Assessment of the quality of care for children in hospitals A … Dokumente/Assessement too… ·...

Assessment of the quality of care for children in hospitals

A generic assessment tool

2

Acknowledgements

This assessment tool is the fruit of the work of many people, who used subsequent versions of it

in many countries. The original tool was conceived and drafted by Dr Giorgio Tamburlini,

Trieste, Italy, to whom CAH is grateful for this work. WHO/CAH wishes to thank particularly

for substantial inputs and revisions Dr Harry Campbell, Edinburgh, UK; Dr Trevor Duke,

Melbourne, Australia; Dr Mike English, Nairobi, Kenya; Dr Andreas Hansmann, Bonn,

Germany; Dr Carolyn Maclennan, Melbourne, Australia; Dr Diana Silimperi, Bethesda, USA;

Ms. Lauri Winter, Dili, Timor Leste, and many others who improved the tool through the use in

countries.

© World Health Organization 2006

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the World Health Organization.

3

Table of Contents

Introduction .................................................................................................................. 4

Guide to the assessment tool ..................................................................................... 5

1. General hospital information .................................................................................. 9

1.1 Layout of health facility ............................................................................. 9

2. Hospital support systems ..................................................................................... 11

2.1.3 Paediatric surgery details ............................................................. 12

2.2. Essential drugs, equipment and supplies .............................................. 14

2.2.1 Drugs .............................................................................................. 14

2.2.2 Equipment and supplies ............................................................... 16

2.2.3 Standards for drugs, equipment and supplies ........................... 18

2.3 Laboratory support ................................................................................. 19

3. Emergency care ..................................................................................................... 20

3.1 Patient flow ............................................................................................. 20

3.2 Staff dealing with emergencies ............................................................... 21

3.3 Layout and structure of emergency area ................................................ 22

3.4 Drugs, equipment and supplies .............................................................. 23

3.5 Case management of emergency conditions ......................................... 23

4. Children’s ward ...................................................................................................... 24

4.1 Layout ..................................................................................................... 24

4.2 Standards and criteria children's ward .................................................... 25

Closest attention for the most seriously ill children ........................... 25

5. Case management of common diseases: ........................................................... 27

5.1 Cough or difficult breathing ............................................................ 27

5.2 Diarrhoea ........................................................................................... 31

5.3 Fever conditions ............................................................................... 33

5.4 Severe malnutrition .......................................................................... 37

5.5 Children with HIV/AIDS .................................................................... 40

6. Supportive care ...................................................................................................... 43

7. Monitoring .............................................................................................................. 45

Follow-up ..................................................................................................................... 46

8. Neonatal Care......................................................................................................... 47

8.1 Nursery layout and staff .......................................................................... 47

8.2 Routine neonatal care ............................................................................ 48

8.3 Nursery facilities ..................................................................................... 50

8.4 Case management and sick newborn care ............................................ 51

9. Paediatric surgery and rehabilitation ................................................................... 53

9.1 Paediatric size anaesthesia-equipment .................................................. 54

10. Other Hospital wards with children .................................................................... 55

11. Hospital administration ....................................................................................... 56

12. Access to hospital care: Interview with care takers and health workers ....... 58

Debriefing and action plan ........................................................................................ 62

Annex: Interviews with caretakers and health workers ......................................... 63

A1. Caretakers view on patients care ........................................................... 63

A2. Health workers interview ....................................................................... 67

A2.1 Guidance for health workers interview ............................................. 67

A2.2 Health worker interview .................................................................... 69

.........................................................................................................................................

4

Introduction

This generic assessment tool helps to evaluate the quality of care for children in hospitals,

based on standards derived from the WHO “Pocket book of Hospital Care for Children”, and

other relevant WHO materials. Before use in a country, the assessment tool should be

reviewed by health professionals for its consistency with national standards and guidelines,

such as an essential drug list, and prevalence of diseases and adapted where necessary.

This generic tool attempts to be comprehensive but not exhaustive in addressing the areas that

are important to provide care for children in hospitals. The assessment tool provides some

prioritisation in that it is recognised that some aspects of care for children are essential. The

suggestion is that hospitals should ensure these aspects are right first and other areas, though

important, are not essential. The priority areas include triage, hand-washing, availability of

emergency and first line drugs, availability of updated standard treatment guidelines,

emergency care and assessment and management of common conditions including cough and

difficulty breathing, diarrhoea, fever, HIV/AIDS and newborn care. This assessment tool has

sections on:

1. Hospital support functions including drugs, supplies and equipment

2. Emergency care

3. Paediatric ward and case management on the ward

Cough or difficult breathing

Diarrhoea

Fever conditions

Malnutrition

Children with HIV/AIDS

4. Monitoring of patients

5. Nursery and care of the newborn

Delivery care of the newborn

Sick newborn care

6. Hospital layout and structure

7. Staffing

8. Supportive care and nutrition

9. Discharge and follow-up

10. Mother and child friendly services

11. Access to hospital

12. Paediatric surgery

The tool is designed in sections so that during adaptation, sections may be removed if

considered not to be a priority for that country. For example:

A section on management of dengue fever will only be necessary in South-East Asia

or Central and South America

In some countries or parts of countries, the malaria component in the fever section

may not be necessary

Paediatricians may only wish to assess medical care so the paediatric surgical section

will not be required in this case

Hospitals may wish to assess only particular conditions or areas of care for example

assessment of emergency care before and after implementation of a training course

such as emergency triage assessment and treatment (ETAT).

Assessment of the quality of hospital care for children Date: 5 ׀__/__/__׀

Country: ____________________ Initials of Health Facility: ׀_׀_׀

Initials of Assessor: ׀_׀_׀

Overview of the assessment process

The hospital assessment may be embedded into a national quality improvement programme,

or interested health authorities at a provincial, district, or hospital level, involving one or

several hospitals, might conduct the assessment. After a period of change, the process of

assessment can be repeated to document improvements.

The core of the assessment is a hospital visit which lasts about 2 days. Assessors complete the

assessment tool recording form. One recording form is used for each hospital. Information is

collected from various sources that are explained in detail below. At the end of the hospital

visit, assessors and hospital administration meet for a debriefing and agree on a plan of action

for immediate and later improvements.

Training of assessors

Before conducting the assessment, all the assessors need to be made thoroughly familiar with

the standards, the guidelines as contained in the pocket book, and the assessment tool. Such a

training course takes about 3 days, with training sessions on the Pocket book (for which the

case-based studies in the CD accompanying the Pocket Book can be used), review of the

forms, and practical sessions on hospital wards to get familiar with the forms and to agree

between the assessors on scoring.

Guide to the assessment tool

To evaluate the different aspects of paediatric care in district hospitals, information is

collected in various formats including:

brief questionnaires on hospital layout and structure with yes or no answers, and space

for written information to be completed during observation during the hospital visit or

through interviews with staff

checklists for equipment, drugs and supplies for completion

forms documenting the management of different medical conditions based on accepted

standards of care and criteria to meet these standards. The forms prompt the

documentation whether practices are good or need improvement, summarize strengths

and weaknesses, and ask for a final score of the area of observation.

Questionnaires and checklists

The first part of the assessment tool is in the form of a questionnaire with checklists that focus

on information expected to be of importance for planning quality improvement interventions.

Examples of information in this section include: hospital layout and structure, admission

rates, case fatality rates for the most common conditions, availability of essential drugs,

availability of diagnostic support and of therapeutic equipment. It is suggested that this

section is sent out (Part 1), together with a letter explaining the purpose of the exercise, to

hospital directors with a request to provide the information in advance of the visit. This allows

the hospital authorities time to find the relevant data and compile them. The advantage of

sending out the questionnaires/checklists is the possibility to obtain, within a short time and at

low cost, comprehensive information on a number of factors that influence the ability of a

hospital to provide good quality care. Information from the questionnaires/checklists will

have to be reviewed together with information from on site observations of quality of care




when interventions for individual hospitals are planned. Information from questionnaires or

checklists should be cross-checked during the hospital visit.

Hospital visit

The sections of the assessment tool for completion during the hospital visits include

information from observations of case management and physical environment with

information from interviews with hospital staff and caretakers of sick children (part 2). It is

suggested to spend as much time as possible on the children’s ward to gain first hand

information by direct observation, especially on the management and care of children in the

hospital. Try to establish by direct observation if the drugs and equipment are available in the

emergency room, on the ward or in pharmacy. Also visit other wards in the hospital where

children are being cared for. If possible have a look in theatre/ operating room to check if

paediatric size equipment is available. Try to verify information provided by the hospital, staff

or patients while observing during the visit.

Sources of information

Information for the hospital assessments may be collected from:

Case observations: For clinical case management, this is the preferred source of information,

and should be used wherever possible. The care for new arrivals and admitted children to the

hospital should be observed without interference from the assessors. This is complemented by

discussion of the case with staff, review of the case records and monitoring charts, and

interviewing the mothers.

Records: Assessors obtain information on the quality of care for admitted and recently

discharged patients by checking records. If there are not sufficient patients for direct case

observations, assessors should ask staff if it is possible to review records. This source of

information is particularly important for relatively rare, but severe conditions such as

meningitis, where there might be no case admitted during the time of the visit.

Interviews: Assessors conduct interviews with hospital staff and caretakers to gain some idea

of their perception of care for children in the hospitals. The assessment tool provides both an

outline for informal interviews and a formal interview structure can be found in Annex 1.

Also, if there are not enough cases for direct review of case management, simulated cases are

presented to staff to assess clinical case management.

Hospital visit: This concerns mainly items amenable to direct observation during the hospital

visit and the round of the hospital, such as cleanliness and availability of items to mothers.

Areas of doubt can be clarified by interviews.

Documenting and scoring the hospital assessment

Each section is scored based on standards and criteria to meet these standards. Standards are

the minimum requirements for good quality of care for children. For the case management

sections, the instructions in the assessment tool provide guidance to the standards, but do not

cover all aspects of a given standard, and therefore reference is made to the guidelines in the

sections of the WHO “Pocket book of Hospital Care for Children”, indicating the relevant

pages.

All sections of the assessment tool leave sufficient space for comments and personal

observations. Where possible additional information should be noted, especially on how the

information has been obtained (chart review, staff interview, observation of care provided).




Each of the different topics ends with a summary table, in which the findings can be

condensed, marking strength and weaknesses, to facilitate a quick overview of each chapter.

This helps with keeping in mind important points which should be covered during the final

debriefing of the hospital director and staff. Finally, all topics are to be marked in a summary

score in the summary evaluation sheet. This is particularly useful to monitor hospital

improvement over time and to enable inter-hospital comparison.

Scoring system: For overall scoring, numbers from 5 to 1 are awarded, 5 being good practice

complying with standards of care, 4 showing little need for improvement to reach standard

care, 3 meaning some need for improvement to reach standards of care, 2 indicating

considerable need for improvement to reach standards of care and 1 being services not

provided, totally inadequate care or potentially life-threatening practices.

