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Primary Health Care Management Advancement Programme
ASSESSING
THE QUALITY
OF SERVICE
MODULE 6
USER’S GUIDE
AGA KHAN FOUNDATION
THE ACA KHAN UNIVERSITY
Primary Health Care Management Advancement Programme
ASSESSING
THE QUALITY
OF SERVICE
Lori DiPrete Brown
University Research Corporation
MODULE 6
USER'S GUIDE
Aga Khan Health Services
University Research Corporation
Center for Human Services
A front-line health worker
Photo by P Almasy for WHO
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.
ft ® ®
f»
T ®
4b
Photo by Ph. Merchez for WHO
® &
A PHC concern: the preparation of food by street vendors
sSLsSS'S
An overview of PHC MAP
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 PRICOR1
2. 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-doing
evaluating. The relationship between the modules and this cycle is illustrated below.
PHC MAP modules and the
planning-evaluation cycle
MODULE g
PHC MAP
MODULES
1. Information needs
2. Community needs
3. Work planning
4x Surveillance
5. Monitoring indicators
6. Service quality
7. Management quality
8. Cost analysis
9. Sustainability
MODULE 1
Module a
1 The Aga Khan Health Network includes the Aga Khan Foundation, the Aga Khan Health Services,
and the Aga Khan University, all of which are involved in the strengthening oi 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
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.
Health and management services
HEALTH SERVICES
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
MANAGEMENT
SERVICES
Planning
Personnel management
Training
Supervision
Financial management
Logistics management
Information management
Community organisation
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-solving, 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.
A midwife in Ulan Bator, Mongolia, calls at a "yurt" to see
how mother and child are doing
Photo by D. Henrioud for WHO
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 Foundation’s
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-00-8161-00, 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.
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
techniques.............................................................................. 17
Step 3: Select and adapt the appropriate service quality
checklists................................................................................ 21
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
action...................................................................................... 34
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
Module 6: Service quality
IB
Acknowledgements
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 Projects 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
India
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.
Module 6: Service quality
Kenya
Colombia
Guatemala
Senegal
Zaire
Mombasa PHC Project; Kisumu PHC Project Facilitators:
Paul Richardson, URC; Esther Sempebwa, Mombasa PHC
Project; Matthew Onduru, Kisumu PHC 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, A1HD; Chaweewon
Boonshuyar, A1HD; 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.
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/HIV
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
Module 6: Service quality
Malnutrition in a land of plenty is not rare. A balanced
diet is essential to good health
Photo by P. Almasy for WHO
Quick start
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 (MOD6 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.
Overall PHC
Family planning
assessment
Breast feeding
Health education
GM/Nut ed
Antenatal care
Immunization
Safe delivery
ARI
Postnatal care
DDC/ORT
Water & sanitation
Child disabilities
Accidents & injuries
STD/HIV/AIDS
Malaria
Tuberculosis
Minor ailments
Chronic, non-com
municable diseases
Hypertension
Diabetes
Anaemia
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.
2.
Question/Variable No.
4
1
2
3
5
Yes =
22 23 21 20 18
Percent
88 92 84 80 72
6
16
64
Q/V
Number of observations = 25
7
8
9 10 11 12 13 14
14 21 20 18 14 18 21 4
56 84 80 72 56 72 84 16
15
6
24
Number of
"Yes"
observations
r
a
9
Variables
1O
11
12 13
14
16
2
3
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
Module 6: Service quality; introduction
4
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.
How you can use this module
You 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:
• 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
5
guide decision-making during service delivery. Checklists
can be modified for use during service delivery or while
carrying out a management activity.
• 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.
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
Aids and
tools
6
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.
Checklists
Client
satisfac
tion also
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
7
This module includes short and long checklists for the
following:
GENERAL
OTHER HEALTH CARE
PHC household visits
Health education
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
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
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
8
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:
Short form
->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
9
Exhibit 1: Rapid service quality assessment checklist Short form
IMMUNIZATION
This checklist is intended for 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
Did the service provider:
13. YES
14. YES
17. YES
19. YES
NO
NO
NO
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 degrees
(C) at all times during the last month?
(For outreach sessions):
41. YES
NO
Were vaccines transported in cold boxes with ice packs?
NO
When should you return for the next immunization?
Ask mother
43. YES
A child is
given rice
ORT in a Dhaka
hospital,
Bangladesh
Photo by
Jean-Luc Ray
for AKF
Module 6: Service quality; introduction
10
• 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
11
Exhibit 2: Rapid service quality assessment checklist - Long form
GROWTH MONITORING
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.
1. Health facility
2. Service provider
3. Observer/supervisor
4. Date
Age calculation
Did the service provider:
5. YES
NO
6. YES
NO
7. YES
NO
Base calculation on a reliable date of birth91
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
14 YES
NO
15. YES
NO
Plot or locate the child’s age at correct age?
Plot or locate the child’s weight at correct weight?
Connect to previous growth point?
Referral and follow-up
16.
17.
YES
YES
NO
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
Tell mother whether child has gained, lost, stayed the same
since last weighing?
19. YES
NO
Tell mother the nutritional status of the child?
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.
1
Module 6: Service quality; introduction
12
20. YES__ _____.NO______ Use growth card to explain to mother how her child is
growing?
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
weighing?
Make recommendations regarding child feeding and care?
22. YES
NO
23. YES______ NO_______ Explain importance of good breast feeding and weaning
practices?
24. YES______ NO_______ Explain which locally available foods constitute a balanced
diet for children?
25. YES
NO.______ Explain how to feed children during illness?
Tell mother when to take child for next weighing?
NO
26. YES
27. YES______ NO_______ Verify that mother understands key messages9
28. YES______ NO_______ Ask mother if she has any questions?
For outreach education session, 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 monitoring services?
32. YES—_____ 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. YES—_____ .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?
The exhibit continues with five more questions on interviewing the service provider
Module 6: Service quality; introduction
13
• When to use discussion guidelines. Some service
quality issues are difficult to understand fully with a yes/no
question. Discussion is a good way to open a dialogue with
service providers and engage them in the quality improve
ment process. Discussion guidelines complement the check
lists by helping managers to explore the complexity and
diversity of service quality issues and to study the problems
in more depth.
Exhibit 3 is an example of a discussion guideline for acute
respiratory infection. Discussion guidelines for all 21 services
are included in Appendix C.
• Multiple observation checklists. Checklists for mul
tiple observations have been developed for selected PHC
services. This form is designed to record up to ten observa
tions for each task or health worker. It also includes space
for comments and actions taken. This checklist can be used,
for example, to record ten observations of the same worker
or 2-3 observations of several workers at one facility. It can Discussion
guides
be used to follow a worker over time, recording 2-3 obser
vations during an initial visit, and 2-3 more during follow-up
visits. With minor modifications these checklists can be used
to observe group sessions. For example, the form could be
enlarged (or several copies made) to observe all of the
children immunized or weighed in a clinic session. Exhibit 4
is an abbreviated example of a multiple observation checklist
for a general PHC visit. Multiple observation checklists for
five of the 21 services are included in Appendix D.
Some limitations
Service quality checklists aid supervisors by making the
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
Module 6: Service quality; introduction
14
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.
Exhibit 3: Service quality assessment discussion guidelines
ACUTE RESPIRATORY INFECTION
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 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.
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 checklist (Appendix B) as a resource for the discussion.
Discussion
• 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?
Key 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?
• Did the service provider 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?"
1 Signs include stridor, chest indrawing/rapid breathing, inability to drink, cyanosis, anxiety,
and weakness or lethargy
Module 6: Service quality; introduction
(Il
(1)
(S'
Exhibit 4:
Rapid quality assessment checklist
PHC household visit (abbreviated)
1.
2.
3.
4.
Health facility
Observer
Observer/supervisor
Date
14/1
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
=
W (I J
(IP
(|J
Observation number
1
2
3
4
5
6
7
8
9
10
TOT
Problems identified
Actions taken
| 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?
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
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?
General
41.
Venfy that the dient(s) understands key information from today’s visit?
42.
Establish a good rapport with the mother?
_
_ __________ !
15
Service quality assessment procedures
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 super
visors 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
17
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 ed /mm. 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?
List
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.
Module 6: Service quality; procedures
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?
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
19
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
^ata
observation is a good way to determine whether service concction
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
if the health workers are afraid that the assessments may
be used against them.
Module 6: Service quality; procedures
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
short and well structured.
Photo by Daniel Hiqckley for AKF
Module 6: Service quality; introduction
Exhibit 5: Example of a checklist developed by a programme manager
Group health education session, EPI, ORT, growth monitoring
1.
2.
3.
Health Facility
Observer
Regular supervisor
4.
Observation number:
22/1
Northwest Center, South Centre
B. Sing_________________
(same)_________________
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
JAN
JAN
JAN
JAt
JAN
JAN
JAN
JAN
JAN
YES
-
-
-
5.
Date:
JAN
6.
Service provider (initials):
LD
JB
KB
RT
MF
DL
Problems identified
Actions taken
—
ORT: Did health worker discuss:
7.
Extra fluid?
Y
Y
Y
Y
Y
Y
6
8.
How to make oral rehydration solution?
Y
Y
Y
Y
Y
Y
6
9.
How much oral rehydration solution to give?
Y
N
Y
N
N
Y
3
Amount of ORT
10.
Sign of dehydration?
N
N
Y
Y
N
N
2
Sign of dehydration
Must explain benefits of
Review messages and tech
niques at next meeting (PEB)
EPI: Did health worker discuss:
11.
Diseases prevented by vaccination?
Y
N
N
Y
Y
Y
4
12.
Age for vaccination?
Y
Y
Y
Y
Y
Y
6
13.
Time and place for vaccination session?
Y
Y
Y
Y
Y
Y
6
14.
The importance of completing the series?
Y
Y
Y
Y
Y
Y
6
Importance of gaining weight?
Y
Y
Y
Y
Y
Y
6
Y
Y
Y
Y
Y
Y
6
Y
Y
Y
Y
Y
6
Y
6
N
2
vaccination
Growth monitoring: Did health worker discuss:
15.
_______________ _______ ____________________
16.
Purpose of growth monitoring?
17.
Time and place for growth monitoring session?
18.
Advice about child nutrition?
Y
Y
Y
Y
Y
19
Advice about weaning?
Y
N
N
Y
N
Y
Not enough emphasis on
weaning___________ ________
6
Y
Y
Y
Y
Y
Y
Y
Y
Y
6
N
Y
N
N
Y
3
Y
Y
N
N
Y
4
20.
The importance of breast feediing?
Y
Y
21.
Did the health worker ask participants if they had any questions?
Y
22.
Did the health worker repeat key messages?
Y
23.
Did the health worker establish a good rapport with participants?
Y
Follow-up on training session
in March
---------------- _---------------------—
InelnnHlial rPVlRW of
Techniques such as repetition
techniques with RT 8 MR
and summary are not used ___
Some health workers fail to
23
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
needs. The Appendices of Module 2 include instructions for
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
Sampling
optional
24
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
objective 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
samples are more likely to be statistically valid and generalis
able than smaller ones. But if the manager would be satisfied
Sample size
with a rough estimate, then a small sample may be adequate.
For 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.
For 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
» r 'i
ir i
iL ’ i
it. I
A 1!
< L 't
ijll
if e i
,;L .i
/ L 't
ill
jk i
tts l
25
large (say 500-1,000), take a ten percent sample; if it is of
medium size (100-500), take a 15-20 percent sample; if it is
small (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. They 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.
■^Random sample. A simple random sample can be
drawn by first assigning a number to each unit included in Sampling
choices
the sampling frame. Second, the units should be selected
randomly until you reach the required sample size. For
example, if the sampling frame includes 200 TBAs, each
TBA would be assigned a number from one to 200. If the
sample size chosen is 20, 20 numbers from one to 200
would be chosen randomly, and the corresponding TBAs
would 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
if 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
'SW,'
26
-^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
if
-»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; ail 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
27
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. _________
lb choose a convenience sample the manager selects a
Easily
time and site for the assessment and makes as many observable
observations as possible during the visit. For example, a
uni*s
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
28
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.
WORKSHEET FOR PLANNING QUALITY ASSESSMENT ACTIVITIES
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 unit9 IQ
WORKSHEET FOR PLANNING QUALITY ASSESSMENT ACTIVITIES
Step 5. Carry out the assessment
8/10
8/16
8/14
8/16
8/12
8/14
8/20
Preparation for the visit
Select and train observers
Produce data collection forms
Conduct a pretest of the checklists
Select dates for the assessment
Inform health centres and service providers (optional)
Arrange for transportation for data collection
Module 6: Service quality; procedures
29
9
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.
e
■B
9
9
9
9
9
9
9
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
if
30
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.
This 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
service 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.
Using
discussion
guides
Module 6: Service quality; procedures
<
i>
<ii
1.
2.
Health Facility
Observer
Northwest Centre
B. Sing
3.
Regular supervisor
B. Sing
4.
Observation number:
5.
6.
<iJ
<tJ
i/n
Exhibit 6: Example of a completed quality assessment checklist
Immunization
30/1
Instructions: Mark "yes" if the service provider carries out these activities during service
delivery.
M
1
2
3
4
5
6
7
8
9
10
TOT
Date:
8/28
8/28
8/28
8/28
8/28
8/28
8/28
8/28
8/28
8/28
YES
Service provider (initials):
KB
KB
KB
LD
LD
LD
SF
SF
SF
SF
N
N
N
N
N
N
N
N
N
N
Problems identified
Actions taken
missed opportunities to identify
in-service training session to
cover this topic
4)
Identification of needed vaccinations
7.
<4i
w
<ii
*A
l
0
needed immunization
8.
Review mother's health record or ask whether she has received Tetanus Toxoid
N
Y
N
N
Y
N
N
N
N
N
2
Y
Y
Y
N
Y
N
N
N
N
N
4
communication for women and
children
immunization?
9.
Review vaccination status of other children in the family?
10.
Recommend vaccination even if the child is sick?
Preparation and care of vaccine
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
15.
Keep the vaccine on ice and covered during the session?
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
10
DK
Y
DK
DK
Y
Y
DK
DK
Y
Y
5
Y
Y
Y
Y
Y
Y
Y
Y
Y
10
earned out well
reviewed sterilization
procedure with LD.
I
Vaccination techniques
<b
&
iiw w w w a n v ■ ■
Reviewhealth records to determine which immunizations are needed today?
16.
Apply the vaccine at the right level (BCG=dermal layer,measles=subcutaneous
layer,DTP/TT=muscle)?
17.
Dispose of the needle and syringe properly?
Y
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
N
Y
N
N
Y
N
N
N
N
N
2
well done
problem relates to failure to ID
mothers.
®
i>
<£i
vaccination?
_______________ _____________ ________________________
Documentation
20.
Record the vaccination on the child's health card?
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
10
21.
Record the vaccination in health centre records?
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
10
Y
N
N
_____________________ I
_________________ —-------------------review educational messages
should
explain
each
time
7
Y
N
N
N
N
0
Y
Y
10
N
0
EPI education
22.
Tell the mother which vaccinations were given during this visit?
Y
Y
Y
Y
N
23.
Inform the mother of possible side effects (i.e. fever and pain)?
N
N
N
N
N
24.
25.
For BCG vaccination explain that a scab will form?
Tell mother where to go if there is a severe reaction to the vaccination?
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
well done
Y
N
Y
N
N
side effects were not discussed,
_____________ —-------------- 1
________ _ ______ _______ ;
severe reactions not discussed
30/2
Observation number:
Actions taken
1
2
3
4
5
6
7
8
9
10
TOT
Y
Y
Y
Y
Y
Y
Y
Y
Y
10
ok
N
-
-
-
Y
1
measles reminder needed each
time
in-service training session
vaccination in cases of illness
review educational technique
assess education for other
services.
Problems identified
EPI education (cont’d)
26.
Explain the importance of completing the vaccination series?
Y
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
N
N
N
N
N
N
N
N
1
29.
Tell mother when to come back for next immunization for herself or one of her
children?
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
10
30.
Ask mother to encourage other women to be vaccinated and have their children
vaccinated?
N
N
N
N
N
N
N
N
N
N
0
missed opportunity to promote
vaccinations
31.
Ask mother to repeat key messages?
N
N
N
N
N
N
N
N
N
N
0
must be sure that mothers
understand
32.
Ask mother if she has any questions?
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
10
Maintenance of cold chain and supplies
33.
Is the refrigeralor working today?
Y
34.
Is there a thermometer or cold chain monitor in the refrigerator?
Y
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
38.
Are all vials in storage unopened?
cold chain is operating well
For outreach session
39.
Were vaccines transported in cold boxes with ice packs?
40.
Were vaccines sufficient?
41.
Were needles and syringes sufficient?
Exit Interview with mother
42.
What immunization(s) did your child receive today?
Y
Y
Y
Y
N
Y
Y
N
N
Y
7
43.
When should you return to the health centre for your next immunization?
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
10
At what age should a child receive the following vaccines'
KB
LD
SE
BCG
Y
Y
Y
mothers who were told know
remind health workers to tell
mothers what immunizations
are given
Interview with service provider
44.
45.
DPT
Y
Y
Y
46.
Measles
Y
Y
Y
47.
OPV
Y
Y
Y
48.
Should you vaccinate a child if she/he is ill?
Y
Y
Y
—
knowledge is adequate
---------- -------------------------------
31
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
32
Exhibit 7: Example of a rapid quality assessment
Observer
ID
Date
A
LM
2
A
3
Observation
No.
