86190 H N P D i s c u s s i o n P a p e R VERIFICATION OF PERFORMANCE IN RESULTS- BASED FINANCING (RBF): The Case of the Burundi Adrien Renaud July 2013 Verification of Performance in Result-Based Financing (RBF): The Case of Burundi Adrien Renaud July 2013 Health, Nutrition, and Population (HNP) Discussion Paper This series is produced by the Health, Nutrition, and Population (HNP) Family of the World Bank's Human Development Network (HDN). The papers in this series aim to provide a vehicle for publishing preliminary results on HNP topics to encourage discussion and debate. The findings, interpretations, and conclusions expressed in this paper are entirely those of the author(s) and should not be attributed in any manner to the World Bank, to its affiliated organizations or to members of its Board of Executive Directors or the countries they represent. Citation and the use of material presented in this series should take into account this provisional character. For information regarding the HNP Discussion Paper Series, please contact Martin Lutalo at mlutalo@worldbank.org or Erika Yanick at eyanick@worldbank.org. © 2013 The International Bank for Reconstruction and Development / The World Bank 1818 H Street, NW Washington, DC 20433 All rights reserved. Health, Nutrition, and Population (HNP) Discussion Paper Verification of Performance in Results-Based Financing (RBF): The Case of Burundi Adrien Renaud, Freelance Health Economist Abstract: Paying health facilities incentives based on their performance is one form of results-based financing (RBF). Verification of the performance of the providers is a vital part of RBF program implementation. Burundi was one of the first African countries to introduce performance-based financing (PBF). The PBF scheme is implemented in the whole country and is led by the Ministry of Health (MoH). It pays incentives based on quantity of services provided as well as a quality of care component. This study describes the methods used for verification in Burundi, which include monthly verification of the quantity and technical quality of services provided on a quarterly basis; semiannual patient tracing and assessment of patient satisfaction; and counter-verification of the information provided by these three mechanisms. The results of verification are presented and it discusses obstacles to verification, how they have been addressed, and the challenges ahead. The case study is part of a broader analysis, which includes multiple country case examples, to expand knowledge about the verification process and practices to address the design and implementation needs of RBF programs. Keywords: Verification, quality, health system, incentives, Burundi Disclaimer: The findings, interpretations, and conclusions expressed in the paper are entirely those of the author, and do not represent the views of the World Bank, its Executive Directors, or the countries they represent. Correspondence Details: Petra Vergeer, The World Bank, 1818 H Street, Washington, DC, USA; e- mail: pvergeer@worldbank.org. Table of Contents List of acronyms .........................................................................................................................6 Executive Summary ....................................................................................................................7 1. Introduction .........................................................................................................................9 2. Methodology......................................................................................................................10 3. Context: PBF in Burundi ...................................................................................................11 4. Major Characteristics of the Verification Method .............................................................13 4.1. General facts about the verification method ..............................................................14 4.2. How is the quantity of services verified? ...................................................................15 4.3. How is the technical quality of services assessed? ....................................................17 4.4. How are household surveys performed? ....................................................................18 4.5. How is verification data counterverified? ..................................................................20 5. Findings of the Verification Methods ................................................................................22 5.1. What are the results of the quantity verification? ......................................................23 5.2. What are the results of the technical quality assessment? ..........................................28 5.3. What are the results of household surveys? ...............................................................30 5.4. What are the results of the counterverification?.........................................................33 5.5. What are the findings used for?..................................................................................38 6. Verification Costs ..............................................................................................................43 7. Lessons Learned ................................................................................................................44 Annex 1: Bibliography..........................................................................................................48 Annex 2: Quantity Declaration Forms in Health Centers and Hospitals ..............................49 Annex 3: Monthly Invoices for Health Centers and Hospitals ...............................................1 Annex 4: Technical Quality Assessment Checklists for Health Centers and Hospitals .........5 Annex 5: Household Survey Questionnaire ..........................................................................52 Annex 6: Analysis Framework for the Case Studies ..............................................................1 Acknowledgments I would like to salute the memory of Dr. Etienne Sekaganda, who died in December 2010, while on a counter-verification mission in Burundi, only a few days after answering my questions. I would like to thank the CT-FBP, and especially its president, Dr. Jean Kamana, who allowed me to access the relevant data; its technical adviser Dr. Olivier Basenya, who gave valuable advice and input on various versions of this document; and Dr. Emmanuel Seheye, who provided me with the Excel database. CPVVs gave full collaboration to the framework of this study, which owes a lot to them. I would also like to express my gratitude toward all the people, inside and outside Burundi, who agreed to answer my questions. Finally, I would like to mention that this study would not have been possible without help, advice, support, and input from the World Bank staff. Special thanks go to Petra Vergeer, Anna Heard, and Moulay Driss Zine-Eddine El-Idrissi. List of acronyms BDS District health office (Bureau du district de santé) BPS Provincial health office (Bureau provincial de la santé) CPVV Provincial committee for verification and validation (comité provincial de vérification et de validation) HMIS Health Management Information System MoH Ministry of Health PBF Performance-based financing RBF Results-based financing n.b. The exchange rate used in this document is the exchange rate in November 2012: 1 US$ = 1464 BIF. Executive Summary Burundi is a low-income country located in the African Great Lakes region. It has approximately 8.6 million inhabitants, and its economic and development indicators are among the weakest in the world. Health indicators are correspondingly very low. Burundi was one of the first African countries to introduce results-based financing (RBF). Its performance-based financing (PBF) scheme is led by the Ministry of Health (MoH), and is implemented countrywide, for all not-for-profit health centers and hospitals, public and private. Implementation at intermediary and operational levels is carried out by provincial committees — comités provinciaux de vérification et de validation (CPVV) and involves local offices of the MoH, NGOs, local government, and civil society. Health facilities are paid a monthly fee-for-service–based subsidy, and a quarterly quality-of-care component based on adherence to clinical guidelines, patient tracing (verifying legitimacy of patients and treatment in the community), and patient satisfaction. This study aims to describe the methods used to verify performance in this scheme, present the results of those efforts, and discuss obstacles they have faced, how these were addressed, and the challenges that lie ahead. There are four types of verification mechanisms in the scheme: • Verification of the quantity of services provided; performed monthly by the CPVVs for every directly contracted facility and every indicator. This verification consists of recounting cases in providers’ registers. • Assessment of the technical quality of the services provided; performed quarterly using a predefined checklist, in every facility, by district health offices for health centers and by peers for hospitals. • Assessment of the extent to which patients actually received these services and their satisfaction with services; performed semiannually by local NGOs for every facility and for selected indicators. Eighty patients are randomly selected and interviewed for each facility every semester. • Counter-verification of the information provided by these three mechanisms; performed quarterly by an independent organization (Health, Development, and Performance — HDP). Four provinces are selected every quarter, and the same tools that have been used for verification are used for counter-verification. The following results of verification were identified by this study: • The verification of quantity in health centers by CPVVs between January and August 2012 found that quantity performance was accurately assessed by providers in 69 percent of the cases. It was overestimated in 22 percent of the cases (average overestimation of 19 percent) and underestimated in 9 percent of the cases (average underestimation of 4 percent). The verification of quantity in hospitals by CPVVs between January and July 2012 found that quantity performance was accurately assessed by providers in 62 percent of the cases. It was overestimated in 26 percent of the cases (average overestimation of 13 percent) and underestimated in 12 percent of the cases (average underestimation of 7 percent). • The assessment of technical quality by local offices of the MoH and by peers found that for the 2010–12 period, the average technical quality score for health centers was 70 percent, 77 percent for district hospitals, and 74 percent for national hospitals. However, these scores can vary greatly depending on the changes that can be made in the quality assessment checklists. • In the health centers of 13 provinces for which disaggregated data on household surveys could be collected, the proportion of patients that could not be located in the community varied from 8.6 percent to 6.9 percent between the first quarter of 2011 and the first semester of 2012. In the hospitals of these same 13 provinces and during the same period, the proportion of patients that could not be located in the community varied from 9.8 percent to 15.4 percent. • For health centers, no significant difference was found during the eight counter-verification rounds between quantity performance as verified by CPVVs and quantity performance as counter-verified by HDP. However, disaggregated data was not available, and overestimations were averaged with underestimations, which leads to underestimating the differences. Conversely, for hospitals, the differences between verification and counter-verification data are large and systematic: the average of the absolute values of the differences between quantity performance as verified by CPVVs and quantity performance as counter-verified by HDP is 31 percent. The study also found large and systematic differences between the technical quality as assessed by local offices of the MoH and by peers and the technical quality as assessed by HDP: compared to HDP results, MoH assessment of technical quality in health centers was overestimated in 79 percent of the cases (average overestimation was 20 percent) and underestimated in 21 percent of the cases (average underestimation was 24 percent). Compared to HDP results, peer assessment of technical quality in hospitals was overestimated in 84 percent of the cases (average overestimation was 24 percent) and underestimated in 16 percent of the cases (average underestimation was 20 percent). The findings of the verification system are primarily used for paying providers: the results of quantity verification are used for paying monthly quantity subsidies, and technical quality assessment combined with household surveys can be translated into a quarterly top-up subsidy or sanction. The results of the counter-verification are used to assess whether CPVVs and local offices of the MoH fulfilled their tasks correctly. All sanctions that are defined in the PBF implementation manual are not enforced yet, because the verification system is not only a control tool, it is also seen as an educational tool for providers. According to all interviewed people, the verification system in the Burundian PBF ensures a satisfactory level of fraud detection. There is a consensus that most errors are unintended mistakes rather than attempts by providers to cheat the system and increase their income. This is confirmed by the fact that underestimations of performance are frequent (although not as frequent as overestimations). In Burundi, the strong integration of the verification system with the MoH regulatory system, combined with the existence of an independent counter-verification mechanism, ensures a degree of confidence such that most actors estimate that data is reliable, at a reasonable cost (about 16 percent of the total PBF expenses). This study found that the level of discrepancy between the results before and after verification was still high, but this could be solved by modifying the incentives system on the one hand (for example, implementing firmer sanctions), and by continuous training of CPVVs, BPS (bureau provincial de la santé, provincial health office), BDS (bureau du district de santé, district health office), and hospital peers, on the other hand. 1. INTRODUCTION Burundi is a low-income country located in the African Great Lakes region. It has approximately 8.6 million inhabitants and its economic and development indicators are among the weakest in the world: in 2011, its GDP per capita was approximately US$270, 1 67 percent of the population lived under the poverty line. With a 0.316 Human Development Index, it ranked 185th out of 187 countries in the 2011 Human Development Report. Not surprisingly, health indicators are very low, too: the total health expenditure is around US$20 per capita, life expectancy at birth does not exceed 50 years, under-five mortality rate is above 140 per 1,000 live births, and the maternal mortality ratio is estimated at 800 per 100,000 live births. Table 1 .1 Basic Facts about Burundi Basic Facts about Burundi Population 8.6 million GNI per capita (current US$) 271 Poverty rate (%) 67 Total health expenditure per capita (current US$) 21 Life expectancy at birth 50 years Under-five mortality (per 1,000 live births) 142 Maternal mortality ratio (per 100,000 live births) 800 Source: World Bank 2011. Burundi was one of the first African countries to introduce results-based financing (RBF), known as “performance- based financing,” (PBF) in Burundi. It was second on the continent (after Rwanda) to make PBF a national policy and to decide to implement it nationwide. Burundian PBF has a dual objective: • It aims to improve the performance of the health system • It is a method to implement as national policy the removal of user fees for pregnant women and children under five years old. Half of the budget is financed by the government (MoH 2012), which is a feature seldom found in RBF schemes in Africa. The other half is financed by various international donors (including the World Bank, European Union, Belgian Development Agency BTC, USAID), which necessitates an important effort of aid coordination. This unique environment gives the Burundian PBF a special interest in studying the various verification methods used in RBF schemes. This study aims to describe the verification system in Burundi, but also to identify the results it has achieved, the obstacles it has faced, how it has solved them, and the challenges that still lie ahead. 1. In current US dollars. This figure, as well as all other figures presented in this section, is taken from World Bank 2011 (unless otherwise indicated). Figure 1.1 Burundi in Africa Source: World Bank 2011. 2. METHODOLOGY Data collection for this study was carried out in two separate steps. First, at the end of year 2010, relevant documents (annex 1) were analyzed, major actors of the PBF scheme in Burundi were interviewed by telephone or by e-mail, and in agreement with the Ministry of Health (MoH), four provinces 2 were selected for telephone interviews with the people who actually implement verification, as well as with provincial health offices (bureaux provinciaux de la santé, BPS). This first step gave us a good description of how verification was carried out, but since it was conducted less than one year after PBF had been rolled out through the whole country, it could not give a satisfactory sense of the results of the verification. Two years later, in 2012, an evaluation mission on PBF in Burundi provided another opportunity for data collection, particularly to document the changes that had been made to the verification process since 2010, to interview more field actors, and to collect in-depth quantitative data on the results of the various verification mechanisms at stake. There are four verification mechanisms (see sections 3 and 4) in the Burundi PBF scheme, and the periods for which the quantitative data could be collected differed from one mechanism to another: • For quantity verification, data on declared and verified services were available from January to August 2012 for health centers, and from January to July 2012 for hospitals. • For technical quality assessment, the results were available from the beginning of PBF scale-up (second trimester 2010) to the third trimester of 2012. 2. Bubanza, Muramvya, Muyinga, and Ruyigi. • For household surveys, the results were available from the first quarter of 2011 to the first semester of 2012, and for only 13 provinces out of 17. • For counter-verification, the results were available from the beginning of PBF scale-up to the third trimester of 2012. Moreover, data on the approximate cost of verification were also collected through the activity reports established by the MoH, which runs the scheme. All the data were made available by the MoH, and they encompass the whole country (except for household surveys). They were used, along with other sources, to calculate the level of error, defined as the difference between the data after verification and the data before verification. The calculation formula for each verification method has been presented in the relevant sections of this case study. The analysis of the quantitative and qualitative data was done according to a framework that has been used in several other case studies on verification mechanisms in various countries (annex 6). This framework was designed to allow comparisons between the systems. It comprises five major elements that determined the major sections of this case study: overview of the PBF scheme (section 3), description of the verification systems at stake (section 4), findings of the verification methods (section 5), cost of verification (section 6), and finally, lessons that can be learned from implementing the verification methods (section 7). 3. CONTEXT: PBF IN BURUNDI PBF was first introduced in Burundi as a pilot project in three provinces in 2006, with the support of Dutch NGOs Cordaid and HealthNet TPO. These pilots aimed at improving low health system performance by increasing and reshaping incentives for health care providers, and by shifting from an input-based to an output-based financing system. As encouraging results were achieved (Cordaid and MoH 2011), the experiment was gradually extended to other districts and provinces. More and more partners became interested in RBF in Burundi. In 2010, the government decided to roll out PBF to the whole country, and assigned it another objective: financing free treatment for pregnant women and for children under five years, a national priority since 2006. PBF benefits from strong support by international donors who, in addition to financing about half of the budget, ensure technical assistance at national and provincial levels. Detailed descriptions of the Burundian PBF are available elsewhere (MoH 2011b); we will only give a brief snapshot here. Participation in the program is mandatory for all public providers in the country. Private providers can also choose to participate. In practice, all not-for-profit private providers do, and some private providers 3 have subcontracts with a not-for-profit or a public provider. The program involves a total of 565 health centers and 50 hospitals (45 district hospitals and 5 national hospitals), plus 151 private health centers with a subcontract. PBF pays health facilities in two steps. The first step is a payment based on fee-for-services that aims to increase the volume of health services delivered (the underlying hypothesis is that health services are underutilized): a set of output indicators 4 has been defined, and a subsidy is attached to each indicator. Payment is not capped: the more the facility produces, the more it gets. Health facilities are paid every month, after verification of their 3. For-profit and not-for-profit: they generally are small health centers, or health centers that are located in remote areas. 4. The lists of indicators have been established during a national workshop, where various health actors listed all relevant indicators, and extracted the most important ones using the DELPHI prioritization method. registers. The second step is a quarterly payment linked to the assessment of the quality of care. It has a dual objective: • Motivating health care providers to adhere to norms (“technical quality”) • Assessing the relationship of providers with patients through the detection of potential “phantom patients” on the one hand (verifying services were actually received), and through the evaluation of patient satisfaction on the other hand (“subjective quality”) The assessment of “technical quality” is done every three months, and the assessment of “subjective quality” every six months;, with the results used to determine payments for two quarters. The assessment results in a score, and subsequently a top-up quality subsidy (financial incentive) if the evaluation is deemed satisfactory (quality score greater than 70 percent). If, on the contrary, it is deemed unsatisfactory, (quality score less than 50 percent), part of the first payment (quantity incitation) can be deducted. PBF money is not paid directly to health staff, but to health facilities. The latter have partial management autonomy and use the amounts they receive to finance general activities. PBF subsidies are a complementary income for health facilities, which already receive user fees from patients, public financing from the state (for salaries), and top-ups and inputs from international donors and vertical programs. PBF money represents between 30 and 35 percent of total cash income for hospitals, and 80 to 85 percent for health centers. Health facilities can allocate a share of it as staff incentives if their budget is balanced (which is generally the case) and if their bank account is sufficiently funded (funds for at least two month of general expenses). Financial incentives are supposed to motivate health staff to increase performance and can amount to as much as one-third of their base salary, as shown in table 1.2. Table 1.2 Average Monthly PBF Incentive for Health Staff Compared to the Average Monthly Salary at the Beginning of the Career Average monthly salary at the beginning of Average monthly PBF incentive in 2010 the career Nurses $200 $72 Physicians $400 $100 Source: MoH 2011a. The scheme is led by the MoH, where a technical unit for PBF (cellule technique du FBP, CT-FBP), based at the General Directorate for Public Health and for AIDS Services coordinates its activities at the central level. Implementation at intermediary and operational levels is carried out by provincial committees for verification and validation (comités provinciaux de validation et de vérification, CPVVs), with district health offices (bureaux de district de santé, BDS) and BPS (the local offices of the MoH). Figure 1.2 presents interaction between the major actors of the PBF scheme. Figure 1.2 PBF Institutional Set-Up Source: MoH 2011b. Note: “C” = contract and “S/C” = subcontract. It is not the aim of this paper to assess the effectiveness of the PBF program, rather the focus is on verification carried out in the Burundi program. Partial information on the evolution performance since PBF was rolled out in the whole country can be found in the report on the technical reviews of the program (Cordaid, EU, WB, WHO 2012) or in the reports of the CT-FBP (MoH 2011a and MoH 2012), which indicate promising initial results based on verified data used for RBF payment. 4. MAJOR CHARACTERISTICS OF THE VERIFICATION METHOD The PBF verification system was set up during the pilot projects between 2006 and 2010. When it was scaled up throughout the whole country, it was adapted by consensus among the actors involved: the MoH, international donors, vertical programs, and NGOs implementing the pilots. The results of this consensus have been summarized in an implementation manual (MoH 2010) that was later revised (MoH 2011b). This document, combined with interviews with the people implementing the verification, is the primary source for this section. Verification is a constantly evolving system, and it should be noted that this study could not take into account the changes that might have happened after the end of year 2012. 4.1. General facts about the verification method The system includes four types of verification: 5 • Verification of the quantity of services provided (called “quantity verification” in the rest of this document): this verification determines whether declared services can be tracked back in the facilities’ registers, and triggers the monthly fee-for-services payment. • Assessment of the technical quality of the services provided (called “technical quality assessment” in the rest of this document). This assessment determines whether facilities are able to provide services that fulfill the norms of MoH, and also informs the quarterly quality top-up or sanction they can receive. • Assessment of the extent to which patients actually received these services and of their satisfaction (called “household surveys” in the rest of this document): this verification has a dual objective. First, it determines whether declared patients actually exist and whether they confirm that they were treated in the facility. Thus, the assessment is a tool for fraud detection (identification of potential “phantom patients”). Second, it determines whether patients were satisfied with the care they received, and is thus a tool for assessing the perceived quality of health care. Together with the technical quality assessment, the household survey is the second part that informs the quality top-up or sanction facilities can receive. • Counter-verification of the information provided by these three mechanisms (called “counter- verification” in the rest of this document) is performed by an independent organization. This counter- verification assesses the quality of the data produced by the PBF system, but also follows up on the implementation of the program. To implement PBF at the decentralized level, the government of Burundi set up the above-mentioned CPVVs. These committees are the key bodies for implementation of the scheme at provincial level. They are responsible for contracting facilities in the name of MoH, for carrying out verification, for deciding to release PBF payment, for analyzing the data, for elaborating and following up recommendations accordingly, and for implementing sanctions if necessary. At the beginning of the scale-up of PBF, discussions were held between the MoH, donors, and NGOs about whether the verifier should be a governmental agency rather than an independent institution as was the case in the pilots. As a compromise between these two options, it was decided that the CPVV would be a joint institution where both civil society and government are represented. The secretary of the CPVV is the head of the BPS, that is, the representative of the MoH at provincial level. The CPVV comprises two units: • A “verification unit” that is in charge of the implementation of the verification at facility level. It is composed of civil servants and of contracted workers. • A “validation 6 unit” that is in charge of validating verification data at provincial level, of creating a combined provincial invoice, of monitoring contracts, and, more generally speaking, of managing the PBF program at local level. It is composed of the following: 5. A fifth type of verification exists: verification of the performance of regulation and implementation bodies at central, intermediary and operational levels: namely CT-FBP, BPS, BDS and CPVV). It has not been included in this study, which is focused on the verification of the performance of health facilities. 6. The word “validation” can be misleading. It also refers to the data provided by the verification unit (verified services that match the exact definitions of the indicators, see part 3.2). • One representative from the local government administration • Representatives from the BPS and BDS • Representatives from donors • Representatives from the civil society During the rollout of PBF to the whole country, the CPVV was not subdivided in such a way: it simply included a technical team in charge of the work currently performed by the verification unit. The decision to separate the validation and the verification functions was made to improve the incentives of both units for better performance. The separation was made to avoid conflicts inside the committee that had occurred in some provinces and were linked to the workload of the members. The objective of the reform was that every member of the CPVV should be rewarded according to his or her contribution to the collective performance of the committee. CPVVs are supported by local technical assistance agencies, often led by the NGOs that implemented the pilot PBF projects in Burundi. CPVV members elect a chairperson and a vice chairperson, but decisions in the committee are made by consensus. One should note that public health facilities are hierarchically accountable to some of the members of the committee. No example of conflict of interest linked to this situation has been reported to the author of this study, but there are reasons to think it could lead to a certain form of complacency, especially for the technical quality assessment (see section 5.2). However, this institutional set-up was the only workable compromise between advocates of a verification carried out by the government and those who preferred it to be implemented by an independent team. 4.2. How is the quantity of services verified? Providers declare the quantity of services they performed using the monthly routine Health Management Information System (HMIS): a manually filled-in form (annex 2) is attached to the HMIS form, and summarizes, for contracted indicators, the data that is relevant for PBF. This declaration is then verified by the verification unit of the CPVV, and the information is used to create an invoice. Every facility is verified every month, in correspondence with the monthly payment schedule. Random checks are not considered an option at this time in Burundi by the people interviewed for this study for at least two reasons: • The monthly invoice on which payment is based is created during verification visits; thus the visits are indispensable to paying providers. • Quantity verification is considered an educational tool to help facilities learn the processes and principles of PBF. On a verification visit, the CPVV verifier(s) and the facility manager collect all registers, and recount all services provided by the facility during the month for relevant indicators: 22 indicators for health centers, 24 indicators for hospitals. If the verified facility has subcontracts with other health care provider(s), the registers of the latter are brought to the principal health facility, and its services are recounted. The team then establishes an invoice (annex 3) citing, for each indicator, three quantities: • The quantity of declared services, which is the quantity that had been counted by the facility and reported in the declaration form before the arrival of the verification team. • The quantity of verified services, which is the quantity of services that have been counted by the facility and the verification team in the registers for the month, not taking into account the exact definition of the indicator. Any service done during the month and reported in the register will be counted. • The quantity of validated services, which is the one used to calculate payment. It is the quantity of services that is reported in the registers for the month and that matches the exact definition of the indicator. For example, if a delivery takes place at the health center and is registered without the date, or if a child is completely vaccinated but finishes the vaccination process after turning one year old, these services will be counted as verified services but not as validated ones. This validation should not be confused with the validation done by the CPVV validation team (see below). The invoice also indicates, if the difference between the declared and verified quantity is too large, sanctions that apply, described in table 1.3. These sanctions did not exist in the initial verification system. They were introduced when the implementation manual was revised (2011), to begin to increase the rigor of the verification process among health providers. Table 1.3 Criteria for the Sanctions in Case of Difference between Declaration and Verification 7 Difference between declared and verified quantities Sanction (%) <5 No sanction 5–10 -5% of the subsidy for the indicator 10–20 -10% of the subsidy for the indicator >20 No subsidy for the indicator Source: MoH 2011b. It should be noted that these sanctions apply to the difference between declared quantity and verified quantity rather than, as might be expected, to the difference between declared quantity and validated quantity that complies with the full definition. The MoH preferred to refer to verified quantities to support its HMIS: the verified quantities are those reported in the HMIS (a woman who delivered at the facility but whose address has not been registered properly must still appear in HMIS data). However, validated quantities are more relevant from the point of view of PBF, since they determine provider payment. Based on the invoice, the verification team can write a report giving recommendations to improve data quality if necessary. The facility and the team are both left with one copy of the invoice and one copy of the verification report, if any. The CPVV verification unit is usually composed of nurses with various qualifications. Half of its members are civil servants, and half are contracted by donors. 