Annex 5: Quality Checklist - Health Centre

Signature:

Date submitted by regulators (E.C):

Date received by PPA (E.C.):

Health centre name: FINAL SCORE=

Leave 1 filled copy of the checklist with the health centre

Quality supervision summary

No Indicator category Indicators Score
Total points
1 General Appearance and Safety 10 17
2 Administration, financial management, HRM and planning 7 10
Health Management Information System (HMIS) and 5
3
Supervision 10
4 Infection control and waste management 8 23
5 General Out-Patient Department (OPD) 6 12
6 Under 5 OPD 5 10
7 Emergency services 4 6
8 Antenatal Care (ANC) 4 13
9 Maternity services 14 36
Expanded Program on Immunization (EPI) and growth 14
10
monitoring (GM) 24
11 Nutrition services 4 5
12 Inpatient services 2 5
13 Referral services 4 6
14 Outreach and health post supervision 4 8
15 Laboratory service (*) 9 13
16 Logistics, medicines, and supplies 8 20
Total: 218
(*) this category is not applicable in health centers that do not have a laboratory.
Date of supervision (E.C.):

Woreda Health Office supervisors Other supervisors

Name Signature Name Signature

Seen and signed by the Health Centre Head:

Zone:

Woreda:

Name of Health Centre:

Number of beds:

Catchment population:

STAFFING
No Professional required Establishment In post Vacant
1 Health Officer 2
2 General Practitioner (optional) 1
3 Midwife 3
4 Nurse 5
5 Ophthalmic nurse 1
6 Psychiatry nurse 1
7 Environmental Health professional 1
8 Laboratory technician or technologist 2
9 Pharmacist or Pharmacy Technician 3
10 Cleaners 5
11 Archive Workers 6
12 Maintenance officer 1
13 Morgue attendant 1

1. General Appearance Verification Guidelines Ye N Elements missing

and Safety
1.1. Outside appearance
1.2. Clean courtyard
s o
1. Sign post- visible and readable
(Afan Oromo and Amharic).
2. Fence intact, without major
1 0
holes.
3. Gate - that can be closed and
locked
1. Grass cut; No animal excreta; no
litter; no waste and dangerous
objects in courtyard such as
needles, syringes, gloves, used
2 0
cotton wool and broken glasses.
2. Environment: resting places
(benches in shade), clear pathways
without cracks/holes
1. General Appearance Verification Guidelines Ye N Elements missing
and Safety s o
1.3. Appearance of 1. Walls, doors and windows
buildings outside painted.
2. Roof intact with gutters.
3. Windows not broken and can be 2 0
locked.
4. Doors not broken and can be
locked.
1.4. Appearance of 1. Walls- clean and painted.
buildings inside (assess per 2. Floors-Clean, without cracks and
department) polished.
2 0
3. Ceiling/ Roof- no cobwebs.
4. Doors- with locks and closing
properly.
1.5. Fire protection system 1. Fire extinguisher available and
functional (check service date,
should be serviced every year)
2. Grounding system available
3. Instructions on procedures to
follow i case of emergency
(including patient evacuation)
2 0
available.
4. Written evacuation diagram
posted on wall
5. Select two staff randomly: they
should be able to explain
firefighting and evacuation
procedure
1.6. Staff dress code 1. All staff should wear clean
uniform
2. All staff should wear badge with
name, profession and department 2 0
3. Hair and nails should be worn in
a way that prevents contamination
4. No open shoes
1.7. Information and 1. All rooms/units are clearly
feedback: labelled for patient
2. Available services and their fees
(including exempted) are clearly
1 0
displayed on the wall (in local
language)
3. Suggestion / comment box or
book for patient is available
1. General Appearance
and Safety
1.8. Electricity
1.9. Water reserve
1.10. Communication
TOTAL 17 points:
Verification Guidelines Ye N Elements missing
s o
1. Electricity is available for 24/7 at
least in delivery, OPD, inpatient
room, cold chain: solar, grid or
generator. Back-up system is
available.
2. If back-up system is generator, 2 0
generator should be functional and
at least 20 liters of fuel available
3. Only solar, grid or generator are
used in the facility (no oil lamps
etc.)
1. Availability of a water reservoir
for the health centre: cistern, water
2 0
tank
2. At least 1000 liters of water
1. Functional mobile phone or
ground phone is available
2. Phone has at least a credit of 25 1 0
Birr
3. Mobile phone is charged
…../17 = ..…

2. Administration, Verification Guidelines Ye N Elements missing

financial s o
management, HRM and
planning
2.1. Job descriptions Check five staff files / documents
available (randomly selected) to assess job 1 0
description is available.
2.2. Mission statement, -Should be on walls clearly visible
vision, and values and 1 0
readable in local language.
2. Administration, Verification Guidelines Ye N Elements missing
financial s o
management, HRM and
planning
2.3. Catchment area / 1. Catchment map showing villages,
Epidemiology health posts, schools, and water
points available and posted on the
wall
2. Catchment population should be
shown on the map and should be
broken down by sex, age and
kebele. 1 0
3. Monitoring graphs for
immunization, delivery, FP, ANC
and 10 top diseases for both <5 and
others including target population
for services calculated correctly,
up-to-date and displayed on the
wall
2.4. Planning documents 1. Current annual plan and
operational plan available, signed
by HC management team and
approved by HC governing body
2. Current quarterly plan available,
signed by HC committee and
approved by WHO available, signed
by HC management team and
approved by HC governing body
3. Monthly plan of last 3 months 2 0
available, signed by HC
management team and approved
by HC management committee.