Facility ID
1
Question number:
27’
20
18
5
6
31
37
41
12-1
Y
Y
Y
N
Y
LM
12-1
Y
Y
N
N
Y
A
LM
12-1
Y
Y
Y
N
N
Y
4
A
LM
12-1
Y
Y
Y
Y
N
Y
5
A
LM
12-1
Y
Y
N
Y
Y
6
A
LM
12-1
Y
Y
Y
N
Y
7
A
WS
12-1
Y
Y
Y
N
Y
8
A
ws
12-1
Y
Y
N
N
Y
9
A
WS
12-1
Y
Y
Y
N
N
10
A
Y
Y
Y
N
N
A
ws
ws
12-1
11
12-1
Y
N
Y
Y
Y
12
B
DN
12-8
Y
Y
Y
N
Y
13
B
DN
12-8
Y
Y
N
N
Y
14
B
DN
12-8
Y
Y
Y
N
N
15
B
DN
12-8
Y
Y
Y
N
Y
16
B
DN
12-8
Y
Y
Y
N
Y
17
B
DN
12-8
N
N
N
N
Y
18
B
JR
12-8
Y
Y
Y
N
Y
19
B
JR
12-8
Y
Y
Y
N
Y
20
B
JR
12-8
Y
Y
N
N
Y
21
B
JR
12-8
Y
Y
Y
N
N
22
C
LD
12-15
N
N
Y
N
Y
23
C
LD
12-15
Y
Y
N
N
Y
24
C
10
12-15
Y
Y
Y
N
Y
25
c
LD
12-15
Y
Y
N
Y
N
Y
26
D
TM
12-15
Y
N
Y
Y
N
Y
27
D
TM
12-15
N
Y
N
Y
N
Y
28
D
TM
12-15
Y
Y
N
N
Y
29
D
TM
12-15
Y
Y
N
N
N
30
D
TM
12-15
Y
Y
Y
N
Y
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
11
Y
Y
N
Y
N
Y
N
Y
Y
N
Y
Y
N
Y
Y
N
N
Y
Y
Y
Y
Y
Y
N
Y
Module 6; Service quality; procedures
33
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.
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.
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.
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.
Module 6: Service quality; procedures
34
Exhibit 8 shows an example of such a graph, depicting
results from 30 observations for immunization services,
broken down into 20 service delivery tasks.
Exhibit 8: Observation of immunization services
30 observations
Step 7: Report the findings, provide feedback,
and take corrective action
Quality assessment is the first step in quality improve
ment. It should be followed by steps designed to maintain
the quality of those tasks that are done well while identifying
and implementing ways to improve the quality of those tasks
that are not.
The following are some guidelines for providing feedback
and taking corrective action.
• Which activities were carried out well? Supervisors
should begin by reviewing what the service provider did well.
This reinforces good performance and establishes a con
structive rapport between the service provider and supervi
sor.
Module 6: Service quality; procedures
35
• 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.
• 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.
• 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-solving 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.
Volunteers in
"Action iodine"
campaign,
Chitral,
Northwest
Frontier
Province,
Pakistan.
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
Appendix A: Rapid service quality
assessment checklists
Short form
GENERAL
OTHER HEALTH CARE
PHC household visits
Health education
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
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
CLIENT SATISFACTION
Module 6: Service quality; appendix A
38
1.
Rapid quality assessment
Community assessment of primary health care (overall)
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.
1. Health facility
3. Observer/supervisor
4. Date
Did the service provider:
Register all children <5 on the family health card?
Register all women over 16 on the family health card?
Vaccinate or arrange for vaccination of children who need to
be immunized?
(If there are malnourished children in the house):
18.
YES
NO
Check to be sure that nutritional counselling, food supplemen
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?
(For each pregnant woman):
27.
YES
NO Ask if she is receiving prenatal care and arrange for a prena
tal visit if necessary?
(For all households):
31.
YES
NO
Refer interested women or couples for family planning ser
vices?
35-38. YES
NO
Discuss water, hygiene, and sanitation, if indicated?
41.
YES
NO
Establish a good rapport with the mother?
5.
6.
11
YES
YES,
YES
NO
NO
NO
Module 6: Service quality; appendix A
39
Rapid quality assessment
2. Health education
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. Health facility
3. Observer/supervisor
4. Date
Did the service provider:
5.
YES_
6.
7-9.
10-17.
18-41.
42-43.
YES
YES
YES
YES
YES
44.
YES
NO Determine participants’ knowledge, attitudes, practices, about
topic?
NO Determine participants’ general level of knowledge?
NO Explain the topic and focus the discussion?
NO
Discuss all relevant aspects of the topic?
NO Use appropriate discussion techniques to encourage active
participation?
NO.Use
appropriate educational materials during the presenta
tion?
NO
Distribute any available educational materials?
Module 6: Service quality; appendix A
IB
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.Health facility
3.Observer/supervisor
4.Date
Did the service provider:
5.
6-12.
13-25.
29-34.
35.
43.
52.
54.
56.
YES
YES
NO
NO
Review and update obstetric record or family health card?
Ask at least two questions about reproductive history risk fac
tors?
YES
NO
Ask at least two questions about risk factors associated with
this pregnancy?
YES
NO
Perform at least 1 physical exam activity?
YES
NO
Immunize or arrange for immunization against tetanus?
YES
NO
Do a blood test (glucose, haemoglobin/haematocrit and malaria)
if medically indicated?
YES
NO
Discuss the importance of having the delivery attended by a
trained health worker?
Yes
No
Explain danger signs which require immediate attention?
Yes____ No______ Tell pregnant woman when and where to go for next prena
tal visit?
Module 6: Service quality; appendix A
41
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. Health facility
3. Observer/supervisor
4. Date
Did the service provider:
Before birth:
YES___ NO_____
5.
6.
YES___ NO
8-16.
YES___ NO_____
17.
YES___ NO_____
During birth:
18-31.
YES
39-43.
44-50.
51-59.
61-62.
YES
YES
YES
YES
64
YES
70-72.
YES
After birth:
73-76.
YES
Sterilise needles, syringes, cord ties, scissors/razor blade?
Prepare a clean birthing place? '
Take labour history?
Review reproductive history for high-risk factors if necessary?
.NO Conduct physical exam and monitor woman throughout lab
our?
NO Assist the progress of labour?
NO Assist with delivery?
NO
Seek help for obstetric problems and emergencies?
NO Tie the umbilical cord with thread in three places and cut
with blade/scissors?
NO
Determine APGAR score at 1 minute and 5 minutes after
birth?
NO Deliver placenta?
NO
__ Monitor mother and provide needed care immediately after
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?
YES __ NO
67.
Give BCG vaccination?
YES
NO
68.
Administer vitamin K?
YFS
NO
97.
__ 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?
Module 6: Service quality; appendix A
42
Rapid quality assessment
5. Postnatal care
This checklist is intended for rapid assessment of service quality in the observation of post
natal 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.Health facility
3.Observer/supervisor
4.Date
Did the service provider:
5-14.
15-21.
22-37.
38.
YES
YES
YES
YES
NO
NO
NO
NO
43.
47.
YES.
YES
NO
NO
44.
45.
48.
YES
YES
YES
NO
NO
NO
54.
YES
NO
55.
YES. __ NO__
Ask the mother at least two medical history questions?
Examine the mother?
Examine the new-born child?
Record findings of history and physical examination health re
cord?
Refer mother for special treatment if necessary?
Refer infant for all physical conditions which need medical at
tention?
Give BCG or verify that child received vaccination at birth?
Give first DPT and OPV?
Tell mother to feed the infant with breast milk only, for the
first 4-6 months?
Discuss family planning with the mother and tell her how she
can obtain family planning services?
Encourage mother to enrol child in well-child clinic?
Module 6: Service quality; appendix A
43
Rapid quality assessment
6. Family planning
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. The checklist item numbers below correspond to that
list.
1.Health facility
3.Observer/supervisor
4.Date
Did the service provider:
Ask at least three medical and reproductive history questions?
Take blood pressure?
Examine breast for lumps?
Examine patient for signs of anaemia?
Recommend a method that was free of contra-indications for
this client?
28,31-33 YES___ NO_____ Discuss side effects?
5-16.
17.
18.
19
24.
YES___ NO_____
YES___ NO_____
YES___ NO_____
YES___ NO_____
YES___ NO_____
Ask client:
44.
45.
YES___ NO_____ How do you use the contraceptive you received today?
What are the possible side effects?
YES
NO
Module 6: Service quality; appendix A
46
Rapid quality assessment
9. Child immunization
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.
1.
3.
4.
______ Health facility
Observer/supervisor
Date
Did the service provider:
13.
14.
17.
19.
YES
YES
YES
YES
NO
NO
NO
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 degrees (C)
at all times during the last month?
(For outreach sessions):
41. YES
NO
Were vaccines transported in cold boxes with ice packs?
NO
When should you return for the next immunization?
Ask mother:
43. YES
Module 6: Service quality; appendix A
47
10.
Rapid quality assessment
Acute respiratory infection
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. The checklist item numbers below correspond to that
list
1. Health facility
3. Observer/supervisor
4. Date
Did the service provider:
5-12.
13.
15.
24.
25.
26.
36
YES
NO
YES __ NO_____
YES
NO
NO
YES
YES_ __ NO_____
NO
YES
NO
YES
Ask at least two medical history questions?
Ask about any treatment administered?
Count respiratory rate?
Classify child by severity of illness?
Give antibiotics for pneumonia, strep throat or otitis?
Refrain from using antibiotics for colds?
Tell mother about at least three signs of pneumonia?1
Ask mother:
(If antibiotics were prescribed):
45-46.
YES
NO
How will you administer the medicine (how much, how often,
for how long)?
1 Signs include stridor, chest indrawing/rapid breathing, inability to drink, cyanosis, anxiety
and weakness or lethargy.
Module 6: Service quality; appendix A
48
11.
Rapid quality assessment
Diarrhoeal disease control/oral rehydration therapy
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. Health facility
3. Observer/supervisor
4. Date
Did the service provider:
5-11.
12-16.
17.
18.
20.
22.
31.
35.
YES
NO
Ask at least two medical history questions?
YES __ NO_____ Perform at least two physical exam activities?
YES.
NO_____ Determine the degree of dehydration (none, moderate, severe)?
YES
NO_____ Prescribe safe ORS solution?
YES. __ NO______ Refrain from using antibiotics, except when stools contain
blood or mucus?
YES.___NO______ If the child is dehydrated, administer ORS solution immediately or refer the child to a nearby centre?
YES.
NO_____ Tell mother how much ORS solution to give and how often
to give it?
YES. __ NO______ Show mother how to prepare ORS solution?
Module 6: Service quality; appendix A
49
12.
Rapid quality assessment
Water supply, hygiene and sanitation
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. _____ Health facility
3. Observer/supervisor
4. Date
Did the service provider:
10. YES
13. YES
NO
NO
16. YES
23. YES
28. YES
30. YES
NO
NO
NO
NO
Discuss keeping water in a clean, covered container?
Discuss the importance of hand washing before eating, feed
ing children, and food preparation?
Inspect latrine?
Discuss appropriate latrine use and human waste disposal
(e.g.
baby potty
for children
underrefuse?
three)?
Recommend
burning
or burying
Recommend penning animals away from the house?
NO
Why is it important to wash your hands?
Ask mother:
37. YES
Module 6: Service quality; appendix A
if
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. Health facility
3.
Observer/supervisor
4. Date
Did the service provider:
-9
5.
YES
NO
10-20.
YES
NO
21-32
33.
YES.
YES
NO
NO
34.
YES
NO
36-37.
YES
NO
42-44.
YES
NO
Ask questions from the mother to identify factors which may
have contributed to a disability?
Ask questions from the mother to determine the type and de
gree of disability?
Correctly examine the child for type and degree of disability?
Administer/prescribe available treatment or therapy accord
ing to established treatment guidelines?
Make the appropriate referral according to established guide
lines?
Provide information on available local services for the dis
abled?
Discuss what parents, family and community can do to help
children with disabilities?
Ask client
53.
What is your child’s disability?
55.
If applicable, do you know how to prevent a similar disability from happening again?
56-59. What information was given to you about treatment and/or where to go for help?
in
Module 6: Service quality; appendix A
itai/iiHiuuiiainBjaHiMKniBiiHii
50
51
Rapid quality assessment
14. Accidents and injuries
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. Health facility
3. Observer/supervisor
4. Date
Did the service provider:
YES___ NO___ __ Correctly identify type of injury?
YES
NO
__ Obtain a history of the injury, e.g., cause, time, etc.?
YES___ NO
__ Administer proper treatment according to established guidelines?
8.
YES___ NO___ __ Make the appropriate referral according to established guidelines?
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?
5.
6.
7.
Module 6: Service quality; appendix A
52
15.
Rapid quality assessment
Sexually transmitted diseases
This checklist is intended for rapid assessment of service quality in the observation of service
delivery for sexually transmitted diseases, lb 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. Health facility
3. Observer/supervisor
4. Date
Did the service provider:
5.
6-9.
YES
YES
NO
NO
10-11.
YES
NO
15-18.
21-30.
38-41.
YES
YES
YES
NO
NO
NO
32-37,42 YES
NO
45-51.
YES
NO
47.
YES
NO
54-67
YES
NO
68-75
YES
NO
IB
Ask about symptoms of infection?
Ask about previous exposure to STD and any treatments ad
ministered?
Ask about exposure to other potential sources of infection,
e.g., blood, non-sterile instruments, etc.?
Ask about possible risk behaviours associated with STD?
Examine patient for signs of infection?
Diagnose and treat patient according to established guide
lines?
Refer patients for diagnoses, treatment or laboratory testing
according to established guidelines?
Provide health education on the modes of transmission and
prevention of STD?
Instruct the client on the correct and consistent use of con
doms?
Provide appropriate counselling on testing procedures, confi
dentiality and meaning of test results?
Provide appropriate counselling to STD cases on available
treatments, complications of disease or any long term effects,
and possible risks to partners and/or children?
Module 6: Service quality; appendix A
53
Rapid quality assessment
16. Malaria
This 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 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. Health facility
3. Observer/supervisor
4. Date
Did the service provider:
5-10.
11.
12.
13.
20.
22.
25-26.
30.
31.
YES
NO
Ask at least two medical history questions?
YES
NO
Ask about anti-malarial drugs taken in the last 24 hours?
YES.___NO_____ Ask about other symptoms to rule out other fever-related
illnesses?
YES
NO
Take temperature?
YES
NO
Make blood slide or refer case to a facility where a blood
slide may be examined?
YES.___NO_____ Administer or prescribe appropriate anti-malarial drug ac
cording to local norms?
YES.___ NO
If fever is over 39 degrees C: Administer antipyretic drug and
sponge or bathe with water?
YES.___ NO______ Discuss danger signs that may indicate unresponsive or com
plicated malaria?
YES.___NO_____ .Tell client to return for consultation if danger signs develop?
Ask client:
52.
YES.
_NO
If medicine is prescribed: How will you take the medicine,
how much, how often, and for how long?
Module 6: Service quality; appendix A
sb
54
Rapid quality assessment
17. Tuberculosis
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
1. Health facility
3. Observer/supervisor
4
Date
Did the service provider:
5.
6.
7.
8.
17.
19.
21.
YES
_NO_______ Ask about persistent cough, two weeks or more?
YES
NO
___ Ask about persistent fever, one month or more?
YES
NO
__ Ask about weight loss?
YES__
NO
_ Ask about blood in sputum?
YES__ _NO__ __ _ Perform cutaneous TB test?
___ Refer for sputum examination?
YES
NO
YES_____NO____ ___ Prescribe medicines or refer for treatment according to local
norms?
22. YES____ _NO___ ___ For follow-up cases: Verify that client is taking medicine correctly?
28. YES____ _NO____ ___ Explain how much and how often to take medicine?
29. YES____ _NO____ ___ Stress the importance of completing the treatment?
Ask client:
44 YES
47. YES
if
_NO___ ___ 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?
NO
Module 6: Service quality; appendix A
55
18.
Rapid quality assessment
Treatment of minor ailments
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. Health facility
3. Observer/supervisor
4. Date
Medical history
Did the health provider:
5. YES
NO
6. YES
NO
7. YES
NO
Ask about the chief complaint, fever, pain, cough, etc?
Determine the present history of the illness?
Determine condition-related past and family history?
Physical examination
Did the service provider:
8. YES
NO
9.
YES
NO
Check vital signs, blood pressure, temperature, pulse, respira
tion rate etc.
Conduct a related physical exam?
Diagnosis
Did the service provider:
10. YES
NO
Make differential diagnosis, e.g., cough, TB, pneumonia, bron
chitis, abdominal pain, gastroenteritis, acute cholestitis, appen
dicitis, etc.?
Laboratory diagnosis
Did the service provider:
11. YES
NO
Order condition- or preliminary diagnosis-related diagnostic
tests, laboratory tests, x-ray studies, etc.?
Treatment and follow-up plans
Did the service provider:
__ Provide appropriate treatment according to the condition?
NO__
13. YES
___ Provide information to the patient about the condition and
14. YES___ ___NO____
treatment plan?
___ Discuss the importance of compliance with the drug therapy?
NO
18. YES
__ How often will you take this medicine?
NO
21 YES
_ What is the dose you will take?
