patient safety country self assessment tool

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Strategic Objective 1:

Strategic Objective 2:

For further information please contact: Dr Sunil Senanayake, Regional Adviser, Health Systems Management and Patient Safety, South-East Asia Regional Office of WHO

senanayakes@who.int

To prevent and control Healthcare associated infections

To Improve implementation of Global patient safety campaigns and strengthen patient safety in all health programmes:

safe surgery, safe childbirth, safe injections, medication safety, blood safety, medical device safety, and safe (organ, tissue

and cell) transplantation

To strengthen capacity for and promote patient safety research

PatientSafety Country Self-Assessment Tool

To improve the structural systems to support quality and efficiency of health care and place patient safety at the core at

national, subnational and healthcare facility level

To assess the nature and scale of adverse events in healthcare and establish system of reporting and learning

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Strategic Objective 1: To improve the structural systems to support quality and

efficiency of health care and place patient safety at the core at national, sub-national

and healthcare facility level .

Question No.

These questions pertain to National and subnational (State/Province) levels. Where indicated please answer in a scale of 0-4: 0= not present/ initiated/planned; 1=planned and initiated but implemention is less than 25%, 2= implemented between 26-50%, 3= implemented between 51-75%, 4= fully implemented (over 76%

implementation) at national level.

Type of Response National

Subnational (State/ Province/ Regional/

District)*

References

(if any) Explanation

1.1

1.1.1

Does the country have comprehensive policies and strategies aiming at quality of care in the country?

Scale of 0-4 for National and _{subnational level}

0

1.1.2 Is there a patient safety committee to formulate national priorities and actions? Scale of 0-4 for National and

subnational level

0

1.1.3 What are the Key government departments and other bodies responsible for execution of the policies Descriptive

1.1.4 Is there a dedicated directorate in the country to coordinate patient safety? Scale of 0-4 for National and

subnational level

0

1.1.5 Indicate whether there are specific laws and regulations on quality of care Scale of 0-4 for National and

subnational level

0

1.1.6 Is there particular regulation on :

1.1.6a a. the quality/competency of healthcare professionals Scale of 0-4 for National and

subnational level

0

1.1.6b b. quality of care services (hospitals, nursing homes, clinics, outpatient departments including GP Clinics/ Dispensaries)

Scale of 0-4 for National and subnational level

0

1.1.6c c. laws on patient rights Scale of 0-4 for National and

subnational level

0

1.1.7 Whether 3rd party payers(eg: health insurance companies) are encouraged to support and provide incentives

for patient safety? Yes/No

No

1.1.8 Whether efforts have been made to sensitise and get the media and civil society involved as responsible partners in patient safety?

0

1.2

1.2.1 Are accreditation mechanisms for healthcare facilities (including accreditation of laboratories and diagnostic facilities) in place? If no go to question 1.2.6

0

1.2.2 Whether the accreditation programme uses international standards and principles of accreditation such as

defined by ISQUA or JCI? Yes/No

No

1.2.3 Whether national standards and indicators for healthcare quality for hospitals have been established that are

used in accreditation Yes/No

No

1.2.4

Does the accreditation programme liaise and collaborate with international, regional or international health-care accreditation institutions such as JCI, ASQUA (Asian safety and quality association), Australian, Thai or Indian accreditation bodies. If so which ones?

Yes/No, if yes please

mention in explanation

No

1.2.5 Please describe briefly the scoring system for hospitals and attach the scoring system for one year. Descriptive

1.2.6 In addition to accreditation programmes is there also an inspectorate of health? Scale of 0-4 for National and

subnational level

0

1.2.7 Are there initiatives with ISO certification in the healthcare system ? Scale of 0-4 for National and

subnational level

0

1.3

1.3.1 Is there national programme to establish quality department / infection control unit in health care facilities / hospitals (HCF)?

0

1.4

1.4: Establish patient centred care and involve patients as partners in their own care

1.4.1 Do patient organizations (both general or disease specific) exist in your country? Yes/No, if yes please

mention in explanation

No

1.4.2 Whether policies exist with respect to the systematic measurement of patient experiences at national and subnational levels?

0

* Please note that countries where health is a State/Provincial responsibility can use this assessment at subnational levels. Please indicate the level in E4 cell

1.1: Institutionalize patient safety and strengthen the legal and regulatory framework and national policies for quality

and patient safety

.

1.2:

Establish accreditation and other external quality assessment mechanisms

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Assessment Questionnaire for Regional Patient Safety Strategy

Question No.

These questions pertain to National and subnational (State/Province) levels. Where indicated please answer in a scale of 0-4: 0= not present/ initiated/planned; 1=planned and initiated but implemention is less than 25%, 2= implemented between 26-50%, 3= implemented between 51-75%, 4= fully implemented (over 76%

implementation) at national level.