Finally, all topics are marked in a summary score in the summary evaluation sheet. This can

assist in monitoring hospital improvements over time and to make inter-hospital comparison

possible. Note that if sections of the tool are removed or edited, the total potential summary

score should be revised.

Composition of the hospital assessment teams

The assessment teams should be composed of people with complementary backgrounds, to

put the findings into perspective, such as a paediatrician, a general physician or clinical

officer working in a hospital similar to the one which is being assessed, and a nurse with

experience in caring for children. Depending on the purpose of the assessment, the teams can

be composed of internal assessors only or a combination of internal and external assessors.

This will have cost implications.

Conducting the hospital visit

The observation visit requires 2 working days, including the possibility to do observations

also during the evening or night. The hospital director must have been informed in advance

and have agreed to the assessment.

It facilitates the work if the questionnaire/checklists (Part 1) has been forwarded to the

hospital in advance or if the hospital administrator has been asked to prepare the requested

information before the assessors arrive.

Suggested timetable of the visit

Day 1: The assessors should arrive at the hospital on the day prior to the assessment or in the

morning of the same day. Hospitals are usually busiest in the mornings with new admissions.

Observations can be conducted irrespective of the weekday. However, since the assessment

begins and ends with hospital staff meetings the schedule should allow for these meetings

during regular working hours.

Introductory meeting

Schedule a meeting with the hospital director and his staff prior to the start of the assessment.

Introduce the purpose of the assessment and describe the assessment process. Emphasize that

the assessment is a voluntary exercise that is part of an initiative to help hospitals improve the

quality of paediatric care. The purpose of the assessment is to identify areas of care with a

large potential for improvement. Explain that you will interview staff about hospital routines

and practices and that you would like to observe care of as many patients as possible, already




admitted as well as new arrivals. Schedule a debriefing meeting at the end of the assessment.

The debriefing can be planned for in advance of the visit to ensure participation of key staff.

Hospital visit

The assessment will normally start with a tour of the hospital. Ask to be shown all areas of the

hospital that will be of relevance to paediatric care. In addition to the paediatric ward(s), the

tour should include the following areas when they exist: the delivery ward, the neonatal

nursery, intensive care unit, other wards where children might be admitted, such as surgical or

infectious diseases ward, emergency area, outpatient department, pharmacy, laboratory unit,

blood bank, radiology department.

The assessors will then continue with the assessment, which does not have to be conducted in

a certain order. Observation over time is important and new arrivals and new admissions to

the hospital should be closely observed. It is an advantage if the assessors can sleep in the

hospital and if the hospital staff is asked to alert them when new patients arrive. The assessors

should not interrupt, interfere or guide medical work in any way. It is important that they are

allowed to move around freely and are free to interview parents and staff.

Day 2: Continue the assessment including interviews with staff and caretakers, case

observations and going through records. Make sure that the necessary information in the

protocol is obtained for all areas. This requires repeated review of the assessment tool for

missing items still to be completed. The team might break up into sub-teams to fulfil certain

tasks. Findings should however be discussed by the whole team at certain intervals. Allow for

sufficient time to prepare your findings for presentation at the debriefing. Transfer all findings

onto the summary sheet of findings for discussion with hospital authorities at the debriefing.

Debriefing visit with the hospital authorities

Each hospital will receive immediate feedback at the end of the visit. The purpose of the

feedback meeting is to review the assessment findings and commence planning for

implementation of the improvement process. The meeting should have the medical director,

senior management and all staff participating in the assessment so that all those involved will

continue to be involved in the planning and implementation of improvement interventions in

their hospital. The hospital staff should be thanked for their cooperation and firstly the

strengths should be highlighted and then the weaknesses discussed. Through discussion, 3

areas for improvement should be prioritised for action, based on the feasibility of

improvement and their impact on mortality. It is best to select areas in which the hospital can

actively engage leaving more structural problems aside for later action. It should be clear to

everyone what are the problems and what can be done to improve the situation. An action

plan should be constructed that will identify:

What tasks are to be carried out?

When will each task be carried out?

Who will carry out the task?

How much will it cost to carry out each task, and where is a budget for this?

Responsible persons should be assigned for each of the 3 identified areas. Any financial

resources, supplies and equipment, training or supervision needs or other technical inputs

should be identified and a time made when the hospital will review progress.

.




1. General hospital information

Source: hospital walk-through observation, and interviews with chief matron/staff.

Instructions: Collect information on numbers and time. Several questions have space for you to

describe your answer in more detail.

Date of assessment: ................../............/...............

Name of interviewer(s).........................................................................................................

Name of the health facility....................................................................................................

District..................................................................................................................................

Type of health facility: …………………………………………………………………………….

1.1 Layout of health facility

Does the health facility have a separate outpatient department? Y N

Comments:

Is the paediatric outpatient separate from the

adult outpatient department? Y N

Comments ........................................................…………………………………………………

At what time does the paediatric outpatient department open? ......................................hrs

At what time does the paediatric outpatient department close? ....................................... hrs

Does the health facility have a separate emergency department? Y N

Is it open 24 hours? Y N

If not, what hours is it open? ……………

Does the health facility have a ward for admitting children? Y N

If so, how many beds? ……………

Does the health facility have a separate ward or room for admitting new-borns?

Y N





Does the health facility have a separate room or ward for admitting paediatric infectious cases

(isolation ward)? Y N


If so, is this separate from the adult infectious cases? Y N

Describe: ……………………………………………………………………………

………………………………………………………………………………………....

Where are children with surgical conditions admitted?

Describe:……………………………………………………………………………...

………………………………………………………………………………………....

Where are children with severe conditions requiring special or intensive care admitted?

Describe:……………………………………………………………………………...

………………………………………………………………………………………....

Are the most seriously ill children cared for in a section where they receive closest attention?

(near the nursing station)

Describe:……………………………………………………………………………...

………………………………………………………………………………………....

Is a qualified nurse available 24 hrs per day on children's ward?

Describe:……………………………………………………………………………...

………………………………………………………………………………………....

What is the estimated HIV prevalence in your area? ……………




2. Hospital support systems

Source: This information should be obtained ideally by the postal questionnaire before the visit. If it is

not available, it should be obtained during the hospital visit, and complemented by interviews with

staff. Information in the postal questionnaire should be cross-checked during the visit for accuracy.

Tick as applicable. Note in comments if supplies are irregular.

Emergency

area/ OPD Ward Comments

Is electricity continuously available?

Is there a back-up power supply in the case

of a power cut (i.e. diesel generator)?

Is there running water?

If no: is there water for hand-washing

available in the area?

Is there soap and/or disinfectant available?

Is there a sharps disposal box available?

Is there a functioning fridge available for

drugs or vaccines?

Is there a complaints box on the hospital

premises or a formal way patients can

communicate with the hospital?




2.1 Hospital health statistics Source: routine statistics. This information should ideally be collected before the visit (postal

questionnaire) and be available for reference during the visit. If it has not been collected before, collect

the information early during the visit from the records department, chief nursing officer, or hospital

administration. Make use of routine statistics; adjust the categories accordingly (e.g. age groups)

where necessary.

2.1.1 Patient load

Indicate the total number of paediatric medical outpatient visits, emergency visits and admissions per

year by age groups and as a total. Include all medical diagnosis but exclude children dead on arrival.

Year: ____________

Outpatient visits Emergency visits Admissions

0 – 28 days _________ _________ _________

1 up to 12 months _________ _________ _________

1 up to 5 years _________ _________ _________

>5 years _________ _________ _________

Total (all age groups)? _________ _________ _________

2.1.2 Admission details List the five most frequent medical reasons (diagnoses) for outpatient visits, emergency visits, and hospital

admissions in children.

Outpatient visits Emergency visits Hospital admissions

1.

2.

3.

4.

5.

2.1.3 Paediatric surgery details

Source: routine statistics. This information should ideally be collected before the visit and be available

for reference during the visit. If it has not been collected before, collect the information early during the

visit from the theatre book, chief nursing officer, or hospital administration. Make use of routine

statistics.

Most common paediatric surgical procedures performed:

Procedure

Annual number of

procedures Performed by

1.




2.

3.

4.

5.

Regular Infrequent Never Performed by:

Referred to

another facility

Phimosis/Circumcision

Hernia repair

Fractures

Skin Grafting

Laparotomy including

appendectomy

Incision and drainage for

abscesses/pyomyositis

How often are the following paediatric surgical procedures performed?




2.2. Essential drugs, equipment and supplies

Source: This information should ideally be collected before the visit (postal questionnaire), and be

available for reference during the visit. If it has not been collected before, collect the information early

during the visit from the emergency area, the ward and the pharmacist and adjust drugs according to

local alternatives.

2.2.1 Drugs

Availability of drugs varies considerably in different regions. Please indicate the drugs available. For

those drugs marked with an asterisk (*), local adaptations of use might be necessary. If drugs are only

available for sale and not freely available for children, make a note. Check for the presence of drugs and

enquire with staff whether drugs are regularly available. Check expiry dates. Note whether drugs with the

earliest expiry date are for first use (in the front-row).

Emergency

area Ward

Pharmacy/

store Comments

Glucose 30-50% i.v.

Glucose 10 % i.v.

Glucose 5 % i.v.

Normal saline i.v.

Ringer’s lactate i.v.

Epinephrine (Adrenaline) s.c.

Corticosteroids i.v. or p.o.

Furosemide i.v.

First line anti-convulsant:

*Diazepam/Paraldehyde i.m., i.v.

*Phenobarbital i.m., i.v.

Antibiotics

*Ampicillin/Amoxicillin

Benzyl penicillin

*Antistaphylococcal penicillin

(e.g. Flucloxacillin)

*3rd generation Cephalosporins

*Chloramphenicol




Emergency

area Ward

Pharmacy/

store Comments

Ciprofloxacin

Gentamicin

Co-trimoxazole

*All anti-Tb drugs needed

according to the national Tb

control programme

*All anti-malaria drugs needed

according to national malaria

control programme

* All Anti-HIV drugs according to

HIV programme

Other:…………………………

Other:…………………………

Fluconazole

Amphotericin

Digoxin

Iron syrup

Iron tablets, ____ mg

Vitamin-mineral mix

Vitamin A oral

Vitamin K i.m. injection

ORS

BCG vaccine

Measles vaccine

Polio vaccine

Pertussis vaccine

Diphtheria and Tetanus vaccine

(DT)

Hepatitis B vaccine




2.2.2 Equipment and supplies


available for reference during the visit. If it has not been collected before, collect the information early

during the visit from the emergency area, the ward and the store.

Is the following equipment available in the emergency area, on the ward, or in the pharmacy or store?

