Name of the facility……………………………………………………………………………………….

Telephone ………………………………………… Address/Email ……………………………………..

Name of facility in-charge & DESGN……………………………………………………………………….

Name of Nursing services Manager & phone number: ………………………………………………….

Date of visit…………………………………………………………………………………………………

DATA - WORKLOAD SUMMARY

Staff-Patient Distribution

Indicate Number Bed Number of

Department/Ward/Unit of Number Patients/ Per Comment if any
Nurses/Midwives Day
OPD
Inpatients
Pediatric
Medical
-Male
-Female
Surgical
-Male
-Female
Psychiatry
A&E/Casualty
Ante-natal ward
Labor ward Delivery
beds-
NBU
Post-natal ward
ICU
HDU
Renal Unit
Theatre
Others (Specify)

TOTAL

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Nursing Staffing & Skill Mix

Cadres Indicate Number Comment if any

MScNs
BScNs 10
BScMs
KRCHNs 79
KRNs
KRN/Ms
KECHNs 06
KENs
High Diplomas
(Specify)
Nephrology Nurses 07
Ophthalmic 02

Others
(Specify)

TOTAL

Clinical staffing
Consultants 13
(Specify)

MOs 13
Pharmacists 06
Dentists/COHO (Specify)
-Dentist doctors 03
-COHO- COMMUNITY ORAL 02
HEALTH
COs 28
HRIOs
Lab. Technologists 16
Pharm. technologists 05
Orthopedic and trauma 05
Plaster technician
PHOs 02
Nutritionists
Health records 10
Occupation therapy 02
Radiographers 08
Medical engineer 03
Others (Specify) 03
Administrators

2
 SUPPLIES
-Supplies Chain Management 01
- Procument 02
-accountants 04

Support staff 09

Drivers 07
Cooks 04
Cateres 01
Tailor 01
Revenue officers 07
Social workers 04
Customer care 03

Indicate Number of Comment if any

Unit Patients/Clients
(Monthly Average)
CWC
Antenatal
Post-natal
FP
OPD
CCC
TB Clinic
SVD Deliveries
C/S Deliveries
Total Surgeries+ C/S

S/No. TARGET Number Comments

1. Total catchment population

2. Total no. of under fives

3. Monthly immunization target for under fives

Key focus areas in the service delivery areas

1. Facility level, bed capacity & average bed occupancy in (%)?

 Level 4 facility
 Bed occupancy = 75%

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2. Which are the various committees in the hospital to inform critical policy and guidelines?


3. Are the equipment’s in facility available and adequate?

Specify in maternity nos. of:

i.) Rescusitaire -
ii.) Suction machine-
iii.) Are there fully equipped PPH, PET & Emergency trays with checklist?

-If Renal unit, how many (i.) Hemodialysis machines? (iii) Dialysis bed?

4. Is documentation of nursing care utilized & adhered to?

a. History taking- YES
b. Cardex-YES
c. Nursing care plans- YES
d. Partographs-YES
e. Observation charts and any others- YES
5. Are there relevant SOPs available in the various departments in the facility? – either displayed or
on files
 YES, available in the files and display

6. How often do you conduct CMEs? Who co-ordinates them?


7. Infection prevention measures- are there presence of:
a. -hand washing facilities? Yes
b. -Availability of water/ or hand sanitizers? Yes
c. -Decontamination procedures- 3 buckets’ systems, decontaminants available and
SOPs showing its preparation? Yes

d. -sterilization procedures to include presence of autoclave, storage of sterile

Equipment? Yes

e. -Waste management – Placenta pit or macerator? composite pit? Incinerator? Yes

8. Do you submit monthly reports to sub-county MOH offices? Yes