All documents should be filed,

stored in chronological order,
clearly labelled and easily
accessible (retrieved in 10 minutes
or less).
2. Administration, Verification Guidelines Ye N Elements missing
financial s o
management, HRM and
planning
2.5. Financial and 1. Health care financing reform
accounting documents guidelines for managing revenue
available.
2. Bank statements, invoices, and
receipts of last 3 months available
and documented according to
health care financing reform
guidelines.
3. Revenue collected report of last
3 months available signed by HC
2 0
head and HC finance officer.
4. Retained revenue utilization plan
of last 3 months available and
approved by HC governing body

All documents should be filed,

stored in chronological order,
clearly labelled and easily
accessible (retrieved in 10 minutes
or less).
2.6. Staff rosters 1. Staff duty roster including
night/weekend/public holidays
duties and leave displayed on wall
accessible to all staff.
1 0
2. Check that all staff which
according to roster should be in the
facility at time of check, are present
or absent with valid reason.
2. Administration, Verification Guidelines Ye N Elements missing
financial s o
management, HRM and
planning
2.7. Documentation of 1. Monthly staff meeting minutes
activities / Reporting including signed attendance
register are available for the last
three months (3 reports).
2. Quarterly health centre
governing body meetings minutes
including signed attendance
register is available for last quarter.
Minutes show that outcomes of
PBF community verification surveys
(as reported on by the CBO) have
been discussed and follow-up
actions agreed upon.
3. Bi-weekly health centre
management committee meetings 2 0
minutes including signed
attendance register are available
for the last 3 months (6 reports).
4. Weekly Public Health emergency
and management report (IDSR /
PHEM) available, signed by PHEM
focal person of last 3 months
available (12 reports.)

All documents should be filed,

stored in chronological order,
clearly labelled and easily
accessible (retrieved in 10 minutes
or less).
TOTAL 10 points: …./10 =

3. Health Management Verification Guidelines Ye N Elements missing

Information s o
System (HMIS/DHIS2)
and Supervision
3.1. HMIS/DHIS2 reporting 1. Monthly HMIS/DHIS2 reports of 2 0
last 3 months are submitted before
the 26th of the reporting month to
WHO (E.C.).
2. Quarterly HMIS/DHIS2 report of
last month submitted on time to
WHO. All reports should be
submitted to WHO before up to
3. Health Management Verification Guidelines
Information
System (HMIS/DHIS2)
and Supervision
the 26th of the month (E.C.).
3.2. HMIS/DHIS2 analysis
3.3. Quality assurance
3.4. Integrated supervision
3.5. Medical Card Room
Ye N Elements missing
s o
All documents should be filed,
stored in chronological order,
clearly labelled and easily
accessible (retrieved in 10 minutes
or less).
1. Monthly minutes of discussions
of HMIS/DHIS2 review team /
Health Centre Performance
Monitoring Team including signed
attendance register are available
for the last 3 months.
2. Monthly planned performance
2 0
monitoring charts for the last 3
months are displayed on the wall.
All documents should be filed,
stored in chronological order,
clearly labelled and easily
accessible (retrieved in 10 minutes
or less).
1. Checklist for self-assessment is
used on a quarterly basis.
2. Self-assessment report is
available. 2 0
3. Follow up actions identified.
4. Proposed solutions are
implemented.
1. A supervisory visitors' book is
available and up to date, with
recent supervisory feedback /
recommendations.
2. Recommendations from previous
supervision by the WHO have been
implemented (check 1 0
documentation)
3. All documents should be filed,
stored in chronological order,
clearly labelled and easily
accessible (retrieved in 10 minutes
or less).
1. Check availability of empty 3 0
Patient folders, MPI cards and
3. Health Management Verification Guidelines Ye N Elements missing
Information s o
System (HMIS/DHIS2)
and Supervision
Appointment cards which are
adequate for the next six months.
Calculate the average monthly
consumption of each of these items
for the last six months and verify
whether stock is available for the
upcoming six months.
2. Check availability of filled Patient
folders and MPI cards in
chronological order for the last
three MRNs registered at the
health center. All demographic data
should be filled on the Patient
folders and MPI cards.
3. Check availability of empty
standard lab-requests, prescription
papers, ANC follow up cards and
partographs which are adequate
for the next six months. See
calculation under point 1. above
TOTAL 10 points : …../10 =