If a postal questionnaire was sent, cross check the information obtained in advance. Check the

information during the visit to the ward, the emergency area, and to the pharmacy. Ask the person in

charge of the area/ward for the items to be shown to you, and check that they are safe, hygienic, and

in good working order. Check that the size is adequate for use in infants and children.

Emergency

area Ward

Pharmacy/

store Comments

Resuscitation table/area

Torch

Otoscope

Scales for children

Measuring board to

measure length and

height (lying/standing

according to age)

Stethoscopes

Thermometers

Heat source

Oxygen

source:

please tick

oxygen

cylinder

oxygen

concentrator

central

supply

Flow-meters for oxygen?

Equipment for the

administration of oxygen?

Indicate

which

equipment

you use:

please tick

nasal

prongs

catheters

masks




Emergency

area Ward

Pharmacy/

store Comments

Self inflating bags for

resuscitation

Masks infant size

child size

adult size

I.v.-giving sets with

chambers for paediatric

use

Butterflies and/or

cannulas of paediatric

size

NG-tubes, paediatric size

Equipment for intra-

osseous fluid

administration

Suction equipment

Chest tubes

Nebulisers for

administration of

salbutamol

Indicate type of nebulizer:

electricity

driven

oxygen

driven

footpump

driven

Spacers with masks for

administration of metered

doses (spray) of

salbutamol?




2.2.3 Standards for drugs, equipment and supplies

An adequate essential drug list exists for the hospital with all drugs being available.

Essential equipment is ready to use and in good working order.

Paediatric size anaesthesia equipment is available and in good working order. See p 44.

Please note: Refer to the above filled tables to mark this section.

Standards and criteria

Good

To be

improved Comments

Availability of essential drugs

An essential drug list exists in hospital

Drugs on the list are adequate for the

management of most common

conditions

Essential drugs are available on the

ward and in the emergency area and

immediately accessible

Drugs are not expired

Oldest drugs are used first

Availability of supplies and equipment

Essential equipment is immediately

available for use

Essential equipment is safe and in

working order

Essential supplies are available

immediately, and are adequate for use

in children

Summary table essential drugs, equipment and supplies

Good

To be

improved Comments

Essential drugs are available, not

expired and old drugs are used first.

Paediatric size anaesthesia equipment

is available and in good working

condition. See p 44

Adequate equipment is available in the

emergency area and on the ward.

There is an adequate range of i.v.-fluids.

Summary score essential drugs, equipment and

supplies Good To be improved

(to be circled) 5 4 3 2 1

Please indicate the quality of support by marking one of the 5 numbers; 5 indicates good

support, 4 to 1 indicating levels of necessary improvement (4=small need for improvement,

1=urgent need for improvement




2.3 Laboratory support


available for reference during the visit. If it has not been collected before, collect the information

early during the visit from the laboratory and chief laboratory technician.

Try to see as many essential laboratory investigations being carried out as possible. Are the

following laboratory investigations and their results available in a reasonably quick manner at this

hospital? (e.g. blood glucose, Hb, PCV within ½ hour, other investigations 1-2 hours). If available,

indicate duration until results are normally obtained.

Not

available Available

Time to

get results Comments

Blood glucose

Haemoglobin

Haematocrit (PCV)

Microscopy or rapid diagnostic test

(RDT) for malaria parasites

CSF and urine microscopy

Urine dip-stick (albumin, glucose,

nitrite, leukocyes, … please indicate)

HIV-serology/PCR

Blood grouping and crossmatch

Bilirubin

CD4 counts or HIV plasma viral loads

according to national guidelines

Standards of essential laboratory tests are reliably carried out and results delivered speedily.

Standards and criteria Good To be

improved Comments

Essential laboratory tests (blood glucose, haemoglobin

or haematocrite (PCV), microscopy for malaria,

microscopy for cells in CSF and urine, blood grouping

and cross-matching, HIV test) are available all the time

and their results delivered in a timely fashion to the

ward/emergency area.

Financial barriers do not deprive patients of the use of

essential laboratory test (free of charge, or an

exemption scheme in place for poor children).

Tests for emergencies are given priority.

Summary score laboratory support Good To be improved


Please indicate the quality of support by marking one of the 5 numbers; 5 indicates good support, 4 to 1 indicating

levels of necessary improvement (4=small need for improvement, 1=urgent need for improvement)

Assessment of the quality of hospital care for children Date: ׀__/__/__׀



3. Emergency care

3.1 Patient flow

Source: Visit to the emergency department and interviews with staff dealing with emergencies.

Instructions: Interview staff where emergencies present, who would see them; how senior staff are

called, and where and how severe conditions are handled.

Where are patients with an emergency medical or surgical condition received?

…………………………………………………………………………….……………………………….

…………………………………………………………………………….……………………………….

Describe patient flow of a typical emergency (patients presenting as an emergency to hospital):

……………………………………………………………………………………………………………..

…………………………………………………………………………….………………......................

How are severely ill patients diagnosed and handled in the outpatient department (i.e. patients

presenting normally to the outpatients department, but severely ill)?

Describe patient flow. ….……………………………………………………………………………….

…………………………………………………………………………………………………………….

…………………………………………………………………………………….………………………

Is there any system in place to prioritize severely ill children (triage)? Y N

If so, describe: .………………………………………………………………………………………….

…………………………………………………………………………………………………………….

…………………………………………………………………………………….………………………

Is there an emergency management area equipped to take care of children? Y N

If so, describe: .………………………………………………………………………………………….

…………………………………………………………………………………………………………….

…………………………………………………………………………………….………………………

Is there a separate consultation area for moderately ill children? Y N

If so, describe: .………………………………………………………………………………………….

………...…………………………………………………………………………………………………..

…………………………………………………………………………………………………………….

Is this separate from the normal outpatient facility dealing with unreferred children (IMCI-facility)?

Y N

If so, describe: .………………………………………………………………………………………….

…………………………………………………………………………………………………………….

…………………………………………………………………………………………………………….




Do patients come with referral notes when they have been referred from first level units?

never sometimes always

Comments: .…………………………………………………………………………….……………….

………...………………………………………………………………………………………………….

Are there any job aids (wall charts, chart booklets) displayed for the management of paediatric

emergencies? Y N

If so, describe about what, and comment on adequacy:……………………………………………

………………..…………………………………………………………………………………………..

………...………………………………………………………………………………………………….

Distance from reception area to emergency management area:

In the same building, distance....................................................................................................

In another building, distance.......................................................................................................

Distance from consultation area to emergency management area:

In the same building, distance....................................................................................................

In another building, distance.......................................................................................................

3.2 Staff dealing with emergencies

This concerns staff who are immediately available to deal with emergencies and their level of

training

Cadre of

staff

during working

hours

Present/not

present

If present,

number

after working

hours

Present/not

present

If present,

number

Trained in

assessment/

detection of

emergency

conditions

Yes/No

Trained in

management

of emergency

conditions

Yes/No

Comments

Gateman

Records

clerk

Triage

nurse

Nurse

Auxiliary

Clinical

officer

Medical

officer




3.3 Layout and structure of emergency area

Standards Patients are assessed for emergency or priority signs before administrative procedures.

The emergency area is adequately equiped and stocked with drugs for the most common

emergencies.

A qualified health professional carries out triage and can implement the emergency guidelines

e.g. for convulsions, neurological deficits, shock and respiratory distress.


improved Comments

Children are assessed for severity/ priority

signs (triaged) immediately on arrival.

Patients do not have to wait for their turn,

registration, payment etc. before a first

assessment is done and action taken.

A wall chart or job aid for identifying children

by severity of condition is located in the

emergency admissions area.

Drugs, equipment and supplies* (see below)

Essential drugs for emergency conditions

(anticonvulsants, glucose, iv fluids) are always

available and free of charge to the family

Essential lab tests (glucose, Hb or PCV) are

available and results are obtained timely

Essential equipment (needles and syringes,

nasogastric tubes, oxygen equipment, self-

inflating resuscitation bags with masks of

different sizes, nebulisers or spacers) is

available

Staffing

A qualified staff member is designated to carry

out triage.

A health professional is available without delay to manage children determined to have an emergency condition.

Case management** (see below)

Staff doing triage is trained in the ETAT

guidelines and can implement them

appropriately when the emergency room gets

busy during peak hours

Staff is skilled in the management of common

emergency conditions and starts treatment

without delay: Management of convulsions,

lethargy, severe respiratory distress, shock

and severe dehydration.




3.4 Drugs, equipment and supplies

(see above p 10-15)

Please refer to the tables above. Please note when judging the adequacy of supplies that

some drugs (e.g. oxygen, anticonvulsants) need to be immediately available, whereas for

others (e.g. antibiotics) it suffices if access is assured.

3.5 Case management of emergency conditions

Source: Information is obtained by case observation of cases presenting, as far as possible, and

through interviews with staff about the routine practice. If you cannot observe one to two cases,

describe scenarios to staff of two to three cases with convulsions, severe respiratory distress, and

shock.

Cases include children presenting with danger signs, severe respiratory distress, severe

dehydration. Case management is observed during working hours and after hours. If no cases

with emergency conditions present, staff is interviewed about how they would manage such

conditions. Enquire about the management of a child presenting with convulsion, with lethargy,

with severe respiratory distress, and with severe dehydration.

Summary table emergency area

Good To be

improved Notes on cases and comments

Layout and physical

structure of the

emergency department.

Adequate staffing.

Availability of essential

drugs.


laboratory support.


equipment.

Practice and case

management of

emergency conditions.

Summary score laboratory support Good To be improved




1=urgent need for improvement)




4. Children’s ward

4.1 Layout

Source: Observation during the visit to the ward, and interviews with staff and guardians of patients.

How many beds does the ward have? …………………………

How many patients are currently admitted? Is this high-season for paediatric admissions or off-

season? Has the number of paediatric patients increased of the last three years? Please comment:

…………………………………………………………………………………………...……………………….

Which age groups are admitted to the paediatric ward? ____ to ____ years

Check the following

Where is the toilet? ………………………………………………………………………………………

Is the toilet clean? Y N

Are the beds safe and well maintained? Y N

Are there mattresses? Y N

Do patients receive bed linen? Y N

Are the beds clean? Y N

Is there an emergency management area in or near to the ward? Y N

Is there a heat source on the ward? Y N

Are mosquito nets available for use of patients? Y N

Comments and observations: ………………………………………………………………...............

………………………………………………………………………………………………...................

………………………………………………………………………………………………………….....

………………………………………………………………………………………………...................

……………………………………………………………………………………………………………..

………………………………………………………………………………………………...................




4.2 Standards and criteria children's ward

Standards Children are seen in OPD by a designated health professional only.

Closest attention for the most seriously ill children is ensured.

There is a separate children's ward or room for children.

There is a separate room for sick neonates with their mothers.

Hygienic and sufficient services facilitate the stay of mother and child.

Staff can wash their hands on the ward and there are sharp disposals available.