Type of response National Subnational (State/

province/ District)* References Explanation

2.1.1 Is there public reporting on quality of care? If no, please go to question 2.1.3

Scale of 0-4 for National and

subnational level

0

2.1.2 If yes, Who is the owner of this information? Descriptive

2.1.3 Does your country also publish a regular national report on the performance of the health care system? (Please

give refrences) Yes/No

No

2.1.4 Please provide a list of the quality indicators currently in use at national level Descriptive

2.1.5 Is there a mechanism of assessing the overall burden of unsafe care in the country?

subnational level

0

2.1.6 Is there a patient safety incident surveillance and a system of reporting and learning from all adverse events and “near misses” at national and sub-national levels?

subnational level

0

2.1.7 What is the system of analysis of reported incidents (adverse events as well as near misses) for the root cause

Give an example and describe the interventions taken on one such case to prevent their re-occurrence? Descriptive

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Strategic Objective 3: To ensure a competent and capable work force which is aware and

sensitive to patient safety

Question No.

These questions pertain to National and subnational (State/Province) levels. Where indicated please answer in a scale of 0-4: 0= not present/ initiated/planned; 1=planned and initiated but implemention is less than 25%, 2= implemented

between 26-50%, 3= implemented between 51-75%, 4= fully implemented (over 76% implementation) at national level.

3.1

3.1.1 Have policies related to licensing of healthcare professionals, continuous professional education and development,

professional certification and recertification been established? Descriptive

3.1.2 Has accreditation been established for healthcare professional education and training? Scale of 0-4 for National and

subnational level

0

3.1.3 Have standard treatment guidelines and SOP’s been developed for healthcare practice? Scale of 0-4 for National and

subnational level

0

3.1.4 Are periodic assessments of healthcare staff conducted on their understanding and awareness of patient safety principles and practice

subnational level

0

3.1.5 Is there adequate number and appropriately trained and skilled staff in position ? Scale of 0-4 for National and

subnational level

0

3.2

3.2: Improve the understanding and application of patient safety and risk management in healthcare

3.2.1 Have the roles of medical councils, universities, professional associations for education and training been identified in

patient safety? Yes/No

No

3.2.2

Have patient safety principles and practice (inclusive of patient safety concepts, development of core competencies, knowledge and skills) been integrated in all healthcare professional courses for doctors, nursing, dental and other paramedical professionals in undergraduate and post graduate disciplines?

subnational level

0

3.2.3 Are thereguidelines to tech patient safety as a part of bedside teaching, onsite learning and field work? Scale of 0-4 for National and

subnational level

0

3.2.4 Is the culture of patient safety being constantly reinforced for involvement and buy-in in by all categories of healthcare staff?

subnational level

0

3.2.5 Are there any assessments conducted on the healthcare staff's understanding and awareness of patient safety risk management?

subnational level

0

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Assessment Questionnaire for Regional Patient Safety Strategy

Strategic Objective 4 : To prevent and control Healthcare associated infections ( HAI)

These questions pertain to National and subnational (State/Province) levels. Where indicated please answer in a scale of 0-4: 0= not present/ initiated/planned; 1=planned and initiated but implemention is less than 25%, 2= implemented between 26-50%, 3= implemented between 51-75%, 4= fully implemented (over 76% implementation) at national level.

Is there a National Infection Prevention and Control (IPC) Guidelines, Programme and Policy ? (please give refrences) Scale of 0-4 for National _{and subnational level}

0

Is there a programme for hand hygiene improvement at various levels of healthcare? (Please explain your response in Cell G7)

Scale of 0-4 for National

and subnational level

0

If yes , are the WHO guidelines for handhygiene being followed? Yes/No

No

Have national IPC guidelines been developed? Scale of 0-4 for National

0

Are these guidelines evidence based and include cost effective interventions? Yes/No

No

Are these guidelines developed by the government (G) or by professional organisations (P)? Indicate G or P or both,

whichever is applicable G/P

P

Does the National authority collect, analyse, and report HAI and AMR data from HCF at country level ? Scale of 0-4 for National

0

If yes, indicate the level of HCF where these guidelines are being followed Scale of 0-4 for National

0

Whether there is a system for monitoring and evaluation of IPC practice? Scale of 0-4 for National

0

Is there a system in place for surveillance of HAI and investigation of outbreaks? Scale of 0-4 for National

0

Does the country have national policies and standards in place for cleaning, disinfection and sterilization and provision of sterilized and disinfected items for patient care? (please give references)

Scale of 0-4 for National

0

What are the mechanisms to ensure compliance with these standards at the various levels of healthcare? Descriptive

Does the country have National policies and standards for safe environment in healthcare? Scale of 0-4 for National

0

Are there regulation and Policies on Medical Waste Management? Scale of 0-4 for National

0 4.1: Strengthen infection prevention and control structure and programmes across all healthcare services and all levels of care

4.2.: Provide appropriately cleaned,disinfected or sterilized equipment for patient care as required

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Question No.

