SMT LEAD SBFR ACTIVITY SITE SUPERVISION ASSESMENT CHECKLIST

LEADERSHIP AND COORDINATION

S.NO. ACTIVITIES YES NO VERIFICATION

1. Enhanced multidisciplinary Functionality of MDT at the point of patient care
team function and clinical Clinical case team leaders functionality (check
leadership culture the round book, clinical forum agenda)
2. SBFR dashboard based Prescience of institution specific SBFR dashboard
intensive SMT monitoring and Daily CEO/CCO SBFR task force forum
supervision Weekly clinical forum led by CEO and CCO with
Weekly SBFR dashboard data summary
Display major service areas performances weekly
Intensive supportive supervision led by SMT with
standard checklist
3. SBFR task force perform daily Service audit for start time, productivity etc
dashboard based performance Chart audit
audit and feed in to database Client interview (scope adherence, quality of
for analysis care)
Observation
Corridor audit
SBFR task force analyze the data and identify
operational or clinical care gaps

Expected Result:

High impact leadership

Well-functioning team work at the point of care level
Well institutionalized clinical leadership
System components of care (IPPS, Hotel services, MCC… ) are well integrated with
clinical care
 EMERGENCY AND CRITICAL CARE
S.NO. ACTIVITIES
1. Implementation of scope
based clinical care practice
2. One-stop shop initial
evaluation and decision
making practice
3. Enhanced senior engagement
for leading and supervising
one stop shop initial evaluation
and decision making practice
4. Implementation of nursing
care practice for all kept cases
5. Institutionalize clinical
leadership culture
YES NO VERIFICATION
Check scope based disposal system at all
emergency units (register, client chart, protocol)
Is there institution specific scope for all
interdepartmental consultation
Check clients were evaluated by the appropriate
scope
All intra-departmental consultations has to be made
immediately (check monitoring mechanism)
Check availability of twice a day MDT round for
all kept cases (Morning and Evening)
Daily clinical audit for
o All newly kept cases of the day
o All emergency deaths, if any by using audit
format
Daily emergency corridor audit & senior led QI
project
Check all kept cases have
o A nursing process
o Regular nursing care audit
o Nursing handover practice (client, drug,
instrument, etc…)
o Health education system for all kept
o Adequate pain control practice
Administrative and clinical leadership roles clearly
defined and implemented with official letter
All MDT rounds are participatory and addresses
roles of all team members which includes
o Nursing care
o IPPS practice
o Hotel service including bed making, food
quality
o MCC practice including information
provision, client provider interactions
6. Emergency team forum Weekly emergency department forum led by the
emergency department head
Evaluates weekly performance based on the
emergency service dashboard
All identified gaps will be linked with an
improvement/action plan

Expected Results

Improved quality of care leading to Improvement in emergency and critical care

morbidity and mortality indicators (HMIS, KPI, SBFR, Facility specific)
Improvement in emergency and critical care client centeredness indicators (HMIS, KPI,
SBFR, Facility specific)
Improvement in resource use efficiency including HR and major supplies
Decreased waiting time to clinical consultation
Decreased emergency care waiting time (arrival to service completion which includes
time for clinical evaluation, workup, consultations, medication etc)
Decreased incidence of unnecessary laboratory and imaging requests and/or repeats
Increased patient experience and satisfaction
Improved rational use of medications
Better undergraduate and postgraduate medical education through improved supervision
and mentoring practice
 OUTPATIENT SERVICES
S.NO. ACTIVITIES YES NO VERIFICATION
1. Better triage, registration and Define scope of practice for top 20 clinical
payment systems conditions in each discipline
Check GP is assigned at triage
Check system of digital/ phone based triaging and
appointment system
Setup one stop shop triage, registration and payment
system in place