8 The coordinator of this team is always a civil servant. The size of the team varies from four to five people. Verifying quantity in one health center usually requires the participation of one to three team members, and takes two to three hours. Verifying quantity in one hospital usually requires four to five people, and takes four hours to the whole day. Verifying quantity for one province usually takes from one to two weeks. Monthly results are captured at provincial level in a national web-based database, and analysis is done by the CPVV validation unit in a monthly meeting. During this meeting, the performance of each facility is analyzed to detect possible 7. Sanctions apply to both positive (underestimation) and negative (overestimation) differences. 8. The coordinator and the other civil servants are chosen by the MoH. The contracted workers are members of supporting organization (such as Cordaid, HealthNet TPO, Pathfinder). All of them receive a salary. Civil servants can receive an additional top-up salary, based on quarterly evaluated performance of the CPVV (evaluators come from central level). underperformance, to analyze its causes, and to make recommendations. The meeting can also detect possible data inconsistency (compilation errors). At the end of the meeting, the compiled provincial invoice is established. 4.3. How is the technical quality of services assessed? The technical quality of services is assessed quarterly. This assessment is performed by staff from the BPS accompanied by the BDS for health centers. It is performed by peers (that is, hospital professionals from other provinces) for hospitals; delegates from MoH at the central level began participating in 2012. Theoretically, health facilities with a subcontract 9 should be evaluated by the facility with which they have signed this contract. In practice, the technical quality of subcontractors is never assessed. Part of the quarterly top-up that the BPS receive from the PBF program is determined by the timeliness of their assessment of health centers’ technical quality. 10 Provincial health offices were chosen for this activity because technical quality is linked to norms, verifying compliance to such norms is precisely the role of the BPS. Peers were chosen to perform assessments in hospitals to enable hospitals to compare against each other. The choice of the assessors, for health centers as well as for hospitals, has been guided by the desire to use the technical quality assessment as an educational tool, enabling health facilities to improve themselves, as much as a verification instrument. At the beginning of the PBF rollout to the whole country, hospital technical quality assessment was done by peers from the same province as the hospitals they were evaluating. It frequently happened that the assessors had themselves been evaluated by those peers from the hospitals they were evaluating. This system could facilitate collusion or, conversely, result in conflicts. For example, in several instances some evaluators gave bad grades in retaliation for a bad grade they had received in the past from the hospital they were assessing. From 2012 on, it was decided that evaluators could come from any hospital in the country that is involved in the PBF scheme. This has not eliminated the problem (only 50 hospitals are involved in the scheme), but it has reduced the scope of the problem. It was decided that a facilitator would be added to the evaluation team. He or she is a third-party observer, commissioned by the CT-FBP, is generally a member of the PBF technical assistance at provincial or central level, and represents the CT-FBP during the peer assessment. The facilitator is to prevent or solve potential conflicts during the assessment. During a quality assessment visit, which the author of this study observed, it was noticed that the role of this facilitator was crucial both for answering technical questions on how to interpret the checklist, and for easing tensions between evaluators and hospital staff. There is no sampling: every facility is assessed every three month as required by the quality payment schedule. The assessment of hospitals is planned at central level, and facilities therefore know the date of their evaluation in advance. For health centers, the situation varies from one province to another, and the decision whether to notify facilities is up to the BPS. Some provinces notify facilities well in advance, others the day before, and others do not notify facilities at all. In any case, health centers know the period when the assessment will take place: during the first two weeks of the first month of each quarter. It would have been interesting to compare the scores of facilities that are warned in advance with the ones that are not, especially on areas such as medicine 9. Subcontractors represent 20 percent of the total of the health centers that are involved in the scheme. They are usually small private facilities that are located in remote areas and are usually less frequented than those of primary contractors, but this is not always the case. 10. The remainder of this top-up subsidy is based on the routine tasks of the BPS. stocks and cleanliness, for which it is easy to prepare. Unfortunately, the data available did not allow such comparisons. The supervisors use a checklist (annex 4) based on the norms defined by MoH. The checklist includes 13 domains for hospitals and 14 for health centers. A score is given for every item on the checklist, which results in a technical quality score (percentage). The list can be modified, but this rarely happens: the checklist has been substantially revised only once. In 2011, more clinical aspects, as well as elements linked to the patient records were added to the hospital checklist. In 2012, a smaller scale revision of the health center checklist was implemented. The technical quality assessment of health centers mobilizes almost the whole staff of BPS, which is composed of nurses with various qualifications and one physician (the director). Assessing one health center mobilizes three to five people, and takes three to four hours. Technical quality assessment in hospitals usually mobilizes four people: the head of a provincial health office (physician), the director of a hospital (physician), the head of the administration services of a hospital (manager), and the head of nursing of a hospital (nurse). Every member of the team focuses on his domain of competence: the administrative staff assesses management, and clinicians assess technical aspects. The visit can take two hours to the whole day: the time it takes varies according to the size of the facility and the results of the assessment, but also in the level of meticulousness of the evaluators. Before leaving the facility, the assessment team gives the manager a copy of the checklist, with recommendations to improve quality. Moreover, a quarterly meeting is organized at province level, where the results of the technical quality assessment are publicly presented. At this meeting, facilities can compare their strategies and share information about the best way to improve quality. Assessing technical quality for one province usually takes one to two weeks. The results are captured in the same national database as the results of quantity verification. 4.4. How are household surveys performed? In addition to its work on quantity verification, the CPVV technical team contracts local organizations (for example, local development associations, women’s associations) at the facility level to carry out household surveys. These surveys have two main objectives: • Determining whether care declared in the facilities’ registers actually took place (detection of “phantom patients”) • Determining the degree of satisfaction of patients Every semester, one or several members of the CPVV verification unit come to the facility and randomly choose a sample of 80 patients who visited the facility for selected services. It should be noted that for confidentiality reasons, three registers are excluded from the random choice: the HIV, tuberculosis, and family planning registers. Thus, the indicators linked to these activities are never verified by the household survey. This represents 9 out of 22 indicators for health centers, and 8 out of 24 for hospitals. Hence, a substantial part of the facilities’ activity is never verified by household surveys, which is a matter of concern that should be dealt with by MoH. The random selection is done in the presence of a member of the health committee to ensure transparency. Local organizations then go to the field for interviews. Patients are not notified in advance about the survey. They do not have the chance to refuse to be on the list of randomly chosen patients, but they can refuse to answer questions in the interview. The questionnaire (annex 5) includes questions on the following: • Whether the patient actually exists • Whether he/she actually visited the facility for the relevant service • Whether he/she was satisfied with care delivered • Whether he/she found care affordable • Whether he/she found waiting time reasonable • Whether he/she was satisfied with reception • Whether he/she was satisfied with the ability of the staff to treat him/her • Whether he/she has suggestion to improve care at the facility Only the first three items are taken into account in the calculation of the household survey score. The other five provide information to the facilities to help them improve according to the needs expressed by the patients. The three “paid” elements are linked to two different aspects of performance (fraud detection and patient satisfaction), which have been paired in the incentive system only because they are verified at the same time. The household survey score is combined with the technical quality assessment score to obtain an “overall quality score,” in which technical quality weighs 60 percent and household survey 40 percent. The 40 percent is distributed as follows: • If more than 5 percent of the randomly selected patients are not found by the household survey, the facility loses 10 percent. If less than 5 percent are not found, it scores 10 percent. • If more than 5 percent of the patients that were found do not confirm having been treated, the facility loses another 10 percent. If less than 5 percent do not confirm care, it scores another 10 percent. • If more than 20 percent of the patients that confirmed having been treated declare that they were dissatisfied with the care received, the facility loses 20 percent. If less than 20 percent are dissatisfied, it scores 20 percent. The global quality score can be translated in a quality top-up subsidy or a financial sanction, as defined in table 1.4. Table 1.4 Criteria for Attributing Quality Top-Up Subsidies or Sanctions Overall quality score (%) Quality top-up subsidy or sanction >90 Fee-for-services amount for the previous trimester × 30% × quality score 70% – 89,9 Fee-for-services amount for the previous trimester × 25% × quality score 50% – 69,9 No quality top-up subsidy 40% – 49,9 - 10% × fee-for-services amount for the previous trimester 30% – 39,9 - 20% × fee-for-services amount for the previous trimester <30 - 25% × fee-for-services amount for the previous trimester Source: MoH 2011b. It should be noted that the household survey is semiannual, while the technical quality assessment is quarterly. For quarters when no household survey is performed, the score of the preceding quarter is used to calculate the global quality score. In 2011 this top-up and sanction system replaced a previous system, where there were no sanctions, only a top- up if the overall quality score exceeded 70 percent. The new system is tiered and is a stronger incentive to improve quality. However, combining the results of the household surveys with the ones of the technical quality assessment has a double disadvantage: • Providers receive a positive incentive (more money in the pocket) for limiting the number of errantly (or fraudulently) listed patients in the registers. Instead of punishing fraud or error, the system rewards honesty and accuracy. • The results of household surveys are seldom analyzed because they are not disaggregated from the results of the technical quality assessment: this means that there is little analysis of the proportion of “phantom patients,” at least at national level. There is one local verification organization contracted per health facility. Each of them has six members trained for the survey, four of which participate each semester (the remaining two are the “reserve” team). The qualifications required to perform this survey are stated as follows: • To be able to read and write • To be proven of “good morality” The capacity of the people implementing the surveys is weak, but local organizations have been selected for this activity because a profound knowledge of the community is needed to perform the household survey. Local organizations are selected through a local tender, to which any association based in the catchment area of the facility can apply. The selection is usually very competitive. Local organizations are paid at the end of each survey on the basis of the number of randomly selected patients they managed to interview. It is a performance-based payment: local organizations do not get paid for clients they do not find to ensure they will do their best to find them. Moreover, in case of low compliance with requirements (for example systematic poor reporting quality), their contract can be terminated. Every member of the local organization has approximately 20 patients to interview every semester. Patients are distributed among organization members according to their place of residence, to reduce transportation costs. Interviews last no more than 15 minutes, but a lot of time can be spent in finding the patient. Performing household surveys for one province takes from one to two weeks. The household surveys were formerly performed every quarter. This activity has been deemed too onerous and burdensome, and the schedule is now semiannual. The results of the household survey are tabulated by the CPVVs and not by local organizations, because the latter do not have the required skills. They are presented to the facility together with the results of the technical quality assessment. They are captured at provincial level in the national database, but only aggregated survey scores are available in this database. Hence, it is currently not possible at national level to access disaggregated results for the three elements included in the incentive system (patient existence, health care confirmation and patient satisfaction). The absence of insight on the proportion of “phantom-patients” at national level was a major weakness of the Burundi BPF information system at the moment of data collection for this case study (the data had to be collected and compiled at provincial level). Since then, the database has been modified to take this concern into account. 4.5. How is verification data counter-verified? The quality of the data provided by the three verification processes we have described is ensured by several mechanisms. First, all actors have been trained for the tool they have to use. “Cascade-trainings” have been organized in the whole country in the event of rolling out PBF nationwide: heads of BPS and BDS have been trained at national level, and they have subsequently organized local training workshops. Moreover, all local organizations have pretested the survey before doing their first household survey. Additionally, CPVVs are accompanied by local technical assistance teams with PBF experience, that are financed by international donors (as described in section 4.1). However, there is a need for more quality assurance since errors can occur in many circumstances (for example, all data collection processes are manual), and since the verification system is mainly implemented by stakeholders from within the health sector: counter-verification provides added assurance of transparency or validity. This is why the three verification/assessment systems are counter-verified by an organization, Health, Development, and Performance (HDP), which is selected through an international tender for a two-year contract. The counter-verification was added as a control: it was a prerequisite set by donors to avoid paying for results with unknown reliability. Hence, every trimester, four provinces are randomly selected (so that at the end of the year, every province has been counter-verified once). HDP goes to these provinces, randomly selects one district, in which it re-performs quantity verification, technical quality assessment and household surveys 11 for the hospital and for 25 percent of the health centers (randomly selected). Counter-verification follows exactly the same rules as verification; the only differences are the people performing the verification and the degree of rigor. During the counter-verification process, the criteria used are strictly followed with no allowance for minor differences. In theory, only a 5 percent discrepancy between the results of verification and the results of counter-verification are tolerated. If the actual difference is greater than this 5 percent margin of error, financial sanctions can be applied against the CPVV. In practice, these sanctions have never been applied yet. This study will show that this is a weakness of the Burundi PBF. In addition to their reporting and analysis of the discrepancies between verification and counter-verification, HDP reports contain extensive comments on the performances of facilities themselves, and on their evolution. They analyze the reasons for possible underperformance and make recommendations to improve the quantity and quality of services delivered by health facilities, instead of focusing solely on data quality. This task has been added to the terms of reference for counter-verification at the request of the MoH, to diversify the channels that can help to improve the system. However, one can question the need for such comments, which are redundant given the analysis performed by the CT-FBP and the large technical assistance received by PBF in Burundi (evaluation or activity reports). The HDP counter-verification team is composed of two physicians, one statistician, two nurses, and one accountant, plus four logistical staff. The average education level of the counter-verification team is greater than the level for verification, and they have more experience with RBF in general, and with verification in particular. Counter-verifying one province takes one week; as the counter-verification teams are more meticulous, they spend more time in every health facility than the verification teams do. Every round results in an extensive report, discussed at national level. HDP also delivers an annual report synthesizing the four rounds and encompassing all the provinces. Table 1.5 summarizes the four types of verification implemented in the framework of PBF in Burundi. 11. The organizations that carry out household surveys for the counter-verification must be different from the ones that usually carry it out for the verification. Table 1.5 Summary of the Four Verification Mechanisms Used in the Framework of PBF in Burundi Quantity Technical quality Household survey Counter-verification verification assessment Institution in CPVV BPS and BDS Local organizations HDP charge Assessing whether Data quality audit Verifying the Assessment of subsidized health and follow-up of the Objective accuracy of provider patient satisfaction care matches PBF process as a declarations and fraud detection national norms whole Recounting cases in Assessment based Every method used Method Patient survey providers’ registers on a checklist by verification Frequency Monthly Quarterly Semiannual Quarterly The hospital and 25% of health No sampling (every No sampling (every centers from 1 80 patients per Sample size facility is verified facility is assessed district within each facility every month) every month) of 4 provinces randomly selected every quarter Number of people 1 to 3 for a health 3 to 5 for a health 10 for the whole needed to center, 4 to 5 for a center, 4 for a 6 country verify one hospital hospital facility 2 to 3 hours for a 3 to 4 hours for a Time needed health center, 4 health center, 2 15 minutes per 2 to 3 times as much to verify one hours to 1 day for a hours to 1 day for a patient as verification facility hospital. hospital Time needed to verify a 1 to 2 weeks 1 to 2 weeks 1 to 2 weeks 1 week whole province Source: World Bank 2011. 5. FINDINGS OF THE VERIFICATION METHODS This section presents the results of the four verification mechanisms we have been describing. Unless mentioned, the data have been extracted from the national database (for practical reasons, an Excel version of this database was used rather than the official web-based version). 5.1. What are the results of the quantity verification? Quantity verification in hospitals and in health centers is based on different indicators, and we will present data separately for these two types of facilities. The formula we used to calculate the differences for each facility is the following: (Verified 12 quantity − Declared quantity) / (Declared quantity) A negative difference therefore means that the facility overestimated its performance. We decided to ignore differences greater than 100 percent because they are probably mostly due to transcription errors. The arithmetical average of the differences gave us an idea of their general tendency, but it does not give a satisfactory estimation of their size because it aggregates positive and negative differences. This is why we also calculated the average of the absolute values of the differences: negative differences have been counted as positive ones, so that they do not cancel the actual positive differences. In health centers, it was possible to gather data on declared and verified quantities in every facility in the country for the January to August 2012 period. Before this date, data were compiled in a way that makes this calculation impossible. As 565 health centers are enrolled in the program, for 8 months and 19 indicators, this translates into a total of 85,580 possible observations. All services are not provided by all facilities every month, and some inconsistent observations have been ignored. 13 The resulting total number of observations is 50,790. The results are presented in table 1.6. 12. As mentioned above, the terminology in use in Burundi can lead to misunderstandings between verification and validation. We decided, in the rest of this document, to abandon the term “validated quantity” (unless mentioned), and to name “verified quantity” the data based on which payment is made (data verified by the verification unit and validated by the validation unit of the CPVV). 13. Most of the missing observations are lacking because services are not provided by the facilities, rather than because data was inconsistent. For example, few health centers in Burundi provide ART, which explains the low number of observations for this indicator. Table 1.6 Differences between Services Declared by Health Centres in the Monthly Declaration Form and Services Paid by PBF after the Verification by CPVVs (January to August 2012) Average difference Average of the abs. 14 N (%) val. of the diff. (%) Consultation (child) -2 4 4,085 Consultation (adult) -1 2 4,085 Observation day (child) -5 8 3,802 Observation day (adult) -4 8 2,896 Small surgery -6 11 3,987 Reference -12 14 3,424 Completely vaccinated child -3 4 4,065 Anti-tetanus vaccination 2–5 0 3 4,055 Pregnant woman under ART (MTCTP) -5 6 375 Newborn under ART (MTCTP) -6 7 288 HIV VCT -2 2 3,737 New ART patient -7 8 253 Patient under ART since 6 months -12 12 245 STI -2 6 3,950 Tuberculosis detected -1 1 599 Tuberculosis treated -5 5 918 Consultation pregnant woman -5 7 4,062 Normal delivery -1 2 3,822 Family planning -1 2 3,458 Implant or DIU -1 2 2,798 Postnatal consultation -5 6 3,784 Prenatal consultation -2 3 4,074 Total -4 5 50,790 Source: Database cellule technique du FBP (CT-FBP), MoH Burundi, 2012. Note: Data is from all health centres contracted in Burundi from January to August 2012 The average difference between declared and verified services in health centers was -4 percent between January and August 2012, which means that health centers have globally overestimated their performance. The average of absolute values of differences was 5 percent. It must be noted that the reasons for these differences are diverse (miscalculation, insufficient identification of patients in the registries, services not matching the exact definitions of indicators) and that they are not necessarily linked to fraud. The differences are not homogenous among indicators and facilities. Table 1.7 describes the distribution of errors between accurate, underestimated and overestimated declarations. 14. Note that N does not report the number of services declared (for example, number of consultations) but the number of declarations made (each health center is supposed to declare the number of consultations once each month). Table 1.7 Distribution of the Declarations between Accurate, Overestimated and Underestimated Declarations as Compared to Services Paid after the Verification by CPVVs (January to August 2012) Overestimation Underestimation Accurate overest. Average Average decl. underest N decl. overest. underest (%) decl. (%) (%) (%) (%) Consultation (child) 22 54 -5 25 21 4,085 Consultation (adult) 30 49 -2 21 19 4,085 Observation day (child) 44 40 -16 16 7 3,802 Observation day (adult) 69 23 -25 8 3 2,896 Small surgery 53 31 -28 16 5 3,987 Reference 70 26 -48 3 1 3,424 Completely vaccinated child 67 23 -13 10 5 4,065 Anti-tetanus vaccination 2–5 68 16 -8 16 8 4,055 Pregnant woman under ART (MTCTP) 91 8 -74 1 0 375 Newborn under ART (MTCTP) 91 8 -81 1 1 288 HIV VCT 71 21 -9 8 5 3,737 New ART patient 89 10 -71 1 1 253 Patient under ART since 6 months 82 17 -73 0 0 245 STI 72 18 -21 10 4 3,950 Tuberculosis detected 97 2 -53 1 0 599 Tuberculosis treated 93 6 -74 0 0 918 Consultation pregnant woman 44 40 -14 17 8 4,062 Normal delivery 85 11 -12 4 2 3,822 Family planning 58 30 -4 12 8 3,458 Implant or DIU 90 6 -24 4 2 2,798 Postnatal consultation 78 18 -28 4 2 3,784 Prenatal consultation 67 23 -10 9 8 4,074 Total 69 22 -19 9 4 50,790 Source: Database cellule technique du FBP (CT-FBP), MoH Burundi, 2012. Note: Data from all health centres contracted in Burundi between January and August 2012 Between January and August 2012, in 69 percent of health center declarations, there was no error, which means that the amount declared by the health center at the beginning of the verification process was the same as the one that was paid after the verification process was completed. The 5 percent average error that was noted in table 1.6 is therefore due to only 31 percent of the declarations. Among these 31 percent of inaccurate declarations, more than two-thirds are overestimations: during the observation period, 22 percent of the declarations were overestimated (average overestimation was 19 percent), while 9 percent were underestimated (average underestimation was 4 percent). In hospitals, it was possible to gather data on declared and verified quantities in every facility in the country for the January to July 2012 period, which yields a total of 8,400 possible observations for 50 hospitals and 25 indicators. As in the case of health centers, all services are not provided by all facilities every month, and some inconsistent observations were ignored; our total number of observations is 6,793. The results are presented in table 1.8. Table 1.8 Differences between Services Declared by Hospitals and Services Paid by PBF after the Verification process is complete (January to July 2012) Average difference Average of the abs. N (%) val. of the diff. (%) Consultation (child) -3 4 355 Consultation (adult) -2 3 355 Consultation (pregnant woman) -5 8 346 Counterreference -8 9 321 Major surgery -2 3 275 Small surgery -6 8 343 Normal delivery -1 2 348 Caesarean section 0 0 338 Complicated delivery -1 2 341 Hospitalization day (child) 0 3 348 Hospitalization day (adult) 0 3 348 Pregnant woman under ART (MTCTP) -2 3 251 Newborn under ART (MTCTP) -2 3 244 HIV VCT -1 2 346 New ART patient -2 2 261 Patient under ART since 6 months -5 6 259 STI -2 9 274 Tuberculosis detected -1 2 231 Circumcision -2 4 251 Implant or DIU 1 1 125 Family planning -2 4 209 Family planning (surgery) -1 1 144 Postnatal consultation -7 9 207 Prenatal consultation -4 7 243 Total -2 4 6,763 Source: Database cellule technique du FBP (CT-FBP), MoH Burundi, 2012. Note: Date from all hospitals contracted in Burundi between January and July 2012. The average difference between the declaration by hospitals and verification by CPVVs was -2 percent between January and July 2012, which means hospitals globally overestimated their performance. As with health centers, the reasons for the errors are not necessarily linked to fraud (indicator definitions, patient identification), and the average size of the errors hides important differences between hospitals. Table 1.9 shows the distribution of errors between accurate, underestimated and overestimated declarations. Table 1.9 Distribution of Declarations between Accurate, Overestimated and Underestimated Declarations Compared to Services Paid after Verification by CPVV (January to July 2012) Accurate Overestimation Underestimation N decl. (%) overest. Average underest. Average decl. (%) overest. decl. (%) underest. Consultation (child) 11 60 -6 29 3 355 Consultation (adult) 18 59 -4 23 4 355 Consultation (pregnant 29 47 -14 24 6 346 woman) Counterreference 60 36 -23 5 10 321 Major surgery 78 14 -19 8 6 275 Small surgery 47 40 -17 13 9 343 Normal delivery 69 22 -6 8 4 348 Caesarean section 92 6 -7 1 3 338 Complicated delivery 78 14 -14 8 7 341 Hospitalization day (child) 14 43 -4 43 4 348 Hospitalization day (adult) 26 39 -4 35 4 348 Pregnant woman under ART 93 6 -43 1 43 251 (MTCTP) Newborn under ART (MTCTP) 94 4 -57 2 19 244 HIV VCT 57 31 -6 13 3 346 New ART patient 93 5 -43 2 16 261 Patient under ART since 6 86 13 -40 1 56 259 months STI 66 20 -25 14 25 274 Tuberculosis detected 96 3 -51 1 75 231 Circumcision 89 8 -39 3 33 251 Implant or DIU 95 3 -12 2 55 125 Family planning 70 24 -11 6 19 209 Family planning (surgery) 99 1 -38 0 n.a. 144 Postnatal consultation 73 23 -33 4 25 207 Prenatal consultation 57 32 -18 12 14 243 Total 62 26 -13 12 7 6,763 Source: Database cellule technique du FBP (CT-FBP), MoH Burundi, 2012. Note: Data from all hospitals contracted in Burundi between January and July 2012 Between January and July 2012, there was no error in 62 percent of hospital declarations, which means that the amount declared by the hospital at the beginning of the verification process was the one that was paid after the verification process was completed. The 4 percent average error that was described in table 1.8 is therefore due to only 38 percent of the declarations. Among these 38 percent, more than two-thirds are overestimations: during the observation period, 26 percent of the declarations were overestimated (average overestimation was 13 percent), and 12 percent were underestimated (average underestimation was 7 percent). There is general agreement among interviewed people that conscious fraud is rare in health centers as well as in hospitals. This is confirmed by the various reports available (MoH 2011a, MoH 2012, HDP counter-verification reports). Some of the interviewed CPVV members reported dishonest behaviors (for example, they discovered during verification visits that some providers tend to report patients who come to the facility for follow-up as new visits, to increase their income), but this is, according to them, very rare. They consider that most errors presented in the above tables result from unintended mistakes: they are due to poor comprehension of indicators, manipulation errors, and errors in counting. Data presented in tables 1.6 to 1.9 seem to confirm the statements made by interview participants. The highest level of error is found for indicators with a high rate of occurrence (for example, outpatient visits in health centers), that is to say, for indicators where the risk of error in counting is greater. Another factor that seems related to higher error is the definition of the indicators: when the definition is complicated, facilities are more likely to count a service that does not match the definition and that will not be validated by the verification team (for example, consultation for pregnant women in health centers: only consultations related to pregnancy must be counted, but many health centers record consultations given to pregnant women for other reasons). Although this situation is not linked to fraud, it is surprising that after two years of PBF implementation in the country, the level of unintended mistakes is still so high. It would have been interesting to study the data for previous years, but this was unfortunately not possible. As explained above, the data compilation method for these calculations has only been implemented since 2012. 5.2. What are the results of the technical quality assessment? During the 2010 to 2012 period, the average technical quality score for health centers was 70 percent, 77 percent for district hospitals, and 74 percent for national hospitals. The results of hospitals are better than those of health centers; however, according to interviewed people, the conclusions drawn from this observation are related more to the assessment methodology than to the performance of facilities themselves. Figure 1.3 shows the evolution of the scores since PBF was rolled out to the whole country for the three categories of health facilities. Figure 1.3: Evolution of the Average Technical Quality Scores in Health Centers, District Hospitals and National Hospitals Contracted in Burundi (January 2010 to November 2012) 100% Modification of the quality 90% assessment 80% checklists 70% 60% Health centers 50% District hospitals National hospitals 40% 30% 20% 10% 0% 2010 Q1 2010 Q2 2010 Q3 2010 Q4 2011 Q1 2011 Q2 2011 Q3 2011 Q4 2012 Q2 2012 Q3 Source: Database cellule technique du FBP (CT-FBP), MoH Burundi, 2012. This graph shows that the results of the technical quality assessment improved for health centers until the second quarter of 2012, and for hospitals until the fourth quarter of 2011. Performance then diminished because of changes in the technical quality assessment checklists (major changes for hospitals and minor changes for health centers), for which health care providers were not prepared (for example, introduction of patient record analysis in the hospital assessment checklist). They soon recovered their earlier scores, indicating that there is a greater focus on items that are measured than on aspects that are not measured. Some people interviewed pointed out some limits of the technical quality assessment. They especially mentioned that it is difficult to maintain the level of technical quality between two evaluations: it is very likely that health facilities, knowing the date or the period of the assessment, prepare themselves accordingly. Moreover, as the technical quality assessment for hospitals is implemented by peers, this probably creates a measure of complacency. Finally, we should note that the technical quality assessment checklists, however modified, are still very focused on the conditions in which the health care is provided, and not on the care itself. In summary, the technical quality assessment might have encouraged providers, especially at the beginning of PBF implementation, to improve their behavior. However with the passage of time, gaming possibilities — opportunities for providers to play with the rules to improve their score without modifying their real quality — can emerge. The MoH must look for mechanisms to curb this tendency. Some possibilities include the regular modification of assessment checklists or generalization of unannounced visits, which were implemented at the beginning of 2013 after data collection for this study was complete. 