accreditation manual 2nd edition

NATIONAL HOSPITAL INSURANCE FUND

ACCREDITATION MANUAL FORHEALTH FACILITIES2ND EDITION - 2007

NHIF ACCREDITATION MANUAL 2ND EDITION

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FORWARD

This is the second edition of the NHIF accreditation manual for Kenya Hospitals. The development of thismanual was a collaborative effort of representatives from all health sectors, including the Ministry ofHealth, University of Nairobi Medical School, the Kenya Medical Association, and the Private Hospitals.The manual is based on the Kenya’s Ministry of Health minimum standards as spelt out in the “Norms andStandards for Health Service Delivery” (2006), The Standards Benefit Package & The Kenya EssentialPackage for Health (KEPH).

Although this manual is specific to Kenya, the contents therein have been compared to InternationalStandards and found to meet basic intent of most international standards that apply to Kenyan laws, PublicHealth Act, and the National Hospital Insurance Fund (NHIF) regulations, vision and mission.

It is expected that this manual will be a catalyst for change and improvement in both the culture andpractice of health care in all NHIF accredited hospitals and guide in the implementation of the KenyaEssential Package for Health services appropriate for every tier level of facilities.

NHIF was established in 1965 by an Act of Parliament as a Department in the Ministry of Health. The mainobjective was to help in financing health care for those in formal employment. In 1998, by another Act ofParliament, it became a parastatal in the Ministry of Health. Today, NHIF is the biggest and the oldestsocial health insurance institution in Africa, supporting the financing of healthcare to both those in formaland informal employment.

This manual, therefore, aims at enhancing NHIF’s ability to define objectively the system and scope ofawarding rebates, and encouraging Quality Improvement of healthcare services in hospitals.

It is designed to help Health Providers be aware of Standards expected of them by NHIF as an accreditinginstitution and Standards set by Ministry of Health. This shall help in assuring that the quality of healthservices accessed by contributors is acceptable.

Through this manual, NHIF now has an objective quantitative tool for accurately awarding rebates andassuring her members of quality health care provision.

As an accreditation tool, this manual shall be used to accredit health facilities every two (2) years.


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ACKNOWLEDGEMENTS

We wish to appreciate the following persons for their active participation in the conceptualization,development and authoring of this manual:

1. The Board of NHIF, for providing leadership and direction towards development this manual.

2. The Chief Executive NHIF-Mr. Richard Kerich, for his support and leadership.

3. Dr. Stephen Ochiel Chairman Kenya Medical Association.

4. Dr. George J. Midiwo, General Manager, Standards and Quality Assurance Department.

5. Mr. Martin Ngari, Manager, Accreditation and Contracting, Quality Assurance Department.

6. Dr. James Njoroge, Manager, Standards and Quality Assurance, NHIF.

7. Mrs. Judith Karimi Otele, Standards and Quality Assurance Officer , NHIF Headquarters.

8. Ms. Naomi Choge, Standards and Quality Assurance Officer, NHIF Headquarters.

9. Mr. Joseph Githinji, Standards and Quality Assurance Officer, NHIF Headquarters.

10. Mr. Erastus Masinde, Standards and Quality Assurance Officer, NHIF Headquarters.

11. Mrs. Julia Ouko, Standards and Quality Assurance Officer, NHIF Headquarters

Special gratitude to Dr. Stephen Ochiel, Chairman, Kenya Medical Association for his valuable suggestionsand input towards development of this manual.


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USER’S GUIDE

1. The Area Manager is the overall in-charge of this exercise and should notify the Health FacilityIn-Charge on the intent of NHIF staff to visit the facility for assessment two weeks in advance ,using the NHIF accreditation notification form and alongside, avail a clean Accreditation manual tothe health facility.

2. The Quality Assurance Officer is the technical in-charge and the team leader to the exercise.

3. On the day of the assessment, the team shall present itself to the facility’s In-Charge. Introducethemselves and explain to him/her the objectives of their visit and request for a hospital staff to beassigned to them during the accreditation exercise.

4. They must at all times wear their clinical white coat and a well-displayed NHIF identificationbadge. They should observe professionalism throughout the assessment exercise.

5. The assessment scores will be based on all or none principle. For example, for “secure fence with agate” the score can only be “3” for YES or “0” for NO fence, fence with a missing gate, etc. Notethat there are no intermediate scores.

6. Scores awarded to the facility are confidential and must not be disclosed to the health facility by theteam. The NHIF Board of Management shall convey results of the assessment to the facility.

7. Ensure you put your remarks about your observations in the “remarks” column and share these withthe hospital representative/management. These remarks are also useful for our reference.

8. Ensure you use a separate assessment manual for each health facility.

9. The hospital representative accompanying you MUST sign the accreditation manual alongside you,upon completion of the exercise.

10. Upon completion, the accreditation manual must be signed, stamped, sealed in envelop marked“confidential” and forwarded to the General Manager, Standards and Quality AssuranceDepartment through the respective Area Manager.

11. The accreditation assessment MUST be carried out by at LEAST THREE NHIF staff.

12. The NHIF management Board reserves the right to order for a reassessment of the facility, and theright to accredit or deny accreditation to a health facility.

13. Note that all pages must be officially stamped using the hospital stamp.


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LAYOUT OF THE MANUAL

This manual has been designed to include levels of care as outlined in the Kenya Essential Packagefor Health.

For each level of care mandatory services have been spelt out viz a viz the other convenientservices. NHIF is currently accrediting hospitals from level III and above.

The levels of care as spelt out in the Kenya Essential Health Package are as shown below:

o LEVEL I…………… Private Single Practice Clinics.

o LEVEL II……………Dispensaries.

o LEVEL III…………...Health Centers, Small Nursing Homes & Private Facilities.

o LEVEL IV……………District Hospitals, Medium Sized Private & Medium Sized Faith based Facilities.

o LEVEL V…………….Provincial Hospitals & Big Private & Faith based Facilities with all Specialists (Paediatricians, Surgeons, Physicians, Gynaecologists, Anaesthetists, etc…)

o LEVEL VI. …………National Teaching & Referral Hospitals.

Note that the entire manual gives a total score of a level VI facility, while levels III, IV and V havethe applicable areas clearly stated.

At the end of each dimension please state clearly the marks scored by the facility at the appropriatecolumn.

Ensure that the sub-totals scores combined tally with the grand total stated at end of the manualtallies.


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TABLE OF CONTENTS

FORWARD………………………………………………………..……………………………………… 2ACKNOWLEDGEMENTS………………………………………..………………………………………3USER’S GUIDE………..………………………………….……………………………………………….4LAYOUT OF MANUAL…………………………………………………………………………………. 5HOSPITAL’S PARTICULARS……………………………………………………………………………7PHYSICAL INFRASTRUCTURE…………………….…………………………………………………..8EXAMINATION/CONSULTATION ROOM…………………………….………………..……………..10EMERGENCY ROOM…………………………………………………………………………………….11LABORATORY SERVICES. ……………………………………………………………………………..12RADIOLOGY……………………………………………………………………………..………………..14PHARMACY……………………………………………………………….……………………………....17FOOD & NUTRITION…………………………………………………………………………………......25THEATRE SERVICES……………………………………….………….………………………………... 26PHYSIOTHERAPY……………………………………………………………………………………….. 28OCCUPATIONAL THERAPY……………………………………………………….……………………29ORTHOPAEDICS………………………………………….………………………………………………29STERILE PREPARATION UNIT…………………………..……………………………………………..30INTENSIVE CARE UNIT…………………………………………………………………………………30LABOUR WARD……………………………………..…………………..….……………………….........30HUMAN RESOURCE……………………..…………….……………..….……………………………... 32WARDS…………………………………………………..…………………………………………….. … 41GOOD HOUSE KEEPING……………………………….…………………….…………………………. 42MOURTUARY……………………………………………...………………………………………………43OTHER SERVICES…………………………………………….…………………………………………..44RECORDS……………..………………………………………..….……….………………………..……. 45FUNCTIONAL COMMITTEES……………………..……………………………..……………………... 45HOSPITALS IN DISADVANTAGED REGIONS ……………………………………………………..… 46MEDICAL TRAINING INSTITUTIONS………………………………..…………………..…………... 47ENGRAVEMENT OF HOSPITAL EQUIPMENTS………………………………………….………… .. 47USE OF ICT……………………………………………………………………………………………….. 47TABULATION OF POINTS…………………………………………………………………………….…47CERTIFICATION OF ASSESMENT………………………………………………………………….…..48REFERENCE LIST………………………………………………………………………………………...49


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NATIONAL HOSPITAL INSURANCE FUND (NHIF)

ACCREDITATION ASSESSMENT MANUAL

(Criteria for Assessing and Grading of Health or Hospital Care Providers for the Approval of BenefitsPackage Standards)

NAME OF INSTITUTION:………………………………………………………………………………..