__ NO__
22. YES
23. YES___ __ NO_______ For how long will you continue treatment?
Module 6: Service quality; appendix A
56
Rapid quality assessment
19a. Hypertension
This checklist is intended for rapid assessment of service quality in the observation of service
delivery for hypertension. 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. Health facility
3. Observer/supervisor
4. Date
Did the service provider:
5-6
7-13.
YES___ NO______ Take a proper blood pressure reading?
YES.___ NO______Ask about chief complaints, e.g., blurred vision, severe headache, shortness of breath, chest pain?
14,16.
YES___ NO______ Ask about prior/current experience and treatments for hypertension?
15.
YES___ NO_____ Ask about family history of hypertension?
17.
YES___ NO______Ask about history of diabetes or stroke?
21.
YES___ NO______Ask about current lifestyle, e.g., work, stresses, home conditions?
23-24. YES___ NO_____ Ask about previous illness and treatment?
25-34. YES___ NO______Perform a physical exam which included a check of vital
signs, blood pressure, heart, pulse in foot, neck veins or other
as per local policy?
35-38. YES___ NO______Provide patients with health education/counselling on hypertension?
39-43. YES
NO
Instruct patients on the use of any prescribed medication?
46.48-49.YES
NO
Educate patients on appropriate low sodium diet and exercise?
44-45. YES___ NO______Inform patients of the warning signs indicating when to return to the clinic?
Module 6: Service quality; appendix A
57
Rapid quality assessment
20b. Diabetes mellitus
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.
1. Health facility
3. Observer/supervisor
4. Date
Did the service provider:
5.
YES
NO
6-15.
YES_
NO
16.
17-19.
YES
YES
NO
NO
22.
YES
NO
25-30.
YES
NO
Ask about symptoms, e.g, blurred vision, unusual thirst, uri
nary tract infection, yeast infection if a woman, foot prob
lems, 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
32.
YES
NO
Discuss the importance of maintaining blood sugar levels
within a specified range before and during pregnancy to pre
vent birth defects?
Refer high risk pregnancies as per local norm?
Module 6: Service quality; appendix A
NO
NO
Determine the
aetiologyconsultation;
of the anaemic
condition?
appropriate
referral
to a specialist, if
Determine
needed? haemoglobin type, region, race, age or sex?
16. YES
24.
NO
Get complete
bloodnutrition
count with
reticulocite count?
Were
you provided
counselling?
15.
29. YES
YES
NO
NO
21.
YES
22.
58 YES
18.
Ask client:
Rapid quality assessment
21c. Anaemia
Ask the service provider:
Give
complete
physical
examination,
chest,how
abdomen,
Do you
know how
to administer
the drug,
much, etc.?
how
often
and
how
long?
This checklist is intended for rapid assessment of service quality in the observation of service
30. YES for anaemia.
NO
Do
know where
you can
getservice
refills provider
for the drug?
delivery
theyou
checklist,
markfor
"yes"
if the
carries out the
34. YES
NO To use How
can you care
anaemia?
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. Health facility
3. Observer/supervisor
4.
Date
13.
YES
NO
Ask about family history of anaemia?
Did the service provider:
5.
6.
7.
11.
9.
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
Ask about chief complaints, whether pregnant?
Ask if there is any blood in stool?
vented?
Determine the occult blood in the stool?
Check colour of conjunctiva?
Discuss some common injuries and how they may be pre
Module 6: Service quality; appendix A
61
Appendix B: Rapid service quality
assessment checklists
Long form
GENERAL
OTHER HEALTH CARE
PHC household visits
Health education
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
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
CLIENT SATISFACTION
Module 6: Service quality; appendix B
if
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.
1. Health facility
2. Service provider
3. Observer/supervisor
4. Date
Registration and documentation
Did the service provider:
5 YES
NO
6. YES
NO
7. YES
NO
8. YES
NO
Register all children under 5 in the family health card?
Register all women over 16 in the family health card?
Update information during the visit?
Record this visit in health centre records?
Under 5 care
Immunization:
Did the service provider:
_NO____ ___ Discuss the importance of vaccination?
9. YES
NO
10. YES
___ Review the immunization status of all children under 5?
11. YES_____ .NO____ ____ Vaccinate or arrange for vaccination of children who need to
be immunized?
12. YES______.NO____ ___ Review vaccinations needed and the appropriate dates with
mother?
13. YES______NO____ ___ Answer mothers questions about vaccination?
Growth
monitoring:
17.
YES
NO
Did
service provider:
16. the
YES
NO
14.
YES.NO
18. YES
NO
15. YES
NO
Answer
mother’s questions about growth monitoring and nu
tional
advice?
Discuss changes in weight with the mother and give nutri
trition?
Review
the
cards of allchildren
childreninunder
5?
If there are growth
any malnourished
the house:
Did the
Weighworker
children
or refer
them
growth
monitoring?
health
check
to be
surefor
that
nutritional
counselling,
food supplementation, and/or medical attention are being re
ceived?
ORT:
Did the service provider:
19. YES
NO
Ask if any children in the household had diarrhoea?
Module 6: Service quality; appendix B
63
20.
YES
NO
21.
YES
NO
22.
23.
YES
YES
NO
NO
If yes, recommend ORT, and help the mother to prepare and
administer it?
If no, review the importance of ORT and encourage mother
to use it in future diarrhoea episodes?
Answer mother's questions about ORT?
Demonstrate how to make ORT, or invite mother to a dem
onstration, if necessary?
Maternal care
Antenatal care:
Did the service provider:
24. YES
NO Discuss the importance of prenatal care?
25. YES
NO
Ask if any women in the household are pregnant?
26. YES
NO Talk with each pregnant woman about her general well
being?
27. YES
NO
Ask if each pregnant woman is receiving prenatal care and
arrange for a prenatal visit if necessary?
28. YES
NO Give nutritional advice and iron/calcium supplementation to
each pregnant woman?
29. YES
NO
Answer pregnant woman’s questions?
Family planning:
Did the service provider:
30. YES
NO
31. YES
NO
32.
YES
NO
33.
34.
YES
YES
NO
NO
Provide information about family planning services?
Refer interested women or couples for family planning ser
vices?
Ask women who already use contraception if they are happy
with their method?
Refer current users for advice or follow-up, if necessary?
Answer questions about family planning?
Water and sanitation:
Health workers should include water and sanitation if there is a current or recent case of
diarrhoea in the home or in any homes where the health worker feels that poor water and
sanitation may constitute a health risk.
Did the service provider:
35. YES
NO
Ask about access to water and provide information about
community efforts to address problems, if necessary?
36. YES
NO
Ask about water storage practices and give appropriate ad
vice?
38. YES
NO
Ask about refuse and excreta disposal and give appropriate
advice?
37. YES
NO
Ask about latrine maintenance and use and give appropriate
advice?
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
PHC service quality checklist
2: Health education1 1
2
This checklist is intended for use in supervision and monitoring of health education services
provided by clinic-based health workers and community-based health workers. The list is
comprehensive and includes some clinical tasks that the traditional birth attendants and other
peripheral workers do not routinely carry out. The checklist should be modified and simplified
according to the local situation. This checklist is intended for use in the observation of service
delivery. It is 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,
provider
carries
activities
service
delivery.
17. YESmark "yes"
NOif the service
Discuss
where
to goout
for these
services
or seekduring
help, if
needed?
needed?
For interview
questions,
mark "yes"
if the
respondent
correctly.
16.
YES
NO
Discuss
when
to go for answers
services/follow
up or seek help, if
Use of appropriate techniques
Did
service provider
15. the
YES
NO
Discuss potential complications and danger signs?
18.
YES
NO facility Establish good rapport with the participants?
1.
Health
19. YES
NO
Demonstrate sensitivity to existing/various levels of KAP?
2.Service provider
14.
YES
NO
Discuss potential obstacles and problems?
3
Observer/supervisor
4.Date
Determine
background
13.
YES educational
NO
Discuss benefits of the proposed behaviour change?
Did the service provider:
5. YES
NO
Determine participants’ knowledge, attitudes, practices (KAP)
about topic?
6. YES
NO
Determine participants’ general level of education?
12. YES
NO
Discuss specific recommended behaviour changes?
Discussion of topic
Did the service provider:
7. YES
NO
8. YES
NO
9. YES
NO
10.
YES
NO
11. YES
NO
Clearly define the purpose of the meeting?
Discuss the relevance and purpose of the topic?
Remain focused on the topic in hand?
Explain transmission
risk factors (i.e.
environmental, socio-eco
Discuss
andbiological,
prevention?
nomic, behavioural, health care related)?
1 Pleiffer, J. (ed.), Theoriesand models inapplied behavioral science, vol. Il, p. 12,28,65-66,139 140 147-149
189, 227
2 Wallerstein, N. & Bernstein, E., Empowerment, education: Freire's ideas adapted to Health education,
Health Education Quarterly, vol. 15, No 4, p. 379-383 (1988)
Module 6: Service quality; appendix B
65
20. YES
NO
21 YES___ ___ NO.
i
-
22. YES
NO
23. YES
___ NO
24. YES
NO
25. YES___
NO
26. YES
NO
27. YES______ NO.
9
28. YES_ ___ NO
29. YES
NO
30. YES
NO
31. YES
NO
32. YES______ NO.
33. YES
NO
34. YES______ NO.
9
3
NO
35. YES
36. YES______ NO.
NO
37. YES
NO
38. YES
NO
39. YES
40. YES
NO
41. 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 of materials
Did the provider:
42. YES
NO
43. YES
NO
44.
YES
Use audio-visual materials during the presentation?
Use materials appropriate for illiterate participants, if neces
sary?
NO Distribute any available educational materials?
Exit interview with participants
Mark "yes" if the respondent answers correctly;
45. YES
NO
What 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?
Interview with provider
Mark "yes" if the respondent answers correctly:
49. YES
NO
Did you communicate the points that you had planned to?
Module 6: Service quality; appendix B
66
PHC service quality checklist
3: Antenatal care
This checklist is intended for use in supervision and monitoring of antenatal services provided
by health workers, community-based health workers, and traditional birth attendants. The list
is comprehensive and includes some clinical tasks that the traditional birth attendants and
other peripheral workers do not routinely carry out. The checklist should be modified and
simplified according to the local situation. This checklist is intended for use in the observation
of service delivery. It is 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 provider
3.Observer/supervisor
4.Date
Reproductive history
Did the service provider-.
5. YES
NO
Review obstetric record or family health card?
Did the service provider update information on the following:
6. YES
NO
Age?
7. YES
NO
Date of last menstrual period?
8. YES
NO
Date of last delivery?
9. YES
NO
Number of previous pregnancies?
10. YES
NO
Outcome of each pregnancy?
11. YES
NO
Complications during previous pregnancies?1
11
12. YES
NO
Current or past breast feeding?
Did the service provider ask about risk factors:
13. YES
NO
Spotting/bleeding during current or past pregnancies?
14. YES
NO
Burning on urination?
15. YES
NO
Foul smelling vaginal discharge?
16. YES
NO. Diabetes?
17. YES
NO
Cardiovascular problems?
18. YES
NO
Renal problems?
19. YES
NO. Female circumcision?
20. YES
NO
Previous injuries, especially to pelvis?
21. YES NO
Medications currently being taken?
22. YES
NO
Smoking?
23. YES
NO
Alcoholism?
24. YES
NO
Drug abuse?
25. YES
NO
Any other problems associated with current pregnancy?
1 Complications include bleeding, toxaemia, infection, prolonged labour, RH incompatibility, Cesarean
section, stillbirth, and spontaneous abortion.
Module 6: Service quality; appendix B
67
Ask about preventive actions taken:
26. YES
NO
Immunization against tetanus?
27. YES
NO
Malaria prophylaxis?
28. YES
NO
Plans for delivery?
Physical exam
Did the service provider:
29. YES
NO
30. YES
NO
31. YES
NO
32. YES
NO
33. YES
NO
34. YES
NO
Take pulse?
Take blood pressure?
Correctly measure height and weight?
Correctly examine legs, face, and hands for signs of oedema?
Calculate expected date of delivery?
Assess adequacy of pelvic outlet?
Routine preventive services for pregnant women
Did the service provider:
35. YES
NO
36. YES
NO
37. YES
NO
38. YES
NO
Immunize or arrange for immunization against tetanus?
Administer or prescribe iron supplements?
Administer or prescribe nutrition supplements?
Administer or prescribe anti-malarial drugs if indicated?
Referral
Did the service provider:
39. YES
NO
40.
41.
42.
YES
YES
YES
NO
NO
NO
43.
YES
NO
44.
45.
YES
YES
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)?
Counselling
Did the service provider:
46. YES
NO
47.
48.
YES
YES
NO
NO
49.
50.
51.
YES
YES
YES
NO
NO
NO
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.
Module 6: Service quality; appendix B
YES
NO
70 YES
21
49.
YES
50. YES
NO
NO
NO
Feel if umbilical cord is around foetus’s neck and slip it over
head?
Determine
position
ofmeconium
foetus?
Suck mucus
and/or
from infant’s nose and mouth?
Deliver shoulders and body?
18. YES
19. YES
20. YES
NO
NO
NO
Regularly take pulse?
Regularly take blood pressure?
Determine strength and length of contractions?
48.
Module 6: Service quality; appendix B
71
Seek help for obstetric problems and emergencies
Did the service provider:
51. YES-------- NO
52.
53.
YES
NO
YES------- NO
54.
YES
NO
55.
YES
NO
56.
57.
58.
59.
YES
YES
YES
YES
NO
NO
NO
NO
For shock and haemorrhage place mother in trendelenberg
position and treat (per local policy)?
Treat infection with antibiotics?
For eclamptic convulsions treat with anticonvulsants, protect
physical safety of mother during convulsions, and im
mediately deliver infant?
Attempt manual manipulation of foetal head in cases of in
complete internal rotation?
Use appropriate technique to deliver foetus in abnormal posi
tion, such as footling, buttocks, face, brow, arm, shoulder pre
sentations?
Provide other emergency care as indicated?
Refer obstetric problems and emergencies?
Perform episiotomy if indicated (per local policy)?
Assist with forceps, vacuum extraction, or symphisiotomy (if
indicated and according to local policy)?
Provide immediate care for new-born
Did the service provider:
60. YES
NO
61. YES
NO
62. YES
NO
63.
64.
YES
YES
NO
NO
65.
66.
YES
YES
NO
NO
67.
68.
69.
YES
YES
YES
NO
NO
NO
Establish respiration/loud cry?
Tie umbilical cord in three places with sterile ties?
Cut umbilical cord with sterile scissors or razor blade; leave
two ties on infant’s side?
Wrap in clean cloth and cover head to maintain warmth?
Determine APGAR score at 1 minute and 5 minutes after
birth?
Give the infant to the mother to suckle?
Insert antibiotic eye ointment or silver nitrate drops into eyes
within one hour after birth?
Immunize?
Administer Vitamin K?
Provide emergency care, as indicated?
Deliver placenta
Did the service provider:
70. YES
NO
Deliver placenta and examine for completeness?
71 YES
NO
Manually remove retained (partial or complete) placenta?
72. YES
NO Establish breast feeding?
Monitor mother immediately after delivery
Did the service provider:
73 YES
NO
74. YES
NO
75.
76.
YES
YES
NO
NO
Regularly monitor blood pressure and pulse?
Massage uterus within 15 minutes after delivery and regularly
thereafter?
Monitor blood loss?
Administer ergonovine 1 mg if mother is bleeding heavily
(per local policy)?
Examine infant
Did the service provider:
77. YES
NO
Assess general appearance, alertness, tone?
Module 6: Service quality; appendix B
72
NO_______ . Take temperature?
NO_______ . Measure respiratory rate?
Measure heart rate?
NO
Weigh?
NO
Examine head and feel for fontanelles and sutures?
NO
Examine eyes for redness, discharge, jaundice, pallor?
NO
Listen to chest to assess respiration and heartbeat?
NO
Palpate abdomen and liver?
NO
Examine genitals for normality, hernias?
NO
Examine for muscle tone and Moro reflex?
NO
Examine extremities and skeletal system for symmetry, moveNO
ment, and broken or dislocated bones?
. Inspect skin for sores, breaks?
NO
89. YES
NO_______ . Examine for birth defects?
90. YES
_NO_______ . Weigh?
91. YES
Take temperature?
NO
92 YES
Refer infants with medical emergencies and birth defects?
NO
93. YES
Record labour and delivery information on labour charts?
NO
94. YES
Watch for and record first urination and bowel movement?
NO
95. YES
96. YES_____ _NO_______ . Give BCG and OPV (per local policy)?
78. YES
79. YES
80. YES
81. YES
82. YES
83. YES
84. YES
85. YES
86. YES
87. YES
88. YES
Education after delivery
Aftercare;
Did the service provider:
97. YES
NO
98. YES
99. YES
100. YES
101. YES
102. YES
103. YES
Tell mother to keep her genital area clean and demonstrate
how to wash her genitals?
Tell mother to return to clinic if gross bleeding occurs, or if IoNO
chia remains red or has foul smell, or if she develops fever or
other unexpected symptoms?
Tell mother to refrain from intercourse for 4-6 weeks?
NO
Tell mother to keep area around cord clean and dry7
NO
_NO_______ . Tell mother not to put anything (soil/salve) on the cord and
not to remove the ties?
NO_______ . Demonstrate how to bathe and clean infant, especially
around umbilical cord?
, Tell mother to bring infant to clinic if any redness or disNO
charge from cord occurs?