5.3. What are the results of household surveys? As seen in section 4.3, the results of the household survey include three types of data related to PBF: • Existence: Could the patient who has been randomly selected in the facilities’ registries be found in the community? • Confirmation: Does the patient confirm that he/she actually visited the facility for the relevant service? • Satisfaction: Was he/she satisfied with care delivered? The score for these three indicators represent what is known as the “subjective quality score.” Between 2010 and 2012, this score raised on average from less than 50 percent to more than 75 percent for health centers, and from less than 40 percent to approximately 60 percent for hospitals. But this aggregated progression does not document the evolution of the proportion of potential “phantom-patients” who could be added by facilities in their registries to maximize their income. As stated above, the disaggregated data on household surveys is not available at central level yet. Only the combined score for the three elements of the household survey (“subjective quality score”) is recorded in the national web-based database. Hence, for the purpose of this study, CPVVs were asked to capture the disaggregated results in an Excel worksheet. Out of the 17, 13 CPVVs submitted data for 2011 and for the first semester of 2012. While not a random sample, the data that has been gathered is informative. Figure 1.4 shows the evolution of the proportion of patients that could not be found in the community (existence) and that did not confirm having received care (confirmation) in 389 health centers of the 13 provinces of the sample (that is, 75 percent of the total number of health centers in the country). Figure 1.4 : Proportion of Patients in Household Surveys Who Are Nonexistent or Nonconfirmed in Health Centers of 13 Provinces (first quarter, 2011 to first semester, 2012 15) 10% 9% 8% 7% 6% Non-existence 5% 4% Non- 3% confirmation 2% 1% 0% 2012 S1 2011 Q1 2011 Q2 2011 Q3 2011 Q4 Source: Information from CPVVs provided by Cellule technique du FBP (CT-FBP) MoH Burundi, 2012. In the health centers of the 13 provinces of the sample, the proportion of patients that could not be located in the community during household surveys varied from 8.6 percent to 6.9 percent between the first quarter of 2011 and the first semester of 2012, with a slight downward trend. The average, however, stays higher than the 5 percent threshold above which health centers lose 10 percent of the overall quality score. The proportion of health facilities for which the percentage was higher than 5 percent decreased from more than 50 percent in the first quarter of 2011 to 40 percent in the first semester of 2012. Among the patients who could be found, the proportion of those who did not confirm having been treated at the health center varied from 3.2 percent to 1.6 percent, with the same downward trend. The average in this case is lower than the 5 percent threshold above which health centers lose another 10 percent of the overall quality score. Figure 1.5 shows the evolution of the proportion of patients who could not be found in the community (existence) and that did not confirm having received care (confirmation) in the 38 hospitals of the 13 provinces of the sample (that is, 84 percent of district hospitals in the country). 15. As explained above, the schedule of the household survey used to be quarterly, but became semiannual starting 2012. Figure 1.5 Proportion of Patients Not Found (Nonexistence) and Not Confirmed (Nonconfirmation) in 38 Hospitals, 13 Provinces, First Quarter, 2011 to First Semester, 2012 18% 16% 14% 12% 10% Non-existence 8% Non- confirmation 6% 4% 2% 0% 2012 S1 2011 Q1 2011 Q2 2011 Q3 2011 Q4 Source: Information from CPVVs, provided by Cellule technique du FBP (CT-FBP) MoH Burundi, 2012. In the hospitals of the 13 provinces of the sample, the proportion of patients that could not be located in the community during household surveys varied from 9.8 percent to 15.4 percent between the first quarter of 2011 and the first semester of 2012, and contrary to what was noticed with health centers, no downward trend could be observed. The average remains much higher than the 5 percent threshold above which hospitals lose 10 percent of the overall quality score. The proportion of hospitals for which the percentage was higher than 5 percent varied between 60 percent and 80 percent between the first quarter of 2011 and the first semester of 2012. Among the patients who could be found back, the proportion of those who did not confirm having been treated at the health center varied from 5.5 to 1.4 percent, with a strong downward trend. Similar to health centers, the average in this case is lower than the 5 percent threshold above which hospitals lose another 10 percent of their overall quality score. The fact that the proportion of patients not found back is higher in hospitals than in health centers can be explained by the kind of patients who come to visit hospitals: they come from further-flung areas, possibly travelling larger distances to seek care than health center patients and thus more difficult to trace. The relatively high proportion of patients who are not found back during household surveys is a matter of concern and should be addressed seriously, but it does not mean that an equally high proportion of patients are “phantom patients.” Many reasons can explain why a patient is not located: • He/she may have been insufficiently identified at the health facility (for example, inaccurate or incomplete address. Patients even intentionally give wrong addresses to the facility). • He/she may have temporarily or permanently moved from the area, (this is especially true for areas with a high number of refugees or seasonal workers). • He/she may refuse to answer the survey. However, as stated earlier, the main concern with household surveys is not their results but their process: they omit a large number of indicators for confidentiality reasons, and their results could not be analyzed in a disaggregated fashion at central level when data for this study was collected to enable assessment and monitoring of trends in individual health facilities. 5.4. What are the results of the counterverification? HDP, the external organization implementing counterverification, gives an account of its activities in quarterly reports that were reviewed and are the source of the data presented in this section. In these reports, unfortunately, the results of the quantity counterverification in health centers were presented in an aggregated fashion (at provincial level). Such a presentation of the results has two consequences: • It underestimates the average error by aggregating the results of the two or three health centers that are randomly selected at provincial level, and by summing up positive and negative differences (under and overestimations). • It makes it impossible to analyze the evolution of the results of counter-verification over time for any individual health center that would be randomly selected more than once. Both of these weaknesses can easily be corrected in the next counter-verification reports. Table 1.10 gives the results of counter-verification over two years in health centers at provincial level. There is a maximum of 32 observations for each indicator: every province has been counter-verified twice. For each province, the formula used to calculate the differences is the following: (Provincial quantity counter-verified by HDP − Provincial quantity verified by CPVV) / (Provincial quantity verified by CPVV) Table 1.10 Difference between Provincial Number of Services Verified and the Provincial Number of Services Counterverified for Health Center Indicators Average of provincial N differences (%) Consultation (child) 0 32 Consultation (adult) 0 32 Consultation (pregnant woman) 0 32 Observation day (child) 2 32 Observation day (adult) -1 29 Small surgery 0 32 Reference 3 32 Completely vaccinated child 1 32 Anti-tetanus vaccination 2-5 -2 32 Distribution of bed nets 1 32 Sanitation construction 0 32 Pregnant woman under ART (MTCTP) 0 12 Newborn under ART (MTCTP) 0 14 HIV VCT 0 31 New ART patient 0 14 Patient under ART since 6 months 0 14 IST -1 32 Tuberculosis detected 6 18 Tuberculosis treated 1 27 Normal delivery 0 32 Family planning 0 30 Implant or DIU 0 28 Postnatal consultation 1 32 Prenatal consultation 0 32 Total 0 665 Source: HDP Reports, 2012. Note: Difference between the provincial number of services verified by the CPVVs and paid by the scheme, and the provincial number of services counter-verified by HDP for health center indicators (N) in all provinces counter-verified during the eight counter-verification rounds The results presented in table 1.10 are underestimated because they aggregate positive and negative differences. However, they show that the differences between counter-verification and verification are on average smaller than the differences between declaration and verification. Except for one indicator (tuberculosis detected), the average differences are (at provincial level) not greater than the 5 percent margin of error defined in the implementation manual. The counter-verification indicates little variation between counter-verification and verification for health centers, although it would be desirable to study the disaggregated data to have a more precise idea on this point: this would allow both a more detailed study of the results and an analysis of their evolution over time. As far as hospitals are concerned, the counter-verification reports do give disaggregated data at facility level. We could thus calculate the average differences exactly with the same methodology as we did for the results of verification presented in section 5.1, which leads to no underestimation of the level of error. Table 1.11 gives the results of the counter-verification in hospitals. There is a maximum for each indicator of 32 observations: every province has been counter-verified twice. For every hospital, the calculation formula is the following: (Quantity counter-verified by HDP − Quantity verified by CPVV) / (Quantity verified by CPVV) Table 1.11 Difference between Verification and Counter-verification for Hospital Indicators Average difference Average of the abs. N (%) val. of the diff. (%) Consultation (child) -10 21 32 Consultation (adult) -12 18 32 Consultation (pregnant woman) 0 27 32 Counterreference -65 77 31 Major surgery -18 26 29 Small surgery -2 27 32 Normal delivery -4 12 32 Caesarean section -2 3 31 Complicated delivery -28 37 30 Hospitalization day (child) -13 20 32 Hospitalization day (adult) -12 18 32 STI 50 74 30 Tuberculosis detected 22 32 29 Tuberculosis treated -46 63 7 Implant or DIU 4 21 17 Family planning -9 16 18 Family planning (surgery) -9 41 22 Postnatal consultation -19 27 24 Prenatal consultation -35 42 23 Circumcision 8 66 7 Total -9 31 522 Source: HDP Reports, 2012. Note: Difference between verification by CPVVs and counter-verification by HDP for hospital indicators in all hospitals counter-verified in Burundi during the eight counter-verification rounds. In hospitals, the differences between verification and counterverification data are large and systematic. The quantity performance is overestimated by CPVVs on average by 9 percent, the average of the absolute values of the differences is 31 percent, and the average difference for all indicators but one (caesarean sections) is greater than the 5 percent margin of error defined in the implementation manual. If the sanctions determined in this manual were implemented, the subsidy to CPVVs would have been diminished. Seven hospitals have been counter-verified twice between 2010 and 2012: they were randomly selected for both counter-verification rounds. This allows us to analyze the evolution of the results of counter-verification for this subsample, to detect a possible learning effect (CPVVs are expected to improve themselves and the level of error is expected to diminish). Table 1.12 presents the results of this analysis. There are 20 counter-verified indicators, which for seven hospitals and two counter-verification rounds yields a total number of possible observations of 280. Because all services are not provided by all hospitals every month, our total number of observations is only 103. Table 1.12 Error by CPVVs As Detected by Counterverification in Seven Hospitals Selected from Two Counter- verification Rounds Average Average Difference N % error round error round (%) 1 (%) 2 (%) Indicators for which the level of error 58 56 -6 -21 14 increased between rounds 1 and 2 Indicators for which the level of error 45 44 -26 -12 -13 decreased between rounds 1 and 2 Total 103 100 -15 -17 2 Source: HDP Reports, 2012. Note: Hospitals randomly selected in both counter-verification rounds (seven hospitals). Between round 1 and 2 of the counter-verification, for indicators that could be counter-verified twice in the same hospital, the average level of error increased from an average 15 percent overestimation to an average 17 percent overestimation. It should be noted that the average level of error in the sample of hospitals that have been counter-verified twice is lower than the results for the whole country presented in table 1.11. For 56 percent of these indicators, the level of error was higher in the second round than in the first round (average increase was 14 percentage points). For the remaining 44 percent, the level of error was lower in the second round than in the first round (average decrease was 13 percentage points). Table 1.12 thus shows that there was no learning effect, and that CPVVs did not improve their performance in verifying the quantity of hospital services between counter-verification rounds 1 and 2. These results show that the performance of CPVVs in verifying hospital quantity is insufficiently rigorous, but according to people interviewed for this study, the differences that they highlight can largely be attributed to the absence of standardized registers at hospital level. Hospitals build their registers themselves, which leads to great variability in the way results are reported. Also, counter-verification applies the greatest rigor, and is therefore sometimes obliged to cancel a whole indicator. Another explanation is that counter-verification happens long after care has been delivered (six months on average): registers in which services have been reported may not be accessible any longer (for example, they may be archived in a room for which an absent staff holds the key). One MoH mission, carried out after a hospital counter-verification, found, for instance, that the reason for the large discrepancy at this hospital was that three registers could not be found by HDP: the counter-verification therefore could not count or include services recorded in those registers, which the CPVV verification had included, rendering the level of error artificially high. These reasons explain the results presented in table 1.11, which are negative on average (overestimation of the performance by the CPVVs). They also explain why the MoH preferred not to implement the sanctions against CPVVs defined in the PBF implementation manual. It can however be argued that these sanctions could incite CPVVs to demand more rigor or better management from hospitals, to improve their own results and ensure registers are available. Hence, it seems desirable to consider implementing such sanctions with clear explanations of what CPVV should demand of hospitals. Counter-verification is not limited to the verification of quantity. It also re-performs the technical quality assessments done by BPS and BDS in health centers, and by peers in hospitals. In counter-verification reports, the results are compared to the results of the preceding quarter. Given that counter-verification generally happens long after verification, technical quality in facilities may have varied in the facilities. This is why in the framework of this study, we preferred to compare the results of the technical quality assessment performed by the counter- verification teams to those of the closest assessment performed by the verification teams (be it before or after counter-verification). This comparison still has problems, because even if the time lag between verification and counter-verification is reduced, the technical quality may have changed in health facilities. However, we estimate that this comparison is more adapted than the one presented in counter-verification reports. The results are presented in table 1.13. 16 For every facility, the following formula has been used to calculate the difference: (Score established by HDP − Score established by BPS, BDS or peers) / (Score established by BPS, BDS or peers) Table 1.13 Difference between Technical Quality Assessment and Counterverification in All Hospitals and Health Centers from Eight Counter-Verification Rounds Average With Average With Average difference overestimat overestimat underestim underestim N 17 18 (%) ion (%) ion (%) ation (%) ation (%) Health centers -11 79 -20 21 24 101 Hospitals -17 84 -24 16 20 32 Source: Author, comparing HDP Reports with database cellule technique du FBP (CT-FBP), MoH Burundi, 2012. Note: Difference between technical quality assessment performed by the BPS, BDS, or peers and counter-verification performed by HDP in all hospitals and health centers counter-verified in Burundi during the eight counter-verification rounds. When compared to HDP results, the technical quality as assessed by BPS, BDS, or peers is overestimated by 11 percent in health centers and by 17 percent in hospitals. This conclusion must be nuanced because, as stated above, both evaluations were made at different points in time. However, this overestimation is systematic (it happens in 79 percent of counter-verified health centers and in 84 percent of counter-verified hospitals), which suggests that the results presented in table 1.13 cannot be explained solely by the time difference between verification and counter-verification. This overestimation can be explained by the rigor applied by counter-verification teams, but interview participants also pointed out institutional factors: BPS and BDS are above health centers in the MoH hierarchy, and they have no interest in highlighting their shortcomings. For hospitals, peers are likely to think that their assessment will influence the way they, in turn, are assessed by their colleagues. For health centers, these institutional issues could be partly addressed by extending (and applying) to the BPS and BDS the sanctions defined against CPVVs in the PBF implementation manual: if the income of BPS and BDS was linked to the results of the counter-verification, they could increase their level of rigor in the quality assessment. As for household surveys, the counter-verification reports do not compare their results with the surveys performed by local organizations under the supervision of the CPVVs. This is justified by the fact that the sample 16. Contrary to what happens for quantity counter-verification, the counter-verification reports present results of the technical quality assessment in health centers in a disaggregated way. We could therefore perform the same calculations for health centers and for hospitals. 17. Percentage of counter-verifications that concluded that technical quality was overestimated by BPS, BDS, or peers. 18. Ibid. of interviewed patients is not the same for both surveys: the results are by nature different. Under these conditions, one wonders why the counter-verification performs household surveys at all; this is a costly activity that necessitates hiring another local organization to re-perform the work that has already been done. It would be preferable either to exclude the household surveys from the counter-verification, or to counter-verify them with the same sample that has been used during verification. 5.5. What are the findings used for? The findings of the verification system are used primarily for paying providers: the results of quantity verification are used for paying monthly quantity subsidies, and technical quality assessment combined with household surveys can be translated into a quarterly top-up subsidy or sanction. As for quantity verification, we tried to assess the amounts saved by the verification by comparing the amounts that would have been paid in the absence of verification (declared amounts) to those that have actually been paid. This comparison is theoretical for two reasons: • Verification, especially frequent and comprehensive verification as done for quantity in Burundi, has a deterrent effect on fraud: it is likely that declared amounts would be much greater in the absence of verification. • To achieve this result, we had to calculate a theoretical declared amount; the declared amount is not registered in the databases. Only declared quantities are available, but it was not possible to use these to calculate the exact monetary value of declared services, as the monetary value of each indicator varies between provinces — the discrepancy exists to attract health staff to work in remote areas. Moreover, monetary values can vary over time. Hence, we had to consider that indicators had the same monetary value in every province: this assumption is not true and leads to small underestimation of the total monetary value of declared and verified quantities, but it has little impact on the percentage of the budget that is saved since it affects both declared and verified amounts. The results of these calculations are presented in table 1.14. Table 1.14 Estimation of the Amounts Saved Due to Quantity Verification (in US$). Health centers Hospitals Total Estimation of declared amounts $9,695,185 $7,179,405 $16,874,590 Verified amounts $9,480,727 $7,098,941 $16,579,668 Estimation of the saved amounts $214,458 $80,464 $294,922 % saved 2 1 2 Source: Author, using database cellule technique du FBP (CT-FBP), MoH Burundi, 2012. Note: Extrapolations for year 2012 based on available data, January–August for health centers and January to July for hospitals. According to our calculations, quantity verification saved about 2 percent of the amount paid to health centers and 1 percent of the amounts paid to hospitals. These percentages are surprisingly low given the level of error shown in tables 1.7 and 1.9. This can be explained by the fact that positive and negative errors cancel each other’s effects. It is another indication of the importance of underestimation of performance by providers. However, these percentages are also different from the error percentages presented in tables 1.6 and 1.8 that sum up overestimations and underestimations. This can easily be understood because in both these tables, every declaration has the same weight, regardless of the number of services it represents and thus of its monetary value. In table 1.14 on the contrary, results are weighed by the quantity declared and by the amount of the subsidy that is attached to each indicator. For example, if a health center declares that it attended 11 deliveries and if only 10 are verified by the CPVV, the overestimation will be 10 percent, exactly the same as another health center that would have attended 22 deliveries but for which only 20 would be verified. But the savings due to the quantity verification in the first health center will be half as much as the second one. The results of PBF verifications are also used to sanction health care providers. This was rare during the first months of PBF implementation in Burundi, but financial sanctions are increasingly being applied. As described earlier (see table 1.3), if any difference greater than 5 percent between declared and verified quantity is found for an indicator, part of the funds that the facility should have earned for this indicator are cut. In the framework of these sanctions, the difference that is taken into account is not the difference between the quantity as self- assessed by the facility (named “declared” quantity in the facilities’ invoice), and the quantity as assessed after the verification process is complete (named “validated” quantity in the facilities’ invoice), but the difference between “declared” quantity and the quantity that is reported in the registries, irrespective of the exact definitions of the indicators (named “verified” quantity in the facilities’ invoice). 19 Figure 1.6 presents the proportion of declarations that were sanctioned between January and August 2012 20 (based on the difference between “declared” and “verified” quantities), as well as the proportion of declarations that would have been sanctioned if the difference between “declared” and “validated” data had been taken into account instead of the one between “declared” and “verified” data. 19. See section 4.2 for further elaboration on “declared,” “verified,” and “validated” quantities. 20. Between January and July 2012 for hospitals. Moreover, for health centers, data on verified quantities for June were missing, and this month could not be taken into account. The total number of declarations considered by figure 1.6 is 44,291 for health centers and 6,762 for hospitals. Figure 1.6 Proportion of Declarations Sanctioned between January and August 2012 18% 16% 16% % facilities 16% sanctonned based on the 14% difference between 12% "declared" and 11% "verified" 10% quantities 10% 8% % facilities sanctonned if 6% sanctions had been based on 4% the difference between 2% "declared" and "validated" quantities 0% centres Hospitals Health Source: Database cellule technique du FBP (CT-FBP), MoH Burundi, 2012 Note: Proportion of declaration that were sanctioned between January and August 2012 (January and July 2012 for hospitals) because the difference between “declared” and “verified” data was greater than 5 percent, compared with the proportion of declarations that would have been sanctioned if sanctions had been based on the difference between “declared” and “validated” data. Between January and August 2012, 11 percent of declarations made by health centers and 10 percent of declarations made by hospitals were sanctioned because the difference between “declaration” and “verification” was greater than 5 percent. These proportions would have been much higher if “validated” data had been taken as the basis of these sanctions instead of verified data (16 percent of declarations made by health centers and hospitals would then have been sanctioned). This option would have been more relevant from the PBF point of view, since validated data determine payment. Therefore, the sanction system should in the future be structured to take into account the differences between “declared” and “validated” data instead of the difference between “declared” and “verified” data. Unfortunately, it has not been possible to calculate the amounts saved by the PBF program due to these sanctions, nor the amounts that would have been saved if sanctions had been based on validated data; the available databases do not register this information. Since the first quarter of 2011, a quality financial sanction was also introduced for facilities whose overall quality score (technical quality score and household survey score) is less than 50 percent. Table 1.15 presents the number of facilities for which this was the case. Table 1.15 Number of Health Facilities Financially Sanctioned for Quality Since the First Quarter of 2011 Health centers Hospitals Nb. Share (%) Nb. Share (%) 2011 Q1 33 6 1 2 2011 Q2 12 2 1 2 2011 Q3 33 6 1 2 2011 Q4 6 1 0 0 2012 Q1 6 1 9 18 2012 Q2 3 1 2 4 Average 16 3 2 5 Source: Database cellule technique du FBP (CT-FBP), MoH Burundi, 2012 Before analyzing these sanctions, one should note that they are not entirely due to misreported information: 60 percent of the score on which they are based assesses technical quality, and 20 percent assesses user satisfaction. Only 20 percent assesses the actual receipt of services; the main reason for these sanctions is underperformance. However, in the absence of disaggregated information on sanctions linked to “phantom- patients” one can only rely on the overall quality scores. On average, 3 percent of health facilities have been financially sanctioned every quarter because their overall quality score was less than 50 percent. This percentage has been consistently decreasing since the first quarter of 2011, when these financial sanctions were introduced (except for the first quarter of 2012 for hospitals, when the new technical quality checklist was introduced). On average, the quality financial sanctions represent 2 percent of the total amount of the quality incentive for health centers, and 4 percent for hospitals (the quality incentive represents between 10 and 15 percent of the total incentive). These amounts could be different if the sanctions linked to “phantom-patients” (as detected by household surveys — about 7 to 9 percent of patients not found back in health centers, and 10 to 15 percent in hospitals) were separate from sanctions linked to technical quality or user satisfaction. Moreover, as discussed above, sanctions should apply against CPVVs when HDP counter-verification findings are different from CPVV findings by more than 5 percent. The modalities and amounts of these sanctions are defined in the implementation manual, but we could not calculate the amounts that would have been saved had they been implemented: as explained earlier (see part 4.4), the counter-verification reports do not provide the differences between verification and counter-verification at health center level, which makes it impossible to calculate hypothetical sanctions. In addition to these sanctions linked to the facilities’ financial incentives, the verification system can detect problems that can lead to administrative sanctions. Table 1.16 shows the number of contract terminations observed in 2010 and 2011 for facilities with a principal contract, facilities with a secondary contract, and local organizations. Table 1.16 Number of Contract Terminations in 2010 and 2011 for Facilities with a Principal Contract, Facilities with a Secondary Contract, and Local Organizations 2010 2011 Contract termination with a facility 0 0 with a principal contract Contract termination with a facility 2 1 with a secondary contract Contract termination with a local 11 6 organization Source: Cellule technique du FBP (CT-FBP), MoH Burundi, 2012. This table shows that contract terminations with health facilities are rare they are nonexistent with facilities with a principal contract. Instead of implementing hard sanctions, the PBF system in Burundi supports facilities, so that they can improve their results. The system takes advantage of the fact that regulation bodies at intermediate and operational levels (BPS and BDS), as members of the CPVV, are strongly involved in the validation of results, and can act to solve discrepancies in data. Usually, if repeated errors are noticed, recommendations are made by the CPVV, further investigations are carried out, and the provincial and district health offices try to find a way, in collaboration with the facility, to improve the quality of data. For example, district health offices can check registers during their monthly supervision visits if the CPVV verification unit reports that they have trouble identifying patients. It should be emphasized that contract termination can be problematic for the health system as a whole in terms of financial accessibility: the PBF system also finances the removal of user fees for pregnant women and children. If a contract is broken with one of the providers, the latter will have to charge the population. The policy toward local organizations implementing the household survey is different: contract terminations with them are more frequent, and usually motivated by substandard conduct of members. This can be explained by lower capabilities of their members, but also by the fact that they are not providing care that is vital for the population: terminating their contract raises fewer problems, and it is easier to find other organizations to perform the job. Sanctions against them, however, became less frequent in the second year of implementation, which could be due to a learning effect or to hiring better organizations. In summary, sanctions still have a marginal impact in the PBF system in Burundi: • Quantity sanctions apply to only 16 percent of declarations, generally (in 92 percent of the cases for health centers and 94 percent for hospitals) they are due to errors that are smaller than 20 percent, hence not necessitating suppression of the complete subsidy for the indicator (as described in table 1.3). • Quality sanctions are only implemented against 3 percent of health centers and 5 percent of hospitals every quarter. • Sanctions against CPVVs are not applied. • Administrative sanctions are rare. This illustrates once more that the Burundian verification system is an internal verification system rather than an independent one; it focuses on educational aspects of the process over its punitive aspects. 6. VERIFICATION COSTS In its 2011 report (MoH 2012), the CT-FBP calculates that payment to providers amounts to 88 percent of the total cost of the PBF scheme, but its estimation of the latter omits a number of items affecting cost: salaries of civil servants working in CPVVs and in the CT-FBP, technical assistance to the CT-FBP, donor contributions to running costs of CPVVs, depreciation of investments. In table 1.17, we tried to reconstitute most of these costs for year 2011. Table 1.17 Estimation of the Verification Cost of PBF for 2011 US$ % Health centers $10,300,743 45 Hospitals $7,675,419 33 BPS and BDS $1,357,278 6 Total payment to providers $19,333,440 84 CT-FBP (including technical assistance) $581,787 3 CPVV $978,601 4 Counterverification $281,108 1 21 Technical assistance at province level $1,393,443 6 Local organizations $344,970 1 Capacity building $113,697 0 Verification cost $3,693,605 16 Total cost $23,027,045 100 Source: Author, using information from annual report cellule technique du FBP (CT-FBP), MoH Burundi, 2011. Note: Estimation excludes depreciation of investment and part of the technical assistance at provincial level. These costs show that verification costs are around 16 percent of total PBF expenditures. This is still an approximation, because of the following: • We could not estimate depreciation of investment. • We could not estimate some part of the technical assistance at provincial level. • Some costs included in the verification costs are not entirely dedicated to verification and could not be disaggregated (the CT-FBP is also in charge of the general management of the scheme, CPVVs are also in charge of signing contracts). However, this figure can be compared to the verification costs of pilot PBF projects in Burundi, which amounted to between 25 and 30 percent of the total budget according to Cordaid estimates. Rolling out PBF at national level seems to have yielded substantial economies of scale, but costs can still be rationalized. Of the total budget (that is, 38 percent of the verification costs), 6 percent is currently allocated to technical assistance at province level, that is, to capacity building of CPVVs by the NGOs that implemented the pilot PBF projects. Given the 21. Excluding technical assistance provided by donors such as the European Union or the Belgian cooperation, for which it has not been possible to distinguish between PBF technical assistance and the one that had a more general purpose. current debates on the actual services rendered by these NGOs (see section 4.1), their cost-effectiveness and alternative use of this technical assistance budget could be studied. It should also be noted that the total budget for verification is much greater than the amount saved from quantity verification (about $300,000 in 2012, see table 1.14) or from quality assessment. However, verification also has a deterrent effect, and the amount saved cannot be adequately estimated nor directly compared to the amounts spent on verification. Moreover, as described above, the monetary value of all sanctions could not be calculated, and since some sanctions are not applied, this results in smaller amounts saved. Lastly, verification contributes to the accuracy of the data in the HMIS and its subsequent use for evidence-based decision making as well as a mechanism to focus all facilities and actors on results. Hence, the contribution of verification is not only in the amount saved. 