P.O.BOX ……………………………………. E-MAIL …………………….. TEL.NO…………………

PROVINCE:……………………………………………………..………..…………………………………

DISTRICT:………………………………………………………..………………………………………….

LICENSED BY REGISTRAR M.P & D.B. /DMS TO OPERATE AS:………….………..…………….

TYPE/CATEGORY:……………………………..(I.E. MISSION, GOK, PRIVATE, COMMUNITY)

WHEN THE HOSPITAL STARTED:…………………………..……………………………………….

BED CAPACITY:……………………………COTS:….……………………………………………….

NUMBER OF FULL-TIME STAFF:……… NO. OF STAFF ON LOCUM:………………………

NEAREST NHIF OFFICE:………………….……………………………………………………………

HOSPITAL ASSESED AT LEVEL: ……………………………………………………………………..

STATE WHETHER NEW OR RE-ACCREDITATION: ……………………………………………


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N.H.I.F ACCREDITATION STANDARDS POINTS

POINTSAWARDED(MAXIMUMOR ZERO)

REMARKS

1.0 PHYSICAL INFRASTRUCTURE.

1.1 ENVIRONMENT.

*APPLICABLE FOR ALL LEVELS.i. Secure perimeter fence with a secure gate. 3ii. Well kept and clean compound. 3iii. a). Treated sewage is discharged into anapproved public sewerage system, where a systemis available, OR b). Sewage is collected, treated, and disposed off inan independent system that complies withappropriate laws and rules.

4

iv. At least placenta pit is available whereapplicable. 3v. The health facility has a functional incinerator. 3vi. Waste is segregated into non-clinical and clinicalrefuse. 1vii. Clinical waste is labeled and can be traced backto its point of origin. 1viii. Clinical waste is kept in designated areas inlockable containers while awaiting disposal. 1ix. Availability of a composite pit. 1x. Availability of sharps disposal facilities/ safetyboxes. 1xi. Presence of 5-10 flushable toilets. 1xii. At least 1-4 pit latrines. 1xiii. At least1- 4 stores. 1xiv. Consultation rooms 1 to 6. 1xv. Staff housing or available transport means forstaff working late night shifts or those summonedfor emergency cases.

1

xvi. 1 Minor theatre at outpatient. 1xvii.1Waiting room with provision for healtheducation. 1xviii At least one registration room. 1xix. 1Cash office. 1xx. 1 Records room. 1xxi. 1 Injection/ Treatment room. 1


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N.H.I.F ACCREDITATION STANDARDS POINTS

POINTSAWARDED(MAXIMUMOR ZERO)

REMARKS

APPLICABLE TO LEVEL IV UPWARD.xxii. 1 Plaster room. 1xxiii. 1 Dental unit room. 1xxiv. 1 ENT Services room. 1xxv. Administration unit. 1xxvi. Ablution block where applicable. 1xxvii. Medical Engineering Unit. 1xxviii. Composite pit for non-clinical waste. 1

1.2 BUILDING.

APPLICABLE TO ALL LEVELS.i. Design approved to be a health facility by publicworks. 5ii. Facility approved to operate by Public HealthAuthority or another body like the NationalEnvironment Management Board.

2

iii. Clean and well painted walls, with washablepaint on the inside. 2iii. Floors are even/leveled and easy to clean withantiseptics. 3iv. Rooms are well ventilated allowing adequatenatural light. 3v. Corridors are wide enough and well lit, allowingfree movement. 3vi. Serviced fire fighting equipment is in place inevery unit. 3

1.3 WATER SUPPLY.

*APPLICABLE TO ALL LEVELS.i. Reliable source of water. 3ii Running water at point of use. 3iii. Water treatment system in place for alternativesources. 2iv. Facility has water storage facilities/reservoirs inplace. 2

1.4 POWER SOURCE.*APPLICABLE TO ALL LEVELS.

i. Electricity (connection to National Grid). 2


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NHIF ACCREDITATION STANDARDS POINTS

POINTSAWARDED(MAX ORZERO)

REMARKS

ii. Generator or solar. 31.5 RELIABLE EMERGENCYCOMMUNICATION CHANNELS.*APPLICABLE FOR ALL LEVELS.Landline; Mobile; Radio call; pager e.t.c. 5

SUBTOTAL FOR LEVEL III. 73SUBTOTAL FOR LEVEL IV. 80SUBTOTAL FOR LEVEL V. 80SUBTOTAL FOR LEVEL VI. 80

2.0 EXAMINATION/CONSULTATION ROOMS.

*APPLICABLE FOR ALL LEVELS.2.1 QUALITY ASSURANCE INEXAMINATION/CONSULTATION. a. The facility has clear guidelines for admittingpatients. 2b. The health facility has clear guidelines regardingpatients they cannot admit. 22.2 EQUIPMENT IN CONSULTATIONROOM.i. Examination coach/bed with a screen. 1ii. Thermometer. 1iii. BP machine with a stethoscope. 1iv. Gloves. 1v. Diagnostic set. 1vi. Availability of consultation rooms:

a. LEVEL III…….1 to 2 rooms.b. LEVEL IV…….3 to 4 rooms.c. LEVEL V……..5 to 6 rooms.d. LEVEL VI…… 6 and above.

1

vii. Sink with running water and soap/antiseptic. 1viii. Clean and sterile swabs with antiseptic. 1ix. Examination light. 1x. Drip stand. 1xi. Relevant furniture. 1SUBTOTAL FOR LEVEL III. 15

SUBTOTAL FOR LEVEL IV. 15

SUBTOTAL FOR LEVEL V. 15

SUBTOTAL FOR LEVEL VI. 15


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REMARKS

3.0 EMERGENCY ROOM.

*APPLICABLE TO LEVEL IV UPWARD.3.1 QUALITY ASSURANCE IN EMERGENCYROOM.1. There are clear guidelines to identify patientswith emergency or immediate needs. 42. There is evidence of staff trained in emergencycare. 4

3.2 RESCUSITATION ROOM. i. Suction machine. 1ii. Stretcher/wheelchair. 1iii. Adjustable bed. 1iv. Ambu bags/masks. 1v. Oxygen cylinder with oxygen or link to mainoxygen line. 1vi. Daily updated emergency tray. 1vii. Defibrillator. 1viii. Emergency theatre annex or quick access tomain facility theatre. 1ix. Well illustrated guidelines on how to handlevarious medical/surgical emergencies. 1x. Stocks consumables and protective gear (Gloves,sutures, sterile kits, dust coats, safety boots). 1xi. Air ways. 1xii. Equipment for performing emergencytracheostomy. 13.3 EMERGENCY STAFF.(As per the triage in emergency situation.)i. Trained Emergency Nurses (minimum three). 5ii. Anesthetist. 3iii. General Surgeon. 3iv. A General Medical Officer. 2v. Trained Emergency Clinical Officer. 23.4 OBSERVATION/RECOVERY ROOM.i. Minimum of 3 beds. 5SUBTOTAL FOR LEVEL III. N/ASUBTOTAL FOR LEVEL IV. 40SUBTOTAL FOR LEVEL V. 40


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REMARKS

SUB TOTAL FOR LEVEL VI. 40

4.0 LABORATORY.

*APPLICABLE FOR ALL LEVELS.4.1 QUALITY ASSURANCE INLABORATORY SERVICES.

a. There is written safety program in place. 3b. Appropriate safety devices are in place and

the laboratory staff is/are well oriented tosafety procedures and practices.