Breast feeding:
Did the service provider:
NO
Instruct mothers in the health benefits of breast feeding?
104. YES
NO_______ , Tell mother to feed colostrum?
105. YES
106. YES
_NO_______ , Tell mother that normal milk flow will begin after 2-3 days?
107. YES_____ _NO_______ Tell mother to breast feed infant frequently during the first
few days?
108. YES_____ NO
Tell mother to use both breasts, feeding from one until it is
empty, then from the other?
109. YES_____ _NO________ Tell mother to start feeding with the breast that is not the
breast she started feeding from last time?
110. YES_____ .NO_______ _Tell mother to continue breast feeding when she or infant is
ill?
IB
Module 6: Service quality; appendix B
73
111. YES
NO
ing?
112. YES_____ _NO______ _ Demonstrate how to express breast milk to relieve congestion and prevent engorgement?
113. YES_____ _NO______ _ Demonstrate how to position infant’s mouth around areola
for breast feeding?
114. YES
NO
_ Tell mother to return if the infant has problems nursing?
Well-child care:
Did the service provider:
115. YES_____ _NO_______ Tell mother about child immunization?
116. YES_____ _NO______ __ Tell mother when to return for first postpartum visit and for
infant’s first well-child visit?
117. YES_____ _NO______ _ Verify that the mother understands warning signs for her
and/or her infant to return to clinic?
118. YES
NO
_ Verify that mother knows when to return for first postpartum
visit and for infant’s first well-child visit?
119. YES_____ _NO______ _ Ask mother if she has any questions?
Supplies
120. YES_____ .NO______ _ Do you have cord ties?
121. YES
NO
_ Do you have a razor or a pair of scissors9
122. YES_____ .NO______ _ Do you have gloves?
NO
Do you have a watch with a second hand to take pulse?
123. YES
124. YES_____ NO______ _ Do you have a stethoscope?
125. YES_____ _NO______ _ Do you have a blood pressure cuff?
_ Do you have antibiotics?
NO__
126. YES
_ Do you have anticonvulsants?
NO
127. YES
127. YES_____ _NO______ _ Do you have needles?
128. YES_____ .NO______ _ Do you have syringes?
Module 6: Service quality; appendix B
PHC service quality checklist
5: Postnatal care
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 attendantsThis 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 is 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 provider
3. Observer/supervisor
4. Date
Medical history
Did the service provider:
5. YES
__ NO
Ask mother when and where she delivered?
6. YES
__ NO____ ___ Ask mother the outcome of the delivery?
7. YES__ ___ NO____ ___ Ask about problems during delivery?
8. YES___
NO
___ Ask mother about vaginal bleeding?
9. YES___ __ NO____ ___ Ask mother about foul smelling vaginal discharge?
10. YES______ NO____ ___ Ask mother if she feels pain or tenderness in the abdomen or
breasts?
11. YES___ __ NO____ __Ask mother if she’s had a fever?
12. YES___ ___NO____ ___ Ask mother if she is taking any medications, including contraceptives?
NO
13. YES___
___ Ask mother what she is eating?
14. YES___ ___NO____ ___ Ask mother about the infant's eating habits?
Physical examination
Mother:
Did the service provider:
15. YES_____ NO____ ___ Examine the abdomen for swelling, condition of caesarean incision, and to determine the size and firmness of the uterus?
16. YES
___ NO____ ___ Examine the genitals for swelling, discharge, bleeding, tears,
fistula, and episiotomy repair?
17. YES
NO____ ___ Examine the breasts for cracked nipples, engorgement, abscess?
18. YES___ __ NO____ ___ Take pulse?
19. YES
__ NO____ ___ . Take blood pressure?
20. YES___ __ NO____ _ Weigh the mother?
21 YES___ __ NO____ __Examine eyes for signs of anaemia?
Module 6: Service quality; appendix B
75
Child (first postnatal visit):
Did the service provider:
22. YES
NO
Assess vital signs?
23. YES___ ___ NO______ _ Measure height and head circumference?
24. YES______ NO______ _ Weigh child?
25. YES______ NO______ _ Monitor child’s growth with growth chart?
26. YES
NO
Examine head and fontanelle*?
27. YES______ NO______ _ Assess eyes (for opacities, jaundice, infection)?
28. YES______ NO______ _ Assess respiration (rate, retraction)?
29. YES
NO
Assess heart (rate murmur)?
30. YES
NO
31. YES______NO______ _ Examine extremities and skeletal system for symmetry, movement, and broken bones?
32. YES___ _NO______ _ Examine umbilicus?
33. YES
__ NO______ Assess general alertness?
34. YES___ __ NO__
Assess suction reflex?
35. YES
NO
Assess Moro reflex?
36. YES___ ___NO______ _ Assess response to brightness?
37. YES
__ NO______ _ Assess response to sound?
Documentation:
Did the service provider:
38. YES
NO
Record findings of history and physical examination on
health record?
Treatment, routine preventive services, and referral
Mother:
Did the service provider:
39. YES
NO
40. YES
NO
41. YES
NO
42. YES
NO
43.
YES
NO
Provide iron and/or folic acid tablets (per local policy)?
Provide nutrition supplements (per local policy)?
Provide malaria chemoprophylaxis (per local policy)?
Give other therapeutic medications to treat medical condi
tions as appropriate?
Refer maternal postpartum cases requiring special treatment?
Child:
Did the service provider:
44. YES
NO
_ Give BCG vaccination or verify that child received vaccination at birth?
NO
_ Give first DPT and OPV (per local policy)?
45. YES
NO
_ If the child is malnourished, refer for nutritional counselling?
46. YES
47. YES___ ___NO______ _ Refer the child for all physical conditions which need medical
attention?
Education
Breast feeding:
Did the service provider:
48. YES
NO
49.
50.
51.
YES
YES
YES
NO
NO
NO
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?
Tell mother to breast feed even if she and/or infant is ill?
Module 6: Service quality; appendix B
76
Child-spacing:
Did the service provider
52. YES
NO
53.
YES
NO
54.
YES
NO
Well child care:
Did the service provider55. YES
NO
56. YES
NO
57. YES
NO
58.
YES
NO
General:
Did the service provider:
59. YES
NO
60. YES
NO
61.
YES
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?
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:
62. YES
NO
Do you have a working scale to weigh the mother?
63. YES
NO
Do you have a working scale to weigh the child?
64. YES
NO
Do you have a watch or time piece with second hand to mea
sure pulse?
65. YES
NO
Do you have a stethoscope and blood pressure cuff?
66. YES
NO
Do you have BCG, OPV, and DPT vaccines?
67 YES
NO
Do you have iron tablets (per local policy)?
Interview with mother
Mark "yes" if the respondent answers correctly:
68. YES
NO
When should your baby receive his or her next vaccination?
69. YES
NO
For how long will you breast feed?
NO
What will you do to space your births?
70. YES
71 YES
NO
Is your child growing normally?
Interview with service provider
Mark "yes" if the respondent answers correctly:
72. YES
NO
Do you maintain records that identify recent mothers and in
fants for postnatal care?
73. YES
NO
Do you educate mothers about postpartum care during pre
natal
carediscuss
and delivery?
74. YES
NO
Do you
family planning during the postpartum visit?
Module 6: Service quality; appendix B
PHC service quality; checklist
6: Family planning services
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.
1. Health facility
2. Service provider
3. Observer/supervisor
4.
Date
Medical and reproductive history (new clients)
Did the service provider:
5. YES
NO
6. YES
NO
7. YES
NO
8. YES
NO
9. YES
10. YES
11. YES
12. YES
13. YES
14. YES
15. YES
16. YES
Ask the client how old she is?
Ask about number, spacing, and outcome of pregnancies?
Ask about previous use of family planning methods?
Ask about reasons for stopping or switching previous meth
ods?
NO
Ask about heart disease?
NO
Ask about liver disease?
NO Ask about high blood pressure?
_NO
Ask about history of Pelvic Inflammatory Disease?
NO
Ask about history of suspected or confirmed venereal disease?
NO
Ask about history of blood clots or thromboembolism?
NO
Ask if she is breast feeding?
NO
Ask about date of last menstrual period?
Physical examination
Did the service provider:
17. YES
NO
18. YES
NO
19. YES
NO
Take blood pressure?
Examine breast for lumps?
Examine patient for signs of anaemia?
Determine method
Did the service provider:
20. YES
NO
21.
22.
23.
YES
YES
YES
NO
NO
NO
24.
YES
NO
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?
Module 6: Service quality; appendix B
78
25.
YES
NO
26.
YES
NO
Verify that the client is comfortable with the recommended
method?
If necessary, refer the client to a doctor or. midwife?
For follow-up cases
Did the service provider:
27. YES
NO
28. YES
NO
29. YES
NO
Verify correct usage?
Ask about side effects?
Give advice about managing side effects?
Counselling (for all)
Did the service provider:
30. YES
NO
31. YES
NO
32. YES
NO
33. YES
NO
34. YES
NO
35. YES
NO
36. YES
NO
37.
38.
YES
YES
NO
NO
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?
Supplies
Ask the service provider about the following supplies:
39. YES
NO
Do you have a blood pressure cuff and stethoscope?
40. YES
NO
Do you have a supply of oral contraceptives?
41. YES
NO
Do you have a supply of IUDs?
42. YES
NO
Do you have a supply of injectable contraceptives?
43. YES
NO
Do you have a supply of implants?
Exit interview with client
Mark "yes" if the respondent answers correctly:
44. YES
NO
How do you use the contraceptive you received today?
45. YES
NO
What are the possible side effects?
46. YES
NO
Where can you get more supplies?
47. YES
NO
When will you come back for a check up?
Service provider interview
Mark "yes" if the respondent answers correctly:
48. YES
NO
Under what conditions should you refrain from prescribing
oral contraceptives?
49. YES
NO
Under what conditions should you refrain from prescribing
the IUD?
50. YES
NO
Under what conditions should you refrain from prescribing in
jectable?
51. YES
NO
Under what conditions should you refrain from prescribing
implants?
Module 6: Service quality; appendix B
79
PHC service quality checklist
7: Breast feeding^2 3 4 5 6 7
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.
9
1- Health facility
2. Service provider
3. Observer/supervisor
4. Date
Medical history
Did the service provider:
5. YES
NO
6.
YES
NO
7.
YES
NO
8.
9.
YES
YES
NO
NO
10.
YES
NO
—k
*9
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 feeding?
Ask about socio-economic status and dietary habits and in
take?
Breast feeding education and counselling
Skills Training:
Did the service provider.11. YES
NO
T-eZ
12.
13.
YES
YES
NO
NO
14.
15.
YES
YES
NO
NO
y-jEt
^9
Instruct mothers on the health benefits to mother and child
of breast feeding?
Instruct mothers on the financial benefits of breast feeding?
Tell mother to feed colostrum (begin breast feeding as soon as
possible)?
Tell mother that normal milk flow will begin after 2-3 days?
Tell mother to breast feed infant frequently during the first
few days?
1
PHC Management Advancement Programme, Module 5, User’s guide
2 PRICOR Thesaurus, vol. II, 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 tn 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
80
Explain the importance of feeding breast milk only, for the
first 4-6 months?
17. YES___ _NO______ _ Tell mother to use both breasts, feeding from one until it is
empty, then from the other?
18. YES___ _NO______ _ Tell mother to start feeding with the breast that is not the
breast she started feeding from the last time?
19. YES___ _NO______ _ Tell mother to continue breast feeding when she or infant is
ill (diarrhoea, infection)?
_ Tell mother to keep nipples clean and dry to prevent crack20. YES___
NO
ing?
_ Tell mother to avoid using soap on nipples and to air breasts?
21. YES
NO
22. YES___ _NO______ _ Demonstrate how to express breast milk to relieve congestion and prevent engorgement?
23. YES
_NO______ _ Demonstrate how to position infant's mouth around areola
for breast feeding?
24 YES__ _NO______ _ Tell mother to return if the infant has problems nursing?
25. YES
NO
_ Counsel on family planning methods with least effect on
quantity and quality of breast milk (spermicides, barrier meth
ods, progesterone only pills or injections, IUDs or abstinence)?
26. YES___ _NO______ _ Teach ways to increase contraceptive benefits of breast feeding (e.g., exclusive and frequent demand feeding for the first
six months)?
NO
_ Use appropriate health education techniques and materials?
27. YES___
_NO______ _ Encourage breast feeding among HIV positive women, if ap28. YES
propria te?
29. YES___ __ NO______ _ Explain that frequent bowel movements in the new-born indicate good milk intake and infrequent stools in the first few
weeks could be a warning sign?
30. YES
__ NO______ _ Ask the mother to repeat key messages?
31. YES______ NO
_ Ask the mother if she has any questions?
16
YES___ _NO______
Nutritional messages:
Did the service provider:
32. YES___ __ NO___ __ _ Tell mother to increase her total food and liquid intake or to
balance her food intake and activities during lactation?
33. YES___ __ NO____ _ Explain to mother the administration schedule for nutrition
supplements, iron and/or folic acid tablets prescribed or dis
tributed for home administration?
34. YES
_NO______ _ Warn mothers of dangers of alcohol and drugs?
35. YES___ __ NO______ _ Tell mother about specific, nutritious, appropriate local foods
(protein rich)?
36. YES___ __ NO._______ Discourage dietary taboos that restrict important foods/food
groups for lactating women?
37 YES___ __ NO.______ _ Encourage those cultural practices that promote consumption of important foods for lactating women?
38. YES___ __ NO______ _ Discuss other feeding options with the mother?
Module 6: Service quality; appendix B
81
Weaning:
Did the service provider:
39. YES------- NO
Explain the importance of introducing complementary foods
during a two-month transitional period (i.e., months five and
six)?
40 YES--------- NO Explain that children should be breastfed (not exclusively) for at
41.
YES
NO
least one year and preferably for up to 2 years of age or beyond.
Demonstrate preparation of weaning foods?
Exit interview with mother
Mark "yes" if the respondent answers correctly.
42. YES
NO
For how long will you breast feed?
43. YES
NO
Do you know the proper position to breast feed your child?
44. YES
NO
Do you know how to care for your breasts?
45. YES
NO
Do you know what/how much you should be eating during
the lactation period?
Interview with service provider
Mark "yes" if the respondent answers correctly.
46. YES
NO
Explain the length of time that mothers should breast feed?
47. YES
NO
Explain the health and economic benefits of breast feeding?
Module 6: Service quality; appendix B
82
PHC MAP service quality
Checklist 8: Growth monitoring/nutrition education
This checklist is intended for use in the observation of service delivery for growth monitoring
and nutrition education. 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 provider
3. Observer/supervisor
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?111
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
14. YES
NO
15. YES
NO
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
16. YES
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.
Module 6: Service quality; appendix B
83
19.
20.
YES
YES
NO
NO
Tell mother the nutritional status of the child?
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 weighing?
22. YES___ __ NO____ .. __Make recommendations regarding child feeding and care?
23. YES__ .___NO____ _ _ Explain importance of good breast feeding and weaning practices?
24. YES______ NO____ ___ Explain which locally available foods constitute 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?
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 monitoring ser
vices?
32. YF.S
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. YES
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:
41. YES
NO
42. YES
NO
Where will you take your child for nutritional rehabilitation?
What will you do to improve your child’s condition?
Interview with service provider
_NO____ __ Do you have a way of tracking malnourished children?
___ NO___ ___ Do you refer malnourished children for nutritional rehabilitation or medical care?
___ Do you follow up malnourished children who do not come
45. YES______ NO
back for growth monitoring?
43. YES
44. YES
Module 6: Service quality; appendix B
84
PHC service quality checklist
9: Immunization
This 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 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 provider
3. Observer/supervisor
4. Date
Identification of needed vaccinations
Did the service provider:
5. YES
NO
6.
YES
NO
7
8.
YES
YES
NO
NO
Review health records to determine which immunizations are
needed today?
Review mother’s health record or ask mother whether she
has received tetanus toxoid immunization?
Review vaccination status of other children in the family?
Recommend vaccination even if the child is sick?
Preparation and care of vaccine
Did the service provider:
9. YES
NO
10. YES
IL YES
NO
NO
Check the label for the correct vaccine and to be sure the
vaccine has not expired?
Load the syringe without contamination?
Keep the vaccine on ice and covered during the session?
Vaccination technique
Did the service provider:
12. YES
NO
13. YES
NO
14. YES
NO
15. YES
NO
16.
17.
18.
YES
YES
YES
NO
NO
NO
Prepare the area of injection?
Use a sterile needle for each injection?
Use a sterile syringe for each injection?
Apply the vaccine at the right level? (BCG = dermal layer,
measles = subcutaneous layer, DPT/TT = muscle)
Properly dispose of the needle and syringe?
Was the child given all vaccinations needed today?
If the mother required TT, did the service provider vaccinate
her or arrange for vaccination?
Documentation
Did the service provider:
19. YES
NO
20. YES
NO
if
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
85
EPI education
Did the service provider:
21 YES__ ___ NO_______ Tell the mother which vaccinations were given during this
visit?
22. YES ___ NO_______ Inform the mother that side effects, such as fever and pain,
are possible?
23. YES___ __ NO__
For BCG vaccination, explain that a scab will form?
24. YES
___ NO____ __ _ Tell mother where to go if she or the child should have a severe reaction to the vaccination?
25. YES___ __ NO____ _ Explain the importance of completing the vaccination series?
NO____ ___ If DPT #3 has been administered, stress the importance of re26. YES
turning for measles vaccination?