4. Infection prevention Verification Guidelines Ye N Elements missing

and waste management
4.1. Infection control policy
4.2. Waste management
s o
1. Exists and is being used.
2. Relevant infection control
procedures posted in delivery
room, emergency, and laboratory. 2 0
3. Infection Prevention committee
is available and meet at least once
a quarter and minutes available
1. Garbage bin with lid in courtyard
accessible to clients, not full
2. Garbage bin with lid not full in
every treatment room
3. Three bin system is used in OPD, 3 0
PPD <5 and maternity: Three bin
system should differentiate
between sharp materials, infectious
materials, and non-risk materials.
4. Infection prevention Verification Guidelines Ye N Elements missing
and waste management s o
4.3. Incinerator 1. Well-constructed (according to
incinerator guidelines)
2. Functional
3. Door should be well closed 2 0
4. Fenced
5.Well cleared and no grass inside
the fence area
4.4. Placenta pit 1. Available
2. Functional – not full and used
3. Width of at least 2.5 meter
4. Covered 2 0
5. Fenced
6. Well cleared and no grass inside
the fenced areas
4.5. Normal waste disposal 1. Solid waste storage area
available and functional (without
infected materials)
2. Septic tank for solid waste
4 0
available and functional
3. Appropriate drainage of
wastewater (presence of septic
tank).
4.6. Latrines / toilets 1. Presence of at least two latrines
(1 for female and 1 for male) with
roof and lockable door. Latrine is
clean, without visible faecal matter,
no smell, or flies, and at least 20
liters of water available for flushing
in the latrine / toilet.
2. Presence of at least two staff
latrines (1 for female and 1 for
4 0
male) with roof and lockable door.
3. Latrine is clean, without visible
faecal matter, no smell, or flies, and
at least 20 liters of water available.
4. Hand washing facility with
running water or at least 20 liters of
water (with bucket) is available
within 10 meters of latrines with
soap available.
4. Infection prevention Verification Guidelines Ye N Elements missing
and waste management s o
4.7. Sterilization 1. Autoclave or steam sterilizer
available and functional, sensitive
tape is intact.
2. Guidelines for sterilization
available and posted on the wall.
3. Check with one staff how to 4 0
prepare chlorine disinfectants
solution.
4. Disinfectants available and
clearly labelled, stored in original
container.
4.8. Cleaning materials 1. Brooms (at least 2)
available and functional 2. Mop (at least 2)
3. Bucket (at least 2)
4. Dust mop (at least 2) 2 0
5. Cleaning clothes (at least 2)
6. Detergent (at least 2 liters)
7. Bleach (at least 2 liters)
TOTAL 23 points: …./23 =

5. General Out-Patient Verification Guidelines Ye N Elements missing

Department (OPD) s o
5.1.OPD Waiting area 1. Protected against sun and rain.
2. IEC available in waiting area.
3. With sufficient benches and / or 1 0
chairs (at least 10 seats or 3
benches).
5.2. Designated nurse 1. Designated nurse triages patients
triages patients in OPD in OPD waiting area during all clinic
shifts, documenting at a minimum
in patient’s card and/or clinic
register (check 5 at random):
2 0
1. Temperature
2. Respiratory rate
3. Pulse
4. Weight
5. BP (if adult)
5. General Out-Patient Verification Guidelines Ye N Elements missing
Department (OPD) s o
5.3. Consultation room 1. Privacy ensured (curtains for
window or window painted).
2. At least one chair and table for
nurse, two chairs for clients.
3. Examination couch in good
1 0
order, cover not torn, screen
around the couch.
4. Running tap water or at least 20
liters of water with bucket and
soap.
5.4. Equipment in 1. Stethoscope
consultation room (OPD) 2. Sphygmomanometer
3. Thermometer
4. Weighing scale for adults
2 0
5. Gloves (at least 10 pairs)
6. Otoscope
All instruments should be tested to
see if they are functional.
5.5. Guidelines / protocols 1. National Malaria guidelines
in OPD 2. TB guideline
3. HIV / ART guideline
4. Pain management
2 0
5. STD / STI
All 5 guidelines are displayed on the
wall, readable and accessible to
staff.
5.6.OPD service providers Randomly select 5 clients from the
treat diagnosed conditions OPD register with different
according to treatment conditions and check if the
guidelines. following is documented correctly:
1. History
2. Main complaint
3. Diagnosis 4 0
4. Appropriate investigations
including results
5. Treatment (including
dosage and duration)

TOTAL 12 points …../12 =

6. Under 5 OPD Verification Guidelines Ye N Elements missing
s o
6.1. Separate Under 5 1. Privacy ensured (curtains for
Consultation room window or window painted).
2. At least one chair and table for
nurse, two chairs for clients.
3. Examination couch in good
order, cover not torn, screen 1 0
around the couch.
4. Footrest, cover not torn.
5. Running tap water or at least 20
liters of water with bucket and
soap.
6.2. Equipment in 1. Stethoscope
consultation room (U-5 2. MUAC tape measure
OPD) 3. Thermometer
4. Weighing scale for children
5. Infant meter and height scale
2 0
6. Otoscope
7. Spatula (tong depressor)