7. LESSONS LEARNED The scaling-up of PBF to the whole country was (and still is) a major challenge for Burundi. In shifting from input- based financing to output-based incentives, PBF is gradually modifying the whole health system by increasing provider autonomy, separation of functions, and transparency. The very existence of the verification process is a key improvement of the governance of the health system. Verification forces providers to open their doors to external scrutiny (although this usually happens in a hierarchical context), which is in the interest of both providers and patients. This could have been felt as a control and disregarded by providers, but testimonies from verification teams and providers show that there is no or little tension between verifiers and providers: verification is mostly seen as an incentive for providers to improve the quantity and quality of their care. Verification teams testify that their work has induced change in the practices of providers. For instance, more attention is paid to the proper management of registers (although considerable progress is still to be made, as described earlier): providers know that any patient that cannot be identified in the registers can result in a lower income (due to the provision of quantity or quality top-up subsidies). In the long run, this will improve the HMIS. Moreover, many PBF actors claim that the quality of care has improved in Burundi since PBF was scaled up (Cordaid, EU, WB, WHO 2012), thanks to both technical quality assessment and household surveys (where patient satisfaction is 50 percent of the score). This study found that the original verification model chosen by Burundi, in which MoH participation is key, made it possible to use the process as an educational tool for providers: the regulator takes an active part in the verification system (the BPS and BDS are preeminent members of the CPVV validation unit, and they are in charge of the technical quality assessment), which greatly helps it to improve its own performance. Capacity building is prioritized over sanctions as a problem solving method. This allows greater ownership of the process by providers as well as by the regulator. Any RBF verification system needs to balance priorities for transparency, independence, integration, and rigor (Ergo and Paina 2012): Burundi has chosen an original method, which is based on strong involvement of the MoH, but also allows civil society to play a role. This verification method is evolving: it first laid the emphasis on supporting contracted health facilities rather than on punishing them, but it gradually introduced firmer sanctions. It is however still based more on dialogue than on sanction. This being said, numerous aspects of verification can be improved in Burundi. First, in spite of the relatively low cost of verification seen in section 6, there is room for cost reduction. For example, the usefulness of the technical assistance provided by NGOs to CPVVs is disputed in the country: their contribution to the quality of the verification system depends on the skills of their staff, which, some interviewed stakeholders report, do not always match the skills required. Their cost is relatively large (6 percent of the total PBF budget, see section 6), and discussions are being held on whether their mission will be renewed in the future. On another note, analysis of the results of verification shows that the choice of a verification system that is integrated into the health system (as opposed to an independent verification) is accompanied by a measure of tolerance as the level of error is still high. Regarding quantity verification, 69 percent of the declarations in health centers and 62 percent in hospitals are accurate when compared to amounts paid at the end of the verification process, but this leaves about one-third of declarations inaccurate. When performance is overestimated, the average overestimation is still above 10 percent, while underestimations are on average greater than 5 percent. The factors that explain these errors are linked to indicator definitions, patient identification, and harmonization of data collection tools, which should have been solved after two years of PBF implementation in the country. Little attention is paid to declared data and the difference between declared and verified numbers. The penalty system introduced after one year of implementation to sanction declared data that is 5 percent greater or lower than verified data does not seem to be tough enough to solve these problems. The MoH (and especially the HMIS, in collaboration with the CT-FBP) must urgently, for every indicator with systematic errors, identify the roots of the problems and propose solutions (for example, building a nomenclature of small surgery services, modifying the tools in which services are registered, and in some cases creating standardized registers). Strengthening the financial sanctions against providers in case of inaccurate declaration can also be considered, for instance, by basing them on validated data instead of on verified data, as is currently the case. With regard to quality assessment, one of the major drawbacks of the Burundian set-up is that technical quality assessment is not implemented in every facility, and patient tracing does not encompass all indicators. First, the technical quality of subcontractors, which represent more than 20 percent of health centers, is never assessed. Moreover, some registers are excluded from household surveys for confidentiality reasons; as a result, the existence of “phantom patients” for almost half of the health center indicators and one-third of hospital indicators is never assessed. Performing the technical quality assessment in all facilities and for all indicators has a cost and raises confidentiality issues, which will need addressing. To reduce the costs of extending technical quality assessment and household surveys to more facilities and indicators, a random sampling of facilities and indicators could be considered: all facilities and indicators would have a chance of being verified, not all of them would be but none would be systematically excluded. This study also noticed that the quality assessment combines in one incentive system, elements linked to technical quality, patient satisfaction, and fraud detection. The reason for this is that the elements linked to patient satisfaction and to fraud detection are assessed by the same actors and by the same means during the household surveys. But the result is inappropriate, for at least two reasons. First, it merges the detection of “phantom patients” with other elements, which makes them less visible as shown by the fact that there is no analysis of the proportion of “phantom patients” at national level. Second, this system rewards facilities for not cheating: in the current set-up, if patients are found back and confirm that they have received care, the provider earns points and money. It would seem more consistent to link the results of the detection of “phantom patients” to the sanction system that applies when declared quantity is different from verified quantity. However, the system is currently taking a different direction: the relative proportions of “technical quality” and “perceived quality” will soon be reduced from 60 percent/40 percent to 70 percent/30 percent. While this will reduce the positive financial incentive for not cheating, it will also reduce the importance of the detection of “phantom patients” in the verification system as a whole. Our study also showed that the technical quality assessment is still highly vulnerable. It seems that providers are tempted to concentrate their efforts on the aspects of quality that are measured, without necessarily increasing the overall quality of the care they provide. Two examples illustrate this statement. First, the technical quality score of hospitals fell dramatically at the beginning of year 2012 after the technical quality assessment checklist was modified. This shows that hospitals were used to an assessment mode rather than making an effort on quality. Such modifications are still too rare; it is important that providers do not get used to a routine assessment methodology. On the contrary, the level of requirement must increase with the skills of providers. Modification in the checklist should also more regularly be enforced for health centers. The main challenge on this aspect will be to make room for the patient in the assessment, in particular by including care observation aspects. The verification process still very much focuses on the conditions in which care is delivered, rather than on care itself: there is no mystery-patient, for instance. In the whole verification process, the only occasion where the patient is present is the household survey. Progress has already been made on this aspect, with the inclusion of clinical aspects linked to the patients’ medical records in the technical quality assessment checklist, and they should be continued. It is important to remember that measuring quality is a complex activity, and that there cannot be ready-made solutions; on the contrary, constant experimentation is needed. Another example challenging the technical quality assessment is the difficulty in maintaining the level of quality between two assessments, which was pointed out by various interview participants. This difficulty is possibly linked to the fact that providers know the period, and sometimes even the date, of their assessment, and are thus able to prepare themselves. One possible solution for this would be to stop advance announcements of assessment visits to health centers, and to make them happen “randomly” during the trimester rather than in a given couple of weeks. This would modify the climate in which the technical quality assessment is done, and it would probably lose some if its educational aspect, but it would on the other hand, force providers to increase their effort to maintain quality. As far as hospitals are concerned, it seems hard to consider a shift toward unannounced visits without abandoning the peer assessment mechanism, since the peer assessment cannot be done without planning. Moreover, the hospital sector in Burundi is relatively small with a limited number of people involved, which makes surprises difficult. However, the credibility of the hospital technical quality assessment must be improved, as shown by the results of the counter-verification in this field. The Burundi verification system must find a compromise between rigor and credibility of the process on the one hand (technical quality assessed by an independent third-party organization) and its integration into the health system on the other hand (peer assessment). Counter-verification brought many positive elements to the system. In spite of some methodological problems, it showed that CPVV quantity verification in health centers was globally reliable. It should be noted that the way health center data are presented in counter-verification reports is problematic: by aggregating health centers by province, the counter-verification underestimates the level of error because it averages both under and overestimations. Moreover, it makes it impossible to analyze the evolution of the level of error over time, for those health centers that would have been selected for several counter-verification rounds. Disaggregated data, with over- and underreporting separated, are needed to assess the reliability of CPVV verification in health centers, as assessed by HDP counter-verification. Such data could also help pinpoint problems, identify error trends and outliers, and assist in performance improvement. Counter-verification results are still underutilized. They show great levels of discrepancy in CPVV quantity verification for hospitals, but this did not lead to a proportionate action against CPVVs or hospitals. They also showed high levels of discrepancy between the technical quality assessments done by BPS, BDS, and peers and the ones done by HDP; once again, this led to no sanctions. Implementing sanctions against CPVVs, BPS, and BDS linked to the counter-verification process could greatly improve the quality of the data provided by the PBF system. Moreover, it would seem relevant to clarify the role of the counter-verification. It currently has a double role of data quality assessment and of PBF implementation process follow-up, and makes recommendations that are meant to improve both the quality of data and the PBF system itself. The fact that counter-verification performs household surveys, but does not compare their results with those of household surveys performed under CPVV supervision is a vivid illustration of this ambiguity: not comparing the results is justified for methodological reasons (the samples are not the same), but does raise the question of why counter-verification performs household surveys at all? It would be preferable if counter-verification focused on the quality of data, and not on the quality of the system; the MoH indeed benefits from a strong technical assistance at central level that allows it to ensure a satisfactory follow-up. More attention to data quality is crucial, and the counter-verification’s external eye can help on this aspect. Numerous long-term development opportunities for the verification system exist beyond the short-term solutions that have been suggested above. The next step for quantity verification would, for example, lead to random sampling of health facilities rather than implementing systematic monthly verification of all facilities. The latter is very costly in time and resources that are better used elsewhere. Health facilities could then be paid on the basis of their declarations rather than on the basis of the systematic verification, as is currently the case. Given the high discrepancy between data declared by providers and verified data, noticed in this study, this may not yet be possible in the short term. When discrepancies are reduced, experimentation of this sampled verification must naturally be done very cautiously, and should be implemented first in a pilot zone before being rolled out throughout the whole country. Burundi probably has not yet reached the level of confidence in its institutions that would allow such a reform to be rapidly implemented. According to all interviewed people, the verification system in the Burundian PBF ensures a satisfactory level of fraud detection. A strong integration of the verification system inside the MoH regulatory system, combined with the existence of an independent counter-verification mechanism, ensures a degree of confidence so that most actors estimate that data is reliable, at a reasonable cost (about 16 percent of the total PBF expenses). This study shows that the discrepancy between the results before and after verification was still high. Improvements can be made by modifying the incentive system on the one hand (for example, implementing tougher sanctions), and by continuous training of CPVVs, BPS, BDS, and hospital peers on the other hand. The major challenge will be to continue to make gradual improvements to the system, to avoid transforming it into a routine exercise, and to maintain the confidence of the actors who use the data it produces. Annex 1: Bibliography Cordaid and Ministry of Health. 2011. Résultats de L’enquête Ménage et de L’enquête Qualité de Base, 2006-208- 2010, Bujumbura. Cordaid, European Union, World Bank, World Health Organization. 2012. Rapport de la 2e Revue Externe du Financement Basé sur la Performance. Ergo, Alex., and Ligia Paina. 2012. Verification in Performance-Based Incentive Schemes, Bethesda, MD: Health Systems 20/20, Abt Associates Inc. Ministry of Health. 2010. Manuel des Procédures pour la Mmise en œuvre du Financement Basé sur la Performance au Burundi, version originale, Bujumbura. _____. 2011b. Manuel des Procédures pour la Mise en œuvre du Financement Basé sur la Performance au Burundi, Version Révisée. Bujumbura _____. 2011a. Rapport de la mise en œuvre du Financement Basé sur la Performance au Burundi, avril 2010 à mars 2011, Bujumbura. _____. 2012. Rapport de mise en œuvre du FBP et de la gratuité des soins pour l’année 2011, Bujumbura. United Nations Development Program. 2011. World Development Report 2011 – Sustainability and Equity: A Better Future For All. World Bank. 2011. World Development Indicators Database. Annex 2: Quantity Declaration Forms in Health Centers and Hospitals REPUBLIQUE DU BURUNDI MINISTERE DE LA SANTE PUBLIQUE ET DE LA LUTTE CONTRE LE SIDA PROVINCE SANITAIRE DE : DISTRICT SANITAIRE DE : CENTRE DE SANTE DE : FICHE DE DECLARATION DES DONNEES MENSUELLES MOIS : ANNEE : N° Indicateur Quantité Déclarée 1 Nouvelle Consultation Curative (>=5 ans) 2 Nouvelle Consultation Curative (< 5 ans) 3 Une journée d’observation (>=5 ans) 4 Une journée d’observation (< 5 ans) 5 Petite chirurgie 6 Référence et patient arrivé à l’hôpital 7 Enfants complètement vaccinés 8 VAT 2-5 9 Femme enceinte VIH+ mise sous protocole ARV prophylactique 10 Prise en charge du nouveau né d’une femme VIH + 11 Dépistage volontaire du VIH/SIDA 12 Nombre de nouveaux cas sous ARV 13 Nombre de clients ARV suivi pendant 6 mois 14 Cas d’IST traits 15 Dépistage des cas TBC positifs 16 Nombre de cas TBC traités et guéris 17 Nouvelle consultation curative pour les femmes enceintes 18 Accouchement eutocique 19 FP: Tot. Nouvelles + Anciennes Acceptantes 20 FP: Implants et DIU 21 Consultation postnatale 22 Consultation prénatale et standard TOTAL Fait à …………………………………………… ; le …………………………………… Le Titulaire du CDS (ou son délégué)…………………………………………………….. (Nom, Prénom et signature) REPUBLIQUE DU BURUNDI MINISTERE DE LA SANTE PUBLIQUE ET DE LA LUTTE CONTRE LE SIDA PROVINCE SANITAIRE DE : DISTRICT SANITAIRE DE : HOPITAL DE DISTRICT/HOPITAL NATIONAL DE : FICHE DE DECLARATION DES DONNEES MENSUELLES MOIS : ANNEE : N° Indicateur Quantité Déclarée) 1 Nouvelle Consultation Curative par un médecin (> =5 ans) 2 Nouvelle Consultation Curative par un médecin (< 5 ans) 3 Nouvelle consultation curative d’une femme enceinte par un médecin 4 Contre référence arrivée au CDS 5 Chirurgie majeure 6 Petite chirurgie 7 Accouchement eutocique 8 Césarienne 9 Accouchement dystocique 10 Une journée d’hospitalisation pour les >= 5 ans 11 Une journée d’hospitalisation pour les < 5 ans 12 Femme enceinte VIH+ mise sous protocole ARV prophylactique 13 Prise en charge du nouveau né d’une femme VIH + 14 Dépistage volontaire du VIH/SIDA 15 Nombre de nouveaux cas sous ARV 16 Nombre de clients ARV suivi semestriellement 17 Cas d’ IST traitées 18 Dépistage des cas TBC positifs 19 Circoncision masculine 20 FP: Implants et DIU 21 FP: Tot. Nouvelles + Anciennes Acceptantes 22 PF : méthode définitive 23 Consultation prénatale 24 Consultation post natale Fait à ...................................… ; le …………………………………………….. Le Directeur de l’Hôpital (ou son délégué) ………………………………………. (Nom, Prénom et signature) Source: MoH 2011b. Annex 3: Monthly Invoices for Health Centers and Hospitals REPUBLIQUE DU BURUNDI MINISTERE DE LA SANTE PUBLIQUE ET DE LA LUTTE CONTRE LE SIDA PROVINCE SANITAIRE DE : DISTRICT SANITAIRE DE : CENTRE DE SANTE DE : FACTURE MENSUELLE PMA MOIS : ANNEE : N° Indicateur Quantité Quantité Quantité Ecart (en Ecart (en Tarif Montant (Fbu) Déclarée (a) Vérifiée (b) Validée (c) chiffre) : %) unitaire (f) g=(f*c) si écart ≤5% d= (a-b) e=d/a *100 g= (f * c)-(f*c*5%) si écart > ±5% et ≤ à ±10% g= (f *c)-(f*c*10%) si écart > ±10% et ≤ à ±20% g=0 si écart > ±20% 1 Nouvelle Consultation Curative (>=5 ans) 2 Nouvelle Consultation Curative (< 5 ans) 3 Une journée d’observation (>=5 ans) 4 Une journée d’observation (< 5 ans) 5 Petite chirurgie 6 Référence et patient arrivé à l’hôpital 7 Enfants complètement vaccinés 8 VAT 2-5 9 Femme enceinte VIH+ mise sous protocole ARV prophylactique 10 Prise en charge du nouveau né d’une femme VIH + 11 Dépistage volontaire du VIH/SIDA 12 Nombre de nouveaux cas sous ARV 13 Nombre de clients ARV suivi pendant 6 mois 14 Cas d’IST traités 15 Dépistage des cas TBC positifs 16 Nombre de cas TBC traités et guéris 17 Nouvelle consultation curative pour les femmes enceintes 18 Accouchement eutocique 19 FP: Tot. Nouvelles + Anciennes Acceptantes 20 FP: Implants et DIU 21 Consultation postnatale 22 Consultation prénatale et standard TOTAL Le Titulaire du CDS………………………………………. Les vérificateurs (Noms, Prénoms et Signatures): 1…………………………………………………………………….. Nom et Prénom 2……………………………………………………………………. Signature 3……………………………………………………………………. REPUBLIQUE DU BURUNDI MINISTERE DE LA SANTE PUBLIQUE ET DE LA LUTTE CONTRE LE SIDA PROVINCE SANITAIRE DE : DISTRICT SANITAIRE DE : HOPITAL DE : FACTURE MENSUELLE PCA MOIS : ANNEE : N° Indicateur Quantité Quantité Quantité Ecart (en Ecart (en %) Tarif unitaire (f) Montant (Fbu) Déclarée (a) Vérifiée (b) Validée (c) chiffre) : e=d/a *100 g=(f*c) si écart ≤5% d= (a-b) g= (f * c)-(f*c*5%) si écart > ±5% et ≤ à ±10% g= (f *c)-(f*c*10%) si écart > ±10% et ≤ à ±20% g=0 si écart > ±20% 1 Nouvelle Consultation Curative par un médecin (> =5 ans) 2 Nouvelle Consultation Curative par un médecin (< 5 ans) 3 Nouvelle consultation curative d’une femme enceinte par un médecin 4 Contre référence arrivée au CDS 5 Chirurgie majeure 6 Petite chirurgie 7 Accouchement eutocique 8 Césarienne 9 Accouchement dystocique 10 Une journée d’hospitalisation pour les >= 5 ans 11 Une journée d’hospitalisation pour les < 5 ans 12 Femme enceinte VIH+ mise sous protocole ARV prophylactique 13 Prise en charge du nouveau né d’une femme VIH + 14 Dépistage volontaire du VIH/SIDA 15 Nombre de nouveaux cas sous ARV 16 Nombre de clients ARV suivi semestriellement 17 Cas d’ IST traitées 18 Dépistage des cas TBC positifs 19 Circoncision masculine 20 FP: Implants et DIU 21 FP: Tot. Nouvelles + Anciennes Acceptantes 22 PF : méthode définitive 23 Consultation prénatale 24 Consultation post natale Le Directeur de l’Hôpital (ou son délégué) Les vérificateurs (Noms, Prénoms et Signatures): Nom et Prénom 1……………..…………………………………………………….. Signature 2……………………………………………………………………. 3……………………………………………………………………. Source: MoH 2011b. Annex 4: Technical Quality Assessment Checklists for Health Centers and Hospitals Former versions: Quarterly Assessment Template on the Technical Quality of Health Centers –DRAFT- REPUBLIC OF BURUNDI MINISTRY OF PUBLIC HEALTH GENERAL DIRECTORATE OF PUBLIC HEALTH QUARTERLY ASSESSMENT TEMPLATE ON THE TECHNICAL QUALITY OF HEALTH CENTERS GENERAL INFORMATION • IDENTIFICATION OF HEALTH CENTER Name of health center: CDS Health district: Province: Telephone: Fax: P.O. Box: Status: Public Accredited Private Number of personnel A0: Pop. served: Number of beds: Number of personnel A1: Number of personnel A2 Ratio qualified personnel Number of beds/ 1000 Number of personnel A3 /2000 inhab.: inhab.: Number of personnel non-qual.(A4/A5): Number of personnel non-qual. (A6) Name of person responsible: Telephone: P.O. Box: E-mail: EVALUATORS No. FIRST AND LAST NAMES FUNCTION SIGNATURE QUARTERLY SUMMARY OF QUALITY OF HEALTH CENTER Available Points % Comments No. ACTIVITY ASSESSED points obtained 1 General activities 230 2 Follow-up assessment /SIS 190 3 Hygiene, environment, and sterilization 230 4 Outpatient and inpatient consultation 180 5 Maternity ward 140 6 Prenatal consultation 140 7 Family planning 110 8 Vaccination and monitoring of newborns 130 9 HIV/AIDS control 270 10 Tuberculosis and leprosy 150 11 Laboratory 66 12 Minor surgery 53 13 Drug management 205 14 Financial management 200 TOTAL 2 294 SUMMARY OF OBSERVATIONS AND RECOMMENDATIONS ON HEALTH CENTERS Health office_____________________________Health center_______________________________ Date ________________ 1. Recommendations from preceding quarter not implemented, and explanation 2. Strong and weak points identified during current quarterly assessment 3. Recommendations concerning weak points 4. Technical supervision recommended Evaluator’s signature___________ Date______________ 1. GENERAL ACTIVITIES (…) MAXIMUM SCORE POINTS No. CHECKLIST POSSIBLE CRITERIA OBTAINED POINTS Availability and posting of the Health Map for the geographical health area: All 4 criteria met Health map of public health facilities (FOSA) showing: = 10 1 1) Hills or neighborhoods 10 2) Main roads One criterion 3) Natural barriers missing = 0 4) Special points and distances Availability of work schedule and duty roster: Criterion met = 2 Work schedule and duty roster are posted and available to the 10 10 public Availability of portable radio or telephone for communication with the local FOSA [health facility]: Criterion met 3 Radio with charged battery (test functionality) and/or 40 = 40 telephone with call units of at least BIF 1000 [BIF: Burundian Franc] Availability of list of fees charged Criterion met = 4 10 List of fees charged is posted and accessible to the public 10 Inventory of equipment and material for each service Updated exists and is updated each quarter inventory exists = 5 10 10 Inventory missing or out-of-date = 0 Services available with staff on duty 24/7, including holidays: Evaluator will confirm: Open status 6 1) The permanent duty roster is prepared and 100 confirmed = 100 accessible to the public (posted) 2) The recording of cases for 3 non-working days selected at random during the quarter being assessed Existence of a source of lighting at night: electricity, Criterion met = 7 20 generator, or solar power 20 Proper reception is provided to patients: 1) Waiting rooms with chairs or benches 2) Existence of a One element 8 triage system, with numbering system and guidance 3) present = 10 30 Presence of a staff member conducting triage according to (Max. 3 elements) seriousness of case and numbered order MAXIMUM POINTS POSSIBLE = OBTAINED 230 = 2. FOLLOW-UP ASSESSMENT/SIS MAXIMUM SCORE POINTS No. CHECKLIST POSSIBLE CRITERIA OBTAINED POINTS Existence of an Annual Action Plan (AAP) based on Minimal Package of Activities (MPA) 1) Minutes of meeting to prepare Annual Action Plan with signed list of participants 2) Involvement of key stakeholders in preparation of One criterion Annual Action Plan, such as heads of service of FOSA, 1 met = 5 20 COSA [health center committee], and BDS [provincial health office] 3) Annual Action Plan based on annual action plan of the health district (using indicators from the health district results) 4) Annual Action Plan transmitted to BDS in the first month of the year Existence of a Quarterly Action Plan approved by ECD: 1) Minutes of meeting to prepare Quarterly Action Plan with signed list of participants 2) Involvement of key stakeholders in preparation of One criterion 2 15 Quarterly Action Plan, such as heads of service of met = 5 FOSA, COSA, and FOSA subcontractors 22 3) Quarterly Action Plan based on Annual Action Plan (including and developing main points of AAP) One set of minutes Monthly minutes of 3 technical meetings of FOSA during the meeting all current quarter: criteria = 10 Each set of minutes should contain: 1) Date and time of opening 3 30 and closing of meeting 2) Agenda or order of the day 3) Signed One set of list of participants 4) Development of meeting and decisions minutes with taken 5) Follow-up of decisions taken at preceding meeting even one criterion missing = 0 One set of minutes Monthly minutes of 3 meetings of Health Committee (COSA) meeting all during the quarter being assessed: criteria = 10 Each set of minutes should contain: 1) Date and time of opening 4 30 and closing of meeting 2) Agenda or order of the day 3) Signed One set of list of participants 4) Development of meeting and decisions minutes with taken 5) Follow-up of decisions taken at preceding meeting even one criterion missing = 0 22 Note on this issue (GF: 18 March 2010): In the Burundian PBF system, there are those who hold the prime purchase contract, and those facilities, predominantly in the private for profit sector, but also those non-for-profit health facilities that offer perhaps a more limited package of services, who are so-called ‘second tier’ contractors. They pass on their production to the prime contract holder, who claims the service production, and passes on the earnings to these second-tier contractors, after charging certain, limited administrative fee. The prime contract holders are responsible for the supervision for the quality and quantity of care of these second-tier contractors. During the verification processes, controllers check also the registers of these second-tier contractors. Community client surveys are also sampled from their registers. 2. FOLLOW-UP ASSESSMENT/SIS MAXIMUM SCORE POINTS No. CHECKLIST POSSIBLE CRITERIA OBTAINED POINTS One data analysis report Health Information System (SIS) data analysis report for the for 5 activities quarter being assessed concerning priority problems (CPC meeting both [first curative consultation], vaccination, PC [prenatal care], 5 criteria = 5 15 family planning, maternity) containing: 1) Graph curve or table One report with of data 2) Comments on evolution of activities compared to even one targets criterion missing = 0 SIS report transmitted to BDS on schedule: 1) Monthly SIS report transmitted to BDS by 5th of following month and 100% complete (i.e., all items are filled out correctly) All expected 2) Weekly report on 7 diseases that could lead to reports for one epidemics (report to be transmitted outside of month 6 30 epidemics to BDS each Monday following week of correctly filled notification) out and on time 3) Monthly report on 16 diseases under surveillance = 10 transmitted to BDS Proper filing of usual FOSA documents (action plans, monthly activity reports, minutes of meetings, personnel administration files, ROI [internal rules and regulations], and administrative letters, etc.): All criteria met 1) Filed on labeled shelves = 20 7 2) Accessible to authorized personnel 20 3) Documents are easy to find within 5 minutes One criterion missing = 0 Availability of tools (documents) for use by different services: 1) SIS report forms (at least 3 copies) 2) Reference/counter-reference cards (at least 10) 3) PC cards (notebooks for mothers) (at least 20) One criterion 8 30 4) FP cards (at least 20) met = 5 5) Blank partograms (at least 10) 6) Inpatient cards (at least 10) MAXIMUM POINTS POSSIBLE = OBTAINED 190 = 3. HYGIENE, ENVIRONMENT, AND STERILIZATION (---) MAXIMUM SCORE POINTS No. CHECKLIST POSSIBLE CRITERIA OBTAINED POINTS Existence of well-kept fencing around FOSA buildings Criterion met = If hedge: trimmed without openings for unauthorized passage 10 1 10 If made of wood or cement: no openings Criterion not met =0 Criterion met = 2 Presence of mosquito nets on all windows 10 10 Clean rooms, courtyard, and yard: 1) presence of trash receptacles (in waiting room and corridor) 2) Absence of Each cleanliness 3 scattered trash 3) Presence of receptacles for injection supplies in criterion met 40 treatment rooms 4) Environment in health center entirely swept = 10 clean with drainage of stagnant water Existence of an incinerator: functional, utilized, and emptied Criterion met = 4 (triage and destruction, etc.) 20 20 Existence of a placenta pit: with slab and cover that can be Criterion met = 5 10 locked 10 Availability of water (running water, well, pump, covered Available water 6 10 tank/cistern/barrel of water) source = 10 Water points available in consultation and inpatient rooms, Water points 7 10 in laboratories, and near latrines available = 10 All latrines meet Presence of latrines 1) usable 2) smooth floor with single hole criteria = 30 8 and cover 3) absence of organic matter in area 4) door that can One criterion 30 be locked from the inside missing for even one latrine = 0 All showers meet Presence of showers 1) usable with running water or tub criteria = 20 holding at least 20 liters of water 2) absence of organic matter in 9 One criterion 20 the area 3) door that locks from inside 4) drainage of used water missing for even in a soakaway one shower = 0 Criterion met = Availability of functional sterilization materials: 1) functional 50 10 steam, autoclave, or Poupinel sterilizer 2) sterilization protocol 50 Criterion not met posted =0 Product present, solution labeled with formula and date of Reserve disinfectant product. Solution labeled with formula 11 preparation. 