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THE PHC MAP SERIES OF MODULES, GUIDES
AND REFERENCE MATERIALS
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Each module includes:
• a User’s guide
• a Facilitators guide
• computer programs
Module 1 Assessing information needs
Module 2 Assessing community health needs and coverage
Module 3 Planning and assessing health worker activities
Module 4 Surveillance of morbidity and mortality
Module 5 Monitoring and evaluating programmes
Module 6 Assessing the quality of service
Module 7 Assessing the quality of management
Module 8 Cost analysis
Module 9 Sustainability analysis
Managers guides and references
Better management: 100 tips
Problem-solving
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Computers
The computerised PRICOR thesaurus
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Production Managers; Ronald Wilson, Aga Khan Foundation, Geneva and
Thongchai Sapanuchart, Somboon Vacharotai Foundation, Bangkok, Thailand
Editor: Jennifer Sharpies, Bangkok, Thailand
Design & Layout: Helene Sackstein, France
Desktop Publishing: Margaret M. Growe, Byte Type Services, Chapel Hill, North
Carolina, USA; Michael S. Sunggiardi, Batutulis Computer, Bogor, Indonesia
Printing: Thai Wattana Panich, Bangkok, Thailand
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Published in 1993 by the Aga Khan Foundation USA, Suite 700, 1901 L Street N.W,
Washington DC and the Aga Khan Foundation, PQ Box 435,1211 Geneva 6, Switzerland.
Additional copies are available at the Aga Khan Foundation Canada in Toronto; Aga Khan
Foundation United Kingdom in London; and AKF offices in Dhaka, Bangladesh; Delhi,
India; Nairobi, Kenya; Karachi, Pakistan; Lisbon, Portugal; and Dar-es-Salaam, Tanzania;
the Aga Khan University Faculty of Health Science in Karachi, Pakistan; the Somboon
Vacharotai Foundation and the ASEAN Institute for Health Development in Thailand
Cover Photo: A community health nurse of the Aga Khan Community Health
Programme in Dhaka measures the blood pressure of a healthy pregnant mother
during a prenatal home visit
Photo by Jean-Luc Ray for AKF
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Basic PHC service quality assessment
If you would like to conduct an assessment quickly, follow these guidelines. If you are using
a computer, load this file (M0D6 QS) into Lotus 1-2-3 or Quattro Pro after you have
collected your data. It will help you analyse it quickly. The Quick Start option assumes that
you want to examine one of the PHC services listed below, and that you will use the checklists
in Appendix A (short) or B (long).
Instructions:
1. Select a PHC service to assess.
Family planning
Overall PHC
Breast feeding
assessment
Health education
GM/Nut ed
Immunization
Antenatal care
Safe delivery
ARI
DDC/ORT
Postnatal care
Water & sanitation
Child disabilities
Accidents & injuries
STD/HIV/A1DS
Malaria
Tuberculosis
2. Go to Appendix A or B and select the checklist for that service. Revise it as you wish.
Select a maximum of 15 variables.
3. Determine, and list, the number of health centres, facilities, or individuals that will be
observed:
4. Determine the number of observations that you will make of each centre, facility,
individual:
5. Select your observers and let them test the checklists with 2-3 similar centres/facilities/individuals.
6. Schedule the observations.
7. Photocopy or duplicate the number of checklists needed.
8. Conduct the observations.
9. Tabulate the resulting data on a blank checklist; enter the total number of "yes" and "no"
observations.
10. Enter those data in the following table. If you use the computer program, It will
automatically compute percentage distributions for you and make a graph.
11. Identify problem areas and discuss with your staff and others to see if you can identify
causes of the problem - as well as possible solutions.
12. Develop a plan of action to deal with the most important problems.
Number of observationsi = 25
Question/Variable No.
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Malnutrition in a land of plenty is not rare. A balanced
diet is essential to good health
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Minor ailments
Chronic, non-com
municable diseases
Hypertension
Diabetes
Anaemia
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Variables
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Acknowledgements
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The prototype of this module was first presented to participants at a PHC MAP
workshop in Dhaka in May, 1990. Their feedback and suggestions were invaluable.
Special thanks go to the staff of the Aga Khan Community Health Programme for
their help in field testing draft materials.
The first draft of this module was reviewed and tested in 1991 by a number of
PHC specialists and field managers. The module was also reviewed and critiqued
by the Project’s Technical Advisory Committee at a PHC MAP meeting in Bangkok
in September 1991. The module was completely restructured and tested again.
Feedback from those tests led to two more revisions. The module was reviewed
again by participants at the International Conference on Management and Sus
tainability of PHC Programmes, held in Bangkok in May 1992. Minor changes
resulted in this final version. Special thanks are due to Jack Reynolds for his help
in conceptualising the module, preparing the Quick start and developing the analysis
procedures; to Paul Richardson, who participated in several field tests and summa
rized the field test results, and Mary Millar, who developed the facilitators guide for
the module, which was very helpful in preparing this revised draft. All of these
contributions were invaluable and greatly appreciated.
Reviewers:
Donald Belcher • Veterans Administration, Seattle, WA, USA
Gilbert M. Bernham • Johns Hopkins School of Public Health, Baltimore, MD, USA
David H. Peters • Johns Hopkins School of Public Health, Baltimore, MD, USA
Paul Zeitz • Johns Hopkins School of Public Health, Baltimore, MD, USA
Micheal Bernhart • University of Puget Sound, WA, USA
Field tests:
Countries
Bangladesh
Pakistan
Thailand
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Module 6: Service quality
Colombia
Guatemala
Senegal
Zaire
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Mombasa PHC Project; Kisumu PHC Project Facilitators:
Paul Richardson, URC; Esther Sempebwa, Mombasa Pl IC
Project; Matthew Onduru, Kisumu Pl IC Project
Fundacion Santa Fe de Bogota; Facilitator: Jorge E. Medina
Institute de Nutricion de Centro America y Panama
(INCAP); Facilitator: Jorge Hermida
Ministry of Health; Facilitator: Mounir Toure
Ministry of Health; Facilitator: Kipasa Mungala
Review and/or development of PHC checklists:
• Aga Khan University, Pakistan: Khatidja Husein, Aamir Sidiqui, Ghazala Parveen
• Thailand: Jumroon Mikhanorn, SVF; Yawarat Porapakkham, AIHD; Chaweewon
Boonshuyar, AIHD; Narawat Suwannapong, AIHD; Som-Arch Wongkhomthong,
AIHD; Orapin Singhadej, AIHD; Peerasit Kamnuansilpa, HPRC; Butsabar Subongkot, HPRC
• PRICOR Staff: Lynne Miller-Franco, David Nicholas, Linda Ashburne, Neeraj Kak,
Maria Francisco, Martine Hilton, Kim Ashburn.
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The following clinicians and specialists provided technical inputs to the PHC
checklists in their area of expertise:
* STDs, HIV, AIDS: Gilbert M. Bernham, Department of International Health,
Johns Hopkins School of Public Health; William Brady, Division of STD/H1V
Prevention, Centers for Disease Control (CDC); Maryanne Neill, Training and
Materials Development Specialist, CDC.
• Childhood disabilities: David Marsh, Salma Alam, Ghazala Parveen, Shafiq-urRab, Mohammad Zahid, Aga Khan University, Pakistan; Pasquale Accardo, Chair,
Section on Children with Disabilities, American Academy of Pediatrics
• Chronic, non-communicable diseases: Marilyn Hartsell, Education Specialist,
National Heart, Lung and Blood Institute, Bethesda, MD, USA
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Participating organisations, field test facilitators
Aga Khan Community Health Programme; Concerned
Women for Family Planning; The Asia Foundation; Facilita
tor: Barkat-e-Khuda, URC/Bangladesh, Dhaka, Bangladesh
Aga Khan University (AKU), Karachi, Pakistan; Facilitator:
Khatidja Husein
Ministry of Public Health, Srisaket; Health and Population
Research Corporation (HPRC); Somboon Vacharotai Foun
dation (SVF); ASEAN Institute for Health Development
(A1HD); Facilitator: Narawat Suwannapong, AIHD, Bang
kok, Thailand
Junagadh PHC Project; Sidhpur Sustainable Health System
Project, Gujarat; Aga Khan Health Service India (AKHS, I);
Facilitators: Neeraj Kak, University Research Corporation
(URC), Bethesda, Maryland, USA; Vijay Moses, AKHS, I.
Kenya
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Module 6: Service quality
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The Primary Health Care Management Advancement
Programme has been funded by the Aga Khan Foundation
Canada, the Commission of the European Communities, the
Aga Khan Foundation U.S.A., the Aga Khan Foundations
head office in Geneva, the Rockefeller Foundation, the
Canadian International Development Agency, Alberta Aid,
and the United States Agency for International Develop
ment under two matching grants to AKF USA. The first of
these grants was "Strengthening the Management, Monitor
ing and Evaluation of PHC Programs in Selected Countries
of Asia and Africa" (cooperative agreement no. OTR-0158A-OCF8161-00, 1988-1991); and the second was "Strength
ening the Effectiveness, Management and Sustainability of
PHC/Mother and Child Survival Programs in Asia and
Africa" (cooperative agreement no. PCD-0158-A-00-110200, 1991-1994). The development of Modules 6 and 7 was
partially funded through in-kind contributions from the
Primary Health Care Operations Research project (PRICOR)
of the Center for Human Services under its cooperative
agreement with USAID (DSPE-6920-A-00-1048-00).
This support is gratefully acknowledged. The views and
opinions expressed in the PHC MAP materials are those of
the authors and do not necessarily reflect those of the
donors.
All PHC MAP material (written and computer files) is in
the public domain and may be freely copied and distributed
to others.
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Contents
QUICK START............................................................................................
1
INTRODUCTION
What is service quality assessment?..................................................... 3
How you can use this module.............................................................. 4
Checklists................................................................................................ 6
Some limitations..................................................................................... 13
SERVICE QUALITY ASSESSMENT PROCEDURES
Step 1: Specify the scope and the objectives.................................... 15
Step 2: Select the unit of observation and data collection
17
techniques..............................................................
Step 3: Select and adapt the appropriate service quality
21
checklists................................................................
Step 4: Develop the sampling procedures and select sample....... 23
Step 5: Carry out the assessment .................................................... 29
Step 6: Compile and analyse the data ............................................. 31
Step 7: Report the findings, provide feedback, and take corrective
34
action......................................................................
APPENDICES
A. Rapid service quality assessment checklists (short form) ......... 37
B. Rapid service quality assessment checklists (long form) ........... 61
C. Service quality assessment, discussion guidelines .................... 123
D. Multiple observation checklists.................................................... 147
E. Other PHC MAP tools ................................................................. 151
REFERENCES AND BIBLIOGRAPHY................................................ 157
ACRONYMS AND ABBREVIATIONS ................................................ 160
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Module 6: Service quality
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Managers can easily adapt these tools to fit local conditions. Both new and
experienced programmers can use them. Government and NGO managers, man
agement teams, and communities can all use the modules to gather information
that fits their needs. Each module explains how to collect, process and interpret
PHC-specific information that managers can use to improve planning and moni
toring. The modules include user’s guides, sample data collecting and data process
ing instruments, optional computer programs, and facilitator’s guides, for those who
want to hold training workshops.
The health and management services included in PHC MAP are listed below.
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Health and management services
HEALTH SERVICES
OTHER HEALTH CARE
Water supply, hygiene and
sanitation
School health
Childhood disabilities
Accidents and injuries
Sexually transmitted diseases
GENERAL
PHC household visits
Health education
MATERNAL CARE
Antenatal care
Safe delivery
Postnatal care
Family planning
HIV/AIDS
Malaria
CHILD CARE
• Breast feeding
• Growth monitoring
Nutrition education
Immunization
Acute respiratory infection
Diarrhoeal disease control
Oral rehydration therapy
MANAGEMENT
SERVICES
Planning
Personnel management
Training
Supervision
Financial management
Logistics management
Information management
Community organisation
Tuberculosis
Treatment of minor ailments
Chronic, non-communicable
diseases
Several manager’s guides supplement these modules. These are: Better manage
ment: 100 tips, a helpful hints book describing effective ways to help managers
improve what they do; Problem-soluing, a guide to help managers deal with
common problems; Computers, a guidebook providing useful hints on buying and
operating computers, printers, other hardware and software; and The computerised
PRICOR thesaurus, a compendium of PHC indicators.
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A midwife in Ulan Bator, Mongolia, calls at a "yurt" to see
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An overview of PHC MAP
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The main purpose of the Primary Health Care Management Ad
vancement Programme (PHC MAP) is to help PHC management
teams collect, process and analyse useful management information.
Initiated by the Aga Khan Foundation, PHC MAP is a collaborative programme
of the Aga Khan Health Network1 and PRICOR2. An experienced design team and
equally experienced PHC practitioner teams in several countries, including
Bangladesh, Chile, Colombia, the Dominican Republic, Guatemala, Haiti, India,
Indonesia, Kenya, Pakistan, Senegal, Thailand and Zaire, have worked together to
develop, test and refine the PHC MAP materials to make sure that they are
understandable, easy to use and helpful.
PHC MAP includes nine units called modules. These modules focus on essential
information that is needed in the traditional management cycle of planning-doingevaluating. The relationship between the modules and this cycle is illustrated below.
PHC MAP modules and the
planning-evaluation cycle..
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PHC MAP
MODULES
1. Information needs
2. Community needs
3. Work planning
4\ Surveillance
5. Monitoring indicators
6. Service quality
7. Management quality
8. Cost analysis
9. Sustainability
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1 The Aga Khan Health Network includes the Aga Khan Foundation, the Aga Khan Health Services,
and the Aga Khan University, al) of which are involved in the strengthening of primary health care
2 Primary Health Care Operations Research is a worldwide project of the Center for Human Services,
funded by the United States Agency for International Development
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Dedicated to
Dr. Duane L. Smith (1939-1992),
Dr. William B. Steeler (1948-1992)
and all other health leaders, managers and workers
who follow their example in the effort to bring quality health
care to all in need.
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A front-line health worker
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ISBN: 1-882839-04-8
Library of Congress Catalog Number: 92-75465
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Introduction
What is service quality assessment?
This module puts forth methods to assess the quality of
PHC services. This type of assessment is different from an
ordinary evaluation of programme performance. Evaluations
often focus on resources (supplies, personnel, equipment) or
inputs, and service delivery outputs (number of children
vaccinated, number of people treated). The tools and meth
ods in this module are designed to assess the process of
service delivery in order to assess the quality of the services
provided. Quality health care has been defined by Roemer
and Aguilar (WHO, 1988) as follows:
"Proper performance [according to standards] of interventions that are known to be safe,
that are affordable to the society in question and that have the ability to produce an impact
on mortality, morbidity, disability, and malnutrition."
Service quality assessment is the process of determining
whether PHC services are provided according to established
norms for quality care.
By using explicit process criteria, in the form of observa
tion checklists, the service quality assessment tools and
methods presented here can help managers determine
whether specified procedures are being carried out, how well
they are being carried out, and which tasks need improve
ment.
This module concentrates on the quality of PHC ser
vices. A companion module, Module 7, follows a similar pro-
Enjoying good health and a long life: three happy
musicians in a Beijing park
Photo by Jean-Luc Ray for AKF
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Module 6: Service quality; introduction
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How you can use this module
\bu can use service quality assessment to monitor and
strengthen the quality of care in your PHC programme. This
module is designed to help managers and supervisors assess
the quality of all or part of each PHC service by using simple
checklists. The module also includes instructions and work
sheets to aid in the planning and implementation of service
quality assessment. Guidelines analysis, interpretation, feed
back, and corrective action are also included.
Service quality checklists can be used in a variety of ways.
Examples include:
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guide decision-making during service delivery. Checklists
can be modified for use during service delivery or while
carrying out a management activity.
cess to examine management support services. Another
module (2: Assessing community health needs and coverage)
can be used to assess the effects and impacts of these
processes on the knowledge, behaviour, and health status of
the target population.
• A framework for supervision. Supervisors can use
these checklists during regular supervisory visits to identify
specific deficiencies in the quality of services, counselling,
Many uses and health education. Afterwards, the completed checklist
—— can serve as a discussion guide to give feedback to the service
provider on the strengths and weaknesses of the service.
Because of the way the checklists are structured, they also
make it easier to identify solutions to the most common
problems. For more complex problems, the checklists pro
vide the basis for a discussion of the causes of problems and
their solutions. Each checklist includes a space for comments
and actions taken so that supervisors can use the forms to
record supervisory activities.
• A self-assessment tool. Programme staff can use these
checklists to assess their own strengths and weaknesses. For
example, a service provider could use a checklist to assess a
given service and to identify areas for improvement. Based
on the results, the service provider might revise technical
norms, ask a supervisor to provide technical support, or
request additional training.
• A job aid for service providers. A job aid is a set of
written or pictorial instructions that prompt action and
Module 6: Service quality; introduction
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• An instrument for area-wide assessment of service
quality. Supervisors or other observers can use these
checklists to conduct a study of service quality in an admin
istrative area, such as a district or province. The results would
identify system-wide strengths and problems that need to
be addressed. Although these results would usually be of
most interest to local managers, such studies could be carried
out at regional and national levels as well.
• As guidelines for training. Service quality checklists
can serve as a framework for training. The checklists make
a convenient reference for trainers because they organise
and summarise the essential knowledge and skills that must
be addressed during training.
Tools for pre-test and post-test assessments of
service enhancing efforts. Service quality checklists
can be used to measure changes in service quality that
result from training efforts, improved supervision, or other
management improvements. If action is taken to correct
problems discovered during an initial assessment, a second
assessment can be done to determine the effectiveness of
the actions taken.
A combination of the above methods. For exam
ple, supervisors could use checklists during regular super
vision, and, at periodic intervals, compile the observations
into a data set to assess area-wide service quality. Or,
supervisors could distribute checklists to health workers
as a self-assessment tool to reinforce points made during
their visits.
Aids and
tools
The frequency with which supervisors use the checklists
can vary widely, depending on the time and resources
available. They can be used routinely or on an ad hoc basis.
Problems identified during community assessments (see
Module 2), activity monitoring (Module 5), personnel perfor-
Module 6: Service quality; introduction
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mance assessments (Module 3), or cost analysis (Module 8),
can be explored in more detail using quality assessment
checklists so that appropriate action may be taken.
Client
satisfac
tion also
Checklists
The service quality checklists provided in this module are
designed to record the observation of service delivery en
counters between providers and clients. The checklists are
made up largely of lists of tasks that providers are expected
to carry out in clinical assessment, treatment, and health
education. The checklists also include a few key questions
to ask providers and clients to check their knowledge of
important bits of information. The items that make up each
checklist for some services are based on more detailed lists
taken from the PRICOR thesaurus. For services not covered
in the thesaurus, checklists were developed based on the
format of the thesaurus. They represent key tasks that
should be carried out in providing quality care. The thesaurus
was developed and tested over a three-year period in con
sultation -with experts in PHC service delivery and are
consistent with WHO norms. Checklists have been devel
oped so far for 21 PHC services. They can be used individ
ually or in various combinations according to the needs of
the user, and they can be easily adapted to fit different
programme norms.
In addition to using service quality checklists to assess
the clinical performance of providers, it is useful to assess
provider performance from the patient or client perspective.
This module includes a client satisfaction questionnaire
which will allow managers to assess whether clients’ needs
and expectations are being met, and will enable managers
to identify opportunities to improve the quality of care as it
relates to patient satisfaction. Client satisfaction is important
because it enhances the likelihood of compliance with the
treatment regimen and follow-up visits. Also, it may be an
important determinant of whether or not patients seek
future care for themselves or their family members. Finally,
client satisfaction contributes to overall programme sus
tainability, having implications for utilisation as well as client
willingness to pay in cost-recovery efforts.
Module 6: Service quality; introduction
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This module includes short and long checklists for the
following:
GENERAL
PHC household visits
Health education
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MATERNAL CARE
Antenatal care
Safe delivery
Postnatal care
Family planning
CHILD CARE
Breast feeding
Growth monitoring
Nutrition education
Immunization
Acute respiratory infection
Diarrhoeal disease control
Oral rehydration therapy
OTHFR HEALTH CARE
V\^ter supply, hygiene and
sanitation
School health
Childhood disabilities
Accidents and injuries
Sexually transmitted diseases
H1V/A1DS
Malaria
Tuberculosis
Treatment of minor ailments
Chronic, non-communicable
diseases
CLIENT SATISFACTION
These service quality checklists are made up of "yes" and
"no" questions that can be answered by observation of the
interaction between health workers and their clients, inspec
tion of the health facility, supplies and equipment, review of
health records, and brief interviews with providers and/or
clients. The questions are phrased so that all "no" responses
indicate potential problems. These potential problem areas
should be evaluated further by the manager and the service
provider. The checklists can, in many instances, be used as
they are. But most managers will want to modify them to fit
their own needs and programme norms. Also, it will be
necessary to determine the requirements of each question
in operational terms. What conditions must be in place for
a "yes" response? What precisely is a "no"? Through discus
sion with staff and by referring to programme norms,
managers should be able to clarify these issues. In some cases
it may be desirable to create an instruction sheet which
explains the purpose of questions when it is not obvious,
and give guidelines about what constitutes a "yes" and "no"
response.
Module 6: Service quality; introduction
e.
Four types of quality assessment tools are included in the
module: short checklists for rapid service quality assessment;
longer checklists for more detailed assessment; multiple
observation checklists for assessing one or more units one
or more times; and discussion guidelines, which permit a
more qualitative assessment.
• When to use the short checklists. Checklists which
include only essential tasks for a PHC service have been
developed for rapid assessment of service quality. Each
includes 10-15 key items which can be easily observed during
service delivery or included in an interview. The short form
is recommended for the following uses:
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Short form
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*>This form may be used when the observer is an expert
who can make reliable implicit judgments about clinical
performance. For example, the rapid form for growth
monitoring asks, "Did the service provider correctly calcu
late the age?" An expert observer could make a judgment
about this, while a non-expert observer might prefer to use
the more detailed checklist, which lists all the components
of correct age calculation.
-*This form may be used when the observer has a great
deal of practice with the detailed checklist, and prefers to
use the short checklist simply as a memory aide.
-*This form may be used if the purpose of the assess
ment is to screen for problems which will be studied in
more detail at a later stage. Rather than providing the
precision of the detailed checklist, this tool gives a quick
overview of service quality so that priority areas can be
identified.
*>This form may also be used when there is a need for
rapid data analysis. Because of the small number of items,
documentation and data analysis are quicker, and results
can be summarised rapidly.
^Exhibit 1, a short rapid service quality checklist for
immunization, provides an example. Short checklists for all
21 services are included in Appendix A.
Module 6: Service quality, introduction
Exhibit 1: Rapid service quality assessment checklist Short form
IMMUNIZATION
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This checklist is intended for rapid assessment of service quality in the observation of ser v..e
delivery^To use the checklist, mark "yes" if the service provider carries out the task during
service delivery. For interviews, mark "yes" if the respondent answers correctly. If you w 'd
like to assess this service in more detail, please refer to the appropriate service quality checl t.
1 he checklist item numbers below correspond to that list.
1-------------- ------ Health facility
3-------------------- Observer/supervisor
4.
Date
Did the service provider:
13. YES
NO
14. YES
NO
17. YES
NO
19. YES
NO
Use a sterile needle for each injection?
Use a sterile syringe for each injection?
Give the child all vaccinations needed today?
Record the vaccination on the child’s health card?
Ask the service provider :
36. YES------------- NO------------ Was the registered temperature between 0 and 8 degree
(C) at all times during the last month?
(For outreach sessions):
41. YES
NO
Were vaccines transported in cold boxes with ice packs?
Ask mother
43. YES
NO.
When should you return for the next immunization?
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Module 6: Service quality introduction
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• When to use the long checklists. More detailed ser
vice quality checklists, which include about 50 tasks each,
have also been developed. These detailed checklists are
recommended for the following uses:
*>When the observers are not familiar with the techni
cal norms being applied it is advisable to use the detailed
checklists. Because the checklists include only explicit
observable criteria, the resulting information will have a
high level of reliability.
-*The detailed checklists may be preferred for peer
review because the service provider being evaluated may
feel more comfortable being judged by explicit, objective
criteria. This is less important if the observer has expert
status, because expert judgments are often more easily
accepted.
Long form
*>These detailed checklists may be preferred for pre-test
and post-test assessments during training, for self-assess
ment and job aids, or for in-depth supervision. In all these
situations, specificity is preferred because it leads to spe
cific, focused action for improvement.
^Detailed checklists could also be used to follow up on
problems identified by the rapid assessment tools, or other
problem identification methods. For example, if a rapid
assessment revealed that health workers were not per
forming a complete physical exam, further study might be
needed to determine which tasks were being performed
and which ones were omitted. The detailed checklist, or
the relevant portion of it, could be used for this purpose.
*>Some managers may prefer to start with a detailed
checklist initially, since it would make it unnecessary to do
two assessments. This is especially important if supervi
sion or assessment takes place over large distances or time
intervals.
Exhibit 2, a long checklist for growth monitoring,
illustrates this second type of checklist. Detailed service
quality checklists for all 21 services are included in Appendix
B.
Module 6: Service quality; introduction
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Exhibit 2: Rapid service quality assessment checklist - Long form
GROWTH MONITORING
t
This checklist is intended for use in the observation of service delivery. Before using it, the
national treatment protocol should be reviewed in order to adapt the tool to the local situation
if necessary. It is also recommended that you review the checklist carefully before using it to
be sure that you understand the questions and know how to use the form. For observation of
service delivery, mark "yes" if the service provider carries out these activities during service
delivery. For interview questions, mark "yes" if the respondent answers correctly.
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1 1
Health facility
2. Service provider
3. Observer/su per visor
4. Date
Age calculation
Did the service provider:
5. YES
NO_
6. YES
NO
7. YES
NO
Base calculation on a reliable date of birth?1
Correctly calculate date of birth?2
Correctly record age?
Weighing
Did the service provider:
8. YES
NO
9- YES
NO
10. YES
NO
11. YES
NO
12. YES
NO
Set scale to 0?
Remove child's clothing?
Place child correctly on scale?
Correctly read scale?3
Correctly record weight?
Locating the child's growth on chart
Did the service provider:
13. YES
NO
Plot or locate the child’s age at correct age?
14. YES
NO
Plot or locate the child's weight at correct weight?
15. YES
NO
Connect to previous growth point?
Referral and follow-up
16. YES
NO
17. YES
NO
Refer sick/malnourished child for medical attention?
Refer malnourished child for nutritional
rehabilitation?
Growth monitoring and nutritional education
Did the service provider do the following for all children weighed:
18. YES------------- NO
lell mother whether child has gained, lost, stayed the same
since last weighing?
19. YES.
NO.
Tell mother the nutritiona
1 Reliable sources for date of birth: growth chart health record or birth certificate. Rely on
mother’s memory only when these are not available.
2 The accuracy of age calculation and weight reading should be determined by comparing
the health worker’s reading with the supervisor’s reading.
3 Reliable sources for date of birth: growth chart health record or birth certificate. Rely on
mother’s memory only when these are not available.
Module 6: Service quality; introduction
12
20. YES.
Use growth card to explain
to mother
child is
• When
tohow
useherdiscussion
guidelines.
NO.
Some service
quality issues are difficult to understand fully with a yes/no
Did the service provider do the following for malnourished children and for children who
question. Discussion is a good way to open a dialogue with
have not gained weight since the last session:
service providers and engage them in the quality improve
21. YES
NO
Ask if the child has had any health problems since last
ment process. Discussion guidelines complement the check
weighing?
lists by helping managers to explore the complexity and
Make recommendations regarding child feeding and care?
NO
22. YES.
diversity
of service quality issues and to study the problems
Explain importance of good breast feeding and weaning
NO.
23. YES.
in
more
depth.
practices?
Explain which locally availableExhibit
foods constitute
balanced of a discussion guideline for acute
NO.
24. YES.
3 is an aexample
diet for children?
respiratory infection. Discussion guidelines for all 21 services
Explain how to feed children during illness?
NO
25. YES.
are included in Appendix C.
Tell mother when to take child for next weighing?
NO.
26. YES.
Verify that mother understands key messages? • Multiple observation checklists. Checklists for mul
NO.
27. YES.
Ask mother if she has any questions?
NO.
28. YES.
tiple observations have been developed for selected PHC
services. This form is designed to record up to ten observa
For outreach education session, did the service provider:
tions for each task or health worker. It also includes space
29. YES
NO
Explain the importance of gaining weight for health?
for comments and actions taken. This checklist can be used,
30. YES
NO
Explain the purpose of growth monitoring?
31. YES
NO
Explain when and where to go for growth monitoring ser
for example, to record ten observations of the-same worker
vices?
or 2-3 observations of several workers at one facility. It can Discussion
Use appropriate health education techniques and materials?
NO
32. YES
guides
be used to follow a worker over time, recording 2-3 obser
Demonstrate preparation of weaning foods ?
NO
33. YES.
vations during an initial visit, and 2-3 more during follow-up
Verify that attendees understand key messages?
NO
34. YES.
Use visual aids in transmitting key messages?
NO.
35. YES.
visits. With minor modifications these checklists can be used
to observe group sessions. For example, the form could be
Supplies
enlarged
(or several copies made) to observe all of the
Ask the service provider about the following supplies:
children immunized or weighed in a clinic session. Exhibit 4
36. YES
NO
Working scale
37. YES
NO
Growth charts
is an abbreviated example of a multiple observation checklist
for a general PI 1C visit. Multiple observation checklists for
Exit interview with mother
five of the 21 services are included in Appendix D.
Mark "yes" if the respondent answers correctly:
growing?
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38. YES
39. YES
NO
NO
40. YES.
NO.
How much does your child weigh?
Some limitations
Did your child gain weight, lose, or stay the same since the
last weighing?
Service quality checklists aid supervisors by making the
When will you return for growth monitoring?
assessment more specific and objective. However, proper use
of the checklists requires sound technical judgement and
such supervisory skills as problem-solving and giving con
structive feedback. Programme managers may find it advis
able, in some cases, to combine the introduction of quality
assessment activities with additional training for supervisors.
Such training might include a refresher course on tech
nical service norms and basic supervisory skills. Some of the
potential uses of the checklists imply a participatory team
The exhibit continues with five more questions on interviewing the service provider
Module 6: Service quality; introduction
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Module 6: Service quality; introduction
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approach to service quality improvement. If such ap
proaches are to be used, managers, supervisors and health
workers will need to complement their technical and man
agerial skills with team-building and group facilitation skills.
E?
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ezs,.
2.
3.
4.
exhibit 3: Service quality assessment discussion guidelines
ACUTE RESPIRATORY INFECTION
0
5
ntroduction: Welcome the group and briefly give the purpose of the discussion.
Ground rules : Explain the following ground rules to the group:
5.
6.
Ground rules for group discussion
M
Everyone’s ideas and opinions are important.
'rhere are no right or wrong answers.
Joth positive and negative comments are welcome.
Participants should feel free to disagree with one another so that all points of view are heard.
Don’t wait to be called on; it s a group discussion.
j^lease speak one at a time.
11
These discussion guidelines are provided to help you to lead a group discussion about the
Quality of your services for Acute respiratory infection. You may also refer to the detailed
ersion of the PHC service quality checklist (Appendix B) as a resource for the discussion.
Hscussion :
• What works well in the way we provide ARI services?
Guidelines :
What does not work well in the way we provide ARI services?
What standards, guidelines or protocols are used for providing ARI services?
• To whom would you go if you had questions about a standard or how to perform an activity?
• What information do you ask from your clients about their medical history?
What activities do you carry out during a physical exam?
What treatments do you prescribe for what types of ARI?
- For what reasons would you refer a client to another service provider?
• What messages do you emphasise when educating or counselling your clients?
ey questions
Are at least two medical history questions asked?
Did the service provider ask about any treatment administered?
• Is the respiratory rate counted?
Is the child classified by severity of illness?
Are antibiotics for pneumonia, strep throat or otitis given?
D’ ’ !he service provider refrain from using antibiotics for colds?
told about at least three signs of pneumonia?*
■ If antibiotics are prescribed, is the client asked, "How will you administer the medicine, how
much, how often, for how long?"
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1 Signs include stridor, chest indrawing/rapid breathing, inability to drink, cyanosis, anxiety,
and weakness or lethargy
Module 6: Service quality; introduction
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9 Exhibit
Rapid quality assessment checklist
PHC household visit (abbreviated)
^1.
Health facility
Observer
2.
.
Observer/supervisor
Date
3.
Instructions: Mark "yes" (Y) if the service provider carries out these activities during observation.
For interview questions, mark "yes" (Y) if the client responds correctly
Observation number
Registration and documentation_______________________
1
—r-
5.
Are all children under 5 registered on the family health card?
6.
Are all women over 16 registered on the family health card?
MCH
11.
Vaccinate or arrange for vaccination of children who need to be immunized?
18.
If there are any malnourished children in the house did the health worker check
to be sure that nutritional counselling, food supplementation and/or medical
attention are being received as indicated?__________________________
20.
If yes, recommend ORT and help the mother to prepare and administer it?
31.
Refer interested women or couples for family planning services?
Water & sanitation____________ ___ ________________________________
I
35.
Ask about access to water and provide information on community efforts to
address problems (if necessary)?
_____________________________
36.
Ask about water storage practices and give appropriate advice?