These questions pertain to National and subnational (State/Province) levels. Where indicated please answer in a scale of 0-4: 0= not present/ initiated/planned; 1=planned and initiated but implemention is less than 25%, 2= implemented between 26-50%, 3= implemented between 51-75%, 4= fully implemented (over 76% implementation) at national level.

5.1 5.1 Safe Surgical care:

5.1.1 Is there a national policy and plan for surgical services at various levels of care? Attach documents/ give references Scale of 0-4 for National and

subnational level

0

5.1.2 What is the extent of implementation of the National policy and plan for surgical services at various levels of HCF? Scale of 0-4 for National and

subnational level

0

5.1.3 list the initiatives being taken to strengthen emergency surgical and obstetric services services at various levels of

care Descriptive

5.1.4 Whether there are mechanisms in place for monitoring compliance with policies on surgical care? Give examples Descriptive

5.2 5.2: Safe childbirth

5.2.1 Are there national standards for basic maternal, neonatal and child health services? Give references Scale of 0-4 for National and

subnational level

0

5.2.2 Is the WHO safe childbirth checklist or any other checklist being applied to support the delivery of essential maternal and perinatal practices?

subnational level

0

5.3 5.3: Safe injections

5.3.1 Are there national policies for the safe and appropriate use of injections? Attach documents/give refrences Scale of 0-4 for National and

subnational level

0

5.3.2 Are there mechanisms existing to ensure the quality and safety of injection equipment? Scale of 0-4 for National and

subnational level

0

5.3.3 Are there National Standards for safe injection practices which are applied at different levels of healthcare? Scale of 0-4 for National and

subnational level

0

5.3.4 Are there regulations and guidelines on management of sharps waste? Scale of 0-4 for National and

subnational level

0

5.4

5.4.: Safe Medication

5.4.1 Is there a national medicines/drug policy ? Scale of 0-4 for National and

subnational level

0

5.5

5.5.: Blood Safety

5.5.1 Whether there are nationally coordinated blood transfusion services supported by national blood policy and legal and regulatory framework?

subnational level

0

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5.6 5.6: Medical device safety

5.6.1 Whether there is dedicated department for Health Technology/medical devices at National Authority? Yes/No

No

5.6.2 Is there a national policy and plan on Health Technology (medical devices) ? Attach the documents Yes/No

No

5.6.3 Whether initiatives have been taken to develop capacity for health technology assessment, management and regulation?

subnational level

0

5.6.4 Whether there is a national medical device regulatory and monitoring programme? Scale of 0-4 for National and

subnational level

0

5.7 5.7: Safe organ, tissue and cell donation and transplantation

5.7.1 Is there a National policy and programme for organ transplantation? Attach documents Scale of 0-4 for National and

subnational level

0

5.7.2 Are there adequate legislation to regulate and monitoe safe organ transplantation in the country? Scale of 0-4 for National and

subnational level

0

5.7.3

Are there adequate health system requirements (including those of physical infrastructure and skilled human resource) to meet the multidisciplinary requirements of transplantation with quality and safety as the fundamental principles?

subnational level

0

5.7.4 Is there an effective oversight mechanism to assure compliance with national regulations on organ transplantation? Scale of 0-4 for National and

subnational level

0

5.7.5 Has a deceased donor organ programme been established to enhance availability of organs? Scale of 0-4 for National and

subnational level

0

5.7.6 Are there initiatives to promote community awareness to overcome religious, social and cultural myths associated with organ donation and stimulate the community and altruistic feelings?

subnational level

0

5.7.7 Have alliances been developed between institutions within and outside the country for cooperation in legal, ethical and technical aspects?

subnational level

0

5.7.8 Is there regulation of health tourism to inhibit illegal organ trafficking? Scale of 0-4 for National and

subnational level

0

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Strategic Objective 6: To strengthen capacity for research on Patient Safety and ensure patient safety in research

These questions pertain to National and subnational (State/Province) levels. Where indicated please answer in a scale of 0-4: 0= not present/ initiated/planned; 1=planned and initiated but implemention is less than 25%, 2= implemented between 26-50%, 3= implemented between 51-75%, 4= fully

implemented (over 76% implementation) at national level.