10 and date of preparation Materials used (if any) soaked in disinfectant solutions = 10 Proper clothing 12 Regulation clothing in good condition worn by all personnel worn by all 10 personnel = 10 MAXIMUM POINTS POSSIBLE = OBTAINED = 230 4. OUTPATIENT/EMERGENCY CONSULTATION (OC) AND INPATIENT CARE (---) MAXIMUM SCORE POINTS No. CHECKLIST POSSIBLE CRITERIA OBTAINED POINTS 4. OUTPATIENT/EMERGENCY CONSULTATION (OC) AND INPATIENT CARE (---) MAXIMUM SCORE POINTS No. CHECKLIST POSSIBLE CRITERIA OBTAINED POINTS Consultation room equipped with 10 Functional supplies available in consultation room: 1) functioning thermometer 2) blood pressure cuff 3) stethoscope, 4) otoscope, supplies = 20 1 5) gloves, 6) adult and Salter scale, 7) tongue depressor 8) One item 20 examination table 9) height gauge 10) height/weight charts and missing or not tape for measuring arm circumference working = 10 More than one item missing or not working = 0 Privacy assured: individual examination room with curtains or Privacy assured 2 painted windows, room divider (if room is shared), doors that 20 = 20 close Support documentation for consultation available to Each document caregiver: 1) IST flowchart 2) National protocol for treatment of present in the malaria 3) Tuberculosis Guide 4) Flowchart for treatment of room = 4 3 20 diarrhea 5) Flowchart for treatment of acute respiratory infections (ARI) All outpatient consultations are done by a qualified nurse Criterion met = 4 20 Consultations conducted by at least a nurse A3 20 Proper treatment of Proper treatment of pathologies according to flowchart or 100 cases = 10 protocol: 5 Betw. 9 and 5 100 Proper treatment of 10 cases selected at random from outpatient records cases = 50 Fewer than 5 cases = 0 Integrated Management of Childhood Illnesses (IMCI) Criterion met = 6 40 strategy is applied 40 Outpatient records correctly filled out: Both criteria 1) Proper numbering (registration) of cases met = 10 7 2) Provision of all information required according to 10 One criterion general format missing = 0 Availability of supplies and equipment in inpatient room: 1) All criteria met = beds with mattresses with waterproof, impermeable covers 2) 10 8 10 mosquito nets for all beds 3) clean, untorn sheets and blankets 4) One criterion at least 1 cupboard available for 4 patients missing = 0 One case with Proper treatment of 5 inpatient cases (analysis of admission all criteria met = cards chosen at random): 1) identification of patient 2) 10 complaints or symptoms on admission 3) clinical examination 9 guided by admissions flowchart 4) laboratory tests according to 50 One case with flowchart 5) diagnosis 6) proper treatment according to flowchart or protocol 7) monitoring of vital signs 8) absence of signs of even one danger 9) length of stay no longer than 2 days criterion missing =0 10 Admission card correctly filled out: Both criteria 5 4. OUTPATIENT/EMERGENCY CONSULTATION (OC) AND INPATIENT CARE (---) MAXIMUM SCORE POINTS No. CHECKLIST POSSIBLE CRITERIA OBTAINED POINTS 1) Proper numbering (registration) of cases met = 5 2) Provision of all information required according to One criterion general format missing = 0 Determination of nutritional status of all children under 5 11 15 who come for consultation Determination of nutritional status of all women with a sick 12 10 child under 6 months of age Screening record of nutritional status available, up-to-date 13 5 and properly filled out 14 Treatment of malnutrition according to national protocol 5 SCORE MAXIMUM POSSIBLE = SCORE 215 OBTAINED = 5. MATERNITY WARD (---) MAXIMUM SCORE POINTS No. CHECKLIST POSSIBLE CRITERIA OBTAINED POINTS All criteria met = Room in good condition, ensuring privacy: plastered and 10 painted walls of solid material without cracks; cement floor, 1 10 without cracks; curtains or painted windows; room divider (if One criterion shared room); doors that close missing = 0 Equipment and supplies available and functional: 1) Delivery One material table manageable and clean 2) at least 3 sterile delivery kits (with available and needle holder, two Kocher clamps, serrated forceps, two pairs of functional = 3 scissors) 3) obstetrical stethoscope 4) suture thread 5) local anesthesia (at least 50 ml in reserve) and ergometrine 6) infant If even one 2 60 scale 7) sterilizing drum 8) ophthalmic ointment 9) gauze drum material from (1) 10) plastic apron 11) source of light 12) infant ventilator 13) to (5) is boots 14) mask 15) goggles 16) impermeable gloves 17) unavailable or umbilical cord clamp 18) placenta container 19) neo-natal non-functional = resuscitation table 20) adequate water point with soap 0 ANALYSIS OF PARTOGRAMS FOR LAST THREE MONTHS One partogram Analysis of 10 partograms selected at random: meeting all 1) Partogram properly filled out (each hour, blood pressure criteria = 10 indicated, etc.) 2) Decision taken if alert line is passed within 3 One partogram 50 one hour 3) Apgar score is measured and included in partogram with even one at 1st, 5th, and 10th minute 4) Delivery by qualified personnel (at criterion missing least a nurse A3) =0 Adequate inpatient rooms: All criteria met = 1) Mattresses covered with impermeable plastic 20 4 2) Sheets, blankets, and mosquito nets on each occupied 20 One criterion bed missing = 0 6. PRENATAL CONSULTATION (---) MAXIMUM POINTS No. CHECKLIST SCORE CRITERIA POSSIBLE OBTAINED POINTS PRENATAL CONSULTATION (PC) PERSONNEL, ROOM AND SUPPLIES Privacy assured: individual consultation rooms with 1 curtains or painted windows, room divider (if rooms are Privacy assured = 10 10 shared), doors that close Available and functional equipment and supplies: 1) All supplies available and Examination table 2) blood pressure cuff 3) stethoscope 4) working = 20 2 20 readable measuring tape 5) scale with height gauge 6) One material unavailable fetoscope 7) impermeable gloves or not working = 0 Group IEC/CCC: 1) Group meeting held before PC 2) IEC/CCC meeting all existence of updated IEC report with: a) topic b) number criteria = 10 3 10 of participants c) leader of activity d) date, and e) Even one criterion missing signature =0 PC conducted by qualified personnel (qualification: at Yes = 5 4 5 least a nurse A3) No = 0 VERIFICATION OF 10 PC CARDS SELECTED AT RANDOM (at time of prenatal consultations) Proper questioning technique: 1) gyneco-obstetric history on pregnancies (including TETANUS SHOT) and One case meeting all previous childbirths 2) fever 3) convulsions 4) medical and criteria = 1 5 surgical history : a) diabetes b) heart disease c) 10 hypertension (HTA) d) nephropathies e) tuberculosis f) One case with even one asthma 5) date of last menstruation 6) general medical missing criterion = 0 history Systematic plan for HIV screening (should be marked on PC card) Exists = 10 6 10 Does not exist = 0 Physical examination conducted: 1) weight 2) height 3) One case with 5 elements blood pressure 4) breast examination 5) palpation 6) PB =1 7 10 One case with even 1 element missing = 0 Obstetrical examination conducted: 1) height of uterus Examination of one case (HU) 2) presentation (from 36 weeks) 3) fetal heartbeat meeting all criteria = 1 (from 20 weeks) 4) fetal movement 8 Examination of one case 10 with even one missing criterion = 0 Additional tests requested, systematic tests for: 1) One case with all syphilis 2) hemoglobin, albumin if signs of HTA 3) additional tests = 1 9 glucose 10 One case with even one test missing = 0 Administration of tetanus shot according to directions: One case of VAT 1) proper intervals 2) unexpired vaccine 3) local administration meeting all 10 preservation in compliance with standards 4) criteria = 0.5 5 administration of vaccine follows directions indicated on One case with one missing vial and injection site is in compliance with standards criterion = 0 Correct prescription of: 1) iron and folic acid 2) mebendazole 3) insecticide-treated mosquito netting One case with all prescriptions done 11 correctly = 0.5 5 One case with even one incorrect prescription = 0 Management of cases with risk factors: 1) risk factors Management of one case identified 2) decision taken correctly according to PC card meeting all criteria = 2 3) information communicated to the patient Management of one case with even one missing 12 criterion = 0 20 PC card correctly filled out: 1) Proper numbering (registration) of cases Both criteria met = 0.5 13 2) Provision of all information required according to 5 One criterion missing = 0 general format MAXIMUM POINTS POSSIBLE OBTAINED = = 130 7. FAMILY PLANNING (---) MAXIMUM POINTS No. CHECKLIST SCORE CRITERIA POSSIBLE OBTAINED POINTS DIRECT VERIFICATION OF ROOMS AND SUPPLIES Privacy assured: individual consultation rooms with 1 Privacy assured = 10 10 curtains or painted windows, doors that close Consultations are conducted by qualified personnel: at 2 Criterion met = 5 5 least a nurse A3 (check at least 5 FP cards) Contraceptive methods: • Pills • Injectables One contraceptive method • Implants meeting both criteria = 4 3 • Condoms 20 • IUD with clamp and hysterometer One contraceptive method with even one criterion 1) Availability of contraceptive (theoretical stock missing = 0 corresponding to actual stock) 2) Alert threshold determined and respected Availability of wall posters or image box to 4 Criterion met = 5 5 demonstrate FP methods 7. FAMILY PLANNING (---) MAXIMUM POINTS No. CHECKLIST SCORE CRITERIA POSSIBLE OBTAINED POINTS FP card available: 5 Criteria met = 5 5 1) up-to-date 2) all blanks filled out Group IEC/CCC: 1) Group meeting held before FP IEC/CCC meeting all criteria consultation 2) existence of updated IEC report with: a) = 10 6 10 topic b) number of participants c) leader of activity d) Even one criterion missing = date e) signature 0 Health center has reached at least 90% of quarterly 7 target for oral and injectable contraceptives Criterion met = 5 5 established in the Action Plan ANALYSIS OF 10 FP CARDS FOR PAST THREE MONTHS SELECTED AT RANDOM FP card available: 8 1) blanks filled out 2) classified by month of scheduled Criteria met for 1 card = 1 10 appointment Justification of methods recommended, chosen, and Proper justification = 3 9 prescribed compared to methods indicated on basis of 30 Not justified = 0 questioning, history, and physical examination Yes = 1 10 Control and follow-up: Appointment made 10 No = 0 MAXIMUM POSSIBLE = POINTS 110 OBTAINED = 8. VACCINATION AND MONITORING OF NEWBORNS (---) MAXIMUM POINTS No. CHECKLIST SCORE CRITERIA POSSIBLE OBTAINED POINTS OBSERVATION OF ROOMS AND SUPPLIES All equipment and supplies Available and functional equipment and supplies in available and functional = 20 health center: 1) refrigerator 2) cold accumulators 3) 1 Even one piece of equipment 20 insulated foam cooler 4) petrol reserve (5 liters minimum) and/or generator 5) thermometer or supply missing or non- functional = 0 Availability of vaccines and diluents: • BCG Availability of all antigens and • Polio diluents meeting both criteria • Rabies 2 = 30 • Pentavalent 30 • Tetanus Expiry or disruption of supply • Diluents of even one antigen or diluent 1) Physical presence of unexpired, labeled antigens 2) =0 No disruption of stock for past 3 months 8. VACCINATION AND MONITORING OF NEWBORNS (---) MAXIMUM POINTS No. CHECKLIST SCORE CRITERIA POSSIBLE OBTAINED POINTS Preservation meeting criterion 3 Preservation of vaccines: No products other than = 20 20 vaccines, accumulators, and dilution water in refrigerator Preservation together with any other product = 0 Available consumables and printed forms: 1) self- 4 blocking syringes 2) dilution syringes (2 and 5 ml) 3) Availability of all items = 10 10 receptacles 4) absorbent cotton 5) vaccination charts 6) Even one item missing = 0 control sheets 7) vaccination record Cold chain: 1) Max. and min. temperatures of Chain meets both criteria = 5 refrigerator (from +2°C to +8°C) 20Even one day’s disruption = 20 2) Unbroken cold chain during past three months 0 Management of vaccine stock: 1) theoretical stock of Management meeting both 6 vaccines corresponds to physical stock 2) minimum criteria = 5 5 stock determined and respected Even one criterion missing = 0 Group IEC/CCC: 1) group meeting held before vaccination 2) existence of updated IEC report IEC/CCC meeting all criteria with: topic, number of participants, leader of activity, 5 7 =5 date, and signature 3) available and appropriate teaching materials 4) meeting held in adequate conditions Even one criterion missing = 0 (covered site, benches or chairs, etc.) System exists = 5 8 System for identifying children expected for meeting 5 System does not exist = 0 System for recovering drop-outs (e.g., schedule, System exists = 10 9 10 record of appointments, classified individual charts) System does not exist = 0 Expanded immunization program (EIP) record Criteria met = 5 10 available: 5 One criterion missing = 0 1) up-to-date 2) all blanks filled in MAXIMUM POINTS POSSIBLE OBTAINED = = 130 9. HIV CONTROL (---) MAXIMUM SCORE POINTS No. CHECKLIST POSSIBLE CRITERIA OBTAINED POINTS Well-equipped counseling room ensuring privacy: 1) Plastered and painted walls of solid material 2) smooth cement One criterion 10 1 floor 3) ceiling in good condition 4) windows with glass and met = 2 curtains 5) doors that close Respect for voluntary screening protocol: 1) pre-test 3 criteria met = counseling 2) use of a sensitive test (Hexagon or Determine) and 40 2 confirmation by specific test (Genie II) 3) Post-test counseling One criterion 40 with delivery of results missing = 0 4 criteria met = 20 Antiretroviral (ARV) treatment protocol available and One criterion 3 utilized: 1) criteria and conditions for ARV treatment are met 20 missing = 0 2) pre-therapeutic assessment has been made 3) first-line regimen in naive patients 4) gradual introduction of nevirapine Proper monitoring of PLHIV under ARV: 4 criteria met = 1) Appointment kept on 14th day (for treatment including 40 nevirapine), each month up to 6 months, and every three months 4 One criterion 40 thereafter 2) Immunobiological assessment done according to missing = 0 protocol 3) Clinical examination during each visit 4) Questioning and assessment of compliance during each visit Reliable supply of reagents, drugs, and ARV: 2 criteria met = 1)Existence of reserve stock (AMC/2) 2) Stock cards are up-to- 20 5 date and theoretical stock corresponds to physical stock One criterion 20 missing = 0 PMTCT protocol available and utilized: 3 criteria met = 1) ARV prophylaxis properly administered in 28 delivery 20 6 rooms 2) Low-risk obstetrical practices used 3) ARV One criterion 20 prophylaxis properly administered to newborns missing = 0 Proper monitoring of infants born to seropositive mothers: 4 criteria met = 1) Monthly medical appointment 2) Administration of 30 7 cotrimoxazole 3) Monitoring of infant’s growth One criterion 30 4) Clinical examination at each visit missing = 0 Psychological support for seropositive pregnant or nursing 2 criteria met = mothers: 40 8 1) Counseling on infant feeding 2) FP counseling for nursing One criterion 40 mothers missing = 0 Patient’s file is available and no monitoring element is Criterion met 9 missing = 30 30 All records are available, properly filled out and well- Criteria met = 10 classified 10 10 Presence of qualified caregivers trained in HIV, PMTCT, Criteria met = 11 and PEC counseling and screening 10 10 MAXIMUM POINTS POSSIBLE = OBTAINED = 270 10.TUBERCULOSIS AND LEPROSY (---) MAXIMUM SCORE POINTS No. CHECKLIST POSSIBLE CRITERIA OBTAINED POINTS OBSERVATION OF SUPPLIES, PRINTED MATERIALS, AND PRODUCTS Management meeting both Management of antitubercular drugs (Rifampicine, anti-TB criteria Streptomycine, Ethambutol): = 30 1 50 1) presence of antitubercular drugs based on patients under treatment 2) theoretical stock corresponds to physical stock One criterion missing = 0 Availability of printed materials: 1) record of TB cases (for Screening and Treatment Center (CDT)) 2) treatment card 3) Presence of all laboratory record (for CDT) 4) transfer card 5) cross-reference printed materials card (for CDT) 6) laboratory record 7) requisition register for = 20 2 20 antitubercular drugs 8) requisition register for laboratory Absence of even supplies and reagents 9) requisition record for printed materials one printed 10) leprosy register 11) short-course and retreatment protocol material = 0 posted in consultation room ANALYSIS OF 2 CASES SELECTED AT RANDOM FROM CARDS AND RECORDS Proper treatment according to guidelines of the National One case Leprosy and Tuberculosis Program (PNLT): 1) at least 2 meeting all sputum tests are positive and recorded on treatment chart for criteria = new PTB+ cases (laboratory results attached to chart) 2) 3 One case with 70 treatment in accordance with PNILT protocols (initial phase, continuation, relapse) 3) sputum monitoring if required, in even one accordance with PNILT instructions 4) HIV test completed (or criterion referred) missing= 0 Existence of a patient recovery system in case of irregularity Strategy exists = 4 10 determined by PNILT (within 6 days) 1 MAXIMUM POINTS POSSIBLE = OBTAINED 150 = 11. LABORATORY (---) MAXIMUM SCORE POINTS No. CHECKLIST POSSIBLE CRITERIA OBTAINED POINTS DIRECT OBSERVATION OF ROOM AND SUPPLIES Available and functional equipment and supplies: 1) microscope 2) centrifuge 3) hemoglobinometer 4) new One piece of razor blades 5) cover slips 6) source of light 7) time equipment or 1 26 switch 8) sputum cups 9) stool vials 10) inoculation loop supply available 11) alcohol lamp 12) diamond-point scriber 13) laboratory and functional = 2 bench Presence of unexpired reagents and test strips: 1) giemsa 2) fuchsin, sulfuric acid, methylene blue, immersion oil, and Each product 2 24 alcohol (for CDT) 3) test strips for albumin and sugar 4) present = 3 pregnancy test 5) immersion oil 6) KOP 7) Hb 8) HIV Waste eliminated Sputum bottles, stool vials eliminated in sealable and 3 in trash receptacle 5 sealed waste receptacle =5 11. LABORATORY (---) MAXIMUM SCORE POINTS No. CHECKLIST POSSIBLE CRITERIA OBTAINED POINTS Presence of environmentally sound wastewater disposal Presence of proper 4 system 5 system = 5 Parasite demonstration is available (thick drop, stools, 5 sputum): on laminated paper, in a colored picture book, or Criterion met = 5 5 on a poster Recording of results in laboratory records: 1)correct 2) 6 Criterion met = 6 6 in conformity with results on test slip Presence of laboratory technician or nurse (multi-role) 7 Criterion met = 5 5 at least A3 level and trained in microscopy MAXIMUM SCORE POSSIBLE OBTAINED SCORE = = 76 12. MINOR SURGERY (---) SCORE MAXIMUM POINTS No. CHECKLIST CRITERIA POSSIBLE POINTS OBTAINED DIRECT OBSERVATION OF ROOM AND SUPPLIES Room for minor surgery available and in good condition: Criteria met = 10 1 - Plastered, painted walls of solid material 10 - Smooth cement floor One criterion missing = 0 Examination bed available: - Easy to handle, with foam mattress covered 2 with impermeable material Criterion met = 5 5 Basic equipment available in room: 1) Local anesthesia available (at least 20 ml) 2) Drum with sterile dressings 3) Kit containing needle holder, anatomical forceps, Kocher clamp, at least 3 pairs of scissors Each available 3 18 4) Sterile gloves (at least 3 pairs) supply = 2 5) Absorbable sutures (at least 2) 6) Bistouries (at least 3) 7) Sterile surgical drapes in drum 8) Kidney basins (at least 2) 9) Disinfectant Record of minor surgery filled out and up-to- Criterion met = 4 date 10 10 Hygienic conditions assured in minor surgery Criteria met = 4 room 5 1) Covered containers for infectious materials 10 One criterion 2) Safety container (for needles) well-located missing = 0 and utilized 12. MINOR SURGERY (---) SCORE MAXIMUM POINTS No. CHECKLIST CRITERIA POSSIBLE POINTS OBTAINED MAXIMUM SCORE POSSIBLE SCORE = OBTAINED = 53 13. DRUG MANAGEMENT (---) MAXIMUM SCORE POINTS No. CHECKLIST POSSIBLE CRITERIA OBTAINED POINTS Pharmacy premises comply with standards: Premises meeting 1) shelves 2) well-ventilated 3) protection against direct all criteria = 10 1 sunlight 4) protection against theft 10 Even one criterion missing =0 Cleanliness of pharmacy (no dust on shelves and products, Cleanliness 2 5 no cobwebs) assured = 5 Stocking procedures meet all standards: 1) Arrangement of products on shelves, not on floor 2) logically arranged Stocking meets products (alphabetical order or by type of therapy) 3) on basis all criteria = 60 3 of expiry date 4) with labels on shelves according to Even one 60 International Common Denomination (generic names) 5) criterion missing concordance between theoretical and physical stock 6) stock =0 cards indicate AMC Management of tools: • stock card One tool meeting • order forms both criteria = 5 • record of receipt of drugs 4 • delivery note One tool with 30 • record of internal requisition even one • monthly drug inventory criterion missing 1) Presence of tool in pharmacy 2) Filled out according to =0 standards Tracer drugs and consumables Availability of tracer drugs and consumables (take sample available from of 10 products): 1) Availability of molecules and sample = 60 5 consumables 2) no disruption of stock since last assessment 60 3) no threat of shortage (check that remaining stock is more Disruption of than AMC) for 10 tracer drugs supply of one drug or consumable = 0 Procedure Compliance with procedure for destruction of outdated meeting both products: 1) inventory card for outdated products 2) criteria = 20 6 20 Acknowledgment of receipt of outdated drugs and reagents by Even one BDS criterion missing =0 Available equipment and supplies for drug distribution: 1) Supplies 7 water filter 2) spatulas 3) spoons 4) beaker 5) cutting tool 5 available = 5 6) packaging 13. DRUG MANAGEMENT (---) MAXIMUM SCORE POINTS No. CHECKLIST POSSIBLE CRITERIA OBTAINED POINTS One tool meeting Use of tools and updated records: both criteria = 5 • Record of daily use of drugs (RUMER) 8 • Daily tracking record 15 • Internal requisition book One tool with 1) Presence of tool 2) Records up-to-date even one criterion missing = 0 MAXIMUM POINTS POSSIBLE = OBTAINED 205 = 14. FINANCIAL MANAGEMENT (---) MAXIMUM SCORE POINTS No. CHECKLIST POSSIBLE CRITERIA OBTAINED POINTS Fees for services, drugs, and consumables: 1) posted 2) All criteria met = legible 3) at reception desk and cashier 4) complied with 20 1 5) within profit margins specified in ministerial instructions 20 Even one criterion missing = 0 Billing records: 1) available 2) specifying: a) client’s All criteria met = name b) amount received in figures and letters c) reason 10 2 for payment (denominated) with amount 20 Even one criterion missing = 0 Cash receipts journal: 1) available 2) in agreement with All criteria met = billing records 3) up-to-date 4) without erasures or 20 3 alterations 20 Even one criterion missing = 0 Expenditure record: 1) available 2) in agreement with All criteria met = documentary evidence of expenditures 3) up-to-date 4) 20 4 without erasures or alterations 20 Even one criterion missing = 0 Documentary evidence of expenditures (10 randomly One voucher selected documents): 1) classified and easy to find within meeting all 5 minutes for each document 2) specifying: a) name of criteria = 20 5 20 purchaser b) amount received in figures and letters c) One voucher with reason for expenditure even one criterion 3) signatures of cashier, owner, and purchaser missing = 0 Bank ledger: 1) available 2) in agreement with All criteria met = documentary evidence of expenditures and bank statements 20 6 20 and cash receipts journal 3) up-to-date 4) without erasures Even one criterion or alterations missing = 0 Treasury situation: 1) Concordance between theoretical Treasury meeting situation (bank ledger) and real situation (bank book or both criteria = 40 7 statement or actual cash holdings) 2) Concordance between 40 monthly SIS treasury report with receipts and expenditures Even one criterion journals missing = 0 Quarterly budget estimate: 1) drawn from the annual One budget 8 budget estimate 2) co-signed by the official and the estimate meeting 20 president of the Health Committee both criteria = 20 14. FINANCIAL MANAGEMENT (---) MAXIMUM SCORE POINTS No. CHECKLIST POSSIBLE CRITERIA OBTAINED POINTS Even one criterion missing = 0 System for calculating staff bonuses: 1) established 2) 9 Criteria met = 20 20 made known to personnel MAXIMUM POINTS POSSIBLE = OBTAINED 200 = Source: MoH 2010. REPUBLIQUE DU BURUNDI MINISTERE DE LA SANTE PUBLIQUE GRILLE DE QUALITE TECHNIQUE DES SOINS DE L’HOPITAL SYNTHESE D’EVALUATION Nombre Points disponibles ENSEMBLE DES COMPOSANTES d’indicateurs composites 8 300 1. Indicateurs généraux 4 150 2. Gestion du malade 3 40 3. Plan d’action 5 380 4. Gestion du budget, des comptes et des biens 9 400 5. Gestion des medicaments 8 220 6. Hygiène & sterilization 20 400 7. Consultation Externe / Urgences 10 45 8. Planification Familiale 14 115 9. Laboratoire 7 80 10. Salles d’hospitalisation 12 190 11. Maternité 9 200 12. Bloc opératoire 16 13. Médicaments traceurs TOTAL 109 2 534 Date: … / ... / 200.. Province de ……………..…….…. District de ……………….……. Hôpital : public / agrée / privé Nom de l hôpital: ………………… Population du district sanitaire : Nombre de médecins Nombre de lits : ……………… …….….. Nombre personnel A0 : …..… Nombre personnel A1 : …….… Nombre personnel A2 : …….. 11 Nombre personnel A3: ……... Pers. non qualifié A4/A5 : ….….. Pers. non qualifié A6: ……….. Ratio de personnel qualifié / 2000 Nombre de lits / 1000 hab. :….. xxxx habitants : ………. EVALUATEURS N° NOM ET PRENOM FONCTION SIGNATURE 11 Personnel non qualifié A4 = Aide Soignant – Agent Formation Rapide (AFR) ; A5 = garçon, fille de salle - stérilisation – maintenance ; A6 = jardinier – sécurité – buanderie. 1. INDICATEURS GÉNÉRAUX Points disponibles Points obtenus 1 Les infrastructures de l’hôpital sont en bon état, c’est-à-dire qu’elles ne nécessitent pas de travaux importants de • reprise générale de la peinture extérieure 10 • reprise générale de la peinture des chambres des 10 malades • réfection de la toiture 10 • réfection du circuit électrique 10 • réfection du système d’adduction d’eau 10 …….…. / 50 2 L’hôpital dispose d’un plan annuel d’action centré sur les prestations du paquet complémentaire d’activités (PCA) 30 ….…. / 30 3 L’hôpital dispose d’un plan annuel de maintenance précisant les activités de maintenance à effectuer pour les bâtiments, le matériel, l’équipement et les personnes internes ou 50 …….…. / 50 externes (contrats de maintenance) responsables 4 Les réunions de l’équipe de direction de l’hôpital ont lieu au moins une fois par mois, avec rapport de réunion disponible 20 …….…. / 20 5 Le rapport SIS du mois précédent est envoyé au BDS (au plus tard le 5 du mois suivant) 30 …….…. / 30 6 Une garde médico-chirurgicale est organisée par l’hôpital, c’est-à-dire que • le rôle de garde est affiché dans un endroit 10 immédiatement visible par les malades • les responsabilités des individus et des services (y 20 compris l’ambulance et le bloc opératoire) dans l’organisation de la garde fait l’objet d’une directive du médecin directeur de l’hôpital • un système d’écoute des appels (radiophoniques ou 70 téléphoniques) est effectif 24h/24 (vérifier la fonctionnalité de la radio et du téléphone portable avec …….…. / 100 tous les CDS) 7 Une cuisine pour les patients hospitalisés est disponible et propre • poubelle pour évacuation des déchets 5 • robinet à moins de 5 m ou réserve d’eau d’au moins 50 l 5 …….…. / 10 8 Une morgue est disponible (chambre ou petit bâtiment) 10 …….…. / 10 Total des points 300 …….…. / 300 2. GESTION DU MALADE Points disponibles Points obtenus 9 La référence des malades est organisée au sein de l’hôpital en fonction du PMA et PCA, c’est-à-dire qu’il y a • Une consultation de triage des consultations externes confiée 10 à un infirmier pour les patients non référés des centres de santé • Un accès direct gratuit au médecin (ou au service des urgences) des patients référés des centres de santé 25 • Un accès direct payant au médecin des patients qui le 15 souhaitent, sans être référés par un centre de santé …….…. / 50 10 Le dossier médical individuel existe pour tous les malades hospitalizes 25 …….…. / 40 11 Les fiches de référence et de contreréférence existent et sont archivées • Fiches de référence 25 …….…. / 50 • Fiches de contreréférence 25 12 L’hôpital dispose d’une signalétique claire des services et des 10 circuits (panneaux, flèches) …….…. / 10 Total des points 150 …….…. / 150 3. PLAN D’ACTION TRIMESTRIEL Points disponibles Points obtenus 13 La cohérence du Plan d’action avec le plan annuel d’activités est assurée. Vérifier si (1) le Plan d’action reprend / développe les lignes du PAA 10 (2) des rapports trimestriels existent faisant le point sur la mise en 10 œuvre du PAA/Plan d’action …….…. / 20 14 L’élaboration du Plan d’action trimestriel implique les chefs de services de l’hôpital [vérifier la liste des présences jointe au 10 rapport de réunion d’adoption du Plan d’action] …….…. / 10 15 Le Plan d’action montre une analyse de l’accessibilité financière [vérifier si le Plan d’action montre une négociation des tarifs avec le Conseil d’Administration (hôpitaux autonomes) ou le Conseil de 10 …….…. / 10 Gestion (hôpitaux non autonomes) de l’hôpital]. Total des points 40 …….…. / 40 4. GESTION DU BUDGET, DES COMPTES ET DES BIENS Points disponibles Points obtenus 16 La gestion financière et comptable répond aux normes et aux bonnes pratiques : (3) L’hôpital tient une comptabilité à partie double (4) Le nombre de comptes bancaires est inférieur à cinq (BRB + fonctionnement + pharmacie + compte facultatif supplémentaire) 12 (5) Les livres de banque sont complets et à jour (6) Les livres de caisse (une caisse par compte) sont complets et à jour 20 points car (7) Les dépenses donnent lieu à un document d’autorisation de dépense critère bien rempli (8) Les recettes donnent lieu à un document d’enregistrement de recette (9) Le rapprochement bancaire mensuel est effectué (10) Le classement des pièces comptables est correct (numérotation en continu + classement chronologique) (11) Le suivi de la caisse (inventaire de caisse) est au moins mensuel [procès verbal signé] (12) L’hôpital dispose d’un fichier de suivi de ses dettes (13) L’hôpital dispose d’un fichier de suivi de ses créances (14) L’hôpital dispose d’un manuel des procédures financières et …….…. / 240 comptables (ou de directives équivalentes du médecin directeur) 17 La gestion budgétaire repose sur (15) Un budget réaliste établi en fonction des ressources disponibles et en concordance parfaite avec le PAA 40 (16) Des fiches de suivi de l’exécution du budget, pour les recettes 40 comme pour les dépenses, rubrique budgétaire par rubrique …….…. / 80 budgétaire 18 La gestion des véhicules est assurée, c’est-à-dire qu’il existe • un règlement précisant les responsabilités (tâches) et les règles dans l’utilisation du charroi de l’hôpital 10 • un dossier par véhicule (y compris les motos) reprenant les fiches de suivi de la maintenance (cf. documents de la DGR) 15 • une synthèse mensuelle des carnets de bord des véhicules (y compris les motos) reprenant au moins leur utilisation, leur 15 kilométrage et leur consommation de carburant mois par …….…. / 40 mois 19 Un tableau des investissements (immobilisations) existe et est à jour, avec les apports de l’Etat et des partenaires 20 …….…. / 20 Total des points 380 …….…. / 380 5. GESTION DES MEDICAMENTS Points disponibles Points obtenus 20 Les fiches de stock sont tenues correctement c’est-à-dire • comportent la mention de la consommation mensuelle moyenne (CMM) 20 • mentionnent les inventaires mensuels 20 • mentionnent un stock restant à jour [vérifier le stock restant 20 théorique de la fiche de stock avec le stock restant réel sur les étagères, pour 5 produits] …….…. / 60 12 Instructions ministérielles permanentes du 17.06.2009. 21 Les commandes sont correctes c’est-à-dire • Sont mensuelles [vérifier dans le classeur des bons de commande] 20 • Reposent sur la formule Commande = CMM x 2 – SR (où SR est le stock restant) [vérifier en comparant le dernier bon de 30 …….…. / 50 commande et les fiches de stock de 10 produits commandés] 22 La réception des produits est correcte c’est-à-dire est accompagnée • d’un bon de livraison (CAMEBU ou grossistes) 20 • d’un bon de réception signé par un Comité de réception 20 …….…. / 40 23 Le stockage des produits est correct c’est-à-dire • Le local est propre, ventilé, protégé 10 • Le rangement des produits se fait par classe (médicaments, consommables, matériel), puis par voie d’administration (per os 10 ou inhalation, injectables, voie cutanée), puis par dosage • La règle du « premier périmé, premier sorti » est appliquée [vérifier 20 sur 5 produits sur els étagères si les produits périmant le plus tôt sont au devant des rayons des étagères] …….…. / 40 24 La livraison des produits est correcte, c’est-à-dire • répond à un bon de commande (réquisition) des services ou de la pharmacie de détail 10 • donne lieu à la production d’un bon de réception signé par le 10 …….…. / 20 service ou la pharmacie de détail 25 La gestion des produits périmés ou détériorés est correcte, c’est- à-dire • est suivie par un registre 10 …….…. / 30 • donne lieu à des procès verbaux de destruction 20 26 La délivrance des médicaments par les services ou par la pharmacie de détail est suivie par une fiche de consommation journalière 20 …….…. / 20 27 La gestion globale de la pharmacie de l’hôpital est efficace, c’est- 2 points par à-dire traceurs = 32 • Il n’y a pas de rupture de stock dans le trimestre [vérifier l’absence de « stock restant = 0 » sur les fiches de stock des 16 médicaments 2 points par traceurs] traceurs = 32 • Il n’y a pas de surstockage [vérifier que le « MAD » est inférieur à 2 mois pour les 16 médicaments traceurs] 2 points par • Il n’y a pas de menace de pénurie [vérifier que le stock restant est traceurs = 32 …….…. / 100 supérieur à ½ CMM pour les 16 médicaments traceurs] 4 points de bonus si tous ces critères sont remplis 28 La fiche de synthèse de la gestion de la pharmacie est complétée et envoyée chaque mois au directeur de l’hôpital [voir modèle dans le module approuvé par le MSP] 40 …….…. / 40 Total des points 400 …….…. / 400 6. HYGIENE & STERILISATION Points disponibles Points obtenus 29 Existence et entretien de la clôture • Si la clôture est une haie, vérifier si la clôture est bien taillée et ne laisse pas de passage non contrôlé 10 • Si la clôture est faite en sticks ou en dur, vérifier si la clôture ne …….…. / 10 laisse pas de passage non contrôlé 30 Présence de latrines en nombre suffisant et en bon état Tous les critères • 1 latrine pour 10 lits remplis=30 • sol sans fissure Un seul critère • murs en briques manque=0 • toit en tôles ou en tuiles • portes fermant correctement • nettoyage récent • absence de matières fécales visibles …….…. / 30 31 Présence de douches en nombre suffisant et en bon état Tous les critères • 1 douche pour 10 lits remplis=30 • eau courante ou récipient avec au moins 20 l Un seul critère • évacuation vers puits perdu …….…. / 30 manque=0 32 Présence d’un incinérateur et d’une fosse à placentas. • incinérateur fonctionnel, utilisé et vidé Tous les critèes • fosse à placentas avec couvercle remplis=20 • incinérateur et fosse à placentas sont dans un enclos sans passages bien construit, avec une porte qui ferme à clé Un seul critère . manque=0 …….…. / 20 33 Présence d’une fosse à déchets pour les détritus décomposables Tous les critèes non bio-médicaux remplis=10 • fosse d’au moins 3 m de profondeur Un seul critère …….…. / 10 • sans déchets non décomposables ni déchets infectés manque=0 • dans un enclose 34 Entretien de la cour intérieure de l’hôpital Tous les critèes • absence de déchets remplis=30 • absence de produits dangereux (aiguilles, compresses, gants, seringues…) Un seul critère • présence de poubelles : accessibles, avec couvercle, non pleines manque=0 • gazon coupé • jardin entretenu …….…. / 30 • absence d’excréta 35 La stérilisation des instruments est correcte • Il y a un système de stérilisation en bon état et effectivement utilisé (Poupinel ou casserole à vapeur) 40 • Le protocole de stérilisation est affiché 20 …….…. / 60 36 Les conditions d’hygiène sont assurées dans toutes les salles de soins • Poubelles avec couvercle pour matériel infecté 10 …….…. / 30 • Boites de sécurité pour les aiguilles, bien placées et utilisées 20 Total des points 220 …….…. / 220 7. CONSULTATION EXTERNE ET URGENCES Points disponibles Points obtenus 37 Le service d’urgence est disponible 24h/24 et 7j/7 avec rôle de 100 …….…. / 100 garde affiché 38 La salle de consultation externe présente de bonnes conditions d’attente Tous les critèes • Les murs sont en dur avec crépissage et peinture remplis=30 • Le pavement est en ciment • Les murs et le pavement sont sans fissures Un seul critère • Le plafond est en bon état manque=0 • Les fenêtres sont en vitres avec rideaux • Les portes sont fonctionnelles avec serrures • Les bancs ou chaises sont suffisants pour 30 personnes …….…. / 30 • L’endroit est protégé du soleil et de la pluie 39 La salle de la consultation externe et l’espace d’attente sont séparés pour assurer la confidentialité, avec porte qui ferme, rideaux à la fenêtre, sans passage 20 …….…. / 20 40 Les principaux tarifs du recouvrement de coût sont affichés et 5 visibles pour les malades avant la consultation …….…. / 5 41 L’ordre d’arrivée est respecté, avec un système de jetons Numérotés 5 …….…. / 5 42 La salle de consultation externe et / ou des urgences est éclairée pendant la nuit (électricité ou lumière solaire) 5 …….…. / 5 43 L’accueil est assuré par un personnel qualifié qui oriente les patients vers les services appropriés 5 …….…. / 5 44 Le personnel est en tenue conforme Tous les critèes • blouse propre, boutonnée remplis=5 • cartes d’identification (badge) • chaussures Un seul critère manque=0 …….…. / 5 45 La numérotation mensuelle des patients est correcte dans le registre de consultation externe est correcte et clôturée à la fin du mois 5 …….…. / 5 46 La disponibilité de l’équipement est assurée dans la salle de consultation externe : • Stéthoscope • Tensiomètre • Otoscope • Thermomètre • Table d’examen Tous les critèes • Pèse-personne pour adulte remplis=20 • Pèse-bébé • Toise Un seul critère • Ruban pour périmètre brachial manque=0 …….…. / 20 47 Les divers protocoles de prise en charge des maladies sont disponibles et/ou affichés sur le mur • Paludisme Tous les critèes • Diarrhée remplis=20 • IRA Un seul critère • Tuberculose manque=0 • Tables poids-taille • Tous les critères doivent être présents …….…. / 20 48 La prise en charge du paludisme simple est correcte 20 Le programme doit préciser les critères et la méthode de contrôle …….…. / 20 49 La prise en charge du paludisme grave est correcte 20 (selon le protocole national) …….…. / 20 50 La prise en charge des IRA est correcte 20 …….…. / 20 (selon le protocole national) 51 La prise en charge de la diarrhée est correcte 20 …….…. / 20 (selon le protocole national) 52 La détermination de l’état nutritionnel de tout enfant de moins 20 de 5 ans est faite à la consultation externe …….…. / 20 (selon le protocole national) 53 La détermination de l’état nutritionnel de la mère de tout enfant 20 de moins de 6 mois est faite à la consultation externe …….…. / 20 (selon le protocole national) 54 La prise en charge de la malnutrition est correcte 20 …….…. / 20 (selon le protocole national) 55 La proportion de malades traités avec des antibiotiques < 50% 20 Voyez le registre les 30 derniers cas en analysant le diagnostic et …….…. / 20 calcule le taux – pas plus de 14 56 Les critères de détection précoce de la tuberculose sont connus 20 par le personnel soignant chargé de la consultation externe Réponse doit contenir : Amaigrissement, Asthénie, Anorexie – …….…. / 20 Température – Toux de 15 jours – Transpiration Total des points 400 …….…. / 400 8. PLANIFICATION FAMILIALE Points disponibles Points obtenus 57 Présence d’au moins une infirmière A3 formée dans la PF 5 …….…. / 5 58 Local disponible et garantissant la confidentialité (salle avec porte 5 …….…. / 5 fermée – rideaux à la fenêtre – pas de passage) 59 Affiche murale ou boite à images disponible pour la 5 démonstration des méthodes de PF …….