37.
Ask about latrine maintenance and use and give appropriate advice?
38.
Ask about refuse and excreta disposal and give appropriate advice?
3 General_________________________ ________________________
41.
Verify that the client(s) understands key information from today’s visit?
42.
Establish a good rapport with the mother?
1
2
3
4
5
6
7
8
9
10
TOT
Problems identified
Actions taken
15
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Service quality assessment procedures
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This section describes the process of designing and car
rying out quality assessment activities. The process, consist
ing of seven steps, can be followed by managers and supervisors at all levels.
Step 1: Specify the scope and objectives
Step 2: Select the unit of observation and data collection techniques
Step 3: Select and adapt the appropriate service quality checklist(s)
Step 4: Develop the sampling procedures and select sample (optional)
Step 5: Carry out the assessment
Step 6: Compile and analyse the data
Step 7: Report the findings, provide feedback, and take corrective action
A worksheet for developing quality assessment proce
dures has been developed and appears in its complete form
in Appendix D. Portions of the worksheet are included in
the steps described below.
Step 1: Specify the scope and objectives
The usual objective of quality assessment is to identify
strengths and weaknesses in service delivery and to make
subsequent corrections in order to improve overall service
quality. The first step in developing quality assessment
procedures, therefore, is for the manager or management
team to define specific objectives and the scope of the assess-
Module 6: Service quality; procedures
16
ment This is important because they have implications for
design, analysis, and documentation. The following ques
tions may help you define what you want to assess and why.
• What is the purpose of the assessment? The purpose
of the assessment may be to monitor individual perfor
mance, to assess service quality in a group of health centres
within a district, or to establish a baseline in order to monitor
improvement over time. The purpose will have important
implications for the design of the assessment.
• What services will be included? As noted previously,
the assessment can be of one or more PHC services (im
munization, antenatal care, etc.). It can also focus on a
specific set of service tasks, e.g., weighing sessions, ANC
counselling. Managers may want to do a quick assessment
of priority PHC services and then follow up with a more
detailed assessment of those that are the most problematic.
• Who will use the information gathered? The infor
mation resulting from a quality assessment can be used by
local managers, the board of directors, regional or national
directors, and/or donors. It can also be used by health
. workers themselves and the communities. Who will use the
information will affect decisions about what information to
collect, how much to collect, and how to report it.
• How will the information be used? The information
can be used in a variety of ways. For example, it might be
used to identify problems so that plans can be made for
training, supervision, or technical assistance. The specific use
.of the information will have implications for what is collected
and how it is analysed.
• What geographic area will be covered? Quality
assessment can be carried out at any level, from a single
health centre to a province, state, or nation. Some managers
may want to pick a pilot area to start out and expand to
other areas.
• Over what period of time will the assessment take
place? When will the information be needed? That will
help answer this scheduling question. How often will the
assessment be done: once, twice, on a regular basis? Short,
rapid assessments may be appropriate if time is short.
Module 6: Service quality; procedures
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Also, some assessments may be carried out on an ongoing
basis, while others may be done once or on an ad hoc basis.
What additional resources, if any, are available?
Ideally, quality assessment should be carried out with re
sources that have been allocated to management and super
vision. However, if a special QA study is planned, it might
involve additional costs for transportation, per diem, and
supplies. In designing studies, managers should assess
whether additional resources are available and keep in mind
the importance of financial feasibility and sustainability.
Part 1 of the worksheet for planning quality assessment
procedures is presented below. A manager could use this
worksheet to specify the scope and objectives of the assess
ment.
WORKSHEET FOR PLANNING QUALITY ASSESSMENT ACTIVITIES
Step 1: Specify the scope and objectives
€»
A. What is the purpose of the assessment? Assess service, quality
B. What services will be included? Health eddmm. ORT. GM)
C. Who will use the information gathered? PHC management team
D. How will the information be used? Identify quality needs
E. What geographic area will be covered? All 4 facilities
F. Over what period of time will the assessment take place? 1 month
G. What additional resources, if any, are available?
Lijt
Step 2: Select the unit of observation and data
collection techniques
The next step in planning the assessment is to determine
the unit of observation and data collection techniques.
• Unit of observation. Quality can be assessed by fol
lowing clients through the system, by observing health
workers provide services to different clients, and by observ
ing a specific procedure multiple times. In addition, the
quality of an entire clinic session or health centre can be
assessed.
€* 9 Module 6: Service quality; procedures
18
19
Client/patient. If the client is the unit of observation,
managers should design data collection instruments so
that they can follow clients through the service delivery
process. This may be appropriate in cases where different
providers carry out different parts of the same service. For
example, if one provider gives injections while another
health worker documents the case and provides health
education, it would be important to describe the main steps
in the process, often called "patient flow," so that each can
be individually assessed.
Which
unit of
observa
tion?
I
Health worker. If individual health workers are the
units of observation, their routines to be observed. In such
. a case, the instruments should be designed to follow
individual health workers rather than clients. For example,
a supervisor might accompany a Community Health
Worker (CHW) on several home visits to observe how he
or she carries out his or her tasks.
Service elements. If the unit of observation is a
service, or specific tasks, then multiple observations of that
service or those tasks need to be made. This can be done
in many ways. For example, an observer can watch the
well-child clinic registration routine for several clients to
determine what tasks are normally performed and how
well they are done.
Clinic session. A variation of this is observation of
an entire clinic session, which will require assessments of
each of the major components of a typical session. A
well-child clinic might include registration, health educa
tion, physical examinations, immunizations, growth mon
itoring, and so forth. Observations could be done by
following a number of clients through the clinic session or
by observing each station in the clinic.
Health centre. The health centre may also be the
unit of observation. This is particularly appropriate if the
objective is to conduct an overall assessment of health
centre operations, or if there are health centre-specific
Module 6: Service quality; procedures
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issues of concern, such as the adequacy of supplies. It might
also be appropriate if the manager has reason to
believe that variations in service quality relate to
differences among health centres rather than differ
ences among individual workers.
• Data collection techniques. Service quality data can
be collected from direct observations, interviews, or a review
of medical records. A brief explanation of each type of data
source follows.
Direct observation by supervisor or peer. Observing
service providers during service delivery directly assesses
how Well they apply their knowledge, and how well the
patient responds to clinical treatment and counselling. It
permits a supervisor, manager, or peer observer to help
the health worker to evaluate service quality, identify
problems, and measure improvement in performance. If
actual service delivery cannot be observed, health workers
can be asked to do a role play of a client encounter. While
Data
observation is a good way to determine whether service collection
providers can do their assigned tasks, the observer has to
be unobtrusive so as not to interfere with or distract the
health worker and client. There is also a possibility that
people will behave differently when being observed. This
can usually be overcome with multiple observations. After
awhile, people tend to ignore the observer and behave
normally.
Self-assessment. Service providers can use the
checklist to assess their own performance by reviewing or
filling out the checklist after a service delivery encounter.
This type of information can support self-improvement
efforts and can be used effectively when a system of
participatory and supportive management is in place.
However, if the self-assessments are to be turned in for
review by superiors, the results may be biased, especially
i
if the health workers are
afraid that the assessments may
be used against them.
I
Module 6: Service quality; procedures
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Structured interviews. The checklists can also be
used as a guide for interviews with providers by asking
whether or not they carry out each activity on the checklist.
Since most of the items are designed to code "no" responses
as problems, the questions should be phrased so that they
are not "leading" questions. For example, the supervisors
could ask, "How do you assess a child with diarrhoea?" The
supervisor would check off all items mentioned by the
service provider. The supervisor would subsequently then
ask about those items not mentioned and record the an
swers.
Record review. Service quality assessments can also
be based on review of records, especially health records.
While a record review has limited value for assessing the
service delivery process, such important information as
whether a treatment was given or whether a required
laboratory test was done can often be collected from
records. If health records in a given health centre are not
adequate, the checklists could serve as a guide for deciding
what information should be collected during the observa
tion period. For example, health workers might be asked
to fill out a form covering a 2-3 week period about each
ARI case contacted. The data generated could be used as
part of a service quality assessment. The worksheet for
Step 2 can be used to help determine the unit of observa
tion and data sources.
Open-ended interviews and discussions. The
checklists can also be used more informally to identify topics
for individual or group discussion. For example, a supervisor
who discovers a persistent problem with accurate recording
of childrens weights in growth monitoring might use the
checklist as a reference guide in a participatory problem
solving session.
if$
WORKSHEET FOR PLANNING QUALITY ASSESSMENT ACTIVITIES
Step 2: Select unit of observation and data
sources
Data sources:
Unit of observation:
Client/patient.
Service elements
X Health worker
Clinic session
Health centre
X Direct observation
X by supervisor
by peer
self-assessment
Interview
structured interviews
open-ended interviews
discussion
Record review
routine records
records kept especially for the as
sessment
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Module 6: Service quality; procedures
Step 3: Select and adapt the appropriate
service quality checklist(s)
Managers may select the long or short version of the
appropriate service quality checklist. While the checklists may
be used as they are in some cases, the checklists will usually
require some adaptation to each programme. Field tests have
shown that it should take no more than 2-3 hours to revise
the checklists. Adaptation can include omitting items that are
not relevant, revising, rearranging and rephrasing items to fit
local conditions, and adding items that are important to your
programme. In certain cases you may wish to combine items
or sections from several checklists to form a new one. The
format and layout may also be modified, of course.
Several managers have found it useful to make these
changes in a group session involving the users who are usually
supervisors and administrative staff. Group work helps to
ensure that the key users become familiar with the instruments
and the procedures and to develop a sense of "ownership" of
the quality assessment. It is also quicker. When an instrument
is prepared by one person it is often circulated for comment,
revised, recirculated, etc. A form has been developed for
managers who want to make up their own checklists. Exhibit
5 on the following page shows how the form might be used.
A blank form is included in Appendix E.
Module 6: Service quality; procedures
Long or
short
checklist
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Consumer satisfaction is one aspect of quality of service.
In Mombasa, Kenya, reliable data is obtained when the
respondent pays full attention and the questionnaire is
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Step 4: Develop the sampling procedures and
select sample (optional)
This step is only necessary if the objective is to conduct
a study or evaluation of quality in an administrative area,
such as a district or province.
The purpose of sampling is to make an objective assess
ment of a large group without having to assess every
member of that group. For example, if there are only ten
health centres it might be best to do an assessment of each
one. But if there are 100 and the manager wants to have an
idea of the overall quality of the group, then a sample would
be appropriate. It would also require much less time and
effort to gather the needed information.
Detailed instructions for drawing random and cluster
samples can be found in Module 2: Assessing community ——
Sampling
needs. The Appendices of Module 2 include instructions for Samplin'
optional
determining sample sizes and computer programs that man* •
agers can use to calculate sample sizes, generate random
samples, and select clusters. An excellent discussion of the
technical issues surrounding sampling techniques can be
found in an article by Lemeshow and Stroh.1
• When is sampling unnecessary? When checklists
are used to structure the performance evaluation of individ
ual workers, sampling is not necessary. The purpose of such
an evaluation should be to identify strengths and weaknesses
and to support the service provider so that performance can
be improved. For example, supervisors could use the check
lists with each health worker, each health centre, and/or at
selected PHC sessions in order to conduct quick assessments
of the quality of each one. The results could be analysed
immediately and discussed with the local staff or managers,
and recommendations for immediate action could be made
on the basis of these discussions. It would not be necessary
to select a sample of workers, health centres, or sessions in
this case.
1 Lemeshow, S. and Stroh, G. Sampling techniques for evaluating health
parameters in developing countries, Washington, DC, National Academy
Press, 1988.
Module 6: Service quality; procedures
The following discussion summarises procedures that
might be appropriate for drawing a sample for quality
assessment, when sampling is required.
• Developing the sampling frame. The sampling frame
is the complete list of all the potential units of study. This
could be a list of health centres, health workers PHC
sessions, or scheduled PHC services. For example,’ if the
objec we is to assess the quality of services provided by
CHWs, then a list of all of the CHWs would be needed. If
the objective is to assess the quality of immunization ser
vices, then a list of scheduled immunization sessions would
be required In most cases managers will have such lists
readily available. However, they should be reviewed to be
sure that they are complete and up-to-date.
In some cases, such as where services will be provided by
different individuals in different locations, lists of each will
be needed For example, prenatal care could involve CHWs
who identify pregnant women, provide prenatal education
and make referrals; TBAs who do initial examinations, home
deliveries, and make referrals; and nurse-midwives at health
centres who see referred cases and make deliveries. A
sampling frame would be made up of a list of all CHWs
TBAs and nurse-midwives.
• Determining sample size. When choosing the sample
size, managers should consider how much precision is re
quired as well as the resources and time available. Larger
------------------3re m°re hkely to be statistical|y valid and generalisSample size
than smaller ones. But if the manager would be satisfied
------------------- with a rough estimate, then a small sample may be adequate.
ror the purpose of service quality assessment, these
issues are only important when the number of units is very
large (say 100 CHWs) and high levels of precision are needed,
ror example, if a baseline study of a service is to be carried
out, and a manager would like to be able to detect small
changes in performance during a follow-up assessment the
precision of the sampling would be very important.
Most managers will be satisfied with rough estimates. A
suggested rule of thumb is: if the number of units is very
Module 6: Service quality; procedures
large (say 500-1,000), take a ten percent sample; if it is of
m |iXSirn^00;5°0)’ take a 15~20 Percent samPle; it is
sma (50- 100), take a 20-30 percent sample; and if it is very
small (less than 50), take a 30-50 percent sample.
• Sampling procedures. The most important principle of
sampling is that the units selected for observation be repre
sentative of all of the units. For example, if there are 20
health centres and ten are going to be selected for the
assessment those ten should not be the best or worst of the
20. I hey should include the same proportion of good and
poor centres as exists overall so that they represent the
entire group.
There are four main sampling procedures that are appro
priate for quality assessment.
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-^Random sample. A simple random sample can be
diawn by first assigning a number to each unit included in Sampling
the sampling frame. Second, the units should be selected
choices
randomly until you reach the required sample size. For '
example, if the sampling frame includes 200 TBAs, each
BA would be assigned a number from one to 200. If the
samp e size chosen is 20, 20 numbers from one to 200
won d be chosen randomly, and the corresponding TBAs
wou d constitute the sample. The random selection could
be done by pulling numbers from a hat, consulting a
random number table, or by using a computerised random
number generator.
A stratified random sample may be more appropriate
i there are significant differences in the units to be
observed; for example, if there are rural and urban health
centres, if the health workers are made up of TBAs
auxiliary midwives, and CHWs, or if the immunization
sessions are held in different sites (hospitals, health centres
schools) In this case the group should be divided into
these categories and the samples should be drawn ran
domly from each subgroup. The number drawn from each
subgroup should be in proportion to its size. For example
if 20 percent of the health workers are TBAs then 20
percent of the sample should be TBAs.
Module 6: Service quality; procedures
■eer--
27
j
-^Systematic sample. A systematic sample of size (n)
may be drawn from the sampling frame by choosing a
random starting point and selecting a unit at regular
intervals (k). To determine (k), divide the total number of
units on the list by the desired sample size (n). For
example, if a programme has 100 service providers and the
manager decides to select a sample of 33 then the manager
would make a complete list of the 100 health workers,
choose a random starting point, and then select every third
health worker (100/33=3) until 33 have been selected.
LQAS
a simple
method
~»Lot quality assurance sampling. Lot Quality As
surance Sampling (LQAS) is a type of random sampling
that uses very small samples, say six to 30 observations,
to determine whether the specific batch or "lot" of finished
products produced by a specific production unit meets a
specified threshold of quality. This method was developed
for industrial production but has recently been applied to
health services. The "production unit" in PHC may be an
individual health worker, a service delivery group, an
encounter, a session, or a health centre. Examples are: all
CHWs in a project area; all growth monitoring sessions
conducted in January; all health centres operating in the
city. Managers can use this technique to determine, for
example, whether children are being weighed properly.
LQAS does not tell a manager what proportion is weighed
properly, just whether the proportion weighed properly is
above or below a designated level.
The procedure requires the manager to specify a goal
that the "batch" is expected to achieve and a "minimal
acceptable" level of achievement. The manager must also
specify the level of precision needed and the time and
resources available for data collection.
With this information, the manager can use an LQAS
table to determine the required sample size. For example,
if the goal of a growth monitoring programme is to weigh
85% of children correctly with a minimum acceptable level
of 65%, the required sample size would be 29 random
obser-vations. The table shows that 23 of 29 observed
weighings would have to be done correctly to conclude
that the programme is meeting its goal.
Module 6: Service quality; procedures
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A table of sample sizes and acceptance thresholds is
included in Appendix E. This table is taken from a manual
on lot quality assessments by Wolff and Black, and is
recommended for managers who wish to use this method.1
It is important to note that LQAS results should never be
presented as a percentage because they would be very
imprecise. Instead, the method should be used only to
determine whether or not performance is meeting a given
standard.
^Convenience sampling. If a manager wants to
gather information quickly, minimise the amount of time
invested in data collection, and is not too concerned about
statistical precision, then a convenience sample may be an
attractive option. A convenience sample is made up of
units that are convenient to observe, usually because they
are close by or scheduled to occur at a convenient time.
To choose a convenience sample the manager selects a
Easily
Easily
time and site for the assessment and makes as many observable
units
observations as possible during the visit. For example, a
supervisor might decide to spend one day in each of three
nearby clinics to observe scheduled MCH sessions. The
health facilities, MCH sessions, and service providers are
not chosen randomly, and therefore the MCH sessions
observed may not be representative of all MCH sessions.
Nevertheless, many managers know their programmes
well enough to spot extreme discrepancies and to interpret
the results realistically.
Two common variations of convenience sampling are
purposive and quota sampling. The former involves
selecting each unit on purpose", i.e., not randomly or
systematically. For example, a manager may decide to
examine three of the best, three of the worst, and three
average health centres.
A quota sample involves deciding how many observa
tions will be made and then observing those that occur
1 Wolff, M. C., and Black, R. Manual for conducting lot quality assessments
in oral rehydration therapy clinics. Baltimore, MD. The Johns Hopkins
University School of Hygiene and Public Health, Institute for
International Programs, 1989.
Module 6: Service quality; procedures
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first until the "quota" of observations is met. For example,
a supervisor might decide to make ten observations, and
then observes the first ten women who come into an ANC
session.
None of the convenience sampling techniques produce
probability samples. This means that it is not possible to
determine the probability that the results obtained are
correct.
Following is a worksheet for planning the sampling
procedures.
ep
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WORKSHEET FOR PLANNING QUALITY ASSESSMENT ACTIVITIES
h
Step 4. Develop the sampling procedures and
select sample (optional)
€
Number of units in sampling frame:
4
Sample size(%) =
(N)
Sampling method:
Census (100 percent sample)
X
all 4 centres
Random sample
Systematic sample
LQAS sample
Convenience sample
Purposive sample
Quota sample
What is the minimum number of observations that should be made for each unit? 10
*1
WORKSHEET FOR PLANNING QUALITY ASSESSMENT ACTIVITIES
Step 5. Carry out the assessment
8/10
8/16
—8/14
8/16
8/12
Preparation for the visit
Select and train observers
Produce data collection forms
Conduct a pretest of the checklists
Select dates for the assessment
—8/2Q---- Arrange for transportation for data collection
Module 6: Service quality; procedures
I’
Step 5 : Carry out the assessment
The preceding worksheet for planning quality assessment
lists several important tasks that the manager or supervisor
should do in preparation for the assessment visit.
Appendix E of Module 2 includes some guidelines for
training and supervising field interviewers, which also apply
to field observers.
Data collection with service quality checklists.
Before the assessment, the manager and/or observers
should review the service quality checklists to be sure that
they are comfortable with the format, procedures, and con
tent. Most managers and supervisors may want to use the
checklists as a part of routine supervision, but some may
also want to use them periodically to do scheduled, formal
assessments. Some may want to make unannounced visits
so that staff do not make special preparations for the
Using
assessments.
checklists
It is usually a good idea to explain what the observer will
be doing and why, thus avoiding misunderstanding and
anxiety. Experience has shown that most workers want to
improve their performance and welcome help and advice
that is constructive. But they will also resist cooperating
when they suspect that the information will be used against
them. Ideally, quality assessment should be carried out in a
supportive, constructive manner to help staff improve the
way services are delivered.
Exhibit 6 shows a hypothetical example of a completed
checklist. Each item requires a response of "yes" (Y), "no" (N),
or "don’t know/didn’t observe/not applicable" (DK), and (NA,’
leave blank). The supervisor used the immunization quality
assessment checklist during a routine supervisory visit. It
shows that three health workers were observed at North
West Health Center as they gave vaccinations. KB was
observed three times, LD was observed three times, and SF
was observed four times. It also records the responses of
mothers, who were interviewed after the immunization, as
well as the response of service providers who were inter
viewed at the end of the day. The cold chain and supplies
were also inspected with the aid of the checklist.
Module 6: Service quality; procedures
30
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&
In
Based on these observations, the supervisor noted the
following problems: health workers were missing opportu
nities to identify women and children who need vaccina
tions, health education about side effects and what to do
about them was not adequate; but mothers did not know
what vaccine their children had received and when to come
back for the next shots. Also, the administration of the
vaccine was done very well.
The checklist also shows that the supervisor addressed
some problems immediately by pointing out errors and
reminding health workers of vaccination norms. He then
planned an in-service training session to review educational
messages and techniques that go along with immunization.
He also decided to check on the educational component of
ORT and growth monitoring because he suspected that the
problems identified were not limited to immunization.
Gathering information with discussion guide
lines. If group discussions are to be held, the manager should
give participants as much notice as possible and provide
them with a brief description of the purpose of the meeting
and the kind of information they will be asked to provide.
Tills will allow staff to prepare by thinking about the topic
beforehand and conferring among themselves. Also, this will
afford participants time to gather information to illustrate
their points of view, if they so desire. The ideal size for a
group discussion is 5-10 people.
Each group discussion should begin with a brief introduc
tion and explanation of the purpose of the discussion. Also,
the person who leads the discussion should explain the
ground rules to the group before the session. This is espe
cially important if the group members normally work to
gether. They should be reminded that this meeting has a
different purpose and structure. The ground rules on the
next page will help the group stay on course.
After the ground rules have been presented, the leader
can use the guidelines to lead the discussion on a given
s.. vice delivery topic. The leader of the group discussion
can refer to the key questions included in the guidelines if
there is a need to probe the issue in more detail.
Observation number:
3.
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Y
Y
EPI education (cont'd)
26.
Explain the importance of completing the vaccination .series?
27.
If DPT #3 has been administered stress the importance of returning for measles
vaccination.
28.
Explain that the child can be immunized even if she/he is ill?
N
Y
t
29.
Tell mother when to come back for next immunization for herself or one of her
children?
Y
Y
't
30.
Ask mother to encourage other women to be vaccinated and have their children
vaccinated?
N
N
b
31.
Ask mother to repeat key messages?
N
N
b
32.
Ask mother if she has any questions?
Y
Y
Maintenance of cold chain and supplies____________________________
Using
discussion
guides
Module 6: Service quality; procedures
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33.
Is the refrigerator working today?
Y
1
34.
Is there a thermometer or cold chain monitor in the refrigerator?
Y
1:
35.
Is there a temperature log?
Y
36.
Is temperature recorded regularly according to the local schedule?
Y
37.
Was the registered temperature betwen 0 and 8 degrees (C) at all times during
the last month?
Y
1
38.
Are all vials in storage unopened?
V
For outreach session
1
39.
Were vaccines transported in cold boxes with ice packs?
40.
Were vaccines sufficient?
41.
Were needles and syringes sufficient?
1
1
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1
1
1
Exit Interview with mother
42.
What immunization(s) did your child receive today?
Y
Y
Y
2
43.
When should you return to the health centre for your next immunization?
Y
Y
Y
2
Interview with service provider
At what age should a child receive the following vaccines:
KB
LD
SE
BCG
Y
Y
Y
Y
Y
0
E
e
2
44.
2
45.
DPT
Y
2
46.
Measles
Y
Y
Y
2
47.
OPV
Y
Y
Y
48.
Should you vaccinate a child if she/he is ill?
Y
Y
Y
il
_
1SEW-I
Exhibit 6: Example of a completed quality assessment checklist
Immunization
Northwest Centre
B. Sing
B. Sing
3.
Health Facility
Observer
Regular supervisor
4.
Observation number:
5.
Date:
6.
Service provider (initials):
1.
2.
Instructions: Mark "yes" if the service provider carries out these activities during service
delivery.
____________ _______________ _____________________
______________________________
1
2
3
4
5
6
7
8
9
10
TOT
8/28
8/28
8/28
8/28
8/28
8/28
8/28
8/28
8/28
8/28
YES
KB
KB
KB
LD
LD
LD
SF
SF
SF
SF
Problems identified
Actions taken
in-service training session to |
cover this topic
|
Identification of needed vaccinations________________________
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7.
Reviewheallh records to determine which immunizations are needed today?
N
N
N
N
N
N
N
N
N
N
0
missed opportunities to identify
needed immunization______
8.
Review mother’s health record or ask whether she has received Tetanus Toxoid
immunization?______ ___ ______________________________________
N
Y
N
N
Y
N
N
N
N
N
2
communication for women and
children
9.
Review vaccination status of other children in the family?
Y
Y
Y
N
Y
N
N
N
N
N
4
10.
Recommend vaccination even if the child is sick?_______________________
Preparation and care of vaccine_________________ ____________________
carried out well
11.
Check the label for the correct vaccine and be sure the vaccine has not expired?
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
10
12.
Load the syringe without contamination?
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
10
13.
Use a sterile needle for each injection?
_______
Y
Y
Y
N
Y
Y
Y
Y
Y
Y
9
in one case LD used
14.
Use a sterile syringe for each injection7_____________________________
Y
Y
Y
N
Y
Y
Y
Y
Y
Y
9
needle and syringe twice
Y
10
15.
Keep the vaccine on ice and covered during the session?
Y
Y
Y
Y
Y
Y
Y
Y
Y
reviewed sterilization
procedure with LD.
Vaccination techniques
16.
Apply the vaccine at the right level (BCG=dermal layer,measles=subcutaneous
layer, DTP/TT=muscle)?
___________________
DK
Y
DK
DK
Y
Y
DK
DK
Y
Y
5
17.
Dispose of the needle and syringe properly?_________________________
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
10
18.
Was the child given all vaccinations needed today?
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
10
19.
If the mother required TT did the service provider vaccinate or arrange for
vaccination?_______________
N
Y
N
N
Y
N
N
N
N
N
2
problem relates to failure to ID
mothers.
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
10
well done
well done
I
Documentation_________________________________
20.
21.
Record the vaccination on the child’s health card?_____________________
Record the vaccination in health centre records?
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
10
EPI education________________ _____________________________
22.
Tell the mother which vaccinations were given during this visit?
Y
Y
Y
Y
N
Y
Y
N
N
Y
7
should explain each time
23.
Inform the mother of possible side effects (i.e. fever and pain)?
N
N
N
N
N
N
N
N
N
N
0
side effects were not discussed,
24.
For BCG vaccination explain that a scab will form?
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
10
25.
Tell mother where to go if there is a severe reaction to the vaccination?
N
N
N
N
N
N
N
N
N
N
0
severe reactions not discussed
review educational messages
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Ground rules for group discussion
Everyone’s ideas and opinions are important.
There are no right or wrong answers.
Both positive and negative comments are welcome.
Participants should feel free to disagree with one another so that all points of view are heard
Don’t wait to be called on; it's a group discussion.
Please speak one at a time.
The group leader should keep track of the time and guide
the group to new topics when it seems that enough infor
mation in a specific area has been shared. Before moving
to a new topic or question, the leader should ask the group
if anyone has any final comments to add. At the end of the
discussion, the leader should thank the group for participat
ing and give everyone in the group one last opportunity to
comment on the overall topic.
The leader should write a summary of the discussion,
organised by topic, soon after the discussion so that key
issues will not be forgotten. This information will be useful
for identifying management problems, their causes, and
possible solutions.
Step 6: Compile and analyse the data
The rapid data analysis plan outlined here allows man
agers to compile, analyse, and interpret results of quality
assessment quickly and easily. Supervisors and managers
can hand tabulate the results depending on the number of
observations.
The information gathered during a service quality assess
ment may be tabulated using a simple matrix. Data is
transferred from observation checklists to the matrix, and
can be summed easily. If multiple observation checklists are
used, the tabulation can be done on the checklist, eliminating
the need to transfer the information to the tally sheet.
Exhibit 7 shows how a tally sheet was used to record and
tabulate 30 observations of the quality of the PHC household
visit. The question numbers correspond to those of the
rapid service quality checklist in Appendix B. Note that the
results show inadequate performance in nutrition counsel-
Module 6: Service quality; procedures
Observation
No.
Facility ID
Observer
ID
Date
1
A
LM
12-1
u2
A
LM
12-1
3
A
LM
12-1
4
A
12-1
6
A
LM
__ U/
LM
___ S___
Y
Y
Y
Y
11
Y
Y
Y.
Y
18
20
27
Y
31
Y
37
N
N
N
N
N
Y
N
Y
Y
N
Y
Y
Y
Y
N
41
Y
Y
Y
Y
_
12-1
7
A
WS
12-1
8
9
A
WS
12-1
A
WS
12-1
10
A
WS
12-1
11
A
12-1
12-8
12
B
WS
DN
13
B
DN
12-8
14
B
DN
12-8
15
B
DN
12-8
16
B
DN
12-8
17
B
DN
12-8
18
B
JR
12-8
19
20
21
B
_B_
JR
JR
12-8
12-8
B
JR
12-8
22
C
LD
12-15
23
24
25
26
27
28
29
30
c
c
c
LD
12-15
LD
LD
12-15
12-15
12-15
D
TM
TM
12-15
D
TM
12-15
D
TM
12-15
D
TM
12-15
D
Question number:
J_
Y
Y
Y
Y
Y
N
Y
_Y
Y
Y
Y
N
N
Y
Y
Y
Y
Y
Y
Y
Y
N__ N
Y
Y
Y
Y
Y
Y
Y __ N
N__ Y
Y
Y
Y I Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
Y
N
Y
Y
N
Y
Y
N
Y
Y
N
Y
Y
Y
Y
Y
Y
N
Y
N
Y
ling, recommending ORT, referral for family planning, and
discussing sanitation (items 18, 20, 31 and 37).
Rapid data analysis plan. The data analysis plan
suggested here provides managers with a model for data
analysis that provides essential service quality information.
We recommend that you do these basic calculations for all
quality assessments. Additional calculations can be carried
out in accordance with the purposes of the study.
e
Exhibit 7: Example of a rapid quality assessment
N
Y
Y
Y
N
N
N
N
N
Y
N
N
Y
Y
Y
Y
Y
Y
N
N
N
N
N
Y
Y
Y
Y
Y
N
A
2L
_Y_
Y
N
N
N
Y
Y
Y
Y
N
N
N
N
N
N
Y
Y
N
Y
Y
Y
Y
Y
Y
Y
A
N
N
Y
N
Y
N
N
N_
N
Total observations
30
30
7
8
10
5
30
30
30
Total correct
27
26
6
4
5
5
20
2
25
Percent correct
90
87
86
50
50
100
67
7
83
€
Total: Sum the number of observations for each variable (service delivery task).
For example, question number 6 in Exhibit 7 resulted in 30 responses.
Frequency distributions or counts: Add up the number of "yes" and "no"
responses for each service delivery task. For example, question number 6 in
Exhibit 7 resulted in 26 "yes" responses and four "no" responses.
•w
9
Percentage distributions: Take the number of each count ("yes" and "no")
divided by the total number of observations x 100. The percentage distribution for
question 6 would be yes=87% and no=13%.
Threshold analysis: This procedures allows the manager to set a minimal
acceptable level for each item to spot problems quickly. Those which exceed that
level are identified as problems. For example, if the threshold is set at 80%, then
question 6 would be classified as acceptable, while question 31, with only 67%
correct performance would be a problem.
e
3
3
€
■
Scoring: In addition to analysing data by specific service delivery tasks, a scoring
system can be developed to assess overall quality. For example, each task that was
carried out could receive a score of one point. The total "quality score" would be
the total number of points for a set of tasks compared with the maximum possible
score. If some tasks are much more important than others, they can be given added
weight (e.g., 1.5 or 2 points). If each question in Exhibit 7 were worth one point,
the maximum possible score would be nine. Variable number 20 (performed by
health worker TR) would receive a score of eight, while variable number 1
(performed by health worker LM) would receive a score of five.
Breakdown by site: Compare one site or session with another. Totals, counts
and percentages can be calculated for each site. This will help managers to identify
strengths and weaknesses at different sites. For example, assessment of facility A
included 11 observations for questions 5 and 6. Correct performance of question 5
was 100% while question 6 was 91%.
Graphs: Results can be plotted on a graph to give a manager or supervisor a
summary of the data. This is a useful visual aid for presenting information. A graph
could be made manually by plotting the variables on the horizontal axis and the
percent on the vertical axis.
^5^
Module 6: Service quality; procedures
J■ 3
Module 6: Service quality; procedures
35
3
• Which activities need improvement? Supervisors
should then review the areas that need improvement, pro
viding as much specific information as possible about what
was incorrect, and how it should be done correctly.
Exhibit 8 shows an example of such a graph, depicting
r alts from 30 observations for immunization services,
broken down into 20 service delivery tasks.