Is there a National policy to promote research on patient safety ? (please give references) Scale of 0-4 for National and

subnational level

0

Has the country identified research needs and priorities at various levels of healthcare(by surveys, consultations, expert group meetings) in patient safety?

subnational level

0

Have ethics committees been established to ensure patient safety in research? Scale of 0-4 for National and

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Strategy

Number Strategic Direction Total Marks Marks Scored Assessment Comments

1 Strategic Direction 1 52 0 Need to commence

1.1 Legal and Regulatory Framework 32 0 Need to commence

1.2 Accreditation and External Quality Assessment 12 0 Need to commence

1.3 Safety Culture at HCF 4 0 Need to commence

1.4 Patient Involvements in PS and Care 4 0 Need to commence

2.1 Adverse Events Monitoring 12 0 Need to commence

Legend

3.1 Competent Workforce 16 0 Need to commence 0% 0 Need to commence

3.2 Patient Safety Risk Management 16 0 Need to commence 1-25% 1 Weak, need attention

26-50% 2 Fair and room to improve

4 Strategic Direction 4 40 0 Need to commence 51-75% 3 Good, need to expand

4.1 Infection Prevention and Control 28 0 Need to commence 76-100% 4 Excellent, and maintain

4.2 Sterilized Equipment 4 0 Need to commence

4.3 Environment, General Hygiene and Sanitation 8 0 Need to commence

5.1 Safe Surgical Care 8 0 Need to commence

5.2 Safe Childbirth 8 0 Need to commence

5.3 Safe Injection 16 0 Need to commence

5.4 Safe Medication 4 0 Need to commence

5.5 Blood Safety 4 0 Need to commence

5.6 Medical Devices Safety 8 0 Need to commence

5.7 Safe Transplantation 32 0 Need to commence

6.1 Research Capacity 12 0 Need to commence

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Term Used Definition/Clarification

3rd Party Payment Payment is not made by the service recipient or his employee but by the Health Insurance System or Company

Accreditation Accreditation is a process of review that healthcare organizations participate in to demonstrate the ability to meet predetermined criteria and standards

of accreditation established by a professional accrediting agency

Adverse events Undesired results due to healthcare provided to a patient are considered under this term. It could be vary from simple drug reaction to loss of life. Many countries report adverse events and near misses to avoid such events in future

AMR Antimicrobial Resistance

Dedicated Directorate Some countries have separate directorate for patient safety and quality of health care, some have appointed focal points for patient safety, If there is no separate director for Patient Safety and Healthcare Quality explain the answer under Column G

Government Hospitals government owned hospitals, semi government hospitals and government appointed board manage hospitals are considered in this category

HAI Healthcare Associated Infections

HCF Health Care Facility

Inspectorate of Health Some countries have a special unit which visits hospitals to observe services provided for quality, safety and whether guidelines are followed, procedures are adopted or not

ISO Certification It is a quality management system that demonstrates its ability to consistently provide a product or a service that matches the applicable statutory and regulatory standards.

ISQUA The International Society for Quality in Health Care

JCI Joint Commission International on Accreditation of Healthcare Organizations

Key government and other bodies Ministries of health, higher education, live-stocks, water sanitation boards etc. could be considered at key government and other bodies. Description of these bodies could be given under Column G

National Authorities Health Ministry / Health Department / Health Quality Secretariat officer responsible for at national level on healthcare quality and safety

National Standards National standards for healthcare quality usually defined by Healthcare Quality Secretariat. If not it is recommended by a special group appointed for setting up healthcare quality standards by the Ministry of Health

Near misses This term is used to explain adverse events which were most certain of death but was able to avoid with lot of interventions

Out-Patient Departments

Departments who treat patients without getting them admitted to the hospital and send them back within the same day. Patients who are coming to get special therapies such as physiotherapy, radiotherapy, dialysis and go back after getting the required treatment. General Practitioners, clinics or surgeries or dispensaries also consider as outpatient department services.

Overall burden of unsafe care Some countries conduct burden of diseases and economic impact of diseases to identify cost effective interventions reduce the burden due to those particular diseases. The studies carried out to assess health and economic loss due to unsafe health care consider under this term

Patient Safety Committee at National Level Some countries have Patient Safety Policy groups, steering committees, national committees or similar committees to guide Ministries of Health on Patient Safety issues, priorities and policies

Policies at National and subnational Levels Some countries have strategies, guidelines circular instructions or similar mechanisms instead of making exclusive policies. If policies and strategies are not available please explain the response under column G

Private Hospitals Private sector owned, non-for profit, nongovernmental or missionary hospitals running for charity could be considered under this group

Public Reporting Public reporting is any information published in public domain of websites, published reports available to public and media publications

Regular national reports on performance of healthcare system

Some countries prepare annual (or periodic) health sector performance (Mainly government) to be presented in Parliament at buget speeches or similar events or for health summits

SOP Standard Operating Procedures

Subnational States, Provinces, Regional and Districts shall be considered as subnational as appropriate to the country if states / provinces / regions / districts are fully responsible for health policy making