3

c. Evidence of continuous training on newprocedures and newly acquired orrecognized hazardous materials.

3

d. Evidence of qualified and experiencedlaboratory staff. 3

e. The facility has in place the expected reporttime for test results and that these results arereported within a period to meet patients’needs.

3

f. The laboratory has established referenceranges for each test performed, and therange is included in the clinical records at

the time test results are reported.

3

4.2 LABORATORY TESTS.i. Hemoglobin test. 3

ii. Differential white cell count. 3 iii. Peripheral blood film. 3 iv. Blood slide for malaria parasite. 3 v. Stool for ova & cyst. 3 vi. Stool for culture & sensitivity. 3 vii. Gram stain. 3 viii. ABO & RH grouping. 3 ix. Urinalysis. 3 x. Urine Microscopy. 3 xi. Pregnancy Test. 3 xii. Blood glucose. 3 xiii. Widal Test. 3 xiv. Brucella Test. 3 xv. HIV Test. 3 xvi. Sickle Cell Test. 3


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REMARKS

*APPLICABLE TO LEVEL IV UPWARD.i. Full Haemogram. 3ii. Blood Screening & Storage. 3iii. Peripheral Blood Count. 3iv. Platlet Count. 3v. Clotting Time. 3vi. Bleeding Time. 3vii. Prothrombin Time. 3viii. Reticulocyte Count. 3ix. Rheumatoid Factor. 3x. Blood Culture & Sensitivity. 3xi. Packed Cell Volume. 3xii. ABO & RH Grouping. 3xiii. Urine Culture & Sensitivity. 3xiv. Hepatitis B Virus Screening 3xv. Hepatitis C Virus Screening. 3xvi. Syphilis Screening. 3

xvii. PSA Determination. 3 xviii. Pap Smear Analysis. 3 xix. Bone Marrow Examination. 3 xx. Compatibility Testing. 3 xxi . Coomb’s Test. 3 xxii. Antibody Screening. 3 xxiii.Pus Swabs. 3 xxiv.Cytological Examinations Of Fluids OR Aspirates. 3 xxv.Blood Glucose. 3 xxvi.CSF Culture. 3 xxvii.Liver Function Tests. 3 xxviii.Cholesterol Test. 3

*APPLICABLE TO LEVEL V & VI.xxix. CD4/CD8. 3xxx.Viral Load. 3xxxi.Parasitology. 3xxxii.Histopathology. 3xxxiii. Blood gases. 3xxxiv. Virology. 3xxxv. Immunatosy. 3xxxvi. Lipid profile. 3


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REMARKS

xxxvii. Other tests (specify). 34.3 EQUIPMENTS & TOOLS.

*APPLICABLE TO ALL LEVELS.i. Fluorescent microscopes. 1ii. Binocular microscope. 1iii. QBC cell counter. 1iv. Weighing balances. 1v. TB Screen. 1vi. Refrigerator and freezer. 1vii. Distillation machine. 1viii. Others e.g. test tubes, slides, flasks, stands,pipettes, burettes, thermometers, racks e.t.c. 1ix. Autoclave. 1

*APPLICABLE TO LEVEL IV UPWARD.x. Haematology counter. 1xi. Tissue processor. 1xii. Incubator. 1xiii. Water bath. 1xiv. Calorimeter. 1xv. Coagulometer. 1xvi. Centrifuge machine. 1xvii. Spectrophotometer. 1xviii. Chemistry analyzer. 1xix. Immuno assay analyzer. 1xx. Hot air oven. 1xxi. Blood bank. 1xxii. Specialized laboratories, e.g. haematology,parasitology e.t.c. 2SUBTOTAL FOR LEVEL III. 75SUBTOTAL FOR LEVEL IV. 173SUBTOTAL FOR LEVEL V. 200SUBTOTAL FOR LEVEL V. 200

5. 0 RADIOLOGY SERVICES.*APPLICABLE TO LEVEL IV UPWARD.5.1 QUALITY ASSURANCE IN RADIOLOGYDEPARMENT.

a. Certification by the Radiation ProtectionBoard. 5


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REMARKS

b. Documented evidence of continuous (24 hrs)Imaging Services. 3

c. A radiology safety program, which iscoordinated with facility’s safetymanagement program is in place andappropriate to the risks and hazardsencountered in a Radiology Department.

3

d. Evidence of continuous training on newimaging procedures and hazardousmaterials.

3

e. The staff who perform and/or interpretstesting or direct or supervise testing areidentified, are appropriately trained andexperienced.

3

f. The health facility has established theexpected report time for radiological results,and that the results are reported within thetime frame to meet patients’ needs.

3

g. There is a radiology equipment managementprogram that includes the selection andacquisition; inventorying, inspecting andtesting; calibrating and maintenance;monitoring and follow-up; anddocumentation of all processes.

3

h. Essential radiological reagents and suppliesare identified, available, are appropriatelystored and dispensed according toguidelines; are periodically evaluated foraccuracy and results; and are completely andaccurately labeled.

3

i. Quality control procedures are in place forvalidating test methods; daily surveillance oftest results; ensuring quick response to adeficiency; testing reagents and solutions;and documenting results and correctiveactions.

3

5.2 RADIOLOGICAL SERVICES.i. Hand And Finger-AP/LAT. 2ii. Wrist Joint - AP/LAT. 2iii. Forearm - AP/LAT. 2


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REMARKS

iv. Elbow Joint - AP/LAT. 2v. Humerus - AP/LAT. 2vi. Shoulder – AP & AXIAL. 2vii. Chest – PA & LAT. 2viii. Clavicle – PA/AXIAL. 2ix. Scapula - AP/LAT. 2x. Sternum – PA & LAT. 2xi. Sterno Clavicular. 2xii. Foot And Toes - AP/LAT. 2xiii. Ankle Joint - AP/LAT. 2xiv. Leg - AP/LAT. 2xv. Knee Joint - AP/LAT. 2xvi. Patella – AP/ASKYLINE. 2xvii. Femur - AP/LAT. 2xviii. Hip Joint - AP/LAT. 2xix. Sacro-Iliac Joint AP/AXIAL. 2xx. Pelvis AP. 2xxi. Abdomen (PLAIN/ERECT). 2xxii. Skull - AP/LAT. 2xxiii. Facial Bones - AP/LAT. 2xxiv. Orbits – OM & LAT. 2xxv. Mandible- AP & OBLIQUES. 2xxvi. Sinuses 3 VIEWS. 2xxvii. Optic Foramina – OM & OBLIQUE. 2xxviii. Mastoids – OM & OBLIQUES. 2xxix. Cervical spine - AP/LAT. 2xxx. Cervical 3 VIEWS. 2xxxi. Thoracic spine - AP/LAT. 2xxxii. Lumbar spine – AP/LAT. 2xxxiii. Lumbosacral spine - AP/LAT. 2xxxiv. Barium meal. 2xxxv. Barium swallow. 5xxxvi. Barium enema. 5xxxvii. Intravenous Urography. 5xxxviii. Hysterosalpingogram. 5xxxix. Cholecystograms. 5xl. Ultrasound. 5xli. Mammography. 5

*APPLICABLE TO LEVEL V& VI.xlii. Angiography. 5


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REMARKS

xliii. Venograms. 5xliv. Myelograms. 5xlv. Mobile Radiography. 5xlvi. MRI + Contrast. 30xlvii. CT Scan. 20xlviii. Cystography. 5xlix. Fluoroscopy. 5SUBTOTAL FOR LEVEL III. N/ASUBTOTAL FOR LEVEL IV. 136SUBTOTAL FOR LEVEL V. 216SUBTOTAL FOR LEVEL V. 216

6.0 PHARMACY SERVICES

*APPLICABLE TO ALL LEVELS.

6.1 QUALITY ASSURANCE IN PHARMACYDEPARTMENT.a. The facility operates its own duly licensedpharmacy, which complies with requirements of thePharmacy and Poisons Board.

4

b. There is a written medicines policy andprocedure, accessible to staff, covering all aspectsof medicines systems in the facility includingordering, procurement, receipt, storage prescription,administration and disposal of medicines and otherpharmaceutical products.