2. Early initiation of outpatient Check OPD initiation time at 8:00am

service and full working hours Check placement of shift based physicians
service assignment
o Shift 1: 8am to 1pm (including lunch time)
o Shift 2: 1pm to 5:30pm
o Time bound assignment: Assigned physician
cannot leave even if he/she completes available
chart
3. One-stop shop initial Check clients are evaluated by the appropriate scope
evaluation and decision and when needed, all intra and inter-departmental
making practice for all new consultations has to be made immediately from the
clients assigned physicians pool
4. Enhanced senior engagement All specialty/referral clinics run by a specialist
for facilitated and better One stop shop consultation service at least 1 senior
quality of care physician per discipline is in place
5. Better appointment system Appointment system should be in blocks of hours
Check presence of refill mechanism for chronic
OPDs
6. Clinical audit linked with an Conduct monthly 3R audit (Right physician or
improvement &/or scope, Right time, Right way)
accountability mechanism General audit based on the respective departments /
disciplines
o Internal medicine - TB care, HIV/AIDS care,
chronic illness care
o Ob/gy - FP, ANC, cancer screening programs,
 general and referral
o clinic services
o Pediatrics: EPI, Well baby clinic, general and
referral clinic services
o Other departments: General outpatient and
referral clinic services
7. Improvement of Chronic care Availability of Chronic clinic management protocol
follow up clinic Chronic OPD should be made functional in morning
and afternoon with different specialist allocation
Controlled patients appointment should be made at
least quarterly
Presence of a telemedicine follow up system for
selected chronic diseases with drug refill system
Check a referral back system is established

8. Better client education and Health literacy Unit established health literacy
counseling system for common professional or at least GP
chronic illnesses Check availability of standardize selected chronic
health education materials
Link chronic follow up clinic follow up patients with
the unit (check register)
Conduct Focus group discussion for selected chronic
follow up patients (check minutes)

Standardize and prepare short videos, brochures and

leaflets to enhance health education efforts
availability (observe availability)

Expected Results

Decreased number of patients not seen the same day

Decreased registration to clinical consultation time
Decreased outpatient waiting time (arrival to outpatient service completion which includes time
for registration, clinical evaluation, workup, consultations, medication etc)
Decreased incidence of unnecessary laboratory and imaging requests and/or repeats
Increased patient experience and satisfaction
Improved quality of care
Improved morbidity and complication indicators
Improved rational use of medications
 Improved supervision and mentoring practice for undergraduate and postgraduate medical
students

INPATIENT SERVICES
S.NO. ACTIVITIES YES NO VERIFICATION
1. Institutionalize clinical Administrative and clinical leadership roles clearly
leadership culture defined and implemented(check letter of
assignment)
Senior physicians should lead all respective
weekly MDT forums

2. Enhanced senior engagement Twice a day MDT round

for better quality of care
3. Improving nursing care quality
through regular audit feedback
mechanisms
o Morning: starts at 9am and ends before 12pm;
address all admitted patients
o Evening: B/n 6pm to 7pm; address only critical
and newly admitted patients and led by duty
emergency consultant
(check MDT format utilization and
adherence)
o Daily clinical audit for all newly admitted cases
of the day to reduce inappropriate variation in
diagnosis and treatment (compare daily
admitted patient with conducted audit)
Senior led QI project designed
o QI project per quarter
Check presence of nursing management rounds
schedule
Nursing director / Matron led daily nursing
management rounds which address:
o Emergency preparedness of each unit/ward
(List of emergency drugs and supplies with
their minimum quantity to be availed should
be standardized, there should be a mechanism
to refill and handover in each shift)
o All patient medications should be kept
 separately in a Room/central cabinet and
secured safe
o Dressing code adherence for all health work
force (Nurses/midwives, physicians, cleaners,
runners, lab/pharmacy/imaging staffs)
o Attendance of all responsible staffs
(Nurses/midwives, physicians, etc - as above)
o IPPS practice - cleanliness of wards,
adherence to waste segregation and instrument
processing standards (cleaning to storage)
Weekly summary reports should be submitted to
quality unit/directorate (check summary report)
Check all audit findings linked with improvement
and/or administrative accountability mechanisms
Check presence of competency assessment
protocol describing the schedule, assessment
procedures, roles and responsibilities etc..