…. / 5 60 Le personnel calcule correctement le nombre de femmes 5 attendues mensuellement pour DIU, ligature ou vasectomie …….…. / 5 61 La disponibilité des contraceptifs est assure 5 Critère : 10.000 hab. = 147 doses DEPO et pilule 3 plaquettes / 4 = 36 …….…. / 5 doses 62 Les méthodes de DIU sont disponibles et le personnel est capable 5 …….…. / 5 de les placer 63 Les méthodes d’implants sont disponibles et le personnel est 5 …….…. / 5 capable de les fixer 64 Le registre de la PF est disponible et bien rempli 5 …….…. / 5 65 La fiche de la PF est disponible et bien remplie 5 …….…. / 5 Vérifier 5 fiches : tension artérielle, hépatomégalie, varices, poids Total des points 45 …….…. / 45 9. LABORATOIRE Points disponibles Points obtenus 66 Laborantin ou infirmier (polyvalent) d’au moins du niveau A2 5 disponible …….…. / 5 67 Le laboratoire est fonctionnel tous les jours et 24h/24 5 …….…. / 5 Vérifier les 2 derniers dimanches dans le registre du labo 68 Transfusion sanguine Tous les critères • Disponibilité d’une chaine de froid avec fiche de vérification de la remplis=30 température à jour • Disponibilité d’au moins 5 sachets du groupe O+ Un critère • Disponibilité d’au moins 2 sachets par autre groupe sanguin manque=0 30 …….…. / 30 69 L’enregistrement des résultats dans le registre du labo est correct 5 et conforme aux résultats dans le carnet du malade ou bon …….…. / 5 d’examen 70 La liste des examens possibles est affichée dans le laboratoire et 5 …….…. / 5 est visible pour le public 71 La démonstration des parasites est disponible 5 Sur papier plastifié ou dans un livre en couleur, ou affichés (goutte épaisse : P. Vivax, Ovale, Falciparum, Malariae) (selles : amibes, …….…. / 5 ascaris, ankylostome, schistosome) 72 Au moins un microscope fonctionnel est disponible Tous les critères • les différents objectifs sont fonctionnels remplis=10 • l’huile à immersion est disponible Un critère …….…. / 10 • la solution de GIEMSA est disponible manque=0 • l’apport de lumière existe (miroir ou électricité) • les lames et lamelles sont disponibles 73 Disponibilité d’une centrifugeuse fonctionnelle 5 …….…. / 5 74 Disponibilité d’un appareil d’examens de biochimie fonctionnel 5 …….…. / 5 75 Disponibilité d’un appareil de numération sanguine fonctionnel 5 …….…. / 5 76 Disponibilité de tests rapides pour le diagnostic de VIH/sida 5 …….…. / 5 77 Maintenance régulière des appareils attestée par les rapports de 15 …….…. / 15 maintenance signés 78 Evacuation des déchets Tous les critères • Déchets organiques dans une poubelle avec couvercle remplis=10 • Boites de sécurité disponibles et détruites dans l’incinérateur Un critère manque=0 …….…. / 10 79 Les lames et pipettes utilisées sont plongées dans un récipient 5 contenant un désinfectant …….…. / 5 Total des points 115 …….…. / 115 10. SALLES D’HOSPITALISATION Points disponibles Points obtenus 80 Le programme de garde est affiché et respecté 5 Vérifier le rapport de garde – noms et signatures …….…. / 5 81 L’équipement est disponible et en bon état Tous les critères • Tous les lits occupés ont des matelas recouvert d’une protection remplis=20 lavable • Le revêtement des matelas n’est pas déchiré Un critère • Tous les lits ont des supports pour une moustiquaire manque=0 • Tous les lits occupés ont une moustiquaire • Tous les lits occupés ont des draps • Tous les lits ont une table de nuit …….…. / 20 • Une armoire est disponible pour 4 malades au maximum 82 Les conditions d’hygiène sont bonnes dans toutes les salles Tous les critères d’hospitalisation. remplis=20 • Toutes les salles d’hospitalisation sont nettoyées régulièrement • Les malades et garde-malades ont accès à l’eau potable à moins de Un critère 20m manque=0 • Les lits sont espacés d’au moins 1m • Les salles sont aérées et sans mauvaises odeurs …….…. / 20 83 Toutes les salles d’hospitalisation peuvent être éclairées pendant 5 la nuit (électricité, groupe électrogène, lumière solaire ou lampe à batterie rechargeable) …….…. / 5 Appuyer sur les interrupteurs pour vérifier s’il y a du courant 84 La confidentialité est assure Tous les critères • Les salles d’hospitalisation des femmes, des hommes et des remplis=15 enfants sont séparées • Les malades hébergés ne sont pas vus de l’extérieur Un critère manque=0 …….…. / 15 85 Le registre d’hospitalisation est disponible et rempli selon les 5 …….…. / 5 normes techniques et de gestion 86 Les fiches d’hébergement sont disponibles et bien remplies Tous les critères • Il y a au moins 10 fiches vierges en réserve remplis=10 • Sur 5 fiches choisies au hasard, le personnel soignant marque : poids, température, TA, examens de labo Un critère • Le suivi du traitement est coché manque=0 …….…. / 10 Total des points 80 …….…. / 80 11. MATERNITÉ Points disponibles Points obtenus 87 La salle d’accouchement est en bon état Tous les critères • murs en dur, sans fissures avec crépissage et peinture remplis=10 • pavement en ciment sans fissures Un critère …….…. / 10 • plafond en bon état manque=0 • fenêtres vitrées avec rideaux • portes fonctionnelles 88 La salle d’accouchement est fonctionnelle Tous les critères • tables d’accouchement en bon état remplis=30 • eau disponible en suffisance avec savon • éclairage possible pendant la nuit (électricité, groupe électrogène, lumière solaire ou lampe à batterie rechargeable) Un critère • poubelle avec couvercle manque=0 • boite de sécurité pour les aiguilles • seau à placenta • seau pour le linge souillé • toise • pèse-bébé • table de réanimation néonatale • stéthoscope obstétrical • désinfectant • compresses stériles • gants stériles (au moins 10 paires) …….…. / 30 • au moins 2 boites d’accouchement stérilisées 89 Le matériel d’épisiotomie est disponible Au moins 2 boites d’épisiotomie avec ciseaux, pinces anatomique et chirurgicale, aiguilles, porte-aiguille, fil catgut et fil non résorbable 15 …….…. / 15 90 La ventouse est disponible et fonctionnelle Tous les critères • Au moins un médecin, un infirmier ou une sage-femme est formé remplis=15 à son utilisation • La ventouse est utilisée (voir registre ou fiches) Un critère manque=0 …….…. / 15 91 L’équipement et les médicaments suivants sont disponibles pour Tous les critères les soins au nouveau-né remplis=20 • Fil stérile de ligature du cordon • Bande ombilicale stérile Un critère • Aspirateur (poire plongée dans un désinfectant non irritant ou manque=0 aspirateur manuel ou électrique fonctionnel) • Lampe chauffante • Onguent ophtalmique de tétracycline 1% (appliqué à chaque …….…. / 20 nouveau né) 92 Le partogramme est disponible et utilize • Au moins 10 partogrammes vierges sont en réserve 10 • Le partogramme est rempli une fois par heure 10 • La tension artérielle est indiquée …….…. / 30 Vérifier 10 partogrammes 10 93 Le partogramme donne lieu à un suivi actif de l’accouchement : 20 une décision figure lorsque la courbe de suivi de l’accouchement entre dans la zone « action » disponible et utilisé …….…. / 20 Vérifier 10 partogrammes du trimestre. e 94 Le score d’Apgar est mesuré et figure dans le partogramme à la 1 , 10 …….…. / 10 e e la 5 et la 10 minutes 95 Tous les accouchements sont effectués par du personnel qualifié 20 …….…. / 20 Vérifier sur base des registres et recouper avec la liste du personnel 96 La salle d’attente est adequate 10 Au moins 4 lits avec matelas …….…. / 10 97 La salle d’hébergement est adequate Tous les critères • Lits avec matelas recouverts de toile cirée sans déchirure remplis=10 • Draps et couverture à chaque lit occupé Un critère • Moustiquaire à chaque lit occupé manque=0 …….…. / 10 Total des points 210 …….…. / 210 12. BLOC OPERATOIRE Points disponibles Points obtenus 98 La salle d’opérations est en bon état Tous les critères • murs en dur, sans fissures avec crépissage et peinture à l’huile remplis=20 • pavement en ciment sans fissures Un critère • plafond en bon état manque=0 • fenêtres vitrées opaques • portes fonctionnelles …….…. / 20 99 La table d’opération est en bon état Tous les critères • Facilement maniable remplis=20 • Revêtement de mousse avec toile cirée Un critère • Manettes fonctionnelles des membres manque=0 …….…. / 20 100 L’éclairage est en bon état Tous les critères • Lampe scialytique avec ampoules fonctionnelles remplis=20 • Lumière de réserve assurée (groupe électrogène, énergie solaire, lampe avec batterie rechargeable) Un critère manque=0 …….…. / 20 101 L’équipement de base est disponible Tous les critères • Appareil d’anesthésie générale remplis=30 • Kit de rachianesthésie Un critère • Respirateur manque=0 • Aspirateur électrique …….…. / 30 • Bistouri électrique et cautérisation 102 Deux kits d’intervention stérilisés sont prêts pour les urgences 30 (césarienne – chirurgie viscérale, traumato-orthopédie, fixateur …….…. / 30 externe facilement maniable) 103 Disponibilité d’un vestiaire et d’un espace de lavage et brossage Tous les critères adéquats remplis=20 • Dispositif de désinfection approprié à pédale ou à coude • Disponibilité de l’eau courante Un critère • Disponibilité de brosses avec savon manque=0 …….…. / 20 104 Disponibilité de tenues adéquates (blouses chirurgicales, masques, 20 …….…. / 20 bonnets, sandales) 105 Registre opératoire bien rempli et à jour 20 …….…. / 20 106 Conditions d’hygiène assurées dans la salle d’opération 20 • Poubelles pour matériaux infectés avec couvercle • Boites de sécurité pour les aiguilles …….…. / 20 107 Existence d’une petite salle de plâtrage et présence du matériel 20 nécessaire (rouleaux de différentes tailles, bassin, coupe plâtre, …….…. / 20 bandes ouatées Points TOTAUX - 200 …………/220 Disponible Disponible NON 13. MEDICAMENTS TRACEURS OUI < CMM / 2 Stock de Sécurité = Consommation Moyenne Mensuelle (CMM) / 2 > CMM / 2 1 0 1. Ampicilline injectable 1g ou 500mg 1 0 2. Cotrimoxazole comp 480 mg 1 0 3. Diazepam 10 mg / 2ml – injectable 1 0 4. Poche de sang 1 0 5. Methergine amp 10 Unités 1 0 6. Metronidazole comp 250 mg 1 0 7. Paracetamol comp 500 mg 1 0 8. Quinine comp 500 mg 1 0 9. Quinine injectable 1 0 10. SRO / oral sachet 1 0 11. Ringer Lactate 1 0 12. Glucosé 5% 1 0 13. Fils résorbable elt non résorbable 1 0 14. Gants stériles 1 0 15. Compresses 1 0 16. Bombone d’oxygène Points TOTAUX 16 …… /16 VERIFIER QUE TOUTES LES QUESTIONS SONT REMPLI ES L’évaluateur remercie le personnel Problèmes prioritaires identifiés …………………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………………………………………………… Actions urgentes d’amélioration proposées …………………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………………………………………………… Current versions: REPUBLIQUE DU BURUNDI MINISTERE DE LA SANTE PUBLIQUE ET DE LA LUTTE CONTRE LE SIDA DIRECTION GENERALE DE LA SANTE PUBLIQUE GRILLE D’EVALUATION TRIMESTRIELLE DE LA QUALITE TECHNIQUE DU CENTRE DE SANTE INFORMATIONS GENERALES • IDENTIFICATION DU CENTRE DE SANTÉ Centre de santé de : CDS District Sanitaire: Province : Téléphone : Fax : B.P : Statut : Public Agréé Privé Nb personnel A0: Pop. desservie : Nombre de lits: Nb personnel A1: Nb personnel A2 Ratio personnel qual/2000 Nombre lits/1000 hab.: Nb personnel A3 hab.: Nb personnel non qual(A4/A5): Nb personnel non qual. (A6) Nom du Responsable : Téléphone : B.P : E-mail : MEMBRES DE L’EQUIPE D’EVALUATION No NOMS ET PRENOMS FONCTION SIGNATURE PARTICIPANTS DU CDS No NOMS ET PRENOMS FONCTION SIGNATURE SYNTHÈSE TRIMESTRIELLE DE L’ÉVALUATION DE LA QUALITÉ DU CENTRE DE SANTÉ Points Points N ACTIVITÉ EVALUEE % Observations Disponibles attribués 1 Activités générales 230 2 Suivi évaluation/SIS 190 3 Hygiène, Environnement et Stérilisation 230 4 Consultation externe et Hébergement 330 5 Maternité 140 6 Consultation Prénatale 130 7 Planning familial 110 8 Vaccination et suivi des nourrissons 130 9 Lutte contre le VIH/SIDA 270 10 Tuberculose et Lèpre 150 11 Laboratoire 76 12 Petite chirurgie 53 13 Gestion des Médicaments 205 14 Gestion financière 200 15 Santé communautaire 56 TOTAL 2 500 SYNTHESE DES OBSERVATIONS ET DES RECOMMANDATIONS SUR LES SERVICES DU CDS BDS_____________________________CDS_______________________________ Date ________________ 5. Recommandations non-appliquées du trimestre précédent et leurs justifications 6. Points forts et points à améliorer identifiés au cours de l’évaluation de ce trimestre 7. Recommandations par rapport aux points à améliorer 8. Supervisions techniques recommandées __________________________ ___________________ Signature de l’évaluateur Date 1. Activités générales (…) POINTS CRITERES DE POINTS No RESULTATS A EVALUER MAXIMUM COTATION OBTENUS POSSIBLE Disponibilité de la Carte Sanitaire de l’aire géographique de santé et affichée: Tous les 4 critères Carte sanitaire de la FOSA montrant : remplis= 10 1 5) Collines ou quartiers 10 6) Routes principales Un des critères 7) Barrières naturelles manque=0 8) Points spéciaux et distances Disponibilité de l’horaire de travail et rôle de garde : 2 Horaire de travail et rôle de garde affichés et accessibles au Critère rempli=10 10 public Disponibilité de Radio ou téléphone portable pour la communication avec la FOSA de première référence : 3 Critère rempli= 40 40 Radio avec batterie chargée (tester la fonctionnalité par appel) et/ou Téléphone avec unités d’appel d’au moins 1000Fbu Disponibilité des tarifs de recouvrement des couts 4 Tarifs de recouvrement des couts affichés et accessibles au Critère rempli=10 10 public Inventaire de l’équipement et matériel pour chaque service Inventaire existe existe et actualisé chaque trimestre et à jour = 10 5 10 Inventaire manque ou non à jour = 0 Services disponibles avec personnel en permanence 24h/24h, 7/7 jours, y compris les jours féries : L’évaluateur confirme par vérification : Permanence 6 3) de l’horaire de permanence élaboré et accessible au 100 confirmée = 100 public (affiché) 4) de l’enregistrement des cas pour 3 jours non ouvrables tirés au hasard au cours du trimestre évalué Existence d’une source d’énergie d’éclairage pendant la nuit : 7 Critère rempli=20 20 électricité, groupe électrogène ou énergie solaire 1. Activités générales (…) POINTS CRITERES DE POINTS No RESULTATS A EVALUER MAXIMUM COTATION OBTENUS POSSIBLE Bon Accueil assuré aux bénéficiaires des services : 1) Lieux d’attente couverts avec chaises ou bancs 2) Existence Un élément 8 d'un système de triage avec numéro d'ordre et orientation 3) présent = 10 (Max 30 Présence d’une personne faisant le triage selon la gravité et le 3 éléments) numéro d’ordre MAXIMUM POSSIBLE = POINTS 230 OBTENU = 2. Suivi évaluation/SIS POINTS CRITERES DE POINTS No RESULTATS A EVALUER MAXIMUM COTATION OBTENUS POSSIBLE Existence du Plan d’Action Annuel centré sur les prestations du PMA 5) Compte rendu de la réunion d’élaboration du Plan d’Action Annuel avec liste des participants signée 6) Implication des acteurs clés dans l’élaboration du Plan Un Critère 1 d’Action Annuel, tels que les responsables de services rempli=5 20 de la FOSA, le COSA et le BDS. 7) Plan d’Action Annuel basé sur le Plan d’Action Annuel du District Sanitaire (reprend les indicateurs de résultats du District Sanitaire 8) Plan d’action annuel transmis au BDS le premier mois de l’année Existence du Plan d’Action Trimestriel approuvé par l’ECD : 4) Compte rendu de la réunion d’élaboration du Plan d’Action Trimestriel avec liste des participants signée 5) Implication des acteurs clés dans l’élaboration du Plan Un critère 2 d’Action Trimestriel, tels que les responsables de 15 rempli=5 services de la FOSA, le COSA, et les responsables des FOSA sous contractées. 6) Plan d’Action trimestriel basé sur le Plan d’Action Annuel (reprend et développe les lignes du PAA) 2. Suivi évaluation/SIS POINTS CRITERES DE POINTS No RESULTATS A EVALUER MAXIMUM COTATION OBTENUS POSSIBLE Un PV Les PV mensuels des 3 réunions techniques de la FOSA au remplissant cours du trimestre évalué : tous les Chaque PV doit contenir : 1) la date, l’heure de début et de fin critères = 10 3 de la réunion 2) l'agenda ou l’ordre du jour 3) la liste de 30 présence des participants signée 4) Déroulement de la réunion Un PV avec et décisions prises 5) suivi des décisions prises lors de la même un réunion précédente critère non- rempli = 0 Un PV Les PV mensuels des 3 réunions du Comité de Santé (COSA) remplissant au cours du trimestre évalué : tous les Chaque PV doit contenir : 1) la date, l’heure de début et de fin critères = 10 4 de la réunion 2) l'agenda ou l’ordre du jour 3) la liste de 30 présence des participants signée 4) Déroulement de la réunion Un PV avec et décisions prises 5) suivi des décisions prises lors de la même un réunion précédente critère non- rempli = 0 Un rapport d’analyse de données pour Rapport d’analyse mensuelle des données SIS du trimestre 5 activités évalué sur les problèmes prioritaires (Vaccination, CPN, PF, remplissant les 5 Accouchement) contenant : 1) Courbe d’évolution ou tableau 15 2 critères = 5 de données 2) Commentaires de l’évolution des activités par Un rapport rapport aux cibles. avec même un critère non rempli = 0 Rapport SIS transmis au BDS dans les délais : ème 4) Rapport mensuel SIS transmis au BDS avant le 5 jour du mois suivant et rempli à 100% (c’est- à dire Tous les toutes les rubriques sont remplies et correctement Rapports remplies) attendus pour 5) Le rapport hebdomadaire des 7 maladies à potentiel un mois 6 épidémique (rapport à transmettre en dehors des 30 correctement épidémies au BDS chaque lundi suivant la semaine remplis et notifiée) dans les délais 6) le rapport mensuel des 16 maladies sous surveillance = 10 transmis au BDS 2. Suivi évaluation/SIS POINTS CRITERES DE POINTS No RESULTATS A EVALUER MAXIMUM COTATION OBTENUS POSSIBLE Archivage correct des documents usuels de la FOSA (Plans d’Actions, Rapports mensuels d’activités, PV des réunions, Dossiers administratifs du personnel, ROI, et lettres administratives…) : Tous les 4) Classeurs dans les étagères étiquetés critères 5) Accessibles au personnel habileté remplis=20 7 20 6) Documents faciles à retrouver dans un délai ne dépassant pas 5 minutes Un critère manque=0 Disponibilité des outils (documents) d’usage pour différents services : 1) Formulaires de rapports SIS (au moins 3 copies) 2) Fiches de référence/Contre référence (au moins 10) Un critère 8 3) Fiches (carnets pour la mère) CPN (au moins 20) 30 rempli=5 4) Fiches PF (au moins 20) 5) Partogrammes vierges (au moins 10) 6) Fiches d’hébergement (au moins 10) MAXIMUM POSSIBLE = POINTS 190 OBTENU = 3. HYGIENE, ENVIRONNEMENT ET STERILISATION (---) POINTS INDICATIONS POUR LA No RESULTATS A EVALUER MAXIMUM POINTS OBTENUS COTATION POSSIBLE Existence d’une clôture des bâtiments de la FOSA et bien entretenue Critère rempli=10 1 Si haie vive : taillée sans passage non contrôlé 10 Si en sticks ou en durs : sans passage Critère non rempli=0 Présence de moustiquaires au niveau de toutes les 2 Critère rempli=10 10 fenêtres Propreté des salles, de la cour et du terrain assurée: 1) présence de poubelles (dans le hall d’attente et le couloir) 2) Absence de déchets dispersés 3) Présence des Chaque critère de 3 40 réceptacles pour matériel d’injection dans les salles de propreté rempli = 10 soins 4) Environnement dans l’enceinte du CS entièrement débroussaillé avec drainage d’eau stagnante Existence d’un Incinérateur : fonctionnel et utilisé et vidé 4 (triage et destruction …) Critère rempli= 20 20 Existence d’une Fosse à placenta : avec dalle et couvercle 5 Critère rempli= 10 10 qui se ferme a clé Disponibilité d'une source d'eau (Eau courante ou puits ou Source d’eau disponible 6 10 pompe ou château/citerne d’eau/ fût d’eau bien couvert) = 10 Points d’eau disponibles dans les salles de consultations, Points d’eau disponibles 7 10 d’hébergement, laboratoire et près des latrines = 10 Toutes les latrines Présence des latrines 1) utilisables remplissent les critères = 2) Plancher sans fissures avec un seul trou et couvercle 3) 8 30 30 absence de matières organiques autour 4) porte qui se Un critère manque pour ferme une fois à l’intérieur même une latrine=0 Présence des douches 1) utilisables avec eau courante ou Toutes les douches récipient avec au moins 20 litres remplissent les critères = 9 2) absence de matières organiques autour 3) porte qui se 20 20 ferme une fois à l’intérieur 4) évacuation des eaux usées Un critère manque pour dans un puits perdu même une douche=0 Disponibilité des matériels de stérilisation et Critère rempli = 50 10 fonctionnels : 1) cocotte ou autoclave ou poupinel si critère 1 n’est pas 50 fonctionnel 2) protocole de stérilisation affiché rempli=0 Produit présent, solution étiquetée avec formule et date de préparation. Réserve de produit de décontamination. Solution 11 matériels utilisés 10 étiquetée avec formule et date de préparation trempés (s’il y en a) dans les solutions de décontamination = 10 Tenue réglementaire propre et en bon état portée par Tenue portée par tout le 12 10 tout le personnel personnel = 10 MAXIMUM POINTS POSSIBLE = OBTENU = 230 4. CONSULTATION EXTERNE (CE)/URGENCE ET HEBERGEMENT (---) POINTS INDICATIONS POUR POINTS No RESULTATS A EVALUER MAXIMUM LA COTATION OBTENUS POSSIBLE Salle de consultation équipée de 10 Matériels d’examens disponibles dans la salle de consultation matériels et fonctionnels : 1) thermomètre 2) tensiomètre 3) fonctionnels = 20 stéthoscope, 4) otoscope, 5) gants, 6) balance adulte et Salter, 7) 1 Un matériel 20 abaisse langue 8) table d’examen 9) Toise 10) Tables de rapport Poids/Taille et ruban pour PB manque ou non- fonctionnel = 10 Plus d’un matériel manque ou non- fonctionnel = 0 Conditions de confidentialité assurées: Local de consultation Confidentialité 2 individuel avec rideaux ou fenêtres peintes, paravent (si salle 20 assurée = 20 partagée) portes fermant Documentation d’appui à la consultation à la portée du Chaque document prestataire : 1) Ordinogramme IST 2) Protocole national de prise présent dans la en charge du paludisme 3) Guide de la Tuberculose 4) salle = 4 3 20 Ordinogramme de prise en charge de la diarrhée 5) Ordinogramme de prise en charge des IRA Toutes les consultations externes sont faites par un Infirmier 4 qualifié Critère rempli=20 20 Consultations faites par un Infirmier au moins de niveau A3 Pris en charge Prise en charge correcte des pathologies selon l’ordinogramme correcte de 100 ou le protocole : 5 cas= 10 100 Prise en charge correcte pour 10 cas tirés au hasard dans le Entre 9-5 cas=50 registre de CE Moins de 5cas=0 La stratégie de prise en charge intégrée des maladies de 6 Critère rempli=40 40 l’enfance PCIME est appliquée Registre de CE correctement rempli : Les 2 critères 3) numérotation (enregistrement) des cas correcte remplis=10 7 4) remplissage de toutes les informations requises selon le 10 Un critère canevas manque=0 Disponibilité du matériel et équipement de la salle Tous les critères d’hébergement : 1) lits avec matelas plastifiés non déchirés 2) remplis=10 8 10 moustiquaires pour tous les lits 3) draps et couvertures propres Un critère et non déchires 4) au moins 1 armoire disponible pour 4 malades manque=0 9 Prise en charge correcte des 5 cas hébergés (Analyse des Fiches Un cas avec tous les 50 4. CONSULTATION EXTERNE (CE)/URGENCE ET HEBERGEMENT (---) d'hébergement choisies au hasard) : 1) identification du patient critères remplis = 2) plaintes ou symptômes à l'entrée, 3) examen clinique orienté 10 par l’ordinogramme à l’admission 4) examens de laboratoire selon l’ordinogramme 5) diagnostic 6) traitement correct selon Un cas avec même l’ordinogramme ou protocole 7) suivi de signes vitaux 8) un critère non- absence de signe de danger 9) durée de séjour ne dépassant pas rempli = 0 2 jours Registre d’hébergement correctement rempli : Les 2 critères 3) numérotation (enregistrement) des cas correcte remplis=5 10 4) remplissage de toutes les informations requises selon le 5 Un critère canevas manque=0 Détermination des cas de malnutrition sur chaque colline (l’état Réalisé=15 11 nutritionnel) de tous les enfants de moins de 5 ans qui viennent 15 Non réalisé=0 en consultation Détermination de l'état nutritionnel de toute femme dont Réalisé=10 12 10 l'enfant malade est âgé de moins de 6 mois Non réalisé=0 Critère rempli=5 Cahier de dépistage de l'état nutritionnel disponible et bien 13 Critère non 5 rempli (à jour) rempli=0 Critère rempli=5 14 Prise en charge de la malnutrition selon le protocole national Critère non 5 rempli=0 SCORE MAXIMUM POSSIBLE = SCORE 330 OBTENU = 5. MATERNITE (---) POINTS INDICATIONS POUR POINTS No RESULTATS A EVALUER MAXIMUM LA COTATION OBTENUS POSSIBLE Salle en bon état et rassurant les conditions de confidentialité : Murs Tous les critères en dur sans fissure avec crépissage et peinture, Pavement en ciment remplis = 10 1 10 sans fissure, Rideaux ou fenêtres peintes, paravent (si salle partagée), portes fermant Un critère manque=0 Equipements et matériel disponibles et fonctionnels : 1) table Un matériel d’accouchement maniable et propre 2) au minimum 3 boîtes disponible et 2 60 d’accouchement stériles (avec pince porte aguille, deux pinces de fonctionnel = 3 Kocher, pince chirurgical à griffes, deux ciseaux) 3) stéthoscope 5. MATERNITE (---) POINTS INDICATIONS POUR POINTS No RESULTATS A EVALUER MAXIMUM LA COTATION OBTENUS POSSIBLE obstétrical 4) fil de suture, 5) anesthésique local (au moins 50ml de Si même un matériel réserve) et ergométrine 6) balance pèse-bébé 7) tambour avec de (1) à (5) non champs stériles 8) pommade ophtalmique 9)tambour avec gaze 10) disponible ou non- tablier en plastique 11) source de lumière 12) embu bébé 13) bottes fonctionnel = 0 14) masque 15) lunettes 16) gants non déchirés 17) Fil de ligature du cordon 18) Sceau a placenta 19) Table de réanimation néonatale 20) point d’eau en suffisance avec savon ANALYSE DES PARTOGRAMMES DES TROIS DERNIERS MOIS Analyse de 10 partogrammes choisis au hasard : Un partogramme 1) Partogramme rempli selon les normes (remplissage chaque heure, remplissant les 4 TA indiquée, …) 2) Décision prise en cas du dépassement de la ligne critères = 5 3 d'alerte endéans une heure 3) Le score d’APGAR est mesure et figure Un partogramme 50 dans le partogramme a la 1ere, 5eme et 10eme minute 4) avec même un Accouchement fait par un personnel qualifié (au moins un infirmier critère non-rempli = A3) 0 Salle d’hébergement des accouchées adéquate : Tous les critères 3) lits avec matelas plastifiés non déchirés 4 remplis=20 20 4) draps et couvertures et moustiquaire à chaque lit occupé Un critère manque=0 MAXIMUM POINTS POSSIBLE = OBTENU = 140 6. CONSULATATION PRENATALE (--) POINTS INDICATIONS POUR POINTS No RESULTATS A EVALUER MAXIMUM LA COTATION OBTENUS POSSIBLE PERSONNEL, SALLE ET MATERIEL DE LA CPN Conditions de confidentialité assurées: Local de consultation 1 individuel avec rideaux ou fenêtres peintes, paravent (si salle Confidentialité assurée = 10 10 partagée) portes fermant Equipement et matériel disponible et fonctionnel : 1) Table Tous les matériels disponibles de consultation 2) Tensiomètre 3) stéthoscope 4) Mètre et fonctionnels = 20 2 20 ruban lisible 5) Balance avec Toise 6) Fœtoscope 7) Gants non Un matériel manque ou non- déchirés fonctionnel = 0 IEC/CCC de groupe : 1) causerie de groupe réalisée avant la IEC/CCC remplissant tous les CPN 2) existence d’un cahier de rapport d’IEC à jour avec : a) 3 critères = 10 10 thème b) nombre de participants c) responsable d’activité d) date et e) signature Même un critère non-rempli = 0 CPN faite par un personnel qualifié (qualification: au moins Oui = 5 4 5 un infirmier A3) Non = 0 VERIFICATION DE 10 FICHES DE CPN CHOISIES AU HASARD (lors de la réalisation des CPN) Interrogatoire correctement mené: 1) antécédents gynéco – obstétricaux sur les grossesses (y compris le VAT) et Un cas remplissant tous les accouchements antérieures (GPAvEV) 2) fièvre 3)convulsions critères = 1 5 10 4) antécédents médico-chirurgicaux : a) diabète b) Un cas avec même un critère cardiopathies c) HTA d) néphropathies e)TBC f) asthme 4) 5) non-rempli = 0 DDR 6) Anamnèse générale Proposition systématique de dépistage VIH (doit être marquée sur la fiche CPN Existe=10 6 10 N’existe pas=0 Examen physique effectué: 1) poids 2) taille 3) TA 4) examen Un cas avec 5 éléments = 1 7 des seins et 5) recherche des œdèmes 6) PB 10 Un cas avec même 1 élément qui manque = 0 Examen obstétrical effectué : 1) HU 2) présentation (à partir Un examen d’un cas de 36 semaines) 3) BCF (à partir de 20 semaines) 4) remplissant les critères = 1 8 Mouvement fœtaux 10 Un examen d’un cas avec même un critère non rempli = 0 Examens complémentaires demandés, Recherche Un cas avec tous les examens systématique de : 1) syphilis 2) hémoglobine, Albumine si complémentaires = 1 9 signe de HTA 3) Glucose 10 Un cas avec un même examen qui manque = 0 Administration du VAT selon les directives : 1) intervalle Un cas d’administration du VAT respecté 2) vaccin non périmé 3) conservation selon les remplissant tous les critères = 10 normes dans le lieu de vaccination 4) voie d’administration du 0,5 5 VAT correspond à celle indiquée sur le flacon et lieu d’injection Un cas avec un critère non selon les normes. rempli = 0 Prescription correcte du : 1) fer et acide folique 2) Un cas avec toutes les Mebendazole 3) moustiquaire imprégnée d’insecticide prescriptions faites 11 correctement =0,5 5 Un cas avec même une prescription incorrecte = 0 Gestion des cas avec facteurs de risque assuré: 1) facteurs de Gestion d’un cas remplissant risque identifiés 2) décision prise correctement selon la fiche tous les critères = 2 CPN 3) information communiquée à la femme Gestion d’un cas avec même un critère non rempli = 0 12 20 Registre de CPN correctement rempli : 3) numérotation (enregistrement) des cas correcte Les 2 critères remplis=0,5 13 4) remplissage de toutes les informations requises selon 5 Un critère manque=0 le canevas MAXIMUM POSSIBLE = POINTS 130 OBTENU = 7. PLANIFICATION FAMILIALE (---) POINTS POINTS No RESULTATS A EVALUER INDICATIONS POUR LA COTATION MAXIMUM OBTENUS POSSIBLE VERIFICATION DIRECTE DE LA SALLE ET MATERIEL Conditions de confidentialité assurées: Local de 1 consultation individuel avec rideaux ou fenêtres Confidentialité assurée = 10 10 peintes, portes fermant Les consultations sont faites par un personnel 2 qualifié : au mois un Infirmier A3 (voir au moins 5 Critère rempli=5 5 fiches de PF) 7. PLANIFICATION FAMILIALE (---) POINTS POINTS No RESULTATS A EVALUER INDICATIONS POUR LA COTATION MAXIMUM OBTENUS POSSIBLE Méthodes Contraceptives : • Pilules • Injectables Une méthode contraceptive • Implant remplissant les 2 critères = 4 • Préservatif 3 20 • DIU avec pince à col et hystéromètre Une méthode contraceptive avec même un critère non rempli = 0 1) Disponibilité du contraceptif avec stock théorique correspondant au stock physique 2) Seuil d’alerte déterminé et respecté. Disponibilité des affiches murales ou boite a image 4 Critère rempli=5 5 pour la démonstration des méthodes de PF Registre PF disponible: 5 Critères remplis=5 5 1) a jour 2) toutes les rubriques remplies IEC/CCC de groupe : 1) causerie de groupe réalisée avant la séance de consultation 2) existence d’un IEC/CCC remplissant tous les 6 cahier de rapport d’IEC à jour avec : a) thème b) critères = 10 10 nombre de participants c) responsable d’activité d) Même un critère non-rempli = 0 date et e) signature Le CDS atteint au moins 90% de la cible trimestrielle 7 en contraceptifs oraux et injectables fixés dans le Critère rempli=5 5 Plan d’Action ANALYSE DE 10 FICHES DE PF DES TROIS DERNIERS MOIS CHOISIS AU HASARD La fiche PF disponible : 8 1) rubriques remplies 2) classées par mois de rendez Critères remplis pour 1 fiche= 1 10 vous dans l’échéancier Justification des méthodes recommandées, retenues Justification correcte = 3 9 et prescrites par rapport aux méthodes indiquées 30 Non justifiée = 0 par l’interrogatoire, antécédents, examen physique. Oui = 1 10 Contrôle et suivi : Rendez vous fixé 10 Non = 0 MAXIMUM POSSIBLE = POINTS 110 OBTENU = 8. VACCINATION ET SUIVI DES NOURRISSONS (---) POINTS INDICATIONS POUR LA No RESULTATS A EVALUER MAXIMUM POINTS OBTENUS COTATION POSSIBLE OBSERVATION DE LA SALLE ET DU MATERIEL Equipement et matériel disponible au CS Tous les équipements et et fonctionnel : 1) réfrigérateur 2) matériels disponibles et accumulateurs de froid 3) boîte isotherme fonctionnels = 20 1 20 avec mousse 4) réserve de pétrole (5 litres Même un équipement ou minimum) et/ou générateur 5) matériel manque ou non thermomètre fonctionnel = 0 Disponibilité des vaccins et diluants: • BCG • VAP Disponibilité de tous les • VAR antigènes et diluants • DTC+HepB+Hib remplissant les 2 critères = 2 • VAT 30 30 • Diluants Péremption ou rupture 1) Présence physique des antigènes non même d’un antigène ou un périmés avec étiquette 2) Absence de diluant = 0 rupture de stock pendant les 3 derniers mois Conservation remplissant le Conservation des vaccins 1) Absence des 3 critère = 20 produits autres que vaccins, accumulateurs 20 et eau de dilution dans le frigo. Conservation avec tout autre produit = 0 Consommables et imprimés disponibles : 1) seringues autobloquantes 2) seringues Disponibilité de tous les 4 de dilution (de 2 et 5 ml) éléments = 10 10 3) réceptacles 4) ouate 5) fiches de Même un élément manque vaccination 6) fiches de pointage 7) registre =0 de vaccination Chaîne rempli les 2 critères Chaîne de froid: 1) Température du frigo = 20 5 dans les limites (entre +2°C et +8°C) 2) 20 Absence de rupture de la chaîne de froid au Même un jour de rupture = cours de 3 derniers mois. 0 Gestion de stock vaccins : 1) stock Gestion remplissant les 2 théorique de vaccins correspond au stock 6 critères = 5 5 physique 2) stock minimum déterminé et respecté. Même un critère non rempli 8. VACCINATION ET SUIVI DES NOURRISSONS (---) POINTS INDICATIONS POUR LA No RESULTATS A EVALUER MAXIMUM POINTS OBTENUS COTATION POSSIBLE =0 IEC/CCC de groupe : 1) causerie de groupe réalisée avant la vaccination 2) existence d’un cahier de rapport d’IEC à jour avec : IEC/CCC remplissant tous les thème, nombre de participants, critères = 5 5 7 responsable d’activité, date et signature 3) Même un critère non rempli matériel didactique disponible et adapté 4) =0 séance tenue en conditions adéquates (lieu couvert, bancs ou chaises…) Existence du système = 5 Système d’identification des enfants 5 8 Non-existence du système = attendus pour la séance 0 Système de récupération des Existence du système = 10 abondons (par ex : échéancier, registre 10 9 Non-existence du système = avec colonne rendez vous, fiche individuelle classée) 0 Registre de PEV disponible: Critères remplis=5 10 5 1) a jour 2) toutes les rubriques remplies Un critère manque=0 MAXIMUM POSSIBLE = POINTS 130 OBTENU = 9. LUTTE CONTRE LE VIH (---) INDICATIONS POINTS POINTS No RESULTATS A EVALUER POUR LA MAXIMUM OBTENUS COTATION POSSIBLE 1 Salle de counseling équipée et garantissant la confidentialité:1) Murs en dur avec crépissage et peinture, 2) Un critère 10 pavement en ciment sans fissures 3) plafond en bon état 4) rempli=2 fenêtres en vitres avec rideaux 5) portes fermant 2 Respect du protocole de dépistage volontaire:1) Conseil pré 3 critères test 2) utilisation d'un test sensible (Hexagon ou Détermine) et remplis=40 confirmation par un test spécifique (Génie II) 3) Conseil post Un critère test avec remise de résultat manque=0 40 9. LUTTE CONTRE LE VIH (---) INDICATIONS POINTS POINTS No RESULTATS A EVALUER POUR LA MAXIMUM OBTENUS COTATION POSSIBLE 4 critères 3 Suivi correct des PVVIH sous ARV remplis=20 1)RDV respecté le 14 ième jour (pour traitement incluant la Un critère Névirapine), chaque mois jusqu'à 6mois et tous les trois mois manque=0 20 4 après 6 mois 2)Bilan immunobiologique fait selon le protocole appliqué 3) Examen clinique fait à chaque visite 4) Recherche et mesure de l'observance à chaque visite Approvisionnement sans faille des réactifs, des médicaments et ARV 4 critères 1)Existence du stock de sécurité (CMM/2) remplis=40 5 2) Les fiches de stock sont à jour et concordance du stock Un critère 40 théorique et physique manque=0 Protocole de la PTME disponible et utilisé 2 critères 1) Prophylaxie antirétrovirale correctement conduite à 28 SA remplis=20 6 2)Pratiques obstétricales à moindre risques appliquées Un critère 20 3) Prophylaxie antirétrovirale correctement conduit chez le NNé manque=0 Suivi correct des NRS nés des femmes séropositives 3 critères 1) RDVmédical mensuel respecté remplis=20 7 2) Administration du cotrimoxazole 20 Un critère 3) Suivi de la croissance de l'enfant manque=0 4) Examen clinique à chaque visite Accompagnement psychosocial de la femme enceinte ou 4 critères allaitante séropositive remplis=30 8 1) Conseils sur l'alimentation du nourrisson Un critère 30 2) Conseils sur la PF chez les femmes allaitantes manque=0 Le dossier du malade existe et aucun élément de suivi ne 2 critères manque remplis=40 9 Un critère 40 manque=0 Tous les registres sont disponibles et sont bien remplis et bien critère 10 classés remplis= 30 30 Présence de prestataires qualifiés formés sur le conseil et critère 11 dépistage du VIH, la PTME et la PEC du VIH remplis=10 10 MAXIMUM POSSIBLE = critère 10 270 remplis=10 9. LUTTE CONTRE LE VIH (---) INDICATIONS POINTS POINTS No RESULTATS A EVALUER POUR LA MAXIMUM OBTENUS COTATION POSSIBLE MAXIMUM POINTS POSSIBLE = OBTENU = 270 10. TUBERCULOSE et LEPRE (---) INDICATIONS POINTS POINTS No RESULTATS A EVALUER POUR LA MAXIMUM OBTENUS COTATION POSSIBLE OBSERVATION DU MATERIEL, IMPRIMES ET PRODUITS Gestion remplissant les 2 Gestion de stock des antituberculeux (Rifampicine, Streptomycine, critères Ethambutol): pour anti-TBC= 1 50 50 1) présence des antituberculeux en fonction des malades sous traitement 2) stock théorique correspond au stock physique Un critère manque=0 Disponibilité des imprimés : 1) registre des cas de tuberculose (pour CDT) 2) fiche de prise en charge 3) registre de laboratoire (pour les Présence de tous CDT) 4) fiche de transfert 5) fiche de contre référence (pour les CDT) les imprimés = 20 2 6) bon de labo 7) registre de réquisition des antituberculeux 8) 20 Absence même registre de réquisition de matériels et réactifs de laboratoire. 