Hygienic and sufficient services facilitate the stay of mother and child.


improved Comments

Children are only seen in OPD by

the designated health professional

in the designated room/area.

Closest attention for the most seriously ill children

The most seriously ill children are

cared for in a section where they

receive closest attention.

This section is close to the nursing

station so that children can be

directly observed most of the time.

Separate ward for children.

Children are kept in a separate

ward or separate area of a ward.

Severely ill children are kept apart

from adults in wards such as for

infectious diseases or intensive

care.

Children with surgical conditions

are at least kept in a separate

room, with staff aware of the

special needs for children such as

feeding and warmth.

Arrangements are made to meet

these needs.

In cold climates, the ward has an

efficient and safe heat source.

Separate room for sick neonates with their mothers

Sick new-borns are kept separate

from healthy babies. Mothers of sick new-borns are

rooming in with their babies, and

have adequate facilities.

Hygiene and accident prevention

Staff has access to hand washing

facilities The ward is kept clean

and dangerous items are

inaccessible for children

Sharps are disposed of in a

special container preventing

accidents





improved Comments

Hygienic and sufficient services facilitate the stay of mother and child

There are sufficient and adequate

toilets which are easily accessible

Mothers have access to running

water and to an appropriate space,

near the ward, to wash themselves

and their child.

Mothers have access to a washing

facility, in order to wash her and

her child’s clothes.

Patients are kept in a bed/cot with

a clean mattress.

Patients receive bed sheets

In malarious areas, beds are

equipped with mosquito nets.

Summary table paediatrics ward

Good

To be


There is a separate ward for children.

There is a separate room for sick

newborn babies with their mothers.

The hygiene of services for children

and their mothers is adequate.

Closest attention is provided for the

most seriously ill children.

Hygiene and accident prevention is in

place.

Summary score children's ward and facilities Good To be improved








5. Case management of common diseases:

5.1 Cough/difficult breathing, (p 69-107)

5.2 Diarrhoea, (p109-130)

5.3 Fever conditions, (p133-171)

5.4 Malnutrition, (p173-196)

5.5 HIV/AIDS, (p199-224)

Source: This information should be collected by observing the treatment and care of children with

the relevant condition and interviewing staff and carers.

Please note: the page-references refer to the English version of the WHO Pocket Bock of Hospital

Care for Children

5.1 Cough or difficult breathing

Standards Pneumonia is diagnosed and classified based on diagnostic signs.

Appropriate antibiotics are administered to children who need them.

Oxygen therapy is administered to all children who need it.

Correct indications for chest X-ray are applied.

Children with wheezing receive correctly administered inhaled brochodilators.

TB treatment is given according to national guidelines.

Adequate monitoring and supportive care is ensured.


improved Comments

Assessment of pneumonia

Health workers correctly diagnose

pneumonia and classify/recognize

severity. pp 69-74, 78

Signs such as chest-indrawing,

respiratory rate, presence of

cyanosis and general condition are

used pp 70-73

Administration of appropriate antibiotics

Antibiotics are given only to

children with cough and difficult

breathing who need them

(pneumonia, severe pneumonia,

very severe pneumonia or very

severe disease) pp 74,75,79,80

Not to children without signs of

pneumonia or there is another

reason for antibiotics p 82

Appropriate antibiotics at correct

doses are administered for

pneumonia according to severity

and weight p 74,75,79,80

If child has not improved after two

days or condition worsens, a

health professional looks for

complications or considers other

diagnoses p 76,79





improved Comments

Oxygen therapy

Oxygen is administered to all

children who need it. p 75, 79,

281-284

Oxygen is not given if there is no

clinical indication for oxygen

therapy (sign of hypoxaemia) p 75

Oxygen is administered correctly

(prongs or catheter, correct flow,

no interruptions) and monitored.

Oxygen mask and headbox are

avoided due to waste of oxygen

and risks p 281-284

Use of chest X-ray

Chest x-rays are performed

when signs of pneumonia are

present in:

- young infants

- cases with suspected

complications (e.g. empyema,

pneumothorax, abscess)

- patients not responding to

appropriate antibiotic treatment for

> 48 hours

- Chest x-ray is not performed in

patients with uncomplicated

pneumonia or cough and cold

unless there is a clear indication

pp 76-77

Wheezing

Children in need of bronchodilators

are correctly identified/diagnosed.

p 87,88

Inhaled bronchodilators are

correctly administered (way, dose

and frequency) by spacer or

nebulizer. p 88-89

Inhaled bronchodilators are

affordable (free of charge or at

least available through an

exemption scheme)

Children with asthma who are

discharged have follow-up

treatment prescribed and

explained to parents p 91





improved Comments

TB treatment

Correct anti-tuberculous

treatment is given to children

with suspected TB according to

national guidelines p 101-104

TB is considered as differential

diagnosis of unresolving pneu-

monia and malnutrition. p 76

Not every child with malnutrition

receives anti-TB treatment

(balance of the likelihood of

having TB) p 192

Monitoring and supportive care

See monitoring and supportive

care, section 10 and 11, pp

261ff and 289ff

Summary table cough/difficult breathing

Good

To be


Severity of pneumonia is correctly

assessed and diagnosed.

Appropriate antibiotics are

administered for pneumonia and

other respiratory diagnoses.

Oxygen is correctly administered

when necessary.

Correct use of chest X-ray.

Appropriate diagnosis and

management of TB.

Inhaled bronchodilators are given

appropriately when indicated.

Patient monitoring appropriately

performed and charted. (see

section 11)

Supportive care provided

appropriate for condition. (see

section 10)




Main strengths:

……………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………...

Main weaknesses

…………………………………………………………………………………………………………………...

…………………………………………………………………………………………………………………...

Summary score cough and difficult breathing Good To be improved








5.2 Diarrhoea

Standards Dehydration is correctly assessed on admission.

An adequate rehydration plan according to severity of dehydration is followed and

monitored.

Appropriate antibiotics are only given when necessary.

Appropriate feeding is continued during diarrhoea.

Monitoring and supportive care is adequate.


improved Comments

Assessment of dehydration

The degree of dehydration is

assessed in all patients with

diarrhoea p 111

Dehydration is correctly classified

based on recommended signs(*)

according to the CDD/IMCI

guidelines pp 18,111-113

Children with dysentery and severe

malnutrition and young infants with

dysentery are properly assessed

and admitted p 127

Management according to rehydration plan

The correct rehydration plan is

chosen based on the assessment of

dehydration (Plan A, Plan B, Plan C)

p 114,117,120

Rehydration is correctly

administered

The amount of fluids by weight and

time is correctly calculated for plan

B and C p 114,117

Signs of dehydration are monitored

during rehydration

Fluid intake and rate of infusion are

monitored and adjusted, if

necessary p115

Use of antibiotics for diarrhoea

Antibiotics are given only to children

with bloody diarrhoea or suspected

cholera p110,128,129

Antibiotics are not given to children

with only watery diarrhoea and without

any other condition requiring antibiotic

treatment p122

Correct choice of antibiotics

according to WHO guidelines and

national adaptations p 128-129

Antidiarrhoeal drugs are not given

p110





improved Comments

Continued feeding

Feeding (breast milk and/or other

food) is continued and encouraged

for children with diarrhoea p118-119

Frequent small feedings are offered

Monitoring & supportive care

See monitoring and supportive care

section 10 and 11, p 261ff & 289ff

Summary table diarrhoea

Good To be


Dehydration is correctly assessed.

The rehydration plan is appropriate to

severity of dehydration, and

appropriately monitored.

Appropriate antibiotics only given when

necessary.

Appropriate (continued) feeding given

during diarrhoea.

Main strengths:

……………………………………………………………………………………………………………….

……………………………………………………………………………………………………………….

Main weaknesses

……………………………………………………………………………………………………………….

……………………………………………………………………………………………………………….

Summary score management of diarrhoea Good To be improved








5.3 Fever conditions

Standards A differential diagnosis of fever is considered and appropriate investigations are undertaken.

Meningitis is correctly diagnosed and managed.

Severe complicated malaria is correctly diagnosed and managed.

Measles is correctly diagnosed and managed.

Dengue Haemorrhagic Fever is correctly diagnosed and managed.

Other febrile conditions are correctly diagnosed and managed.

Adequate monitoring and supportive care is ensured.


improved Comments

Differential diagnosis and investigations

Appropriate assessment is

undertaken for all children with

febrile conditions p 133-134

-History

-Examination

-Laboratory

Children admitted with fever

have a differential diagnosis for

possible and likely conditions

considered p 135

Appropriate examinations are

undertaken to establish a

diagnosis (LP, blood film for

malaria, urine examination, chest

x-ray) p 137

Diagnosis and management of meningitis

Lumbar puncture is performed

without delay when meningitis is

suspected. p 149

Adequate antibiotic treatment is

started without delay when

bacterial meningitis is suspected.

p 150

Complications of meningitis are

diagnosed and treated

appropriately:

-Convulsions

-Hypoglycaemia p 153

Appropriate patient monitoring is

performed and charted: p 153

-State of consciousness

-Respiratory rate

-Pupil size





improved Comments

Diagnosis and management of severe or complicated malaria

Malaria diagnosis is confirmed by

microscopy or a rapid diagnostic

test. p 137

For possible cerebral malaria

and malaria associated

respiratory distress, alternative

diagnoses are ruled out (LP for

meningitis, x-ray for e.g.

pneumonia). p 139-140

Correct antimalarial treatment is

given. p 140-141

Patients are monitored

adequately, and complications

such as hypo-glycaemia are

prevented. p 143-144

Complications are correctly

diagnosed and treated; p 142-

144

-Coma

-Severe anemia

-Hypoglycemia

-Acidosis

-Aspiration pneumonia

Diagnosis and management of measles

Measles cases are assessed for

complications and treated

appropriately p 154

Vitamin A is given to all patients

with measles p 155

Appropriate nutritional support is

given p 155

Public health measures are

taken when a child is admitted

with measles: p 157

-Isolation

- patients and staff are checked

for immunization status and

-immunized if necessary





improved Comments

Diagnosis and management of Dengue Haemorrhagic Fever

Children are assessed correctly

where the risk of Dengue exists.

p 166-168

The severity of Dengue is classified

by looking for signs of plasma

leakage, shock, altered

consciousness level and bleeding.

p 167-168

Correct management of severe

Dengue and monitoring;p 168-169

-i.v. fluids to prevent shock

-correct shock treatment

Monitoring of the clinical course with

haematocrit (PCV) checks, pulse and

blood pressure repeatedly. p 171

Other severe febrile conditions are assessed and managed correctly (Typhoid, Mastoiditis, UTI,

Septic arthritis and Osteomyelitis)

Appropriate assessment and

differential diagnosis performed.

p 133-138

Correct treatment given.

Monitoring and supportive care, see

section 10 and 11. pp 261ff & 289ff

Summary table fever

Good To be


Differential diagnosis of fever

considered and appropriate

investigations undertaken.