Conduct regular nurses competency assessment

Staff interview and/or observation for
o Knowledge and skill (adopt/adapt core
competencies from national competency lists)
o Awareness of SBFR reform standards
Nursing handover practice
o Cardex for medications the client is taking
o handover register (Summary notes of all
patients should be kept )
o Clinical forms in the client chart (v/s sheet,
input and output monitoring form, nursing care
plan and progress notes, medication
administration form etc…)
All admitted patients in the ICU/HDU are
followed closely with 4P’s (Pain, Position, Potty,
Possess)
Standardized ICU nursing care protocol which
 addresses all the follow up and care packages
Establish full time nursing/midwifery clinical audit
team (Prepare institutional nursing protocols)
Conducts regular nursing care audit and link
identified gaps with and improvement &/or
accountability mechanism)
Protocol for common nursing procedures (at
least 20)
Protocol for common nursing problems and
their management (at least 20)
Daily nursing care audit, with all identified gaps
linked with an improvement and/or accountability
mechanisms
o Chart audit for nursing process cycle
implementation, V/S follow up as per patient
condition, twice daily progress note,
medication administration (At least 3 charts
should be audited from each unit/ward.)
o Client interview for client satisfaction in
relation to hotel service (food quality, linen
and pajama change etc), adherence to MCC
principles, quality of client education
Establish a skill lab
o standardized package available
o SOP for common nursing procedures present
(at least 20)
o Use the skill lab for need based capacity
building activities , based on gaps identified
from clinical audits and staff interview
4. Adequate pain control practice Pain management protocol
Regular pain scoring and control practice and
auditing mechanism
o Chart audit for regular pain scoring and
management as per the score.
o Client interview for adequacy of pain control (
 At least 10 client in each ward)
o All audit findings should be linked with
improvement plan
Weekly summary reports should be submitted to
quality unit
Regular audit for narcotic drugs and narcotic
prescription
Improved pressure ulcer tracking and surveillance
(check performance report/ trend)
Discharged patients have screened for pressure
ulcer
Availability of pressure ulcer register
5. Inpatient team forum Weekly Inpatient unit/ ward forum led by the
assigned senior
Evaluates weekly performance based on the
inpatient service dashboard
All identified gaps will be linked with an
improvement
6. Improved clinical pharmacy Clinical pharmacy service is availed for all
admitted patients
service and rational use of
Clinical pharmacy service audit well addresses
drugs o Rational use of drugs (2nd and 3rd line
antibiotics, polypharmacy …)
o Abuse for most expensive or narcotic
medications (top 20 drugs prioritized by the
specific institution)
All audit findings should be linked with
improvement and/or administrative accountability
mechanisms.
Weekly summary reports should be submitted to
quality unit/directorate
7. Establish good patient care All staffs on duty should be available in working
stations and wards
practice culture during night
Only if conditions allows, 50% staff from a team
time duty hours will rest and 50% should stay at working stations
(incident night time observation)
Check All corridor lights are functional

Expected Results

Improved quality of care leading to improvement in inpatient care morbidity and mortality indicators
(HMIS, KPI, SBFR, Facility specific)
Improvement in nursing care quality index
Improvement in pharmaceutical care quality index
Improved discharge planning
 Less ALOS
Decreased incidence of unnecessary laboratory and imaging requests and/or repeats
Improved rational use of medications

SURGICAL AND ANESTHESIA CARE

S.NO. ACTIVITIES YES NO VERIFICATION
1. Improve Operating theater OR director assigned to the major OR with clear
Leadership clinical leadership role (check letter of
assignment)
Weekly regular forum (check minute)
OR should have an annual plan which includes
surgical KPI reviewed and corrective action taken
based on identified gaps (check dep’t PMT book)
Establishing OT Dashboard
o Key OR performance indicators that address at
least efficiency, safety, and access (eg. TAT,
cancellation rate, incision time, SSC adherence,
Table output)
o Daily and weekly analysis of performance and
action taken

2. Improve operation room Standardized surgical workflow system

performance o A digital backlog management system
o Elective surgery appointment system should
only base on case category pool
o Clearly defined prioritization criteria
o Regular backlog data analysis
Avail a pre-admission surgical and anesthetic
evaluation clinic
o Ensuring all the minimum preparations are
made – Investigations, blood etc;
o Conducting a pre-anesthetic evaluation and
decide on their fitness
Standardized scheduling system and pre-operative
admission stay
o Pre-operative hospital stay for all elective
surgical admissions should not be more than 2
days (audit every month)
o All schedules should be posted 1 day ahead and
not later than 3 pm
o The nursing team should ensure all required
instruments, drapes and other needed materials
are ready
o The anesthesia team ensures all the preparations
are made
Standardize table productivity per day
o A minimum of 3 surgeries/table/day