All instruments should be tested to

see if they are functional.
6.3.ORT corner available in 1. Measuring Jug
U-5 OPD 2. Water
3. ORS
2 0
4. Spoon
5. Cup
6. Tray with cover
6.4. IMNCI chart posted on -
the wall and booklet 1 0
available.
6. Under 5 OPD Verification Guidelines Ye N Elements missing
s o
6.5.OPD <5 service OPD <5 service provider can
provider can diagnose check/assess children and
dehydration in children document at least for 4 signs of
with diarrhea and manage dehydration and treat the diarrhea
it correctly correctly

1. Skin tone (pinch goes back very

slowly)
2. Thrust
4 0
3. Sunken eye
4. Irritability or lethargy
5. Inability to suck
6. Eager to drink

Check 6 OPD under-5 records for

the past 3 months ( 2 from each
months). If there are less cases
check the available cases/records.
TOTAL 10 points: …./10=

7. Emergency services Verification Guidelines Ye N Elements missing

s o
7.1. Separate Emergency 1. Privacy ensured (curtains for
Consultation room window or window painted).
2. At least one chair and table for
nurse, two chairs for clients.
3. Examination couch in good
1 0
order, cover not torn, screen
around the couch.
4. Running tap water or at least 20
liters of water with bucket and
soap.
7.2. Equipment in 1. Stethoscope
emergency room 2. Thermometer
3. Otoscope
4. Sphygmomanometer
1 0
5. Spatula (tong depressor)

All instruments should be tested to

see if they are functional.
7. Emergency services
7.3. Supplies / medicines in
emergency room
7.4. Emergency OPD tray
TOTAL 6 points:
Verification Guidelines Ye N Elements missing
s o
1. Gloves (at least 10 pair), face
mask, goggles
2. Instrument tray and trolley,
kidney basin
3. Minor surgical set: Scalpel
handle,2 medium Artery forceps,
Mosquito forceps, Clamper forceps,
1Toothed and 1 non-toothed
forceps, 2 Needle holder, 10-20
Sterilized gauze, 2 Sponge forceps,
2 0
2 skin retractor, 1 curved scissor, 1
straight scissor, 1 kidney dish, Blade
holder)
4. IV stand
5. Dressing set (at least 5): Adison
tissue forceps, Kelly forceps,
Dressing forceps, Forester sponge
forceps, 1 Dissecting Scissor
(sharp/blunt), Galli pots, Kidney
dish, Gauze)
1. Drug : 50%/40% dextrose,
adrénaline, lagnotaine diazépam,
atropine available.
2. Accessories : cannula, giving
sets, syringes and needles, drip
stand, swabs, strapping, 2 0
disinfectant, gloves, face mask,
specimen bottles.
3. IV fluids (ringer lactate, 5%
dextrose, normal saline). Should be
part of emergency tray.
…./6 =
8. Antenatal care (ANC)
8.1.ANC providers can
monitor, document, and
manage danger signs
properly during pregnancy
Verification Guidelines Ye N Elements missing
s o
ANC providers can monitor and
documents danger signs during
pregnancy:
Check if any danger sign was
documented and managed properly
(if no danger signs detected it must
be stated on the card. Any advice
or counselling provided should still
be documented)
o Danger signs identified and
Investigation
o Action, Advice, counseling
o Date of follow-up visit
documented.
4 0
o Examples of danger signs
1. Bleeding during
pregnancy (ante partum
haemorrhage
2. General body Swelling
3. convulsion during
pregnancy
4. Blurred vision during
pregnancy
5. Foul smelling discharges
6.Eclampsia/pre-eclampsia
Check six ANC cards from the past
three months (2 from each month).
8. Antenatal care (ANC) Verification Guidelines Ye N Elements missing
s o
8.2. ANC providers 1. Obstetric history (if not first
correctly fill ANC cards pregnancy): Previous stillbirth or
neonatal loss, history of 3 or more
consecutive spontaneous
abortions, Birth weight of last baby
< 2500g or > 4000g, hospital
admission for hypertension or
preeclampsia/eclampsia. Previous
surgery on reproductive tract like
myomectomy, removal of septum,
fistula repair, cone biopsy,
Caesarian Section, repaired
rapture, cervical cerclage
2. Current pregnancy: Diagnosed or
suspected multiple pregnancy, Age
(<16 or >40), Isoimmunization Rh (-)
in current or in previous pregnancy,
vaginal bleeding, pelvic mass,
diastolic blood pressure 90mm Hg
3 0
or more at booking
3. General medical: diabetes
mellitus, renal disease, cardiac
disease, chronic hypertension,
known substance abuse (including
heavy alcohol drinking, Smoking),
any other severe medical disease or
condition TB, HIV, Ca, DVT.
4.Services provided during current
visit
5. Follow-up date documented
6. If 1-3 above are not
applicable/present it must be
indicated on the cards as “N’’ as
evidence that the elements were
checked, and answer is “NO”.