E hibit 8: Observation of immunization services
• Which can be corrected easily? Some problems are
easy to correct, have obvious solutions, and require little
extra effort to do correctly. Supervisors should begin with
these, exploring with the health worker and manager ways
that corrections can be made. Experience has shown that
those changes will be more acceptable and will more likely
be implemented if they are suggested by the providers. The
supervisor should encourage the health workers to take the
initiative to make the corrections.
3. observations
30
25
20
“I
—11
15
'5
I
• Which problems will be more difficult to correct?
These problems may need to be analysed more formally,
either by a problem-solving group or through a formal study.
The PHC MAP Problem-soloing guide provides some guide
lines and experiences that may be helpful. Also, the
PRICOR Operations Research manuals describe procedures
for setting priorities and designing and conducting studies
to develop and test solutions to operational problems in
PHC1.
__
10
1
5
0
1
2
yes
12
3
’no
13
14
15
16
17
18
19 20
Immunization variables
Step 7: Report the findings, provide feedback,
c “d Lake corrective action
Quality assessment is the first step in quality improve
ment. It should be followed by steps designed to maintain
tM quality of those tasks that are done well while identifying
e 1 implementing ways to improve the quality of those tasks
Lidt are not.
The following are some guidelines for providing feedback
i d taking corrective action.
• Which activities were carried out well? Supervisors
should begin by reviewing what the service provider did well.
lis reinforces good performance and establishes a con—■uctive rapport between the service provider and supervi
sor.
Module 6: Service quality; procedures
ep
fep
ep
i
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e
Volunteers in
"Action iodine"
campaign,
Chitral,
Northwest
Frontier
Province,
Pakistan.
I
Photo by
Jean-Luc Ray
for AKF
1 Blumenfeld, S. PRICOR Monograph series. Methods Paper 1. Operations research methods: A
general approach in primary health care. Bethesda, MD: Center for Human Services, 1991.
Module 6: Service quality; procedures
■
3
J
3
Appendix A: Rapid service quality
assessment checklists
Short form
GENERAL
9
PHC household visits
Health education
MATERNAL CARE
Antenatal care
Safe delivery
Postnatal care
Family planning
a
$
CHILD CARE
Breast feeding
Growth monitoring
Nutrition education
Immunization
Acute respiratory infection
Diarrhoeal disease control
Oral rehydration therapy
OTHER HEALTH CARE
Wfater supply, hygiene and
sanitation
School health
Childhood disabilities
Accidents and injuries
Sexually transmitted diseases
HIV/AIDS
Malaria
Tuberculosis
Treatment of minor ailments
Chronic, non-communicable
diseases
CLIENT SATISFACTION
I
I
$
|
I :■
$
5
b
Module 6: Service quality; appendix A
39
38
1
i
Rapid quality assessment
1. Community assessment of primary health care (overall)
Rapid quality assessment
2. Health education
This checklist is intended for rapid assessment of service quality in the observation of service
delivery during primary care visits in the household or health centre. To use the checklist,
mark "yes" if the service provider carries out the task during service delivery. For interviews,
mark "yes" if the respondent answers correctly. If you would like to assess this service in more
detail, please refer to the appropriate service quality checklist. The checklist item numbers
below correspond to that list.
This checklist is intended for rapid assessment of service quality in the observation of service
delivery of health education. To use the checklist, mark "yes" if the service provider carries
out the task during service delivery. For interviews, mark "yes" if the respondent answers
correctly. If you would like to assess this service in more detail, please refer to the appropriate
service quality checklist. The checklist item numbers below correspond to that list.
1.
3.
4.
e
1.
3.
4.
Health facility
Observer/supervisor
Date
Did the service provider:
5.
YES
NO
Register all children <5 on the family health card?
6.
YES
NO
Register all women over 16 on the family health card?
11.
YES
NO
Vaccinate
or arrange
vaccination
of children
who need
(If
there are
children
intothe
house):
18.
YESmalnourished
NO
Check
be for
sure
that nutritional
counselling,
food to
supplemen
be immunized?
tation
and/or medical attention are being received?
(If any children have diarrhoea):
20.
Yes
No
Recommend ORT and help the mother to prepare and admin
ister it?
(Fur each pregnant woman):
27.
YES
NO
Ask if she is receiving prenatal care and arrange for a prena
tal visit if necessary?
i
I
I
Health facility
Observer/supervisor
Date
Did the service provider:
YES
NO Determine participants’ knowledge, attitudes, practices, about
5.
topic?
Determine participants’ genera
YES
NO.
6.
Explain the topic and focus the discus
YES
NO.
7-9.
Discuss all relevant aspects of the to
YES
NO.
10-17.
Use appropriate d
18-41.
YES
NO.
participation?
Use appropriate edu
NO.
42-43. YES
tion?
Distribute any available education
44.
YES
NO.
€4"
(For all households):
YES
NO.
31.
35-38.
41.
YES
YES
NO
NO.
Refer interested women or couples for family planning ser
vices?
Discuss water, hygiene, and sanitation, if indicated?
Establish a good rapport with the mother?
I
I
I
I
!
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€’:9
ek
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Module 6: Service quality; appendix A
ir era ’
Module 6: Service quality; appendix A
40
Rapid quality assessment
3. Antenatal care
This checklist is intended for rapid assessment of service quality in the observation of service
delivery of antenatal care. To use the checklist, mark "yes" if the service provider carries out
the task during service delivery. For interviews, mark "yes" if the respondent answers correctly.
If you would like to assess this service in more detail, please refer to the appropriate service
quality checklist. The checklist item numbers below correspond to that list.
1.
3.
4.
6— 3
e=3
e=3
e=3
Rapid quality assessment
4. Safe delivery
This checklist is intended for use in rapid assessment of service quality in the observation of
service delivery. To use the checklist, mark "yes" if the service provider carries out the task
during service delivery. For interviews, mark "yes" if the respondent answers correctly. If you
would like to assess this service in more detail, please refer to the appropriate service quality
checklist. The checklist item numbers below correspond to that list.
1.
3.
4.
Health facility
Observer/supervisor
Date
Health facility
Observer/supervisor
Date
hDid the service provider:
Did the service provider:
Before birth:
Review and update obstetric record or family health card?
YES
NO
5.
5.
YES
NO
Ask at least two questions about reproductive history risk fac
Sterilise needles, syringes, cord ties, scissors/razor blade?
YES
NO
6-12.
6.
YES
NO
Prepare a clean birthing place?
tors?
8-16.
YES
NO
YES
NO
Ask at least two questions about risk factors associated with
Take labour history?
13-25.
17.
YES
NO
this pregnancy?
Review reproductive history for high-risk factors if necessary?
Perform
at
least
1
physical
exam
activity?
YES
NO.
29-34.
Immunize or arrange for immunization against
YES
NO.
Duringtetanus?
birth:
35.
Do a blood test (glucose, haemoglobin/haematocrit
and malaria)
Conduct physi
18-31.
YES
NO.
YES
NO.
43.
if medically indicated?
our?
Discuss the importance of having
byAssist
a
39-43.the delivery
YES
NO.
52.
YES-----attended
NO
the progress of labour?
trained health worker?
44-50. YES
NO
Assist with delivery?
Explain danger signs which require
immediate
attention?
.No.
51-59.
Yes.
54.
ES----NO-------- Seek help for obstetric problems and emergencies?
Tell pregnant woman when
and where
goNO
for--------next prena
umbilical cord with thread in three places and cut
61-62.
No.
Yes.
56.
YESto
----Tie the
tal visit?
with blade/scissors?
YES----- NO-------- Determine APGAR score at 1 minute and 5 minutes after
64.
birth?
70-72.
YES
NO.
Deliver placenta?
€'=3
I
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I
I
e-:3
II
I
I
After birth:
73-76.
YES
NO.
Monitorcare
mother
and provide
immediately
afterneeded
birth?
77-96.
YES
NO
Examine infant?
66.
YES
NO.
Insert antibiotic eye ointment or silver nitrate drops into eyes
within one hour after birth?
67.
YES---- NO Give BCG vaccination?
68.
YES---- NO Administer vitamin K?
97.
YES----- NO-------- Discuss postnatal cleanliness and provide related instruction?
104-114. YES---- NO
Give advice about breast feeding?
115-119. YES-----NO
Give advice about well-child care?
t’-i
I
i
(0)1* ■
Module 6: Service quality; appendix A
E
Module 6: Service quality; appendix A
r
e-a
42
43
Rapid quality assessment
5. Postnatal care
Rapid quality assessment
6. Family planning
This checklist is intended for rapid assessment of service quality in the observation of post
natal care. 4b use the checklist, mark "yes" if the service provider carries out the task during
service delivery. For interviews, mark "yes" if the respondent answers correctly. If you would
like to assess this service in more detail, please refer to the appropriate service quality checklist.
The checkli&t item numbers below correspond to that list.
This checklist is intended for rapid assessment of service quality in the observation of service
delivery for family planning services. To use the checklist, mark "yes" if the service provider
carries out the task during service delivery. For interviews, mark "yes" if the respondent
answers correctly. If you would like to assess this service in more detail, please refer to the
appropriate service quality checklist. 4 he checklist item numbers below correspond to that
list.
3
i.
3.
4.
1
1
II
S-
Health facility
Observer/supervisor
Date
1.
3.
4.
Did the service provider:
Ask the mother at least two medical history questions?
YES
NO.
5-14.
Examine the mother?
YES
NO.
15-21.
Examine the new-born child?
NO.
22-37. YES
Record findings of history and physical examination health re
YES
NO.
38.
cord?
Refer mother for special treatment if necessary?
YES
NO.
43.
Refer infant for all physical conditions which need medical at
YES
NO.
47.
tention?
Give BCG or verify that child received vaccination at birth?
YES
NO.
44.
Give first DPT and OPV?
YES
NO.
45.
Tell mother to feed the infant with breast milk only, for the
YES
NO.
48.
first 4-6 months?
Discuss family planning with the mother and tell her how she
YES
NO.
54.
can obtain family planning services?
Encourage mother to enrol child in well-child clinic?
YES
NO.
55.
Health facility
Observer/supervisor
Date
Did the service provider:
5-16.
YES
NO
Ask at least three medical and reproductive history questions?
17.
YES
NO
Take blood pressure?
18.
YES
NO
Examine breast for lumps?
19.
YES
NO
Examine patient for signs of anaemia?
24.
YES
NO
Recommend a method that was free of contra-indications for
this client?
28,31-33 YES
NO.
Discuss side effects?
11
Ask client:
44.
YES
45.
YES
NO
NO.
How do you use the contraceptive you received today?
What are the possible side effects?
’-3
4
1
IJ
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J
'/SI
Module 6: Service quality; appendix A
'f
Module 6: Service quality; appendix A
f
■
Rapid quality assessment
7. Breast feeding
Rapid quality assessment
8. Growth monitoring/nutrition education
e
This checklist is intended for rapid assessment of service quality in the observation of service
delivery for promotion of breast feeding. To use the checklist, mark "yes" if the service provider
carries out the task during service delivery. For interviews, mark "yes" if the respondent
answers correctly. If you would like to assess this service in more detail, please refer to the
appropriate service quality checklist. The checklist item numbers below correspond to that
list.
1.
3.
4.
This checklist is intended for rapid assessment of service quality in the observation of service
delivery for growth monitoring and nutrition education. To use the checklist, mark "yes" if the
service provider carries out the task during service delivery. For interviews, mark "yes" if the
respondent answers correctly. If you would like to assess this service in more detail please
refer to the appropriate service quality checklist. The checklist item numbers below corre
spond to that list.
Health facility
Observer/supervisor
Date
1.
3.
4.
Did the service provider:
5-10.
YES
NO.
Ask about mothers knowledge and practice concerning
breast feeding?
11.
YES
NO.
Instruct mothers on the health benefits to mother and child
of breast feeding?
12-19.
YES
NO.
Recommend how long to breast feed and encourage continued
breast feeding during illness?
20-23. YES
NO
Instruct mother on method of breast feeding?
24,29.
YES
NO.
Explain warning signs that indicate the mother should seek
help?
25-26 YES
NO.
Provide counselling, as appropriate, on family planning meth
ods and contraceptive benefits of breast feeding?
32-35
YES
NO.
Provide appropriate counselling on diet during lactation, nu
trition supplements, and important locally available foods?
39-41
YES
NO.
Advise mother on weaning practices and food preparation.
^=3
s.
Health facility
Observer/supervisor
Date
Did the service provider:
5-7.
YES----- NO
Calculate the age correctly?
8-12.
YES
NO
Weigh the child correctly?
13-15.
YES----- NO Plot the child’s weight correctly?
(If the child is malnourished):
17.
YES---- NO
Refer for nutritional counselling?
18-28.
YES----- NO-------- Make at least 1 appropriate recommendation about child feed
ing and care?
Ask mother:
39.
YES
NO.
Did your child gain weight, lose, or stay the same since the
last weighing?
Ask service provider:
36.
YES
NO Do you have a working scale?
43.
YES----- NO-------- Do you have a way of tracking malnourished children?
F
*1*
I
&
Module 6: Service quality; appendix A
I
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Module 6: Service quality; appendix A
I
I
"E- ■
46
47
Rapid quality assessment
9. Child immunization
Rapid quality assessment
10. Acute respiratory infection
This checklist is intended for rapid assessment of service quality in the observation of service
delivery for child immunization. To use the checklist, mark "yes" if the service provider carries
out the task during service delivery. For interviews, mark "yes" if the respondent answers
correctly. If you would like to assess this service in more detail, please refer to the appropriate
service quality checklist The checklist item numbers below correspond to that list.
This checklist is intended for rapid assessment of service quality in the observation of service
delivery for acute respiratory infection. To use the checklist, mark "yes" if the service provider
carries out the task during service delivery. For interviews, mark "yes" if the respondent
answers correctly. If you would like to assess this service in more detail, please refer to the
appropriate service quality checklist. 1 he checklist item numbers below correspond to that
list.
1.
3.
4.
Health facility
Observer/supervisor
Date
1.
3.
4.
Did the service provider:
Use a sterile needle for each injection?
13. YES
NO
Use a sterile syringe for each injection?
14. YES
NO
.Give the child all vaccinations needed today?
17. YES
NO
.Record the vaccination on the child’s health card?
19. YES
NO
I
I
Ask the service provider:
36. YES
NO
Was the registered temperature between 0 and 8 degrees (C)
at all times during the last month?
(For outreach sessions):
.Were vaccines transported in cold boxes with ice packs?
41. YES
NO
Ask mother:
43. YES
NO.
When should you return for the next immunization?
I
Health facility
Observer/supervisor
Date
Did the service provider:
5-12.
YES
NO
Ask at least two medical history questions?
13.
YES
NO
Ask about any treatment administered?
15.
YES
NO
Count respiratory rate?
24.
YES
NO
Classify child by severity of illness?
25.
YES
NO
Give antibiotics for pneumonia, strep throat or otitis?
26.
YES
NO
Refrain from using antibiotics for colds?
36.
YES
NO
Tell mother about at least three signs of pneumonia?1
Ask mother:
(If antibiotics were prescribed):
45-46. YES
NO
1 low will you administer the medicine (how much, how often,
for how long)?
I
€ tS
Module 6: Service quality; appendix A
Trr
-
€r':^
1 Signs include stridor, chest indrawing/rapid breathing, inability to drink, cyanosis, anxiety
and weakness or lethargy.
Module 6: Service quality; appendix A
48
3
Rapid quality assessment
11. Diarrhoeal disease control/oral rehydration therapy
e=^
i-^
This checklist is intended for rapid assessment of service quality in the observation of service
delivery for diarrhoeal control and oral rehydration therapy. To use the checklist, mark "yes"
if the service provider carries out the task during service delivery. For interviews, mark "yes"
if the respondent answers correctly, if you would like to assess this service in more detail,
please refer to the appropriate service quality checklist. The checklist item numbers below
correspond to that list.
1.
3.
4.
I
1
Health facility
Observer/supervisor
Date
&
Did the service provider:
Ask at least two medical history questions?
YES
NO.
5-11.
Perform at least two physical exam activities?
YES
NO.
12-16.
Determine the degree of dehydration (none, moderate, se
YES
NO.
17.
vere)?
Prescribe safe ORS solution?
YES
NO.
18.
Refrain from using antibiotics, except when stools contain
YES
NO.
20.
blood or mucus?
If the child is dehydrated, administer ORS solution im
YES
NO.
22.
mediately or refer the child to a nearby centre?
Tell mother how much ORS solution to give and how often
YES
NO.
31.
to give it?
Show mother how to prepare ORS solution?
YES
NO.
35.
i
Rapid quality assessment
12. Water supply, hygiene and sanitation
&
€
i:
■:
i
This checklist is intended for rapid assessment of service quality in the observation of service
delivery for education in water supply, hygiene and sanitation. To use the checklist, mark "yes
if the service provider carries out the task during service delivery. For interviews, mark "yes
if the respondent answers correctly. If you would like to assess this service in more detail,
please refer to the appropriate service quality checklist. The checklist item numbers below
correspond to that list.
1.
3.
4.
Health facility
Observer/supervisor
Date
Did the service provider:
Discuss keeping water in a clean, covered container?
10. YES
NO
Discuss the importance of hand washing before eating, feed
13. YES
NO
ing children, and food preparation?
Inspect latrine?
NO.
16. YES
Discuss appropriate latrine use and human waste disposal
23. YES.
NO.
(e.g. baby potty for children under three)?
Recommend burning or burying refuse?
NO.
28. YES
NO.
Recommend penning animals away from the house?
30. YES.
Ask mother:
37. YES
NO.
Why is it important to wash your hands?
eU
I
I
Module 6: Service quality; appendix A
I
Module 6: Service quality; appendix A
50
51
Rapid quality assessment
13. Childhood disabilities
This checklist is intended for rapid assessment of service quality in the observation of service
delivery for childhood disabilities. To use the checklist, mark "yes" if the service provider carries
out the task during service delivery. For interviews, mark "yes" if the respondent answers
correctly. If you would like to assess this service in more detail, please refer to the appropriate
service quality checklist. The checklist item numbers below correspond to that list.
1.
3.
4.
Health facility
Observer/supervisor
Date
Did the service provider:
Ask questions from the mother to identify factors which may
YES
NO.
5.-9
have contributed to a disability?
NO.
Ask questions from the mother to determine the type and de
10-20. YES
gree of disability?
Correctly examine the child for type and degree of disability?
21-32
YES
NO.
Administer/prescribe available treatment or therapy accord
33.
YES
NO.
ing to established treatment guidelines?
Make the appropriate referral according to established guide
34.
YES
NO.
lines?
NO.
Provide information on available local services for the dis
36-37. YES
abled?
Discuss what parents, family and community can do to help
42-44. YES
NO.
children with disabilities?
Ask client
53.
What is your child’s disability?
If applicable, do you know how to prevent a similar disability from happening again?
55.
56-59. What information was given to you about treatment and/or where to go for help?
Rapid quality assessment
14. Accidents and injuries
& jS
I
ep
I
e-'d
I
fl
&
I
t
This checklist is intended for rapid assessment of service quality in the observation of service
delivery for accidents and injuries. To use the checklist, mark "yes" if the service provider
carries out the task during service delivery. For interviews, mark "yes" if the respondent
answers correctly. If you would like to assess this service in more detail, please refer to the
appropriate service quality checklist. The checklist item numbers below correspond to that
list.
1.
3.
4.
1 lealth facility
Observer/supervisor
Date
Did the service provider:
5.
YES
NO.
Correctly identify type of injury?
6.
YES
NO
Obtain a history of the injury, e.g., cause, time, etc.?
7.
YES
NO
Administer proper treatment according to established guide
lines?
8.
YES
NO.
Make the
lines?
9.
YES
NO
Discuss some common injuries and how they may be prevented?
10,11,13 YES
NO
Discuss child safety in and around the home?
12.
YES
NO
Discuss any occupational safety issues?
14-15.
YES
NO
Explain how to recognise an emergency and where to go for
help?
I
I
^762-
ia
ri
Module 6: Service quality; appendix A
I
l
Module 6: Service quality; appendix A
s(
pOC'
/'J
=
52
Rapid quality assessment
15. Sexually transmitted diseases
'3
A
sBsS'ispi
appropriate■Me quality checklist. The checklist item numbers below correspond to that
list.
Rapid quality assessment
16. Malaria
his checklist is intended for rapid assessment of service quality in the observation of service
delivery for malaria. To use the checklist, mark "yes" if the service provider carries out the task
during serv.ce delivery. For interviews, mark "yes" if the respondent answers correctly If you
I1'5 SCrViCe in m°re detail’ P,ease refer to ,he appropriate service quality
checklist. The checklist item numbers below correspond to that list.
V
.
1.
3.
4.
Health facility
Observer/ supervisor
Date
1.
3.
4:
Health facility
Observer/supervisor
Date
Did the service provider:
5-10.
YES----- NO---------Ask at least two medical history questions?
Did the service provider:
11.
Ask about symptoms of infection?
YES-----NO--------- Ask about anti-malarial drugs taken in the last 24 hours?
YES
NO
5.
Ask about previous exposure to STD and any treatments ad
12.
Ytb-----N0--------- Ask about other symptoms to rule out other fever-related
. YES___ NO_____
6-9.
ministered?
. .
illnesses?
13.
Ask about exposure to other potential sources of infection,
YES
NO
Take temperature?
YES
_N0.
10-11
20.
e.g., blood, non-sterile instruments, etc.?
YES
NO.
Make blood slide or refer case to a facility where a blood
Ask
about
possible
risk
behaviours
associated
with
SIU.
slide may be examined?
YES
NO
15-18.
22.
Examine patient for signs of infection?
YES
NO.
Administer or prescribe appropriate anti-malarial drug ac
YES
NO.
21-30.
Diagnose and treat patient according to established guidecording to local norms?
NO.
38-41. YES
25-26. YES
NO.
If fever is over 39 degrees C: Administer antipyretic drug and
_ Refer patients for diagnoses, treatment or laboratory testing
sponge or bathe with water?
32-37,42 YES
NO.
30.
according to established guidelines?
YES
NO.
Discuss danger signs that may indicate unresponsive or com
Provide health education on the modes of transmission and
plicated malaria?
YES
>JO.
45-51
31.
YES
NO.
prevention of STD?
Tell client to return for consultation if danger signs develop?
YES
no
Instruct the client on the correct and consistent use of con
47.
Ask client:
doms?
,
r.
Provide appropriate counselling on testing procedures, con i52.
vYES
NO.
__NO__
If medicine is prescribed: How will you take the medicine
54-67
dentiality and meaning of test results?
how much, how often, and for how long?
available
Provide appropriate counselling to STD cases on
YES
NO.
68-75
treatments, complications of disease or any long tei:rm effects,
and possible risks to partners and/or children.
t
i
L
I
f
efe
i
€
0
e
€
I
-5
Module 6: Service quality; appendix A
e 3
Module 6: Service quality; appendix A
I
1
H
54
!
Rapid quality assessment
17. Tuberculosis
Rapid quality assessment
18. Treatment of minor ailments
This checklist is intended for rapid assessment of service quality in the observation of service
delivery for tuberculosis. To use the checklist, mark "yes" if the service provider carries out the
task during service delivery. For interviews, mark yes if the respondent answers correctly.
If you would like to assess this service in more detail, please refer to the appropriate service
quality checklist. The checklist item numbers below correspond to that list.
This checklist is intended for rapid assessment of service quality in the observation of service
delivery for minor ailments. To use the checklist, mark "yes" if the service provider carries out
the task during service delivery. For interviews, mark "yes" if the respondent answers correctly.
If you would like to assess this service in more detail, please refer to the appropriate service
quality checklist. The checklist item numbers below correspond to that list.
1.
3.
4.
I
1
55
eU
Health facility
Observer/supervisor
Date
Di. the service provider:
Ask about persistent cough, two weeks or more?
NO
5. Y ES
Ask about persistent fever, one month or more?
NO
6. YES
Ask about weight loss?
NO
7. YES
Ask about blood in sputum?
NO
8. YES
.NO____ Perform cutaneous TB test?
17. YES.
NO____ Refer for sputum examination?
19. YES.
NO_______ Prescribe medicines or refer for treatment according to local
21. YES
norms?
For follow-up cases: Verify that client is taking medicine cor
NO.
22. YES.
rectly?
Explain how much and how often to take medicine?
.NO.
28. YES.
Stress the importance of completing the treatment?
NO.
29. YES
As.: client:
44. YES
NO_
47. YES.
NO.
I
If drugs were prescribed: How will you take your medication,
how much, how often, and for how long?
If further testing is needed: Where will you go for the test?
€
Physical examination
Did the service provider:
8. YES
NO
9.
b
YES.
NO.
Diagnosis
Did the service provider:
10. YES
NO
€ ; ■?
Laboratory diagnosis
Did the service provider:
11. YES
NO
€
t!
t ‘3
I
Module 6. Service quality: append1
Health facility
Observer/supervisor
Date
Medical history
Did the health provider:
5. YES
NO
6. YES
NO
7. YES
NO
€’ !
I
1.
3.
4.
3
Ask about the chief complaint, fever, pain, cough, etc?
Determine the present history of the illness?
Determine condition-related past and family history?
Check vital signs, blood pressure, temperature, pulse, respira
tion rate etc.
Conduct a related physical exam?
Make differential diagnosis, eg., cough, IB, pneumonia, bron
chitis, abdominal pain, gastroenteritis, acute cholestitis, appen
dicitis, etc.?
Order condition- or preliminary diagnosis-related diagnostic
tests, laboratory tests, x-ray studies, etc.?
Treatment and follow-up plans
Did the service provider:
13 YES
NO
Provide appropriate treatment according to the condition?
14. YES
NO.
Provide information to the patient about the condition and
treatment plan?
18. YES
NO
Discuss the importance of compliance with the drug therapy?
21. YES
NO.
How often will you take this medicine?
22. YES
NO
What is the dose you will take?
23. YES
NO
For how long will you continue treatment?
v'
'? 6: Service quality; appendix A
-
56
Rapid quality assessment
19a. Hypertension
Rapid quality assessment
20b. Diabetes mellitus
This checklist is intended for rapid^
delivery, --for hypertension.
u:"
j i T,
° US
p J • tpruiews mark "yes" if the respondent answers correctly,
the task during service delivery, f
refer to the appropriate service
X--Respond to that .tst
This checklist is intended for rapid assessment of service quality in the observation of service
delivery for diabetes mellitus. To use the checklist, mark "yes" if the service provider carries
out the task during service delivery. For interviews, mark "yes" if the respondent answers
correctly. If you would like to assess this service in more detail, please refer to the appropriate
service quality checklist. The checklist item numbers below correspond to that list.
I
9
Health facility
Observer/supervisor
_ Date
1..
3.
4.
Did the service provider:
5-6
7-13.
'i!i=So=z KSfifiSSSK'
I
14,16.
a
:d
......
no
Ask about family history of hypertension?
I
YES
YES
NO.
NO.
YES
N0
-
*>*
SS
39-43. YES
46.48-49.YES
NO.
NO.
YES
NO.
„..
- Signs,Uoodpressure, heart, pulse in foot, neck vems or other
Health facility
Observer/supervisor
Date
Did the service provider:
YES----- NO--------- Ask about symptoms, e.g., blurred vision, unusual thirst, uri
5.
6-15.
YES
NO.
16.
17-19.
YES
YES
NO
NO.
22.
YES
NO.
25-30.
YES
NO.
nary tract infection, yeast infection if a woman, foot problems, numbness, recurrent infection?
Perform a physical exam including a check of vital signs, gen
eral appearance, appearance and pulse in feet, fast breathing,
signs of dehydration, or others as per local norm?
Conduct lab tests, (e.g., blood sugar, urine) as appropriate?
Provide patients with health education/counselling on appro
priate diet and exercise?
Instruct family members how to handle common diabetic
emergencies?
Educate the patient on proper foot care and protection?
For women of child bearing age:
31.
YES----- NO--------- Discuss the importance of maintaining blood sugar levels
proPvideOpaLentsCwith health education/counselling on hyper-
35-38.
44-45.
1.
3.
4.
NO.
15.
17.
2L
23-24.
25-34.
I
YES
YFS
s
I
i
i
i
within a specified range before and during pregnancy to pre
tetruct patients on the use of any prescribed-edicatmn^
vent birth defects?
Educate patients on appropriate low
diet and NO.
32.sodium YES
Refer high risk pregnancies as
Mfo’m patients of the warning signs indicating when to return to the clinic?
a«
* 14
I u
Module 6: Sen/
appendix A
I
MuJule 6: Ser' i
Quality; appendix A
1
£2
58
Rapid quality assessment
21c. Anaemia
This checklist is intended for rapid assessment of service quality in the observation of service
delivery for anaemia. To use the checklist, mark "yes" if the service provider carries out the
task during service delivery. For interviews, mark "yes" if the respondent answers correctly,
if you would like to assess this service in more detail, please refer to the appropriate service
quality checklist. The checklist item numbers below correspond to that list.
I
I-
3.
4.
Health facility
Observer/super visor
Date
3id the service provider:
YES
NO
Ask about chief complaints, whether pregnant?
NO
Ask if there is any blood in stool?
6. YES
NO
Determine the occult blood in the stool?
7. YES
NO
Check colour of conjunctiva?
11. YES
NO
Discuss some common injuries and how they may be pre
9. YES
vented?
NO.
Ask about family history of anaemia?
-3. YES.
Give complete physical examination, chest, abdomen, etc.?
NO.
15. YES.
Get complete blood count with reticulocite count?
.NO.
16. YES.
Determine haemoglobin type, region, race, age or sex?
NO
18. YES
Determine the aetiology of the anaemic condition?
NO.
21 YES
Determine appropriate consultation; referral to a specialist, if
NO
22. YES
needed?
Ask client:
Were you provided nutrition counselling?
NO.
24. YES
3
I
■
I
.Ask the service provider:
NO
Do you know how to administer the drug, how much, how
29. YES
often and how long?
Do you know where you can get refills for the drug?
30. YES
NO.
How can you care for anaemia?
NO.
34. YES.
..-aaa
fid
■
*
i
■
&
■
Module 6: Service quality; appendix A
61
3
3
"3
Appendix B: Rapid service quality
assessment checklists
Long form
GENERAL
PHC household visits
Health education
MATERNAL CARE
Antenatal care
Safe delivery
Postnatal care
Family planning
CHILD CARE
Breast feeding
Growth monitoring
Nutrition education
Immunization
Acute respiratory infection
Diarrhoeal disease control
Oral rehydration therapy
OTHER HEALTH CARE
Water supply, hygiene and
sanitation
School health
Childhood disabilities
Accidents and injuries
Sexually transmitted diseases
HIV/AIDS
Malaria
Tuberculosis
Treatment of minor ailments
Chronic, non-communicable
diseases
CLIENT SATISFACTION
i
I
r
92
I
I
Module 6: Service quality; appendix B
I'
e
62
PHC service quality checklist
1: Community assessment of primary health care
This checklist is intended for use in the observation of service delivery during primary care
visits in the household or health centre. Before using it, the national treatment protocol should
be reviewed in order to adapt the tool to the local situation if necessary. It is also recommended
that you review the checklist carefully before using it to be sure that you understand the
questions and know how to use the form. For observation of service delivery, mark "yes" if
the service provider carries out these activities during service delivery. For interview questions,
mark "yes" if the respondent answers correctly.
-f
63
■
a. nr
1^5?
Health facility
___________ Service provider
3. Observer/supervisor
4
Date
.
■I
a
J
ill SEE aS
Registration and documentation
Did the service provider:
Register all children under 5 in the family health card?
5. YES
NO
Register all women over 16 in the family health card?
5. YES
NO
Update information during the visit?
7. YES
NO
Record this visit in health centre records?
8. YES
NO
Jnder 5 care
immunization:
Did the service provider:
YES
NO
NO
10. YES
NO
11. YES
12. YES.
NO.
13. YES.
NO.
Discuss the importance of vaccination?
Review the immunization status of all children under 5?
Vaccinate or arrange for vaccination of children who need to
be immunized?
Review vaccinations needed and the appropriate dates with
mother?
Answer mothers questions about vaccination?
IM
mi
■
—
i
I1
17. YES
NO.
18. YES.
NO.
ORT:
■ Did the service provider:
19. YES
NO
Review the growth cards of all children under 5?
Weigh children or refer them for growth monitoring?
Discuss changes in weight with the mother and give nutri
tional advice?
Answer mother’s questions about growth monitoring and nu
trition?
If there are any malnourished children in the house: Did the
health worker check to be sure that nutritional counselling,
food supplementation, and/or medical attention are being re
ceived?
Ask if any children in the household had diarrhoea?
■
Module 6: Service quality; appendix B
V
NO.
-
21. YES.
NO.
22. YES
23. YES.
NO.
NO.
If no, review the importance of ORT and encourage mother
to use it in future diarrhoea episodes?
_ Answer mothers questions about ORT?
Demonstrate how to make ORT, or invite mother to a dem
onstration, if necessary?
ir^°n(’.?end 0RT’ and he,P the mother to prepare and K
Maternal care
Antenatal care:
Did the service provider24.
----------- Discuss the importance of prenatal care?
25.
ypc--------- NO----------- if aIly WOmen in the household are pregnant?
26.
--------- Wlth each pregnant woman about her general well
being?