27. YES___ __ NO.____ __Explain that the child can be immunized even if she/he is ill?
28. YES___
NO
___ Tell when to come back for the next immunization for
mother or child?
29. YES___ ___ NO____ ___ Ask mother to encourage other women and their children to
be vaccinated?
30. YES___ _NO____ __ _ Verify that mother understands key messages?
31. YES___ ___NO____ ___ Ask mother if she has any questions?
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?
___ Is there a thermometer or cold chain monitor in the refrigera33. YES______ NO
tor?
34. YES___ __ NO____ _ Is there a temperature log?
35. YES______NO____ ___ Is temperature recorded regularly according to the local
schedule?
NO____ ___ Was the registered temperature between 0 and 8 degrees (C)
36. YES_
at all times during the last month?
NO
__ Are all vials in storage unopened?
37. YES___
38. YES___ __ NO____ _ Were vaccines sufficient during the last month?
_NO____ _ Were needles and syringes sufficient during the last month?
39 YES
NO
40. YES_
_ Were vaccination cards sufficient during the last month?
41. YES___ __ NO____ ___ For outreach sessions, were vaccines transported in cold
boxes with ice packs?
Exit interview with mother or caretaker
Mark "yes" 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
86
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
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 provider
3. Observer/supervisor
4. Date
Medical history
Did the service provider:
5. YES
NO
6. YES
NO
7. YES
NO
8. YES
NO
9. YES
NO
10, YES
NO
11.
YES
NO
12.
13.
YES
YES
NO
NO
Ask about presence/level of fever?
Ask about duration of cough?
Ask about activity level?
Ask about ability to drink7
Ask about presence of sore throat?
Ask about presence of earache?
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?
Physical examination
Did the service provider:
14. YES
NO
15. YES
NO
16. YES
NO
17. YES
NO
18. YES
NO
19. YES
NO
20. YES
NO
2L YES
22. YES
23. YES
NO
NO
NO
Assess general status (alertness, muscle tone)?
Count respiratory rate?
Take temperature?
Observe breathing for chest indrawing?
Listen for stridor, wheeze, and/or hoarseness?
Auscultate chest?
Examine throat for discharge, enlarged tonsils, or inflamed
pharynx?
Examine neck for tender glands?
Examine ears?
Observe colour of lips, ears, face, and nail beds?
Classification, treatment and referral
Did the service provider:
24. YES
NO
IB
Classify child by severity of illness (cold, pneumonia, severe
pneumonia)?
Module 6: Service quality; appendix B
87
25.
YES------- NO
26. YES
27- YES
28. YES
29. YES
NO
NO
NO
NO
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:
30. YES
NO
31. YES
NO
33. YES NO
32. YES
NO
34. YES
NO
36. YES
NO
35. YES
NO
37. YES
NO
38.
39.
YES
YES
NO
NO
Explain how to administer antibiotics?
Explain the importance of completing entire treatment
often,
how long)?
Explain
course? how to drain child’s nose (especially if mother is
Explain
how to administer cough mixture (how much, how
breast
feeding)?
Tell mother to give extra fluids, continue feeding/breast feed
Tellduring
mother
about at least three of the signs/symptoms of
ing
illness?
moderate/severe
ARI?1 a neutral temperature for the child?
Tell mother to maintain
Tell mother to return for further consultation if the child’s
condition worsens or does not improve?
Verify that mother understands key messages?
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 supplies adequate during the last month?
42. YES
NO
Do you have a thermometer to measure the patient’s temper
ature?
Interview with mother
Mark "yes" if the respondent answers correctly:
43. YES
NO
How will you treat your child at home?1
2
44. YES
NO
What danger signs indicate that you should bring child to the
health centre?1
45. YES
NO
If antibiotics were prescribed: How will you administer the
medicine?
46. YES
NO
If antibiotics were prescribed: When will you stop giving the
medicine to your child?
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
Interview with health worker
Mark "yes" if the respondent answers correctly:
47. YES
NO
What are the signs and symptoms of pneumonia?1
48. YES
NO
How can you differentiate a cold from pneumonia?
49.
YES
NO
50.
51.
YES
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?1
2
When should you refer a child to the health centre/hospital?
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).
in
Module 6: Service quality; appendix B
wuiuiuAunwjnnB ■ ■ vim iM a
88
89
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.
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?
7 YES
NO
Frequency of stools?
8. YES,N0
YES
NO
blood and/or mucus in stools?
9.
Presence
10.
YES
NO
Fever? of vomiting?
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
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?
Classification and treatment
Did the service provider:
17. YES
NO
18.
19.
YES.NO
YES
NO
20.
YES
NO
21 YES
NO
Determine the degree of dehydration (none, moderate, se
vere)?
Prescribe safe ORS or cereal-based ORT?
Recommend safe home treatment with ORS, or cereal-based
ORT?
Refrain from using antibiotics, except when stools contain
blood or mucus?
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 fs
asked to describe what he or she is doing.
Module 6: Service quality; appendix B
22. YES
NO
23. YES
24- YES
NO
NO
25.
YES
NO
26.
YES
NO
28.
YES
NO
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?
ORT education
Did the service provider:
29. YES
NO
30. YES
NO
31. YES
NO
32.
YES
NO
33.
34.
YES
YES
NO
NO
35.
36.
37.
38.
YES
YES
YES
YES
NO
NO
NO
NO
Tell mother to give extra fluids during diarrhoea?
Tell mother how to prepare ORS solution?
Tell mother how much ORS solution to give and how often
to give it?
Tell mother about appropriate feeding practices during and
after diarrhoea?
Tell mother about at least three signs of dehydration?1
Tell mother about at least two danger signs that indicate that
she should bring the child to health centre?1
2
Show mother how to prepare ORS solution?
Show mother how to administer ORS solution?
Verify that mother understands key information?
Ask mother if she has any questions?
Essential supplies for ORT
39.
40.
YES
YES
NO
NO
Was the supply of ORS packets adequate for the past month?
Do you have the materials necessary (cup, spoon, water) to
prepare and administer ORS solution?
Exit interview with the child’s mother/c^retaker
Mark "yes" if the respondent answers correctly:
41. YES
NO
___ How do you make ORS solution?
42. YES___ __ NO____ ___ How much ORS solution will you give your child?
43. YES__ __ NO__
__How often will you give ORS solution?
44. YES___ NO
___ What danger signs indicate that you should bring your child
back to the health centre?
Interview with service provider
Mark "yes" if the respondent answers correctly:
45. YES
NO
When you examined the child for dehydration, what physical
signs did you look for?1
46. YES
NO
What was the child’s degree of dehydration?
1 Signs for dehydration; 1) lethargy; 2) absence of tears while crying; 3) pinched skin retracts slow
2 Danger signs : 1) many watery stools; 2) repeated vomiting; 3) very thirsty; 4) eating or drinking poorly;
5) fever; 6) blood in stool; 7) child shows signs of dehydration.
Module 6: Service quality; appendix B
91
PHC service quality checklist
12: Water supply, hygiene, and sanitation
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 provider
3.
_____ Observer/supervisor
4. Date
Observation of health education sessions or individual counselling1
Did the service provider:
5. YES
NO
6.
7.
8.
YES
NO
YES
NO
YES NO
9.
YES
NO
Water storage and use:
Did the service provider:
10. YES
NO
11. YES
NO
12.
13.
YES
YES
NO
NO
14.
YES
NO
15.
YES.NO
Explain that dirty water, human and animal waste, and refuse
can cause disease?
Explain the link between water and sanitation and diarrhoea?
Explain that cleanliness can prevent disease?
Discuss whether the woman has adequate access to water (i.e.
located within 15 minutes of a water source)’
If there is a problem with access, discuss current or potential
community efforts to address water supply problems and tell
the woman how she can be involved?
Discuss keeping water in a clean, covered container?
Recommend use of a long-handled dipper to remove water
from container?
Recommend keeping soap near the water storage container?
Discuss the importance of hand washing before eating, feed
ing children, and food preparation?
Discuss the importance of washing hands with soap after
using the latrine, cleaning children, or handling refuse or ex
creta?
Encourage use of safe water for drinking, cooking, and wash
ing vegetables or fruit?
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 Individual counselling should be carried out in cases of diarrhoea, or in any cases where the health worker
feels that poor water and sanitation may constitute a health risk.
Module 6: Service quality; appendix B
92
19. YES
__NO
Recommend making sure that latrine is absent of puddles?
20. YES
NO
___ Recommend making sure that latrine is absent of flies?
21 YES___
NO
___ Recommend making water or paper available in latrine?
22. YES___ __ NO____ ___ Advise not to use latrine for storage?
23. YES___ __ NO__ ___ Advise to keep animals out of the latrine?
24. YES___
NO____ ___ Discuss appropriate latrine use and human waste disposal
(e.g. baby potty for children under three)?
Refuse and excreta disposal:
Did the service provider:
25. YES
NO
26. YES
NO
27.
YES
NO
28.
29.
YES
YES
NO
NO
30.
YES
NO
Recommend sweeping house and courtyard daily?
Recommend keeping animals away from cooking and eating
areas?
Recommend collecting and drying animal excreta for ferti
liser, fuel, or as a construction material?
Recommend burning or burying refuse?
Recommend collecting used water and channel it into the
garden?
Recommend penning animals away from the house?
Interview with health workers
Mark "yes" if the respondent answers correctly:
31. YES
NO
Do you talk to individuals or groups about water and sanita
tion?
32. YES
NO
Do you keep a list of neighbourhoods or households that do
not have adequate access to water?
33. YES
NO
What do you tell mothers about how to keep the drinking
water at her home safe?
34. YES
NO
What do you tell mothers about how to keep the latrine
clean?
35. YES
NO
What do you tell mothers about refuse disposal?
Interview with mothers
Mark "yes" if the respondent answers correctly:
36. YES______ NO____ ___ Has a health worker ever talked to you, individually or in a
group, about water and sanitation?
37. YES__ __ NO____ ___ Why is it important to wash your hands?
38. YES______NO____ ___ What do you do to keep the drinking water at your home
safe?
NO____ _ What do you do to keep your latrine clean?
39. YES
40. YES___ ___NO____ ___ How do you dispose of refuse?
Module 6: Service quality; appendix B
93
PHC service quality checklist
13: Childhood disabilities
3
$
3
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. It is
expected that providers will have different levels of training and expertise and have varied
access to resources such as diagnostic, treatment, rehabilitation, and special education services.
Therefore, national management and treatment protocols should be reviewed in order to adapt
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.
NOTE: Questions included in this checklist were constructed from existing manuals and
references on disabilities,Z'314-5 and from the reported field experiences of relevant clinicians
and researchers.6
1. Health facility
2. Service provider
3.
Observer/supervisor
4. Date
Medical history
£
Did the service provider:
5. YES
NO
6. YES
NO
7. YES
12.
YES
11.
YES
8. YES
9. YES
10. YES
NO
NO
NO
NO
NO
NO
Ask the mother if she received prenatal care?
Ask the mother if her deliveries were attended by a health
worker or TBA?
do
things
like 3-9
other
children
his/her
age?
Ask
the
mother
about
the
of thewhether
newborn?
For
children
yrs.
old,health/size
ask
the mother
the child’s
Askthe
the
mother
whether
child
learning
Ask
thedifferent
childthe
’s growth
wasdifficulty
monitored?
speech
ismother
in any if
way
from has
normal,
e.g, not
clear to
Ask the to
mother
if the child
fully immunized?
enough
be understood
byispeople
outside the immediate
sitting, standing, or walking?
Ask the mother whether the child had any serious delay in
family?
3
3
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.
Module 6: Service quality; appendix B
if
94
13. YES______ NO______ _ For 2-year-old children, ask whether he/she can identify and
say the name of at least one object?
14. YES______ NO______ _ Ask whether the child has difficulty in walking, moving
his/her arms, or has weakness or stiffness in the arms or legs?
15. YES___ __ NO
_ Ask whether the child has had trouble seeing, either in the
daytime or evening?
16. YES______ NO______ _ Ask whether the child has had trouble hearing?
17. YES______ NO______ _ Ask the mother whether the child has had fits (e.g., lost consciousness, blank stares, twitching or other uncontrolled
movements)?
18. YES______ NO______ _ Ask the mother whether the child has had any behavioural
or emotional problems?
19. YES______ NO______ _ Ask when the disability began?
20. YES______ NO______ _ Ask whether any family members or relatives have had a similar problem?
21. YES______ NO______ _ Ask whether medical care was sought for the disability?
Physical exam
Did the service provider:
22. YES_
NO
_ Note the presence of any deformities or defects?
NO
_ Check for normal range of motion in legs, knees, feet, hips?
23. YES_
24. YES_ __ NO__
_ Check for differences in leg length?
25. YES___ _NO.____ _ _ Check muscle strength in legs, knees, feet, hips, shoulders,
back, arms or hands9
26. YES
-_NO______ _ Check sense of balance and coordination?
27. YES
NO
_ Check reflexes in knee?
NO
_ Check ability to touch or feel pain?
28. YES
NO
_ Check for abnormal curve of the spine?
29 YES
_ Examine ears and test hearing?
30. YES
__ NO__
_ Examine and test eyes?
NO
31 YES
32. YES______ NO.____ _ _ Examine oral cavity?
Case identification/referral
Did the service provider:
33 YES______ NO
_ Administer/prescribe appropriate treatment or therapy according to established treatment guidelines?
34. YES______ NO______ _ Make the appropriate referral according to established guidelines?
35. YES_____NO______ _ Record the case according to established guidelines?
Counselling client on childhood disabilities
Did the service provider:
36. YES______ NO________ Provide adequate information about local or regional referral
services for people with disabilities (e.g., NGOs, special
schools, therapy, and treatment centres)?
NO____ ___ Provide adequate information on local or regional medical
37. YES___
specialists?
Discuss with the client what may have caused the disability?
NO
38. YES
Discuss available medicine or treatment, if any?
NO
39. YES
40. YES______ NO_______ Discuss any possible long-term outcomes associated with the
condition and, if applicable, the need for ongoing treatment?
Module 6: Service quality; appendix B
95
41.
YES
NO
42.
YES
NO
43.
YES
NO
44.
YES
NO
If applicable, discuss the possible risk of having another child
if more than one child is known to have been born with a ge
netic condition?
Discuss what parents and families can do to help the disabled
child?
Discuss what community or schools can do to help children
with disabilities?
Discuss how a child with a disability can still do many things
normally and can continue to be a productive member of the
community?
Interview with service provider
Mark "yes" if the respondent answers correctly:
45. YES______ NO_______ What are some signs and symptoms associated with disabilities?
46. YES______ NO____ ___ What are the local treatment guidelines and available treatments?
47. YES
__ NO____ ___ . What are some ways that disabilities can be prevented?
48. YES
___ NO____ ___ When should you refer cases for further diagnosis, testing, or
treatment?
49. YES_____ .NO____ ___ What are the local or regional referral services, e.g. NGOs,
special schools, therapy and treatment centres, or specialists
available to clients with disabilities?
50. YES___ ___NO____ ___ Who is the individual in the community responsible for supervising or organising disability-related activities, such as reha
bilitation, special education, recreational activities?
51. YES___ __ NO
___ What are the committees or support groups in the commanity which are responsible for the above disability-related ac
tivities?
52. YES___ ___NO____ ___ What is the process of recording or following up the progress
of individuals?
Exit interview with client
Mark "yes" if the client responds correctly:
53. YES___ __ NO____ ___ What is your child’s disability?
54. YES
__ NO____ ___ Do you know how he/she got it?
NO
55. YES__
__ _ If applicable, do you know how to prevent a similar disability
from happening again?
56. YES___ __ NO____ ___ What treatment did you receive?
57. YES___ __ NO____ ___ How do you administer it?
58. YES___ _NO____ __ Where do you go for treatment or follow-up?
59. YES___ ___ NO____ ___ What are some of the available therapy and treatment centres and/or community groups which can help your child?
60. YES___ __ NO____ ___ What kinds of things can your child still do normally despite
his/her disability?
61. YES___ ___NO____ ___ Do you have some questions or concerns that were not addressed by the provider?
Module 6: Service quality; appendix B
96
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.
1. Health facility
2. Service provider
3. Observer/supervisor
4. Date
Medical history
Did the service provider:
5. YES N0
6. YES
NO
Correctly identify type of injury?
Obtain history of the injury (cause, time of injury, determine
type of poisoning, etc.)?
Physical examination
Did the service provider:
7. YES
NO
8.
YES
NO
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 pre9. YES.__ ___ NO
vented?
10. YES______NO____ ___ Discuss the use of alcohol and dangers related to alcohol consumption?
11. YES___ ___NO____ ___ Discuss the importance of proper storage of dangerous substances?
12. YES___ __ NO___ ____ Discuss occupational safety issues?
NO____ ___ Discuss child safety in and around the home?
13. YES
14. YES__ __ NO____ ___ Explain how to recognise an emergency?
__ NO___ _ __ Discuss location of emergency facilities in the area?
15. YES
16. YES
___ NO.____ ___ Explain the importance of determining the cause of the injury, particularly in the case of poisonings?
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
97
Interview with service provider
This section can be used to assess the knowledge of the service provider depending on his or
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
recognise
emergency?
20.
YES
NO
Where
canyou
treatment
bean
obtained?
21 YES
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?
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. YES
NO.What medication were you given?