Correct diagnosis and management

of meningitis.

Severe complicated malaria correctly

managed.

Measles correctly managed.

Dengue Haemorrhagic Fever

correctly managed.

Other febrile conditions correctly

managed.




Main strengths:…………………………………………………………………………………………….

………………………………………………………………………………………………………………

Main weaknesses:………………………………………………………………………………………..

………………………………………………………………………………………………………………

……………………………………………………………………………………………………………...

Summary score management of fever conditions Good To be improved








5.4 Severe malnutrition

Standards Nutritional status is assessed by weight for height/MUAC and differential diagnoses for severe

malnutrition are considered.

Infections are appropriately managed by giving empiric treatment.

Micronutrients are appropriately substituted.

Dehydration and electrolyte imbalance are appropriately assessed, treated and monitored

Hypoglycaemia and hypothermia are prevented, checked and managed.

Feeding with correct type, frequency and amount of food in severely malnourished children is

ensured.

Associated conditions of severe malnutrition are appropriately managed.



improved Comments

Assessment of nutritional status, including differential diagnoses for severe malnutrition

Scale available, weight for height

correctly calculated. p 174

An appropriate history is taken and

laboratory exams done. p 174-175

Clinical examination for: wasting,

oedema, skin changes, signs of

dehydration, eye signs of Vit A

deficiency, severe palmar pallor,

localizing signs of infection, mouth

ulcers, fever/hypothermia. p 174-175

Differential diagnosis considered for

severe malnutrition, if doubt about

protein-energy malnutrition as likely

cause (rule out TB, malabsorption,

etc). p 174-175

Management of infection and micronutrients

Broad spectrum antibiotics are

administered to all severely

malnourished patients. p 182-183

Measles vaccination if needed. p182

Treatment of worms with

Mebendazole. p 183

Vitamin A given orally. p 184

Vitamin/mineral supplementation

given. p 183,184

Iron only given in the recovery phase.

p 183





improved Comments

Management of dehydration

ReSoMal given orally or NG- tube for

rehydration. p 179-181

I.v. rehydration not given except for

shock and inability to take orally. p

179

Potassium and magnesium

supplement given. p 181-182

Use of low sodium rehydration fluid

and food preparation without salt.

p182

Prevention and management of hypoglycaemia and hypothermia

Routine procedures in place to

prevent hypoglycaemia and

hypothermia. p 177-178

Frequent feeding of malnourished

children from admission. p 177

If a child is deteriorating, blood

glucose is checked. p177

Correct feeding of severely malnourished children

Appropriate (caloric intake and

frequency) feeding regimen is started

in all severely malnourished children.

p 184

Frequent feeding - day and night. p

184,187

Monitoring of intake and weight gain.

p 188

Follow up is organised for children

discharged before recovery. p 193-

194

Correct management of associated conditions and supportive care

Correct treatment of associated

conditions: eye problems, severe

anaemia, dermatitis, diarrhoea, TB. p

190-192

Sensory stimulation and emotional

support is provided. p 189-190

Monitoring & supportive care

See monitoring and supportive care.

section 10 and 11 pp 261ff and

289ff




Summary table malnutrition

Good To be


Nutritional status assessed by weight

for height, including differential

diagnosis for severe malnutrition.

Management of infection.

Management of electrolyte imbalance

and micronutrients.

Correct management of dehydration.

Hypoglycaemia and hypothermia

checked and managed in children

with severe malnutrition.

Correct feeding of severely

malnourished children.

Correct management of associated

conditions in children with severe

malnutrition.

Main strengths:

………………………………………………………………………………………………………………

………………………………………………………………………………………………………………

Main weaknesses

………………………………………………………………………………………………………………

………………………………………………………………………………………………………………

Summary score management of severe malnutrition Good To be improved








5.5 Children with HIV/AIDS

Standards Guidelines are in place for counselling, diagnosing and staging of paediatric HIV.

Guidelines are in place for the treatment and monitoring of antiretroviral therapy.

All HIV infected children receive standard immunisations, prophylaxis/treatment of opportunistic

infections and supportive care.



improved Comments

Counselling and diagnosis of paediatric HIV

Counselling is done in a separate room

and confidentiality is ensured p 201-203

During breastfeeding-counselling, the

importance of exclusive breastfeeding

for 6 months only is stressed. If bottle

feeding is considered, the financial and

hygienic requirements are explained p

219, 220

Counsellors receive formal training in

HIV counselling, are regularly updated

and do get adequate supervision and

support p 202

Detailed counselling-documentation is

done.

Women attending ANC and delivering in

the hospital have been offered an HIV

test. Those found to be positive receive

breast feeding counselling and learn

about symptoms of paediatric HIV. A

follow up appointment is given.

Clinical signs of paediatric HIV infection

are recognized and an HIV test is offered

routinely for a child with clinical signs of

possible HIV infection. p 200, 201

HIV testing against the will or without the

knowledge of the family is prohibited.

All family members of children with a

positive HIV test are offered HIV testing

and counselling p 201

A high proportion of current inpatients

with severe malnutrition or TB show a

documented offer of HIV screening.

DNA/RNA tests are used for children

<18 months and HIV antibody tests for

those >18months p 203, 204

The staging is done according to the

WHO paediatric clinical staging system

p 204-206





improved Comments

Antiretroviral treatment (ARV) and monitoring

Antiretroviral regimens are initiated and

switched according to national guidelines

p 207-209

If possible, paediatric formulations and

fixed-dose combinations are given.p 207

On all follow-up visits weight and height

are taken. In children < 24 months the

head circumference is also recorded to

detect growth failure. The dosing of ARV

is done correctly and adjusted for weight-

gain regularly

CD4%/PVL and/or clinical monitoring is

done according to national guidelines.

p 210

Opportunistic infections and supportive care

Immunization-status is checked and

updated except for Yellow Fever and

BCG in symptomatic disease

Measles vaccine is added at age 6

months. p 214

All mothers receive nutritional advice

before discharge p 216

Correct treatment of:

Opportunistic infections

Persistent diarrhoea

TB (no Thioacetazone)

Recurrent pneumonia p 216-219

Initiation of ARV is deferred until patient

has been stabilized and opportunistic

infections are treated (incl. TB) p 209

Supportive care and follow-up of HIV infected children

Carers are referred to home based care-

/palliative care-/support before discharge

p 221-224

Terminal care focuses on symptom

control p 221

Follow-up is ensured for all HIV infected

children discharged from the ward p 220

Prophylactic Co-trimoxazole is offered to

all children at risk of or suspected of HIV

p 214, 215




See monitoring and supportive care,

section 10 and 11, pp 261ff and 289ff

Summary table HIV/AIDS

Good To be

improved

Notes on cases and

comments

HIV tests used correctly and when indicated.

Professional counselling services are in

place with confidentiality ensured.

ARV treatment follows national guidelines.

Nutritional advise provided, (on exclusive

breastfeeding for 6 months/bottle feeding).

Immunizations and Co-trimoxazole-

prophylaxis given correctly.

Opportunistic infections correctly

diagnosed/treated.

Patients are referred for home based care

and palliative care focuses on symptom

control.

Main strengths

………………………………………………………………………………………………………………

………………………………………………………………………………………………………………

Main weaknesses

………………………………………………………………………………………………………………

………………………………………………………………………………..........................................

Summary score management of HIV/AIDS Good To be improved








6. Supportive care

(p261-287)

Standards Nutritional needs of admitted children are met, breastfeeding is continued.

Breastfeeding is encouraged and where necessary expressed breast milk is given.

Appropriate intravenous fluids are only given where indicated and flow is monitored.

Drug treatment started only where necessary, polypharmacy avoided were possible.

Blood transfusions are only given where indicated and only screened blood is used.


improved Comments

Nutritional needs of admitted children

Nutritional needs of all patients are

covered, according to age and

ability to feed p 261-272

Breastfed infants continue to receive

breast milk p 262

Appropriate complementary

feedings should be offered at least 3

times a day to breastfed infants of 6-

12 months of age p 262

Feedings should be offered at least

5 times a day to non-breast-fed

infants of 6 to 24 months of age

p 271

All children admitted should receive

their full caloric requirement unless

there is good medical reasons for

not giving it p 270

A sufficient caloric intake (100

calories/kg for children under 10 kg)

should be provided; for children too

sick to feed by nasogastric tube

i.v.-glucose should not be used as

calorie source for more than a

maximum 24 hours p 273

Promotion of breastfeeding

Mothers of children below two years

of age are encouraged and helped

to breastfeed p 262-266, 271

Expressed breastmilk should be

given with a cup or NG-tube when

the child is unable to feed or if the

mother cannot stay with the child all

the time p 267

Use of intravenous fluids

Intravenous fluids are given only

when indicated p 273

Appropriate fluids are chosen p 273

The flow rate is monitored closely

p 273





improved Comments

Drug treatment and avoidance of polypharmacy

Drugs are only given for an

established or highly suspected

diagnosis

No drugs are given without a good

reason

No routine use of sedative drugs or

anti-histamines.

Corticosteroids are only given for a

clear indication for which steroids

are useful p 151

Blood transfusion

Blood is only given when indicated

p 277

Only screened blood is used p 277

The flow rate is monitored p 279

Summary table supportive care

Good To be


Nutritional needs are met, according

to age and ability to feed.

Breastfeeding is promoted.

Intravenous fluids given only when

indicated, appropriate choice of

fluids, and monitoring of rate.

Drug treatment according to

diagnosis, polypharmacy is avoided.

Blood transfusion only when

indicated, blood is screened, rate

monitored.

Main strengths:

………………………………………………………………………………………………………………

………………………………………………………………………………………………………………

Main weaknesses

………………………………………………………………………………………………………………

………………………………………………………………………………………………………………

Summary score supportive care Good To be improved


Please indicate the quality of support by marking one of the 5 numbers; 5 indicates good support, 4 to 1

indicating levels of necessary improvement (4=small need for improvement, 1=urgent need for improvement




7. Monitoring

(p289-290)

Standards All children are assessed for their nutritional status on admission.

Every child has a monitoring chart according to severity of condition where individual progress

is monitored.

Reassessment and monitoring is adequately done and correctly recorded by the nurses and a

senior health professional is called when needed.

Admitted children are reassessed by a doctor regularly according to severity of illness.