27. YES--------- N0------------Ask if ea,ch Pregnant woman is receiving prenatal care and
Ypc
arrange for a prenatal visit if necessary?
28.
--------- NO------------ Giv® nutritional advice and iron/calcium supplementation to
YF
each pregnant woman?
29.
--------- N0----------- Answer pregnant womans questions?
Family planning:
Did the service provider30. YES
NO
31. YES
NO.
Provide information about family planning services?
vice^?in*erCSted W°meri °r couPles for family planning ser-
a
I
1^
IZ
Water and sanitation:
Health workers should include water
water and
and sanitation
sanitation ifif there
there is
is a current or recent case of
diarrhoea in the home or m any homes where the health worker feels that poor water and
sanitation may constitute a health risk.
Did the service provider35. YES.
_NO.
Ask about access to water and provide information about
community efforts to add
36. YES.
NO.
- A^ahout water storage practices and give appropriate ad-
■
37. YES.
Mb £5
Growth monitoring:
Did the service provider:
NO
14. YES
NO
15. YES
NO
16. YES
20. YES.
32. YES.
NO.
Ask women who already use contraception if they are happy
with their method?
y
33. Ypl--------- m------------Refer current users for advice or follow-up. if necessary?
follow-up, if necessary?
34.
c
----------- Answer questions about family planning?
-NO----------- - ^sk nhout latrine maintenance and use and give appropriate
38. YES--------- NO------------Ask ab°l" refuse and excreta disposal and give appropriate
General
Did the service provider
39. YES
NO
40. YES
NO
41. YES
NO
Ask if anyone in the household is ill and give appropriate advice?
Follow up on recent illnesses?
Verify that the client(s) understands key information from
today’s visit?
Module 6: Service quality; appendix B
64
e
PHC service quality checklist
2: Health education1
"
This checklist is intend Jfor use in supervision and
1
■
n
For interview questions, mark "yes" if the respondent answers correctly.
1
2..
34..
s
*i9
Health facility
Service provider
Observer/supervisor
Date
Determine educational background
Did the service providen
participants- knowledge, attitudes, practices (KAP)
6.
YES
NO------
Discussion of topic
Did dje service provider.
7. yes
NO
8. ypc
NO
9. Xis-------- NO.
10.
■^i
... ;
NO.
I
E
I- >
e*8
Use of appropriate techniques
Did die sei vice P^vlGer
Establish good rapport with the participants?
19. VF-S-------- NO
Demonstrate sensitivity to existing/vanous levels of KAP.
2 W«n, N. & Bernstein, E
Health Education Quarterly, vol. 15, No. 4, p. 379-383 (1988)
Module 6: Service quality; appendix B
20. YES.
NO.
21. YES.
NO.
22. YES
23. YES.
24. YES
25. YES
NO
NO.
NO
NO
26. YES.
NO.
27. YES.
NO.
28. YES
29. YES
30. YES
31. YES
32. YES
NO.
NO
NO
NO.
NO
33. YES.
NO.
34. YES.
NO.
35. YES36. YES.
NO
NO.
37. YES.
38. YES
39. YES
40. YES
41. YES.
.NO.
NO
NO
NO.
NO.
Use of materials
Did the provider:
42. YES.
NO.
43. YES.
NO.
44. YES--------- NO---------
Appeal to emotional and intellectual reasons for behaviour
change?
, Solicit participants’ honest opinions at the outset of the meet
ing?
Avoid use of technical/medical terminology?
Speak clearly and make eye contact?
Use verbal and non-verbal communication?
Use creative presentations, appealing to all five senses, to
help to mitigate boredom and fatigue?
Focus on observable behaviour that can be relatively easily
changed?
Communicate the desired behaviour change in a specific, non
threatening and non-judgemental manner?
Display willingness to compromise as needed?
Avoid imposing his/her cultural values and choices?
Use demonstrations or models during the presentation?
Use role playing during the presentation?
Promote group discussion and participation during the pre
sentation?
Promote group members’ practice/application of their newly
acquired behaviour, to allow them to gain confidence?
Discuss problems and examples that are realistic and relevant
to the participants?
Repeat or restate key messages?
Ask participants to repeat key messages or demonstrate an
activity?
Verify that participants understand key information?
Ask participants if they have any questions?
Respond thoroughly to questions from the audience?
Ask for feedback on the presentation from the participants?
Allocate time well?
Use audio-visual materials du
Use materials appropriate for illiterate participants, if neces
sary?
Distribute any available educational materials?
Exit interview with participants
Mark "yes" if the respondent answers correctly:
45. Y
----ES
N()
Wh.it are the main points that you discussed today?
46. YES
NO
Do you feel ready/able to begin the behaviour change?
47. YES
NO
When should you return to the health centre (if needed)?
48. YES
NO
Was this helpful/interesting to you?
- Discuss where to go for services or seek help, if needed?
1 Pleiffer,J.(ed.), Theories and models in applied behauioralscience, vol. II, p. 12,28,65 66,139,140,
El
I
Clear|y de{ine the pUrpOse of the meeting?
Discuss the relevance and purpose of the topic.
Remain focused on the topic in hand?
Explain risk factors (i.e. biological environmental, socio-eco
nomic, behavioural, health care related).
ypc
NO
Discuss transmission and prevention?
11. YES
NO
Discuss specific recommended behaviour changes.
12.
13 YES
NO
Discuss benefits of the proposed behaviour change.
14. YES
NO
Discuss potential obstacles and problems.
YES
NO
Discuss potential complications and danger signs,
16. VFSZ------ NO------------Discuss when to go for services/follow up or seek help, tf
17 YES
3
Determine participants’ general level of education?
u
e -a
Interview with provider
Mark "yes" if the respondent answers correctly:
49. YES--------- NO
Did you communicate the points that you had planned to?
■rid
Module 6: Service quality; appendix B
e
66
PHC service quality checklist
3: Antenatal care
!
I
1;
Yes
NO
__________
smelling
vaginal discharge?
"NO
—_______ Eoul
Burning
on urination?
YES
______ Spotting/bleeding
during current
YES’
'NO
no—
________
Diabetes?
YES
NO—_Cardiovascular problems?
Did the
ask Renal
about problems?
risk factors:
1R
VPSservice provider
NO________
in’ YES
NO—
Female circumcision?
9Q YES
NO
Previous injuries, especially to pelvis.
*2
NO.
Current or past
breastbeing
feeding?
21 yes
YF.S".
NO
Medications
currently
taken?
22. YES.
NO
Smoking?
YES.
,NO
_«Alcoholism?
'23
s^rvU
the serv>ce provider carries out these activities dur,ng serv.ce
25.
NO---------- -- An^otherproblems
associated with
current
pregnancy?
rj"Fo
‘ ----iXie'^questions,
mark "yes' if the Respondent
answers
correctly.
11 YES
NO
- Complications during previous pregnancies.
3._
ypc
I
1
I
1
1
•Si
Review obstetric record or family health card?
_NO_
_NO_
__NO_
_NO_
-NO_
_NO_
-NO_
_NO_
_NO_
__NO_
__NO_
—NO
NO.
&
i
e —1
$
I
€■ s
I
€’®i9
I
€^‘ z
Did the service provider update information on the following:
YES
NO------------- Age?
Number of previous pregnancies?
YES
NO
Y£S
NO.
Date of last menstrual period’’
7. Yes
NO
_ Date of last delivery?
3.
9.
13.
14.
15.
16.
17.
e
Ask about preventive actions taken:
26. YES
NO
Immunization against tetanus?
27 YES
NO
Malaria prophylaxis?
28. YES
NO
Plans for delivery?
Wi
€
Health facility
Service provider
Observer/supervisor
"n
O
Outcome of each pregnancy?
Date
leproduciive history
Did the service provider:
YES
NO
e
67
r
or past pregnancies?
_I
a r’i.
I -3
Take pulse?
Take blood pressure?
Correctly measure height and weight?
Correctly exam
Calculate expected date of delivery?
Assess adequacy of pelvic outlet?
Routine preventive services for pregnant women
Did the service provider:
Immunize or arrange for immunization against tetanus?
NO
35. YES
Administer or prescribe iron supplements?
36. YES
_NO
Administer or prescribe nutrition supplements?
37. YES.
.NO.
Administer or prescribe anti-malarial drugs if indicated?
38. YES.
NO.
Referral
Did the service provider:
39. YES
NO
40. YES
41. YES.
42. YES.
NO_
NO_
NO_
43. YES.
NO.
44. YES
45. YES.
NO.
NO.
Counselling
Did the service provider:
46. YES.
NO.
47. YES
48. YES.
NO.
NO.
49. YES
50. YES
51. YES
NO
NO
NO
Encourage mother to attend prenatal sessions at the local
health facility?
Refer high-risk pregnancies for additional medical attention?1
Recommend hospital birth for high-risk pregnancies?
Refer for urine examination (sugar and protein) if medically
Indicated?
Refer for blood test (glucose, haemoglobin/haematocrit or
malaria diagnosis) if medically indicated?
Refer for blood test for RH factor determination?
Refer for syphilis serology test (per local norms or if medi
cally indicated)?
Explain the importance of continuing prenatal care during
pregnancy?
Explain the benefits of weight gain during pregnancy?
Discuss the types of foods to include in diet during preg
nancy?
Explain how to take iron tablets/nutrition supplements?
Warn about dangers of alcohol, smoking, drugs?
Explain the importance of tetanus toxoid immunization dur
ing pregnancy?
1 Referral is indicated if: 1) one or more high-risk factors (see reproductive history) are present; 2) there is
a history of complications during pregnancy or birth; 3) the woman is older (per local norms) or has had
many pregnancies (number determined by local norms). Referral is also indicated for obstetric and
medical problem(s) and emergencies, ectopic pregnancy, infection or bleeding from abortion, and other
prenatal problems and emergencies, especially haemorrhage, sepsis and eclampsia. Guidelines for referral
should follow local norms.
1 Complications include bleeding, toxaemia. Infection, prolonged labour, RH incompatibility. Cesarean
section, stillbirth, and spontaneous abortion.
Module 6: Service quality; appendix B
Physical exam
Did the service provider:
29. YES
NO
30. YES
NO.
31. YES
NO
32. YES
NO.
33. YES
NO
34. YES
NO
erd
Module 6: Service quality; appendix B
G
*
■
I
■t-
I
I
a
52. YES.
NO.
53. YES
.NO.
54. YES
55- YES.
NO
NO.
56. YES.
NO.
57. YES
58. YES.
NO.
NO.
Explain the importance of having delivery attended by a
trained health worker?
Explain the dangers of abortions performed by unqualified in
dividuals?
Explain danger signs which require immediate attention?1
Tell pregnant woman to have family seek assistance or trans
port her to clinic/hospital if danger signs of obstetric emer
gencies or complications of labour occur?
Tell pregnant woman where and when to go for next prena
tal visit?
Verify that pregnant woman understood key messages?
Ask if she has any questions?
Supplies
Ask the service provider about the following supplies:
59. YES
NO
Do you have a working scale (to weigh the pregnant woman)?
60. YES
NO
Do you have a measuring tape?
61. YES
NO
Do you have a stethoscope and blood pressure cuff?
62. YES
NO
Do you have a watch with a second hand to take pulse?
63. YES
NO
Do you have tetanus toxoid vaccine?
64. YES
NO
Do you have iron tablets (per local policy)?
65. YES
NO
Do you have drugs for malaria prophylaxis (per local policy)?
66. YES
NO
Do you have forms or health cards to record the antenatal
visit?
PHC service quality checklist
4: Safe delivery
1/
This checklist is intended for use in supervision and monitoring of service qualitu ■
provide
dantrA’hholh)is d7f° ^7’ C°?ln]U|nitVbaScd health workers and tradHional as
birth
u.i atten
b. ;.™d
tO lf’e
I
1.
2.
3.
4.
'
Health facility
Service provider
Observer/supervisor
Date
Prepare for delivery
Did the service provider-
5.
" yes
NO.
” gloves? needleS’ Syrin9eS' Cord lies’ scissors/razor blade, and
Interview with pregnant woman
6. YES
NO____
Mark "yes" if the respondent answers correctly:
Prepare a clean birthing place?
7. YES.
NO____
67. YES
NO
Do you plan to have a trained health worker attend your
Assess potential complications and oiiiercicncles?
birth?
Take labour history
What are the danger signs during pregnancy
that require
68. YES.
NO.
Did the service
provider:
medical attention?1
9
YeI---------- no------------- Ask Whcn labour pains began?
69. YES
NO
When and where is your next prenatal visit?
10 YFq---------- m-0\k arb°Ut fre9uency of contractions?
If pregnant woman is at high-risk for any reason:
11 YRQ---------- MO------------- Ask 1 and when ba9 of watcr broke?
70. YES
NO
Do you plan to seek further medical attention?
12 YPq----- mo-Askab°Ut va9inal bleeding?
71. YES
NO
Do you plan to have your baby at a hospital?
13 YES
NO------------ aSl a*iOUt dark b,ack/9recn discharge (meconium)?
€‘: 9
Interview with service provider
Mark "yes" if the respondent answers correctly:
72. YES
NO
What are the danger signs during pregnancy that require
medical attention? 1
73. YES.
NO.
Do you refer high-risk pregnancies?
74. YES
NO
Do you have a way of tracking high-risk pregnancies?
75. YES.
Do you follow up pregnant women who do not return to pre
.NO.
natal sessions?
i
14 YES----- mo-----
a S.k When WOman in ,abour ,ast a{e?
YES------------ NO------------ a 7 W!,en W°man in ,abour ,ast passed st°ol?
---------------- Ask
woman in ,abour ’ast urinated and about problems
x/r-o----------------------------- urinating/
17’ VCC--------- m2-------------- Ask about anV medication
or treatment taken?
1/- YES--------- NO-------------- Ask about risk factors jf
no information is available from prenatal records?1
Conduct physical examination and monitor woman throughout labour
Did the service provider:
15
J•
1 Danger signs include swelling of hands and face, severe or prolonged dizziness, bleeding from vagina,
sharp or constant abdominal pain, fever, vaginal odour or discharge.
•
'■/'J
Module 6: Service quality; appendix B
J
XT
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?
i
" B“ G"“”
Module 6.- Service quality; appendix B
-
IB
e=3
70
18. YES
19. YES.
20. YES
21. YES22. YES.
‘8
■,=
J
I
I
71
Regularly take pulse?
Seek help for obstetric problems and emergencies
Regularly take blood pressure?
Did the service provider:
Determine strength and length of contractions?
51. YES
NO.
For shock and haemorrhage place mother in trendelenberg
Determine position of foetus?
position and treat (per local policy)?
Palpate cervix to determine thickness, firmness, and open
52. YES
NO.
Treat infection with antibiotics?
ness?
53. YES
NO.
For eclamp
23. YES
NO.
Determine whether bag of water has broken?
physical safety of mother during convulsions, and im
Determine
how
far
into
the
pelvis
the
presenting
part
has
24. YES.
.NO.
mediately deliver infant?
come (station)?
54. YES.
NO.
Attempt
NO.
25. YES.
Determine the presenting part and its position?
complete internal rotation?
26. YES.
.NO.
Feel for prolapsed cord, placenta previa?
Use appr
55. YES
NO.
27. YES
NO.
Regularly measure duration and frequency of contractions?
tion, such as footling, buttocks, face, brow, arm, shoulder pre
.NO.
23. YES
Regularly check foetal heart beat?
sentations?
.NO.
Regularly palpate abdomen to determine
29. YES.
56. YES any changes
NO. in foe
Provide other emergency care as
tal position?
57. YES.
NO.
Refer obstetric problems and emerge
Observe perineum for crowning, opening
of the vulva
39. YES.
NO.
58. YES
NOand/or
Perform episiotomy if indicated (per local policy)?
rectum to indicate beginning of second stage of labour?
59. YES
NO.
Assist with forceps, vacuum extraction, or symphisiotomy (if
NO
Regularly monitor blood loss?
31. YES.
indicated and according to local policy)?
D iagnose obstetric complications and emergencies
Provide immediate care for new-born
Did the service provider:
Did the service provider:
NO
32. YES
Diagnose dystocia if present?
60. YES
NO
Establish respiration/loud cry?
NO
33. YES
Diagnose haemorrhage and shock if present?
61. YES
NO
Tie umbilical cord in three places with sterile ties?
YES
NO
Diagnose eclampsia if present?
62. YES
NO
Cut umbilical cord with sterile scissors or razor blade; leave
YES
NO
Diagnose infection if present?
two ties on infant’s side?
NO
36. YES
Diagnose cause of any maternal distress if present?
63. YES.
NO.
Wrap in clean cloth and cover head to maintain warmth?
NO
37. Y ES
Diagnose cause of foetal distress if present?
64. YES.
NO.
Determine APGAR score at 1 minute and 5 minutes after
NO
Diagnose abnormal presentation of foetus if present?
38. YES
birth?
65. YES
NO.
Give the infant to the mother to suckle?
Assist progress of labour
66. YES.
NO.
Insert antibiotic eye ointment or silver nitrate drops into eyes
Did the service provider:
within one hour after birth?
NO
39. YES
Tell woman not to bear down until fully dilated and effaced?
67. YES
NO.
Immunize?
NO
40. YES
Encourage woman to urinate frequently?
68. YES.
NO
Administer Vitamin K?
NO
Reposition woman in labour or increase her activities (e.g.,
41. YES
69. YES
NO
Provide emergency care, as indicated?
walking) to help labour progress?
42. YES.
NO.
Administer low enema if bowelDeliver
is full of placenta
stool and woman in
labour cannot pass it (per local policy)?
Did the service provider:
.NO.
Administer anaesthetic or analgesic (per local
43. YES.
70. policy)?
YES
NO
Deliver placenta and examine for completeness?
71. YES
NO
Manually remove retained (partial or complete) placenta?
Assist with norma! delivery
72. YES
NO
:Establish breast feeding?
Did the service provider:
44. YES
NO.
Wash hands and mothers perineum?
Monitor mother immediately after delivery
Deliver head?
45. YES
NO
Did the service provider:
46. YES
NO
Support perineum to prevent tearing when foetal head is
73. YES.
NO
Regularly monitor blood pressure and pulse?
crowning?
74. YES.
NO.
Massage uterus within 15 minutes after delivery and regularly
47. YES
NO
Support foetus’s head as it passes over perineum?
thereafter?
48. YES.
NO.
Feel if umbilical cord is around foetus’s neck and slip it over
75. YES
.NO
Monitor blood loss?
head?
76. YES.
NO.
Administer ergonovine 1 mg if mother is bleeding heavily
49. YES
NO
Suck mucus and/or meconium from infant’s nose and mouth?
(per local policy)?
50. YES.
.NO.
Deliver shoulders and body?
Examine infant
Did the service provider:
77. YES
NO
Assess general appearance, alertness, tone?
NO
NO.
NO
NO.
NO
9
e=3
*
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i
ep
Module 6: Service quality; appendix B
i
Module 6: Service quality; appendix B
TBr”
72
NO
Take temperature?
78. YES_
YES
NO
Measure respiratory rate?
79.
_NO.
Measure heart rate?
80. YES
°------------ WWeigh?
eigh? ; head and feel for fontanelles and sutures?
81. YES-------- NNO
82. YES
NO
Examine
YFS
NO?
Examine eyes for redness, discharge, ja^dice, pallor.
83. YEs
no
Listen to chest to assess respiration and heartbeat.
84.
Yes
NO.
Palpate abdomen and liver?
85.
YES.
~NO_
Examine genitals for normality, hernias
86.
YES
NO
Examine for muscle tone and Muro reflex.
87. Yt-5------- _nq~ Examine extremities and skeletal system for symmetry, move
88. YES-------- - ----------ment, and broken or dislocated bones?
89 YES
NO
Inspect skin for sores, breaks?
90 YES.
~NO ______ Examine for birth defects?
91. YES
NO
Weigh?
93 YFS---------NO
RekHn^n^with medical emergencies and birth defects?
94 YES-------- NO.
Record labour and delivery information on labour charts
OS YFS ---- NO'
Watch for and record first urination and bowel movement.
YES
NO
Give BCG and OPV (per local policy)?
i
i
I
■d
1
J
B
NO.
112. YES.
NO.
113. YES.
NO.
114. YES.
.NO.
Well-child care:
Did the service provider:
115. YES
NO
116. YES
NO
117. YES.
NO.
118. YES.
NO.
119. YES.
NO.
120. YESNO.
121. YESNO
Education after delivery
122. YESNO.
Aftercare:
123. YES
NO
Did the service provider:
area
clean
and
demonstrate
124.
YESNO
Tell mother to keep her genital
97. YES
NO
125. YES.NO
how to wash her genitals?
YESNO. or
Tell mother to return to clinic if126.
gross
bleeding occurs
NO.
98. YES.
NO
127. YESchia remains red or has foul smell, or if she develops fever or
127. YESNO
other unexpected symptoms?
9
128. YES
NO
qq YES
NO
Tell mother to refrain from intercourse for 4- wee s.
100 YES-------- NO.
Tell mother to keep area around cord clean and dry.
101 YEsZZZno"
Tell mother not to put anything (soil/salve) or. the cord and
not to remove the ties?
...
102 YES
NO
Demonstrate how to bathe and clean infan , especia y
around umbilical cord?
,.
b's i103. YES
NO
Tell mother to bring infant to clinic if any redness or
charge from cord occurs?
Breastfeeding:
Did thesennceprwiden^
heahh benef.ts of breast feeding?
108. YES.
NO.
109. YES.
110 yes_
NO.
NO
Tell mother to keep nipples clean and dry to prevent crack
ing?
Demonstrate how to express breast milk to relieve conges
tion and prevent engorgement?
Demonstrate how to position infants mouth around areola
for breast feeding?
Tell mother to return if the infant has problems nursing?
Tell mother about child immunization?
Tell mother when to return for first postpartum visit and for
infant’s first well-child visit?
Verify that the mother understands warning signs for her
and/or her infant to return to clinic?
Verify that mother knows when to return for first postpartum
visit and for infant's first well-child visit?
Ask mother if she has any questions?
Supplies
107^IsZTZnoZZZZ Tell mother to breast feed infant frequently durmg the f.rst
r1
111. YES.
Do you have cord ties?
Do you have a razor or a pair of scissors?
Do you have gloves?
Do you have a watch with a second hand to take pulse?
Do you have a stethoscope?
Do you have a blood pressure cuff?
Do you have antibiotics?
Do you have anticonvulsants?
Do you have needles?
Do you have syringes?
€-p
TeU mother to use both breasts, feeding from one until it is
’
with the breast that is not the
breast she started feeding from last time?
.
.
Tell mother to continue breast feeding when she or infant is
ill?
flI
Module 6: Service quality; appendix B
Module 6: Service quality; appendix B
PHC service quality checklist
5: Postnatal care
'F
■i
This checklist is intended for use in supervision and monitoring of postnatal care provided by
clinic-based health workers, community^based health workers, and traditional birth attendants.
This list is comprehensive and includes some clinical tasks that traditional birth attendants
and other peripheral workers do not routinely carry out. The list should be modified and
simplified according to the local situation. It lsxrecommended that you review the checklist
carefully before using it to be sure that you understand the questions and know how to use
;ne form. For observation of service delivery, mark^ves" if the service provider carries out
these activities during service delivery. For interview questions, mark "yes" if the respondent
•. answers correctly.
X.
I
1
2.
3.
4.
I
i
J
1
Health facility
Service provider
Observer/supervisor
Date
r adical history
Did the service provider:
NO
5. YES
6. YES
NO
NO
7. YES
• £. YES
NO
NO
9. YES
10. YES
NO
11. YES
12. YES.
NO.
NO.
13. YES
14. YES.
NO
NO.
Physical examination
Mother:
Did the service provider:
15. YES
NO
I
''
$’• ■
:. YES.
.NO.
17. YES.
NO.
13. YES
YES
2Q. YES.
21 YES.
NO
jNO
NO.
NO.
I
€ s9
I
I
j BE •
I
I
1
Module 6: Service quality; appendix B
Sr —•
e
I_
1 a
I
Child:
Did the service provider:
44. YES
NO
9
NO.
NO
NO
Education
Breast feeding:
Did the service provider:
48. YES
NO
49. YES.
50. YES.
51. YES.
I ■
F
i
Record findings of history and physical examination on
health record?
Treatment, routine preventive services, and referral
Mother:
Did the service provider:
Provide iron and/or folic acid tablets (per local policy)?
39. YES
NO.
Provide nutrition supplements (per local policy)?
40. YES
NO.
Provide malaria chemoprophylaxis (per local policy)?
41. YES
NO.
Give other therapeutic medications to treat medical condi
42. YES NO.
tions as appropriate?
Refer maternal postpartum cases requiring special treatment?
43. YES.
NO.
45. YES.
46. YES.
47. YES
f 19
i.
NO
NO.
NO
_NO.
.NO.
NO.
Assess vital signs?
Measure height and head circumference?
Weigh child?
Monitor child’s growth with growth chart?
Examine head and fontanelle?
Assess eyes (for opacities, jaundice, infection)?
Assess respiration (rate, retraction)?
Assess heart (rate, murmur)?
Examine skin (pallor, jaundice, petechiae, infection)?
Examine extremities and skeletal system for symmetry, move
ment, and broken bones?
Examine umbilicus?
Assess general alertness?
Assess suction reflex?
Assess Moro reflex?
Assess response to brightness?
Assess response to sound?
Documentation:
Did the service provider:
38. YES
NO
6'1 £
Examine the abdomen for swelling, condition of caesarean in
cision, and to determine the size and firmness of the uterus?
Examine the genitals for swelling, discharge, bleeding, tears,
fistula, and episiotomy repair?
Examine the breasts for cracked nipples, engorgement, ab
scess?
Take pulse?
Take blood pressure?
Weigh the mother?
Examine eyes for signs of anaemia?
Child (first postnatal visit):
Did the service provider:
22. YES
NO
23. YES
NO
24. YES
NO
25. YES
NO
26. YES
NO
27. YES
NO
28. YES
NO
29. YES
NO
30. YES
NO
31. YES
NO
32. YES.
33. YES.
34. YES.
35. YES.
36. YES
37. YES
j
Ask mother when and where she delivered?
Ask mother the outcome of the delivery?
Ask about problems during delivery?
Ask mother about vaginal bleeding?
Ask mother about foul smelling vaginal discharge?
Ask mother if she feels pain or tenderness in the abdomen or
breasts?
Ask mother if she’s had a fever?
Ask mother if she is taking any medications, including contra
ceptives?
Ask mother what she is eating?
Ask mother about the infants eating habits?
/J
NO.
NO.
NO.
Give BCG vaccination or verify that child received vaccina
tion at birth?
Give first DPT and OPV (per local policy)?
If the child is malnourished, refer for nutritional counselling?
Refer the child for all physical conditions which need medical
attention?
Tell mother to feed infant with breast milk only, for the first
4-6 months?
Tell mother to eat extra food while she is breast feeding?
Recommend locally available protein-rich foods?
lell mother to breast feed even if she and/or infant is ill?
Module 6: Service quality; appendix B
v
/u
x )
Child-spacing:
Did the service provider:
52. YES
NO
53. YES.
NO.
54. YES.
NO.
Well child care:
Did the service provider:
NO
55. YES
56. YES
NO
NO
57. YES
58. YES.
.NO.
General:
Did the service provider:
NO
59. YES
NO
60. YES
61. YES.
I
NO.
Tell mother to refrain from intercourse for 4-6 weeks after de
livery?
Explain that breast feeding will not prevent her from getting
pregnant even if her periods have not begun?
Discuss family planning with the mother and tell her how she
can obtain child spacing services?
Tell mother about enrolling infant in well-child clinic?
Tell mother when and where to enrol child in clinic?
Tell mother when and where to take infant for first or further
immunizations?
Verify that mother understands key messages?
e
This checklist is intended for use in the observation of delivery of family planning services.
Before using it, the national treatment protocol should be reviewed in order to adapt the tool
to the local situation, if necessary. It is also recommended that you review the checklist
carefully before using it to be sure that you understand the questions and know how to use
the form. For observation of service delivery, mark "yes" if the service provider carries out
these activities during service delivery. For interview questions, mark "yes" if the respondent
answers correctly.
€
L sssa
1. _
2. _
3.
4. _
Provide counselling for specific medical problem(s)?
Tell mother when to return for next postpartum visit, if indi
cated?
Verify that mother understood key messages?
Supplies
Ask the service provider about the following supplies:
Do you have a working scale to weigh the mother?
.NO.
62. YES.
Do you have a working scale to weigh the child?
NO
63. YES.
Do you have a watch or time piece with second hand to meaNO
64. YES
sure pulse?
Do you have a stethoscope and blood pressure cuff?
NO
65. YES.
Do you have BCG, OPV, and DPT vaccines?
NO.
66. YES
Do you have iron tablets (per local policy)?
MO.
67. YES.
Interview with mother
Mark "yes" if the respondent answers correctly:
When should your baby receive his or her next vaccination?
NO
68. YES
For how long will you breast feed?
NO.
69. YES.
What will you do to space your births?
NO
70. YES
Is your child growing normally?
NO
71. YES
a
PHC service quality checklist
6: Family planning services
Interview with service provider
Mark "yes" if the respondent answers correctly:
Do you maintain records that identify recent mothers and in
NO.
72. YES.
fants for postnatal care?
Do you educate mothers about postpartum care during pre
NO.
73. YES.
natal cafe and delivery?
Do you discuss family planning during the postpartum visit?
.NO.
74. YES.
I Ml
-
€ ’^-9
e la
I
e sa
Health facility
Service provider
Observer/supervisor
Date
Medical and reproductive history (new clients)
Did the service provider:
5. YES
NO
Ask the client how old she is?
6. YES
NO
Ask about number, spacing, and outcome of pregnancies?
7. YES
NO
Ask about previous use of family planning methods?
8. YES
NO
Ask about reasons lor stopping or switching previous meth
ods?
9. YES
_NO
Ask about heart disease?
10. YES.
_NO.
Ask about liver disease?
11. YES.
_NO.
Ask about high blood pressure?
12. YES
_NO.
Ask about history of Pelvic Inflammatory Disease?
13. YES.
_NO.
Ask about history of suspected or confirmed venereal disease?
14. YES
_NO.
Ask about history of blood clots or thromboembolism?
15. YES.
_NO.
Ask if she is breast feeding?
16. YES
NO
Ask about date of last menstrual period?
Physical examination
Did the service provider:
17. YES
_NO
18. YES.
..NO
19. YES.
NO
Determine method
Did the service provider:
20. YES.
NO.
21. YES22. YES23. YES-
NO
NO.
NO.
24. YES.
NO.
Tike blood pressure?
Examine breast for lumps?
Examine patient for signs of anaemia?
Ask if and when the client and her spouse would like to have
children?
Describe contraceptive options to the client?
Ask about the clients preference?
Offer to discuss child spacing and methods with spouse or
family?
Recommend a method that was free of contra-indications for
this client?
1
I
f
I
Module 6: Service quality; appendix B
Module 6: Service quality; appendix B
25. YES.
NO.
26. YES
NO
For follow-up cases
Did the service provider:
27. YES
NO
28. YES
NO
29. YES
NO
Cc^aselling (for ail)
Did the service provider:
NO_
30. YES.
_NO_
31. YES.
NO32. YES
NO33. YES.
NO
34. YES.
NO
35. YES.
NO
36. YES.
37. YES.
38. YES.
J
I
i
'/V
“*’3
78
NO.
NO.
Verify that the client is comfortable with the recommended
method?
If necessary, refer the client to a doctor or. midwife?
Verify correct usage?
Ask about side effects?
Give advice about managing side effects?
PHC service quality checklist
7: Breast feeding‘2 3 4 5 6 7
€
W___
J
Explain the correct usage of the selected method?
Explain possible minor side effects of the selected method?
Explain how to manage side effects at home?
Explain major side effects which require medical attention?
Explain where and when to go for resupplies?
Explain where and when to go for routine follow-up?
Explain how to discontinue the method when pregnancy is
desired?
Verify that the client understands key messages?
Ask the client if she has any questions?
Sii- plies
Ask the service provider about the following supplies:
NO
Do you have a blood pressure cuff and stethoscope?
39. YES
NO
Do you have a supply of oral contraceptives?
40. YES
NO
Do you have a supply of IUDs?
41. YES
NO
Do you have a supply of injectable contraceptives?
42. YES
NO
Do you have a supply of implants?
43. YES
Ex< interview with client
Mark "yes" if the respondent answers correctly:
How do you use the contraceptive you received today?
NO
44. YES
What are the possible side effects?
NO
45. YES
Where can you get more supplies?
NO.
46. YES
When will you come back for a check up?
NO.
47. YES.
Service provider intervie!W
Mark "yes" if the respondent answers correctly:
Under
NO
L’..d- 1 what
----- conditions should you refrain from prescribing
48. YES
oral contraceptives?
Under what conditions should you refrain from prescribing
NO.
49. YES.
the IUD?
Under what conditions should you refrain from prescribing in
NO.
50. YES
jectable?
Under what conditions should you refrain from prescribing
NO.
51. YES.
implants?
1.
2.
3.
4.
Health facility
Service provider
Observer/supervisor
Date
Medical history
Did the service provider:
€
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3
I.