3

c. Records of ordering, receipt, supply,administration and disposal of all medicines andmedical supplies in order to maintain an audit trailare kept.

3

d. Lockable cupboard is provided for all controlleddrugs (Dangerous Drug Act) and properly keptregister.

3

e. There are policies and procedures in place togovern the documentation and management of anymedication brought into the facility for or by thepatient.

3

f. Pharmacist /Technologist licensed by pharmacyand poison board supervises the storage,preparation, and dispensing of medications.

3


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REMARKS

g. Medications prescribed and administered to thepatient are written in the patient’s records. 36.2 DRUGS/PREPARATIONS.* APPLICABLE TO LEVEL III & IV ONLY. (As per MoH Essential Drugs List).6.2.1 General Anaesthetics & Theatre Agents.

Diazepam Inj.5mg/mi (ampoule). 2 Oxygen Inhalation (Cylinder). 2

6.2.2 Local Anaesthetics. Lignocain HCL Inj 2% (50ml bottles). 2 Ethyl Chloride Spray (100 ml. Bottle). 2

6.2.3 Non-Opioids, NSAIDS & Antimigraine. Aspirin Tabs 100mg / 300 mg. 2 Indomethacin Caps 25 mg. 2 Paracetamol Paediatric Oral Suspension

120 mg/ml (100 ml bottle). 2 Paracetamol Tabs 500 mg. 2 Ibuprofen Tabs 200mg. 2 Ibuprofen Syrup 100mg / 5ml / 60ml

(bottle).2

Liniments. 2

6.2.4 Anti-Allergies & Drugs Used InAnaphylaxis.

Adrenaline Tart Inj 1mg / 1ml (ampoule). 2 Chlorpheniramine Maleate Inj 10mg / ml

(ampoule). 2 Chlorpheniramine Maleate syr 2mg / 5ml

(bottle). 2 Chlorpheniramine Maleate Tabs 4mg. 2 Hydrocortisone Sodium Succinate Inj 100 mg

Base (vial). 2

6.2.5 Non-Specific Antidotes & OtherSubstances Used In Poisoning. Charcoal Tabs 125 mg. 2


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REMARKS

6.2.6 Specific Antidotes & Other substancesUsed In Poisoning.

Atropine Sulphate Inj 1 mg/ml (IV&IM /vial). 2

Pralidoxine Mesylate (PAM) Inj. 2

6.2.7 Antiepileptics/Anticonvulsants. Diazepam Inj 10gm / 2ml (IV & IM per

vial). 2 Phenobarbitone Tabs 30 mg. 2

6.2.8 Anti-Infective drugs – Anthelminthics. Mebendazole Suspension 100 mg / 5ml

(bottle). 2 Mebendazole Tabs 100 mg. 2 Niclosamide Tabs 500mg. 2 Albendazole Chewable Tabs 400 mg. 2 Albendazole Syrup 400 mg / 10 ml (bottle). 2 Levamisole Hydrochloride Tabs 50 mg. 2 Levamisole Hydrochloride Syrup 40

mg/5ml (bottle). 2 Praziquantel Tabs 600 mg. 2

6.2.9 Antibacterial – Oral Liquids. Amoxycillin Suspension 125 mg / 5 ml

(100 ml bottle). 2 Co-trimoxazole Suspension 240mg /

5ml(50 ml bottle). 2 Erythromycin Ethyl Succinate, dry 200mg/

5ml. 2 Ampiclox Neonatal drops 60 mg/ 30mg. 2

6.2.10 Antibacterial – Oral Tabs/Caps. Amoxycillin Caps 250 mg. 2 Amoxycillin Caps 500 mg. 2 Amoxycillin 250 mg + Clavulanic Acid 125

mg Tabs. 2 Co-trimoxazole Tabs 480mg. 2 Doxycline HCI Caps 100mg. 2 Nitrofurantoin Sodium Tabs 100mg. 2


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REMARKS

Nalidixic Acid Tabs 500 mg. 2 Tetracycline Caps 250 mg. 2 Norfloxacin 400 mg tablets. 2

6.2.11 Antibacterials – Injectables. Benzathine Penicillin Inj 2.4 MU IV (vial). 2 Benzyl Penicillin Inj 5MU / 1 IMU (vial). 2 Fortified Procain Penicillin Inj. 4.0 MU

(vial). 2 Triple Penicillin Inj 6:3:3 (Vial). 2 Gentamycin 80 mg / 2ml. 2 Gentamycin 20 mg / 2ml. 2

6.2.12 Antifungals. Clotrimazole Cream 1% 15gms. 2 Clotrimazole Vaginal Pessaries 100 mg. 2 Clotrimazole Ear Drops 1% 20 gms. 2 Benzoic acid 6% + Salicylic acid 3%

Ointment. 2 Nystatin Oral Suspension 100,000 Units/ml (24ml). 2 Nystatin Ointment. 2

6.2.13 Antiprotozoal Drugs. Metronidazole Tabs 200 mg. 2 Amodiaquine 200 mg tabs. 2 Amodiaquine susp. 50mg/5ml. 2 Sulfadoxine 500 mg + Pyrimethamine 25

mg Tabs / Drops 10 mg. 2 ACT (AntiMalaria-Combined –Therapy). 2

6.2.14 Dermatological Drugs. Benzyl Benzoate Emulsion 25% x 100mls. 2 Compound Benzoic Acid 6%+Salicylic

Acid3%. 2 Calamine Lotion 100ml. 2 Gentian Violet Crystals Powder 10 gms. 2 Hydrocortisone Skin Ointment 1% 10g. 2


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REMARKS

6.2.15 Gastrointestinal Drugs. Compound Magnesium Trisilicate Tabs. 2 Compound Magnesium Trisilicate Mist

(100mls bottle). 2 Oral Rehydration Salts Powder (WHO

Formulation). 2

6.2.16 Hormones, Endocrine Drugs andContraceptives.Adrenal Hormones and Substitutes

Hydrocortisone Sodium Succinate Inj 100mg Base. 2

Hormonal Contraceptives Ethinylestradiol + Levonorgestrel Tabs

(30mcg + 150mcg packet). 2 Ethinylestradiol + Norethisterone Tabs

(35mcg + 1.0mg packet). 2Oxytocics & Antioxytocics 2

Ergometrine Maleate Inj 500mcg / ml. 2

6.2.17 Immunologicals (Vaccines). BCG Vaccine Dried Powder (per 10 dose

vial). 2 Hepatitis B Vaccine. 2 Measles Vaccine. 2 Poliomyelitis Oral Vaccine (per 10 dose

vial). 2 Rabies Vaccine. 2 Tetanus Toxoid Vaccine. 2 Pentavalent Vaccine. 2 Anti-snake venom (10ml ampoule). 2

6.2.18 Opththalmologicals & ENT Preparations Tetracycline Eye Ointment 1% 3.5gms. 2 Zinc Sulphate 0.25% Eye Drops. 2 Oxytetracyline 3% + Hydrocortisone 1%

Ear Suspension. 2

6.2.19 Psychotherapeutic Drugs. Chlorpromazine HCI Inj 50 mg / 2ml. 2


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REMARKS

Chlorpromazine HCI Tabs 100 mg (sc). 2 Chlorpromazine HCI Tabs 25 mg (sc). 2 Fluphenazine Decanoate Inj 25 mg / 1ml. 2

6.2.20 Respiratory Tract Drugs. Aminophylline Inj 25mg/ml IV (10ml). 2 Salbutamol Syrup 2mg/5ml (100mls). 2 Salbutamol Tabs 2 mg/4mg. 2

6.2.21 Cardiovascular Drugs. Frusemide Tabs 40mgs. 2 Propanolol 40mg. 2

6.2.22 Solutions for Water, Electrolyte & Acid– Base Disturbance.

Darrows Solution ½ Strength (500ml). 2 Dextrose Inj 50% W/V (50 ml). 2 Dextrose Inj 10% W/V (500ml). 2 Dextrose Inj 5% W/V (100ml). 2 Normal Saline Inj 0.9% (500ml). 2 Water for Inj (10ml). 2

