual return demonstration. A total of 3 TPT was successfully
reported.

Suggested to collaborate with Gabaldon Medicare, which is

an infimary hospital and the cxr provider of the facility, to
engage in the CXR voucher system and increase facility’s
utilization and screening rate.

The facility’s xpert utilization last September is only 6 since

RMT was placed on quarantine. The team requested to
identify and train alternate RMT.

Conforme:
Name:
Signature:
CONTINUOUS QUALITY IMPROVEMENT MONITORING TOOL
Items Yes No Remarks
1.   Program structure
a.  There is a designated CQI-team yes

b. CQI Team/committee headed by a CQI-trained health worker yes

c.  There are written policies/ guidelines/ protocols on quality provided brief overview of the
improvement for the following key elements (see DOH AO no policy, asked rhu to amend tb
2020-034 Annex B: Elements of CQI Program: policy to inckude cqi policy

1.     people-centeredness
2.     effectiveness
3.     patient safety
4.     efficiency
5.     equity
6.     access
7.     appropriateness
d. CQI interventions and activities have budgets and integrated
no
into the AOP
2.   CQI process
a.  CQI Charter

1.     There is a plan that provides details on the facility’s

yes
improvement aims, objectives, and indicators;

2.     The plan indicates the interventions and change

ideas that will be implemented to address the identified yes
quality issues

b. There is a documentation of CQI implementation along the

yes
Plan-Do-Study-ACT (PDSA) cycle
3.   Output monitoring
a.  There are QI output indicators identified and defined yes
b. There are standard monitoring and tracking tools for (a) yes
c. monitoring tools (eg. SSE Journal) is updated for the last
yes
three months
4.   Outcome monitoring

reviewed and to be updated, tbp

to do ff up visit to prepare
a.  There are QI outcome indicators identified and defined yes
revised plan and indicator.
targets

b. There are standard monitoring and tracking tools for (a) Yes

c.  A client satisfaction survey tool is available, implemented, resultsnchecked but needs to be
yes
and with results documented

5.   Rewards and Incentives

a. There is a policy on non-monetary rewards and incentives

b. There are opportunities for training and/or career

development
c. Facility is recognized by PCAHO, PHA or other societies

C. Data Quality Check (See PIRS in Annex A for indicator definition)

1.      Availability of Source Documents

Source Document to Verification (Available/Not

Items Remarks
Review Available)

Validate participants in training

1.      QI trained health worker Training Attendance Sheets avail database.
 Facility Quality
2.      Quality Improvement Plan avail Secure signed copy
Improvement Plan
3.      QI report in at least 3 periods during the year SES Journal Report avail
Secure signed copy
4.      QI Indicators SES Journal Report avail
Patient Visit Logbook or
Secure signed summary report for the
5.      Patient OPD Visits Monthly Summary of Client avail period monitored
Visits

2.      Validation of consistency of source documents with reported figures.

a.      Select last three-month figures reported in the SES Journal on “Total number of annual outpatient department visits”. This shall include all client visits from all service entry point in
b.      Compare reported figures in SES Journal with source documents (Patient Logbook or Monthly Summary Report)

                                                i.     SES Reported Figures are consistent with source documents? ⃣ Yes ⃣ No

Remarks: _________________________________________________
client visits from all service entry point in the facility during the validation period.