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I
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€‘“ S
i
Module 6: Service quality; appendix B
This checklist is intended for use in the observation of service delivery for promotion of breast
feeding.. Before using it, the national treatment protocol should be reviewed in order to adapt
the tool to the local situation, if necessary. It is also recommended that you review the checklist
carefully before using it to be sure that you understand the questions and know how to use the
form. For observation of service delivery, mark "yes" if the service provider carries out these
activities during service delivery. For interview questions, mark "yes" if the respondent answers
correctly.
r
5.
YES
NO
6.
YES.
NO.
7.
YES.
NO.
8.
9.
YES
YES.
NO.
NO.
10. YES.
NO.
Ask about the mothers knowledge, attitudes and beliefs
about breast feeding?
Ask about previous use of breast feeding with each child
born in the last five years?
Ask about duration of previous breast feeding and reasons
for stopping?
Ask about use of medications and alcohol?
Ask about any current illnesses that might affect breast feed
ing?
Ask about socio-economic status and dietary habits and in
take?
Breast feeding education and counselling
Skills Training:
Did the service provider:
ii. YES
NO.
Instruct mothers on the health benefits to mother and child
of breast feeding?
12. YES_
NO
Instruct mothers on the financial benefits of breast feeding?
13. YES_
NO.
Tell mother to feed colostrum (begin breast feeding as soon as
possible)?
Tell mother th
14. YES.
NO.
Tell mother to
15. YES.
NO.
few days?
1 PHC Management Advancement Programme, Module 5, User's guide
2 PRICOR Thesaurus, vol. 11. p. 232, 253
3 WHO, Indicators for assessing breast feeding practices, p. 4
4 Mothercare : Interventions to improve maternal and neonatal nutrition, Working Paper # 4, November
1990 (John Snow, Inc)
5 USAID, Maternal and child health in Bolivia: Report on the in-depth DHS Survey in Bolivia 1989, p. 49
6 USAID, Media promotion of breast feeding: A decade's experience, Nutrition Communication Project, p.
45
7 Breast feeding for child survival strategy, USAID, May 1990 p. 29-30, 38
Module 6: Service quality; appendix B
e
80
YES
16.
NO
17. YES.
NO
18.
Y£s
NO
20. YES.
NO.
21. YES.
22. YES.
NO
NO.
23. YES.
NO.
24. YES.
25. YES.
NO.
NO.
26. YES.
NO..
27. YES.
28. YES.
NO.
NO.
29. YES.
NO.
30. YES.
31. YES.
NO.
NO.
19.
I
1I
Nutritional messages:
Did the service provider:
YES
NO
32.
33. YES.
NO.
YES
34.
VFS_
35.
36 YES
NO_j
~NQ
37. YES.
38. YES.
NO
NQ
_NO.
Weaning:
Did the service provider:
39. breasts,
YES feeding
NO from one until
Tell mother to use both
it isthe importance of introducing complementary foods
Explain
during a two-month transitional period (i.e., months five and
six)?
40. YES.
NO.
Explain that children should be breastfed (not exclusively) for a
least one year and preferably for up to 2 years of age or beyom
41. YES.
NO.
Demonstrate preparation of weaning foods?
Tell mother to keep nipples clean and dry to prevent crackExit interview with mother
TeU mother to avoid using soap on Mark
nipples
andif to
breasts? answers correctly.
"yes"
theairrespondent
42.
2 Demonstrate how to express
breast
milk
to
relieve
conges
NO
For
howknow
longhow
will to
youcare
breast
YES
-------NO
Do
for feed?
your
. I
YES
NO
Doyou
you
know
what/how
much
youbreasts?
should be eating during
43. YES
tion and prevent engorgement?
NO
Do you
knowperiod?
the proper position to breast feed your child?
the
lactation
Demonstrate how to position infant44.
’s mouth around areola
45.
for breast feeding?
Tell mother to return if the infant has problems nursing/
Counsel on family planning methods with least effect on
quantity and quality of breast milk (spermicides, barrier meth
Interview with service provider
ods, progesterone only pills or injections, IUDs or abstinence)?
Mark "yes" if the respondent answers correctly.
Teach ways to increase contraceptive
benefits
breast feedExplain the length of time that mothers should breast feed?
46. YES
--------ofNO
ing (e.g., exclusive and frequent demand feeding for the first
47. YES
NO
Explain the health and economic benefits of breast feeding?
six months)?
. . 3
Use appropriate health education techniques and materials.
Encourage breast feeding among HIV positive women, if ap
propriate?
.
Explain that frequent bowel movements in the new-born indi
cate good milk intake and infrequent stools in the first few
weeks could be a warning sign?
_ Ask the mother to repeat key messages?
Ask the mother if she has any questions?
Explain the importance of feeding breast milk only, for the
first 4-6 months?
NO
empty, then from the other?
_ Tell mother to start feeding with the breast that is not the
breast she started feeding from the last time?
Tell mother to continue breast feeding when she or infant is
ill (diarrhoea, infection)?
e
u
i
a
JL
a;
§
I
Tell mother to increase her total food and liquid intake or to
balance her food intake and activities during lactation?
Explain to mother the administration schedule for nutrition
supplements, iron and/or folic acid tablets prescribed or dis
tributed for home administration?
Warn mothers of dangers of alcohol and drugs?
Tell mother about specific, nutritious, appropriate local foods
Discourage dietary taboos that restrict important foods/food
groups for lactating women?
Encourage those cultural practices that promote consump
tion of important foods for lactating women?
Discuss other feeding options with the mother?
£
Module 6: Service quality; appendix B
Module 6: Service quality; appendix B
e
PHC MAP service quality
Checklist 8: Growth monitoring/nutrition education
I
&
c
3.
4.
Base calculation on a reliable date of birth:’1
Correctly calculate date of birth?2
Correctly record age?
Weighing
Did the service provider.
_NO
_
3. YES
NO
9. YES
NO
10. YES
YES
NOJ
NO
12. YES
Set scale to 0?
Remove child’s clothing?
Place child correctly, on
- scale?
Correctly read scale?3
Correctly record weight?
Locating the child’s growth on chart
Did the service provider:
A
Piot or locate the child’s weight at correct age?
13. YES
NO
Plot or locate the child’s weight at correct weight?
14. YES
NO
Connect to previous growth point?
15. YES
NO
Referral and foliow-up
16.
YES
•' ----NO
17. YES
NO
NO.
Refer sick/malnourished child for medical attention?
Refer malnourished child for nutritional rehabilitation?
Growth monitoring and nutrition education
Did the service provider do the following for all children weighed:
18. YES
NO
Tell mother whether child has gained, lost, stayed the same
since last weighing?
1 Reliable sources for date of birth: growth chart, health record, or birth certificate. Rely on mother’s memory
only when these are not available.
2 The accuracy of age calculation and weight reading should be determined by comparing the health
worker’s reading with the supervisor’s reading.
3 The accuracy of age calculation and weight reading should be determined by comparing the health
worker’s reading with the supervisor’s reading.
o
V
Module 6: Service quality; appendix B
Tell mother the nutritional status of the -hild?
Use growth card to explain to mother how her child is grow
ing?
Did the service provider do the following for malnourished children and for children who have
not gained weight since the last session:
21. YES--------- NO------------Ask if the child has had any health problems since last weigh
ing?
22. YES.
_NO
Make recommendations regarding child feeding and care?
23. YES.
.NO.
Explain importance of good breast feeding and weaning prac
tices?
Explain which locally available food
24. YES.
NO.
a balanced
diet for children?
25. YES---------- NO----------- Explain how to feed children during illness?
26. YES---------- NO----------- Tell mother when to take child for next weighing?
27. YES---------- NO----------- Verify that mother understands key messages?
28. YES--------- NO
Ask mother if she has any questions?
j- — a
—
:__ _____ 1
... _ • _ 1a
•
ii
i
.
I
£
^ge calculation
Did the service provider:
~ YES '
NO
5.
NO
5. YES
7. YES
NO
NO
NO.
::
~his checklist is intended for use in the observation of service delivery for growth monitoring
.nd nutrition education. Before using it, the national treatment protocol should be reviewed
.a order to adapt the tool to the local situation if necessary. It is also recommended that you
review the checklist carefully before using it to be sure that you understand the questions and
’ now how to use the form. For observation of service delivery, mark "yes" if the service
rovider carries out these activities during service delivery. For interview questions, mark
yes" if the respondent answers correctly.
Health facility
. Service provider
Observer/supervisor
Date
19. YES
20. YES.
6
€: !
€ «
For outreach education sessions:
Did the service provider:
29. YES
NO
Explain the importance of gaining weight for health?
30. YES
■ NO
Explain the purpose of growth monitoring?
31. YES
NO
Explain when and where to go for growth mon:storing services?
32. /ES
NO
Use appropriate health education techniques and materials?
33. YES
NO
Demonstrate preparation of weaning foods?
34. YES.
NO
Verify that attendees understand key messages?
35. YES
NO
Use visual aids in transmitting key messages?
Supplies
Ask the service provider about the following supplies:
36. YES--------- NO
Working scale
37. \ ES
NO
Growth charts
Exit interview with mother
Mark "yes" if the respondent answers correctly:
38. YES--------- NO
How much does your child weigh?
39. YES--------- NO------------Did your child gain weight, lose, or stay the same since the
last weighing?
40. YES
NO
When will you return for growth monitoring?
If the child is malnourished:
YES-------- NO------------- Where will you take your child for nutritional rehabilitation?
QZ. YES-------- NO------------ What will you do to improve your child’s condition?
II
I
i-
i
r
Interview with service provider
43. YES-------- NO------------ Do you have a way of tracking malnourished children?
44. YES--------- NO----------- E)o you refer malnourished children for nutritional rehabilita
tionyou
or follow
medicalupcare?
YES--------- NO------------Do
malnourished children who do not come
45.
back for growth monitoring?
Module 6: Service quality; appendix B
K
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k.
|sai-
84
cm
1
PIIC service quality checklist
9: Immunization
i
un. -mi i ■■n ■■n >■■ ■ ihi 11 ■ ——rrT-nr t-^~"
Tills checklist is intended for use in the observation of service delivery for immunization.
Before using it, the national treatment protocol should be reviewed in order to adapt he too
w
answers correctly.
29. YES.
Identification of needed vaccinations
YFS_erViCg ^NO
Review health records to determine which immunizations are
5.
needed today?
YRS
NO
Review mother’s health record or ask mother whether she
6.
has received tetanus toxoid immunization?
Yes
NO
Review vaccination status of other children in the family?
7.
YES
NO
Recommend vaccination even if the child is sick?
8.
Preparation and care of vaccine
Did the service provider:
_ Check the label for the correct vaccine and to be sure the
9. YES
NO
vaccine has not expired?
in YES.
NO
Load the syringe without contamination?
vES.
NO.
Keep the vaccine
. and covered during the session?
Vaccination technique
Did the service provider:
_ Prepare the area of injection?
12. YES
NO
Use a sterile needle for each injection?
13. YES
NO
_
Use a sterile syringe for each injection?
14. YES
NO
__ Apply the vaccine at the right level? (BCG = dermal layer,
15. YES
NO
measles = subcutaneous layer, DPT/TT = muscle)
_ Properly dispose of the needle and syringe?
NO.
5
YES.
Was the child given all vaccinations needed today?
NO.
17. YES.
If the mother required TT, did the service provider vaccinate
NO.
18. YES.
her or arrange for vaccination?
I
25. YES
26. YES.
27. YES.
28. YES.
Health facility
Service provider
Observer/supervisor
Date
Documentation
Did the service provider:
19. YES
NO
20. YES
NO
22. YES.
23. YES
24. YES.
it
1.
2.
3.
4.
EPI education
Did the service provider:
21. YES
NO
30. YES
31. YES.
H
€ *3
E
s
J
I
$
6
Record the vaccination on the child’s health card?
Record the vaccination in the appropriate health centre record(s)?
Module 6: Service quality; appendix B
€’1 *•
lell the mother which vaccinations were given during this
visit?
.NO.
Inform
the and
mother
as fever
pain,that side effec
are possible?
_NO.
For BCG vaccination, exp
NO.
Tell mother where to go if she or the child should have a se
vere reaction to the vaccination?
NO.
Explain the imp
NO.
If DPT #3 has been administered, stress the importance of re
turning for measles vaccination?
NO.
Explain that
NO.
Tell when to come back for the next immunization for
mother or child?
Ask mother
NO.
be vaccinated?
-NO----------- Verify that mother understands key messages?
-NO
Ask mother if she has any questions?
1
Maintenance of cold chain and supplies
Observe the facility or ask health worker to determine the following:
32. YES
_NO_
Is the refrigerator working today?
33. YES.
NO__ -------- Is there a thermometer or cold chain monitor in the refrioeraI?
tor? .
34. YES
NO.
Is there a temperature log?
35. YES.
NO. -------- Is temperature recorded regularly according to the local
schedule?
Was th
36. YES.
NO.
at all times during the last month?
37. YES
_NO_
Are all vials in storage unopened?
38. YES
_NO
Were vaccines sufficient during the last month?
39. YES
_NO__
Were needles and syringes sufficient during the last month?
40. YES
_NO__ ------- Were vaccination cards suffic'
; i the last month?
r
-----------------------------------------------------------For outreach
41. YES
NO_
boxes with ice packs?
l
Exit in rview with mother or caretaker
Mark "yt • if the respondent answers correctly:
42. YES--------- NO
What immunization(s) did you or your child receive today?
43. YES--------- NO------------When should you return to the health centre for your next
immunization?
Interview with service provider
Mark "yes" if the service provider answers correctly:
44. YES--------- NO
At what age should a child receive BCG vaccine?
45. YES-------- NO------------ At what age should a child receive DPT vaccine?
46. YES-------- NO------------ At what age should a child receive Measles vaccine?
47. YES-------- NO
At what age should a child receive OPV vaccine?
48. YES
NO
Should you vaccinate a child if she/he is ill?
Module 6: Service quality; appendix B
I
F
I
L
87
6
PHC service quality checklist
10: Acute respiratory infection
This checklist is intended for use in the observation of service delivery for acute respiratory
infection. Before using it, the national treatment protocol should be reviewed in order to adapt
the tool to the local situation if necessary. It is also recommended that you review the checklist
carefully before using it to be sure that you understand the questions and know how to use
die form. For observation of service delivery, mark "yes" if the service provider carries out
these activities during service delivery. For interview questions, mark "yes" if the respondent
answers correctly.
1.
2.
3.
4.
11. YES.
.NO.
12. YES.
13. YES.
.NO.
.NO.
Physical examination
Did the service provider:
NO.
14. YES,
.NO.
15. YES
NO.
16. YES.
NO.
17. YES.
NO.
18. YES
.NO.
19. YES.
NO.
20. YES.
1-
NO
NO
NO
NO.
26. YES
27. YES
28. YES
29. YES
NO
NO
NO
NO
32. YES.
33. YES.
34. YES.
Ask about presence/level of fever?
Ask about duration of cough?
Ask about activity level?
Ask about ability to drink?
Ask about presence of sore throat?
Ask about presence of earache?
Administer/prescribe antibiotics for pneumonia, strep throat,
or otitis (per local policy)?
Refrain from using antibiotics for colds?
Administer or prescribe drug for fever (per local policy)?
Administer or prescribe cough mixture (per local policy)?
Refer children with severe pneumonia or cough lasting more
than 30 days?
ARI education
Did the service provider:
NO
30. YES
31. YES
NO
Health facility
Service provider
Observer/supervisor
Date
Medical history
Did the service provider:
NO
5. YES
NO
6. YES
NO
7. YES
NO
8. YES
NO
9. YES
NO
10. YES
21. YES
22. YES
23. YES
eep
F
25. YES
35. YES
36. YES.
I
37. YES.
38. YES.
39. YES
Explain how to administer antibiotics?
Explain the importance of completing entire treatment
course?
NO
Explain how to a
often, how long)?
Explain how to d
NO.
breast feeding)?
Tell mother to
NO.
ing during illness?
NO.
Tell mother to m
Tell mother abo
NO.
moderate/severe ARI?1
Tell mother to retur
NO.
condition worsens or does not improve?
-NO----------- Verify that mother understands key messages?
NO
Ask mother if she has any questions?
Essential supplies for ARI treatment
Ask the service provider about the following supplies:
40. YES--------- NO------------Do you have a watch with a second hand or other timepiece
to assess respiratory rate?
41. YES
NO.
Were antibiotic supplie
42. YES.
Do you have a the
NO.
ature?
Ask about any past history of respiratory problems (e.g.
asthma)?
Ask about family history of TB or other respiratory illness?
Ask about any treatment administered?
Assess general status (alertness, muscle tone)? Interview with mother
Count respiratory rate?
Mark "yes" if the respondent answers correctly:
43. YES
Take temperature?
NO
How will you treat your child at home?2
What danger signs indicate that you should bring child to the
44. YES--------- NO
Observe breathing for chest indrawing?
Listen for stridor, wheeze, and/or hoarseness?
health centre?1
If antibiotics we
45. YES.
Auscultate chest?
NO.
Examine throat for discharge, enlarged tonsils, or inflamed
medicine?
If antibiotics w
46. YES.
pharynx?
NO.
Examine neck for tender glands?
medicine to your child?
Examine ears?
Observe colour of lips, ears, face, and nail beds?
e:-s
Classification, treatment and referral
Did the service provider:
Classify child by severity of illness (cold, pneumonia, severe
24. YES NO
pneumonia)?
Module 6: Service quality; appendix B
1 Danger signs include stridor, chest indrawing/rapid breathing, inability to drink, cyanosis, anxiety, and
weakness or lethargy.
2 Supportive home treatment includes extra fluids, continued feeding, maintaining a neutral temperature,
clearing the nose, and using cough medicine or antihistamine (per local policy).
Module 6: Service quality; appendix B
■
88
Interview witli health worker
Mark "yes" if the respondent, answers correctly:
What are the signs and symptoms of pneumonia?1
NO.
47. YES.
How can you differentiate a cold from pneumonia?
NO.
48. YES.
49. YES.
NO.
50. YES.
51. YES.
NO
NO.
52. YES.
.NO.
How can you differentiate pneumonia from severe pneumo
nia?1
When do you prescribe antibiotics?
What home treatments do you recommend for colds and
pneumonia?2
When should you refer a child to the health centre/hospital?
3
I
ILW1
IE
J*
£
€ "'3
a
I
€
€
I
1 Severe pneumonia is defined as cases with respiratory rates over 50 for children from 2 months to 5
years old (over 60 for children under 2 months), and with danger signs such as severe chest indrawing,
inability to drink, or stridor.
2 Supportive home treatment includes extra fluids, continued feeding, maintaining a neutral temperature,
ciearning the nose, and using cough medicine or antihistamine (per local policy).
4
Module 6: Service quality, appendix B
eU
ep
PHC service quality checklist
11: Diarrhoeal disease control/oral rehydration therapy
This checklist is intended for use in the observation of service delivery for oral rehydration
therapy. Before using it, the national treatment protocol should be reviewed in order to adapt
the tool to the local situation if necessary. It is also recommended that you review the checklist
carefully before using it to be sure that you understand the questions and know how to use
the form. For observation of service delivery, mark "yes" if the service provider carries out
these activities during service delivery. For interview questions, mark "yes" if the respondent
answers correctly.
1.
2.
3.
4.
I'
Health facility
Service provider
Observer/supervisor
Date
Medical history
Did the service provider check for:
5. YES
NO
Duration of diarrhoea?
6. YES
NO
Consistency of stools?
NO
Frequency of stools?
7. YES
8. YES
NO
Presence of blood and/or mucus in stools?
9. YES
NO
Presence of vomiting?
10. YES
NO
Fever?
11. YES
NO
Home treatments?
Physical examination
Did the service provider:
12. YES_NO_
13. YES_NO_
14. YES_NO_
15. YES.
NO_
16. YES.
f
NO.
Assess general status (alert or lethargic)?
Pinch skin?1
Weigh child?
Determine nutritional status to be sure the child is not se
verely malnourished?
Take temperature?
f
!
J
Classification and treatment
Did the service provider:
17. YES.
NO.
Determine the degree of dehydration (none, moderate, se
vere)?
18. YES
NO
Prescribe safe ORS or cereal-based ORT?
19. YES
NO.
Recommend safe home treatment with ORS, or cereal-based
ORT?
20. YES.
NO.
Refrain from using antibiotics, except when stools contain
blood or mucus?
21. YES.
NO.
Refrain from using anti-diarrhoeals?
1 Health workers should also look for sunken fontanelle and examine the mucus membrane. These are
omitted here because they cannot be observed, however they could be included if the health worker is
asked to describe what he or she is doing.
Module 6: Service quality appendix B
I
I
91
90
22. YES.
.NO.
23. YES.
24. YES.
NO.
NO.
25. YES.
NO.
26. YES.
.NO.
28. YES
NO
ORT education
Did the service provider:
.NO.
29. YES.
NO.
30. YES.
NO.
31. YES.
If the child is dehydrated, administer ORS or cereal-based
ORT immediately or refer the child to a nearby centre?
Give sufficient amount of ORS solution?
Plan to reassess child’s hydration status after an appropriate
interval?
Rehydrate with intravenous fluid or naso-gastric tube if dehy
dration is severe?
Try ORS solution, if IV or NG tube are not available within
30 minutes of facility?
NG treatment, if child cannot drink, refer/evacuate for IV?
Tell mother to give extra fluids during diarrhoea?
Tell mother how to prepare ORS solution?
to give it?
32 YES.
NO.
.—I.
PHC service quality checklist
12: Water supply, hygiene, and sanitation
-
I
This checklist is intended for use in the observation of service delivery for education in water
supply, hygiene, and sanitation. Before using it, the national treatment protocol should be
reviewed in order to adapt the tool to the local situation if necessary. It is also recommended
that you review the checklist carefully before using it to be sure that you understand the
questions and know how to use the form. For observation of service delivery, mark "yes" if
the service provider carries out these activities during service delivery. For interview
questions, mark "yes" if the respondent answers correctly.
1.
Health facility
2.
Service
Tell mother how much ORS solution to give and how
often provider
3.
Observer/supervisor
4.
Date and
Tell mother about appropriate feeding
practices during
after diarrhoea?
!
Observation of health education sessions or individual counselling^
Tell mother about at least three signs of dehydration?
the signs
service
provider:
Tell mother about at least two Did
danger
that
indicate that
5. YES
NO
she should bring the child to health centre?
Explain that dirty water, human and animal waste, and refuse
YES
NO
Show
mother
how
to
prepare
ORS
solution?
can
cause disease?
35.
6. YES---------- NO
YES
NO
Show mother how to administer ORS solution?
Explain the link between water and sanitation and diarrhoea?
36.
7. YES
YES
NO
Verify that mother understands key information?.
NO
Explain that cleanliness can prevent disease?
37.
8. YES---------- NO
Discuss whether the woman has adequate access to water (i.e.
38. YES
NO_
Ask mother if she has any questions?
located within 15 mlniilrn of n water source)?
It there h a problem w
Essential supplies for ORT
9. YES.
NO.
Was the supply of ORS packets adequate for the past month?
39. YES
NO.
community efforts to address water supply problems and tell
Do you have the materials necessary (cup, spoon, water) to
40. YES
NO.
the woman how she can be involved?
pi epare and administer ORS solution?
Ufa ter storage and use
Did the service provider:
Exit interview with the child’s mother/caretaker
10. YES
NO
Discuss keeping water in a clean, covered container?
Mark ’’yes" if the icspondent answers correctly:
NO
How do you make ORS solution?
11. YES
NO
Recommend use of a long-handled dipper to remove water
41. YES
NO
How much ORS solution will you give your child?
from container?
42. YES
NO
How often will you give ORS solution?
12. YES_ __ NO.
Recommend keeping soap near the water storage container?
43. VF-S
aIumiKI bHnd wmiv ehiM
13 YE5v
NO
Ph<
fho hujvMtAiuxi of h.md u’rtthln;) taforti anting, fa^d
44. YES.______ NO________ WMt daiujer shjn* h^liCAte tlwt
back to the fiealth centre?
ing cfiildren, and food preparation?
14. YES.
NO.
Discuss the importance of washing hands with soap after
Interview with service provider
using the latrine, cleaning children, or handling refuse or ex
■ Mark "yes" if the respondent answers correctly:
.
J
creta?
45 YES
NO.
When you examined the child for dehydration, what physical
15.
YES.
NO.
Encourage use of safe water for drinking, cooking, and wash
signs did you look for?1
ing vegetables or fruit?
What
was
the
child
’
s
degree
of
dehydration?
NO.
46. YES.
Latrine maintenance and use:
Did the service provider:
16. YES
NO
Inspect latrine?
17. YES
NO
Recommend cleaning latrine daily with brush or broom?
18. YES
NO
Recommend making sure that latrine is absent of faeces?
1 Siqns for dehydration; 1) lethargy; 2) absence of tears while crying; 3) pinched skin retracts slow
1
Individual
counselling
should
be
carried out in cases of diarrhoea, or in any cases where the health worker
2 Danger signs : 1) many watery stools; 2) repeated vomiting; 3) very thirsty; 4) eating or drinking poorly,
feels that poor water and sanitation may constitute a health risk.
5) fever; 6) blood in stool; 7) child shows signs of dehydration.
33. YES.
34. YES.
NO.
NO.
I
II
Module 6: Service quality; appendix B
.V.
^>41
Module 6: Service quality; appendix B
I
92
19. YES.
20. YES
21. YES.
22. YES.
23. YES.
24. YES.
PHC service quality checklist
13: Childhood disabilities
Recommend making sure that latrine is absent of puddles?
Recommend making sure that latrine is absent of flies?
Recommend making water or paper available in latrine?
Advise not to use latrine for storage?
Advise to keep animals out of the latrine?
Discuss appropriate latrine use and human waste disposal
(e.g. baby potty for children under three)?
NO
NO.
NO.
NO.
.NO.
NO.
Q’
This checklist is intended for use in the observation of services provided by clinic-based and
community-based service providers to clients with Childhood Disabilities. In this instance,
the term "disabilities" will refer to clients who are crippled, who have trouble moving, speaking,
seeing, hearing, or learning, and who have physical, mental, or emotional handicaps.1 It Is
expected that providers will have different levels of training and expertise and have varied
Refuse and excreta disposal:
access to resources such as diagnostic, treatment, rehabilitation, and special education services.
Did the service provider:
Therefore, national management and treatment protocols should be reviewed in order to adapt
Recommend sweeping house and courtyard daily?
NO.
25. YES.
the tool to the local situation. PHC managers can use the checklist as a supervision tool to
Recommend keeping animals away from cooking and eating
MO.
26. YES.
determine whether services are delivered according to established norms.
areas?
Recommend collecting and drying animal excreta for ferti
NO.
27. YES.
NOTE: Questions included in this checklist were constructed from existing manuals and
liser, fuel, or as a construction material?
references on disabilities,2, 31 4’ 5 and from the reported field experiences of relevant clinicians
Recommend burning or burying refuse?
NO
28. YES
and
researchers.
Recommend
collecting
used
water
and
channel it6into the
MO.
29. YES.
garden?
NO
Recommend penning animals away from the house?
30. YES
1..
Health facility
Interview with health workers
2.
Service provider
Mark "yes" if the respondent answers correctly:
3.
Observer/supervisor
Do
NO
F you talk to individuals or groups about water and sanita
4.
31. YES
Date
tion?
Do you keep a list of neighbourhoods or households that do
NO.
32. YES.
Medical history
not have adequate access to water?
Did the service provider:
What do you tell mothers about how to keep the drinking
MO.
33. YES.
5. YES
NO
Ask the mother If she received prenatal care?
water at her home safe?
6. YES
NO
Ask the mother if her deliveries were attended by a health
What do you tell mothers about how to keep the latrine
NO.
34. YES.
worker or TBA?
clean?
7. YES
NO_
Ask the mother about the health/size of the newborn?
What
do
you
tell
mothers
about
refuse
disposal?
NO
35. YES
8. YES
.NO_
Ask the mother if the child’s growth was monitored?
NO__
9. YES
Ask the mother if the child is fully immunized?
Interview with mothers
10. YES
NO_
Ask the mother whether the child had any serious delay in
Mark "yes" if the respondent answers correctly:
NO
Has a health worker ever talked to you, individually or in a
sitting, standing, or walking?
36. YES
11. YES
NO.
group, about water and sanitation?
Ask the mother whether the child has difficulty learning to
Why is it important to wash your hands?
do things like other children his/her age?
.NO.
37. YES.
What do you do to keep 12.
the drinking
YES.
water
NO.at your home
For children 3 - 9 yrs. old, ask the mother whether the child’s
NO.
38. YES.
speech is in any way different from normal, e.g., not clear
safe?
What do you do to keep your latrine clean?
enough to be understood by people outside the immediate
NO.
39. YES.
family?
How do you dispose of refuse?
.NO.
40. YES.
ft
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1 This is the working definition used by the following contributors: Dr. David Marsh, Aga Khan
University, with Drs. Salma Alam, Ghaxala Parveen, Shafiq-ur-Rab, and Mohammed Zahid.
2 Helander, E., et al. Training In the Community for People with Disabilities, Geneva, WHO, 1989.
3 Thorburn, M.J, & Marfo, K, Practical approaches to childhood disability in developing countries-. Insights
from experience and research, 3D Projects, Spanish Town, Jamaica, 1990.
4 Wallace, H, "Health care of women and children in developing countries", Chapter 38, Handicapped
children and youth In developing countries, Third party publishing company, Oakland, CA, 1990.
5 Werner, D. Disabled Village Children, Hesperian Foundation, Palo Alto, CA, 1987.
6 See footnote 3. Also Dr. Pasquale Accardo, Chair, Section on children with disabilities, American
Academy of Pediatrics, provided some meaningful comments.
i
Module 6: Service quality, appendix B
"
......................
‘
Module 6: Service quality; appendix B
I
i
I
$
94
•;
If applicabl
NO.
can —identify
and
41. YES
For 2-year-old
children, ask whether he/she
if more than one child is known to have been born with a ge
say the name of at least one object?
netic condition?
NO
Ask whether the child has difficulty in walking, moving
Dis
NO.
42. YES.
his/her arms, or has weakness or stiffness in the arms or legs.
child?
N0
Ask whether the child has had trouble seeing, either
in the
15. YES.
Discu
NO.
43. YES.
daytime or evening?
with disabilities?
_Ask
whether
the
child
has
had
trouble
hearing?
NO.
16. YES_
Di
NO.
Ask the mother whether the child44.
hasYES.
had fits (e g.,
lost con
NO.
17. YES.
normally and can continue to be a productive member of the
sciousness, blank stares, twitching or other uncontrolled
community?
movements)?
..
. ,
, <
i
_ Ask the mother whether the child
has
had
any
behavioural
Interview with service provider
NO.
18. YES.
or emotional problems?
Mark "yes" if the respondent answers correctly:
19 YES
NO
Ask when the disability began?
Wh
NO.
45. YES.
or
relatives
have
had
a
sim20 YES
NO
Ask whether any family members
ties?
”~
ilar problem?
,9
W
NO.
46. YES.
Ask whether medical care was sought for the disability.
ments?
2L YES
NO-----What are some ways that disabilities can be prevented?
NO
47. YES
Physical exam
When should you refer cases for further diagnosis, testing, or
NO.
48. YES.
Did the service provider:
treatment?
YES
NO
.Note the presence of any deformities or defects.
22. YES.
Wha
NO.
49. YES.
NO
Check for normal range of motion in legs, knees, feet, hips.
23.
special schools, therapy and treatment centres, or specialists
YFS
NO
.Check for differences in leg length?
24. Yes
available to clients with disabilities?
NO.
Check muscle strength in legs, knees, feet, hips, shoulders,
25.
W
NO.
50.
YES.
back, arms or hands?
vising
or
organising
disability-related
activities,
such
as
reha
YES
NO
Check sense of balance and coordination?
26.
bilitation, special education, recreational activities?
27 YES
NO
Check reflexes in knee?
What
NO.
YES.
51
28 YES
NO
Check ability to touch or feel pain?
nity which are responsible for the above disability-related ac
29 YES
NO
Check for abnormal curve of the spine?
tivities?
30 YES
NO
—Examine ears and test hearing?
.Wh
NO.
YES.
52.
31 YES
.NO
.Examine and test eyes?
of
individuals?
32 YES.
NO
Examine oral cavity?
Exit interview with client
Case identification/referral
Mark "yes" if the client responds correctly:
Did the service provider:
53. YES
_ Administer/prescribe appropriate
treatment orNO
therapy ac What is your child’s disability?
NO.
33. YES.
NO
Do you know how he/she got it?
54. YES
cording to established treatment guidelines?
YES
NO
if applicable,
do you know how to prevent a similar disability
55.
..Make
the
appropriate
referral
according
to
established
guideNO.
34. YES.
from happening again?
What treatment did you receive
NO.
56. YES.
YES
NO
Record the case according to established guidelines?
35.
How do you administer it?
NO.
57. YES.
Where do you go for
Counselling client on childhood disabilities
NO.
58. YES.
What are some of the available therapy and treatment ce
NO.
59. YES.
Did the service provider: _ Provide adequate information about local or regional referral
tres and/or community groups which can help your child?
36. YES
NO__---services for people with disabilities (e.g., NGOs, specia
Wh
NO.
60. YES.
schools, therapy, and treatment centres)?
....
his/her disability?
Provide adequate information on local or regional medical
D
NO.
61. YES.
NO.
37. YES.
dressed
by
the
provider?