Preventive and curative maintenance check for all

major OR by duty medical equipment team, every
morning before 6:30am (Should at least address
OR tables, anesthesia machines, cautery
machines, suction machines, and others which
are deemed necessary)
Establish system of early initiation of surgery with
and incision time at or before 8 am (anesthesia
induction time should be b/n 7:30-8:00am) check
monitoring mechanism
Avoid unjustified cancellation for a scheduled
patient (on the day of surgery, on table)
o Approving such cancellations only by an
anesthesiologist or most senior anesthesia staff
o Mechanism to verify all cancellation daily
(check cancelled charts)
Decreasing OR downtime and days
o Introducing a concept of shift based schedule
(morning, afternoon) to improve OR end time
(check OR register)
o Arrange OR disinfection days for weekends
3. Reduce the surgical site Consistent and correct use of safe surgery checklist
infection and other safety (check client charts)
related problems OR zoning based on the national IPPS guideline
(Restricted, Semi-restricted, Transitional and
Unrestricted)

OR operational management protocol

o Work flow and standards (incision time, time
b/n procedures, roles and responsibilities of
different team members etc…)
o Cleaning procedures and schedules
o Instrument processing, packaging and storing
procedures
o Patient preparation procedures
o Dressing protocols including jeweler, personal
watch, nail and hair management
o Antibiotic prophylaxis (indications, choice of
antibiotics, timing)
Improving surgical site infection tracking and
surveillance
o Ensuring all surgical patients have screened for
SSI based on WHO SSI surveillance checklist
at the time of discharge
o Availing SSI register
o Use of SSI surveillance data for improvement
4. Efficiency gain in supply Establish a registered and prescription based
utilization system of requesting and dispensing OR supplies
5. Establish OR pharmacy
Expected Results

Improve quality of care evidenced by surgical outcome measures

Increase OR productivity (at least 3 major procedures/table/day)
Increase staff efficiency
Decrease in elective surgical waiting list and waiting time
Low pre-operative hospital stay
Decrease in SSI and other safety related incidents
Very low/no incident of major OR medical equipment failure during the date of/at the
time of surgery
 DIAGNOSTIC CARE
S.NO. ACTIVITIES YES NO VERIFICATION
1. Improve access to quality Ensure availability of all test menu based on expected
diagnostic services standard (partially or fully outsourcing major
machines, including CT and MR)
Standardize productivity for imaging services
o Productivity per machine per day
o Productivity per health care provider per hour
Monitor the performance (check PMT book)
2. Establish client centered Assigning phlebotomist and decentralizing sample
system sample collection collection sites
and result delivery o Emergency sample collection and result delivery
service
o OPD sample collection and result delivery service
o Inpatient sample collection and result delivery
service
Microscopic examination and other tests requiring
simple machines should be done at major clinical
service areas
Result should be delivered based on the agreed TAT
o Undertake specific tests based methods of TAT
monitoring for compliance to the TAT (check
register)
o Client interview, patient walk, laboratory register
data review etc…
o Result should be delivered electronically or by a
runner
Monitor for unnecessary lab repeats/ requests and
establish notification system
Establish system of auditing justifications of major
laboratory/imaging requests
Establish system of auditing laboratory and imaging
 requests which are sent outside the institution
3. Improve diagnostic System of preventive and curative maintenance
service equipment and system for laboratory and imaging medical equipment
supply (check document )
management system Establish agreement for equipment maintenance
through outsourcing (Public and private)
Partially Outsource the management of selected
diagnostic service
4. Laboratory has Implement a process control system (internal quality
implemented quality control (IQC) and participates in external quality
management system, assurance (EQA).
incident handling and Established incident handling and reporting system
reporting system, LMIS which includes errors or near errors (near misses).
The hospital has established laboratory management
information system.
The hospital laboratory should be designed and
organized at least for bio safety level 2 or above and
work environment is clean and well maintained at all
times.
5. Hospital implemented Appropriate storage and stock management system
appropriate and safe for blood and blood products
blood transfusion service Blood mobilization strategy in collaboration with
nearby blood bank
Appropriate cold chain system for blood and blood
products (observe refrigerator temp. monitoring)
Actively functioning HTC and regularly audits
practice of appropriate and safe use of blood