6.2.23 Vitamins and Minerals. Ferrous Sulphate Tabs 200 mg. 2 Folic Acid Tabs 5 mg. 2 Vitamin B Complex Tabs. 2 Multivitamin Tabs. 2 Multivitamin Syrup 100 ml. 2

6.2.24 Pharmaceutical Dressings. Sterile Medicated (Antimicrobial). 2 Paraffin Gauze 10cm x 10cm (pkt). 2 Sterile Medicated (Antimicrobial) Paraffin

Gauze 15cm x 20 cm) (pkt). 2

* APPLICABLE TO LEVEL V & VI ONLY.A. Gastro Intestinal Tract.i. Antacids. 5ii. Laxatives/purgatives. 5iii Anthelminthics. 5


of 49 JUNE 2007

NHIF ACCREDITATION STANDARDS

POINTSAWARDED(MAX OR ZERO REMARKS

iv. Anti diarrhoeals. 5v. Hepatic preparations. 5vi. Lubricants. 5vii. Suppositories. 5

B. Central Nervous System.i. Analgesics and antipyretics. 5ii. Anti- inflammatory agents. 5iii. Anti-convulsants. 5iv. Sedatives and tranquilizers. 5v. Hypnotics. 5vi. Anti-histamines. 5vii. Anti-depressants. 5viii. Stimulants. 5ix. Antiemetics, anti-nauseants. 5x. Muscle relaxatants. 5

C. Ear, Nose And Throat.i. Nasal preparations. 5ii. Oro-pharyngeal preparations. 5iii. Nasopharyngeal preparations. 5

D. Cardio-Vascular System.i. Anticoagulants. 5ii. antihypertensives. 5iii. Clotting agents. 5

E. Genito-Urinary.i. Urinary antiseptics. 5ii. Diuretics and anti-diuretics. 5iii. Anti-spasmodics. 5iv. Preparations acting on the uterus. 5v. Pessaries. 5

F. Endocrines.i. Steroids hormones. 5ii. Corticosteroids. 5iii. Trophic hormones. 5

G. Respiratory System.i. Cough expectorants. 5


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REMARKS

ii. Cough suppresants. 5iii. Inhalations. 5iv. Bronchial spasms relaxants. 5v. Respiratory stimulants. 5

H. Infections.i. Antibiotics. 5ii. Sulphonamides. 5iii. Sulphonamides and Trimethoprim. 5iv. Anti-TB preparations. 5v. Anti amoebics. 5vi. Anti leprotics. 5vii. Anti malarials. 5viii. Anti virals including ARVS. 5ix. Anti schistosomiasis and Filiariacides. 5x. Anti trichomonal agents. 5xi. Anti-fungals. 5xii. Vaccines, serums and immunoglobulins. 5

I. Opthalmic Preparations.i. Antibacterial preparations. 5ii. Steroid preparations. 5iii. Anti allergic preparations. 5iv. Anti viral preparations. 5v. Local anesthetics. 5vi. Mydriatics, myotics drugs used in glaucoma. 5vii. Miscellaneous ophthalmic preparations. 5

J. Dermatological Preparations.i. Anti pruritics. 5ii. Locally acting sedatives. 5iii. Dermatological stimulants. 5iv. Dermatological antiseptics. 5v. Topical preparations for muscular disorder. 5vi. Topical corticosteroids with/withoutantibiotics. 5vii. Anti parasitics. 5viii. Keratolitics. 5ix. Fungicides. 5x. Cleansing agents. 5


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REMARKS

K. Nutritive Preparations.i. Insulin. 5ii. Oral hypoglycaemics. 5iii. Vitamins. 5iv. Food products e.g. lipovenous, AKE. 5v. Iron and erythropoietics. 5vi. Minerals. 5vii. Anabolic agents. 5viii. Thyroid and antithyroid preparations. 5ix. Carcino chemotherapeutic agents. 5x. Drugs for metabolic disorders. 5

L. Anaesthetics, Surgical Antiseptics.i. Anaesthetics (local and general). 5ii. Surgical antiseptics and applications. 5

M. Contraceptives Agents.i. Oral. 5ii. Spermicidal. 5iii. Injectables. 5iv. Contraceptive devices. 5

N. Others.i. Antiretrovirals (ARVs). 5ii. Post Exposure Prophylaxis (PEP) drugs. 5SUBTOTAL FOR LEVEL III. 234SUBTOTAL FOR LEVEL IV. 234SUBTOTAL FOR LEVEL V. 437SUBTOTAL FOR LEVEL VI. 437

7.0 FOOD AND NUTRITION.

* APPLICABLE TO ALL LEVELS.

7.1 QUALITY ASSURANCE ON FOOD ANDNUTRITION.a. There is a qualified nutritionist/dieticianinvolved in preparing patients menu. 3


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REMARKS

b. Guidelines on food appropriate for the patientand consistent with his/her clinical care isavailable, including orders for nil by mouth, aregular diet, a special diet, and parenteral ornasogastric tube nutrition.

3

c. Food preparation, handling, storage, anddistribution are safe and comply with laws,regulations, and current acceptable practices.

3

d. The facility identifies patients at nutrition riskand commences them on nutrition therapy. 3e. Nursing staff assists patients unable to feedthemselves to feed. 3f. Facility disposes off kitchen garbage and refuseproperly. 3g. Persons handling patients’ food haveappropriate uniforms and are medically examinedevery six months.

3

SUBTOTAL FOR LEVEL III. 21


SUBTOTAL FOR LEVEL V. 21


8.0 THEATRE.

* APPLICABLE TO ALL LEVELS.8.1 QUALITY ASSURANCE STANDARDSFOR THEATRE.i. Written policies and procedures addresscompliance with applicable standards, laws andregulations, including maintenance of sterilityand safety

4

ii. There is a theatre equipment managementprogram that includes the selection andacquisition; inventorying, inspecting and testing;calibrating and maintenance; monitoring andfollow-up; and documentation of all processes.

4

iii. Evidence of continuous training on newtheatre procedures for theatre staff. 4iv. The theatre services are available foremergencies after normal working hours. 4


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REMARKS

v. Daily record of all surgeries performed intheatre, and by whom, is kept. 4vi. Availability of theatre trained nurses or theatretechnicians. 48.2 SURGICAL SERVICES.I. Minor Incision and drainage of Cyst /Abscess. 3II. Circumcisions. 3III. POP Applications. 3IV. Removal of POP. 3V. Suture of cut small, medium wounds &arresting haemorrhage. 3VI. Removal of stitches. 3VII. Tongue-tie release. 3VIII. Catheterization. 3IX. Manual Vacuum Aspiration. 3X. Implants insertion & removal. 3XI. Minor Removal of FB nose, ear. 3XII. Ear syringing. 3XIII. Giving Enema. 3XIV. Surgical dressing (small & mediumwounds). 3XV. Tonsillectomy. 3* APPLICABLE TO LEVEL IV UPWARD.i. General surgery. 10ii. Obstetric/gynecological surgeries. 10iii. Orthopedics operations. 10iv. Ear, Nose and Throat operations. 10v. Neuro-surgery. 10vi. Reconstructive surgery. 10vii. Urological surgeries. 10viii. Maxillo-facial surgeries. 10ix. Pediatric surgeries. 10x. Cardio-thoracic surgeries. 10xi. Endoscopic surgeries. 10xii. Endocrinological surgeries. 108.3 THEATRE EQUIPMENTS.i. At least 2 (two) standard operating tables. 4ii. Anesthetic machine. 4iii. Operating lamps/lights. 3


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REMARKS

iv. Suction machine. 3v. Oxygen supply. 3vi. Sterilizers/ autoclave. 3vii. Diathermy machine. 3viii. Cardio-pulmonary monitor. 3ix. Endoscopes. 3x. Extra anesthetic machine. 3xi. Drip stands. 3xii. Varied operating sets. 3xiii. Defibrillator. 3xiv. A minor theatre for day or uncomplicatedcases. 38.4 THEATRE LAYOUT.i. Receiving area/reception. 3ii. Changing room. 3iii. Scrubbing room/area. 3iv. Operating room. 3v. Recovery room. 3vi. Sluice room. 3vii. Doctors’ room. 3viii Store. 3ix. Theatre sterile supply unit (TSSU). 3SUBTOTAL FOR LEVEL III. 69SUBTOTAL FOR LEVEL IV. 260SUBTOTAL FOR LEVEL V. 260SUBTOTAL FOR LEVEL VI. 260