-Discus^with the client what may have caused the disability?
NO.
38. YES_
Discuss available medicine or treatment, if any?
NO.
39. YES.
Discuss any possible long-term outcomes associated with the
NO.
40. YES.
condition and, if applicable, the need for ongoing treatment/
13. YES.
VFS
14.
NO.
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Module 6: Service quality; appendix B
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Module 6: Service quality; appendix B
€
9b
PHC service quality checklist
14: Accidents and injuries1
This checklist is intended for use in the observation of service delivery for accidents and injuries.
Before using it, the national treatment protocol should be reviewed in order to adapt the tool
to the local situation if necessary. It is also recommended that you review the checklist
carefully before using it to be sure that you understand the questions and know how to use
the form. For observation of service delivery, mark "yes" if the service provider carries out
these activities during service delivery. For interview questions, mark "yes" if the respondent
answers correctly.
Health facility
Service provider
Observer/supervisor
Date
1. _
2.
3..
4..
Medical history
Did the service provider:
5. YES
NO
6. YES
NO
Physical examination
Did the service provider:
7. YES
NO
8.
j
4
YES.
NO.
i '9
€'
H
a
Correctly identify type of injury?
Obtain history of the injury (cause, time of injury, determine
type of poisoning, etc.)?
Administer proper treatment according to established guide
lines?
Make the appropriate referral according to established guide
lines?
Education on injury prevention
Did the service provider:
Discuss some common injuries and how they may be pre
NO
9. YES
vented?
Discuss the use of alcohol and dangers related to alcohol con
NO.
10. YES.
sumption?
Discuss the importance of proper storage of dangerous sub
NO.
11. YES.
stances?
Discuss occupational safety issues?
NO.
12. YES
Discuss child safety in and around the home?
NO.
13. YES.
Explain how to recognise an emergency?
NO
14. YES
Discuss location of emergency facilities in the area?
NO
15. YES.
Explain the importance of determining the cause of the in
NO
16. YES.
jury, particularly in the case of poisonings?
Exit interview with client
Mark "yes" if the respondent answers correctly:
24. YES
NO
What is your injury?
25. YES-------- NO
Do you understand how to care for the injury?
26. health
YES kind
NO
What
medication
you
given?
care of
facility
for help?
What
rehabilitative
carewere
does
your
injury
NOfollow-up
------------or
What
are
the danger
signs
that
warn
you to return to the
27. YES
-------Do
you
understand
how
to
take
this medication?
require?
28.
ture?
29. YES.
N0_
‘-I
.
Interview with service provider
1 his section can be used to assess the knowledge of the service provider depending on his oi
her training. A response should be judged correct if it is in agreement with local guidelines.
Mark "yes" if the respondent answers correctly:
17. YES---------- NO
What are some common injuries
18. YES--------- NO
How can these injuries be prevented?
19. YES--------- NO
How can you recognise an emergency?
20. YES--------- NO
Where can treatment be obtained?
21. Y ES-------- NO
When should a patient be referred?
22. YES--------- NO------------ How should a patient with an injury be transported?
23. YES--------- NO------------ What important information do you need to obtain from a
patient regarding their injury?
30. YES.
?
How can
§
NO.
€? ™ sS
■
€ rd
e? fd
i
1 Kirsch, T. and Kiess, L. Thesaurus of Injury care skills. Draft. Baltimore, MD, The Johns Hopkins University,
1992. ’
Module 6: Service quality; appendix B
F
I
7
Module 6: Service quality; appendix B
i
s
e
98
99
PHC service quality checklist
15: Sexually transmitted diseases and HIV/AIDS
■4
j
1
This checklist is intended for use in the observation of STD-related services which are delivered
by health care service providers in STD clinics, PHC centres, MCH facilities or FP clinics. It
is expected that providers will have different levels of training and expertise, and have varied
access to resources such as clinical, diagnostic, and treatment services Therefore, national
management and treatment protocols should be reviewed in order to adap the tool to the
local situation. PHC managers can use the checklist as a supervision tool to determine whether
services are delivered according to established norms. Because of the confiden ial nature of
the questions, supervisors may want to observe simulated visits rather than actual visits, or
to use an interview with the health worker rather than observation.
NOTE: Questions included in this checklist
materials2 3 and from related studies on counselling and education’
reported field experiences of relevant clinicians and researchers.
1
I
1
2.
3. __
4.
and drawn from the
Health facility
Service provider
Observer/supervisor
Date
*i
t:
£
eh
$
This section can^be used to assess the service provider who takes the medical history. The
purpose of taking the medical history is to alert the provider to possible types of infection
associated with STDs.
Did the service provider:
Ask about symptoms of infection such as prolonged fever?
NO
5. YES
unexplained weight loss?
YES
NO
chronic diarrhoea?
YES
NO
persistent cough?
YES
NO
visual symptoms?
YES
NO
1 World Health Organization: Management of patients with sexually transmitted diseases. WHO
2 Lamptey,1 P^o?P?TheAIDS prevention In A/rlca. Durham, NC, Family Health
3 World^lealth Organization, AIDS prevention: guidelines for MCH/FP Programme managers. Global
Programme on AIDS, Geneva, World Health Organization, 1990
4 Andrist, L, Taking a sexual history and educating clients about safe sex. Nursing Clinics of North
5Slwe,CD»jSuK,Cou2>W"nJAIOSn.l>ondl«A/o.AIDSp«wn<w.lnaAI«>. 1SI-190.
1
Module 6: Service quality; appendix B
NO
_NO
_NO.
_NO
_NO.
.NO.
NO
.NO
NO_
NO
11. YES.
NO.
12. YES
NO
€*
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1
6 3
genital ulcers?
. urethral/vaginal discharge?
painful or difficult urination?
mouth sores?
night sweats?
Ask about previous exposure to STDs?
Ask about treatments administered?
Ask about follow-up and compliance with treatment?
Ask about treatment of partner(s)?
Ask whether client has ever had transfusion of blood or
blood products?
Ask whether client has ever been exposed to non-sterile in
struments such as needles or knives?
If applicable, take the medical history in private?
■
Sexual history
The purpose of taking a sexual history is to alert the service provider to possible risk
behaviours associated with STDs. Due to the sensitive nature of the subject matter, the provider
should be careful to explain the reason for obtaining this information and to assure the client
of the confidentiality of his/her responses.
Did the service provider:
13. YES
NO.
Explain why taking a sexual history is useful in identifying a
condition?
14. YES
_NO
Assure the client that all responses will remain confidential?
15. YES.
NO.
Ask whether client is currently sexually active?
16.
17.
18.
19.
r. ,
Training and Materials Development Specialist, CDC; Alwood, C., NP, AIDS Clinic, Johns Hopkin
Hospital.
YES
YES.
YES
YES
YES.
6. YES
7. YES.
8. YES
9. YES
10. YES-
YES
YES
YES
YES
NO
NO
NO
NO
20. YES
NO
Ask whether client is active with more than one partner?
Ask about types of sexual practice?
Ask whether condoms are used during sexual activity?
Ask client for questions or concerns regarding his/her sexual
activity?
Take the sexual history in private?
Physical examination
This section can be used to assess how the physical examination is conducted given that
proper equipment such as an examination table, gloves, and speculum, may not be available.
Did the service provider:
21. YES
NO
If client felt feverish, take temperature?
22. YES
NO
Weigh client?
23. YES
NO
Examine oral cavity for signs of infection e.g., thrush?
24. YES
NO
Examine eyes (infant) for conjunctiva?
25 YES
NO
Check for swollen glands in the neck, armpit, or groin?
26. YES
NO
Tor women, check for lower abdominal pain/tenderness?
27. YES
NO
For women, examine cervix, vagina, and labia?
28. YES
NO
For men, examine .penis base, and scrotum, and retract fore
skin?
29. YES
NO_
Examine anus for ulcers or warts?
30. YES
.NO_
Check for possible skin infection?
31. YES
NO_
Take the necessary precautions to minimise exposure to
blood and body fluids during the examination?
Module 6: Service quality appendix B
I
iUU
'I
I
Case identification/treatment/referral
Guidelines for diagnosis, testing, treatment and referral of priority diseases or syndromes will
need to be reviewed in order to correctly identify and treat cases.
Pre- and post- test counselling for HIV antibody testing or S1 D laboratory testing
This section is applicable only if laboratory testing is indicated for the client and adequate
laboratory protocols and facilities are available.
Did the service provider:
With appropriate laboratory support:
54. YES
NO
Explain the testing procedure to the client?
Did the service provider:
i -Ea
55. YES
NO
Assure the client of the confidentiality of his/her test results?
Practise universal precautions before and after drawing a
NO.
32. YES
56. YES
NO
Discuss the meaning of a negative test result?
sample, e.g., blood, urethral/vaginal discharge?
57. YES
NO.
Discuss the meaning of a positive test result?
NO
Draw the sample according to protocol?
33. YES
58. YES
NO.
Discuss available treatment of conditions, if any?
NO
Take the recommended amount of specimen?
34. YES
59. YES
NO.
Discuss the importance of notifying a partner?
YES
NO
Seal
and
label
container
of
specimen?
35.
60. YES
NO.
Discuss the possibility that the infected client or partner may
NO
Complete record of transfer to laboratory?
36. YES
not yet have symptoms or show signs of being infected?
YES
NO.
Transfer
specimen
to
laboratory
within
prescribed
time
limit?
37.
61. YES.
NO.
Explain about some common symptoms which may occur as
I
ri
After testing is complete or in the absence of laboratory support *
a result of infection and should be reported to the provider?
Did the service provider:
i
For HIV positive women:
Identify disease according to established guidelines?
NO
38. YES
Did
the
service
provider:
Inform the client of the diagnosis?
NO
39. YES
62. YES
NO.
Advise client of the risks to a foetus/inf
Administer/prescribe appropriate treatment according to es
NO
40. YES
63. YES.
NO.
Give contrace
tablished treatment guidelines?
family
planning services?
Instruct client on tieatment compliance and when to
return?
41. YES.
NO.
YES. according
NO.to established guide
Suggest any pren
Make theI appropriate64.
referral
NO.
42. YES.
lines?
For mothers of HIV-infected newborns:
NO
Record the case according to established guidelines?
.NO.
43. YES
Did the service provider:
NO
Ask for questions from the client?
.NO.
44. YES
65 YES
NO_
Explain that the child could have many years of normal life?
I r
66. YES
NO
Encourage breast feeding and growth monitoring of the child?
Counselling client on prevention of ST D and HIV/A1DS
67. YES
NO
Recommend complete immunizations except BCG if the child
Counselling the client about STDs is intended to prevent behaviours that lead to infection
shows clinical signs of HIV infection?
and to provide support to those who are infected or are caring for someone who is infected.
I ffll
This section can be used if the medical/sexual history indicates that the client may be at risk
Counselling client with diagnosed STD
for STD.
In this section, counselling is intended to provide support to clients whose laboratory testing,
Did the service provider:
if available, and clinical findings indicate STD infection.
Inform the client about the ways in which STDs can be trans
45. YES
NO
Did the service provider:
I
mitted within that community?
68. YES
NO
Explain how the infection may have been transmitted?
Discuss some basic ways to prevent sexual transmission of
.NO.
46. YES.
69 YES
NO
Discuss available treatments, if any?
STDs?
70. YES
NO
Explain if the infection is curable, and if not, the long term ef
the
correct
and
consistent
use
of
conInstruct the client on
NO.
47. YES.
fects?
doms?
71. YES
NO
Discuss complications, if any, of disease or treatment?
Teach
client
how
to
recognise
some
common
symptoms
of
NO.
48. YES.
72. YES.
.NO.
Discuss the possibility that infected partners may not yet
S I Ds and understand the importance of getting correct treat
f
have symptoms or show signs of being infected?
I i ro#
ment?
73. YES.
NO.
Explain th
Explain that some STDs are not curable (HIV infection;
NO.
49. YES.
1
treated partner?
human papillomavirus)?
74. YES--------- NO
Explain that STDs may increase the transmission of HIV?
Explain that behaviours that may lead to STD also put client
.NO.
50. YES.
75. YES
NO
Counsel client in private?
at risk of HIV infection?
Provide the client with any available brochures or handouts?
Interview with service provider
NO
51. YES
Use available educational materials to instruct the client?
This section can be used to assess a service provider depending on his/her level of training,
NO.
52. YES.
education, and skill in the delivery of STD-related services. A response should be judged as
Ask for questions from the client?
NO
53. YES.
correct if it is in agreement with local guidelines and his/her level in these areas.
Mark "yes" if the respondent answers correctly.
76 Y ES
NO
What are some common examples of STDs?
1 When laboratory support is unavailable, the identification of STD cases may be based on the client’s
77. YES
NO
I low are HIV infection and AIDS defined?
medical/sexual history and physical examination alone.
I f «ol
3
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Module 6: Service quality; appendix B
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Module 6: Service quality; appendix B
103
.1 z
78. YES
79. YES.
NO
NO.
80. YES
81. YES
82. YES
83. YES
84. YES85. YES
NO
NO.
NO
NO
NO.
NO
8b. YES.
.NO.
How are they transmitted?
PHC service quality checklist
What are some signs or symptoms of a sexually transmitted
I
16: Malaria
disease? of HIV infection? of AIDS?
What are some risk factors for STDs?
What are some preventive measures against infection?
This checklist is intended for use in the observation of service delivery for malaria. Before
Which STDs may increase the transmission of HIV?
III
using it, the national treatment protocol should be reviewed in order to adapt the tool to the
I
What treatments are available?
local situation if necessary. It is also recommended that you review the checklist carefully
What tests should be carried out if you suspect infection?
before using it to be sure that you understand the questions and know how to use the form.
Who are the people at greatest risk of being infected in your
For observation of service delivery, mark "yes" if the service provider carries out these activities
I
I
area?
during service delivery. For interview questions, mark "yes" if the respondent answers
When and to whom should you refer cases for further diagno
correctly.
ses, testing, or treatment?
e
•v
■■
e*1!
!
Exit interview of client with STD
1.___
Health facility
Mark "yes" if the client responds correctly
2. ___
Service provider
NO
What is your illness?
87. YES
3. ___
Observer/supervisor
88. YES
NO
How do you think you got it?
4. ___
Date
89. YES
NO
How do you prevent giving what you have to someone else
and how do you prevent becoming infected again?
Medical
history
What treatment/medicine did you receive
or will
receive?
90. YES.
.NO.
Did
the
service
provider:
YES
91.
NO.
How much and how often will you take it?
5. YES
NO treatment,
Askorabout level of fever?
92. YES.
NO.
When and where will you return
for test results,
6. YES
NO
Ask about pattern of fever?
follow-up?
7. sexual
YES partnerNO
Ask about chills/sweats?
Were you asked to encourage your
to come
93. YES.
NO.
YES
NO
8.
Ask about headache?
for an examination?
{■R ) I
YES not addressed
NO
9. were
Ask about vomiting?
94. YES.
Do you have questions or concerns that
.NO.
10. YES
NO
Ask about convulsions?
by the provider?
11. YES
NO
Ask about anti-malarial drugs taken in last 24 hours?
Exit interview of client without STD
12. YES
NO
Ask about other symptoms to rule out other fever-related
Mark "yes" if the client responds correctly
illnesses?1
95. YES
NO
How are STDs transmitted in your community?
Physical examination
96. YES
NO
How can you protect yourself from getting an STD?
Did the service provider:
•' I
97. YES
NO
How would you know if you got an STD?
13. YES
_NO
Take temperature?
98. YES
NO
What would you do if you thought you had an STD?
14. YES
__NO.
Examine neck for stiffness?
99. YES
NO
Did you receive any educational brochures or handouts?
YES
_NO.
Palpate abdomen/stomach?
.NO
Do you have questions 15.
or concerns
that
were not addressed
100. YES.
16. YES
_NO.
Ascultate lungs?
. I
by the provider?
17. YES.
_NO
Examine ears, nose, throat?
18. YES.
_NO.
Examine skin?
19. YES
_NO
Weigh patient?
i
20. YES.
NO.
Make blood slide or refer case to a facility where a blood
slide may be examined?
21. YES.
NO.
Examine blood slide?
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Treatment and Referral
Did the service provider:
22. YES
NO
e !
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3
Module 6: Service quality; appendix B
Administer or prescribe appropriate anti-malarial drug ac
cording to local norms?
!
1 Other symptoms that might indicate a cause other than malaria are diarrhoea, cough, runny nose, sore
throat, ear pain, urinary symptoms (dysuria, frequency), and joint pain or swelling.
P-S'/iR.
\
Module 6: Seryfj^qualT^ appendix
lRfr v'
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J V-
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06762
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23. YES.
24. YES.
NO.
Refer case of cerebral or other serious/complicated or unresponsive malaria?
MO.
lated illness is suspected?
Malaria education and counselling
Did the service provider:
Tell how to administer anti-malarial drug?
27. YES
NO
Provide drugs or verify that client has access to drugs?
28. YES
NO
Discuss the importance of completing entire treatment
29. YES
NO
course?
•4
1
i
30. YES.
NO.
31. YES
32. YES
33. YES
34. YES
NO
NO
NO
NO
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- •
I
Explain the use of mosquito nets?
Explain the use of household spraying?
Tell where nets and sprays are available?
Explain how to eliminate standing water?
Chemoprophylaxis for pregnant women:
Did the service provider:
Explain which drug(s) can be used for malaria prevention?
46. YES
NO
■
■ » £
Ask the service provider about the following supplies:
50. YES
NO
Do you have a thermometer?
51. YES
NO
Do you have a stethoscope?
52. YES
NO
Do you have a scale?
53. YES
NO
Do you have a working microscope and slides?
54. YES
NO
Do you have chloroquine?
55. YES
NO
Do you have other anti-malarial drugs?
Discuss danger signs that may indicate unresponsive or com
plicated malaria?^
Tell client to return for consultation if danger signs develop?
Discuss prevention?2
Verify that client understands key messages?
Ask client if he or she has any questions?
Outreach education (household visits or group sessions):
Case identification and treatment
Did the service provider.
Ask if anyone in the household has fever?
35. YES
NO.
Explain malaria signs and symptoms, especially fever?
36. YES
NO.
Explain importance of immediate treatment of malaria (fever)
37. YES
NO.
in the home?
Explain which drug(s) should be used to treat fever in the
.NO.
38. YES.
home?
Explain recommended treatment schedule for anti-malarial
NO.
39. YES.
drugs?
Explain where drugs can be obtained?
NO.
40. YES.
Explain indications for seeking medical care?
NO.
41. YES.
Preuention:
Did the service provider:
42. YES
NO
43. YES
NO
44. YES
NO
45. YES
NO
■
Supplies
If fever is over 39 degrees centigrade:
25. YES
NO
Administer anti-pyretic drug?
26. YES
NO
Sponge or bathe with water?
1
NO.
Explain recommended anti-malarial drug administration
schedule for prevention?
Discuss possible side effects?
NO.
48. YES
Refer for further diagnosis/treatment
if other serious
49. YES.
NO. fever-reExplain when and where to go to obtain chemoprophylaxis
services?
■ I F 0^
47. YES.
•11
1 Danger signs include: unconsciousness, severe drowsiness, fever continuing for more than two days after
initiation of treatment, relapse of fever within three weeks.
2 Preventive measure include chemoprophylaxis, the use of mosquito nets, household spraying, and
eliminating standing water.
Module 6: Service quality; appendix B
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Module 6: Service quality; appendix B
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■.
PHC service quality checklist
17: Tuberculosis
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Health facility
Service provider
Observer/supervisor
Date
Medical History
Did the service provider:
NO
5. YES
6. YES
NO
NO
7. YES
NO
8. YES
NO
9. YES
10. YES
NO
Physical examination
Did the service provider:
11. YES
NO
12. YES
NO
13. YES
NO
14. YES
NO
15. YES
NO
16. YES
NO
heatment and referral
Did the service provider:
17. YES
18. YES
19. YES
20. YES
21. YES
NO
NO
NO
NO
NO
For follow-up cases
Did the service provider:
22. YES
NO
23. YES
NO
24. YES-,NO
ii
3
Ask about persistent cough (2 weeks or more)?
Ask about persistent fever (1 month or more)?
Ask about weight loss?
Ask about blood in sputum?
Ask about persistent chest or back pain (1 month or more)?
Ask if household members or neighbours have had similar
symptoms?
Take temperature?
Take respiratory rate?
Take pulse?
Weigh patient?
Lymph node examination?
Auscultate lungs?
Perform cutaneous TB test (per local policy)?
Tell the patient that he has (or may have ) TB?
Refer for sputum examination?
Refer for chest X-ray?
Prescribe medicines or refer for treatment according to local
norms?
Correctly verify that client is taking medicine?
Assess client’s progress?
Ask about side effects or adverse reactions?
Module 6: Service quality; appendix B
NO.
26. YES.
NO.
Health education
Did the service provider:
27. YES
NO
28. YES
NO
29. YES
NO
30. YES
NO
31. YES
NO
32. YES
NO
This checklist is intended for use in the observation of service delivery tuberculosis. Before
using it, the national treatment protocol should be reviewed in order to adapt the tool to the
local situation if necessary. It is also recommended that you review the checklist carefully
before using it to be sure that you understand the questions and know how to use the form.
For observation of service delivery, mark "yes" if the service provider carries out these activities
during service delivery. For interview questions, mark "yes" if the respondent answers correctly.
2.
3..
4..
25. YES.
1
&I
33. YES
34. YES.
NO
NO.
35. YES.
36. YES.
NO
NO.
If side effects are present: give advice about managing.side ef
fects?
Change treatment procedure if necessary?
Explain where to go for examinations/lab tests?
Explain how much and how often to take medicine?
Stress the importance of completing the treatment?
Inform the patient if he or she is contagious?
Discuss how to prevent spread of the disease?
Discuss danger signs and adverse reactions that require fur
ther care?
Tell when to return for a follow-up visit?
Discuss the importance of testing and treating family mem
bers with similar symptoms?
Verify that the patient understood key messages?
Ask if the patient has any questions?
Supplies
Ask the service provider if he or she has the following supplies:
37. YES
NO
Thermometer?
38. YES
NO
Watch?
39. YES
NO
Stethoscope?
40. YES
NO
Scale?
41. YES
NO
Cutaneous TB test?
Interview with patient
Mark "yes" if the respondent answers correctly:
42 YES
NO
What is your illness?
43 YES
NO
Did you receive medicine or a prescription?
44 YES-------- NO
If prescription: do you know where you can get the needed
medicine?
How much and how often
45. YES.
NO.
Did the healt
46. YES.
NO.
you to have a sputum test?
47 YES
NO
If test was arranged: Where will you go for the test?
48. YES.
NO.
What can you do to prevent the spread of the disease?
49. YES
NO
What are the danger signs that indicate that you should
come back to the health centre?
When will you come back fo
50. YES.
NO.
I
Interview with service provider
Mark "yes" if the respondent answers correctly:
51 YES
NO
What are the signs and symptoms of TB?
52. YES
NO
What tests should be carried out if TB is suspected?
53. YES
NO
What medicines do you use to treat TB?
54 YES
NO
How much and how often should that patient take the medi
cines?
What are the d
55. YES.
NO.
quires further care?
■
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Module 6: Service quality; appendix B
108
PHC service quality checklist
18. Treatment of minor ailments
cm=.d the
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Health facility
Service provider
Observer/supervisor
Date
l._
2..
3,
4..
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Diagnosis
Did the service provider:
10. YES
NO------
e '! 9
dicitis, etc.)?
Laboratory diagnosis
Did the service provider:
11.
co.---------
-
pveliminary diagnosis.re|ated diagnostic
(|aboratory tcstSi x-ray studies, etc)
Treatment and follow-up plans
Did the service provider:
appropriate treatmen( acco ding to the condition?
14 YFS-------- NO
~ Provide information to the patient about the condition and
18 YES.
NO
21 YES--------- NO.
99 ypc
NO
23 vFsZZZnQ-
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1 F
Kscussdw'mportance of compliance with the drug therapy?
How often will you take this medicine?
What is the dose you will take?
For how long will you continue treatment?
This checklist is intended for use in the observation of service delivery for hypertension. Before
using it, the national treatment protocol should be reviewed in order to adapt the tool to the
local situation if necessary. It is also recommended that you review the checklist carefully
before using it to be sure that you understand the questions and know how to use the form.
For observation of service delivery, mark "yes" if the service provider carries out these activities
during service delivery. For interview questions, mark "yes" if the respondent answers correctly.
1__
2. _
3. _
4. _
■ * ‘9
If diastolic blood pressure is over 90: Did provider ask the patient about:
11 YES
NO
Chest pain?
12. YES
NO
Shortness of breath?
Medical history
Did the service provider:
13. YES
NO
14. YES
NO
15. YES
NO
YES
YES
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
NO
NO
23. YES
24. YES.
_NO
16.
17.
18.
19.
20.
21.
22.
NO____
Ask about chief complaints?
Ask about duration of hypertension?
Ask about family history of hypertension?
Ask about previous or current treatment and response?
Ask about history of diabetes, stroke?
Ask about previous heart trouble, chest pain?
Ask if patient has had excessive thirst?
Ask about swelling, varicose veins and blood clots?
Ask about current lifestyle (work, stresses, home conditions)?
Ask about eating habits, smoking, alcohol and drug consump
tion?
Ask about previous serious illness?
Ask about medications patient is taking now?
Physical examination
Did the service provider:
■i ■
I
Take a blood pressure reading?
_Make sure proper cuff size was utilised in taking blood pres
sure?
If diastolic blood pressure is 115 or more: Did provider ask patient about:
NO_
“7. YES
NO
Blurry vision?
8. YES
NO
Severe headache that is getting worse?
NO9 YES
NO.
NO
. Chrmg<'in mental status (sleepy, confused)?
10. YES
NO
N()_
Seizure?
25. YES
Module 6: Service quality; appendix B
!•
Health facility
Service provider
Observer/supervisor
Date
Initial reading
Did the service provider:
5. YES
NO
6. YES
NO
Medical history
Did the service
------- provider:
Q J
AsR about thc chief complaint (fever, pain, cough, etc)?
5. VFS
NO
Determine the present history of the illness.
6. vEsZZZnODetermine condition-related past and family history.
7.
Physical examination
Did the service provider:
Check vital signs (blood pressure, temperature, pulse, respira
8. YES
NO--------- -tion rate etc.)
Conduct aa related
related physical
physical exam.
exam?
9 YES
NO
Conduct
-E.SS
PHC service quality checklist
19a: Hypertension
NO
Check vital signs?
Module 6: Service quality; appendix B
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11U
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26. YES.
27. YES.
28. YES.
29. YES.
30. YES.
31. YES
32. YES.
33. YES.
34. YES
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4
NO_
NONO.NO
NONO.
NO_
.NONO-
Check and record blood pressure in both arms?Interview with service provider
Mark "yes" if the respondent answers correctly.
64. YES
NO
What blood pressure measurement is considered high blood
pressure?
Check neck veins?
Feel for thyroid?
Listen to lungs?
Listen to heart?
Check for oedema in lower legs?
Check for pulse in top of foot?
Examine abdomen?
Conduct urinalysis?
Hypertension education and counselling
40.
39.
YESservice provider:
NO.
NO
Did the
Explain hypertension?
35. YES
NO.
Explain the prognosis?
36. YES
NO.
38.
NO.
Inform patient of blood pressure level?
37. YES
YES
NO.
Explain lack of symptoms?
Explain treatment goal?
Provide patient with regimen sheet for systematic antihyper
tensive therapy?
Explain how to take medication?
41. YES.
.NO.
Discuss importance of taking medication daily?
42. YES
NO
Discuss the possible side effects of medication?
43. YES
NO
Discuss possible warning signs of high blood pressure?
NO
44. YES
Tell patient to return if warning signs appear?
45. YES.
NO.
Advise patient to restrict sodium and fat intake?
NO.
46. YES.
Advise patient to avoid nicotine?
.NO
47. YES.
Advise patient to lose weight if overweight?
48. YES.
.NO.
Discuss the importance of following the prescribed diet?
49. YES
NO.
Verify that patient understands key points?
NO
50. YES.
Ask if the patient has any questions?
51. YES.
.NO.
Supplies
Does the service provider have the following supplies:
52. YES
NO
A stethoscope?
53. YES
NO
Blood pressure cuffs (different sizes)?
54. YES
NO
Medications available to treat emergencies?
55. YES
NO
Medications used in treatment of hypertension?
65. YES.
NO.
66. YES.
NO.
67. YES.
.NO.
68. YES
69. YES.
NO.
NO.
I
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j
When should patient be referred to a physician for an emer
gency?
At what point entreatment should a patient be referred to a
physician?
What drugs should be prescribed for the treatment of hyper
tension?
What kind of diet should be prescribed for hypertension?
How can hypertension be prevented?
& -s
ep
Exit interview with client or caretaker
Mark "yes" if the respondent answers correctly.
56. YES
NO
Why is it important to have your blood pressure checked at
least once a year?
Where can you have your blood pressure checked?
57. YES
NO
NO.
Where can you receive treatment?
58. YES
How should you take medication?
59. YES_
NO.
Why is it important to follow treatment instructions daily?
- !■ 60. YESNO.
How often should you have your blood pressure checked?
61 YESNO.
62. YES
NO
What danger signs indicate you should return to clinic?
What can you do to prevent hypertension?
63. YES
NO
e: 3
e 3
Module 6: Service quality; appendix B
I
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Module 6: Service quality; appendix B
r
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i
112
PHC service quality checklist
19b: Diabetes mellitus 1 2
?
5
$1
This checklist is intended for use in the observation of service delivery for diabetes mellitus.
Before using it, the national treatment protocol should be reviewed in order to adapt the tool
to the focal situation if necessary. It is also recommended that you review the checklist
carefully before using it to be sure that you understand the questions and know how to use
the form. For observation of service delivery, mark "yes" if the service provider carries out
these activities during service delivery. For interview questions, mark "yes" if the respondent
answers correctly.
1..
2.
3..
4.
I
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€p
Health
Service provider
Observer/ supervisor
Date
Medical history
Did the service provider:
5. YES
NO
YES
YES
YES.
YES.
YES
YES.
YES.
YES.
. Ask about early symptoms such as frequent urination, un
usual thirstiness (dry mouth), loss of appetite, nausea, vomit
ing and weight loss?
NO
blurry vision that comes and goes?
.NO.
vaginal itching or yeast infections (if patient is a woman)?
.NO.
_gum swelling or soreness?
.NO.
chest pain, especially when exercising?
.NO symptoms of urinary tract infection, such as pain or burning
when urinating?
.NO.
_foot problems such as a sore or injury that does not heal, a
change in the skin or toe nails, or numbness?
NO____
.numbness, tingling, weakness or pain in any part of the body?
NO____
.other infections that don’t clear up (skin, gums, urine)?
Physical examination
Did the service provider:
6. YES
NO
7.
8.
YES
YES.
NO.
.NO.
9.
YES.
NO.
10. YES.
11. YES.
NO
.NO.
e 3
13. YES
14. YES.
NO
NO.
15. YES
16. YES.
NO
NO.
Check the gene
shape?
Check for pitting oedema by pressing thumb over shin bone?
Check for strength of pulse in each foot (top of foot) and be
hind medial ankle bone?
Check for poor blood supply, if pulse in foot is weak?
Conduct lab tests for blood sugar and urine dipstick for pro
tein, glucose and ketones?
Diabetes education and counselling
Did the service provider:
17. YES
NO.
Discuss diet guidelines, such as avoidance of sugars and fats,
and eating more fibre?
18. YES
NO.
Discuss weight control and diet, if the patient is overweight?
19. YES
NO.
Recommend regular exercise, after consultation with doctor?
20. YES
NO
Demonstrate how to do blood and urine tests?
21. YES
NO.
Discuss the importance of avoiding/stopping smoking?
22. YES
NO
Discuss how to teach the family about handling common dia
betic emergencies?
23. YES
NO
Ask the patient to repeat key messages?
24. YES
NO.
Ask the patient if he/she has any questions?
Foot Care:
Did the service provider:
25. YES
NO
Discuss the importance of proper foot care (i.e. daily, gentle
cleansing)?
26. YES
NO.
Discuss foot protection?
27. YES.
NO.
Recommend not walking barefoot and wearing proper fitting
shoes?
28. YES.
NO
Discuss avoiding injury from heat or cold?
29. YES.
NO.
.Discuss cutting toe nails straight across with proper instru
ments, and not cutting calluses?
30. YES.
NO.
Recommend wearing soft, dry socks without tight elastic, and
using foot powder to keep feet dry?
32. YES
B
■
■*
Module 6: Service quality; appendix B
NO.
Women of child bearing age:
Did the service provider:
31. YES
NO.
Check the patients general appearance, vital signs and
weight?
Check lor fast, deep breathing, or acetone breath?
Check for signs of dehydration such as weight loss and dry
mouth?
Observe mental changes (confusion, sleepiness, unconscious
ness)?
Do Snellen test, if patient complains of change in vision?
Check gums for inflammation, tenderness, redness, swelling?
1 Burgess, R., Community health aide/practitioner manual, 55-58, Washington, DC, United States
Department of Health and Human Services, 1987.
2 Hoole, A., Greenber, R., & Pickard, G., Patient care guidelines for family nurse practitioners, p 265-272,
Boston, MA, Little Brown and Company, 1976.