9) d’un imprimé = 0 registre de réquisition des imprimés 10) Registre Lèpre 11) Protocole schéma court et retraitement affiché dans la salle de consultation ANALYSE DE 2 CAS CHOISIS AU HASARD SUR LES FICHES ET REGISTRE Prise en charge correcte selon les directives PNLT : 1) au moins 2 Un cas examens de crachat sont positifs et enregistrés sur la fiche de remplissant tous traitement pour les nouveaux cas TPM+ (résultat de laboratoire les critères = 70 3 annexé à la fiche) 2) traitement conforme aux protocoles PNLT (phase 70 d’initiation, de continuation, de rechute) 3) crachat de contrôle si Un cas avec indiqué fait conformément aux instructions PNLT 4) test VIH effectué même un critère (ou référé) non rempli = 0 Existence d’une stratégie de récupération des malades en cas Stratégie existe = 4 10 d’irrégularité défini par le PNLT (endéans 6 jours) 1 MAXIMUM POINTS POSSIBLE = OBTENU = 150 11. LABORATOIRE (---) POINTS INDICATIONS POUR POINTS No RESULTATS A EVALUER MAXIMUM LA COTATION OBTENUS POSSIBLE OBSERVATION DIRECTE DE LA SALLE ET DU MATERIEL Equipement et matériel disponible et fonctionnel : 1) Microscope Un équipement ou 2) centrifugeuse 3) Hemoglobinomètre 4) lames neuves 5) un matériel 1 lamelles 6) source de lumière 7) Minuterie 8) Flacons à crachat 9) 26 disponible et flacons à selles 10) Anse de platine 11) Lampe à alcool 12) Crayon fonctionnel = 2 diamant 13) Paillasse Présence de produits réactifs et de bandelettes non périmés : 1) Giemsa 2) Fuchsine, Acide Sulfurique, Bleu de méthylène, Huile à Chaque produit 2 immersion et Alcool (pour CDT) 3) Bandelettes pour albumine et 24 présent = 3 sucre 4) Test de grossesse 5) Huile à immersion 6) KOP 7) Hb 8) VIH Crachoirs, récipients à selles éliminées dans une poubelle Déchets éliminés 3 5 fermable et fermée dans la poubelle = 5 Présence du système d’évacuation des eaux usées garantissant la Présence du système 4 5 protection de l’environnement conforme =5 Disponibilité des démonstrations des parasites (GE, Selles, 5 crachats) : (sur papier plastifié, dans un livre en couleurs, ou Critère rempli=5 5 affiches) Enregistrement des résultats dans le registre de labo : 6 Critère rempli=6 6 1) Correct 2) conforme aux résultats du bon d’examen Présence d’un laborantin ou Infirmier polyvalent d’au moins de 7 Critère rempli=5 5 niveau A3 formé en microscopie SCORE MAXIMUM SCORE POSSIBLE = OBTENU = 76 12. PETITE CHIRURGIE (---) INDICATIONS POUR LA POINTS MAXIMUM POINTS No RESULTATS A EVALUER COTATION POSSIBLE OBTENUS OBSERVATION DIRECTE DE LA SALLE ET DU MATERIEL Salle pour la petite chirurgie disponible et en bon état - Murs en dur avec crépissage et peinture Critères remplis=10 1 - Pavement en ciment sans fissures 10 Un critère manque=0 Lit d’examen disponible - Facilement maniable avec mousse garnie de toile 2 cirée Critère rempli=5 5 Equipement de base disponible dans la salle : 1)Anesthésie locale disponible (au moins 20 ml) 2)Tambour avec compresses stériles 3) Boite à pince avec porte aiguille, pince anatomique, pince de cocher, paire de ciseaux (au moins 3) Chaque matériel 3 4) Gants stériles (au moins 3 paires) 18 disponible = 2 5) Fils résorbables (2 au minimum) 6) Bistouri (au moins 3) 7) Champs stériles dans un tambour 8) Bassins réniformes (au moins 2) 9) présence d’un désinfectant Registre de petite chirurgie bien rempli et à jour 4 Critère rempli =10 10 Conditions d’hygiène assurées dans la salle de petite chirurgie Critères remplis=10 5 1) Poubelles pour matériaux infectés avec couvercle 10 Un critère manque=0 2) Boite de sécurité (pour les aiguilles) bien placé et utilisé SCORE MAXIMUM SCORE POSSIBLE = OBTENU = 53 13. GESTION DES MEDICAMENTS (---) POINTS INDICATIONS POUR LA POINTS No RESULTATS A EVALUER MAXIMUM COTATION OBTENUS POSSIBLE Local de la pharmacie conforme aux normes : Local remplissant tous 1) Etagères 2) local aéré 3) protection contre la lumière directe du les critères = 10 1 soleil 4) protection contre le vol. 10 Même un critère non rempli = 0 Propreté de la pharmacie (absence de poussière sur les étagères et 2 Propreté assurée= 5 5 les produits, de toiles d’araignée) Stockage conforme aux normes : 1) Rangement de tous les produits sur l’étagère et non par terre 2) Ordre de rangement Stockage remplissant logique (ordre alphabétique ou par forme thérapeutique) 3) En tous les critères = 60 3 fonction de la date de péremption 4) avec étiquette sur l’étagère de 60 la dénomination Commune Internationale (noms génériques) 5) Même un critère non Concordance entre le stock théorique et le stock physique 6) Fiches rempli = 0 de stock indiquant la CMM Gestion des outils : • fiche de stock • bons de commande Un outil remplissant • registre d’entrées des médicaments les 2 critères = 5 4 • bon de livraison Un outil avec même 30 • registre de réquisition interne un critère non rempli • inventaire mensuel des médicaments =0 1) Présence de l’outil dans la pharmacie de stock 2) Remplissage conforme aux normes Les médicaments et Disponibilité de médicaments et consommables traceurs (prendre consommables un échantillon de 10 produits) : 1) Disponibilité des molécules et traceurs de consommables 2) Absence de rupture de stock à partir de la l’échantillon 5 60 dernière évaluation 3) Absence de menace de pénurie (vérifier que disponibles = 60 le stock restant est supérieur à la CMM) pour les 10 médicaments Rupture même d’un traceurs) médicament ou consommable = 0 Respect de la procédure de destruction des produits périmés : 1) Procédure remplissant Fiche d’inventaire des produits périmés les 2 critères = 20 6 20 2) Accusé de réception des médicaments et réactifs périmés reçus Même un critère non par le BDS rempli = 0 Equipements et matériel disponibles pour la distribution des matériels disponibles 7 médicaments : 1) filtre à eau 2) spatules 3) cuillères 4) gobelet 5) 5 =5 objet coupant 6) emballages. Utilisation des outils et remplissage à jour : 8 • Registre d’utilisation journalière des médicaments Un outil remplissant 15 (RUMER) les 2 critères = 5 13. GESTION DES MEDICAMENTS (---) POINTS INDICATIONS POUR LA POINTS No RESULTATS A EVALUER MAXIMUM COTATION OBTENUS POSSIBLE • Registre de pointage journalier Un outil avec même • Cahier de réquisition interne un critère non rempli 1) Présence de l’outil 2) Remplissage à jour =0 MAXIMUM POSSIBLE POINTS = OBTENU = 205 LISTE DES MEDICAMENTS TRACEURS DU NIVEAU CENTRE DE SANTE 1. Albendazole co 400 mg 2. Amoxycilline co 500 mg 3. Amoxicilline sirop 4. Paracétamol sirop 5. Mebendazole sirop 6. Métronidazole sirop 7. Chlorhexidine solution 8. Artésunate-amodiaquine Cp enft 2 - 11 mois 9. Artésunate-amodiaquine Cp enft 1 - 5 ans 10. Artésunate-amodiaquine Cp enft 6 – 13 ans 11. Artésunate-amodiaquine Cp enft 14 ans et plus 12. Cotrimoxazole co 480 mg 13. Ergométrine ampoule 14. Fer / Acide folique co 15. Hydroxide d’aluminium co 16. Indométhacine co 25 mg 17. Mébendazole co 100 mg 18. Métronidazole co 250 mg 19. Paracétamol co 500 mg 20. Pénicilline V co 250 mg 21. Quinine co 500 mg 22. Sérum glucosé 5% 500ml 23. SRO sachets 14. GESTION FINANCIERE (---) POINTS INDICATIONS POUR POINTS No RESULTATS A EVALUER MAXIMUM LA COTATION OBTENUS POSSIBLE Tarifs des actes, médicaments et consommables : 1) affichés 2) Tous les critères lisibles 3) à la réception et à la caisse 4) respectés 5) respectant remplis = 20 1 les marges bénéficiaires selon les instructions ministérielles 20 Même un critère non rempli = 0 Quittanciers : 1) disponibles 2) spécifiant : a)nom du client b) le Tous les critères 2 montant reçu en chiffres et en lettres c) le motif de payement remplis = 20 20 (libellé) avec quantification Même un critère non rempli = 0 Journal des recettes : 1) disponible 2) concordant avec le Tous les critères quittancier 3) à jour 4) sans surcharge d’écritures remplis = 20 3 20 Même un critère non rempli = 0 Journal des dépenses : 1) disponible 2) concordant aux Tous les critères justificatifs de dépenses 3) à jour 4) sans surcharge d’écritures remplis = 20 4 20 Même un critère non rempli = 0 Pièces justificatives de dépenses (sur 10 pièces choisies au Une pièce remplissant hasard) : 1) classées et retrouvable endéans 5 min par pièce 2) tous les critères = 20 5 spécifiant : a)nom de l’acquéreur b) le montant reçu en chiffres Une pièce avec même 20 et en lettres c) le motif de dépense, 3) Les signatures du un critère non rempli caissier, du titulaire et de l’acquéreur pour une pièce = 0 Tous les critères Livre caisse banque : 1) disponible 2) concordant avec les remplis = 20 6 pièces justificatives de dépenses et les extraits bancaires et le 20 journal de recettes 3) à jour 4) sans surcharge d’écritures Même un critère non rempli = 0 Trésorerie Situation de trésorerie : 1) Concordance entre situation remplissant les 2 théorique (livre caisse banque) et réelle (livret ou extrait critères = 40 7 bancaire ou caisse physique) 2) Concordance entre Rapport Même un critère non 40 mensuel SIS de trésorerie avec les journaux de recettes et rempli = 0 dépenses Une prévision budgétaire Prévision budgétaire trimestrielle : 1) tirée de la prévision remplissant les 2 8 budgétaire annuelle 2) cosignée par le responsable et le 20 critères = 20 président du Comité de santé Même un critère non rempli = 0 Système de calcul des primes de performance 1) établi 2) 9 Critères remplis= 20 20 connu par le personnel MAXIMUM POINTS POSSIBLE = OBTENU = 200 15. SANTE COMMUNAUTAIRE (---) INDICATIONS POINTS POINTS No RESULTATS A EVALUER POUR LA MAXIMUM OBTENUS COTATION POSSIBLE Disponibilité au CDS des copies des rapports mensuels (3 rapports) Un rapport 1 des TPS indiquant (1) le Nombre de nouvelles latrines hygiéniques remplissant 15 aménagées au cours du trimestre évalué, (2) Identification tous les complète des ménages (Nom et Prénom du chef de ménage, colline critères=5 et sous-colline…) (3) date de visite du ménage par le TPS (4) Nom, prénom et signature du TPS Disponibilité au CDS des copies des rapports mensuels des ASC (3 Critère rempli 2 rapports) indiquant notamment le % de ménages de la ZR avec les pour un 15 MII suspendus sur le lit rapport=5 Le CDS dispose (1) d’un système de collecte des informations dans la communauté et (2) des rapports mensuels concernant : (a) le % des collines dont les Batwa font partie des ASC et Les 2 critères COSA remplis pour : (b) le % des enfants de moins de 2 ans ayant terminés la (a)=6 vaccination (tous les antigènes) au sein des groupes vulnérables en général et la communauté Batwa en (b)=5 56 particulier (c) l’identification de cas de malnutrition sur la colline de (c)=5 recensement (d) l’identification de cas de TBC sur la colline de recensement (d)=5 (e) l’identification et la relance de cas de tuberculeux par les (e)=5 COSA et ASC MAXIMUM POINTS POSSIBLE = OBTENU 56 = REPUBLIQUE DU BURUNDI MINISTERE DE LA SANTE PUBLIQUE ET DE LA LUTTE CONTRE LE SIDA GRILLE D’EVALUATION TRIMESTRIELLE DE LA QUALITE TECHNIQUE DE L’HOPITAL SYNTHESE D’EVALUATION Nombre Points POINTS OBTENUS ENSEMBLE DES COMPOSANTES d’activités à disponibles évaluer I. Indicateurs généraux 9 90 II. Plan d’action semestriel 1 40 III. Gestion financière et Comptabilité 3 70 IV. Gestion des médicaments et produits 7 80 pharmaceutiques V. Hygiène, salubrité de l’environnement et 16 100 stérilisation VI. Laboratoire et transfusion sanguine 8 60 VII. Consultations Externes et Urgences 9 120 VIII. Maternité 8 200 IX. Bloc opératoire 10 140 X. Hospitalisation 3 100 % TOTAL 74 1000 ……………. Date: … / ... / 200.. Province de ……………..…….…. District de ……………….……. Hôpital : public / agrée / privé Nom de l hôpital: ………………… Population du district sanitaire : Nombre de médecins Nombre de lits : ……………… …….….. Nombre personnel A0 : …..… Nombre personnel A1 : …….… Nombre personnel A2 : …….. Nombre personnel A3: ……... Pers. non qualifié A4/A5 23 : ….….. Pers. non qualifié A6: ……….. Ratio de personnel qualifié / 2000 Nombre de lits / 1000 hab. :….. …………….. habitants : ………. EQUIPE D’EVALUATION N° NOM ET PRENOM FONCTION SIGNATURE 23 Personnel non qualifié A4 = Aide Soignant – Agent Formation Rapide (AFR) ; A5 = garçon, fille de salle - stérilisation – maintenance ; A6 = jardinier – sécurité – buanderie. PARTICIPANTS DE L’HOPITAL EVALUE N° NOM ET PRENOM FONCTION SIGNATURE I. INDICATEURS GENERAUX Sujet Activités Indicateurs et critères de verification Indications Points pour la obtenus cotation Gestion des 1. Planification L’hôpital dispose d’un plan d’action annuel centré Critère ressources de annuelle des sur les prestations du Paquet Complémentaire rempli=5 l’hôpital activités d’Activités (PCA) 2. Tenue de Une réunion a lieu au moins une fois par mois, avec Tous les réunions de compte rendu contenant : critères l’équipe de (1) ordre du jour détaillé remplis pour direction de (2) suivi des recommandations de la dernière 1 mois=5 l’hôpital réunion (3) évaluation de l’exécution du plan d’action de Même un l’hôpital critère non (4) recommandations de la réunion avec rempli pour responsable du suivi et délais d’exécution 1 mois=0 (5) liste de présence signée (6) dirigée par le Médecin Directeur de l’hôpital Max-15 3. Entretien des Les infrastructures de l’hôpital sont en bon état, Tous les infrastructures de c’est-à-dire qu’elles ne nécessitent pas de travaux critères l’hôpital importants de remplis=10 • reprise générale de la peinture extérieure • reprise générale de la peinture des Même un chambres critère non • réfection de la toiture rempli=0 • réfection du circuit électrique • réfection du système d’adduction d’eau 4. Maintenance du Existence d’un plan annuel de maintenance Critère matériel et précisant les activités de maintenance à effectuer rempli=5 équipements pour les bâtiments, le matériel, l’équipement et les personnes internes ou externes (contrats de maintenance) responsables 5. Gestion du La gestion rationnelle des véhicules est assurée : Tous les charroi (1) un règlement précisant les responsabilités critères (tâches) et les règles dans l’utilisation du remplis=10 charroi de l’hôpital (2) un dossier par véhicule (y compris les motos) Même un reprenant les fiches de suivi de la critère maintenance (cf. documents de la DGR) manque=0 (3) une synthèse mensuelle des carnets de bord des véhicules (y compris les motos) reprenant au moins leur utilisation, leur kilométrage et leur consommation de carburant mois par mois 6. Disponibilité Une cuisine pour les patients hospitalisés est Tous les d’infrastructures disponible et propre, avec (1) poubelle pour critères complémentaires évacuation des déchets, (2) robinet à moins de 5 m remplis=5 ou réserve d’eau d’au moins 50 litres Un des critères manque=0 Une morgue est disponible (chambre ou petit Critère bâtiment) rempli=5 Permanence des 7. Assurance de la Une garde médico-chirurgicale est organisée par Tous les services garde médico- l’hôpital, c’est-à-dire que critères chirurgicale (1) le rôle de garde est affiché dans un endroit remplis=15 immédiatement accessible au public (2) les responsabilités des individus et des services Chaque (y compris l’ambulance et le bloc opératoire) critère dans l’organisation de la garde fait l’objet rempli=5 d’une directive du médecin directeur de l’hôpital Max=15 (3) un système d’écoute des appels (radiophoniques ou téléphoniques) est effectif (note 24h/24 (vérifier la fonctionnalité de la radio et possible : du téléphone portable avec tous les CDS) 5-10-15) Gestion de 8. Transmission des Pour chaque mois du trimestre présentement Critère l’information rapports évalué, le rapport mensuel du SIS a été transmis rempli=10 eme sanitaire mensuels SIS au BDS au plus tard le 25 jour du mois suivant 9. Analyse des Rapport d'analyse trimestrielle des données SIS Tous les données SIS de comprenant : critères l’hôpital des (1) La liste signée de présence des participants a remplis=10 périodes la séance d’analyse des données antérieures (2) résultats d’analyse sous forme de graphiques Même un avec commentaires, au moins pour 5 critère indicateurs jugés prioritaires (comparaison manque=0 avec cibles, détection des situations particulières, recherche de causes éventuelles, décision ou actions entreprises/corrections éventuelles des erreurs) SOUS-TOTAL INDICATEURS GENERAUX 90 II. PLAN D’ACTION SEMESTRIEL DE L’HOPITAL Sujet Activités Indicateurs et critères de vérification Indications Points pour la obtenus cotation Planification 1. Elaboration et (1) Existence du Plan d’Action Semestriel : Critère (1) semestrielle suivi du Plan (a) Cohérent avec le PAA (reprend / rempli=10 d’Action développe les lignes du PAA) semestriels (b) implication des chefs de services de Critère (2) l’hôpital [vérifier la liste des présences rempli=20 jointe au rapport de réunion d’adoption du Plan d’action] Max=30 (2) Existence d’un rapport trimestriel de suivi de l’exécution du Plan d’Action semestriel (Note indiquant : possible : 0 ; (a) le niveau d’exécution des activités 10 ; 20 ; 30) planifiées pour le trimestre évalué (b) les forces/les opportunités dans l’exécution du PA (c) les difficultés/les défis rencontrés dans la mise en œuvre du PA (d) les solutions/les stratégies envisagées pour faire face aux difficultés/défis Le Plan d’action montre une analyse de Critères l’accessibilité financière : remplis=10 (a) respecte les tarifs fixés au niveau national Un critère (b) existence d’un plan de recouvrement des manque=0 coûts SOUS-TOTAL PLAN D’ACTION SEMESTRIEL 40 III. GESTION FINANCIERE ET COMPTABILITE Sujet Activités Indicateurs et critères de vérification Indications Points pour la obtenus cotation Budget 1. Gestion La gestion budgétaire repose sur : Tous les budgétaire (1) Un budget réaliste établi en fonction des critères ressources disponibles et en concordance remplis=15 parfaite avec le PAA Chaque (2) Un tableau des investissements critère (immobilisations) existe et est à jour, avec les rempli=5 apports de l’Etat et des partenaires Note (3) Des fiches de suivi de l’exécution du budget, possible : pour les recettes comme pour les dépenses, 0 ; 5 ; 10 ; 15) rubrique budgétaire par rubrique budgétaire Comptabilité 2. Gestion de La comptabilité répond aux normes et aux bonnes Tous les comptes de pratiques : critères l’hôpital (1) L’hôpital tient une comptabilité à partie remplis=25 double (2) L’hôpital dispose d’un logiciel de comptabilité De critère (1) (3) Un(e) comptable qualifié(e) (Niveau A1 au à (11)=2 minimum) tient la comptabilité de l’hôpital points par (4) Le nombre de comptes bancaires est inférieur critère rempli à cinq (BRB + fonctionnement + pharmacie + compte facultatif supplémentaire) Critère (12) (5) Les livres de caisse sont complets et à jour rempli=3 (6) Les dépenses donnent lieu à un document d’autorisation de dépenses (7) Les recettes donnent lieu à un document d’enregistrement de recettes (Max=25) (8) Le classement des pièces comptables est correct (numérotation en continu + classement chronologique) (9) Le suivi de la caisse (inventaire de caisse) est au moins mensuel [procès verbal signé] (10) L’hôpital dispose d’un fichier de suivi de ses dettes (11) L’hôpital dispose d’un fichier de suivi de ses créances (12) L’hôpital dispose d’un manuel des procédures financières et comptables (ou de directives équivalentes du médecin directeur) Rapport financier 3. Elaboration et Existence d’un rapport financier mensuel : Tous les transmission (1) conforme au canevas standard du SIS critères du rapport (2) transmis au BDS avec accusé de réception (3 remplis pour financier rapports transmis au cours du trimestre 1 mois=10 mensuel évalué) (Max=30) SOUS-TOTAL GESTION FINANCIERE ET COMPTABILITE 70 IV. GESTION DES MEDICAMENTS ET PRODUITS PHARMACEUTIQUES Sujet Activités Indicateurs et critères de vérification Indications Points pour la obtenus cotation Stock 1. Gestion du Le stockage des produits est correct : Tous les stock de (1) Le local est propre, ventilé, protégé critères médicaments (2) Le rangement des produits se fait par classe remplis=10 de l’hôpital (médicaments, consommables, matériel), puis Même 1 par voie d’administration (per os ou critère non inhalation, injectables, voie cutanée), puis par rempli=0 dosage et par ordre alphabétique (3) La règle du « premier périmé, premier sorti » est appliquée [vérifier sur 5 produits sur les étagères si les produits périmant le plus tôt sont au devant des rayons des étagères] Les fiches de stock sont tenues correctement : Tous les (1) comportent la mention de la consommation critères mensuelle moyenne (CMM) remplis=5 (2) les inventaires mensuels mentionnent un Même 1 stock (quantité) restant à jour [vérifier le critère non stock restant théorique de la fiche de stock rempli=0 avec le stock restant réel sur les étagères, pour au moins 5 produits] La gestion des produits périmés ou détériorés est Tous les correcte est : critères (1) suivie par un registre spécifique remplis=5 (2) donne lieu à des procès verbaux de Même 1 destruction ou Accusé de réception du BDS critère non des produits périmés ou détériorés rempli=0 Commande 2. Assurer les Les commandes sont effectuées selon les normes : Critères commandes (a) reposent sur la formule Commande = CMM x remplis=10 des 2 – SR (où SR est le stock restant) [vérifier en Même 1 médicaments comparant le dernier bon de commande et les critère non fiches de stock de 10 produits commandés] rempli=0 (b) les instructions pour l’achat des médicaments ont été respectées Réception 3. Assurer la La réception des produits est accompagnée : Critère réception des (1) d’un bon de livraison (CAMEBU ou grossistes) rempli=10 médicaments (2) d’un bon de réception signé par un Comité de Critère non réception rempli=0 Livraison 4. Assurer la La livraison des produits : Critère livraison des (1) répond à un bon de commande (réquisition) rempli=10 médicaments des services ou de la pharmacie de détail Critère non (2) donne lieu à la production d’un bon de rempli=0 réception signé par le service ou la pharmacie de détail Distribution 5. Suivi de la La délivrance des médicaments par les services ou Critère consommation par la pharmacie de détail est suivie par une fiche rempli=10 des de consommation journalière Critère non médicaments rempli=0 Médicaments 6. Assurer la (1) Absence de rupture de stock dans le trimestre Tous les traceurs disponibilité [vérifier l’absence de « stock restant = 0 » sur critères permanente les fiches de stock des médicaments traceurs] remplis=15 des (2) Il n’y a pas de sur-stockage [vérifier que le Chaque médicaments « MAD » est inférieur à 2 mois pour les 23 critère traceurs médicaments traceurs] rempli=5 (3) Absence de menace de pénurie [vérifier que le (Max=15) stock restant est supérieur à ½ CMM pour les médicaments traceurs] (voir liste EPISTAT) Gestion globale de 7. Suivi mensuel La fiche de synthèse de la gestion de la pharmacie Critère la pharmacie de la gestion de est complétée et envoyée chaque mois au rempli=5 la pharmacie directeur de l’hôpital pour approbation [voir Critère non modèle dans le module approuvé par le MSPLS] rempli=0 SOUS-TOTAL GESTION DES MEDICAMENTS ET PRODUITS 80 PHARMACEUTIQUES V. HYGIENE, SALUBRITE DE L’ENVIRONNEMENT ET STERILISATION Sujet Activités Indicateurs et critères de vérification Indications Points pour la obtenus cotation Comité d’hygiène, 1. Mise en place et Existence de comité fonctionnel d’hygiène, santé et Les 2 critères santé et sécurité fonctionnement sécurité a l’hôpital avec: remplis=5 en milieu de d’un comité (1) de procès-verbaux de réunions mensuelles Même 1 travail d’hygiène, santé et (2) de plan d’action et d’un rapport trimestriel du critère non sécurité de l’hôpital CHSST rempli=0 (CHSST) Promotion de la 2. Assurer la (1) Existence d’un technicien de promotion de la Critère (1)=3 Santé promotion de santé dans l’hôpital Critère (2)=2 la santé au (2) Affichage accessible au public et au personnel (Max=5) niveau de de l’hôpital des instructions relatives à l’hôpital l’hygiène, environnement et stérilisation Maladies et 3. Notification Existence d’un système (directives) de Notification Critère accidents des maladies et des maladies et accidents professionnels au sein de rempli=5 professionnels en accidents l’hôpital milieu de travail professionnels Protection de 4. Mise en place Existence d’une clôture des bâtiments de l’hôpital l’enceinte l’hôpital et entretien de et bien entretenue : la clôture des Critère (1) Si haie vive : taillée sans passage non rempli=5 bâtiments de contrôlée l’hôpital Critère non (2) Si en briques ou en durs : sans passage rempli=0 (3) Si en fil barbelé, présence de treillis métalliques 5. Dispositifs de Présence de treillis moustiquaires à petite maille au Critère treillis sur les niveau de toutes les fenêtres et sur les combles rempli=5 ouvertures des Critère non bâtiments rempli=0 6. Utilisation de (1) Existence de montants sur les lits pour servir 2 critères MII de support aux moustiquaires remplis=5 (2) Moustiquaire rectangulaire imprégnée Même 1 d’insecticide pour chaque lit occupé critère non rempli=0 Etat des salles, de 7. Entretien de la Propreté des salles, de la cour et du terrain Critère (A) la cour et du propreté des assurée: rempli=5 terrain salles, de la (A) Absence de mauvaises odeurs dans les salles Critère (B) cour et du (B) existence d’un système de triage préalable des rempli=2 terrain déchets placés dans différentes poubelles Critère (C) étiquetées, de préférence de différentes couleurs rempli= 5 (C) présence dans les salles de soins de différentes Critère (D) poubelles avec étiquettes, de préférence de rempli=3 différentes couleurs remplies au ¾ maximum Critère (E) Au niveau de la production des déchets ces rempli=5 poubelles sont les suivantes : Critère (F) 1. Boîtes de sécurité des injections pour déchets rempli=5 pointus, tranchants ou coupants (aiguilles, (NB : si seringues et bistouris ; généralement de couleur critères (A) et jaune) de 5 litres; (F) non 2. Poubelle pour déchets infectieux (pansement, remplis à la ouate, sparadraps, compresses) de couleur bleue ; fois=0) 3. Poubelle pour déchets anatomiques (placentas et amputations), de couleur rouge de 20 litres ; (Max=25) 4. Poubelle pour déchets de récupération ou recyclables (bouteilles, flacons, plastics, ferrailles), de couleur marron de 20 litres; 5. Poubelle pour déchets ordinaires ou ménagers ou décomposables (épluchures, restes d’aliments, etc..) de couleur verte ou noire de 20 litres. Au niveau du stockage : Présence des mêmes types de poubelles que ci- haut à l’exception de la poubelle n°1 et n°3 où les déchets sont immédiatement acheminés dès leur production respectivement à l’incinérateur et dans les fosses biologiques construites pour cette fin. La capacité de ces quatre types de poubelles est de 90 litres. (D) Présence d’autres poubelles étiquetées ou de différentes couleurs dans le hall d’attente et le couloir pour éviter de jeter des déchets par terre (Vérifier si l’introduction de déchets dans les poubelles se fait après le triage préalable) (E) Environnement dans l’enceinte de l’hôpital entièrement débroussaillé avec drainage d’eau stagnante (F) Absence de déchets dispersés NB : Au niveau de l’entreposage pratiqué en ville, il s’agit des mêmes caractéristiques qu’au niveau du stockage mais la capacité des containers sera de 500 litres Traitement des 8. Utilisation et Existence d’un incinérateur avec: Tous les déchets entretien de (1) porte de chargement et porte d’évacuation de critères l’incinérateur la cendre en fonctionnelles remplis =5 (2) l’intérieur de la chambre de combustion Même 1 nettoyé et bien entretenu ; critère non (3) disponibilité d’alcool ou carburant pour la rempli=0 combustion de déchets (4) absence de déchets sur le plancher et dans le voisinage immédiat de l’incinérateur ; (5) existence de brosses, balais de rigole, râteaux, pelles et brouettes pour l’entretien de l’incinérateur (6) présence de clôture avec porte fonctionnelle (7) Existence d’une fosse à cendre d’une profondeur supérieure à 1,50m (excepté en mairie de Bujumbura) 9. Utilisation et Existence d’une fosse biologique à placentas et Tous les entretien d’une amputations : critères fosse à déchets remplis =5 biologiques (1) d’une profondeur de 6 m (là où c’est possible compte tenu de la nature du sol) dont les parois Même 1 critère non sont bétonnées et la couverture portera une dalle rempli=0 en béton armé ; (2) avec couvercle qui se ferme à clé. (3) clôturée, non accessible aux personnes non autorisées et animaux. 10. Mise en place Existence d’une fosse organique ou à compost Critère d’une fosse d’une profondeur supérieure à 1, 50m (excepté en rempli =5 organique ou à mairie de Bujumbura) Critère non compost rempli=0 Source d’eau 11. Mise en place Disponibilité en permanence de point d’eau : Les 2 critères et entretien de remplis=5 point d’eau au (1) eau courante ou puits ou pompe ou Même 1 sein de château/citerne d’eau/ fûts d’eau bien critère non l’hôpital couvert rempli=0 (2) Absence de fuites d’eau (robinetterie en bon état) Latrines 12. Mise en place Existence des latrines bien nettoyées et Tous les et entretien entretenues pour le personnel et patients : critères des latrines remplis =5 Même 1 1) utilisables (accessibles) critère non 2) plancher sans fissures et lavables rempli=0 3) murs avec peinture à huile ou carrelés 4) absence de matières fécales sur le plancher, autour du trou de défécation et sur les murs 5) portes en bon état qui se ferment à l’intérieur 6) existence d’un dispositif de lavage des mains avec savon 7) Fosse septique bien couverte et régulièrement entretenue Douches 13. Mise en place Existence des douches pour le personnel et Tous les et entretien patients : critères des douches 1) utilisables avec eau courante ou récipient d’une remplis =5 Même 1 capacité d’au moins 20 litres critère non 2) portes qui se ferment à l’intérieur rempli=0 3) évacuation des eaux usées dans un puits perdu pour les structures non connectées au réseau public, 4) absence de fuite d’eau aux robinets et douches Stérilisation 14. Assurer la Disponibilité des matériels de stérilisation et Les 2 critères disponibilité fonctionnels : remplis =5 des matériels 1) cocotte ou autoclave ou four poupinel Même 1 de stérilisation fonctionnel critère non 2) protocole de stérilisation affiché rempli=0 15. Assurer la Présence de réserve de produit de Les 2 critères disponibilité décontamination : remplis =5 des produits de Même 1 décontaminati (1) Solution étiquetée avec formule et date de critère non on préparation. rempli=0 (2) Matériels utilisés trempés (s’il y en a) dans les solutions de décontamination Tenue 16. Port et (1) Tenue réglementaire propre et en bon Tous les règlementaire, entretien de la état portée par tout le personnel soignant critères vestiaire et tenue (2) Existence d’une buanderie remplis =5 buanderie règlementaire (3) Existence des matériels de protection Même 1 adaptés pour chaque service : gants, critère non blouse, bottes, bonnets rempli=0 (4) Existence de vestiaire fermant à clé avec deux casiers dont un pour la tenue de service et l’autre pour la tenue de ville pour chaque personnel soignant SOUS-TOTAL HYGIENE, SALUBRITE DE L’ENVIRONNEMENT ET 100 STERILISATION VI. Laboratoire et transfusion Sujet Activités Indicateurs et critères de vérification Indications Points pour la obtenus cotation Personnel du 1. Assurer le Le service dispose d’au moins un laborantin ou Critère service service par un infirmier de niveau A2 (ayant bénéficié d’une rempli=6 personnel qualifié formation en technique labo avec certificat) Capacité du 2. Affichage de la Critère La liste des examens possibles est affichée dans le service liste des examens rempli=4 laboratoire et est visible pour le public disponibles Documentation 3. Assurer la Critère La démonstration des parasites est disponible disponibilité de rempli=4 Sur papier plastifié ou dans un livre en couleur, ou la affichés (goutte épaisse : P. Vivax, Ovale, documentation Falciparum, Malariae) (selles : amibes, ascaris, d référence (de ankylostome, schistosome) base) au labo Matériel 4. Assurer la Au moins un microscope fonctionnel est disponible Critère disponibilité du • les différents objectifs sont fonctionnels rempli=5 matériel de • l’huile à immersion est disponible base au labo • la solution de GIEMSA est disponible • l’apport de lumière existe (miroir ou électricité) • les lames et lamelles sont disponibles Disponibilité d’une centrifugeuse fonctionnelle Critère rempli=5 Disponibilité d’un appareil d’examens de Critère biochimie fonctionnel rempli=5 Disponibilité d’un appareil de numération Critère sanguine fonctionnel rempli=5 Disponibilité de tests rapides pour le diagnostic de Critère VIH/sida rempli=5 Permanence du 5. Assurer la Critère Le laboratoire est fonctionnel tous les jours et service permanence rempli=5 24h/24, y compris les week-ends et les jours fériés du service de (vérifier dans le registre de labo) laboratoire Les résultats des 6. Enregistrement L’enregistrement des résultats dans le registre de Critère examens des résultats labo est correct et correspond aux résultats inscrit rempli=4 des examens sur le bon d’examen Maintenance du 7. Assurer la Critère materiel maintenance Maintenance régulière des appareils attestée par rempli=4 du matériel de les rapports de maintenance signés laboratoire Transfusion 8. Assurer la (1) Disponibilité d’une chaine de froid avec fiche Tous les sanguine disponibilité du de vérification de la température à jour critères service de (2) Disponibilité d’au moins 5 sachets du groupe remplis=8 transfusion O+ Même 1 sanguine (3) Disponibilité d’au moins 2 sachets par autre critère non groupe sanguin rempli=0 SOUS-TOTAL LABORATOIRE ET TRANSFUSION SANGUINE 60 VII. CONSULTATIONS EXTERNES ET URGENCES Sujet Activités Indicateurs et critères de vérification Indications Points pour la obtenus cotation Infrastructure, 1. Entretien et Chaque salle de consultation externe présente de Tous les équipement et équipement de bonnes conditions suivantes: critères Plateau technique chaque salle de • Les murs sont en dur avec crépissage et remplis =10 consultation peinture externe Un critère • Le pavement est en ciment manque=0 • Les murs et le pavement sont sans fissures • Le plafond est en bon état • Les fenêtres sont en vitres avec rideaux • Les portes sont fonctionnelles avec serrures • Les bancs ou chaises sont suffisants pour au moins 10 personnes • L’endroit est protégé du soleil et de la pluie • La salle de la consultation externe et l’espace d’attente sont séparés pour assurer la confidentialité, avec porte qui ferme, rideaux à la fenêtre, sans passage • Existence d’une source de lumière pendant la nuit (électricité ou lumière solaire) 2. Affichage des Les principaux tarifs du recouvrement des coûts Critère tarifs de sont affichés et visibles pour le public avant la rempli =5 recouvrement des consultation couts 3. Existence d’un L’accueil