9.0 PHYSIOTHERAPY SERVICES.

* APPLICABLE TO LEVEL IV UPWARD.9.1 Special Examination Assessment.1.Electro diagnosis. 22. Manual muscle training (MMT). 23. Electromyography (EMG). 2

9.2 Heat Therapy.1. Laser jet. 12. UVR (ultra violet radiation). 13. IRR (infra red radiation). 14. SWD (short wave diathermy). 1


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REMARKS

5. MWD (micro wave diathermy). 16. Hot packs. 17. Hydrotherapy. 19.3 Exercise Therapy.1. Pre and post natal exercises. 22. General exercises. 23. Pre and post operative exercises. 24. Specialized exercises training. 25. Keep fit/group exercises. 26. Pediatric physiotherapy. 29.4 Electrotherapy.1. Ionization. 22. Stimulation. 29.5 Manipulative Therapy.1. Therapeutic massage. 22. Passive stretching. 23. Active movements. 24. Firm/ pressure bandaging. 29.6 Chest Physiotherapy.1. Postural drainage. 22. Nebulization. 23. Cryo-therapy. 14. Hydrotherapy. 15. Bedside physiotherapy. 26. Physiotherapy medical report. 27. Counseling. 3SUBTOTAL FOR LEVEL III. N/ASUBTOTAL FOR LEVEL IV. 50SUBTOTAL FOR LEVEL V. 50SUBTOTAL FOR LEVEL VI. 50

10.0 OCCUPATIONAL THERAPY SERVICES.* APPLICABLE TO LEVEL IV UPWARD.1. Physical Disabilities. 52. Psychiatry Counseling. 53. Rehabilitation. 5SUBTOTAL FOR LEVEL III. N/ASUBTOTAL FOR LEVEL IV. 15SUBTOTAL FOR LEVEL V. 15


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REMARKS


11.0 ORTHOPAEDICS* APPLICABLE TO LEVEL IV UPWARD.I. At least 1 Plaster room. 3II. TRACTION.a. Intermittent 3b. Continuous. 32. Electrotherapy and traction. 33. Reduction of joints, fractures and POPimmobilization/splinting. 3SUBTOTAL FOR LEVEL III. N/ASUBTOTAL FOR LEVEL IV. 15SUBTOTAL FOR LEVEL V. 15SUBTOTAL FOR LEVEL VI. 15

12. 0 STERILE PREPARARION UNIT (SPU)* APPLICABLE TO LEVEL IV UPWARD.QUALITY ASSURANCE IN SPU.1. The facility has a sterilization room wheresterile instruments are processed. 32. The facility has developed and implementedwritten policies and procedures for the cleaning,antimicrobial processing, and storage of suppliesand equipment to prevent the transmission ofinfection through their use.

3

3. The unit maintains a separate area forprocessing, decontamination, and storage ofsupplies, and is restricted to properly attiredauthorized personnel.

2

4. Instructions for the operation of autoclaves areposted near the equipment. 2SUBTOTAL FOR LEVEL III. N/ASUBTOTAL FOR LEVEL IV. 10SUBTOTAL FOR LEVEL V. 10SUBTOTAL FOR LEVEL VI. 10

13.0 ICU ROOM.* APPLICABLE LEVEL V & VI.


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REMARKS

1. Cardio pulmonary monitor. 52. Respirator. 53. Automatic blood pressure monitor. 54. Defibrillator. 55. Central Venous pressure monitor. 56. Blood Gas Analyzer. 57. Injection Pump. 58. I.C.U beds:

a. 2 (two beds).b. 3-4 beds.c. 5-10 beds.d. Over 10 beds.

5101520

SUBTOTAL FOR LEVEL III. N/ASUBTOTAL FOR LEVEL IV. N/ASUBTOTAL FOR LEVEL V. 85SUBTOTAL FOR LEVEL VI. 85

14. 0 LABOUR WARD.* APPLICABLE TO ALL LEVELS.14.1 QUALITY ASSURANCE IN LABOURWARD.1. The department has in place policies andprocedures for obtaining patient’s informationand records of the patient’s care (including Partographing) and response to care isdocumented and shared among medical, nursingand other care providers during each staffingshifts.

5

2. The department has in place guidelines andprocedures for dealing with clients with obstetricemergency or immediate needs including APH, PPH, PET, eclampsia, obstructed labor,cardiac disease, fetal distress, e.t.c.

5

3. The department has in place policies andprocedures addressing use of analgesia inprenatal and past natal care of clients. 514.2 EQUIPMENT.1. Standard Delivery Bed:

a. At least 2 delivery couches.b. 2-4 delivery couches.c. 5 and above delivery couches.

3


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REMARKS

2. Vacuum Extractor. 13. Suction machine. 14. Resuscitation Kit. 25. Cord ligatures. 16. Baby labels. 27. Sterile delivery packs. 38. Ergometrine/syntocinon, fluids, syringesneedles. 29. Maternity pads. 110. Baby weighing scale. 211. Clean floor and waste bins. 212. Source of clear overhead light. 113. Baby resuscitoir. 214 Quick access to nursery. 2 15. Labour acute room. 216. Sluice room. 217. Running water. 218. Quick access to theatre or annex maternity. 219. Provision for hot drink after delivery. 2SUBTOTAL FOR LEVEL III. 50SUBTOTAL FOR LEVEL IV. 50SUBTOTAL FOR LEVEL V. 50SUBTOTAL FOR LEVEL VI. 50

15.0 PERSONNEL.* APPLICABLE TO ALL LEVELS.15.1 QUALITY ASSURANCE FORPERSONNEL.1. There is a written policy on how the facilitydetermines the number, types, and desiredqualification of their staff.

5

2. There are procedures for orientation of all staffmembers to the facility and to their specific jobresponsibilities at the appointment of new staff.

4

3. There is a program to ensure each staffmember receives ongoing in-service andcontinuous education to maintain or advancehis/her skills and knowledge.

3

4. The facility has an effective job descriptionpolicy. 3


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REMARKS

B. CATEGORIES OF PERSONNEL (FULLTIME) IN THE STAFF LIST, PHYSICALPRESENCE AND EVIDENCEOFQUALIFICATION.* APPLICABLE TO LEVEL III ONLY.Medical Officer (S);1 And Above 15Clinical Officers;1-2,3 And Above.

1020

Nursing Staff;6-10,11 And Above.

2030

Laboratory Technician/ Technologist;At least 1,2 And Above.

1015

Pharmaceutical Technologist;1 And Above. 10Records Officer;1 And Above. 5Cashier. 3Subordinate Staff;2 And Above. 5Cooks;1 And Above. 3Watchmen/Security Officers;2 And Above. 5At Least 1 Public Health Technician. 5Oral Health Officers;1 And Above. 5Drivers;1 And Above. 3At Least 1 Plaster Technician. 5At Least 1 Hospital Secretary /Typist. 3At Least 1 Procurement Officer. 3SUBTOTAL FOR LEVEL III 150

* APPLICABLE TO LEVEL IV ONLY.Clinical Officers;At Least 2 And Above. 10Specialized Clinical Officers:


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REMARKS

Anesthesiologist;1 And Above. 10Paediatrics;1 And Above. 5At Least 1 Psychiatrist. 5At Least 1 Dermatologist. 5At Least 1 ENT Specialist. 5At Least 1 Ophthalmologist. 5Nursing Staff:Nurses;10-20,21 And Above.Specialized Nurses:Midwives.Theater.Psychiatry.Emergency.Any Other Speciality.

1020

55555

Radiographer;At Least 1,2 And Above.

510

Laboratory Technicians;At Least 1,2 And Above,

510

Laboratory Technologists;At Least 1,2 And Above.

510

Pharmacists;At Least 1,2 And Above.

510

Pharmaceutical Technologist;At Least 1,2 And Above.