Check six ANC cards from the past

three months (2 from each month).
8. Antenatal care (ANC) Verification Guidelines Ye N Elements missing
s o
8.3. All ANC attending 1. HIV
mothers are referred if 2. Hemoglobin (Hgb)
indicated 3. U/A
4. Blood group and Rh factor
testing
5. VDRL
6. Danger signs/complications
(should be specified)

Check six ANC cards from the past

three months and assess whether:
1. The above-mentioned 2 0
laboratory tests were done during
first ANC visit at the PHCU or
referred to other health facilities
for the tests.
2.Also check if the danger
signs/complications were check and
documented/specified. If there
were no danger signs the health
worker should also indicate on the
card.
8. Antenatal care (ANC) Verification Guidelines Ye N Elements missing
s o
8.4. ANC providers conduct ANC service provide check, provide,
full physical examination and document the following visit
and provide visit appropriate services:
appropriate services to
mothers during ANC visits o Gestation age (LMP)
o BP
o Weight (Kg)
o Pallor Uterine height (Wks.)
o Fetal heartbeat (N/A in ANC
1 before 16 wks.)
o Presentation (N/A in ANC 1
before 16 wks.)
o Urine test for infection
o Urine test for protein
o Rapid syphilis test (N/A in 4 0
ANC 4)
o Hemoglobin
o Blood Group and Rh (N/A in
ANC 4)
o TT (dose)
o Iron/Folic Acid (N/A in ANC
4)
o Mebendazole
o Use of ITN
o ARV Px (type)

Check six ANC cards from the past

three months (3 for ANC 1 and 3 for
ANC 4).
TOTAL 13 points: …./13 =
9. Maternity services Verification Guidelines Ye N Elements missing
s o
9.1. Partographs properly 1. Patient information: Fill out
utilized to monitor women name, gravida, para, hospital
in labour number, date and time of
admission and time of ruptured
membranes
2. From admission until delivery the
following parameters should be
documented according to the
frequencies specified:
o FHR:30min
o Amniotic fluid color 4
hourly
o Moulding: 4 hourly
o cervical dilatation: 4 hourly
o descent of presenting part:
4 hourly
o Contractions: half hourly
o maternal BP:4 hourly for
6 0
normal and 2 hourly for
complications
o pulse: 30 min
o temperature: 2 hourly
o respiratory: 30min
o Protein and acetone
output (every urine
output)
o Drugs administered
o Time of delivery
o Oxytocin Unit/Liter or
Drops per minute if
induction or Augmentation
Randomly check 6 partographs
from the previous 3 months (2 from
each month). All should be filled
correctly according to the criteria
above.
9. Maternity services Verification Guidelines Ye N Elements missing
s o
9.2. Maternal health For newborns with an APGAR score
service provider can less than 5 (check partograph
resuscitate newborn who is and/or register), check whether
not breathing resuscitation procedures were
done timely and properly. Maternal
health service provider must
position, clear airways, ventilate
and monitor the newborn
according to BEMONC guideline.
1.Dry the newborn, remove the wet
cloth, and wrap the newborn in a
dry, warm cloth. 2 0
2. Clamp and cut the cord
immediately if not already done.
3. Move the newborn to a firm,
warm surface under a radiant
heater for resuscitation.
4.Observe standard infection
prevention practices when caring
for and resuscitating a newborn.
Assess knowledge question if there
is no case with APGAR score below
5.
9.3. Delivery room 1. Running water or at least 20
liters of water with soap.
2. At least 2 delivery beds in good
state (not broken, mattress not
2 0
torn, not rusty).
3. Woman’s privacy is respected
(Single room or curtains/screens
available between beds).
9.4. Supplies / equipment 1. Baby scale
in delivery room 2. Weighing scale adult
3. Tape measure
4. Stethoscope
5. vitamin K,
2 0
6. Eye ointment/drops
(tetracycline, silver nitrate or
povidone iodine)
7. Oxytocin
8. At least 5 pair of gloves
9. Maternity services Verification Guidelines Ye N Elements missing
s o
9.5. Instruments in delivery1. Three delivery sets (2 clamper
room forceps, Sponge forceps, 2 scissor,
1 Kidney dish, Cord tie (rope/ cord
clamp), 10 Sterilized Gauze, 1
fenestrated towel or Drapes)
2. One episiotomy set (Sponge
Forceps, 1 Kidney Dish, 1
4 0
Episiotomy Scissor, 1 Tissue
Forceps, 1 Needle Holder, 10
Sterilized Gauze)
3. Speculum of different sizes
4. Standing lamp (2)
5. Refrigerator for Oxytocin
6. IV stand (2)
9.6. Sanitation in delivery 1. Accessible, working bathroom
room available for women with running
water or at least 50 liters of water
near the labour ward
2 0
2. One toilet / latrine dedicated for
maternity near the labour ward
with lockable door running water
or bucket with 20 liters of water.
9.7. At least 3 personnel At least 3 personnel protective sets
protective sets in delivery in delivery room containing cape, 2 0
room goggle, mask, apron, and boots.
9.8. Clean pre-natal room 1. 2 beds, mattress with cover
available (clean not torn and not rusty),
2 0
mosquito nets, sheets.
2. With hand washing basin.
9.9. Clean post-natal room 1. 2 beds, mattress with cover
available (clean not torn and not rusty),
mosquito nets (only in malaria 2 0
endemic sites), sheets.
2. With hand washing basin.
9. Maternity services Verification Guidelines Ye N Elements missing
s o
9.10. Availability of 1. BEmONC guidelines in delivery
guidelines/protocols on room
MNCH care 2. PMTCT Option B+ guidelines
(only in PMTCT sites)
3. HIV test algorithm for both
mother and infant
4. Technical and Procedural 2 0
Guidelines for Safe Abortion
Services in Ethiopia
5. Infection prevention guideline
6. Hand washing poster
7. Focused ANC protocol available
in ANC care area
9.11. Emergency tray 1. With all the necessary medicines
available (50%/40% dextrose, adrenaline,
lignocaine, diazepam, atropine.
(Not expired)
2. With all important Accessories:
cannula, IV giving sets, syringes and
2 0
needles, drip stand, swabs, (non-
Pneumonic anti shock garment
(NASG), disinfectant, gloves, face
mask, specimen bottles, IV fluids
(ringer lactate, 5% Dextrose,
normal saline).
9.12. Newborn care corner 1. Cloth/blanket
in delivery room 2. Neonatal / Ambu bag with
different size of mask 2 0
3. Suction bulb
4. Stethoscope
9.13. Uterotonic drugs and 1.Uterotonic drugs (Oxytocin or
Anti shock garment Ergometrine or Misoprostol)
available in delivery room available in delivery room.
2. Stored properly and stock card
2 0
used.
3. anti-shock garment (non-
Pneumonic anti shock garment
(NASG)
9. Maternity services Verification Guidelines Ye N Elements missing
s o
9.14. Women and Maternity service providers
newborns are monitored monitor and document the
for danger signs post following vital signs and danger
delivery signs and document them properly:

1.From birth to 2 hours (mother,

every 30 minutes) document:
vaginal bleeding, uterine
contraction, BP, pulse, and
temperature.
2.From birth to 2 hours (baby,
every 30 minutes) document:
temperature, RR, BF/feeding status,
4 0
color. APGAR score registered.

Danger signs in newborns

1. Unable to breastfeed
2. Vomiting everything
3. History of convulsions or
convulsing now
4. Lethargic /unconscious
5. Axillary temperature is <35
degree C or >37.5
6. Red swollen eye lid and pussy
discharge from the eye
7. Jaundice / yellow skin
TOTAL 36points: …/36 = ….

10. Expanded Program on Verification Guidelines Ye N Elements missing

Immunization s o
(EPI) and growth
monitoring (GM)
10.1 Immunization services 1.Immunizations services are
provided on daily basis provided on daily basis (check
1 0
register)
2. Static EPI schedule available
10.2.EPI monitoring chart 10.2.EPI monitoring chart is
consistent with tally report consistent with tally report for
penta1, penta3, measles and fully
2 0
vaccinated child. Observe for
previous 3 months record randomly
selected.
10. Expanded Program on Verification Guidelines Ye N Elements missing
Immunization s o
(EPI) and growth
monitoring (GM)
10.3. Availability of Auto Disposable Syringes (AD):
syringes Minimum stock = Monthly Average
Consumption (MAC)/3
1 0
2. Other syringes for dilution:
Minimum stock = Monthly Average
Consumption (MAC)/3
10.4. Availability of sharps Sharps boxes being used correctly
boxes and available in immunization 1 0
room/corner/area
10.5. Salter scale(baby 1. Balance calibrated to zero.
scale) available 2. Plastic basins available, clean and in 2 0
good state.
10.6.EPI accessories 1. Vaccine carriers (2)
2. Cold box (1)
3. Gas regulator (only applicable
where gas fridges are used) 2 0
4. Scissors
5. EPI modules available and easily
accessible.
10.7. Forms available 1. Vaccine order forms
2. Vaccine stock cards
3. Adverse Effect Investigation
Forms
4. Case investigation forms for EPI
targeted diseases 2 0
5. Vaccine wastage monitoring
forms
6. EPI card.

At least 5 of each available.