27. YES
NO
Do you understand how to take this medication?
28.
NO
What care
are
signs
that warn youcare
to return
to the
health
facility
for help?
29. YES
YES
NO
What
kindthe
of danger
follow-up
or rehabilitative
does your
injury
require?
30. YES
NO
How can this kind of injury be prevented or avoided in the fu
ture?
Module 6: Service quality; appendix B
98
PHC service quality checklist
15: Sexually transmitted diseases and HIV/AIDS
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 adapt 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 confidential 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 were constructed from existing STD/HIV/AIDS
medical and management protocols developed by WHO1 from AIDS prevention programme
materials*
12 345and from related studies on counselling and education14 3 6and drawn from the
reported field experiences of relevant clinicians and researchers7
1. Health facility
2. Service provider
3. Observer/supervisor
4. Date
Medical history
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:
5. YES
NO
Ask about symptoms of infection such as prolonged fever?
YES
NO
unexplained weight loss?
YES
NO
chronic diarrhoea?
YES
NO
persistent cough?
YES
NO
visual symptoms?
1 World Health Organization: Management of patients with sexually transmitted diseases. WHO
Technical report series 810, Geneva, World Health Organization, 1991.
2 Lamptey, P, Piot, Pr The handbook for AIDS prevention in Africa. Durham, NC, Family Health
International, 1990.
3 World Health Organization, A IDS 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
America, Dec.,23(4):959-73 (1988).
5 Stone, D. & Kaleeba, Nn Counselling and AIDS. The handbook for AIDS prevention in Africa, 181-190,
Durham, NC, Family Health International, 1990.
6 World Health Organization: Management of patients with sexually transmitted diseases. WHO
technical report series 810, 61-7, Geneva, World Health Organization, 1991.
7 Bernham, G., Department of International Health, Johns Hopkins School of Public Health; Brady, W.,
PA-C, MPH Division of STD/HIV prevention, Centers for Disease Control; Millar, M, University
Resesarch Corporation, Training programme as part of WHO Global Programme on AIDS; Neill, M.,
Training and Materials Development Specialist, CDC; Alwood, C., NP, AIDS Clinic, Johns Hopkins
Hospital.
tn
Module 6: Service quality; appendix B
99
YES___ ___ NO____ ___ genital ulcers?
YES___ ___ NO____ ----- urethral/vaginal discharge?
YES
___ NO____ ----- painful or difficult urination?
YES___ __ NO____ ___ mouth sores?
YES______ NO____ ___ night sweats?
6. YES___ ___ NO____ ----- Ask about previous exposure to STDs?
7. YES___ ___ NO____ ----- Ask about treatments administered?
8. YES___ ___ NO____ ----- Ask about follow-up and compliance with treatment?
9. YES___ ___ NO____ ----- Ask about treatment of partner(s)?
10. YES___ ___ NO____ ----- Ask whether client has ever had transfusion of blood or
blood products?
11. YES___ ___NO____ ----- Ask whether client has ever been exposed to non-sterile instruments such as needles or knives?
12. YES___ ___ NO____ ----- 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
14. YES
15. YES___
condition?
NO
Assure the client that all responses will remain confidentiaP
NO____ ___ Ask whether client is currently sexually active?
16. YES___
NO
___ Ask whether client is active with more than one partner?
26.
check
forcervix,
lower
abdominal
27.
YES
NO
Forabout
women,
examine
vagina, andpain/tenderness?
labia?
17. YES
___ __ NO____
___ Ask
types
of sexual
practice?
25.
YES
NO
Check
forexamine
swollen
glands
in the
neck,
armpit,
or retract
groin? fore
28.
Forwhether
men,
penis
and
scrotum,
and
18. YES
NO
Ask
condoms
arebase,
used
during
sexual
activity?
skin?
19. YES
NO
Ask client for questions or concerns regarding his/her sexual
24.
YES
NO
Examine
eyes (infant)
foror
conjunctiva?
29. YES
NO
Examine anus
for ulcers
warts?
activity?
30.
YES
NO
Check
possible
skinin infection?
20. YES
___ __ NO____
___ Take
the for
sexual
history
private?
31. YES
NO
Take the necessary precautions to minimise exposure to
Physical
23.
YES examination
NO
Examine
oral cavity
signsthe
of examination?
infection e.g., thrush?
blood
and body
fluids for
during
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?
Module 6: Service quality; appendix B
100
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.
With appropriate laboratory support:
Did the service provider:
32. YES
NO Practise universal precautions before and after drawing a
sample, e.g., blood, urethral/vaginal discharge?
33. YES
NO
Draw the sample according to protocol?
34. YES
NO
Take the recommended amount of specimen?
35. YES
NO
Seal and label container of specimen?
36. YES
NO
Complete record of transfer to laboratory?
37. YES
NO
Transfer specimen to laboratory within prescribed time limit?
After testing is complete or in the absence of laboratory support:1
Did the service provider:
38. YES
NO
Identify disease according to established guidelines?
39. YES
NO
Inform the client of the diagnosis?
40 YES
NO
Administer/prescribe appropriate treatment according to es
tablished treatment guidelines?
41. YES
NO
Instruct client on treatment compliance and when to return?
42. YES
NO
Make the appropriate referral according to established guide
lines?
43. YES
NO
Record the case according to established guidelines?
44. YES
NO
Ask for questions from the client?
Counselling client on prevention of STD and HIV/AIDS
Counselling the client about STDs is intended to prevent behaviours that lead to infection
and to provide support to those who are infected or are caring for someone who is infected.
This section can be used if the medical/sexual history indicates that the client may be at risk
for STD.
Did the service provider:
45. YES___ ___ NO____ ___ Inform the client about the ways in which STDs can be transmitted within that community?
46. YES___ ___ NO____ ___ Discuss some basic ways to prevent sexual transmission of
STDs?
NO____ ___ Instruct the client on the correct and consistent use of con47. YES___
doms?
48. YES___ ___ NO____ ___ Teach client how to recognise some common symptoms of
STDs and understand the importance of getting correct treat
ment?
49. YES___ ___NO____ ___ Explain that some STDs are not curable (HIV infection;
human papillomavirus)?
NO____ ___ Explain that behaviours that may lead to STD also put client
50. YES___
at risk of HIV infection?
Provide the client with any available brochures or handouts?
NO
51. YES
Use available educational materials to instruct the client?
NO
52. YES
53. YES___ __ NO____ __ Ask for questions from the client?
1 When laboratory support is unavailable, the identification of STD cases may be based on the client’s
medical/sexual history and physical examination alone.
Module 6: Service quality; appendix B
66.
67.
YES
YES
NO
NO
57.
YES
NO
Encourage breast
feeding
and growth monitoring
Recommend
complete
immunizations
except BCGofif the
the child?
child
shows clinical signs of HIV infection?
101
Discuss the meaning of a positive test result?
Pre- and post- test counselling for HIV antibody testing or STD 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:
56.
YES
NO
Discuss the meaning of a negative test result?
54. YES
NO
Explain the testing procedure to the client?
55. YES
NO
Assure the client of the confidentiality of his/her test results?
Counselling client with diagnosed STD
In this section, counselling is intended to provide support to clients whose laboratory testing,
if available, and clinical findings indicate STD infection.
Did the service provider:
68. YES___ __ NO____ __ Explain how the infection may have been transmitted9
69. YES___ __ NO____ ___ Discuss available treatments, if any?
70. YES______ NO____ ___ Explain if the infection is curable, and if not, the long term effects?
71 YES______ NO____ ___ Discuss complications, if any, of disease or treatment?
72. YES______NO____ ___ Discuss the possibility that infected partners may not yet
have symptoms or show signs of being infected?
73. YES______ NO____ ___ Explain the risk of reinfection if sex is resumed with an untreated partner?
74. YES___
NO
___ Explain that STDs may increase the transmission of HIV?
75. YES
___NO____ ___ Counsel client in private?
Interview with service provider
This section can be used to assess a service provider depending on his/her level of training,
education, and skill in the delivery of STD-related services. A response should be judged as
correct if it is in agreement with local guidelines and his/her level in these areas.
Mark "yes" if the respondent answers correctly.
76. YES
NO
What are some common examples of STDs?
77. YES.NO
,,. ..Ujow.are HIV infection and AIDS defined?
V \
Module 6pervjtej4ualtty; apjjenc}ix.<B/
//?/
A#
pHC-iC
1
■ .; , > .- ,
102
78.
79.
YES
YES
NO
NO
80.
81.
82.
83.
84.
85.
YES
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
NO
86.
YES
NO
How are they transmitted?
What are some signs or symptoms of a sexually transmitted
disease? of HIV infection? of AIDS?
What are some risk factors for STDs?
What are some preventive measures against infection?
Which STDs may increase the transmission of HIV?
What treatments are available?
What tests should be carried out if you suspect infection?
Who are the people at greatest risk of being infected in your
area?
When and to whom should you refer cases for further diagno
ses, testing, or treatment?
Exit interview of client with STD
Mark "yes" if the client responds correctly
87. YES
NO
What is your illness?
88. YES
NO
How do you think you got it?
89. YES
NO
How do you prevent giving what you have to someone else
and how do you prevent becoming infected again?
90. YES
NO
What treatment/medicine did you receive or will receive?
91. YES
NO
How much and how often will you take it?
92. YES
NO
When and where will you return for test results, treatment, or
follow-up?
93. YES
NO
Were you asked to encourage your sexual partner to come
for an examination?
94. YES
NO
Do you have questions or concerns that were not addressed
by the provider?
Exit interview of client without STD
Mark "yes" if the client responds correctly
95. YES
NO
How are STDs transmitted in your community?
96. YES
NO
How can you protect yourself from getting an STD?
97. YES
NO
How would you know if you got an STD?
98. YES
NO
What would you do if you thought you had an STD?
99. YES
NO
Did you receive any educational brochures or handouts?
100. YES
NO
Do you have questions or concerns that were not addressed
by the provider?
Module 6: Service quality, appendix B
103
PHC service quality checklist
16: Malaria
This checklist is intended for use in the observation of service delivery for malaria. 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 provider
3. Observer/supervisor
4. Date
Medical history
Did the service provider:
5. YES
NO
Ask about level of fever?
6. YES___ __ NO_______ _Ask about pattern of fever?
NO
Ask about chills/sweats?
7. YES
NO
Ask about headache?
8. YES
9. YES___ __ NO_______ _ Ask about vomiting?
Ask about convulsions?
NO
10. YES
NO
Ask about anti-malarial drugs taken in last 24 hours?
11. YES
Ask about other symptoms to rule out other fever-related
12. YES
NO
illnesses?1
Physical examination
Did the service provider:
NO
13. YES
14. YES
NO
NO
15. YES
NO
16. YES
NO
17. YES
NO
18. YES
NO
19. YES
NO
20. YES
21. YES
NO
Take temperature?
Examine neck for stiffness?
Palpate abdomen/stomach?
Ascultate lungs?
Examine ears, nose, throat?
Examine skin?
Weigh patient?
Make blood slide or refer case to a facility where a blood
slide may be examined?
Examine blood slide?
Treatment and Referral
Did the service provider:
NO
22. YES
Administer or prescribe appropriate anti-malarial drug according 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.
Module 6: Service quality; appendix B
104
23.
YES
NO
24.
YES
NO
Refer case of cerebral or other serious/complicated or unre
sponsive malaria?
Refer for further diagnosis/treatment if other serious fever-re
lated illness is suspected?
If fever is over 39 degrees centigrade.:
25. YES
NO
Administer anti-pyretic drug?
26 YES
NO
Sponge or bathe with water?
Malaria education and counselling
Did the service provider:
27. YES
NO
28. YES
NO
29. YES
NO
30.
YES
NO
31 YES
32. YES
33. YES
34 YES
NO
NO
NO
NO
Tell how to administer anti-malarial drug?
Provide drugs or verify that client has access to drugs?
Discuss the importance of completing entire treatment
course?
Discuss danger signs that may indicate unresponsive or com
plicated malaria?1
Tel! client to return for consultation if danger signs develop?
Discuss prevention?12
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;
35. YES
NO
Ask if anyone in the household has fever?
36. YES
NO
Explain malaria signs and symptoms, especially fever?
37. YES
NO
Explain importance of immediate treatment of malaria (fever)
in the home?
38. YES
NO
Explain which drug(s) should be used to treat fever in the
home?
39. YES
NO
Explain recommended treatment schedule for anti-malarial
drugs?
40. YES
NO
Explain where drugs can be obtained?
41. YES
NO
Explain indications for seeking medical care?
Prevention:
Did the service provider:
42. YES
NO
43. YES
NO
44. YES
NO
45. YES
NO
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:
46. YES
NO
Explain which drug(s) can be used for malaria prevention?
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
105
47.
YES
NO
48.
49.
YES
YES
NO
NO
Explain recommended anti-malarial drug administration
schedule for prevention?
Discuss possible side effects?
Explain when and where to go to obtain chemoprophylaxis
services?
Supplies
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?
Module 6: Service quality; appendix B
106
PHC service quality checklist
17: Tuberculosis
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.
1. Health facility
2. Service provider
3.
Observer/supervisor
4. Date
Medical History
Did the service provider:
5. YES
NO
6. YES
NO
7. YES
NO
8. YES
NO
9. YES
NO
10 YES
NO
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?
Physical examination
Did the service provider:
11. YF.S
NO
12. YES
NO
13. YES
NO
14. YES
NO
15. YES
NO
16. YES
NO
Take temperature?
Take respiratory rate?
Take pulse?
Weigh patient?
Lymph node examination?
Auscultate lungs?
Treatment and referral
Did the service provider:
17. YES
NO
18. YES
NO
19. YF.S
NO
20. YES
NO
21. YES
NO
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?
For follow-up cases
Did the service provider:
22. YES
NO
23. YES
NO
24. YES
NO
Correctly verify that client is taking medicine?
Assess client’s progress?
Ask about side effects or adverse reactions?
Module 6: Service quality; appendix B
107
25.
YES
NO
26.
YES
NO
If side effects are present: give advice about managing side ef
fects?
Change treatment procedure if necessary?
Health education
Did the service provider:
27. YES
33.
NO
32.
NO
28. YES
34.
29. YES
YES
NO
35.
NO
31.
NO
30. YES
YES
NO
36.
Explain
to gofor
fora examinations/lab
Tell
whenwhere
to return
follow-up visit? tests?
ther
care?
Discuss
signsand
andhow
thatfamily
require
fur
Explain danger
howimportance
much
oftenreactions
to take
medicine?
the
ofadverse
testing
and
treating
mem
Stress
the
importance
of
completing
treatment?
bers
withthat
similar
symptoms?
Verify
the patient
understood
keythe
messages?
Discuss
how
to prevent
spread
the disease?
Inform
the
patient
if he
or questions?
she of
is contagious?
Ask
if the
patient
has
any
40.
YES
NO
Scale?
41.
YES
NO
Cutaneous
TB test?
Supplies
39.
YES
NO
Stethoscope?
Ask the
service provider
Interview
with patientif he or she has the following supplies:
43.
Did you receive medicine or a prescription?
37. YES
NO
Thermometer?
Mark
answers
38. "yes"
YES if the respondent
NO
Watch?correctly:
42. YES
NO
What is your illness?
Module 6: Service quality; appendix B
108
PHC service quality checklist
18. Treatment of minor ailments
This checklist is intended for use in the observation of treatment of minor ailments. Before
using it, the local 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 provider
3, Observer/supervisor
4. Date
Medical history
Did the service provider:
5. YES,.NO
6. YES
NO
7. YES
NO
Ask about the chief complaint (fever, pain, cough, etc)?
Determine the present history of the illness?
Determine condition-related past and family history?
Physical examination
Did the service provider:
8. YES
NO
9.
YES
NO
Check vital signs (blood pressure, temperature, pulse, respira
tion rate etc.)
Conduct a related physical exam?
Diagnosis
Did the service provider:
10. YES
NO
Make differential diagnosis (e.g., cough, TB, pneumonia, bron
chitis, abdominal pain, gastroenteritis, acute cholestitis, appen
dicitis, etc.)?
Laboratory diagnosis
Did the service provider:
11. YES
NO
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
14. YES
NO
18.
21
22.
23
YES
YES
YES
YES
NO
NO
NO
NO
Provide appropriate treatment according to the condition?
Provide information to the patient about the condition and
treatment plan?
Discuss the importance 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 treatment7
Module 6: Service quality; appendix B
109
PHC service quality checklist
19a: Hypertension
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. Health facility
2. Service provider
3. Observer/supervisor
4. Date
Initial reading
Did the service provider:
5. YES
NO
6. YES
NO
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:
Blurry vision?
7. YES
NO
NO
8. YES
Severe headache that is getting worse?
NO
Change in mental status (sleepy, confused)?
9. YES
10. YES
NO
Seizure?
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
16. YES
NO
17. YES
NO
18. YES
NO
19. YES
NO
20. YES
NO
21. YES
NO
22. YES
YES
NO
23.
NO
24.
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
about
eating
habits,
smoking,
alcoholnow?
and drug consump
Ask
serious
illness?
about previous
medications
patient
is taking
tion?
Physical examination
Did the service provider
25. YES
NO
Check vital signs?
Module 6: Service quality; appendix B
110
26. YES
27. YES
28 YES
29 YES
30. YES
31. YES
32. YES
33. YES
34.
YES
NO
NO
NO
NO
NO
NO
NO
NO
NO
Check and record blood pressure in both arms?