510

Health Records Officer;At Least 1,2 And Above,

510

At Least 1 Statistical Clerk. 3At Least 1 Cashier. 3At Least 1 Accountant. 3At Least 1 Health Administrative Office. 3At Least 1 Oral Health Officers. 3


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REMARKS

Dental Technologists;At Least 1,2 And Above.

510

Dentists;At Least 1,2 And Above.

510

Medical Officers;4 – 10,10 And Above.

1520

Interns Qualified As General Medical Officers. 10Visiting Specialists:Physicians.Obstetric & Gynaecologists.Paediatricians.Surgeons.Any Other (Specify).

3030303030

Physiotherapists;At Least 1,2 And Above.

510

Security. 3Cooks. 3Occupational Physiotherapists;At Least 1,2 And Above.

510

Nutritionist;At Least 1,2 And Above.

510


510

Public Health Officers;At Least 12 And Above

510

Public Health TechnicianAt Least 1,2 And Above.

510

Subordinate Staff;At Least 1,2 And Above.

510

Plaster Technician. 3Mortuary Attendants. 3


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REMARKS

Drivers;At Least 1,2 And Above.

510

Hospital Secretary /Typist. 3Procurement Officers;At Least 1,2 And Above.

510


* APPLICABLE TO LEVEL V ONLY.Clinical Officers;At Least 2 And Above. 10Specialized Clinical Officers:Anesthesiologist;1 And Above. 10Paediatrics;1 And Above. 5At Least 1 Ophthalmologist. 5At Least 1 Psychiatric. 5At Least 1 Dermatologist. 5Ophthalmologist;1 And Above. 5At Least 1 ENT. 5Reproductive Health;1 And Above 5Nursing Staff:Nurses;50-100.101 And Above.Specialized Nurses:Midwives.Theater.Psychiatry.Emergency.ICU.Any Other Speciality.

50100

101010101010


510


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REMARKS

Laboratory Technologists/Technicians;At Least 2,3 And Above.

510


510

Clinical Pharmacist;At Least 2,3 And Above.

510


510

Health Records Officer;At Least 2,3 And Above.

510

Cashier;At Least 2,3 And Above.

510

Accountant;At Least 1,2 And Above.

510

Health Administrative Officers. 5Oral Health Officers;At Least 2,3 And Above.

510

Dental Technologists;At Least 2,3 And Above.

510

Dentists;At Least 1,2 And Above.

510

Medical Officers;4-10,10 And Above.

1020

Interns Qualified As General Medical Officers. 10At Least 1 Physician. 30At Least 1 Obstetrician Gynecologist. 30At Least 1 Pediatrician. 30At Least 1 Surgeon. 30At Least 1 Psychiatrist. 30At Least 1 ENT Specialist. 30


of 49 JUNE 2007

NHIF ACCREDITATION STANDARDSPOINTS


REMARKS

At Least 1 Dermatologist. 30At Least 1 Anaesthetist . 30At Least 1 Pathologist. 30At Least 1 Radiologist. 30At Least 1 Orthopaedic Surgeon. 30Rehabilitative Therapists:Physiotherapists;At Least 2,3 And Above.

510

Occupational Therapists;At Least 2,3 And Above.

510

Orthopaedic Technologist;At Least 2,3 And Above.

510

Social Worker;At Least 2,3 And Above.

510

Counselor;At Least 2,3 And Above.

510

Nutritionist;At Least 2,3 And Above.

510

Security;5-10,10 And Above.

510

Cooks;At Least 4,5 And Above.

510


510

Drivers;3 -6,6 And Above.

510

Public Health Technicians / Officers;At Least 2,3 And Above.

510

Subordinate Staff;10-20,20 And Above.

510


of 49 JUNE 2007

NHIF ACCREDITATION STANDARDSPOINTS


REMARKS

Mortuary Attendants;At Least 2,3 And Above.

510

Plaster Technician;At Least 2,3 And Above.

510

Hospital Secretary /Typist;At Least 2,3 And Above.

510

Procurement Officers;At Least 2,3 And Above.

510

Medical Engineer;At Least 2,3 And Above.

510

SUBTOTAL FOR LEVEL V 875

* APPLICABLE TO LEVEL VI ONLY.Specialized Clinical Officers:Anesthesiologist;5 And Above. 10Paediatricians;1 And Above. 5At Least 1 Ophthalmologist. 5At Least 1 Psychiatrist. 5At Least 1 Dermatologist. 5At Least 1 ENT. 5Ophthalmologist;1 And Above. 5Nursing Staff:Nurses;50-100,101 And Above,Specialized Nurses;Midwives.Theater.Psychiatry.Emergency .ICU.Any Other Speciality.

2030

101010101010


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REMARKS

Reproductive Health;1 And Above. 5Radiographer;At Least 4,5 And Above.

510

Laboratory Technicians;At Least 4,5 And Above.

510

Laboratory Technologists;At Least 4,5 And Above.

510


510

Clinical Pharmacist;At Least 4,5 And Above.

510


510

Health Records Officer;At Least 4,5 And Above.

510

Cashier;At Least 4,5 And Above.

510

Accountant;At Least 4,5 And Above.

510

Health Administrative Officer(s). 5Oral Health Officers;At Least 4.5 And Above.

510

Dental Technologists;At Least 4.5 And Above.

510

Dentists;At Least 4.5 And Above.

510

General Medical Officers:At Least 4.5 And Above.

1020


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REMARKS

Interns Qualified As General Medical Officers. 10Anaesthetists. 50Physicians. 50Obstetrician Gynecologists. 50 Pediatricians. 50 Surgeons. 50 Psychiatrists. 50Ophthalmologists. 50ENT Specialists. 50Dermatologists. 50Anesthetists. 50Pathologists. 50Radiologists. 50Orthopaedic Surgeons. 50Rehabilitative Therapists:Physiotherapists. 10Occupational Therapists. 10Orthopaedic Technologist. 10Social Workers. 10Counselors. 10Nutritionists. 10Security. 10Cooks. 10Radiographers. 10Public Health Officers. 10Public Health Technicians. 10Subordinate Staff. 10Drivers. 10Mortuary Attendants. 10Plaster Technicians. 10Hospital Secretary /Typist. 10Procurement Officers. 10Medical Engineers. 10


16.0 WARDS.* APPLICABLE TO ALL LEVELS.1. Male ward(s). 22. Female medical ward(s). 23. Isolation Ward. 2


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REMARKS

4. Paediatric Ward. 25. Post – Natal Ward 26. Ante-Natal Ward. 27. Labour Ward. 2* APPLICABLE TO LEVEL IV UPWARD.8. Male surgical ward(s). 29. Male medical ward(s). 210. Male isolation ward(s). 211. Female medical ward(s). 212. Female surgical ward(s). 213. Female isolation ward(s). 214. Female obstetric ward(s). 215. Female gynecological ward(s). 216. Pediatrics medical ward(s). 217. Pediatrics surgical ward (s). 218. New born unit. 2

* APPLICABLE TO LEVEL V- VI.19. High dependency unit (at least 6 beds). 220. Burns unit. 221. Renal unit. 222. Cardio-thoracic ward. 223. Neurosurgical ward. 224. E.N.T. unit. 225. Eye unit. 226. Dental Unit. 2SUBTOTAL FOR LEVEL III. 14SUBTOTAL FOR LEVEL IV. 36SUBTOTAL FOR LEVEL V. 52SUBTOTAL FOR LEVEL VI. 52

17.0 GOOD HOUSE KEEPING.* APPLICABLE TO ALL LEVELS.17.1 BED QUALITY.1. Metallic. 32. Firm. 33. Adjustable. 34. Has wheels. 35. Of good height (30 inches from the floor). 36. At least 3 ft wide and 6ft long. 3


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REMARKS

7. Spaces between beds at least 1.5 meters. 38. Number of beds:

a. LEVEL III 5-50.b. LEVEL IV 51-100.c. LEVEL V 100-200.d. LEVEL VI 200 and above.

5

17.2 LINEN.QUALITY ASSURANCE IN LINENPROVISIONS.1. There are written guidelines on the cleaningand disinfection of linen and protection of thelaundry staff.