et orientation des patients sont assurés Tous les service en permanence : critères d’accueil et • Disponibilité d’un personnel infirmier remplis =10 orientation qualifié qui oriente les patients vers les Un critère services appropriés manque=0 • L’ordre d’arrivée est respecté, avec un système de jetons numérotés • Les portes sont fonctionnelles avec serrures • Les bancs ou chaises sont suffisants pour 30 personnes au moins • L’endroit est protégé du soleil et de la pluie • La salle de la consultation externe et l’espace d’attente sont séparés pour assurer la confidentialité, avec porte qui ferme, rideaux à la fenêtre, sans passage • Existence d’une source de lumière pendant la nuit (électricité ou lumière solaire) 4. Gestion du L’organisation du service permet: Tous les patient (1) un service de triage des consultations critères externes confié à un infirmier pour les remplis=15 patients non référés des centres de santé Un critère (2) un accès direct gratuit au médecin (ou au manque=0 service des urgences) des patients référés des centres de santé (3) un accès direct payant au médecin des patients qui le souhaitent, non référés par un centre de santé 5. Disponibilité La disponibilité de l’équipement suivant est Tous les d’équipement assurée dans chaque salle de consultation critères et matériel externe : remplis=10 dans chaque • Stéthoscope Un critère salle de manque =0 • Tensiomètre consultation externe • Otoscope • Thermomètre • Table d’examen • Pèse-personne pour adulte • Pèse-bébé • Toise • Ruban pour périmètre brachial 6. Disponibilité Au moins les protocoles de prise en charge des Tous les de protocoles maladies suivants sont disponibles et/ou affichés critères de prise en sur le mur : remplis=5 charge des • Paludisme maladies Chaque • Diarrhée critère • IRA rempli=1 • Tuberculose • Tables poids-taille 7. Permanence Le service d’urgence est disponible 24h/24 et 7j/7 Critère du service avec rôle de garde affiché rempli=5 d’urgence 8. Disponibilité Existence de la salle d’urgence contenant au Tous les d’équipement moins : critères et matériel de • Obus d’oxygène remplis=10 service des • Aspirateur urgences • Laryngoscope Un critère • Matériel d’intubation manque=0 • Matériel de perfusion • Médicaments d’urgence (Diurétique, cardiotonique, corticoïde, vaso-dilatants, matériel de pansement, insuline, broncho- dilatateurs, infusion (glucose, ringer- lactate, physiologique, glycose hypertonique), adrénaline) • Matériel de prélèvement • Sonde naso-gastrique • Sonde vésicale Service de 9. Consultation Proportion de consultations externes prises en Tous les consultation externe (10 charge selon les normes : critères externe cas tirés au Pour chaque consultation tirée au hasard dans le remplis hasard du registre de consultation médicale où tous les cas pour 1cas =5 registre de sont identifiés Un critère chaque salle (1) Fiche de consultation médicale contenant : manque pour de a) Identification du patient (nom, prénom, âge, 1 cas =0 consultation) sexe, commune, colline, sous-colline, chef de (Max=50) famille, profession) b) Date de la consultation NB : Si plus c) nom et signature du médecin de 10 cas d) Anamnèse (plaintes et antécédents) analysés e) Examen clinique: Signes vitaux (TA, pouls, T°, FR, (plusieurs poids), inspection, examen clinique des systèmes salles de affectés consultation) f) Diagnostic provisoire et différentiel : faire une g) Examens complémentaires avec résultats selon moyenne sur le diagnostic provisoire, différentiel et les 50 protocoles h) Traitement selon le protocole ou référence (2) Fiche de référence des cas référés disponible (3) Copie de la Fiche de contre-référence signée par le médecin (résultats/ observations significatives, diagnostic, traitement reçu/interventions, suivi, recommandations/ traitement à suivre) SOUS-TOTAL CONSULTATION EXTERNE ET URGENCE 120 VIII. MATERNITE Sujet Activités Indicateurs et critères de vérification Indications Points pour la obtenus cotation Infrastructure, 1. Entretien de la La salle d’accouchement est en bon état : Tous les équipement et salle • murs en dur, sans fissures avec crépissage critères Plateau technique d’accouchement et peinture remplis =10 Un critère • pavement en ciment sans fissures manque=0 • plafond en bon état • fenêtres vitrées avec rideaux • portes fonctionnelles 2. Disponibilité L’équipement et matériel de la salle Tous les d’équipement et d’accouchement sont disponibles : critères matériel de la salle • tables d’accouchement en bon état remplis =10 d’accouchement Un critère • source d’eau disponible avec savon manque=0 • éclairage possible pendant la nuit (électricité, groupe électrogène, lumière solaire ou lampe à batterie rechargeable) • poubelle avec couvercle • boite de sécurité pour les aiguilles • seau à placenta • seau pour le linge souillé • toise • pèse-bébé • table de réanimation néonatale • tensiomètre • stéthoscope obstétrical • stéthoscope médical • désinfectant • compresses stériles • gants stériles (au moins 10 paires) • au moins 2 boites d’accouchement stérilisées • au moins 10 partogrammes vierges en réserve 3. Disponibilité Le matériel d’épisiotomie est disponible : Critère du matériel Au moins 2 boites d’épisiotomie avec ciseaux, rempli=10 d’épisiotomie pinces anatomique et chirurgicale, aiguilles, porte- aiguille, fil résorbable et fil non résorbable 4. L’équipement L’équipement et les médicaments suivants sont Tous les et les disponibles pour les soins au nouveau-né : critères médicaments • Fil stérile de ligature du cordon remplis=10 suivants sont Un critère • Bande ombilicale stérile disponibles manque=0 pour les soins • Aspirateur (poire plongée dans un au nouveau- désinfectant non irritant ou aspirateur né manuel ou électrique fonctionnel) • Lampe chauffante • Onguent ophtalmique de tétracycline 1% 5. Disponibilité (1) La salle d’attente est disponible et équipée: Tous les et avec au moins 4 lits avec matelas critères équipement (2) La salle d’hébergement est disponible et remplis=10 de la salle équipée: d’attente et avec Un critère de la salle • Lits avec matelas recouverts de toile cirée manque=0 d’hébergemen sans déchirure t • Draps et couverture à chaque lit occupé • Moustiquaire à chaque lit occupé Service de 6. Assurer la L’organisation du service de maternité répond aux Tous les maternité disponibilité critères suivants : critères des (1) Les supports matériels sont faciles à remplis matériels/sup manipuler : Fiche d’hospitalisation, fiche pour tous les ports de base d’admission/Fiche de référence, Dossier services=50 du dossier médical ; Partogrammes, Registre de Un critère médical en maternité rempli pour 1 maternité (2) La présentation du cahier/Fiche d’observation service=10 est claire (suivi régulier, et décisions prises bien documentées dans le cahier/Fiche avec (Max=50) nom et signature du Médecin) (3) Archivage des dossiers médicaux par ordre chronologique est adapté à son utilisation pendant l’hospitalisation (classeur, chariot, …) (4) Les dossiers médicaux sont facilement accessibles en cours d’hospitalisation (5) Existence des procédures écrites permettant d’assurer le secret médical et la sécurisation du dossier médical 2. Gestion du Pour chaque cas sortant du trimestre évalué, Tous les dossier médical choisi au hasard dans le registre de maternité : critères (10 cas tirés au (1) Le dossier médical a été retrouvé endéans au remplis hasard du plus 5 min dès la demande pour 1cas =5 registre ; si le (2) Les supports matériels sont en bon état Un critère nombre de (dossier, examens) manque pour prestations est <10 (3) Le dossier présenté sous forme d’un ensemble 1 cas =0 cas, vérifier tous) cohérent, organisé, avec un classement clair et (Max=50) chronologique des éléments constitutifs (Si cas (4) L’identité du malade est notée : nom et analysés <10, prénom ; âge, sexe ; profession faire la (5) Tous les éléments du dossier médical sont moyenne sur identifiés au nom du malade 50) (6) Nom et prénom et qualification du Médecin ayant décidé l’hospitalisation (7) Les informations liées au séjour sont notées (date d’entrée ; date de sortie) (8) Les modalités d’entrée sont indiquées (9) Les modalités de sortie sont indiquées : Guérison, Décès, Evasion, Transfert 7. Accouchemen Proportion d’accouchements eutociques pris en Tous les ts eutociques charge selon les normes (avec utilisation du critères (10 cas tirés Partogramme): remplis au hasard du Pour chaque accouchement eutocique tiré au pour 1cas =4 registre ; si le hasard dans le registre : (1) Raison de référence Un critère nombre de selon le partogramme du CS ou fiche de référence manque pour prestations en cas de phase de latence pour les cas référés 1 cas =0 est <10 cas, (2) Partogramme de l'hôpital complètement et (Max=40) vérifier tous) correctement rempli au recto et au verso (Si cas (dilatation, descente et TA toutes les 4h, pouls, BCF analysés <10, et contractions toutes les 30 minutes, score faire la d’Apgar) moyenne sur (3) Examen clinique par le médecin (nom et 40) signature sur la fiche et sur le partogramme) (4) Fiche de contre référence signée par le médecin avec accusé de réception pour les cas référés. 8. Accouchemen Proportion d'accouchements dystociques Tous les ts dystociques (Forceps - Ventouse - manipulation du fœtus en critères (10 cas tirés cas de siège, gémellaire) pris en charge selon les remplis au hasard du normes : pour 1cas =5 registre ; si le Pour chaque accouchement dystocique tiré au Un critère nombre de hasard dans le registre: manque pour prestations (1) Partogramme complètement et correctement 1 cas =0 est <10 cas, rempli au recto et au verso (dilatation, descente et (Max=50) vérifier tous) TA toutes les 4h, pouls, BCF et contractions toutes (Si cas les 30 minutes, score d’Apgar) analysés > (2) Examen par le médecin (nom et signature) en ou<10, faire cas d'arrivée à la ligne d'alerte endéans une heure la moyenne (3) Indication valide de la ventouse ou forceps/ sur 50) manœuvre (4) Conseil sur la PF et l'allaitement maternel donné par le médecin (5) Fiche de contre référence signée par le médecin avec accusé de réception pour les cas référés NB : partogramme complètement et correctement rempli sauf pour les cas de dystocie et autres urgences obstétricales 9. Césariennes Proportion de césariennes prises en charge selon Tous les (10 cas tirés les normes : critères au hasard du Pour chaque césarienne tirée au hasard dans le remplis registre ; si le registre (1) Partogramme correctement et pour 1cas =6 nombre de complètement rempli au recto et au verso Un critère prestations (dilatation, descente et TA toutes les 4h, pouls, BCF manque pour est <10 cas, et contractions toutes les 30 minutes ; score 1 cas =0 vérifier tous) d’Apgar) (2) Examen par le médecin en cas d'arrivée à la (Max=60) ligne d'alerte endéans une heure (Si cas (3) Indication valide à la césarienne posée par le analysés <10, médecin faire la (4) protocole opératoire détaillé avec nom et moyenne sur signature du médecin (5) Fiche d'anesthésie 60) complètement remplie (6) Suivi journalier, et chaque fois que de besoin, de la mère et de l'enfant par le médecin (7) Absence d'infection de la plaie opératoire (8) Conseil sur la PF et l'allaitement maternel noté sur la fiche par le médecin (9) Copie de la Fiche de contre référence signée par le médecin pour les cas référés SOUS-TOTAL ACTIVITES DE MATERNITE 200 IX. BLOC OPERATOIRE Sujet Activités Indicateurs et critères de vérification Indications Points pour la obtenus cotation Infrastructure, 1. Entretien de la La salle d’opérations est en bon état : Tous les équipement et salle d’opérations • murs en dur, sans fissures avec crépissage critères Plateau technique et peinture à l’huile remplis=10 Un critère • pavement en ciment sans fissures manque=0 • plafond en bon état • fenêtres vitrées opaques • portes fonctionnelles 2. Entretien de la La table d’opération est en bon état : Tous les table d’opérations • Facilement maniable critères remplis=10 • Revêtement de mousse avec toile cirée Un critère • Manettes fonctionnelles des membres manque=0 3. Disponibilité L’éclairage est assuré: Tous les de la source • Lampe scialytique avec ampoules critères d’éclairage fonctionnelles remplis=5 Un critère • Lumière de réserve assurée (groupe manque=0 électrogène, énergie solaire, lampe avec batterie rechargeable) 4. Disponibilité Le matériel de base suivant est disponible: Tous les du matériel • Appareil d’anesthésie générale critères de base remplis=10 • Kit de rachianesthésie Un critère • Respirateur manque=0 • Aspirateur électrique • Obus d’oxygène • Tensiomètre • Stéthoscope médical • Laryngoscope • Matériel de perfusion • Matériel d’intubation • Matériel de prélèvement • Sonde naso-gastrique • Sonde vésicale • Bistouri électrique et cautérisation • Tenues adéquates (blouses chirurgicales, masques, bonnets, sandales 5. Disponibilité Les médicaments d’urgence suivants sont Tous les des disponibles : critères médicaments • Diurétique remplis=10 d’urgence • Cardiotonique Un critère • Corticoïde manque=0 • Vaso-dilatants • Matériel de pansement • Insuline • Broncho-dilatateurs • Infusion (glucose, ringer-lactate, physiologique, glycose hypertonique) • Adrénaline 6. Disponibilité Au moins 2 kits d’intervention stérilisés sont prêts Tous les de kits pour chacun des types d’urgences : critères d’intervention • césarienne – chirurgie viscérale remplis=10 • traumato-orthopédie Un critère • fixateur externe facilement maniable manque=0 7. Disponibilité Un vestiaire et un espace de lavage et brossage Tous les d’un vestiaire adéquats : critères et d’un espace • Dispositif de désinfection approprié à remplis=5 de lavage et pédale ou à coude Un critère brossage manque=0 • Disponibilité de l’eau courante • Disponibilité de brosses avec savon 8. Assurance des Conditions d’hygiène assurées dans la salle Tous les conditions d’opération : critères d’hygiène • Poubelles pour matériaux infectés avec remplis=5 couvercle Un critère manque=0 • Boites de sécurité pour les aiguilles 9. Disponibilité Existence d’une salle de plâtrage avec matériel Tous les d’une salle de nécessaire : critères plâtrage • rouleaux de différentes tailles remplis=5 • bassin Un critère • coupe plâtre manque=0 • bandes ouatées Service de chirurgie 10. Assurer la L’organisation du service de Chirurgie répond aux Tous les disponibilité critères suivants : critères des matériels/ (1) Les supports matériels sont faciles à manipuler : remplis supports de Fiche d’hospitalisation, fiche d’admission/Fiche pour tous base du de référence, Dossier médical ; Registre les dossier de d’hospitalisation services=50 malade (2) La présentation du cahier/Fiche d’observation Un critère hospitalisé est claire (suivi régulier du malade et décisions rempli pour prises bien documentées dans le cahier/Fiche 1 service=10 avec nom et signature du Médecin) (Max=50) (3) Archivage des dossiers médicaux par ordre (Si services chronologique est adapté à son utilisation d’hosp.>1, pendant l’hospitalisation (classeur, chariot, …) faire la (4) Les dossiers médicaux sont facilement moyenne accessibles en cours d’hospitalisation sur 50) (5) Existence des procédures écrites permettant d’assurer le secret médical et la sécurisation du dossier médical 11. Gestion du Pour chaque cas sortant du trimestre évalué, choisi Tous les dossier au hasard dans le registre d’hospitalisation critères médical (10 (Chirurgie) : remplis cas tirés au (1) Le dossier du patient a été retrouvé endéans au pour 1cas hasard du plus 5 min dès la demande =5 registre d’hos (2) Les supports matériels sont en bon état (dossier, Un critère pitalisation; si examens) manque le nombre de (3) Le dossier présenté sous forme d’un ensemble pour 1 cas prestations cohérent, organisé, avec un classement clair et =0 est <10 cas, chronologique des éléments constitutifs (Max=50) vérifier tous) (4) Tous les éléments du dossier médical sont (Si cas identifiés au nom du malade analysés <10, faire la moyenne sur 50) 12. Interventions Proportion d’interventions chirurgicales prises en Un dossier chirurgicales charge selon les normes : remplissant autres que les Pour chaque dossier d'hospitalisation tiré au hasard tous les césariennes dans le registre des interventions chirurgicales: critères= 7 (les 10 cas (1) Identification du patient (nom, prénom, âge, Un critère tirés au sexe, Commune, Colline, sous-colline, noms du chef non rempli hasard du de famille, profession) pour un registre d’hos (2) Date et heure d'admission dossier= 0 pitalisation) (3) Date et heure du premier examen fait par le médecin de service (endéans 1 heure de l'admission sauf pour les interventions programmées) (Max=70) (4) Nom et signature du médecin (Si cas (5) Anamnèse (plaintes et antécédents) analysés > (6) Examen clinique: a) Signes vitaux et constantes ou<10, faire (TA, pouls, T°, FR) b) Inspection c) Examen clinique la moyenne des systèmes affectés sur 70) (7) Diagnostic provisoire et différentiel (8) Examens complémentaires selon le diagnostic provisoire, différentiel + bilan préopératoire avec résultats (9) Diagnostic retenu (10) Protocole opératoire (11) Fiche d'anesthésie complètement remplie (12) Traitement post opératoire et plan de suivi du patient bien respecté (13) Suivi journalier par le médecin (14) Absence d'infection de la plaie opératoire (15)Les modalités de sortie sont indiquées : Guérison, Décès, Evasion, Transfert SOUS-TOTAL ACTIVITES DU BLOC OPERATOIRE 140 X. HOSPITALISATION : Médecine Interne, Pédiatrie Sujet Activités Indicateurs et critères de vérification Indications Points pour la obtenus cotation Dossier médical de 1. Assurer la Pour chaque service d’hospitalisation : Tous les malade hospitalisé disponibil (1) Les supports matériels sont faciles à manipuler : critères ité des Fiche d’hospitalisation, fiche d’admission/Fiche remplis matériels de référence, Dossier médical ; Registre pour tous /supports d’hospitalisation les de base (2) La présentation du cahier/Fiche d’observation services=20 du est claire (suivi régulier du malade et décisions Un critère dossier de prises bien documentées dans le cahier/Fiche rempli pour malade avec nom et signature du Médecin) 1 service=2 hospitalis (3) Archivage des dossiers médicaux par ordre (Max=20) é chronologique est adapté à son utilisation pendant l’hospitalisation (classeur, chariot, …) (4) Les dossiers médicaux sont facilement accessibles en cours d’hospitalisation (5) Existence des procédures écrites permettant d’assurer le secret médical et la sécurisation du dossier médical Analyse de 20 2. Gestion Pour chaque cas sortant du trimestre évalué, choisi Tous les dossiers de sortants du au hasard dans le registre d’hospitalisation : critères du trimestre évalué dossier (1) Le dossier du patient a été retrouvé endéans au remplis dans chaque médical plus 5 min dès la demande pour 1cas service (2) Les supports matériels sont en bon état (dossier, =1,5 d’hospitalisation (1 examens) Un critère 0 cas MI et 10 cas (3) Le dossier présenté sous forme d’un ensemble manque Pédiatrie) cohérent, organisé, avec un classement clair et pour 1 cas chronologique des éléments constitutifs =0 (4) L’identité du malade est notée : nom et (Max=30) prénom ; âge, sexe ; profession (Si cas (5) Tous les éléments du dossier médical sont analysés > identifiés au nom du malade ou<10, faire Nom et prénom et qualification du Médecin la moyenne ayant décidé l’hospitalisation sur 30) (6) Les informations liées au séjour sont notées (date d’entrée ; date de sortie) (7) Les modalités d’entrée sont indiquées: consultation externe ou urgence (8) Les modalités de sortie sont indiquées : Guérison, Décès, Evasion, Transfert 3. Assurer la Pour les mêmes cas ci-haut : Tous les complétu (1) Le motif d’hospitalisation est noté critères de des (2) Histoire de la maladie remplis informati (3) Anamnèse (Plaintes et Antécédents) pour 1cas ons (4) Facteurs de risques =2,5 médicales (5) Examens cliniques comportant les données relatives aux signes vitaux (T°, FR, TA, Un critère Pouls), examens cliniques des systèmes manque affectés : inspection, palpation, percussion, pour 1 cas auscultation =0 (6) Hypothèses diagnostiques argumentées (7) Examens complémentaires et résultats (Max=50) (8) Conduite thérapeutique adoptée : traitement avec posologie et modalités (Si cas d’administration du traitement analysés > (9) Traitement selon le protocole ou Référence ou<10, faire (10) Suivi journalier par le médecin la moyenne (11) Autres éléments nécessaires sur 100) SOUS-TOTAL HOSPITALISATION 100 TOTAL GENERAL 1000 PERFORMANCE TRIMESTRIELLE GLOBALE % VERIFIER QUE TOUTES LES RUBRIQUES SONTCOMPLETEES L’évaluateur remercie le personnel Problèmes prioritaires identifiés ………………………………………………………………………………………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………………………………………………………………………………… Etat de la mise en œuvre des recommandations des évaluations précédentes (vérifier sur la copie de la précédente évaluation) ………………………………………………………………………………………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………………………………………………………………………………… Actions urgentes d’amélioration (recommandations) proposées ………………………………………………………………………………………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………………………………………………………………………………… Source: MoH, 2011b. Annex 5: Household Survey Questionnaire QUESTIONNAIRE D’ENQUÊTE MÉNAGE EN FRANÇAIS PROVINCE SANITAIRE DISTRICT SANITAIRE CENTRE DE SANTE/HOPITAL JOUR DE LA CONSULTATION NOM DE L’ASSOCIATION LOCALE No Nom et Prénom du Client Colline Sous Colline Nom du chef de référence famille fiche 1. DONNEES SUR LE CLIENT 1.1 Date de l‘enquête (Jour-Mois-Année) …………../…………../…………. 1.2 Le (la) nommé (e) est il connu dans ce ménage? Oui/ Non 1.3 Si vous le connaissez, quel âge a-t-il (elle)? ……………. 1.4 Indiquez celui qui affirme que le (la) Client est connu dans Lui (elle) meme ce ménage ? Un autre membre du ménage Chef de la sous colline Autre (préciser) 1.5 Si c’est lui même: es tu allé à la formation sanitaire de…………………. Oui/Non durant les six derniers mois? Si c’est une autre personne: le client ou la cliente ………….., se serait Oui/Non elle rendue à la formation sanitaire de ……………………….. durant les six derniers mois? 1.6 Si oui, était ce pour une consultation, un accouchement, une vaccination, une consultation prénatale, une consultation postnatale ou une autre prestation ? 1.7 Pourriez vous nous dire à quelle date vous vous êtes rendu à la formation sanitaire (estimation) Si vous trouvez que le client ou la cliente s’est fait soigné durant les six mois précédents à la formation sanitaire de …………………………, veuillez continuer avec les questions de la section 2 et 3. Sinon, arrêtez l’enquête à ce niveau. 2. SATISFACTION PAR RAPPORT AUX PRESTATIONS SANITAIRES RECUES 2.1 Etes vous satisfez des prestations sanitaires offertes par le Très satisfait/ Moyennement CDS le plus proche de chez vous? satisfait/ Pas du tout satisfait 2.2 La dernière fois où vous êtes tombé malade, êtes vous allez Oui/ Non vous faite soigner à la formation sanitaire proche de chez vous ? Pour celui qui n’est pas allé se faire soigner à la formation sanitaire la plus proche: 2.3 Vous êtes vous fait soigner? (Sinon, arrêtez l’enquête à ce Oui/ Non niveau) 2.4 Si oui, où êtes vous allez vous faire soigner? 1. Un autre CDS Public 2. Un CDS Privé 3. A l’Hôpital 4. Chez les guérisseurs traditionnels 5. Ailleurs (préciser)………………………… 3. SATISFACTION DES USAGERS PAR RAPPORT AUX PRESTATIONS DE LA FORMATION SANITAIRE 3.1 Quelle est votre appréciation par rapport au temps 1. Réduit d’attente avant de vous faire soigner? 2. Moyen 3. Très long 3.2 Avez vous été bien accueilli? (Respect et courtoisie) 2= Très bien 1= Bien 0 = Mauvais 3.3 Le prestataire qui vous a soigné, vous a-t-il bien expliqué la 2= Très bien pathologie dont vous souffrez, les médicaments qu’il vous 1= Bien donne ainsi que la manière de prendre ces médicaments ? 0 = Mauvais 3.4 Les prestations sanitaires ont elles étaient réalisées dans de 2= Très bien bonnes conditions de confidentialité? 1= Bien 0 = Mauvais 3.5 Selon vous, les prestataires à la formation sanitaire de 2= Très bien …………sont ils compétents? 1= Bien 0 = Mauvais 3.6 à la formation sanitaire de………………est il ouvert 7 jours sur Oui 7 et 24H/24H ? Non 3.7 Selon vous, les prix des prestations sanitaires à la formation 2 = Très abordable sanitaire de …………sont ils acceptables? 1 = Abordable 0 = Très cher 3.8 Le paiement des soins est il transparent? (sur base des tarifs Oui affichés, remise des factures aux malades, les enfants de moins Non de 5 ans et les femmes enceintes sont soignés gratuitement) 3.9 La formation sanitaire de …………a-t-il des conditions 2 = Très bonnes d’hygiène et des services acceptables ? (Propreté générale, 1 = bonnes Latrines propres, Electricité, Eau propre, Douche) 0 = mauvaises 3. 10 Les médicaments qu’on vous a prescrit étaient ils Oui disponibles à la formation sanitaire Non 3.11 En résumé, quels sont les aspects positifs que vous avez observé à la formation sanitaire? 3. 12 Quels sont les points négatifs que vous avez relevé ? 3.13 Quelles recommandations donneriez-vous pour améliorer les prestations au niveau de la formation sanitaire? Source: MoH 2011b. Annex 6: Analysis Framework for the Case Studies Framework for Analyzing Verification in RBF Schemes October 1, 2010 Supply-Side RBF Schemes Country: Name of Program: Year it Began: Scheme Characteristics Description Component BACKGROUND Summary of the Scheme Socioeconomic context Health system description Policy What were the health system problems identified that the RBF objectives scheme was designed to address? Base payment What type of underlying payment system is used to pay system providers participating in the P4P scheme (e.g. capitation, fee- for-service, case-based payment)? 1 Scheme Characteristics Description Component Stakeholder Which Government agencies involvement stakeholders are Purchasers (public or private) involved in Providers/provider associations designing and implementing the Other independent associations scheme and what Patients/ advocacy groups are their roles? Donor organizations Has that changed over time? Provider Is participation mandatory or voluntary? participation Is the scheme implemented nationally or only in some regions, or by some purchasers? Which providers All (public and private) participate? Only public Only private Some public and some private What is the Hospitals number (and Provider groups share) of providers Physicians who participate? Nurses Population How many people are served by covered providers/interventions covered by the scheme? Performance Which services are eligible for payment? Measures What are the domains of performance that are rewarded? # of indicators 2 Scheme Characteristics Description Component Frequency of reporting Incentive Payment Is the incentive payment paid to the provider per service, per capita (person), a percentage of total payment to the provider, or other? Is the incentive payment capped? What is the average % of total reimbursement to providers from the incentive payment? Who assesses indicators? Purchaser, independent agency, other? How are indicators assessed? Manually, electronic algorithm, combination? What is the trigger for the incentive payment to be made to the provider? When the indicators are reported and assessed? Or when the information is independently verified? Data Sources What are the Routine health Generated by data sources for information participating performance systems Generated by measures? (electronic) other parts of the Routine health t Generated by information participating systems (manual) Generated by other parts of the Claims/ Generated by reimbursement participating data Generated by other parts of the system 3 Scheme Characteristics Description Component Reporting system Generated by introduced for participating providers the RBF scheme Generated by other parts of the system Separate Generated by reporting system participating for the RBF Generated by scheme that is other parts of the extracted from system existing information systems Data Quality What are the major concerns with data quality? [Ask for each data source] VERIFICATION Who implements Are performance measures verified/validated? verification What type of technical assistance was provided to set up the verification system? Which institution/organization provided funds to set up the verification system? Which institution/organization provides funds to operate the verification system? Who implements the verification? Governmental or non- 4 Scheme Characteristics Description Component governmental organization, either internal or external, such as a private firm, university, NGO, etc.? What was the composition of the team(s) conducting the verification? Please describe the different roles and responsibilities of the team members and the technical skills of each Why and how were the actors/organization selected to carry out the verification? To whom do they report? How are they paid? How is their performance in verification evaluated? Verification Which method(s) is used Consistency/accuracy of reporting method for verification? (e.g. self-audit, peer review, supervision) Algorithms applied to electronic data from routine reporting system On-site spot checks of source data Routine on-site verification checks of source data Follow-up with a small sample of patients/ beneficiaries Larger scale health facility and household surveys For which indicators/services is reporting verified? Why were these selected? Has this changed over time? Who selected this method of verification and what was the rationale for choosing this method over other possible options (political, policy, programmatic, financial or technical 5 Scheme Characteristics Description Component circumstances influencing the decision)? Frequency How frequently are indicators/services verified? Geographic scope Which and how many administrative units in the country of verification were included in the verification process? How are facilities/communities/households selected for verification? What is the sampling method? At which levels was the verification carried out (household, health facility, district, province, national)? How were providers or facilities, and/or households selected? (Please describe the type of sampling method pursued, such as purposive, census, random, cluster, etc.) How verification Preparation (e.g., Were verification visits carried out on visits are a random basis or were those receiving a visit notified in conducted advance?, etc.) Process (e.g., How was the visit organized, what procedures were followed, how long did it take?, etc. Exit (e.g., How was the visit concluded and was any written information left behind or feedback given?, etc.) How much time did it take to carry out the different verification activities? Please describe all data collection, tabulation, analysis and reporting procedures and tools followed and used (Any written tools and procedures can be annexed to the case- Please describe any patient confidentiality procedures that were followed for all steps in the verification process (collection, tabulation, analysis and reporting) (Any written 6 Scheme Characteristics Description Component procedures can be annexed to the case-study) Please describe any control or assurance measures followed to ensure both transparency and the quality of the verification process and data (e.g., training of verifiers, pre-testing of the method, cross and re-checking of data, etc.) Is Information Technology used in results verification? If so, please describe what and how. Was the verification a one-off process or is it carried out routinely? During the last 12 months how many times have verification visits been conducted? Findings from the How consistent or accurate was the reporting on the quantity application of the of services provided? verification method What was the definition of an error? Please provide a quantitative measure of the (average) size of the error, if any (i.e., discrepancy between what was reported and what was observed via verification Please describe any explanations that were given for the degree of error Please describe any recommendations that were made or actions taken to reduce error How consistent or accurate was the reporting on the quality (conditions) of services provided? What was the definition of an error? Please provide a quantitative measure of the (average) size of the error, if any (i.e., discrepancy between what was reported and what was observed via verification Please describe any explanations that were given for the degree of error 7 Scheme Characteristics Description Component Please describe any recommendations that were made or To what extent did beneficiaries actually receive the (quantity and quality of) services that were reported to What was the definition of an error? Please provide a quantitative measure of the (average) size of Please describe any explanations that were given for the degree of error Please describe any recommendations that were made or actions taken to reduce error Are any indicators, services, or data sources particularly problematic? If yes, why might that be the case? What was the allowable margin of error? Why were certain thresholds set as allowable margin of error and Use of If known, how long was the interval between the decision to Verification pay and actual payment? Findings If the size of the error was outside of the margin, what action was taken? (e.g., withholding of payment until error reduced, If verification occurred after payment, was some kind of system instituted to recover over-payments or correct for under- payments? What kind of system? How are discrepancies in data resolved? Discrepancies/ What is the procedure if the providers dispute the verification disputes results? Scheme Characteristics Description Component Verification What were the direct costs (in absolute figures) of Costs implementing the verification method? If possible, please provide an estimate of the major direct costs expenditures items for the verification. What were the indirect costs of implementing the verification method (e.g. administration, training, etc) If possible, please provide an estimate of the major indirect costs expenditures items for the verification. What were the verification costs relative to financial incentives paid for performance (verification costs/performance payments) What were the verification costs relative to the savings generated by reduced incentive payments? Challenges and Has the verification method and/or process evolved over Lessons time? What changes have been made and why? How do the provider respond to the verification process? Is there tension, cooperation? What are their main What were the major strengths of the verification method, including any positive unanticipated benefits or effects? What were the major challenges or weaknesses in implementing the verification? (problems, difficulties, constraints, obstacles) Why did these problems occur and what measures were taken to address these problems? What were the major lessons learned from applying this method, and any recommendations for the future for improving upon it? 9 About this series... This series is produced by the Health, Nutrition, and Population Family (HNP) of the World Bank’s Human Development Network. The papers in this series aim to provide a vehicle for publishing preliminary and unpolished results on HNP topics to encourage discussion and debate. The findings, interpretations, and conclusions expressed in this paper are entirely those of the author(s) and should not be attributed in any manner to the World Bank, to its affiliated organizations or to members of its Board of Executive Directors or the countries they represent. Citation and the use of material presented in this series should take into account this provisional character. For free copies of papers in this series please contact the individual authors whose name appears on the paper. Enquiries about the series and submissions should be made directly to the Editor Martin Lutalo (mlutalo@worldbank.org) or HNP Advisory Ser- vice (healthpop@worldbank.org, tel 202 473-2256, fax 202 522-3234). For more information, see also www.worldbank.org/hnppublications. The world bank 1818 H Street, NW Washington, DC USA 20433 Telephone: 202 473 1000 Facsimile: 202 477 6391 Internet: www.worldbank.org E-mail: feedback@worldbank.org