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
Did the service provider:
35. YES
NO
36. YES
NO
37. YES
NO
38. YES
NO
39 YES
NO
40. YES
NO
41 YES
42. YES
43. YES
44. YES
45. YES
46 YES
47. YES
48. YES
49. YES
50. YES
51. YES
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
Explain hypertension?
Explain the prognosis?
Inform patient of blood pressure level?
Explain lack of symptoms?
Explain treatment goal?
Provide patient with regimen sheet for systematic antihyper
tensive therapy?
Explain how to take medication?
Discuss importance of taking medication daily?
Discuss the possible side effects of medication?
Discuss possible warning signs of high blood pressure?
Tell patient to return if warning signs appear?
Advise patient to restrict sodium and fat intake?
Advise patient to avoid nicotine?
Advise patient to lose weight if overweight9
Discuss the importance of following the prescribed diet?
Verify that patient understands key points?
Ask if the patient has any questions?
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?
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?
57. YES
NO
Where can you have your blood pressure checked?
58. YES
NO
Where can you receive treatment?
59 YES
NO
How should you take medication?
60. YES
NO
Why is it important to follow treatment instructions daily?
61. YES
NO
How often should you have your blood pressure checked?
62. YES
NO
What danger signs indicate you should return to clinic?
63. YES
NO
What can you do to prevent hypertension?
tn
Module 6: Service quality; appendix B
Ill
Interview with service provider
Mark "yes" if the respondent answers correctly.
64. YES
NO
What blood pressure measurement is considered high blood
pressure?
68.
69.
65.
YES
YES
NO
NO
66.
67.
YES
YES.
NO
NO
Whatcan
kindhypertension
of diet should
prescribed for hypertension?
How
bebe
prevented?
When should patient be referred to a physician for an emer
tension?
gency?
At what
point
entreatment
shouldfora patient
be referred
to a
What
drugs
should
be prescribed
the treatment
of hyper
physician?
Module 6: Service quality; appendix B
112
PHC service quality checklist
19b: Diabetes mellitus 1 2
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 .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
2. Service provider
3. Observer/supervisor
4. Date
Medical history
Did the service provider:
5. YES
NO Ask about early symptoms such as frequent urination, un
usual thirstiness (dry mouth), loss of appetite, nausea, vomit
ing and weight loss?
YES
NO
blurry vision that comes and goes?
YES
NO
vaginal itching or yeast infections (if patient is a woman)?
YES
NO
gum swelling or soreness?
YES
NO
chest pain, especially when exercising?
YES
NO
symptoms of urinary tract infection, such as pain or burning
when urinating?
YES
NO
foot problems such as a sore or injury that does not heal, a
change in the skin or toe nails, or numbness?
YES
NO
numbness, tingling, weakness or pain in any part of the body?
YES
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
Check the patients general appearance, vital signs and
weight?
Check for 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/practltioner 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.
Module 6: Service quality; appendix B
113
12 YES--------- NO
Check the general appearance of the feet, their size and
13. YES
16.
YES
14 YES
15
shape?
Check
for lab
pitting
by sugar
pressing
over shinforbone?
Conduct
testsoedema
for blood
andthumb
urine dipstick
pro
of supply,
pulse inifeach
(top isofweak?
foot) and be
Check
for strength
poor
pulsefoot
in foot
tein, glucose
andblood
ketones?
hind medial ankle bone?
NO
NO
NO
Diabetes education and counselling
Did the
service provider:
23.
YES
NO
24.
17. YES
NO
Foot Care:
Did
service provider:
22. the
YES
NO
18.
YES
NO
25. YES
NO
19. YES
NO
20. YES
NO
2L
NO
26.
YES
NO
27. YES
30. YES
NO
29.
NO
28. YES
Ask the patient to
repeat key
messages?
if he/she
has any
questions?
Discuss
diet guidelines, such as avoidance of sugars and fats,
betic
emergencies?
and eating more fibre?
Discuss weight
how to control
teach the
handling
common dia
Discuss
andfamily
diet, ifabout
the patient
is overweight?
Discuss the importance of proper foot care (i.e. daily, gentle
Recommend regular exercise, after consultation with doctor?
cleansing)?
Demonstrate how to do blood and urine tests?
Discuss
importance
of avoiding/stopping
smoking?
Discussthe
foot
protection?
Recommend
not walking
barefoot and wearing
proper fitting
ments,
and notwearing
cutting calluses?
shoes?
Recommend
soft, dry socks without tight elastic, and
Discuss
straight
across
with proper instru
avoiding
injury
from
or cold?
using
footcutting
powdertoe
to nails
keep
feetheat
dry?
Women of child bearing age:
Did the service provider:
31. YES
NO
Discuss the importance of maintaining blood sugar levels
32.
within a specified range before and during pregnancy to pre
vent birth defects?
Refer high risk pregnancies (per local policy)?
YES
NO
Exit interview with the patient
Mark "yes" if the respondent answers correctly?
NO
___ Do you know what medications to take, and when?
_NO____ ___ Where will you get the needed medicine?
NO____ ____ How will you administer the drug (how much, how often, for
how long)?
36. YES______ NO____ ___ What danger signs indicate that you should come back to the
health facility?
37. YES______ NO
___ What will you do to care for your diabetes?
33. YES
34. YES
35. YES
Module 6: Service quality; appendix B
114
Interview with service provider
Mark "yes" if the respondent answers correctly.
38. YES
NO
What are the signs and symptoms of diabetes that require fur
ther medical attention?
39. YES
N0
When should you refer a case for further diagnosis?
40. YES
NO
What measures can be taken to prevent or care for diabetes?
Module 6: Service quality; appendix B
115
PHC service quality checklist
19c: Anaemia
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. Health facility
2 Service provider
3. Observer/supervisor
4.
Date
Medical history
8.
about menstrual
history?
Did the
9.
YESservice provider:
NO
Ask whether
vomit with
blood?
7.
NO
Determine
the occult
blood in
the stool?
5. YES
Ask about chief
complaints:
whether
pregnant?
6. YES
NO
Ask if there is any blood in stool?
14. YES
NO.Ask
previous
or current
treatment
and
response?
15.
NO
Give about
complete
physical
examination
(chest,
abdomen,
etc.)?
13. YES.
NO
Ask about family anaemia history?
Laboratory test
Did
service provider:
12. the
YES
NO
Check occult blood in stool?
16.
Get
count
with reticulocite
count?
Physical
19.
YES examination
NO
Determine
ironblood
binding
capacity?
20.
NO
Get complete
full chemical
analysis
(calcium,
potassium
etc.,) (optional)?
17.
YES
NO
Get
sedimentation
rate? type (region, race, age or sex)?
18.
Determine
haemoglobin
Did the
service provider:
Diagnosis
nutrition
10. YES treatment,
NO
Take education
pulse and blood pressure?
Did
service provider:
11. the
YES
NO
Check colour of conjuctiva?
21 YES
NO
Determine the aetiology of the anaemic condition?
22. YES
NO
Determine appropriate consultation (referral to a specialist, if
needed)?
23. YES
NO
Provide appropriate treatment according to condition?
24. YES
NO
Provide nutrition counselling?
Module 6: Service quality; appendix B
116
Women of child bearing age
Did the service provider:
25. YES
NO
26.
YES
NO
27.
YES
NO
Discuss the importance of proper nutrition (high in iron) and
iron supplementation during pregnancy?
Schedule a return/follow-up appointment after 46 weeks of
treatment to evaluate treatment response?
Provide a referral to a specialist if anaemia is due to a malig
nant condition?
Exit interview with client
Mark "yes" if the respondent answers correctly:
28. YES
NO
Do you know about what diet is good for you?
29. YES
NO
Do you know how to administer the drug (how much, how
often and how long)?
30. YES
NO
Do you know where you can get refills for the drug?
31. YES
NO
Do you know why you need to comply with the drug/nutrition therapy?
Interview with service provider
Mark "yes" for correct answers:
32. YES
NO
What are the signs and symptoms of anaemia?
33. YES
NO
Under what conditions should you refer a client to a special
ist?
34. YES
NO
How can you care for anaemia?
Module 6: Service quality; appendix B
117
PHC MAP Service quality checklist
20: Client satisfaction
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 checklist will thus enable managers to 1) examine the degree to which services and
providers meet the expectations of the client, and 2) identify opportunities to improve the
quality of care based on the client's perspective.
The dimensions of client satisfaction
Client satisfaction consists of a number of dimensions, each of which should be addressed in
a client satisfaction survey. These dimensions include:
Accessibility of services: Do clients feel they can easily take advantage of services? How
convenient are services for clients?
Facilities, equipment and supplies: Do clients feel that the health facility (hospital, clinic,
health centre, outreach service), equipment and supplies are acceptable to them?
Availability of services: Do clients believe that the providers and services they need are
available?
Continuity of care: Do clients feel that the same level of care is provided from visit to visit
or from provider to provider?
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 adequate7
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?
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
ill
118
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 "excellent1' to "poor," or a six-point scale ranging from
"very satisfied" to "very dissatisfied." 1 12You 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.
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
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)
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/river/lake, etc.)
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/cem
Wood planks/palm/bamboo
Other
6. Does any member of your family own
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.
2.
Module 6: Service quality; appendix B
IB
120
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?
Y
N
DK
NA
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.?
4. After arriving at the clinic, did you feel that the time spent waiting to be seen by a pro
vider was reasonable?
Y
N
DK
NA
a.
About how long (no. of minutes/hours) did you have to wait?
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.
About how long (no. of days) did you have to wait?
6. Do you feel that the provider spent enough time with you during the visit?
Y N
DK
NA
DK
NA
8. The overall cleanliness and comfort of the examination room or place where you reY
N
DK
ceived service?
NA
Facilities, equipment, and supplies
Were you satisfied with:
7. The overall cleanliness and comfort of the waiting area?
Y
N
9. The condition of any instruments or equipment used by the provider to treat or examDK
NA
ine you?
Y
N
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
NA
a.
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?
Y
N
DK
NA
12.
Were the same services available during this visit as on your last visit? Y
N
DK
NA
Were you treated with courtesy and respect by the provider during your visit?
Y
N
DK
NA
Interpersonal qualities of service provider
13.
Module 6: Service quality: appendix B
121
14.
Did the provider allow you to ask questions?
Y
N
DK
NA
Were you satisfied overall with the services you received from the provider?
Y
N
a. If not, what are some reasons why?
DK
NA
Did you feel comfortable discussing your problem with the provider? Y
DK
NA
Professional competence and skill of the service provider
15.
16.
N
Were you satisfied with the provider’s skills and ability in treating your problem?
Y
N
DK
NA
18. Were you satisfied with the completeness of the information given to you about your
problem?
17.
Were you given any information which you did not understand? Y
If "Yes," what information did you not understand?
a.
N
DK
NA
Cost
19.
Did you feel that the cost for services you received at the health facility was reasonable?
Y
N
DK
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
Other
21.
Were you satisfied with the measures taken to assure privacy during your examination
e.g, a private room, curtained or screened area, etc.?
Y
N
DK
NA
22.
Were you satisfied with the measures taken to assure confidentiality about your health
problem?
Y
N
DK
NA
Would you recommend the services at this health facility to someone else?
Y N
DK
NA
24. What do you think should be done to improve the quality of the services in this health
facility?
23.
References
L Dovlo, D., etal. What does the public wantfrom 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
123
Appendix C: Service quality assessment
Discussion guidelines
GENERAL
OTHER HEALTH CARE
PHC household visits
Health education
Vtater 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
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
Module 6: Service quality; appendix C
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PHC service quality assessment
Discussion guidelines: 1. PHC household visit
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.
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.
Discussion
• What works well in the way we provide services during a household visit?
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?
• To 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 information do you ask from clients who have malnourished children?
• What information do you ask from clients who have children with diarrhoea?
• What information do you ask from clients who are pregnant?
• What information do you ask from all households you visit?
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 ?
• Has water, hygiene and sanitation been discussed?
• Has a good rapport been established with the mother?
Module 6: Service quality; appendix C
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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; 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 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 health education?
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
• 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?
Module 6: Service quality; appendix C
• 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?
Key questions
)5|,
ffi
• Are obstetric records or 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 blood test, glucose, haemoglobin/haematocrit and malaria, if
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?
K H lW U ittH lia W H a M il ■UHWitew
Discussion
(p
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.
(K,
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.
fl
Ground rules for group discussion
A
Introduction: Welcome the group and briefly give the purpose of the discussion.
Ground rules: Explain the following ground rules to the group:
to
PHC service quality assessment
Discussion guidelines: 3. Antenatal care
9
126
Module 6: Service quality; appendix C
127
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:
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.
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.
Discussion
• What works well in the way we provide safe delivery services?
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?
• To 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?
Module 6: Service quality; appendix C
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PHC service quality assessment
Discussion guidelines: 5. Postnatal care
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 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?
• 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 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?
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?
• Was 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?
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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
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?
Module 6: Service quality; appendix C
if
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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:
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.
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.
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
practices?
• What additional messages do you emphasise when educating or counselling your clients on
nutrition?
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?
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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
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 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 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?
• To 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?
• 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?
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PHC service quality assessment
Discussion guidelines: 9. Immunization
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.
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.
Discussion
• What works well in the way we provide immunization 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?
• 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 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
services?
• What messages do you emphasise when educating or counselling your clients?
Key questions
• Is a sterile needle used for each injection?
• Is a sterile syringe used for each injection?
• Do service providers give the child ail 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?
Module 6: Service quality; appendix C
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PHC service quality assessment
Discussion guidelines: 10. Acute respiratory infection
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.
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 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?
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?"
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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PHC service quality assessment
Discussion guidelines: 11. Diarrhoeal disease control/oral rehy
dration therapy
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.
These discussion guidelines are provided to help you to lead a group discussion about the
quality of your services for diarrhoeal disease control/ORT 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 diarrhoeal disease control/ORT services?
Guidelines
• What aspects do not work well in the way we provide diarrhoeal disease control/ORT
services?
• What standards, guidelines or protocols are used for providing diarrhoeal disease con
trol/ORT 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 and when would you normally prescribe them?
• 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 at least two medical history questions asked?
• Are at least two physical exam activities performed?
• Was the degree of dehydration determined (none, moderate, severe)?
• Is safe ORS prescribed?
• Do service providers refrain from using antibiotics, except when stools contain blood or
mucus?
• Do service providers administer ORS solution immediately or refer the client to a nearby
centre, if the child is dehydrated?
• Are clients informed how much ORS solution to give and how often to give it?
• Are clients shown how to prepare ORS solution?
Module 6: Service quality; appendix C
<U 41
41
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PHC service quality assessment
Discussion guidelines: 12. Water supply, hygiene and sanitation
Introduction: Welcome the group and briefly give the purpose of the discussion.
Ground rules: Explain the following ground rules to the group:
41
U
S
4J
4J
4l
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.
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.
Discussion
• What works well in the way we provide services related to water supply, hygiene and
sanitation?
ir
<i»
<r
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, eg. 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?
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Discussion guidelines: 13. Childhood disabilities
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.
These 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.
Discussion
• What works well in the way we provide services for childhood disabilities?
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 in 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?
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Discussion guidelines: 14. Accidents and injuries
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 your services for accidents and injuries. 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 for accidents and injuries?
Guidelines
• What does not work well in the way we provide services for accidents and injuries?
• What standards, guidelines or protocols are used for providing services for accidents and
injuries?
• 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 injury
prevention?
Key questions
• Is the type of injury correctly identified?
• Do service providers obtain a history of the injury, e.g. cause, time, etc.?
• Is proper treatment administered according to established guidelines?
• Is appropriate referral made according to established guidelines?
• Do service providers discuss some 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?
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Discussion guidelines: 15. Sexually transmitted diseases and
H1V/AIDS
Introduction: Welcome the group and briefly give the purpose of the 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; 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 your STD-related 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 STD services?
Guidelines
• What does not work well in the way we provide STD services?
• What standards, guidelines or protocols are used for providing STD 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 information do you ask from your clients about their sexual 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 clients on prevention of
STD?
• What messages do you emphasise when educating or counselling clients on laboratory
testing?
• What messages do you emphasise when educating or counselling clients with diagnosed
STD?
Key questions
• Are at least two symptoms of infection asked9
• Do service providers ask about current sexual practices?
• Is a complete physical examination as required for male, female or infant conducted?
• Is the illness correctly identified and appropriate treatment prescribed?
• Do service providers discuss some basic ways to prevent sexual transmission of STDs?
• Is the client assured of confidentiality of test results?
• Is the importance of notifying a partner discussed?
• Do service providers explain the risk to a foetus/infant and the avoidance of pregnancy
through the use of appropriate contraception?
• Do service providers suggest any prenatal or postnatal care, if any, that is needed?
Module 6: Service quality; appendix C
139
•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?
Module 6: Service quality; appendix C
140
PHC service quality assessment
Discussion guidelines: 16. Malaria
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.
These discussion guidelines are provided to help you to lead a group discussion about the
quality of your malaria 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 malaria services?
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?
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.
• Do service providers discuss danger signs that may indicate unresponsive or complicated
malaria?
• Are 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)?
Module 6: Service quality; appendix C
<>
<i
141
PHC service quality assessment
Discussion guidelines: 17. Tuberculosis
&
Introduction: Welcome the group and briefly give the purpose of the discussion.
Ground rules: Explain the following ground rules to the group:
U>
& ill
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.