5

2. There is enough stock of assorted linen(uniform, theatre, sheets, blankets, bed covers,mackintosh, pillow slips, mattresses, e.t.c)

5

3. The linen is clean and well pressed (ironed). 34. The linen is well labeled with facility’s nameand department. 35. The linen is not torn. 26. There is a responsible person who controls theuse of linen. 217.3 WHEEL CHAIR.One wheel chair per ward.Presence of wheel chairs but not in every ward.

21

17.4 STRETCHER.1 – 34 or more.

12

SUBTOTAL FOR LEVEL III. 50SUBTOTAL FOR LEVEL IV. 50SUBTOTAL FOR LEVEL V. 50SUBTOTAL FOR LEVEL VI. 50

18. 0 MORTUARY* APPLICABLE TO LEVEL IV UPWARD.18.1 QUALITY ASSURANCE IN THEMORGUE.1. The facility has training program for themortuary attendants on admission,identification/documentation, disinfection,preservation and storage of bodies.

3


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REMARKS

2. There is a mortuary equipment managementprogram that includes the selection andacquisition; inventorying, inspecting and testing;calibrating and maintenance; monitoring andfollow-up; and documentation of all processes.

3

3. The facility has guidelines on disposal ofunclaimed bodies. 34. The facility has enough stock of protectivegear for the mortuary attendants. 3B. MORTUARY SERVICES.1. Embalming facilities. 22. Refrigeration. 23. Other forms of preservation (formalin). 24. Prayer room. 2C. PROVISIONS FOR POSTMORTEMEXAMINATION.1. Separate post mortem room. 22. Build-in post mortem table. 23. Running water with antiseptic. 24. Tissues disposal facilities. 25. Clean postmortem set. 2SUBTOTAL FOR LEVEL III. N/ASUBTOTAL FOR LEVEL IV. 30SUBTOTAL FOR LEVEL V. 30SUBTOTAL FOR LEVEL VI. 30

19. 0 OTHER SERVICES* APPLICABLE TO ALL LEVELS.1. Well equipped, working ambulance. 32. MCH/FP (Maternal-Child Health/FamilyPlanning). 33. K.E.P.I (Kenya Expanded Program onImmunization). 34. VCT (Voluntary Counseling and Testing). 35. PMTCT (Prevention of Mother –To- Child-Transmission of HIV). 36. Infectious Diseases (TB, Leprosy e.t.c). 3* APPLICABLE TO LEVEL IV UPWARD.7. Palliative Care. 38. Dental unit. 39. Fertility Services. 3


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REMARKS

10. Speech therapy. 3SUBTOTAL FOR LEVEL III. 18SUBTOTAL FOR LEVEL IV. 30SUBTOTAL FOR LEVEL V. 30SUBTOTAL FOR LEVEL VI. 30

20. RECORDS & INFORMATION SYSTEMS.* APPLICABLE TO ALL LEVELS.A. QUALITY ASSURANCE IN RECORDSAND INFORMATION SYSTEMS1. The facility has policy that identifies thoseauthorized to make entries in the patient clinicalrecord& determines the record’s content&format.

5

2. The facility initiates and maintains a clinicalrecord, which contains all information for everypatient assessed and/or treated (files).

5

3. The facility contributes to external databases inaccordance with law or regulation (e.g. notifiablediseases) and produces relevant reports (monthly,quarterly).

5

4. The facility has systems in place to ensuremaintenance of confidentiality of patients’ dataand information.

5

B. RECORDS.1. Availability, usage and keeping of necessaryrecords. 32. Qualified Records Officers. 23. Health Management Information systems inplace and up-to-date. 34. In-patient/out patient registers. 2SUBTOTAL FOR LEVEL III. 30SUBTOTAL FOR LEVEL IV. 30SUBTOTAL FOR LEVEL V. 30SUBTOTAL FOR LEVEL VI. 30

21. 0 FUNCTIONAL COMMITTEES.

* APPLICABLE TO ALL LEVELS.

1. INFECTION CONTROL.


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REMARKS

a. The committee is constituted of persons fromall departments, with a Person qualified ininfection control as the leader.

2

b. The program is appropriate to the facility’ssize and geographical location, services andpatients.

2

c. The facility has identified the procedures andprocesses associated with the risk of infectionand the strategies to reduce infection risk.

2

2. MORTALITY REVIEW. a. The committee is constituted of persons fromall concerned department(s), and a qualifieddoctor/ clinical officer/nurse is the leader.

2

b. Monthly mortality meeting. 23. QUALITY IMPROVEMENT TEAM. a. There is a written plan for the facility’s qualityimprovement program. 5 b. The hospital management participates inplanning and monitoring a quality improvementand patient safety program.

5

c. All departments collaborate in planning andcarrying out the quality improvement program. 5d. Continuing Education (ProfessionalDevelopment). 5e. Evidence of certification by another qualitycertification body (e.g. ISO, KBS). 154. OTHER COMMITTEES.a. Hospital Management Board. 4b. Hospital Management Team. 4c. Executive Expenditure Committee. 2SUBTOTAL FOR LEVEL III. 55SUBTOTAL FOR LEVEL IV. 55SUBTOTAL FOR LEVEL V. 55SUBTOTAL FOR LEVEL VI. 55

22.0 HOSPITALS IN DISADVANTAGED REGIONS.

* APPLICABLE TO ALL LEVELS. Those in hardship areas, as recommended by theGovernment Notice. 100


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REMARKS

23.0 MEDICAL TRAINING INSTITUTIONS.

* APPLICABLE TO LEVEL III.1. Rural Health Training Facilities 30* APPLICABLE TO LEVEL IV - VI.1. Diploma Training Institutions 502. Degree Training / Referral Institutions 100SUBTOTAL FOR LEVEL III. 30SUBTOTAL FOR LEVEL IV. 150SUBTOTAL FOR LEVEL V. 150SUBTOTAL FOR LEVEL VI. 150

24. 0 ENGRAVEMENT OF ALL HOSPITALEQUIPMENT*APPLICABLE TO ALL LEVELS. 20

25.0 USE OF ICT IN THE FACILITY*APPLICABLE TO ALL LEVELS. 20

TABULATION OF POINTS.FACILITY LEVEL

POINTSSCORED ONASSESSMENT.

MAXIMUMPOSSIBLESCORE.

REMARKS

GRAND TOTAL FOR LEVEL III 1024

GRAND TOTAL FOR LEVEL IV 2105

GRAND TOTAL FOR LEVEL V 2906

GRAND TOTAL FOR LEVEL VI 3146


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ACCREDITATION ASSESSMENT REPORT DONE BY THE FOLLOWING

Assessment Certified by:

1. Name……………………………………………………………………………………

Signature……….………………………Date:…………………

2. Name…………………………………………………………….

Signature.……………………………….Date:…………………

3. Name:……………………………………………………………..

Signature.……………………………… Date:………………..

I…………………………………………….the Area Manager of

……………………………………………Area Office certifies that this assessment exercise took place.

Signature:…………………………………Date:……………………………………..

OFFICIAL NHIF STAMP

Hospital represented by:…………………………………Designation…………………….

Signature……………….Date……………..

OFFICIAL HOSPITAL STAMP

A need for re-assessment may arise if the NHIF Management/Board is not satisfied with theinitial assessment.

ENSURE THAT ALL PAGES ARE DULY STAMPED USING THE HOSPITAL STAMP BYTHE HOSPITAL REPRESENTATIVE.


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REFERENCE LIST

1. JCI. (2003). Joint Commission International Accreditation Standards (2nd Ed). Oakbrook Terrace: U.S.A.

2. Omaswa F. G. and others. (1996. Quality Assurance for Health Workers in Uganda: A Manual ofQuality Improvement Methods. Quality Assurance Program: Uganda.

3. The Kenya Public Health Act.

4. The Egyptian Accreditation Manual (2001).

5. Rudman, Willian J. (1997). Performance Improvement in Health Information Services. W.B SaundersCompany: USA.

6. White, Alasdair. (1996). Continuous Quality Improvement: A Hands-on Guide to Setting up&Sustaining a Cost Effective Quality Programme. Performance Management Solutions Ltd: Great Britain.

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accreditation manual 2nd edition

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