10.8. Case definitions of 1. Neonatal TT
vaccine preventable 2. Measles
2 0
diseases displayed and 3. Polio
readable
10.9. EPI outreach Should have been updated during
schedule and contingency the last 3 months 2 0
plan available
10. Expanded Program on Verification Guidelines Ye N Elements missing
Immunization s o
(EPI) and growth
monitoring (GM)
10.10.EPI refrigerator clean 1. Presence of a functional fridge
and kept properly 2. Temperature monitoring chart
filled 2 times per day including
weekends and holidays
3. Temperature between + 2 and+ 8
2 0
degrees Celsius
4. Functional fridge tag/ dial
thermometer in the refrigerator
(external or internal)
5. No ice-forming in the refrigerator
10.11. Stock Control Cards Antigens (BCG, measles, polio,
for Antigens used properly Penta, tetanus, vitamin A,
pneumococcal and Rota virus
vaccine) 2 0
1. Presence of stock control cards
2. Physical stock in the fridge tallies
with stock control cards
10.12. Vaccines are 1. Freezing compartment: ice packs
correctly stored in fridge well frozen
2. None freezing compartment: top
shelf BCG, OPV, measles
3. Lower shelf: Penta, Hepatitis B,
TT. 2 0
4. Absence of expired vaccines
5. VVM status (using FEFO or FIFO
system)
6. Readable labels on vials with
matching diluents
10.13. Multi dose vial Multi dose vial policy (MDVP),
policy (MDVP) is followed check vials of Penta, polio, BCG,
1 0
measles, and TT for dates opened
to see if protocol is followed.
10.14. Plan of Action (PoA) Plan of Action (PoA) for
for power interruption is preparedness during power
available interruption is available. Staff can
show PoA and summarize its
2 0
content. (Using cold box, using
stand by generator, transporting
vaccines to pre-identified place,
kerosene...)
TOTAL 24 points: …./24 =….
11. Nutrition services Verification Guidelines Yes No Elements missing
11.1. Stabilization Centre Separate room or designated area
(SC) service provided by available for SC
1 0
trained staff Severe Acute Malnutrition
guidelines available
11.2.OTP Cases admitted 1. MUAC less than 11.5 as cm
based on admission criteria 2. Presence of bilateral pitting
oedema
3. Weight for height less than 70%
Check all cards from the last 3
months. If no cases are admitted, 2 0
ask OTP / SC service provider for
the 3 admission criteria.

Check for most five recent cases

cards
11.3. Separate room Separate room available for
available for Nutritional Nutritional stabilization Centre
Stabilization Centre functional and equipped according
to the national standard
1. Matrass, sheets, pillow
2. Red scoop
1 0
3. Stove
4. Formula milk F-75, F -100
5. Bucket for milk preparation
6. Drugs Mebendazole, Amoxicillin
syrup, Folic Acid, Vit. A,
Gentamycin.
11.4. Health workers stick 1. No oedema for 2 weeks
to the discharge criteria 2. Target weight is reached

Check all cards for the last three 1 0

months. If no cases were
discharged ask the OTP / SC service
provider for the discharge criteria.
TOTAL 5 points: …./5 =
12. Inpatient services Verification Guidelines Yes No Elements missing
12.1. Inpatient Ward 1. Ward is well ventilated and is clean

2. In the ward, there at least 3 beds,

with sufficient space between the
beds
3. Beds are in good state with 3 0
mattresses covered with plastic,
mosquito nets(only in malaria
endemic areas) and sheets.
4. For each of the 3 beds, IV stand is
present
Indicator 12.2 was
removed from the checklist
12.3. Information on in- No patient has been admitted
patient register and patient longer than 3 days. 2 0
cards is the same
TOTAL 5 points: ……/5 =

13. Referral services Verification Guidelines Yes No Elements missing

13.1. Mobile phone number -
2 0
to call for ambulance visible
13.2. Standard forms for At least 10 empty ones
1 0
referral available
13.3. Referral register There referral register, properly filled
1 0
available and properly filled.
13.4. Filled referral 1.Filled referral notes copies
notes/feedback notes available for the last three
available months.

2. Check for completeness

2 0
(demographic details of the
patient, diagnosis, reason for
transfer, pre-referral
management), name and
signature of referring clinician.
TOTAL 6 points: …./6 =
14. Outreach and Health Verification Guidelines Yes No Elements missing
Post Supervision
14.1. Regular supervision 1. Randomly select one month of the
of the satellite health posts quarter. A minimum number of
satellite health posts should be visited
in every week of that month: if the HC
has five or less health posts, all should
be visited every week. If the HC has
more than five health posts, they
should visit at least 75% per week.
(CHECK)
2. Summarized supervision reports
available
3. Reports include clear action points
to be followed up and issues
addressed during the visit.
4. All documents should be filed, 2 0
stored in chronological order,
clearly labelled an easily accessible
(retrieved in 10 minutes or less).

Visit one of the satellite health

posts of the PHCU randomly each
quarter, to verify whether
supervisory visit has taken place.
Compare findings with the report
filled at the health centre.
Interview health extensive worker
to learn the date of the last visit. If
no visit has taken place, no score.
14.2. Community meetings 1. One meeting is organized for each
with health centre head: kebele per quarter.
2. Meetings are minuted and
attendance record signed both by HC
representative and community
representative (one of the community
leaders). Minutes are stored in files.
3. Issues discussed should address the
outcomes of the community
verification surveys, as reported
2 0
quarterly by the CBO, as well as
challenges in planned activities and
meeting targets.

All documents should be filed, stored

in chronological order, clearly labelled
and easily accessible (retrieved in 10
minutes or less).
14. Outreach and Health Verification Guidelines Yes No Elements missing
Post Supervision
14.3. Health promotion 1. Health promotion plan
(outreach) available, including school health
2. At least one session per month
3. Report of 3 sessions during last
quarter, including topic,
attendance, locations are filed.
2 0
All documents should be filed,
stored in chronological order,
clearly labelled and easily
accessible (retrieved in 10 minutes
or less).
14.4. Health education 1. Availability of Health education
(health centre) schedule
2. Different health related topics
addressed.
3. Health professional assigned
and posted.
4. Reports of daily HE sessions of
last 3 months available, signed and 2 0
attendance recorded.