Follow up is arranged prior to discharge with a discharge note explaining the condition and

further treatment needed.


improved Comments

Nutritional status is assessed in

all admitted children

Monitoring of individual progress

At the time of admission, a

monitoring plan is prescribed

according to the severity of the

patient's condition. p 289,290

A standard monitoring chart is

used with the following

information: patient details; vital

signs; clinical signs depending

on condition; treatments given,

feeding and outcome. p 290,369

Reassessment and monitoring by nurses

Key risk signs are monitored and

recorded by a nurse twice a day

and at least four times a day for

critically ill patients. p 289,290

Doses and time are recorded for

medications and i.v.-fluids given

by the nurse for every patient

receiving medication or i.v.-fluids.

p 289,290

Additional special monitoring is

performed and recorded

appropriately when needed to

follow the progress of particular

conditions: e.g. in malnourished

children, fluid balance (input –

output) in severe dehydration,

oxygen, coma scale for

unconscious children. p 289

Nurses use the results of patient

monitoring to alert the physicians

of problems or changing patient

status warranting their attention.




Summary table monitoring

Good To be


Nutritional status is assessed in all

admitted children.

Each child’s progress is individually

monitored, and charts are used.

The most ill children receive highest

attention.

All admitted children are appropriately

reassessed by a nurse.

All admitted children are appropriately

reassessed by a doctor.

Main strengths:

……………………………………………………………………………………………………………….

……………………………………………………………………………………………………………….

Main weaknesses

……………………………………………………………………………………………………………….

……………………………………………………………………………………………………………….

Summary score monitoring Good To be improved


Please indicate the quality of support by marking one of the 5 numbers; 5 indicates good support, 4 to 1 indicating levels

of necessary improvement (4=small need for improvement, 1=urgent need for improvement


improved Comments

Reassessment of admitted children by a doctor

Seriously ill patients are reassessed

by a doctor upon admission and

reviewed at least twice daily until

improved. p 289

All patients are reassessed daily

during working days by a doctor

Sick patients or new admissions are

also reviewed by a physician on

weekends and holidays. p 289

Follow-up

Before discharge follow up is

arranged in the health facility closest

to the patient's home that provides

the necessary follow up treatment.

All children receive a discharge note

explaining their condition and

providing information for the staff at

the follow up facility.




8. Neonatal Care

8.1 Nursery layout and staff

8.2 Routine neonatal care, (p42-47)

8.3 Nursery facilities

8.4 Case management and sick newborn care, (p47-61)

8.1 Nursery layout and staff

Source: This information should ideally be collected partly before the visit (see postal

questionnaire), and be available for reference during the visit. If it has not been collected before,

collect the information early during the visit from the doctor/nurse in charge.

Layout

How many cots/beds does the nursery have? Number of cots / beds: _______

Up to which age are new-borns admitted to the nursery? Age in months: _______ months

Are out-born infants admitted in the nursery? Y N

If so, are they admitted in a separate room? Y N

Check the following:

Where is the toilet? …………………………………………………………………………................

Is the toilet clean? Y N

Are the beds safe and well maintained? Y N

Are there mattresses? Y N

Do patients receive bed linen? Y N

Are the beds clean? Y N

Is there an emergency management area in or near to the ward? Y N

Is there a heat source on the ward? Y N

Are mosquito nets available for patient use? Y N

Staffing of delivery room and newborn nursery

Indicate the number of staff available for the

care for new-borns.

day night

Doctors

Medical assistants

Midwives

Nurses

Auxiliary staff

Who is available during the weekend? …………………………………………………………………

If senior staff is not available all the time, how are they called? …………………………………….

……………………………………………………………………………………………….....................




8.2 Routine neonatal care

Source: Please collect the information by observing the treatment and care of children with the

relevant condition and interviewing staff and carers.

Standards Neonatal resuscitation guidelines are available and staff is trained in their use.

Early and exclusive breastfeeding and skin contact is ensured.

Clean delivery with clean instruments and hands is practiced.

Neonates are kept warm.

Eye prophylaxis, Vitamin K and immunisations are given.


improved Comments

Neonatal resuscitation guidelines are available and staff are trained in their use

Written guidelines for resuscitation

and care of the newborn are

available, followed, practised and

documented. p 42-46

There is a resuscitation place with

heating and equipment ready to use.

A functioning self-inflating bag with

new-born- + premature size masks is

available. p 45

If a neonate is not breathing,

ventilation by self-inflating bag is

initiated according to WHO

guidelines. p 44

There is a plan to call a senior health

professional for resuscitation, if

required. p 43

Early and exclusive breastfeeding and skin contact is ensured

Within the first ½ hour, a newborn

has prolonged skin contact with the

mother. p 42

Mothers are assisted with the first

breastfeeding: correct attachment

and positioning is demonstrated. p 42

There is no promotion of infant

formula on the ward or distributed to

mothers/staff.

There are no restrictions on the

frequency or length of breastfeeds.

Mothers stay with their infants in the

same room day and night.

Clean delivery with clean instruments and hands

The birth attendants hands are clean.

p 46

Clean (sterile) instruments are used.

p 46,47

Nothing is applied to the cord.

p 46





improved Comments

Children are kept warm

Newborns are kept in a warm room,

with no draught. p 46

Newborns are cleaned with dry/warm

cloth, no bathing or washing. p 46

Body temperature is monitored.

Eye prophylaxis, Vitamin K and

immunisations are given according to

local policy. p 46

Summary table routine neonatal care

Good To be

improved

Notes on cases and

comments

Resuscitation procedures are correctly

performed and trained.

Early and exclusive breastfeeding is

promoted, skin contact ensured.

Clean delivery and newborn care is

practised.

Thermal protection is practised.

Eye and Vitamin K prophylaxis and

immunisations are given.

Main strengths

………………………………………………………………………………………………………………

………………………………………………………………………………………………………………

Main weaknesses

………………………………………………………………………………………………………………

………………………………………………………………………………..........................................

Summary score routine neonatal care Good To be improved








8.3 Nursery facilities

Standards There is a separate room for sick newborn babies with their mothers.

There are hygienic services for mothers.

There is adequate accident prevention in place and disposition of sharps.

Closest attention for the most seriously ill newborns/ infants is provided.

Sick newborns are kept in a separate unit

or room from healthy babies.

Mothers of sick newborns are rooming in

with their babies, with adequate facilities.

There are hygienic services for mothers

Toilets are adequate & easily available.

The mother has access to running water

and to an appropriate space, near the

ward, to wash herself and her child.

Mothers have access to a washing facility,

to wash hers and her child's clothes.

There is adequate accident prevention in place and disposition of sharps

The ward is kept clean.

Sharps are disposed of in a special

container preventing accidents.

Mothers and children sleep under

mosquito nets.

Closest attention for the most seriously ill newborns is provided.

The most seriously ill infants are cared for

in a section near the nursing station for

direct observation.

Summary table nursery facility

Good To be


There is a separate room for sick newborn

babies with their mothers.

There are hygienic services for the mothers of

the newborns.

Clean ward; accident prevention and

disposition of sharps is in place.

Closest attention for the most seriously ill

newborn is ensured.

Summary score routine neonatal care Good To be improved


Please indicate the quality of support by marking one of the 5 numbers; 5 indicates good support, 4 to 1 indicating levels

of necessary improvement (4=small need for improvement, 1=urgent need for improvement.


improved Comments

There is a separate room for sick newborn babies with their mothers




8.4 Case management and sick newborn care

Note: Sick newborns might be admitted in different areas, the maternity ward or the infant ward.

Information should be primarily by case observation.

Standards Neonatal sepsis is appropriately diagnosed and investigated.

Neonatal sepsis is adequately treated.

Specific feeding needs of sick young infants and those with low birth weight are taken care

of.

Severe jaundice is recognized and appropriately managed.


improved Comments

Diagnosis and investigation of neonatal sepsis

Neonatal sepsis is suspected in

neonates with signs such as fever

or difficulty feeding and

appropriately investigated (e.g.

urine microscopy, foci of infection).

See p 53, 47

Lumbar puncture is done to rule

out/confirm meningitis. p 50

Newborns get oxygen if cyanosed

or in severe respiratory distress. p

52

Treatment of neonatal sepsis

Effective antibiotics are given

according to age and weight of the

baby. p 49-50,62-66

The response to treatment is

monitored. p 48

Specific feeding needs of sick young infants and those with low birth weight

All efforts are made to give

mother’s milk to LBW babies. p

53-55

Frequent feedings (at least 8 x per

day) are provided to LBW-babies

and intake is monitored. p 54

To children unable to feed

expressed breast milk is given by

cup and spoon or fed by

nasogastric tube in adequate

amounts according to age. Intake

is monitored. p 55

If i.v.-fluids are given, they are

recorded and precautions are in

place to prevent fluid overload. p

51,52

In LBW-babies, heat loss is

minimized by kangaroo-care and a

cap on the head. p 54





improved Comments

Recognition and management of jaundice

Facilities for exchange

transfusion are available, or there

are guidelines when to refer a

child. p 58

Phototherapy and guidelines

when to use it are available and

adequate hydration is ensured. p

58, 59

Procedures are in place to check

the bilirubin level.

Summary table case management and sick newborn care

Good To be

improved Comments

Neonatal sepsis is appropriately

diagnosed.

Neonatal sepsis is appropriately

treated.

Specific feeding needs of sick

young infants and those with low

birth weight, are met.

Jaundice is adequately

recognized and managed.

Main strengths

………………………………………………………………………………………………………………

……………………………………………………………………………………………………………...

Main weaknesses

……………………………………………………………………………………………………………...

……………………………………………………………………………………………………………...

Summary score case management and sick newborn care Good To be improved








9. Paediatric surgery and rehabilitation

(p227-259)

Source: This information should be collected by observing the treatment and care of children

undergoing surgical treatment, interviewing staff and carers and reviewing guidelines, if available.

Standards Pre-operative care is child-friendly and starving is kept to a minimum.

Intra-operatively routine procedures prevent hypothermia and hypoglycaemia.

Post-operative care ensures save recovery including monitoring, pain relief and early feeding.

The surgical ward is child friendly, provides food for children and opportunities to play.

Paediatric size anaesthesia equipment is available (see table below).

Basic rehabilitation equipment is available.


improved Comments

Pre-operative care

Standard procedures are in place to

prepare a child for surgery: weight,

haemoglobin level, blood group of the child

and consent of the carer is recorded.

p 228-229

Starving is kept to a minimum (8hrs no

solids/6hrs no formula/4 hrs no milk or

clear liquids) and children are put first on

the operating list to avoid unnecessary

starving. p 228

Intra-operative care

The child is kept warm during surgery and

i.v.-fluids containing glucose are given for

long procedures (e.g. 0.45% NaCl + 5%

glucose). p 231

Guidelines are in place for the safe use of

local anaesthetic (weight adjusted). p 229

Blood loss is monitored. p 231

Post-operative care and monitoring

There are specific notes from the surgeon

on the procedure performed, necessary

monitoring and treatment. There is a

handover for the nurses from theatre staff.

Post-operatively, children are closely

observed in a safe place and frequent

recording of vital signs (blood pressure,

pulse, respiration rate every 15-30 min

initially) is ensured. p 232

Oxygen and equipment for resuscitation/

suction are readily available and working.