12. YES
e
6
Discuss the impo
within a specified range before and during pregnancy to pre
vent birth defects?
-NO------------ Refer high risk pregnancies (per local policy)?
Exit interview with the patient
Mark "yes" if the respondent answers correctly?
33. YES--------- NO------------ Do you know what medications to take, and when?
34. YES--------- NO
Where will you get the needed medicine?
35. YES--------- NO------------ How will you administer the drug (how much, how often, for
how long)?
What dang
36. YES.
NO.
health facility?
What will you do to care for your d
37. YES.
NO.
Module 6: Service quality; appendix B
1
115
114
Interview with service provider
Mark "yes" if the respondent answers correctly.
What are. the
38. YES
NO
•’ signs and symptoms of diabetes that require fur
ther medical attention?
When should you refer a case for further diagnosis?
NO.
39. YES.
What measures can be taken to prevent or care for diabetes?
.NO.
40. YES.
PHC service quality checklist
19c: Anaemia
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Module 6: Service quality; appendix B
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This checklist is intended for use in the observation of service delivery for anaemia. Before
using it, the national treatment protocol should be reviewed in order to adapt the tool to the
local situation if necessary. It is also recommended that you review the checklist carefully
before using it to be sure that you understand the questions and know how to use the form.
For observation of service delivery, mark "yes" if the service provider carries out these activities
during service delivery. For interview questions, mark "yes" if the respondent answers
correctly.
1.
2.
3.
4.
Health facility
Service provider
Observer/supervisor
Date
Medical history
Did the service provider:
NO
5. YES
NO
6. YES
NO
7. YES
8. YES
NO
9. YES
NO
Ask about chief complaints: whether pregnant?
Ask if there is any blood in stool?
Determine the occult blood in the stool?
Ask about menstrual history?
Ask whether vomit with blood?
Physical examination
Did the service provider:
10. YES
NO
11. YES
NO
12. YES
NO
13. YES
NO
14. YES
NO
15. YES
NO
Take pulse and blood pressure?
Check colour of conjuctiva?
Check occult blood in stool?
Ask about family anaemia history?
Ask about previous or current treatment and response?
Give complete physical examination (chest, abdomen, etc.)?
Laboratory test
Did the service provider:
16. YES
NO
17. YES
NO
18. YES
NO
19. YES
NO
20. YES
NO
Get complete blood count with reticulocite count?
Get sedimentation rate?
Determine haemoglobin type (region, race, age or sex)?
Determine iron binding capacity?
Get full chemical analysis (calcium, potassium etc.,) (optional)?
Diagnosis treatment, nutrition education
Did the service provider:
21. YES
NO
Determine the aetiology of the anaemic condition?
22. YES
NO.
Determine appropriate consultation (referral to a specialist, if
needed)?
Provide appropriate treatment according to condition?
23. YES
NO.
24. YES.
NO.
Provide nutrition counselling?
Module 6: Service quality; appendix B
110
6*:
Women of child bearing age
PHC MAP Service quality checklist
Did the service provider:
20: Client satisfaction
25. YES
NO.
Discuss the importance of proper nutrition (high in iron) and
iron supplementation during pregnancy?
26. YES.
NO.
Schedule a return/follow-up appointment
after
weeks
of quality checklists to assess the clinical performance of
In addition
to 46
using
service
treatment to evaluate treatment response?
providers, it is useful to assess provider performance from the patient or client perspective.
Provide a referral to a specialist This
if anaemia
is due
a malig
27. YES.
NO.
checklist
willtothus
enable
managers to 1) examine the degree to which services and
nant condition?
providers meet the expectations of the client, and 2) identify opportunities to improve the
quality of care based on the clients perspective.
Exit interview with client
Mark "yes" if the respondent answers correctly:
Do you know about what diet is good for you?
28. YES NO
The dimensions of client satisfaction
NO
Do you know how to administer the drug (how much, how
29. YES
Client satisfaction consists of a number of dimensions, each of which should be addressed in
often and how long)?
a client satisfaction survey. These dimensions include:
30. YES
.NO
Do you know where you can get refills for the drug?
of services: Do clients feel they can easily take advantage of services? How
31. YES.
.NO.
Do you know why you need to complyAccessibility
with the drug/nutriconvenient are services for clients?
tion therapy?
Facilities, equipment and supplies: Do clients feel that the health facility (hospital, clinic,
Interview with service provider
health centre, outreach service), equipment and supplies are acceptable to them?
Mark "yes" for correct answers:
Availability of services: Do clients believe that the providers and services they need are
32. YES.
NO
What are the signs and symptoms of anaemia?
available?
33. YES.
.NO.
Under what conditions should you refer a client to a special
Continuity of care: Do clients feel that the same level of care is provided from visit to visit
ist?
or from provider to provider?
34. YES.
.NO.
How can you care for anaemia?
Interpersonal qualities of service provider: Do clients feel that the provider possesses
adequate interpersonal skills?
Professional competence: Do clients feel that the provider’s technical skills and knowledge
are adequate?
Cost: Are clients satisfied with the cost of the service?
Resulting health status/Efficacy of treatment: Are clients satisfied with their health
outcome after service is provided to them?
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Module 6: Service quality; appendix B
How to use the checklist
This checklist can be used:
• as part of an exit interview at the health facility,
• as a guide for discussion in a focus group setting,
• as part of a comprehensive household interview survey, or
• as a questionnaire distributed to clients.
This checklist is designed to be used as a client interview at the time of the clinic encounter.
Depending on how you choose to use the instrument, the wording and tense of questions
can be changed to reflect the client’s experience during the last clinic visit, or to assess a more
general level of satisfaction with services regardless of what visit. When modifying the
checklist consider all the dimensions and adapt, or add questions or delete those you feel are
not relevant for your situation.
A pre-test of the checklist may allow you to identify the issues of concern for the facility.
In a pre-test, you should be able to identify the major issues which clients believe should be
addressed and then modify the instrument to collect that information.
You may also wish to change the order in which the questions are asked. One way is to
structure questions so that they follow the flow of activities in the health facility, e.g.,
registration, examination by the provider, referral, etc. However you modify the instrument,
keep in mind that questions should be organised to facilitate response by the client, not just
to make it easier for the interviewer.
Module 6: Service quality; appendix B
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You may find that a YES/NO format limits the range of responses to a given question, in
which case a rating scale may be substituted. Some of the more common ones include a
five-point response scale ranging from "excellent" to "poor," or a six-point scale ranging from
"very satisfied" to "very dissatisfied."1 zYou may also wish to substitute any other scale that
you feel clients would more easily recognise and understand.
Throughout the checklists, the term "health facility" has been used. This term can be
replaced with other, more specific terms such as hospital, clinic, outreach centre or any other
facility. Also "provider" can be substituted with the terms doctor, nurse, midwife, community
health worker or any other local provider.
Finally, this checklist can be made more specific to assess the quality of a specific clinic
encounter or to evaluate certain providers or services. However, be careful not to over-generalise. Do not assume that dissatisfaction within one dimension or with one service or
provider will reflect dissatisfaction in other areas.
119
Client satisfaction checklist
If you wish to assess whether socio-economic factors such as clients’ background,
education levels, etc., are affecting their satisfaction, you could begin by asking
questions similar to the ones below. Otherwise, proceed to the next page.
Health facility/location
Supervisor/observer
Date of interview
1. Age of client?years Sex (M/F)
2. a. What is the last year of school completed? (modify according to local education
system)
b. What is the last year of school completed by your spouse?
3. What is the main source of drinking water for your household? (check one)
Piped water
Surface water (spring
4. Does your household have:
Electricity
YES
NO
Radio
YES
NO
Television
YES
NO
5. What is the main material of the floor of your home? (check one)
Earth/sand
Finished surface (wood/cement/tile)
Wood planks/palm/bamboo
Other
6. Does any member of your family own
___ YES
Bicycle
YES___ NO Donkey, horse, camel
YES
NO
Motorbike
YES
NO Other
YES
NO
Car
YES
NO
7. What is the main economic activity of your household? (check one)
Agriculture
Manufacturing
Fishing
Other
Trading/marketing
8. Where is the principle place you receive health care? (check one)
Public hospital
Private hospital/clinic
Public health centre/clinic
Local TBA/healer
9. Ask a country/region-specific question on type of religion.
10. Ask a country/region-specific question on ethnicity, if applicable.
11. Ask any additional questions you feel are appropriate.
1 Ware, J. E & Hays, R. "Methods for measuring patient satisfaction with specific medical encounters."
Medical Care 1988;26:393-402.
2 Osterweis, M. & Howell, J. "Administering patient satisfaction questionnaires at diverse ambulatory care
sites." Journal of Ambulatory Care Management 1979;67-88.
!
Module 6: Service quality; appendix B
Module 6: Service quality; appendix B
£u
Please circle a response or fill in blanks where indicated for each question. (Y Yes, N " No, DK - Don’t Know, NA - Not Applicable)
1. Did you feel that the schedule (clinic hours) at the health facility was adequate for your
needs?
- Jn
”
N
DK
Y
NA
it
2. Were you able to get to the health facility easily?
Y
N
DK
NA
a. How long (minutes/hours) does it normally take you to get to the health facility?
b. By what means do you normally get to the health facility, e.g., walking, motorcyle,
etc.?
<
I
a.
About how long (no. of minutes/hours) did you have to wait?
Were you given any information which you did not understand? Y
If "Yes," what information did you not understand?
About how long (no. of days) did you have to wait?
Y
6. Do you feel that the provider spent enough time with you during the visit?
Y
N
Facilities, equipment, and supplies
Were you satisfied with:
7. The overall cleanliness and comfort of (he waiting area?
Y N
DK
NA
DK
NA
1
I1 '
1
6
NA
DK
NA
N
£
N
NA
Satisfaction with resulting health status/Efficacy of treatment
20. Do you feel that services you received at the health centre were effective in solving
your problem?
Y
N
DK
NA
NA
NA
9. The condition of any instruments or equipment used by the provider to treat or examine you?
Y
N
DK
NA
22. Were you satisfied with the measures taken to assure confidentiality about your health
problem?
Y
N
DK
23. Would you recommend the services at this health facility to someone else?
Y
NA
If not, please list any services which are not available at the health facility but are
important to meet your needs.
Continuity of care
11. Did you see the same provider during this visit as on the last visit?
NA
DK
NA
a.
NA
DK
Other
21. Were you satisfied with the measures taken to assure privacy during your examination
e g., a private room, curtained or screened afea, etc.?
Y
N
DK
Y
N
DK
NA
12. Were the same services available during this visit as on your last visit? Y
N
DK
NA
Interpersonal qualities of service provider
13. Were you treated with courtesy and respect by the provider during your visit?
Y
N
DK
NA
1
!
DK
8. The overall cleanliness and comfort of the examination room or place where you re
ceived service?
Y
N
DK
Availability of services
10. Were all the services you needed to treat your problem available at the health facility
during your visit?
Y
N
DK
.
N
NA
Cost
19. Did you feel that the cost for services you received at the health facility was reasonable?
1
1
Y
DK
17. Were you satisfied with the provider's skills and ability in treating your problem?
Y
N
DK
18. Were you satisfied with the completeness of the information given to you about your
problem?
5. For follow-up or referral visits, did you feel that you were able to see a provider within
a reasonable period of time?
Y N
DK
NA
a.
Professional competence and skill of the service provider
15. Were you satisfied overall with the services you received from the provider?
Y
N
a.
If not, what are some reasons why?
16. Did you feel comfortable discussing your problem with the provider?
4. After arriving at the clinic, did you feel that the time spent waiting to be seen by a provider was reasonable?
Y
N
DK
NA
a.
N
14. Did the provider allow you to ask questions?
Module 6: Service quality; appendix B
N
DK
24. What do you think should be done to improve the quality of the services in this health
facility?
References
1. Dovlo, D., et al. What does the public wont from us? A study of user satisfaction with services in government
health facilities in the eastern region, Ghana. April, 1992.
2. Ware, J. E. & Hays, R. "Methods for measuring patient satisfaction with specific medical encounters."
Medical Care 1988,26:393-402.
3. Osterweis, M. & Howell, J. "Administering patient satisfaction questionnaires at diverse ambulatory care
sites." Journal of Ambulatory Care Management 1979;67-88.
Module 6: Service quality; appendix B
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Appendix C: Service quality assessment
Discussion guidelines
GENERAL
PHC household visits
Health education
MATERNAL CARE
Antenatal care
Safe delivery
Postnatal care
Family planning
CHILD CARE
Breast feeding
Growth monitoring
Nutrition education
Immunization
Acute respiratory infection
Diarrhoeal disease control
Oral rehydration therapy
OTHER HEALTH CARE
Vtater supply, hygiene and
sanitation
School health
Childhood disabilities
Accidents and injuries
Sexually transmitted diseases
HIV/AIDS
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Malaria
Tuberculosis
Treatment of minor ailments
Chronic, non-communicable
diseases
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Module 6: Service quality; appendix C
124
PHC service quality assessment
Discussion guidelines: 1. PHC household visit
non
8 ■i
Introduction: Welcome the group and briefly give the purpose of the discussion
Ground rules: Explain the following ground rules to the group:
■Bl-
Ground rules for group discussion
PHC service quality assessment
Discussion guidelines: 2. Health education
Introduction: Welcome the group and briefly give the purpose of the discussion.
Ground rules: Explain the following ground rules to the group:
Ground rules for group discussion
Everyone’s ideas and opinions are important.
There are no right or wrong answers.
Both positive and negative comments are welcome.
Participants should feel free to disagree with one another so all points of view are heard.
Don’t wait to be called on; its a group discussion.
Please speak one at a time.
These discussion guidelines are provided to help you to lead a group discussion about the
quality of services provided during a household visit. You may also refer to the detailed
version of the PHC service quality checklists, Appendix B, as a resource for the discussion.
6
Everyones ideas and opinions are important.
There are no right or wrong answers.
Both positive and negative comments are welcome.
Participants should feel free to disagree with one another so all points of view are heard.
Don t wait to be called on; it’s a group discussion.
Please speak one at a time.
€
BWt
These discussion guidelines are provided to help you to lead a group discussion about the
Quality of your health education services. You may also refer to the detailed version of the
PHC service quality checklists, Appendix B, as a resource for the discussion
Discussion
• What works well in the way we provide services during a household visit?
Discussion
• What works well in the way we provide health education?
Guidelines
• What does not work well in the way we provide services during a household visit?
• What standards, guidelines or protocols are used for providing services during a household
visit?
• lb whom would you go if you had questions about a standard or how to perform an activity?
• What information is registered on family health cards or other records during a household
visit?
• What informationdo you ask from clients who have malnourished children?
• What information do you askfrom clients who have children with diarrhoea?
• What information do you askfrom clients who are pregnant?
• What informationdo you ask from all households you visit?
Guidelines
• What does not work well in the way we provide health education?
• What standards, guidelines or protocols are used for providing health education?
• To whom would you go if you had questions about a standard or how to perform an activity?
• What information do you ask from your clients about their educational background?
• What techniques do you use when presenting and discussing health topics?
• What educational materials do you use?
• What key messages related to your health topic do you emphasise to clients during health
education sessions?
Key questions
• Do service providers register all children under five on a health card?
• Do service providers register all women over 16 on a family health card?
• Do service providers make arrangements for vaccination of children requiring immunization?
• Are nutritional counselling, food supplementation and/or medical attention being received?
• Has ORS solution been recommended to the client and is help in preparing to administer
it available?
• Has the client received prenatal care ? If necessary, has a prenatal visit been arranged?
• Are interested women or couples referred for family planning services ?
• I las water, hygiene and sanitation been discussed?
• Has a good rapport been established with the mother?
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Key questions
Are participants’ knowledge, attitudes, and practices of health education determined?
Is participants’ general level of knowledge determined?
Do service providers explain the topic and focus the discussion?
Are all relevant aspects of the topic discussed?
Are appropriate discussion techniques used to encourage active participation?
Do service providers use appropriate educational materials during the presentation?
Are any available educational materials distributed?
■
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Module 6: Service quality; appendix C
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Module 6: Service quality; appendix C
127
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PHC service quality assessment
Discussion guidelines: 3. Antenatal care
PHC service quality assessment
Discussion guidelines: 4. Safe delivery
Introduction: Welcome the group and briefly give the purpose of the discussion.
Ground rules: Explain the following ground rules to the group:
Introduction: Welcome the group and briefly give the purpose of the discussion.
Ground rules: Explain the following ground rules to the group:
b
II
Ground rules for group discussion
Ground rules for group discussion
1
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Everyone’s ideas and opinions are important.
There are no right or wrong answers.
Both positive and negative comments are welcome.
Participants should feel free to disagree with one another so all points of view are heard.
Don’t wait to be called on; it's a group discussion.
Please speak one at a time.
Everyone's ideas and opinions are important.
There are no right or wrong answers.
Both positive and negative comments are welcome.
Participants should feel free to disagree with one another so all points of view are heard.
Don’t wait to be called on; it’s a group discussion.
Please speak one at a time.
These discussion guidelines are provided to help you to lead a group discussion about the
quality of your antenatal services. You may also refer to the detailed version of the PHC
service quality checklists, Appendix B, as a resource for the discussion.
These discussion guidelines are provided to help you to lead a group discussion about the
quality of your safe delivery services. You may also refer to the detailed version of the PHC
service quality checklists, Appendix B, as a resource for the discussion.
i
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1
Discussion
• What works well in the way we provide safe delivery services?
Discussion
• What works well in the way we provide antenatal services?
Guidelines
• What aspects do not work well In the way we provide antenatal services?
• What standards, guidelines or protocols are used for providing antenatal services?
• To whom would you go if you had questions about a standard or how to perform an activity?
• What information do you review on the’clinic record during the antenatal visit?
• What do you ask your clients about their reproductive history?
• What do you ask your clients about risk factors associated with their current pregnancy?
» What do you ask your clients about preventive actions taken?
• What activities do you carry out during a physical exam?
• For what reasons would you refer a client to another service provider?
• What messages do you emphasise when educating or counselling your clients?
I
I
Kay questions
• Are obstetric records of family health cards reviewed and updated?
• Are at least two questions about reproductive history risk factors asked?
• Are at least two questions about risk factors associated with this pregnancy asked?
• Is at least one physical exam activity performed?
• Are clients immunized against tetanus or have arrangements for immunization been made?
••Are clients referred for
and malaria, if
— blood test, glucose, haemoglobin/haematocrit
.
medically indicated?
• Do service providers discuss with clients the importance of having the delivery attended by
a trained health worker?
• Do service providers explain the danger signs which require immediate attention?
• Do service providers tell pregnant woman when and where to go for next antenatal visit?
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Guidelines
• What aspects do not work well in the way we provide safe delivery services?
• What standards, guidelines or protocols are used for providing safe delivery services?
• lb whom would you go if you had questions about a standard or how to perform an activity?
• What activities do you perform before the labour begins?
• What information do you review with your clients or ask from your clients before labour
begins?
• What activities do you perform during the progress of labour and delivery?
• For what reasons might you seek help during the progress of labour and delivery?
• What activities do you perform immediately after birth?
• What messages do you emphasise when educating or counselling your clients after birth?
Key questions
• Do service providers sterilise needles, syringes, cord ties, scissors/razor blades before the
birth?
• Is a clean birthing place prepared?
• Do service providers take labour history?
• If necessary, is the reproductive history for high-risk factors reviewed?
• Is the woman monitored throughout labour and is a physical exam conducted?
• Is the progress of labour assisted?
• Is the delivery assisted?
• Is help sought for obstetric problems and emergencies?
• Do service providers tie the umbilical cord with thread in three places and cut with
blade/scissors?
• Do service providers determine APGAR score at one minute and five minutes after birth?
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Module 6: Service quality; appendix C
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Module 6: Service quality; appendix C
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PHC service quality assessment
Discussion guidelines: 5. Postnatal care
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Introduction: Welcome the group and briefly give the purpose of the discussion.
Ground rules: Explain the following ground rules to the group:
I
Ground rules for group discussion
Everyone's ideas and opinions are important.
There are no right or wrong answers.
Both positive and negative comments are welcome.
Participants should feel free to disagree with one another so all points of view are heard.
Don’t wait to be called on; it’s a group discussion.
Please speak one at a time.
■'2
■7
These discussion guidelines aie provided to help you to lead a group discussion about the
quality of your postnatal services. You may also refer to the detailed version of the PHC
service quality checklists, Appendix B, as a resource for the discussion.
Discussion
• What works well in the way we provide postnatal services?
Guidelines
• What does not work well in the way we provide postnatal services?
• What standards, guidelines or protocols are used for providing postnatal services?
• Id whom would you go if you had questions about a standard or how to perform an activity?
• What information do you review on the clinic record during the antenatal visit?
• What do you ask your clients about their medical history?
• What activities do you carry out during a physical exam?
• What treatment or routine preventive services do you provide?
• For what reasons would you refer a client to another service provider?
• What messages do you emphasise when educating or counselling your clients?
•4
Key questions
• Did the service provider ask the client at least two medical history questions?
• Was the client examined?
• Were findings of history and physical examinations recorded on the clients health record?
• Did the service provider refer the client for special treatment if necessary?
• W'as the infant referred for all physical conditions requiring medical attention?
• Was a BCG given or verification received that the child received vaccination at birth?
• Did the service provider give first DPT and OPV?
• Was the client told to feed the infant with breast milk only, for the first 4-6 months?
• Was family planning and how to obtain its services discussed with the client?
• Are clients encouraged to enrol their child in the well-child clinic?
PHC service quality assessment
Discussion guidelines: 6. Family planning
Introduction: Welcome the group and briefly give the purpose of the discussion.
Ground rules: Explain the following ground rules to the group:
Ground rules for group discussion
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Everyone’s ideas and opinions are important.
There are no right or wrong answers.
Both positive and negative comments are welcome.
Participants should feel free to disagree with one another so all points of view are heard.
Don’t wait to be called on; it’s a group discussion.
Please speak one at a time.
These discussion guidelines are provided to help you to lead a group discussion about the
quality of your family planning services. You may also refer to the detailed version of the
PHC service quality checklists, Appendix B, as a resource for the discussion.
Discussion
• What works well in the way we provide family planning services?
Guidelines
• What does not work well in the way we provide family planning services?
• What standards, guidelines or protocols are used for providing family planning services?
• To whom would you go if you had questions about a standard or how to perform an activity?
• What do you ask from your clients about their medical and reproductive history?
• What activities do you carry out during a physical exam?
• What do you ask from your clients in order to determine which method to recommend?
• What messages do you emphasise to all clients when educating or counselling them?
• What information do you ask from clients during follow-up visits?
Key questions
• Are clients asked at least three medical and reproductive history questions?
• Did the service provider take the clients blood pressure?
• Are clients breast examined for lumps?
• Did the service provider examine the patient for signs of anaemia?
• Did the service provider recommend to the client a method that was free of contraindica
tions?
• Are side effects discussed?
• Is the client asked about use of the contraceptive received?
• Was the client asked about the possible side effects?
i
Module 6: Service quality; appendix C
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Module 6: Service quality; appendix C
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131
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PHC service quality assessment
Discussion guidelines: 7. Breast feeding
Introduction: Welcome the group and briefly give the purpose of the discussion.
Ground rules: Explain the following ground rules to the group:
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■
PHC service quality assessment
Discussion guidelines: 8. Growth monitoring/nutrition education
Introduction: Welcome the group and briefly give the purpose of the discussion.
Ground rules: Explain the following ground rules to the group:
Ground rules for group discussion
Ground rules for group discussion
Everyone’s ideas and opinions are important.
There are no right or wrong answers.
Both positive and negative comments are welcome.
Participants should feel free to disagree with one another so all points of view are heard.
Don’t wait to be called on; it’s a group discussion.
Please speak one at a time.
Everyone’s ideas and opinions are important.
There are no right or wrong answers.
Both positive and negative comments are welcome.
Participants should feel free to disagree with one another so all points of view are heard.
Don’t wait to be called on; it’s a group discussion.
Please speak one at a time.
These discussion guidelines are provided to help you to lead a group discussion about the
quality of your breast feeding activities. You may also refer to the detailed version of the PHC
service quality checklists, Appendix B, as a resource for the discussion.
These discussion guidelines are provided to help you to lead a group discussion about the
quality of your growth monitoring services. You may also refer to the detailed version of the
PHC service quality checklists, Appendix B, as a resource for the discussion.
Discussion
• What works well in the way we perform our breast feeding activities?
Guidelines
• What does not work well in the way we perform our breast feeding activities?
• What standards, guidelines or protocols are used for carrying out breast feeding activities?
• To whom would you go if you had questions about a standard or how to perform an activity?
• What information do you ask from your clients about their medical history?
• What messages do you emphasise when educating or counselling your clients on breast
feeding practices?
• What messages do you emphasise when educating or counselling your clients on weaning
pt actices?
• What additional messages do you emphasise when educating or counselling your clients on
nutrition?
5
Key questions
• Do service providers ask about the mother’s knowledge and practice concerning breast
feeding? Are mothers instructed on the health benefits to mother and child of breast feeding?
• Do service providers recommend how long to breast feed and encourage continued breast
feeding during illness?
• Is the client instructed on the method of breast feeding?
• Are warning signs that indicate the mother should seek help explained?
• Do service providers provide counselling, as appropriate, on family planning methods and
contraceptive benefits of breast feeding?
• Is appropriate counselling provided on diet during lactation, nutrition supplements, and
important locally available foods?
• Is the client advised on weaning practices and food preparation?
Module 6: Service quality; appendix C
I
Discussion
• What works well in the way we provide growth monitoring services?
Guidelines
• What aspects do not work well in the way we provide growth monitoring services?
• What standards, guidelines or protocols are used for providing growth monitoring services?
• lb whom would you go if you had questions about a standard or how to perform an activity?
• What growth monitoring activities do you perform?
• How do you determine the child’s age?
• What do you do to prepare the child for weighing?
• What information do you record?
E
• What information do you ask from your clients about the child’s growth and nutrition?
• What are some reasons you would refer a client to another service provider?
• What messages do you emphasise when educating or counselling your clients on growth
monitoring and nutrition?
Key questions
• Was the clients age calculated correctly?
• Is the child weighed correctly?
• Is the child’s weight plotted correctly?
• Are clients referred for nutritional counselling?
• Is at least 1 appropriate recommendation about child feeding and care made?
• Are clients asked if their child gained weight, lost, or stayed the same since the last weighing?
• Do service providers have a working scale?
• Do service providers have a method of tracking malnourished children?
Module 6: Service quality; appendix C
[
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PHC service quality assessment
Discussion guidelines: 9. Immunization
rd
Introduction: Welcome the group and briefly give the purpose of the discussion.
Ground rules: Explain the following ground rules to the group:
Introduction: Welcome the group and briefly give the purpose of the discussion.
Ground rules: Explain the following ground rules to the group:
Ground rules for group discussion
Ground rules for group discussion
I
PHC service quality assessment
Discussion guidelines: 10. Acute respiratory infection
Everyone’s ideas and opinions are important.
There are no right or wrong answers.
Both positive and negative comments are welcome.
Participants should feel free to disagree with one another so all points of view are heard.
Don’t wait to be called on; it’s a group discussion.
Please speak one at a time.
Everyone’s ideas and opinions are important.
There are no right or wrong answers.
Both positive and negative comments are welcome.
Participants should feel free to disagree with one another so all points of view are heard.
Don’t wait to be called on; it’s a group discussion.
Please speak one at a time.
These discussion guidelines are provided to help you to lead a group discussion about the
quality of your immunization services. You may also refer to the detailed version of the PHC
service quality checklists, Appendix B, as a resource for the discussion.
These discussion guidelines are provided to help you to lead a group discussion about the
quality of your services for acute respiratory infection. You may also refer to the detailed
version of the PHC service quality checklists, Appendix B, as a resource for the discussion.
Discussion
• What works well in the way we provide immunization services?
Discussion
• What works well in the way we provide ARI services?
Guidelines
• What aspects do not work well in the way we provide immunization services?
• What standards, guidelines or protocols are used for providing immunization services?
• 'Id whom would you go if you had questions about a standard or how to perform an activity?
• What information, do you review on the clinic record and/or ask from your clients during
the immunization visit?
• What activities do you perform during an immunization visit?
• What is your technique for providing vaccinations?
• What sterilisation procedures do you follow?
• How are supplies stored and how is the cold chain maintained, for clinic and outreach
‘I. services?
• What messages do you emphasise when educating or counselling your clients?
& I
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Key questions
1- • Is a sterile needle used for each injection?
I
• Is a sterile syringe used for each injection?
• Do service providers give the child all vaccinations needed today?
• Are vaccinations recorded on the child’s health card?
• During the last month was the registered temperature between zero and eight degrees (C)
at all times?
• Are vaccines transported in cold boxes with ice packs?
• Is the return for the next immunization discussed with the client?
I
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4
Module 6: Service quality; appendix C
tr
Guidelines
• What does not work well in the way we provide ARI services?
• What standards, guidelines or protocols are used for providing ARI services?
• To whom would you go if you had questions about a standard or how to perform an activity?
• What information do you ask from your clients about their medical history?
• What activities do you carry out during a physical exam?
• What treatments do you prescribe for what types of ARI?
• For what reasons would you refer a client to another service provider^
• What messages do you emphasise when educating or counselling you/ clients?
Key questions
• Are at least two medical history questions asked?
• Do service providers ask about any treatment administered?
• Is the respiratory rate counted?
• Is the child classified by severity of illness?
• Are antibiotics for pneumonia, strep throat or otitis given?
• Do service providers refrain from using antibiotics for colds?
• Are clients told about at least three signs of pneumonia?1
• If antibiotics are prescribed, is the client asked, "How will you administer the medicine; how
much, how often, for how long?"
r
I
7
1 Signs jnclude stridor, chest indrawing/rapid breathing, inability to drink, cyanosis, anxiety,
and weakness or lethargy.
Module 6: Service quality; appendix C
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134
PHC service quality assessment
Discussion guidelines: 12. Water supply, hygiene and sanitation
PIIC service quality assessment
Discussion guidelines: 11. Diarrhoeal disease control/oral rehy-
Introduction: Welcome the group and briefly give the purpose of the discussion.
Ground rules: Explain the following ground rules to the group:
dration therapy
I .mduction Welcome the group and briefly give the purpose of the drscussron.
Ground rules: Explain the following ground rules to the group.
I
J
I
I
F
1
Ground rules for group discussion
€‘l
Ground rules for group discussion
Everyone’s ideas and opinions are important.
There are no right or wrong answers.
"“"L
” ■"
Lton't wait to be called on; it's a group discussion.
Please speak one at a time.
Everyone’s ideas and opinions are important.
There are no right or wrong answers.
Both positive and negative comments are welcome.
Participants should feel free to disagree with one another so all points of view are heard.
Don’t wait to be called on; it's a group discussion.
Please speak one at a time.
These discussion guidelines are provided to help you to lead a group discussion about the
quality of your services related to water supply, hygiene and sanitation. You may also refer to
the detailed version of the PHC service quality checklists, Appendix B, as a resource for the
discussion.
_
These discussion guidelines are provided to help you^to lead a group^^c^ssion^bout the
Discussion
discussion.
• What works well in the way we provide services related to water supply, hygiene and
sanitation?
Discussion
We provide diarrhoeal disease control/ORT services?
• What works well in the way
we provide diarrhoeal disease control/ORT
Guidelines
. .
. What aspects do not work well in the way
rvices?
used for providing diarrhoeal disease con• What standards, guidelines or protocols are
standard or how to perform an activity?
eb
e. ■ j
|Tb t uill
'. __________
”!“1? d,
.dical history questions as^ed?
’--- activities performed?
•. Are
twoofphysical
exam determined (none, moderate, severe).
Wasat
’theleast
degree
dehydration
•l^^v^e^To^'refrain
Is safe ORS prescribed?
from using antibiotics, except when stools contain biood or
.“Jvice providers administer ORS solution immediately or refer the client to a nearby
h”' o'“ “ s“
. Are clients shown how to prepare ORS solution.
Module 6: Service quality, appendix C
*4?^
Guidelines
• What aspects do not work well in the way we provide services related to water supply,
hygiene and sanitation?
• What standards, guidelines or protocols are used for providing services related to water
supply, hygiene and sanitation?
• To whom would you go if you had questions about a standard or how to perform an activity?
• What messages do you emphasise when educating or counselling your clients about
contaminated water and disease?
• What messages do you emphasise when educating or counselling your clients about water
storage and use?
• What messages do you emphasise when educating or counselling your clients about latrine
maintenance and use?
• What messages do you emphasise when educating or counselling your clients about refuse
and animal excreta disposal?
Key questions
• Is keeping water in a clean, covered container discussed?
• Is the importance of hand washing before eating, feeding children, and food preparation
discussed?
• Do service providers discuss appropriate latrine use and human waste disposal, e.g. baby
potty for children under three?
• Is burning or burying refuse recommended?
• Do service providers recommend penning animals away from the house?
• Is the importance of washing hands discussed with the client?
Module 6: Service quality; appendix C
6
j
PMC service quality assessment
Discussion guidelines: 13. Childhood disabilities
J
-
I
Introduction: Welcome the group and briefly give the purpose of the discussion.
Ground rules: Explain the following ground rules to the group:
5
rs:
€
Ground rules for group discussion
Everyone’s ideas and opinions are important.
There are no right or wrong answers.