Expected Results

Improve ED/OPD/IPD lab turn-around-times

Decrease incidence of hemolysis /Clotted specimens
Decrease incidence of unnecessary lab repeats
Decrease in backlog for imaging services and acceptable performance level for the
available resource (HR, diagnostic machines)
Improved diagnostic service quality index
 PHARMACEUTICALS AND MEDICAL DEVICES
S.NO. ACTIVITIES
1. Establish system of control
over top 20 prioritized drugs
2. Establish system of control
over prioritized 5 supply items
3. Regular audit on appropriate
use of drugs and supplies for
an exempted, CBHI and other
credit services
4. The hospital implements
auditable, transparent and
accountable pharmaceutical
transactions and services
(APTS).
YES NO VERIFICATION
List of 20 prioritized drugs
o Prioritization should be based on cost,
addiction risk and risk for drug resistance
and shall include 2nd and 3rd line antibiotics,
Pethidine, anti-coagulants, PTU, anti-D
etc…(check the document)
o Define scope for prescribing selected items
Daily stock status report for the prioritized drugs
Daily prescription audit
o Audit for possible evidences of abuse or
irrational use
Decide on list of 5 prioritized supply items
o Define scope for prescribing selected items
Daily stock status report for the prioritized supplies
(observe for audit report)
Daily prescription audit (observe audit report)
Staff clinic establishment
Weekly audit on dispensed drugs and supplies for
an exempted, CBHI and other credit services
o Compare register vs prescription agreement
with a focus on prioritized drugs and supplies
listed out above
o Use a sampling procedure
o Link all identified gaps with an improvement/
action plan
Presence of properly recorded and filed
prescriptions, sales tickets and registers at
dispensaries
o
Implementation of coding to uniquely identify
medicines (service areas, stores)
o Bin ownership and updating is implemented
 o Presence of regular monthly reports for
products, finance and services which is
evaluated by DTC and SMT with corrective
actions
o Annual ABC and VEN analyses report
Expected Results

Improved drug availability

Decreased drug abuse
Improved rational use of drugs leading to less AMR risk
 MOTIVATED, COMPETENT, AND COMPASSIONATE CARE
S.NO. ACTIVITIES
1. Conducive working
environment for general duty
staffs without compromising
timely access for patient care
2. Conducive working
environment for consultant
physicians without
compromising timely
access for patient care
3. Incentives and work load
based payments management
Expected Results
Motivated workforce
Improved productivity of health care workers
Improved access and safety of care
YES NO VERIFICATION
Gender based (not scope or profession based) duty
room arrangement with bathroom and hand
washing facility
Number of beds: 50% of duty staff number
Equipped with furniture, computer
Cup board for all staffs to secure all their personal
belongings, gowns and uniforms
24 hrs. access to water (portable purifier)
Central coffee and tea service
Duty room regular housekeeping service with
daily cleaning and linen change service
Zonal duty room service focal assigned and
manage the above requirements
Should have bathroom and hand washing facility
Equipped with furniture, computer, internet, tv
Cup board for all staffs to secure all their personal
belongings, gowns and uniforms
24 hrs. access to water (portable purifier)
Central coffee and tea service
Duty room regular housekeeping service with
daily cleaning and linen change service
Zonal duty room service focal assigned and
manage the above requirements (shared with
general duty management)
All duty payments should be paid after all
activities and expected audit area executed (check
finance, and department heads)
 DATA QUALITY AND EVIDENCE USE
S.NO. ACTIVITIES YES NO VERIFICATION
1. Full automation of electronic Invest on full digitization of the clinical care
medical record system for process (observe for functionality)
quality data and its use for Monitor overall productivity, clinical and non-
decision making clinical functions of the hospital using facility
specific, regional and national HMIS and KPI
indicators (check PMT report)
2. IT structure to support digital 24 hrs. IT personnel is assigned
health activities
3. Data quality audit for HIT department in collaboration with quality team
completeness, correctness and and SBFR taskforce conducts sampling based daily
timeliness data audit for completeness and correctness (check
audit report)
4. DHIS2 implementation Hospital submits reports timely
Hospital keeps hard copy of all reported data and it
is consistent with DHIS2 data (check PMT book)

Expected Results

HR productivity (dis-aggregated by type of profession) variation is less than 15%

Morbidity and Mortality indicators are with in an acceptable range (Ensure all HMIS, KPI, SBFR and
facility specific indicators are addressed)
Process indicators for SBFR and other facility specific measurements are with in an acceptable range