Nursing staff have adequate guidelines on

post-operative pain relief. p 233

Children are allowed to eat as soon as

they have fully recovered from

anaesthesia. p 233






The surgical ward is child friendly,

provides food for children and

opportunities to play.

Rehabilitation

Basic rehabilitation equipment is

locally manufactured or provided for

to children (crutches…).

Some form of organized

physiotherapy is available to children.

Summary table paediatric surgery and rehabilitation

Good To be


Standard procedures are followed for

preoperative surgical care.

Pre- and post-operative starving is kept to

a minimum.

Hypoglycaemia and hypothermia are

prevented during surgery.

Frequent post-operative monitoring with

regular checks of vital signs is ensured.

Resuscitation equipment is available and

pain relief adequately addressed.

Basic rehabilitation equipment is available.

Summary score paediatric surgery and rehabilitation Good To be improved





9.1 Paediatric size anaesthesia-equipment

Paediatric size…..are available, in good

working condition not always available not available

Tracheal tubes

Face masks

Laryngoscope blades

Oropharyngeal airways

Breathing valves

Resuscitation bags

Blood pressure-cuffs




10. Other Hospital wards with children

Check whether children are admitted to other hospital departments such as the infectious disease

ward or intensive care unit. Assess the adequacy of the layout for children, staffing with paediatric

expertise, availability of supplies for children (e.g. paediatric size cannulae, food supply), and

knowledge of monitoring and case management of children.

Notes and comments;

Layout: …………………………………………………………………………….…

………………………………………………………………………………………...

…………………………………………………………………………….…………..

………………………………………………………………………………………...

Staffing:…………………………………………………………………………….…

………………………………………………………………………………………...

…………………………………………………………………………….…………..

………………………………………………………………………………………...

Supplies and equipment for paediatric care……………………………………..

………………………………………………………………………………………...

…………………………………………………………………………….…………..

………………………………………………………………………………………...

Monitoring of children:...……………………………………………………………

………………………………………………………………………………………...

…………………………………………………………………………….…………..

………………………………………………………………………………………...

Supportive therapy for children:…...…………………………………………….…

………………………………………………………………………………………...

…………………………………………………………………………….…………..

…………………………………………………………………………….…………..




11. Hospital administration

This section builds on findings in the section "General hospital information" obtained by postal

survey and cross checked during the visit. It complements this information by findings during the

visit and might pull together items which were obtained by different team members.

Standards Adequate and updated treatment guidelines are available and implemented

Audits with all staff participating and in regular intervals are performed

Essential drugs are stocked, a safe supply ensured and old drugs used first.

Essential equipment is available and serviced.

Essential lab tests are reliably performed and results speedily forwarded.

Transport for referral is available


improved Comments

Availability of adequate and updated treatment guidelines

A recent paediatric textbook is easily

available.

Guidelines for common conditions are

available as pocket instructions, wall

charts, or job aids.

Recommended antibiotics for common

infections according to hospital

essential drugs list are available.

Pocket guidelines and wall charts for

emergency care are available.

Newborn resuscitation is described in

wall charts

Performance of audits

Audits and regular staff meetings are

conducted to review fatal cases and

problems with the organisation at the

hospital.

The audits take into aspect monitoring,

hospital flow and quality of care as

well as more academic aspects on

diagnosis.

All staff participate in the audit

Essential drugs (see list above) are

always available and free. p 10

Essential equipment (see list above) is

available and functioning. p 12

Essential lab tests (see list above) are

available and delivered timely. p 15

Transport for referral is available.




Summary table hospital administration

Good To be

improved Comments

Adequate and updated treatment

guidelines are available at the hospital.

Audits on hospital deaths are performed.

Essential drugs are available.

Essential equipment is available.

Essential laboratory support is available.

Transport is available for referral.

Main strengths

…………………………………………………………………………………………………………………..

…………………………………………………………………………………………………………………..

Main weaknesses

…………………………………………………………………………………………………………………..

…………………………………………………………………………………………………………………..

Summary score hospital administration Good To be improved








12. Access to hospital care: Interview with care takers and health workers

Interview 2-3 mothers or care takers about their experience of care seeking before coming to

hospital. This part of the form is intended to provide a background to the child’s condition, and to

document factors which are outside the hospital. Where necessary, complement with interviews of

staff to obtain their perspective.

Standards and criteria Notes

Referral by first level or primary health care

worker

Patients referred from first level facilities

are correctly assessed and classified for

the most common conditions requiring

referral (IMCI standards for districts where

IMCI has been implemented). Expected

classifications (and reasons for referral

would be: Severe pneumonia or Very

severe disease, Very severe febrile

disease, etc, see IMCI guidelines for

classifications requiring referral).

In districts where ARI and CDD has been

implemented, referral is due to pink

classifications.

Referred patients receive appropriate pre-

referral treatment when indicated.

Referred patients are provided with

referral notes stating the condition, reason

for referral and any treatment given.

Transport to hospital

Lack of transport to hospital is not a cause

of delayed referral

Own or commercial transport is available

to get to hospital

The hospital is geographically accessible

Cost for transport does not represent a

major barrier to referral

Careseeking by parents

Parents adequately recognize signs and

symptoms that require contact with health

services

Ask the mother open questions on how

her child fell ill and probe into what she

did, in which order and when and why she

decided to seek help

Sick children are brought to health

services without significant delay

If delays in care seeking exist, try to find

out why.

Parents bring their children to hospital

without major delay when advised by first

level health staff that the child is in need of

referral care




Economic barriers to hospital care

Hospital fees do not pose a major barrier

to hospital care for the majority of patients.

(Ask about all types of fees, such as:

admission fees, cost of drugs or laboratory

investigations, examinations, equipment

used at the hospital). “major” to be defined

as high enough to represent, for some

families, a barrier to seek and obtain

hospital care or the need for the parents to

borrow money to be able to have access

to care

Hospital fees are clearly communicated to

the carers and fees are displayed in the

ward/hospital.

Did carers at any point have to pay a fee

without knowing for which services?

Traditional medicine

Was a traditional practitioner consulted

prior to going to the hospital?

If yes:

Why was the traditional medicine

practitioner preferred (fees, transport,

culture…)?

What treatment was received?

How much was paid for the traditional

medicine (incl. goods)?

Why did they come to the hospital now

(referred,…)? By how much was the

hospital visit delayed due to the visit?

Summary table access to hospital care interview

Good To be

improved Comments

Appropriate referral by PHC.

Transport easily available.

Appropriate care seeking by

parents.

No significant fees or economic barriers to hospital services.

Traditional medicine no barrier to access to hospital.




Main strengths

………………………………………………………………………………………………………

………………………………………………………………………………………………………

Main weaknesses

………………………………………………………………………………………………………

………………………………………………………………………………………………………

Summary score access to hospital care Good To be improved








Summary evaluation score Summarize the individual items found above in this summary sheet to guide the discussion with senior hospital staff at the debriefing.

Good To be improved

5 4 3 2 1

1. Summary score essential drugs, supplies and equipment

2. Summary score laboratory support

3. Summary score emergency area and management

4. Summary score children's ward and facilities

5. Summary score cough or difficult breathing

6. Summary score diarrhoea

7. Summary score fever conditions

8. Summary score malnutrition

9. Summary score HIV/AIDS

10. Summary score supportive care

11. Summary score monitoring

12. Summary score routine neonatal care

13. Summary score nursery facilities

14. Summary score case management and sick newborn care

15. Summary score paediatric surgery and rehabilitation

16. Summary score hospital administration

17. Summary score access to hospital

Total score

Hospital summary score = total score / 17




Debriefing and action plan

Discuss above summary of hospital findings with the senior hospital management, giving details as appropriate. Discuss their perception of the findings, and

how action could be taken to improve services for children. Discuss importance in terms of morbidity and mortality, and the feasibility to take action. Develop a

plan of action, using the following list.

Items Summary

score

Impact

on

mortality

and

morbidity

Action needed Feasibility Priority Timetable and responsible person

To

be

str

on

gly

im

pro

ve

d

To

be

im

pro

ve

d

No

t to

be

im

pro

ve

d

H

igh

Low

Hig

h

Low

Hig

h

Low

Annex: Interviews with caretakers and health workers

A1. Caretakers view on patients care

Caretaker interview

Age of interviewee: Education of interviewee:

Date child was admitted: Length of stay:

Relationship to patient: Place of admittance:

1) Time on ward with child: <25% 25%-50% 50%-75<% >75%

2 a) How far away do you live from the

hospital?

Kilometres: Hours:

3) What type of transport did you use to come to the hospital?

After arrival at the hospital, we would like to know how you were treated in the OPD.

4) Were there any other good / bad things about the time your child spent in outpatients?

5) What do you think about the care in OPD, before your child

was admitted:

Worse

than

expected

As expected

Better than

expected

5 a) The actual time you had to wait was___hours. This was: □ □ □

5 b) The politeness with which you were treated: □ □ □ 5 c) The care the doctor took over the examination (the

completeness of his/her assessment of your child’s problem) □ □ □ 6) Was the reason for admission explained to you?

Y / N

7) What was the reason for admission?

We are also interested in what you thought about the ward and care of to your child.

8) Once your child was on the ward what did you think

about: Better than

expected

As

expected

Worse

than

expected

8 a) the amount of space for you and your child to stay □ □ □ 8 b) the place/bed where you and your child slept?

If worse what was bad about it? □ □ □ 8 c) the place to wash and the toilet

If worse what was bad about it? □ □ □ 8 d) the cleanliness of the ward □ □ □ 8 e) the number of nurses available to look after the sick

children. The number was □ □ □

8 f) The care the doctor took over re-examining your child

(the completeness of his/her assessment)? □ □ □ 8 g) Did the nurses/doctors check your child often enough? □ □ □ 8 h) The nurses/doctors examined your child good/long

enough? □ □ □ 9) Are there other things about the ward itself or the hospital site that concern you?

We now would like to know what you thought about the medical care on the ward.

10) What do you think about the actual medical

treatment your child received:

Too

often /

much

OK Too few

/ little N/A

10 a) Blood was taken____ times. This was…..? □ □ □ □ 10 b) The amount of blood taken was: □ □ □ □ 10 c) Injections were given____times. This was….? □ □ □ □ 10 c) Intravenous fluids were given: □ □ □ □ 11) What other tests/treatments were done (Lumbar puncture, blood transfusion etc.)?

What did you feel about each of these (were they harmful/necessary / explained / useful?)

12 a) What is the name of the disease/condition of your child?

12 b) From whom did you receive most information about the disease of your child?

12 b) Who was the person you could ask most easily about the care of your child?

13) Did you want to know more about the sickness your child had and the tests and treatment s/he

had? Y / N

If yes, what did you want to know more about?

14) Did you learn anything new on how to keep your child healthy while on the ward? Y / N

If yes what did you learn and who told you about it?

We now want to ask you what you thought about the staff looking after your child.

15) What was the attitude of the different types of

staff towards you and your child most of the time? Polite,

helpful

Good or

bad at

different

times

Rude,

unhelpful

15 a) Doctors □ □ □

15 b) Nurses □ □ □

15 c) Cleaning / kitchen staff / subordinate staff □ □ □ 15 d) Other hospital staff (e.g. nutritionists / Xray /

physio/laboratory etc) □ □ □

16) Can you think of any examples or ways in which you were spoken to or dealt with well / badly?

Finally, we would like to ask you about your discharge from hospital.

17) What do you think of the condition of your child now

(at the time of discharge)? Very good OK Still poor

18) Do you think the amount of time spent in hospital

was? Too long Just right Too short

19) Is your child to be sent home on medicines? Y / N

20) Did the ward staff tell you how much to give? Y / N

21) Did the ward staff tell you how often to give the medicines to take home? Y / N

22) Did the ward staff tell you how many days you should give the medicines when you

are at home? Y / N

23) Did you receive a follow up appointment to see how your child is doing?

23 a) If yes, why do you have to go?

If no, go to question 27.

Y / N

24) Did the doctor/ward staff tell you where to go? Y / N

25) Do you know when to go to the follow up appointment? Y / N

26) Did you receive a discharge/follow up note explaining the illness of your child and

providing information for the staff at the follow up clinic and the time/place of follow up? Y / N

27) What do you think about the cost of treatment at the hospital? (Add questions on how the family

finance the hospital-stay of the child?/If costs are clearly communicated?/If they had to pay fees

which were unclear what they were for?)

28) Looking back on the time your child was in hospital what, if any, are the areas that you think need

most improvement to make the admission and stay easier to bear?

29) Overall, how satisfied are you with the care of your child at the hospital?

Summary table interview care takers

Good

To be

improved Notes on cases and Comments

Carer is satisfied with

procedures at OPD, knows

reason for admission.

On the ward procedures are

explained and staff is

supportive.

Carer knows how to continue

medicine and know when and

where to go for follow up.

Main strengths

…………………………………………………………………………………………………………….

…………………………………………………………………………………………………………….

Main weaknesses

…………………………………………………………………………………………………………….

…………………………………………………………………………………………..

Summary score: care takers satisfaction with hospital

care is: Good To be improved



support, 4 to 1 indicating levels of necessary improvement (4=small need for

improvement, 1=urgent need for improvement

A2. Health workers interview

A2.1 Guidance for health workers interview

All groups of health workers should be considered for this interview. This includes cleaners,

nursing assistants, nurses, matron, medical officers and doctors. We would like to record the

health workers honest opinions. For this it is important that the health workers understand the

aims of the survey and know and trust that the information will be stored and used while

maintaining confidentiality. Please let them know that their names or initials will not be

mentioned in any report or to supervisors in the hospital.

Please do not leave forms lying about or in a place that people who are not members of the

team can read them.

Try to interview two staff each from the above mentioned categories of health workers so that

a minimum of six to eight forms should be filled during the assessment visit. Health workers

are welcome to fill in the forms themselves, however, please do not let them take it away and

return later due to the shortness of your stay.

Ask the questions in a face to face interview in a suitable place. At the end of the interview

you should be happy for the health worker to read whatever is written down and they should

be offered the chance to read the form and make any changes. Try to record comments as

they are spoken rather than trying to summarise the views expressed. Recording the real

words used often helps to properly represent what the person is trying to say. When doing

this please put the comments in quotation marks. For example:

“we have a real problem with the water supply, sometimes days go by without piped water,

how can we wash our hands to prevent spreading infection”

To start, please fill in the date, the hospital name and the health worker initials on all five

sheets. After this, please fill the little information on the interviewee, so that the answers in the

questionnaire can be put in better perspective.

Question 1: We begin the interview with an open question. Some health workers may have

several things to say without prompting them with specific questions. For these people it is

important to allow them the chance to speak and to record what they actually say as far as

possible.

Question 2 : In question 1 you are asked to mark the quality of the facilities of the children's

ward. Please see the criteria below for the four different possibilities:

For the scale "Good" to "Usually inadequate" consider the following as an explanation:

Table 1

Usually inadequate On four or more out of ten times when something is used or

wanted or on four or more out of ten visits to an area things

are unavailable or not of an acceptable standard.

Occasionally inadequate On two to three out of ten times when something is used or

wanted or two to three out of ten visits to an area things are

unavailable or are not of an acceptable standard.

Fair On one out of ten times when something is used or wanted or

once out of ten visits to an area things are unavailable or are

not of an acceptable standard.

Good Only rarely are things unavailable or are not of an acceptable

standard.

Question 3: This question is meant to highlight the understanding of the health worker as to

which disease contributes most to inpatient mortality. In question 3b) difficulties in the care of

these important conditions are explored.

Question 4: To answer this question please refer to table 1.

Question 5: Please write down the words as spoken by interviewee.

Question 6-10: To answer the questions, please refer to table 1.

Question 14: All forms of training should be considered from on the job training, introduction

to new equipment/procedures to workshops or taught courses outside the hospital.

Question 15: In a number of institutions, nursing staff is rotated within different wards in

regular intervals. Please find out if this is the case, what the interviewee thinks about it and to

which professional groups this applies.

Question 16, 17: In this question we are interested if there are some form of meetings which

reflect on the quality of care in the hospital/ward and the communication within the hospital.

Question 18: Please mention the type of guidelines (books, posters, charts, oral guidelines,

etc.).

Question 19-21: Please refer to table 1.

Finally: Before thanking the interviewee, please ensure that all questions are correctly

answered. If a health worker does not want to answer a particular question please note and

proceed to the next question. Offer the health worker to read what you have written. If he

wishes he should be allowed to make changes. Please thank him for forwarding the

information.

A2.2 Health worker interview

Health worker interview

Position of health worker being interviewed:

Current place of work (childrens

ward, paediatric OPD, nursery etc):

How long have you worked at this

hospital?

How long have you been working in the nursery, paediatric OPD or childrens’ ward?

We are first interested in your views on the children's ward.

1) Are there any things about the hospital buildings/ward that you think are good or things that could

be improved?

2) For children admitted to the hospital Good Satis-

factory

Occasionall

y

inadequate

Usually

inadequate

2 a) the accommodation (space/beds) for patients is □ □ □ □

2 b) the toilets and washing facilities for patients is □ □ □ □ 2 c) the cleanliness of the ward is … □ □ □ □ 2 d) the food given to the children is … □ □ □ □

Now we would like to ask you what the causes auf children's death are in the hospital.

3) In your opinion what are the commonest illnesses resulting in childhood deaths in the

hospital?

1.

2

3

4

3 b) Why do you think these children die?

Name of disease No 1:

……………………………. Yes No Details

Nature of the disease □ □

Late presentation of

children □ □

Problems with laboratory

diagnosis □ □

Insufficient drugs □ □

Inadequate equipment □ □

Lack of staff for care and

monitoring □ □

Wrong treatment given □ □

Other reasons:

Name of second disease:

Nature of the disease □ □

Late presentation of

children □ □

Problems with laboratory

diagnosis? □ □

Insufficient drugs □ □

Inadequate equipment □ □

lack of staff for care and

monitoring □ □

Wrong treatment given □ □

Other reasons:

We now want to ask you about the drugs, supplies and staff in the children's ward.

4) The availability of (the following) are: Plenty Satis

factory

Occasionally

inadequate

Usually

inadequate

N/A

4 a) Drugs □ □ □ □ □

4 b) Oxygen □ □ □ □ □

4 c) Blood for transfusion □ □ □ □ □

4 d) i.v. fluids □ □ □ □ □

4 e) food/special milk for malnutrition □ □ □ □ □

4 f) laboratory tests (eg. Hb) □ □ □ □ □ 5) Do you have problems with/lack any other equipment or supplies that make it hard to look after

sick children well or are supplies generally good?

The availability of staff: Plenty Satisfactory

Occasionally

inadequate

Usually

inadequate

6) Do you think the number of staff available

to care for sick children is? □ □ □ □ 7) Do you think there is enough time

available to care for a child the best way

you know how to (the way you were trained)? □ □ □ □

8) There is sufficient nursing staff during the

night. □ □ □ □ 9) There is sufficient nursing staff during the

weekend. □ □ □ □ 10) If you have a problem with a sick child is

supervision / support (e.g. from more

senior clinical staff) available to you? □ □ □ □

11) Do you think the hospital lacks any important staff to help look after sick children? Are the

number and quality of staff in general good?

12)If you have problems getting help when you think you need it is it because:

..there are not enough skilled people to call?

..you are unable to contact the right people?

..the response to your request is too slow?

..another reason?

What do you think about the training of staff and the organization of your work?

Training of staff Very

good OK

Occasionally

inadequate

Usually

inadequate

13) How is your own knowledge about the

illnesses of children? □ □ □ □ 13 a)..if it is sometimes inadequate what areas do you think you need more training on or are

there areas you would like to improve your knowledge further?

14) Are there possibilities for further professional training in your hospital? Please explain.

15) Is there a fixed rotation of nursing staff within the hospital at regular intervals? Y / N 15 a) If

yes, how often do you rotate?

15 b) What do you think about this?

16) Are there regular meetings of all nurses/ other staff/doctors who work on children's ward?

Please explain who participates, frequency and nature of meetings.

17) Is there a regular feedback/audit session in terms of quality of care/mortality in children's

ward? Please explain.

18) Do you have clear guidelines on the work you are doing. Please explain:

We would like to know what your think about the care you/the hospital give to children?

Very

good OK

Occasionally

inadequate

Usually

inadequate

19)The information / explanations families are

given about their child’s illness is … □ □ □ □

20) The time you have to explain to the parents

and children about their illness is … □ □ □ □

21) How do you think the carers view the care

on the ward? □ □ □ □

22) Can you think of any ways to improve parents’ understanding of their children’s illness?

23) Care of children Can you remember a child you looked after recently when you were pleased

with how things turned out? Yes / No

23 a) If yes, were you pleased with how you helped the child do well?

23 b) What aspects of your own performance / role pleased you?

24) Can you think of a child you looked after recently when you were disappointed with how things

turned out? Yes / No

24 a) If yes, what aspects of the child’s care / progress did you think went badly and what do you

think were the reasons for this?

Always Often Sometimes Rarely Never

25) Overall are you

pleased with what this

hospital is able to do

to help sick children

while on the ward?

□ □ □ □ □

26) Are there any other things that you have not told us about that could be changed to improve the

care of children in the hospital?

27) Have you ever suggested these improvements to matron/doctors/management and with what

results?

28) Do you think the majority of your colleagues are generally satisfied with their work in the hospital?

Yes / No

28 a) What things do you think make people dissatisfied with their work?

28 b) What about the working conditions?

28 c) What could be improved to make people in the hospital more satisfied with their work?

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