Both positive and negative comments are welcome.
Participants should feel free to disagree with one another so all points of view are heard.
Don’t wait to be called on; its a group discussion.
Please speak one at a time.
1 hese discussion guidelines are provided to help you to lead a group discussion about the
quality of your services for childhood disabilities. You may also refer to the detailed version
of the PHC service quality checklists, Appendix B, as a resource for the discussion.
€
GroundruU.’
the group and briefly give the purpose of the discussion.
Ground rules: Explain the following ground rules to the group:
Ground rules for group discussion
Everyones ideas and opinions are important.
There are no right or wrong answers.
Both positive and negative comments are welcome.
Participants should feel free to disagree with one another so all points of view are heard
Dont wait to be called on; it’s a group discussion.
Please speak one at a time.
4 Ml r
Discussion
• What works well in the way we provide services for childhood disabilities?
1
Guidelines
• What does not work well in the way we provide services for childhood disabilities?
• What standards, guidelines or protocols are used for providing services for childhood
disabilities?
• To whom would you go if you had questions about a standard or how to perform an activity?
• What information do you ask from your clients about their child’s medical history?
• What activities do you carry out during a physical exam?
• For what reasons would you refer a client to another service provider?
• What messages do you emphasise when educating or counselling your clients on childhood
disabilities?
Key questions
• Are clients asked about the prenatal and antenatal care of the child?
• Do service providers ask the client whether the child's speech, development, mobility,
strength, sight, hearing, behaviour is ifi any way different from normal?
• Is an examination conducted for the presence of any deformities or defects?
•Is appropriate treatment or therapy administered/prescribed according to established
treatment guidelines?
• Do service providers discuss available medicine or treatment, if any?
• If applicable, is the possible risk of having another child discussed, if more than one child is
known to have been born with a genetic condition?
• Do service providers discuss what parents and families can do to help the disabled child?
• Is the client questioned about their child's disability?
• If applicable, is the client questioned about their knowledge of how to prevent a similar
disability form happening again?
• Is the client aware-of where to go for treatment or follow-up?
• Is the client questioned about the treatment they received?
■
PHC service quality assessment
Discussion guidelines: 14. Accidents and injuries
8
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&H 1^ -VSSfe
J
'
€'
These discussion guidelines are provided to help you to lead a group discussion about th.
oUheVne011’ SerVlces or accdents and injuries. You may also refer to the detailed version
of the PHC serv.ce quality checklists, Appendix B, as a resource for the discussion.
!
Discussion
• What works well in the way we provide services for accidents and injuries?
Guidelines
Wh,! c!’65
injuries?
u'ork.w;el1 in lllc W'V we Provide services for accidents and Injuries?
9U
" “ PrO,OC°IS
USed f°r pr0Vidin9 services (°r ^cidents and
• Whal1Or? WOUltd
30 if y°V hrad ques,ions about a standard or how to perform
• Wha lnfor"’at'°n do Vou ask from your clients about their medical history? an activity?
What activities do you carry out during a physical exam?
’ o/ . ‘ reasonsiwould you refer a client to another service provider?
Sndon?3965
y°U emphasiSe When locating or counselling your clients
on injury
Key questions
Is the type of injury correctly identified?
Do service providers obtain a history of the injury, e.g. cause, time etc?
s proper treatment administered according to established guidelines?
Is appropriate referral made according to established guidelines^
krhildtf PrOViderSJ discuss
common injuries and how they may be prevented?
Is child safety in and around the home discussed?
Are occupational safety issues discussed?
Do service providers explain how to recognise
an emergency and where to go for help?
I
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e
I
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Module 6: Service quality; appendix C
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Module 6: Service quality; appendix C
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.38
TIC service quality assessment
transmitted diseases and
discussion guidelines: 15. Sexually
C_
3
&
hiv/aids
itroduction: Welcome the group and briefly give the purpose of the discussion.
•Are the risks of re-infection and/or transmission explained if sex is resumed with an
untreated partner?
• Is the client asked about their illness?
• Are clients asked about their knowledge on how to prevent giving it to someone else and
how to prevent becoming infected again?
• Is the client aware of when and where to return for test results, treatment, or follow-up?
Ground rules for group discussion
veryone’s ideas and opinions are important.
There are no right or wrong answers.
loth positive and negative comments are welcome.
articipants should feel free to disagree with one another so all points of view are heard.
Don’t wait to be called on; its a group discussion.
Please speak on# at a time.
These discussion guidelines are provided to help you to lead a group discussion about the
quality of your STD-related services. You may also refer to the detailed version of the PH
.ervice quality checklists, Appendix B, as a resource for the discussion.
€
Discussion
• What works well in the way we provide STD services?
^Wha^does not work well in the way we provide STD services?
'i
• What standards, guidelines or protocols are used for providing SID service^
. To whom would you go if you had questions about a standard or how to perform an activity?
What information do you ask from your c ients abou heir medical h story.
What information do you ask from your clients about their sexual history.
• What activities do you carry out during a physical exam.
.
• Fnr what reasons would you refer a client to another service provider.
. Wi J XagesTyou emphasise when educating or counselling clients on prevention of
I
STD?
on laboratory
• What messages do you emphasise when educating or counselling clients
testing?
.
,
,
counselling clients with diagnosed
• What messages do you emphasise when educating or
1 Bl
e! 1:
STD?
Key questions
• Are at least two symptoms of infection asked.
• Is the client assured of confidentiality of test results?
• 11
I
•"d '*’• -d““o' ™n“’
1
1'^
Module 6: Service quality; appendix C
Module 6: Service quality; appendix C
i
140
PHC service quality assessment
Discussion guidelines: 16. Malaria
^'■<3
introduction: Welcome the group and briefly give the purpose of the discussion.
Ground rules: Explain the following ground rules to the group:
€ I **)
3
£
1
Guidelines
• What does not work well in the way we provide malaria services?
• What standards, guidelines or protocols are used for providing malaria services?
• To whom would you go if you had questions about a standard or how to perform an activity?
• What information do you ask from your clients about their medical history?
• What activities do you carry out during a physical exam?
• What treatments do you prescribe for malaria?
• For what reasons would you refer a client to another service provider?
• What messages do you emphasise when educating or counselling your clients?
■1
•1 •*!
Key questions
• Are at least two medical history questions asked?
• Do service providers ask about anti-malarial drugs taken in the last 24 hours?
• Do service providers ask about other symptoms to rule out other fever-related illnesses?
• Is the clients temperature taken?
• Is a blood slide made or the client referred to a facility where a blood slide may be examined?
• Are appropriate anti-malarial drugs administered or prescribed according to local norms?
• Do service providers administer antipyretic drug and sponge or bathe the client with water
if fever is over 39 degrees C.
.
• i
• Do service providers discuss danger signs that may indicate unresponsive or complicated
malaria?
• .■Me clients told to return for consultation if danger signs develop?
• Is the client questioned about the prescribed medicine, e.g. how will you take the medicine
(how much, how often, and for how long)?
Everyone’s ideas and opinions are important.
There are no right or wrong answers.
Both positive and negative comments are welcome.
Participants should feel free to disagree with one another so all points of view are heard.
Don’t wait to be called on; it’s a group discussion.
Please speak one at a time.
■
These discussion guidelines are provided to help you to lead a group discussion about the
quality of your tuberculosis services. You may also refer to the detailed version of the PHC
service quality checklists, Appendix B, as a resource for the discussion.
These discussion guidelines are provided to help you to lead a group discussion about the
quality of your malaria services. \bu may also refer to the detailed version of the PHC service
quality checklists, Appendix B, as a resource for the discussion.
Discussion
» What works well in the way we provide malaria services?
Introduction: Welcome the group and briefly give the purpose of the discussion.
Ground rules: Explain the following ground rules to the group:
Ground rules for group discussion
Ground rules for group discussion
Everyone’s ideas and opinions are important.
There are no right or wrong answers.
Both positive and negative comments are welcome.
Participants should feel free to disagree with one another so all points of view are heard.
Don’t wait to be called on; it’s a group discussion.
Please speak one at a time.
PHC service quality assessment
Discussion guidelines: 17. Tuberculosis
Discussion
• What works well in the way we provide tuberculosis services?
€’
1
■
■
1
”9
Guidelines
• What does not work well in the way we provide tuberculosis services?
• What standards, guidelines or protocols are used for providing tuberculosis services?
• lb whom would you go if you had questions about a standard or how to perform an activity?
• What information do you ask from your clients about their medical history?
• What activities do you carry out during a physical exam?
• What treatments do you prescribe for tuberculosis?
• For what reasons would you refer a client to another service provider?
• What messages do you emphasise when educating or counselling your clients?
Key questions
• Are clients questioned about persistent coughs; two weeks or more?
• Are clients questioned about persistent fever; one month or more?
• Do service providers ask clients about weight loss?
• Do service providers ask clients about blood in sputum?
• Is cutaneous TB test performed?
• Is client referred for sputum examination?
• Do service providers prescribe medicines or refer for treatment according to local norms?
• Is verification made that follow-up cases have taken medicine correctly?
• Do service providers explain how much and how often to take medicine?
• Is the importance of completing the treatment stressed?
• Is the client questioned about prescribed drugs, e.g., how will they take their medicine (how
much, how often, and for how long)?
• Is the client questioned about the need for further testing, e.g., where will they go for the
test?
■
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t
E
I
f
.4
Module 6: Service quality; appendix C
Module 6: Service quality; appendix C
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143
142
PHC service quality assessment
Discussion guidelines: 18. Treatment of minor ailments
I
Introduction: Welcome the group and briefly give the purpose of the discussion.
Ground rules: Explain the following ground rules to the group:
PHC service quality assessment
Discussion guidelines: 19a. Hypertension
Ground rules for group discussion
Ground rules for group discussion
Eveiyone’s ideas and opinions are important.
There are no right or wrong answers.
Both positive and negative comments are welcome.
Participants should feel free to disagree with one another so all points of view are heard.
I
Don't wait to be called on; it’s a group discussion.
Please speak one at a time.
' I These discussion guidelines are provided to help you to lead a group discussion about the
B quality of your treatment of minor ailment services. You may also refer to the de ailed version
•
|
of Hie PHC service quality checklists, Appendix B, as a resource for the discussion.
Everyone’s ideas and opinions are important.
There are no right or wrong answers.
Both positive and negative comments are welcome.
Participants should feel free to disagree with one another so all points of view are heard.
Don’t wait to be called on; it’s a group discussion.
Please speak one at a time.
These discussion guidelines are provided to help you to lead a group discussion about the
quality of your hypertension services. You may also refer to the detailed version of the PHC
service quality checklists, Appendix B, as a resource for the discussion.
Discussion
D/Jhat works well in the way we provide treatment of minor ailment services?
1
i
1
Guidelines
• What does not work well in the way we provide for treatment of minor ailments?
for providing services for the treatment of
• What standards, guidelines or protocols are used
l_
minor ailments?
• 'lb whom would you go if you had questions about a standard or how to perform an activity?
• What activities do you perform for the treatment of minor ailments.
.• What messages an
when educating
do v/nu
you emnhasise
emphasise when
educating or counselling your clients.
Key questions
• Do you ask patients about their chief complaint?
•• Do
drug allergies?
Do you
you determine
determine medical
medical history
history and
anc past
,
• 1 low do you check vital signs?
dated physical exam?
• 1 low do you conduct a related
• Flow do you make an appropriate diagnosis?
"• Do*ot°provide approp^e treatment and discuss compliance with drug therapy?
• Do you provide information to the patient about the condition and treatment plan.
• Do you explain to the patient how often to take this medicine.
• Do you explain what dose to take?
• Do you tell the patient how long to continue treatment?
r
I
Module 6: Service quality; appendix C
II
Introduction: Welcome the group and briefly give the purpose of the discussion.
Ground rules: Explain the following ground rules to the group:
• What works well in the way we provide hypertension services?
€1
■) ■ II$
1■
?>I 3
e
I I '
e
i 1
■' ■ u5^
Guidelines
• What does not work well in the way we provide hypertension services?
• What standards, guidelines or protocols are used for providing hypertension services?
• To whom would you go if you had questions about a standard or how to perform an activity?
• What information do you ask from your clients about their medical history?
• What activities do you carry out during a physical exam?
• For what reasons would you refer a client to another service provider?
• What messages do you emphasise when educating or counselling your clients on hyperten
sion?
Key questions
• Is a proper blood pressure reading taken?
• Do service providers ask about chief complaints, e.g. blurred vision, severe headache,
shortness of breath, chest pain?
• Do service providers ask about prior/current experience and treatments for hypertension?
• Do service providers ask about family history of hypertension?
• Do service providers ask about history of diabetes or stroke?
• Do service providers ask about current lifestyle, e.g. work, stresses, home conditions?
• Do service providers ask about previous illness or treatment?
• Is a physical exam performed, which includes a check of vital signs, blood pressure, heart,
pulse in foot, neck veins or other as per local policy?
• Are patients provided with health education/counselling on hypertension?
• Are patients instructed on the use of any prescribed medication?
• Are patients informed of the warning signs indicating when to return to the clinic?
1
I
1
s
i
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■
i
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•I
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Module 6: Service quality; appendix C
a
4
144
PIIC service quality assessment
Discussion guidelines: 19b. Diabetes mellitus
_k
I
I
Introduction: Welcome the group and briefly give the purpose of the discussion.
Ground rules: Explain the following ground rules to the group:
Ground rules for group discussion
Everyone’s ideas and opinions are important.
There are no right or wrong answers.
Both positive and negative comments are welcome.
Participants should feel free to disagree with one another so all points of view are heard.
Don’t wait to be called on; it’s a group discussion.
Please speak one at a time.
!
■
PHC service quality assessment
Discussion guidelines: 19c. Anaemia
Introduction: Welcome the group and briefly give the purpose of the discussion.
Ground rules: Explain the following ground rules to the group:
Ground rules for group discussion
Everyone’s ideas and opinions are important.
There are no right or wrong answers.
Both positive and negative comments are welcome.
Participants should feel free to disagree with one another so all points of view are heard.
Don’t wait to be called on; it's a group discussion.
Please speak one at a time.
Thes6 discussion guidelines are provided to help you to lead a group discussion about the
quality of your diabetes services. You may also refer to the detailed version of the PHC service
quality checklists, Appendix B, as a resource for the discussion.
These discussion guidelines are provided to help you to lead a group discussion about the
quality of your anaemia services. You may also refer to the detailed version of the PHC service
quality checklists, Appendix B, as a resource for the discussion.
Discussion
• What works well in the way we provide diabetes services?
Discussion
• What works well in the way we provide services during a visit for anaemia?
Guidelines
• What does not work well in the way we provide diabetes services?
• What standards, guidelines or protocols are used for providing diabetes services?
• To whom would you go if you had questions about a standard or how to perform an activity?
• What information do you ask from your clients about their medical history?
• What activities do you carry out during a physical exam?
• For what reasons would you refer a client to another service provider?
• What messages do you emphasise when educating or counselling your clients on treatment
of diabetes?
,
• What messages do you emphasise to women of child bearing age when providing education
or counselling on diabetes?
Key questions
• Do service providers ask about symptoms, e.g. blurred vision, unusual thirst, urinary tract
infection, yeast infection if a woman, foot problems, numbness, recurrent infection?
• Is a physical exam performed, including a check of vital signs, general appearance, and pulse
in feet, fast breathing, signs of dehydration, or others as per local policy?
• Are lab tests (e.g^sugar, urine) conducted, as appropriate?
• Are patients provided with health education/counselling on appropriate diet and exercise?
• Do service providers instruct family members how to handle common diabetic emergencies?
• Is the patient educated in proper foot care and protection?
• Is the importance of maintaining blood sugar levels within a specified range before and
during pregnancy to prevent birth defects discussed with women of child bearing age?
• Are high-risk pregnancies referred as per local policy?
e1 :<>
€* i d
im
id
e rd
Guidelines
• What does not work well in the way we provide services for anaemia?
• What standards, guidelines or protocols are used for providing services for anaemia?
• To whom would you go if you had questions about a standard or how to perform an activity?
• What information do you ask from clients about their medical history?
• What activities do you carry during a physical exam?
• For what reasons would you refer a client to another provider?
• What messages do you emphasise when educating or counselling your clients on treatment
for anaemia?
Key questions
• Do service providers ask about chief complaints, whether pregnant?
• Is occult blood in the stool determined?
• Is the client asked if blood is in the stool?
• Do service providers check colour of conjuctiva?
• Are clients asked about family history of anaemia?
• Is the client given a complete physical examination; chest, abdomen, etc.?
• Do service providers get a complete blood count with reticulocite count?
• Is the haemoglobin type; region, race, age or sex determined?
• Do service providers determine the aetiology of the anaemic condition?
• Is appropriate consultation determined; referral to a specialist, if needed?
• Are clients provided with nutrition counselling?
• Are clients asked about their knowledge in how to administer the drug; how much, how
often and how long?
• Is the client aware how to get refills for drugs?
__ L _
AW
Module 6: Service quality; appendix C
i
Module 6: Service quality; appendix C
I
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F
I
Ts
147
I
Appendix D: Multiple observation
checklists
PHC household visit
Growth monitoring
Immunization
Oral rehydration therapy
Family planning
‘i-
*
f
Module 6: Service quality; appendix D
R<
PI
148
c:,*>
eU
1.
2.
Antenatal care:
3.
4.
I'
5.
In
8.
9.
1C
11
12
K
G
V
15
0
15
17
u
|
3
__ ______________________
24.
Discuss the importance of prenatal care?
25.
Ask if any women in the household are pregnant?
26.
Talk with each pregnant woman about her well-being?
27.
Ask if each pregnant woman is receiving prenatal care and arrange for a
prenatal visit if necessary?
___ ______________________
28.
Give nutritional advice and iron/calcium supplementation to each pregnant
woman?
____________________________________________
29.
Answer pregnant woman’s questions?
6.
7.
Wl ■
2
Observation number/registration and documentation
u
Family planning
30.
Provide information about family planning services?
31.
Refer interested women or couples for family planning services?
32.
Ask women who already use contraception if they are happy with their method?
33.
Refer current users for advice or follow-up if necessary?
34.
Answer questions about family planning?
Water and sanitation
35.
Ask about access to water and provide information about community efforts to
address problems (if necessary)?___________________________________
36.
Ask about water storage practices and give appropriate advice?
37.
Ask about latrine maintenance and use and give appropriate advice?
38.
Ask about refuse and excreta disposal and give appropriate advice?
1
"i
General
0
39.
Ask if anyone in lhe household is ill and give appropriate advice?
:i8K) 12
40.
Follow up on recent illnesses?
2(
41.
Verify that the client(s) understand key information from today's visit?
21
42.
Establish good rapport with the mother?
!k|
22
E
ۥ 3
appendix D
Module 6: Service q* ■
W|V ’
»• m)
w
T
W
” W ’ WBRSk^v
li
11 ^1-
Rapid service quality assessment checklist
PHC household visit
3.
4.
Health facility
Observer
Regular supervisor
Date
Instructions: Mark "yesu (Y) if the service provider carries out these activities during observation.
For interview questions, mark ‘'yes" (Y) if the client responds correctly
Observation number/registration and documentation
5.
Are all children under 5 registered on the family health card?
6.
Are all women over 16 registered on the family health card?
7.
Was information updated during the visit?
Immunization
8.
Was this visit recorded in health centre records?
9.
Discuss the importance of vaccination?
10.
Review the immunization status of all children < 5?
11.
Vaccinate or arrange for vaccination of children who need to be immunized?
12.
Review vaccinations needed and the appropriate dates with mother?
13.
Answer mother’s questions about vaccination?
14.
Review the growth cards of all children < 5?
a - Growth monitoring
15.
Weigh children or refer them as appropriate?
16.
Discuss changes in weight with the mother and give nutritional advice?
17.
Answer mother’s questions about growth monitoring and nutrition?
18.
If there are any malnourished children in the house did the health worker check
to be sure that nutritional counselling, food supplementation, and/or medical
attention are being received as indicated?
ORT
— S) 19. Ask if any children in the household have diarrhoea?
•)
■1
>3
3
148/1
20.
If yes, recommend ORT, and help the mother to prepare and administer it?
21.
If no, review the importance of ORT and encourage mother to use it in future
diarrhoea episodes?
22.
Answer mother’s questions about ORT?
23.
Demonstrate how to make ORS solution, or invite mother to a demonstration if
necessary?
1
2
3
4
5
6
7
8
9
10
TOT
Problems identified
Actions taken
148/2
Observation number/registration and documentation
1
2
3
4
5
6
7
8
9
10
TOT
Problems identified
Actions taken
__ m
i':
Antenatal care:
24.
Discuss the importance of prenatal care?
25.
Ask if any women in the household are pregnant?
26.
Talk with each pregnant woman about her well-being?
27.
Ask if each pregnant woman is receiving prenatal care and arrange for a
prenatal visit if necessary?
28.
Give nutritional advice and iron/calcium supplementation to each pregnant
woman?
29.
Answer pregnant woman’s questions?
Family planning
30.
Provide information about family planning services?
31.
Refer interested women or couples for family planning services?
32.
Ask women who already use contraception if they are happy with their method?
33.
Refer current users for advice or follow-up if necessary?
34.
Answer questions about family planning?
Water and sanitation
35.
Ask about access to water and provide information about community efforts to
address problems (if necessary)?_________________
36.
Ask about water storage practices and give appropriate advice?
37.
Ask about latrine maintenance and use and give appropriate advice?
38.
Ask about refuse and excreta disposal and give appropriate advice?
mH
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Mt m K
11
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General
39.
Ask if anyone in the household is ill and give appropriate advice?
40.
Follow up on recent illnesses?
ilti vgr
Verify that the client(s) understand key information from today's visit?
Establish good rapport with the mother?
e
3
I
3
1 Si
1
Rapid quality assessment checklist: Growth monitoring
1.
2.
3-
-----4.
!.
Health facility
Observer
Observer/supervisor
Date
148/3
Instructions: Mark Hyes“ (Y) if the service provider carries out these activities during observation.
For interview questions, mark "yes" (Y) if the client responds correctly
Observation number/registration and documentation
1
2
3
4
5
6
7
8
9
10
TOT
Problems identified
Actions taken
Age calculation
5.
Base calculation on a reliable date of birth?
6.
Correctly calculate date of birth ?1
7.
Record age?
Weighing
8.
Set scale to 0?
9.
Remove the child’s clothing?
11^ 10.
Place child correctly on scale?
11.
Correctly read scale?2
12.
Record weight?
Plotting the child's growth on chart
13.
u 3 14.
15.
Plot or locate the child's weight at correct age?
Plot or locate the child's weight at correct weight?
Connect to previous growth point?
Referral and follow-up
((i$
17.
Refer malnourished child for nutritional rehabilitation?
18.
Tell mother whether child has gained lost stayed the same since last weighing?
11$ 19.
:i<
Tell mother the nutritional status of the child?
20.
Use growth card to explain to mother how her child is growing?
21.
Ask if the child has had any health problems since last weighing?
22.
Make recommendations regarding child feeding and care?
23.
Explain importance of good breast feeding and weaning practices?
24.
Explain which locally available foods constitute a balanced diet for children?
25.
Explain how to feed children during illness?
26.
Tell mother when to take child for next weighing?
27.
Verify that mother understands key messages?
28.
Ask mother if she has any questions?
36.
Do you have a working scale?
43.
Do you have a way of tracking malnourished children?
i
I
148/3
J Rapid quality assessment checklist : Growth monitoring
Health facility
Observer
Observer/su pervisor
Date
1.
2.
3.
4.
AV »
4
"
ri?
5
MCI
1
Observation number/registration and documentation
Age calculation________________________________________ _
5.
Base calculation on a reliable date of birth?
6.
Correctly calculate date of birth ?1
7.
Record age?
Weighing
1 ir r
Instructions: Mark "yes" (Y) if the service provider carries out these activities during observation.
For interview questions, mark “yes" (Y) if the client responds correctly
__________________________________________ __ __
8.
Set scale to 0?
9.
Remove the child's clothing?
10.
Place child correctly on scale?
11.
Correctly read scale?2
12.
Record weight?
________________________
Plotting the child’s growth on chart______________________ _____________
13.
Plot or locate the child's weight at correct age?
14.
Plot or locate the child’s weight at correct weight?
15.
Connect to previous growth point?
Referral and follow-up_____________________________________________
17.
Refer malnourished child for nutritional rehabilitation?
18.
Tell mother whether child has gained lost stayed the same since last weighing?
19.
Tell mother the nutritional status of the child?
20.
Use growth card to explain to mother how her child is growing?
21.
Ask if the child has had any health problems since last weighing?
22.
Make recommendations regarding child feeding and care?
23.
Explain importance of good breast feeding and weaning practices?
24.
Explain which locally available foods constitute a balanced diet for children?
25.
Explain how to feed children during illness?
26.
Tell mother when to take child for next weighing?
/ 27.
Verify that mother understands key messages?________________________
28.
Ask mother if she has any questions?
36.
Do you have a working scale?
43.
Do you have a way of tracking malnourished children?
_
2
3
4
5
6
7
8
9
10
TOT
Problems identified
Actions taken
;
Rapid quality assessment checklist
Immunization
1.
2.
3.
4.
Health facility
Observer
Observer/supervisor
Date
I'k;, i
I
Instructions: Mark "yes" (Y) if the service provider carries out these activities during observation.
For interview questions, mark "yes" (Y) if the client responds correctly
Observation number:
13.
Use a sterile needle for each injection?
14.
Use a sterile syringe for each injection?
* .■
1
2
3
4
5
6
7
8
9
10
TOT
Problems identified
Actions taken
if
Vaccination technique
17.
Was the child given all vaccinations needed today?
Documentation
19. Record the vaccination on the child's health card?
36.
Was the registered temperature between 0 and 8 degrees (C) at all times during
the last month?_________________________________________
41.
Were all vaccines transported in cold boxes with ice packs?
Exit Interview with mother
43. When should you return to the health center for your next immunization?
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148/5
Rapid quality assessment checklist
Oral rehydration therapy
_
Health facility
Observer
Observer/supervisor
Date
1.
2.
3.
4.
Instructions: Mark “yes" (Y) if the service provider carries out these activities during observation.
For interview questions, mark "yes" (Y) if the client responds correctly
■StrObservation number/registration and documentation
1
2
3
4
5
6
7
8
10
9
TOT
Problems identified
Actions taken
Med i c a I histo ry
rr
I "
1.
1.
5.
Duration of diarrhea?
6.
Consistency of stools?
7.
Frequency of stools?
8.
Presence of blood and/or mucus in stools?
9.
Presence of vomiting?
10.
Fever?
11.
Home treatments?
Physical examination____________________________________________
12. Assess general status (alert or lethargic)?1
13.
Pinch skin?
14.
Weigh child?
15.
Determine nutritional status to be sure the child is not severely malnourished?
16.
Take temperature?
17.
Determine the degree of dehydration (none, moderate, severe)?2
18.
Prescribe ORS or cereal-based ORT?
20.
Refrain from using antibiotics except when stools contain blood or mucus?
22.
If the child is dehydrated administer ORS solution or cereal-based ORT
immediately or refer the child to a nearby centre?_____________________
31.
Tell mother about appropriate feeding practices during and after dehydration?
35.
Show mother how to administer ORS solution or cereal-based ORT?
T7
r
1 Signs of dehydration I lethargy; 2 absence of tears while crying; 3. pinched skin retracts slowly, 4. dry mouth; 5. sunken yeys.
Danger signs: 1. many watery stools; 2. repeated uomiting; 3. very thirsty, 4. eating or drinking poorly; 5. fever; 6. lood in stool; 7. dehydration persists.
'ib L
Health facility
Observer
Observer/supervisor
Date
1.
2.
3.
4.
_____________
_____________
1
BB
Instructions: Mark "yes’* (Y) if the service provider carries out these activities during observation.
For interview questions, mark “yes" (Y) if the client responds correctly
______________
Observation number:
5
148/6
Rapid quality assessment checklist
Clinical family planning services
______________
1
2
3
4
6
5
7
8
9
10
TOT
Problems identified
Actions taken
Medical and reproductive history* (new clients)
J J!.
JU
I j
5.
Ask the client how old she is?
6.
Ask about number, spacing and outcome of pregnancies?
7.
Ask about previous use of family planning methods?
8.
Ask about reasons for stopping or switching previous methods?
9.
Ask about heart disease?
10.
Ask about liver disease?
11.
Ask about high blood pressure?
Ziit
PIB
________________________
12.
Ask about history of pelvic inflamatory disease?
13.
Ask about history of suspected or confirmed venereal disease?
I 14.
Ask about history of blood clots or thromboemboli?
| 15.
Ask if she is breast feeding?
I 16.
Ask about dale of last menstrual period?
Physical examination *_________
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Take blood pressure?
i is.
19.
fc
Examine breast for lumps?
Examine patient for signs of anaemia?
| Selection of a method
mb
w
1.
_________
24.
Choose a method that was free of contra-indications for this client?
28.
Ask about side effects?
___________________________
Counselling (for all)*_____________________________________
I
31.
Describe possible minor side effects of the selected method?
32.
Explain how to manage side effects at home?
33.
Describe major side effects which require medical attention?
Exit interview with client **___________________________
44.
How do you use the contraceptive you received today?
45.
What are the possible side effects?
er
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Appendix E: Other PHC MAP tools
■«
Worksheets for planning quality assessment activities
■•
Form for making your own checklist
Form for manual tabulation
Table for selection of an LQAS sample
I «
■
■ <w
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Module 6: Service quality; appendix E
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WORKSHEET FOR PLANNING QUALITY ASSESSMENT ACTIVITIES
Step 1. Specify the scope and objectives
A. What is the purpose of the assessment?
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WORKSHEET FOR PLANNING QUALITY ASSESSMENT ACTIVITIES
Step 3: Select and adapt the appropriate PHC MAP checklist(s)
Will the checklist require adaptation?
B. What services will be included?
1
C. Who will use the information gathered?
D. How will the information be used?
5
I
E. What geographic area will be covered?
F, Over what period of time will the activities take place?
WORKSHEET FOR PLANNING QUALITY ASSESSMENT ACTIVITIES
Step 4. Determine sampling procedures and select sample (optional)
I
G. What additional resources, if any, are available?
Number of units in sampling frame:
Sample size
(%) =
(N)
Sampling method:
Census (100 percent sample)
Random sample
Systematic sample
LQAS sample
Convenience sample
Purposive sample
Quota sample
What is the minimum number of observations that should be made for
'I
WORKSHEET FOR PLANNING QUALITY ASSESSMENT ACTIVITIES
X
Step 2: Select unit of observation and data sources
Data sources:
Direct observation
by supervisor
by peer
self-assessment
Unit of observation:
Client/patient
Service elements
Health worker
Clinic session
Health centre
eU
Interview
structured interviews
open-ended interviews
each unit?
I
discussion
Record review
routine records
records kept especially for the as
sessment
1
i
n
I
11
I
Module 6: Service quality; appendix E
Module 6: Service quality; appendix E
ii
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Manual tabulation exhibit
PHC MAP tally sheet
Observation
Facility ID
Worker ID
Observer ID
Date
Questions
■hi
1
2
S
3
4
e
5
6
7
€' ■
fc'
L
€
L
€
8
9
€
11 WT'- £
10
11
12
13
14
13
%
D
£
U
6-
n
€
15
16
17
I
e- I
18
19
-
5
& mor
20
21
22
23
24
25
26
e
27
28
29
e
30
Total observations
Total correct
Percent correct
6
k
if
154/3
on worst clinics and
Determination of minimum level, sample size, and acceptable size based on differences between clinics. Need to focus
pre-established goals
1) Big difference
YES
2) Focus on worst
YES
IF' MH
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I) I
H
i m
J.
■ is
NO
YES
NO
SI
Al
M2
S2
A2
M3
S3
A3
Ml
Acceptable size
Minimum level
Sample size
Acceptable size
Minimum level
Goal
Sample size
Acceptable size
Minimum level
Sample size
Goal
12
75%
18
16
80%
95%
13
26
70%
28
95%
13
70%
24
20
75%
90%
16.
34
65%
40
98%
15
65%
29
23
70%
85%
19
39
60%
49
85%
22
16
60%
33
24
65%
50%
23
15
55%
36
60%
eT”
75%
24
42
43 ~
80%
55%
57
80%
15
50%
38
23
66
70%
25
43
45%
55%
70%
14
45%
40
23
41
65%
25
70
40%
50%
65%
25
40%
40
20
72
60%
35%
45%
60%
12
38
38%
55
26
40%
55%
18
35
35%
40
72
55%
16
33%
54
23
35%
50%
38
31
30%
70
50%
13
28%
51
19
30%
45%
36
25
25%
67
45%
33
10
23%
48
15
25%
21
40%
20%
63
40%
7
18%
43
11
20%
35%
29
16
15%
57
35%
5
13%
36
8
15%
30%
24
11
10%
49
30%
"25%
3
8%
29
5
10%
40
25%
28
7
5%
■
I ) I MSI
NO
YES or NO
’
Example;
Goal: weigh 85% of children correctly
Minimal acceptable level: 65% weighed correctly
Table row: 85%
Table column: M2=65%
Required sample size: 52=2
Acceptable size: A2-23
Decision rule: 23 of 29 observed weighings must be done correctly to
conclude that the programme is meeting its goal
75%
=
Position: 2590 (2 views)