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
& &
Discussion
• What works well in the way we provide tuberculosis services?
Guidelines
• What does not work well in the way we provide tuberculosis services?
• What standards, guidelines or protocols are used for providing tuberculosis 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 tuberculosis?
• For what reasons would you refer a client to another service provider?
• What messages do you emphasise when educating or counselling your clients?
W
<
1
'»
ii'
ii
’
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 stressed7
• 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?
Module 6: Service quality; appendix C
142
PHC service quality assessment
Discussion guidelines: 18. Treatment of minor ailments
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.
These discussion guidelines are provided to help you to lead a group discussion about the
quality of your treatment of minor ailment 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 treatment of minor ailment services?
Guidelines
• What does not work well in the way we provide for treatment of minor ailments?
• What standards, guidelines or protocols are used for providing services for the treatment of
minor ailments?
• To 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 do you emphasise when educating or counselling your clients?
Key questions
• Do you ask patients about their chief complaint?
• Do you determine medical history and past drug allergies?
• How do you check vital signs?
• How do you conduct a related physical exam?
• How do you make an appropriate diagnosis?
• How do you schedule diagnostic testing?
• Do you provide appropriate 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?
Module 6: Service quality; appendix C
143
PHC service quality assessment
Discussion guidelines: 19a. Hypertension
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.
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
• What works well in the way we provide hypertension services?
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?
Module 6: Service quality; appendix C
if
144
PHC service quality assessment
Discussion guidelines: 19b. Diabetes mellitus
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.
These 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.
Discussion
• What works well in the way we provide diabetes services?
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?
Module 6: Service quality; appendix C
145
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.
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 services during a visit for anaemia?
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?
Module 6: Service quality; appendix C
147
Appendix D: Multiple observation
checklists
PHC household visit
Growth monitoring
Immunization
Oral rehydration therapy
Family planning
Module 6: Service quality; appendix D
d service quality assessment checklist
household visit
2.
3.
Health facility
Observer
Regular supervisor
Date
148/1
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
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?
2
3
4
5
6
7
8
9
10
TOT
Problems identified
Actions taken
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?
Growth monitoring
14.
Review the growth cards of all children < 5?
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__________________________________________________________________
19.
Ask if any children in the household have diarrhoea?
20.
If yes, recommend ORT, and help lhe 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?
Demonstrate how to make ORS solution, or invite mother to a demonstration il
necessary?
____
148/2
1
Observation number/reoistration and documentation
1 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?
2
3
5
6
7
8
9
10
TOT
Problems identified
Actions taken
_________ __ —
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?
General
39.
Ask it anyone in the household is ill and give appropriate advice?
40.
Follow up on recent illnesses?
41.
Verify that the dient(s) understand key information from today's visit?
42.
Establish good rapport with the mother?
—I
>
*
>
Rapid quality assessment checklist: Growth monitoring
£1 tfil
1.
2.
3.
4.
Health facility
Observer
Observer/supervisor
Date
148/3
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
2
3
4
5
6
7
8
9
10
TOT
Problems identified
Actions taken
<> «> <ii
Age calculation_______________________________________________________________ ________ _____ ____________
5.
Base calculation on a reliable date of birth?
6.
Correctly calculate date of birth ?’
7.
Record age?
<
1
1
Weighing
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
tl ‘ <*) G'l ® ®
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?
118.
Tell mother whether child has gained lost stayed the same since last weighing?
119.
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?
I 22.
Make recommendations regarding child feeding and care?
123.
Explain importance of good breast feeding and weaning practices?
| 24.
Explain which locally available foods constitute a balanced diet for children?
Explain how to feed children during illness?
26.
Tell mother when to take child for next weighing?
'»*'
<
!■
I 25.
27.
Verify that mother understands key messages?
28.
Ask mother if she has any questions?
36.
Do you have a working scale?
I 43.
Do you have a way of tracking malnourished children?
I
<il
®
—
———
148/4
Rapid quality assessment checklist
Immunization
1.
Health facility
2.
3.
Observer
Observer/supervisor
4.
Date
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?
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?
1
2
3
4
5
6
7
8
9
10
TOT
Problems identified
Actions taken
<
*>
ii
Rapid quality assessment checklist
Oral rehydration therapy
1.
2.
Health facility
Observer
Observer/supervisor
...........
. ..------
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
1
2
3
4
5
6
7
Duration of diarrhea?
6.
Consistency of stools?
7.
Frequency of stools?
8.
Presence of blood and/or mucus in stools?
9.
| 10.
Presence of vomiting?
Fever?
11.
10
TOT
Actions taken
Problems identified
Home treatments?
12.
Assess general status (alert or lethargic)?1
13.
Pinch skin?
14.
Weigh child?
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
Prescribe ORS or cereal-based ORT?
Refrain from using antibiotics except when stools contain blood or mucus?
£>
15.
20.
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 dunng and after dehydration?
35.
Show mother how to administer ORS solution or cereal-based ORT?
Signs of dehydration: 1 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 vomiting; 3. very thirsty, 4. eating or drinking poorly; 5. fever; 6. lood in stool; 7. dehydration persists.
®
9
Physical examination
16.
S
8
Medical history
5.
&
® ®
<
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ii ii <»
Observation number/registration and documentation
_=——
■—
■
-
-
148/6
Rapid quality assessment checklist
Clinical family planning services
1.
2.
3.
Health facility
Observer
Observer/supervisor
4.
Date
1
. !
Instructions: Mark "yes" (Y) if the service provider carries out these activities during observation.
Observation number:
Medical and reproductive history* (new clients)
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 lor stopping or switching previous methods?
9.
Ask about heart disease?
10.
Ask about liver disease?
|| 11.
Ask about high blood pressure?
: 12.
Ask about history of pelvic inflamatory disease?
| 13.
Ask about history of suspected or confirmed venereal disease?
14.
Ask about history of blood clots or thromboemboli?
15.
Ask il she is breast feeding?
16.
Ask about date of last menstrual period?
For interview questions, mark “yes" (Y) if the client responds correctly
1
2
5
3
6
7
8
9
10
TOT
Problems identified
______________ ___ _—
Physical examination*
I 17.
Take blood pressure?
18.
Examine breast for lumps?
19.
Examine patient for signs of anaemia?
Selection of a method
| 24.
Choose a method lhat was free of contra-indications for this client?
28.
Ask about side effects?
Counselling (for all)*
31.
Describe possible minor side effects ot 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?
■---------
------------------------------------------------
f
I
Actions taken
151
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
Module 6: Service quality; appendix E
152
WORKSHEET FOR PLANNING QUALITY ASSESSMENT ACTIVITIES
Step 1. Specify the scope and objectives
A.
What is the purpose of the assessment?______________________________________
B.
What services will be included?
C.
Who will use the information gathered?
D.
How will the information be used? __________________________________________
E.
What geographic area will be covered?
F.
Over what period of time will the activities take place?
G.
What additional resources, if any, are available?
____________________________________________
,
______________________________________
WORKSHEET FOR PLANNING QUALITY ASSESSMENT ACTIVITIES
Step 2: Select unit of observation and data sources
Unit of observation:
Client/patient
_____ Service elements
Health worker
_____ Clinic session
_____ Health centre
Data sources:
Direct observation
_____ by supervisor
_____ by peer
_____ self-assessment
_____ Interview
_____ structured interviews
_____ open-ended interviews
_____ discussion
_____ Record review
_____ routine records
_____ records kept especially for the assessment
Module 6: Service quality; appendix E
153
WORKSHEET FOR PLANNING QUALITY ASSESSMENT ACTIVITIES
Step 3: Select and adapt the appropriate PHC MAP checklist(s)
Will the checklist require adaptation?
Who will adapt the checklist?
_
WORKSHEET FOR PLANNING QUALITY ASSESSMENT ACTIVITIES
Step 4. Determine sampling procedures and select sample (optional)
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 each unit?
Module 6: Service quality; appendix E
154/2
Manual tabulation exhibit
PHC MAP tally sheet
^Selection of LQAS sample
^Determination of minimum level, sample size, and acceptable size based on differences between rlintr-o w . x ,
pre-established goals
C',n,CS- Nccd to focus
5^ A)
a
ir
i 53
i
-V:
1
NO
YES
2) Focus on worst
YES
NO
S1
A1
M2
S2
A2
M3
S3
A3
Goal
Minimum level
Sample size
Acceptable size
Minimum level
Sample size
Acceptable size
Minimum level
Sample size
Acceptable size
Goal
95%
70%
13
12
75%
18
16
80%
28
26
95%
98%
65%
16.
13
70%
24
20
75%
40
34
90%
85%
60%
19
15
65%
29
23
70%
49
39
85%
80%
55%
22
16
60%
33
24
65%
57
42
80%
75%
50%
23
15
55%
36
24
60%
63
43
75%
70%
45%
25
15
50%
38
23
55%
66
43
70%
65%
40%
25
14
45%
40
23
50%
70
41
65%
60%
35%
25
12
40%
40
20
45%
72
38
60%
55%
35%
40
18
38%
55
26
40%
72
35
55%
50%
30%
38
16
33%
54
23
35%
70
31
50%
45%
25%
36
13
28%
51
19
30%
67
25
45%
40%
20%
33
10
23%
48
15
25%
63
21
40%
57
16
35%
49
11
30%
40
7
25%
35%
15%
29
7
18%
43
11
20%
30%
10%
24
5
13%
36
8
15%
5%
28
3
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.
B
NO
M1
25%
8%
29
154/3
----------- --------------- =
YES or NO
YES
1) Big difference
worst clinics and
5
10%
157
References and bibliography
• Andrist, L. "Taking a sexual history and educating clients
about safe sex." Nursing Clinics of North America, 23(4),
Dec., 1988. pp. 959-73.
• Blumenfeld, S. PRICOR Monograph series: Methodspaperl
Operations research methods: A General approach in pri
mary health care. Center for Human Services, Bethesda,
MD, 1986.
• Brown, L.D., et al. Quality assurance of health care in
developing countries. Center for Human Services,
Bethesda, MD, 1992.
• Burgess, R. Community health aide/practitioner manual.
United States Department of Health and Human Services,
Washington, DC, 1987. pp. 55-58.
• Dovlo, D., et al. What does the public want from us? A study
of user satisfaction with services in government health facil
ities in the eastern region, Ghana. April, 1992.
• Helander, E., et al. Trainingin thecommunityforpeoplewith
disabilities, Geneva, WHO, 1989.
• Hoole, A., R. Greenber and G. Pickard. Patient care guide
lines for family nurse practitioners, Little Brown and Com
pany, Boston, MA, 1976. pp. 265-272.
• Kirsch, T. and L. Kiess. Thesaurus of injury care skills. Draft.
The Johns Hopkins University, Baltimore, MD, 1992.
• Lamptey, P and P Piot. ThehandbookforAIDSprevention
in Africa. Family . Health International, Durham, NC, 1990.
• Lemeshow, S. and G. Stroh. Sampling techniques for eval
uating health parameters in developing countries. National
Academy Press, Washington, D.C., 1988.
9 McMahon, R., et al. On being in charge: A guide to manage
ment in primary health care. World Health Organization,
Geneva, Switzerland, 1992.
Module 6: Service quality; bibliography
158
Nicholas, D., et al. "The quality assurance project: Intro
ducing quality improvement to primary health care in less
developed countries, Quality assurance in healthcare. Vol.3.
No. 3,1991. pp. 147-165.
Osterweis, M. and J. Howell. "Administering patient satis
faction questionnaires at diverse ambulatory care sites,"
Journal of ambulatory care management, 1979. pp. 67-88.
• Pleiffer, J. (Ed.). Theories and models in applied behavioral
science, vol. Il, pp. 12, 28, 65-66, 139-140, 147-149, 189,
227
• PRICOR Project, Center for Human Services, Primary
health care thesaurus, volumes I and II, Bethesda, Maryland,
1992.
• Stone, D. and N. Kaleeba. "Counselling and AIDS," The
handbook for AIDS prevention in Africa, Family Health
International, Durham, NC, 1990. pp. 181-190.
• Thorburn, M.J. and K. Marfo. Practical approaches to child
hood disability in developing countries: Insights from expe
rience and research, 3D Projects, Spanish Town, Jamaica,
1990.
• USAID. Media promotion of breast feeding: A decade’s
experience, p. 45.
• USAID. Breast feedingfor child survival strategy, May, 1990,
pp. 29-30, 38.
• Wallace, H. "Health care of women and children in devel
oping countries," (Chapter 38), Handicapped children and
youth in developingcountries, Third Party Publishing Com
pany, Oakland, CA, 1990.
• Wallerstein, N. and E. Bernstein. "Empowerment, educa
tion: Freire’s ideas adapted to health education," Health
Education Quarterly, vol. 15, No. 4, pp. 379-383,1988.
• Ware, J. E. and R. Hays. "Methods for measuring patient
satisfaction with specific medical encounters," 'Medical
Care, 1988. pp. 26, 383-402.
Module 6: Service quality; bibliography
159
• Werner, D. Disabled Village Children. Hesperian Founda
tion, Palo Alto, CA, 1987.
• Wolff, M. and R. Black. Manual for Conducting Lot Qualify
Assessments in Ora! Rehydration Therapy Clinics. The
Johns Hopkins University School of Hygiene and Public
Health, Institute for International Programs, Baltimore,
MD, 1989.
• World Health Organization. AIDS prevention: guidelinesfor
MCH/FP Programme managers. Global Programme on
AIDS, World Health Organization, Geneva, 1990.
• World Health Organization: Management of patients with
sexually transmitted diesases. WHO Technical report series
810, Geneva, World Health Organization, 1991.
Module 6: Service quality; bibliography
160
Acronyms and abbreviations
AIDS
AKF
ANC
ARI
BCG
CHW
DK
DPT
EPI
FP
GM
HIV
IEC
IV
KAP
LQAS
MCH
MIS
NA
NG
NGO
OPV
ORS
ORT
PHC
PHC MAP
PRICOR
RH
STD
TB
TBA
TT
WHO
Acquired immune deficiency syndrome
Aga Khan Foundation
Antenatal care
Acute respiratory infection
Bacillus of Calmette and Guerin (tuberculosis vaccine)
Community health worker
Don’t know
Diptheria, pertussis and tetanus vaccines
Expanded Programme for Immunization
Family planning
Growth monitoring
Human Imunodeficiency Virus
Information, education, communication
Intravenous
Knowledge, attitudes, practice (behaviour)
Lot quality assurance sampling
Maternal and child health
Management information system
No answer
Nasal Gastric
Non-governmental organisation
Oral poliovirus vaccine
Oral rehydration salts
Oral rehydration therapy
Primary health care
Primary Health Care Management Advancement Programme
Primary Health Care Operations Research
Rhesus
Sexually transmitted diseases
Tuberculosis
Traditional birth attendant
Tetanus toxoid
World Health Organization
Module 6: Service quality; acronyms and abbreviations
PHC MAP MANAGEMENT COMMITTEE
Dr. Ronald Wilson • Aga Khan Foundation, Switzerland (Co-Chair)
Dr. Jack Bryant • Aga Khan University, Pakistan (Co-Chair)
Dr. William Steeler • Secretariat of His Highness the Aga Khan, France (Co-Chair)
Dr. Jack Reynolds • Center for Human Services, USA (PHC MAP Director)
Dr. David Nicholas • Center for Human Services, USA
Dr. Duane Smith • Aga Khan Foundation, Switzerland
Dr. Pierre Claquin • Aga Khan Foundation, Switzerland
Mr. Aziz Currimbhoy • Aga Khan Health Service, Pakistan
Mr. Kabir Mitha • Aga Khan Health Service, India
Dr. Nizar Verjee • Aga Khan Health Service, Kenya
Ms. Khatidja Husein • Aga Khan University, Pakistan
Dr. Sadia Chowdhury • Aga Khan Community Health Programme, Bangladesh
Dr. Mizan Siddiqi • Aga Khan Community Health Programme, Bangladesh
Dr. Krasae Chanawongse • ASEAN Institute for Health Development, Thailand
Dr. Yawarat Porapakkham • ASEAN Institute for Health Development, Thailand
Dr. Jumroon Mikhanorn • Somboon Vacharotai Foundation, Thailand
Dr. Nirmala Murthy • Foundation for Research in Health Systems, India
PHC MAP TECHNICAL ADVISORY COMMITTEE
Dr. Nirmala Murthy • Foundation for Research in Health Systems, India (Chair)
Dr. Krasae Chanawongse • ASEAN Institute for Health Development, Thailand
Dr. Al Henn • African Medical and Research Foundation (AMREF), formerly of
the Harvard Institute for International Development
Dr. Siraj-ul Haque Mahmud • Ministry of Planning, Pakistan
Dr. Peter Tugwell • Faculty of Medicine, University of Ottawa, Canada
Dr. Dan Kaseje • Christian Medical Commission, Switzerland, formerly of the
University of Nairobi, Kenya
KEY PHC MAP STAFF AT THE CENTER FOR HUMAN SERVICES
Dr. Jack Reynolds (PHC MAP Director)
Dr. Paul Richardson
Dr. David Nicholas
Dr. Wayne Stinson
Ms. Maria Francisco
Dr. Neeraj Kak
Ms. Lori DiPrete Brown
Ms. Pam Homan
Dr. Lynne Miller Franco
Ms. Mary Millar
MODULE 6
USER’S GUIDE
Primary Health Care Management Advancement Programme
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