All documents should be filed,

stored in chronological order,
clearly labelled and easily
accessible (retrieved in 10 minutes
or less).
TOTAL 8 points: …. /8 =

15. Laboratory services Verification Guidelines Ye N Elements missing

(this category is not s o
applicable in HCs without a
laboratory)

Indicator 15.1 was

removed from the checklist
15.2. Procedure manuals or
guidelines available
Procedure manuals (Standard
Operating Procedure, SOP) or
1 0
guidelines for all tests and
equipment are available
15. Laboratory services Verification Guidelines Ye N Elements missing
(this category is not s o
applicable in HCs without a
laboratory)

15.3. Monitoring and 1. Standard Operating Procedures

evaluation tools available
15.4. Results recorded
correctly in lab register
2. Safety guidelines
3. QA activities
1 0
4. Laboratory performance and
workload
5. Laboratory services
Results recorded correctly in
laboratory register and match with
results in inpatient register. 1 0

Verify the last 5 results

15.5. Parasite’s
demonstrations available
15.6. Microscope (mirror or
electric) available and
functional
15.7. Staff maintains bin
cards or stock book for
reagents
Parasite’s demonstrations are
available on plastic paper, in a color
book, or put on wall
1 0
1. Blood smear: Vivax, Oval,
Falciparum, Malaria
2. Stools: Ascaris, entamoebae,
ankylostome, Schistosoma
1. Reagents available
2. Functional objectives
3. Immersion oil
4. Blades 1 0
5. Cover glass
6. Slides
7. GIEMSA-stain
Staff maintains bin cards or stock
book for laboratory reagents
showing minimum stock level

1. Monthly Average Consumption

(MAC)/3. 2 0
2. Supply on bin card or stock book
corresponds with physical count.

Use sample of three laboratory

reagents.
15.8. Laboratory functional Laboratory is functional and
and available for available for emergencies after
emergencies after working working hours. Verifies weekend 2 0
hours and night duty roster activities in
the laboratory register
15. Laboratory services Verification Guidelines Ye N Elements missing
(this category is not s o
applicable in HCs without a
laboratory)

15.9. List of all laboratory -

examinations and prices 2 0
displayed
15.10. Laboratory 1. Centrifuge
Equipment 2. Full blood count machine
3. Autoclave 2 0
4. Timer with alarm
5. Serviced and functional.
TOTAL 13 Points: …../13 =…..

16. Logistics, medicines Verification Guidelines Yes No Elements missing

and supplies
16.1. Daily drug 1. All columns filled properly
dispensed register 2 0
available at dispensary
16.2. Model 19 and Following registers are available and
Model 22 registers up-to date (counter check with
available and up-to date available drugs)
2 0
1. Model 19: received by storekeeper
from Woreda
2. Model 22: issued by storekeeper
to pharmacist
16.3. Drug request Copies of requests of last 3 months
mechanism exists and are available and stored in
2 0
can be explained by chronological order
pharmacist
16.4. Staff maintains Showing minimum stock level =
stock cards for essential Monthly Average Consumption
medicines (MAC)/3
2 0
Supply on stock card corresponds
with physical count (use sample of
three medicines)
16.5. Correct storage of 1. Well secured storeroom with
drugs lockable door
2. Clean place
3. Well ventilated 2 0
4. Cupboards with labelled shelves
5. Medicines stored per category
6. FEFO and FIFO rule observed
16. Logistics, medicines Verification Guidelines Yes No Elements missing
and supplies
16.6. No expired Supervisor verifies randomly 3
products in stock medicines and 2 consumables (check 2 0
stock and bin cards).
16.7. Adequate anti-TB Stock available = Monthly Average
drug stock available Consumption (MAC)/3
2 0
Supply on stock card corresponds
with physical count (use sample of
three medicines)
16.8. No stock out of Over the last 3 months, there was no
essential drugs over the stock out for at least 12 out of the 16
last 3 months following essential drugs. If less than
12 drugs qualify, the score will be
zero.

1. Doxycycline capsules 100mg

2. Metronidazole tablets 200mg
IV/Oral
3. Diazepam injection 5mg/ml
4. Benzathine Penicillin injection
5. Amoxycillin suspension 125mg/5ml

6. Ferrous sulphate tablets

7. Zinc Sulphate 6 0
8. Paracetamol 500g tablets
9. Paracetamol syrup 125mg/5ml
10. Oxytocin 10IU/ml Injection, 1ml
Ampoule.
11. Magnesium Sulphate 500mg/ml
12. Gentamycin 40mg/ml Injection,
2ml Ampoule
13. Artemether 20mg + Lumefantrine
120mg Tablets
14. Depo Medroxyprogesterone
150mg/ml injection, 1 vial
15. Levonorgestrel + Ethinyl, Estradiol
(0.15+0.03mg), 28 tablets, 100 cycles
16. Copper-T plus insertion kit
TOTAL 20 Points: …./20 =
Improvements made according to recommendations of last supervisory visit?
(Mention also recommendations of last supervisory visit)

If not, what was the reason?

Priorities identified during this quality assessment: