Infrastructure

Quality Surveillance Map Standard : Infrastructure Level 1 Initial Technical Quality Human Quality STRUCTURE The policlinic has drinking water 24 Sanitary facilities include toilets hours a day and sinks in good working order for use by the public and staff. These are adequately ventilated and all appropriate signs are posted. Level 2 Intermediate Technical Quality Human Quality There are well defined areas for, user information, eligibility, waiting rooms, examination rooms for family practice and specialties, general services such as laundry, garment storage, ironing facilities, storage rooms and ancillary services such as labo Natural lighting in all areas throughout the policlinic is sufficient to carry out ordinary daily activities; room temperature and ventilation are adequate. Level 3 Maturity Technical Quality Human Quality There are sanitary facilities for the handicapped with appropriate entrances, ramps and handrails. The outpatient unit has separate areas to guarantee privacy and confidentiality. The gynecological examination rooms have a bathroom or access to one located nearby. Recreational facilities are available at the policlinic for the users as well as the staff. The paint on the facility's inner and outer walls is in good condition, the colors are pleasant, and there are no drip or seepage marks. There is an auditorium or special area for continuous education and health education activities. Doors and windows are in good working order, and the respective locks, bolts and security systems are in place (bars or other security mechanisms). There is toilet paper, a towel and soap in the policlinic's bathrooms or these items may be requested from the admissions and/or nursing units. The policlinic's managerial staff is familiar with the policlinic's electricity, water and maintenance costs. The special area or auditorium is used at least twice a week by the public as well as the staff. The policlinic has an emergency plan and the necessary infrastructure in case a disaster occurs. PROCESS There are no posters or papers stuck to the walls, windows or doors. There is a bulletin board for this purpose and/or the former are framed. Throughout the policlinic there are no burnt light bulbs or out of order switches, or items that failed to be installed. The furniture, equipment, utensils and other items are functionally located, and there are no improvisations as to their layout throughout the policlinic. All electric installations are in good working order and the switches and outlets are in good condition. RESULT There are no improvised areas. All of them have been planned or improved for efficient and current use. Three users who were surveyed stated that the infrastructure is comfortable and pleasant. Three members of the policlinic's staff were surveyed, and all of them stated that the infrastructure is adequate and suitable to carry out their activities. Three users who were surveyed stated that the infrastructure projects a sense of comfort. The policlinic carries out surveys constantly and applies suggestions to improve the infrastructure for the users' benefit. These can be certified. Total Number of Questions Human Quality Questions Technical Quality Questions 23 12 11 Quality Surveillance Map Standard : Information and Sign Posting Level 1 Initial Technical Quality Human Quality STRUCTURE At the policlinic there is one person who is specifically responsible for furnishing information, who is duly identified and is permanently available to provide services to users in a visible place during working hours The policlinic has reference and information signs concerning its services posted in strategic locations throughout the facility Level 2 Intermediate Technical Quality Human Quality There are visible, framed posters, explaining the programs and services offered by the policlinic as well as the user's rights using clear language, which allow the user to be continuously informed and educated. There are information, communication and education supplies such as flipcharts, graphs, educational material and other visual aids permanently posted in visible locations in waiting areas. Level 3 Maturity Technical Quality Human Quality A system of house calls and/or community visits is in place, which advertises and explains the benefits of the services offered by the policlinic on a regular basis using written and graphic materials. There are internal regulations for the policlinic's staff, which specify how users should be treated, and also include norms to regulate the staff's behavior and interaction with them. There is an analysis committee responsible for handling the users' suggestions and complaints, which is capable of addressing them, and which can be contacted by the users at any time. It meets at least once a month. There is a suggestions and complaints system in place for the users, which uses either a complaints box and/or book. Visible, explanatory and educational posters are exhibited in waiting rooms and examination rooms. During their passage through the policlinic, users easily identify the location of the examination rooms and other facilities from the time they enter and until they leave the facility. Addressing users as Mr. or Ms. the receptionist establishes visual contact with them and greets them in his/her personal way and then furnishes the information they request. The policlinic held a communications planning session for its IEC activities which identified the messages required by target audiences as well as population segments that come to the facility for services. It has broadcasting material to disseminate thes PROCESS The suggestions box or book is checked on a weekly basis by the policlinic's Analysis Committee, which tries to correct mistakes and adopt suggestions through the subscription of agreements. The policlinic has its own committee, which allows users to participate on a regular basis in the systematic handling of complaints and suggestions, and to take part in the meetings held with the aim of finding solutions or improving its services. The com A clear and visible identification tag is worn by all staff members. RESULT In a survey of three users they stated that they had received and understood without difficulty the services offered, the facility's working hours and the educational messages conveyed through existing means. Three users were consulted and they stated that the information posted on bulletin boards as well as that requested from the policlinic's staff was sufficient, and had been furnished to the client's satisfaction. At least two communication planning activities are carried out. The user finds at the policlinic a unit that furnishes him/her timely and complete information upon request. Total Number of Questions Human Quality Questions Technical Quality Questions 18 3 15 Quality Surveillance Map Standard : Cleaning and Maintenance Level 1 Initial Technical Quality Human Quality STRUCTURE There is a manual of cleaning procedures and functions with which the staff is familiar. There are clean and accessible bathrooms available for the policlinic's staff. Level 2 Intermediate Technical Quality Human Quality There is a person in charge of cleaning. Cleaning and maintenance procedures are standardized, including the use of disinfectants. Norms are in place for treating potentially contaminating elements or body wastes (hepatitis B, AIDS, salmonella). The policlinic's staff has warm and cold water taps available, especially in the laboratories, sterilization and dental facilities. Level 3 Maturity Technical Quality Human Quality The policlinic's infections committee and/or an epidemiologist actively participate in the elaboration and supervision of cleaning standards. The facility has cleaning materials such as brooms, soap, detergent, plastic bags, garbage cans and waste baskets on a permanent basis. The staff knows that the policlinic There are clean robes and sheets has elaborated in conjunction with for users in sufficient quantities, to the institution's technical staff the be changed on request. preventive maintenance and repairs plan as well as the periodicity therof. The staff knows which items must be replaced and when. Preventive maintenance is in place for all sanitary facilities. Solid wastes are identified, and treated and then stored in a previously identified specific area. There is a training program in place for cleaning crews regarding the adequate use of disinfectants and cleaning procedures. Sinks and toilets for public use and staff use are cleaned with detergent at least twice a day and decontaminated with bleach once a day. The policlinic's cleaning supervision functions are clearly defined in writing, and the manager is responsible for this task. PROCESS The crews in charge of cleaning the entire policlinic at least once a week are clearly identified, and they must perform these tasks after working hours, when no medical services are offered. The facility is responsible for the provision of working clothes and uniforms for staff use, as well as the decontamination and washing thereof, either at the facility or under a contract with a laundry. Dirty clothes and uniforms are timely replaced. The staff knows how many light bulbs, glass panes or other materials must be replaced on a weekly basis, and replacements are carried out within one week after breakage at the most [check written order and delivery forms] Each staff member has a medical record where all his/her results and health problems are registered, in connection with infectious diseases. All floors are cleaned with soap and/or detergent or bleach twice a day. Sweeping is forbidden, except in special cases like examination rooms, heavy traffic areas or special floor surfaces. It can be seen and verified that the policlinic's walls and furniture are dusted and cleaned at least once a day. There are no complaints regarding the supplies of basic cleaning inputs such as soap, toilet paper, towels, bleach and rubber gloves. The facility's floors, ceilings, physical structure, doors and windows are periodically checked, at least once a year, in order to make all needed repairs and correct possible problems. RESULT Observing the policlinic, no waste accumulations were found in the premises. After consulting with three users, none of them complained about the sanitary facilities after using them. They stated that they found them clean. Verify supervision activities as regards cleaning norms in charge of the epidemiologist and/or the infections committee. Garbage is collected at least once a day in polyethylene bags in adherence to written procedures and according to contamination hazards, and these are disposed of in a timely manner. Instructions concerning the hazards involved as a result of contact with contaminating diseases and biosafety precautions to be followed are exhibited in examination rooms, waiting rooms, physician's lounges and other areas. There are no accumulated wastes in the policlinic. Total Number of Questions Human Quality Questions Technical Quality Questions 26 8 18 Quality Surveillance Map Standard : Equipment Level 1 Initial Technical Quality Human Quality The family practice and general The furniture in the waiting room is medicine examination rooms have adequate and offers minimum the following equipment: 1 comfort to the users. examination table, 2 chairs, 1 desk, scales and height measuring device, 1 pinard, 1 blood pressure gage, 1 stethoscope, 2 thermometers, 1 othoophtalmoscope, and 1 Level 2 Intermediate Technical Quality Human Quality In the waiting room users have health education materials and equipment (TV and video) available, which are permanently operating. Level 3 Maturity Technical Quality Human Quality The policlinic ha a list of equipment that is currently used as well as the future requirements, which was submitted to the pertinent department of the Caja Nacional de Salud. Before ordering any equipment, the policlinic evaluates the actual needs and trends, as well as the appropriate technology. STRUCTURE A complete inventory of the policlinic's equipment is available, which specifies the quantity and location thereof. The inventory does not state the condition of these items. There are written and verifiable safety standards for the operation of different types of equipment for users as well as staff members who operate the equipment. The pediatrics examination room is furnished with at least one examination table, 2 chairs, 1 desk, pediatric scales and child measuring device and/or measuring tape, 1 stethoscope, 1 blood pressure gage, 1 othoscope, 2 thermometers and toys. The obstetrics-gynecology examination room has the following furnishings and equipment: a specialized examination table, a pinard, 1 measuring tape, 2 chairs, 1 desk, scales and robes for patients in addition to a physical system to guarantee the user's p There are written strategies and procedures to be followed in the event of equipment failures, especially as regards the cold chain and sterilization equipment. At the policlinic, there is a Containers, needles and utensils procedure to detect obsolete labeled "disposable" are disposed equipment, outdated techniques, of after a single use. absence of spare parts and other factors, as well as instruments and equipment whose disposal must be arranged. A permanent training program is available for the staff concerning the handling and appropriate use of the policlinic's equipment. At least 50% of this program has been completed. Recommendations made during clinical sessions were taken into account. The staff has been duly trained to carry out basic preventive maintenance tasks in small equipment and has been instructed about the hazards arising from the unnecessary or excessive handling thereof. PROCESS RESULT 100% of the staff members in charge of operating the equipment knows that written norms are available and they also know how to proceed when the equipment fails. 80% of the equipment and supplies 100% of the staff has been trained requested by the policlinic were in the proper handling, use and delivered. adequate preservation of the equipment in their area. No equipment has been sent to a higher level without a prior request issued by the policlinic. No equipment has been disposed of or is out of order due to human error arising from regular handling or normal use. 100% of the equipment is fully operational. Total Number of Questions Human Quality Questions Technical Quality Questions 21 8 13 Quality Surveillance Map Standard : Management and Organization of Health Care Level 1 Initial Level 2 Intermediate Technical Quality Human Quality Technical Quality Human Quality STRUCTURE The policlinic has a medical director in charge, who was elected on a merit basis and in adherence to institutional regulations. He must organize and chair the CQI committee. Detailed and updated descriptions of the different staff positions are available. The Medical director and/or Head of each Unit supervises diagnosis and treatment-related decisions. There are written supervision guidelines in place. Level 3 Maturity Technical Quality Human Quality There are files of the policlinic's permanent staff, which certify that their academic titles are fully accredited and that they posses a license issued by the Ministry of Health and the respective Professional Colleges in 100% of the cases. Successes, problems and The administrator has at least a solutions are shared. Solutions are two-year experience in sought jointly through natural administration and/or management. teams. The policlinic must keep (original documents are not required) equipment, instruments and laboratory inventories, as well as a list of services offered by each unit. Each user is assigned to one professional. Referrals to other specialists are channeled by him(her) if required. The policlinic has a manual of administrative procedures and routine paperwork, which stipulates in writing the steps of each circuit. The policlinic's objectives and strategies determine its work based on the vision, mission and strategies of Caja Nacional de Salus (CNS). There is a written mission statement and the entire staff, directive officers and community members are familiar with it. There is a personnel office with its respective internal regulations. There is an organization chart at the policlinic which clearly defines the roles of the director, support staff, technical structure, advisory committees, medical and nursing departments, administtrative area, personnel unit and others, as well as their o The policlinic's structure is governed by the strategies set forth by the CNS and it is periodically revised to guarantee compliance therewith. There is a monthly schedule of continuous medical education meetings. Instruction is offered concerning the 20 most frequently diagnosed diseases in the policlinic, especially in those cases with the lowest clinical-diagnosis congruence indexes. Verify if the policlinic's physicians and other specialists hold clinical meetings at least once a month. There is an Annual Operations Plan (AOP), it is clear, realistic and measurable. The staff took part in the elaboration thereof. At least 50% of the AOP's objectives have been attained. The objectives of the AOP are clear, realistic and measurable. More than 75% of them have been attained. There is one person responsible for organizing and chairing clinical meetings. The modality, operation and case selection are known. The organization's structure is revised on a regular basis so as to guarantee its consistency with the policlinic's strategies. There is a written protocol for users with chronic illnesses which includes self-help meetings. RESULT PROCESS Total Number of Questions Human Quality Questions Technical Quality Questions 22 7 15 Quality Surveillance Map Standard : Procedures Level 1 Initial Technical Quality Human Quality STRUCTURE Institutional "sample" clinical histories are used at the facility, and these are filed at the end of each visit in duly numbered files according to the insured/beneficiary's code. The policlinic and the directive staff offered orientation sessions to at least 50% of the staff concerning personnel-related policies, and they explained what is expected of them. Level 2 Intermediate Technical Quality Human Quality The policlinic schedules appointments for 10 - 30% of the users who request services offered by the family practice unit, dental care division and other specialties. Level 3 Maturity Technical Quality Human Quality An internal audit is performed at the facility at least once a year. A written policy and a manual on user's rights is available. It includes at least the following: access to treatment, respect and dignity, privacy, confidentiality, personal safety, identity, information, communication, consent. There is a quality committee and continuous quality improvement (CQI) teams that meet at least once a month. The policlinic has implemented a review system for clinical records, which is periodically implemented. In the facility's medical histories it is possible to verify if all the boxes were properly filled out, as well as to determine the diagnosis and therapeutical procedures. Medical histories must bear the legible signature and stamp of the attending physic The policlinic's petty cash is regulated in writing. It is possible to know the income and expenses thereof at the time the evaluation is performed. Accounts are rendered on a regular basis. There is a person in charge of the facility's statistics, who can furnish timely and complete information about the services offered by the policlinic, and there is also a summarized annual report. PROCESS The personnel office has a registry of the entire professional and non professional staff, as well as their vacations schedule. There is a permanent motivation and development plan for the staff, which includes motivation, incentives and acknowledgements. It is implemented on a regular basis. There is an inventory of all fixed assets, updated as of the first month of the year, which can be verified through sampling at the time the evaluation is carried out. The CQI teams are in charge of implementing continuous quality improvement procedures, whereby all the policlinic's processes are analyzed in order to make improvements. There are at least 4 quality improvement projects per month, and upon their conclusi The policlinic has an epidemiological surveillance system in place for prevalent diseases within the target population, which uses instruments governed by the country's norms and submits periodic reports to the corresponding entities in adherence to pre Level 1 Initial Technical Quality Human Quality A SNIS registration system is in place in all examination rooms throughout all shifts. Data are collected by a person in charge of processing information. Level 2 Intermediate Technical Quality Human Quality At least 10 critical processes (protocols) for prevalent diseases have been identified at the outpatient facilities. The protocols were elaborated by the policlinic's staff and validated by the physicians. Performance evaluations of the policlinic's staff are carried out periodically by areas. These are scheduled by mutual agreement with the interested parties. These evaluations are based on the job descriptions corresponding to each employee. Level 3 Maturity Technical Quality Human Quality The Information Analysis Committee (IAC) holds quarterly meetings covering at least the following topics: outpatient care, Extended Immunization Program, Sexual and Reproductive Health, BPMH and all the information generated by health-related activities carried out at the policlinic. At least three critical processes corresponding to the users' most frequent illnesses (protocols) were identified at the outpatient facilities. RESULT The policlinic implemented an appointment system at the family practice unit, specialties and dental care division. Average waiting time to receive medical care at the family practice unit for users who have previously scheduled appointments is approximately 20 minutes. There are continuous quality improvement procedures in place implemented by CQI teams, which analyze the policlinic's processes and foster the improvement thereof. There are at least 2 improvement projects per month, and their results are measurable. There is at least a 70% compliance with previously scheduled appointments. Average waiting time for users who scheduled an appointment to receive medical care at the family practice unit is 15 minutes. Compliance with previously scheduled appointments is 80%. Average waiting time for users who do not have an appointment to receive medical care is less than 30 minutes. The percentage of clinicaldiagnostic-therapeutical congruence is 80%. An evaluation of 5 clinical records per examination room are performed every month, and these are analyzed by an evaluation committee which feeds back the findings. Average waiting time for users who failed to schedule an appointment to receive medical care does not exceed 30 minutes. The percentage of clinicaldiagnostic-therapeutical congruence is 90%. Average waiting time for users that The percentage of clinicalfailed to schedule an appointment diagnostic-therapeutical to receive medical care does not congruence is 85%. exceed 60 minutes. At least 20% of the staff is familiar with the results of their performance evaluations. Total Number of Questions Human Quality Questions Technical Quality Questions 34 12 22 Quality Surveillance Map Standard: Curative Consultations Level 1 Initial Technical Quality Human Quality STRUCTURE The family practice unit is open daily during two 6 hour shifts. It has radiological and laboratory support at least during 6 hours. Level 2 Intermediate Technical Quality Human Quality There are health care standards and protocols available at least for the 10 most frequently diagnosed diseases at the policlinic. The staff in each family practice examination room is familiar with his/her area of influence, the population pyramid, and health indicators of the population they serve, as well as its epidemiological profile. Level 3 Maturity Technical Quality Human Quality All protocols are updated on a The family practitioner must carry yearly basis in adherence to the out well defined activities which go guidelines of the CNS and the beyond outpatient care, and are epidemiological profile of its area of summarized in an action plan that influence. is submitted to the policlinic's director. W orking hours in the specialist's examination facilities are at least three hours per day. There is a permanent education program in place for the staff in the family practice unit, of which at least 50% is implemented on a regular basis in conjunction with the staff of the family practice unit. W ithout making any calculations, the policlinic can determine the total number of physicians and nurses hours offered, and establish that there is at least one hour of nursing care for each hour of medical care. During a visit to several examination rooms it can be observed that the following items are readily available: medical history forms, evolution forms, prescription forms, complementary tests, referrals and transfers, AVC 09 forms. There is a sufficient qu The staff in each family practice examination room is familiar with its area of influence and its population pyramid. PROCESS A daily user registration sheet is filled out in each examination room, and the records of the previous day may be readily verified. Decision trees (algorithms for diagnosis and treatment) are systematically used at least for ARI, ADD, cholera, TB, STDs and other local epidemiological problems. Physicians perform their duties in adherence to current norms and protocols. The user feels that he/she is actively listened to by the physician during the visit. The records of users who do not comply with their treatment is submitted for consideration by the social work unit. Physicians receive or have received training in active listening techniques such as the Balint method and others. Physicians use simple, clear and adequate language to convey messages to users concerning the nature of their disease and diagnosis, the steps to be followed and the treatment thereof. RESULT The average number of consultations per family practitioner in one hour ranges between 2 and 4. The average time per visit at the family practice unit ranges from 10 to 15 minutes. The average number of consultations at the family practice unit per 100 beneficiaries ranges between 9 and 14. The average number of consultations per family practitioner in one hour ranges between 3 and 4. Total Number of Questions Human Quality Questions Technical Quality Questions 21 8 13 Quality Surveillance Map Standard: Medications Level 1 Initial Technical Quality Human Quality STRUCTURE There is a pharmacy in the facility, Therapeutic forms issued by the which is open 12 hours per day, and CNS are available in examination has its own operation regulations. rooms throughout the facility. Level 2 Intermediate Technical Quality Human Quality The area allocated to the pharmacy is large, well lit and the room temperature and humidity levels are adequate for the storage of medications. Written and graphic procedures (flowcharts) are in place to make it easier for the user to follow the required steps to pick up their medications. Level 3 Maturity Technical Quality Human Quality The policlinic's pharmacy must be managed by a legally accredited professional pharmacist. There is a medication replenishment system in place, and medications are ordered from the central warehouse at least every month. The staff in charge of delivering medications to the users, does it in a cordial and friendly manner. Antiseptics and other medications for external use as well as disinfectants are stored separately from medications for internal use and injectables. There is a monthly schedule of meetings with the purpose of discussing and analyzing the procedures implemented in the pharmacy with the aim of improving them. Verify compliance therewith in the minutes book. Waiting time for the delivery of medications to the user is at least 15 minutes. PROCESS Medications are delivered respecting the "the first in first out" rule. In 10 medical records selected at random from the previous month, it is verified that the instructions and administration of medications prescribed by attending physicians, comply with the norms and there is clinical-diagnostic-therapeutical congruence. The required quantity of medications are stored, and a weekly inventory is kept and supervised by the pharmacy's regent on a monthly basis . In a random sample of 10 medical records from the previous month, 75% of the medications prescribed must be essential and bear a generic name. In a sample of 10 medical records selected at random from the previous month, 100% of the medications prescribed must be essential and bear their generic name. Number of meetings held and agreements entered by the CQI team or teams concerning medications. In a survey of three users, it was determined that they were able to repeat precisely the indications given by the physician and/or pharmacy attendant. RESULT Total Number of Questions Human Quality Questions Technical Quality Questions 17 6 11 Quality Surveillance Map Stan d ar d : Pr even tio n an d Pr o m o tio n L evel 1 In itial Tec h n ic al Qu ality Hu m an Qu ality STRUCTURE The policlinic's staff is familiar with the entire population in its assigned geographic area, by gender and age group, and these data are registered. L evel 2 In ter m ed iate Tec h n ic al Qu ality Hu m an Qu ality There is a map of the geographical area posted in a visible location, which shows schools, health centers, churches, businesses and the population pyramid. There are family folders for the insured population which identify individual or family risks and allow for the adoption of preventive measures. L evel 3 Matu r ity Tec h n ic al Qu ality Hu m an Qu ality The policlinic owns a refrigerator with a thermometer and control log. The vaccines inside it are duly organized and marked. A descriptive emergency plan must be included in case of power failures. There is a schedule of educational presentations and talks on prevention and promotion to be offered at the policlinic. PROCESS Procedures are in place to train the staff concerning cold chain norms and standards. The staff received training in interpersonal communications to offer orientation sessions and educational talks. All promotion and prevention strategies are communicated to the entire staff and a consensus is reached before applying it to the population. A system is in place for house calls carried out by the policlinic's staff members, which are scheduled and monitored by a person in charge. Prevention and promotion activities are carried out in the companies affiliated to the CNS in coordination with the Occupational Medicine unit. The staff is familiar with the most significant environmental hazards. Coverage of the third polio booster among children under the age of 5 who came to the policlinic is between 50% and 70% by the end of the year. Self-help groups are established (social networks and groups) and these are supported and monitored by the policlinic's staff members. Coverage of the measles vaccine ranges between 71% and 85% among children under the age of 2 who came to the policlinic by the end of the year. There is a smoking prohibition throughout the policlinic. Coverage of the third polio booster ranges between 86% and 100% among children under the age of 2 who came to the policlinic by the end of the year. RESUL T The family practitioner who provides care to newborns for the first time, must verify if they received the BCG vaccine. Coverage of the BCG vaccine among children aged 1 and under who came to the policlinic ranges between 71% and 85% by the end of the year. Coverage of the third DPT booster ranges between 86% and 100% in children under the age of 2 who came to the policlinic by the end of the year. Coverage of the measles vaccine among children under the age of 5 who came to the policlinic is between 50% and 70% by the end of the year. Coverage of the third polio booster is between 71% and 85% among children aged 2 and under, who came to the policlinic by the end of the year. Coverage of the measles vaccine ranges between 86% and 100% in children under the age of 2 who came to the policlinic by the end of the year. All the family practice examination rooms implemented children's growth and development control. Coverage of the third DPT booster ranges between 71% and 85% among children under the age of 5 who came to the policlinic by the end of the year. Coverage of the BCG vaccine ranges between 86% and 100% in children under the age of 2 who came to the policlinic by the end of the year. Total Number of Questions Human Quality Questions Technical Quality Questions 25 7 18 Quality Surveillance Map Standard : Sexual and Reproductive Health Level 1 Initial Technical Quality Human Quality STRUCTURE The policlinic has incorporated sexual and reproductive health services as an integral part of its basic health care services. The family practice and the gynecology-obstetrics examination rooms have educational material concerning all the components of this program. Level 2 Intermediate Technical Quality Human Quality The policlinic has estimated its coverage and input needs for sexual and reproductive health activities, including printed and audiovisual educational material. Level 3 Maturity Technical Quality Human Quality The policlinic has an isolated or private area for individual orientation activities. The policlinic has sufficient Educational group talks are quantities of the following inputs scheduled for the policlinic's users. and supplies: Base Perinatal Medical History forms and perinatal cards. Appropriate instruments for the insertion and removal of IUDs and supplies to prevent infections. 50% of the policlinic's medical, nursing and social work staff are trained to carry out sexual and reproductive health activities and they have developed their interpersonal communication skills. The policlinic has health care norms and protocols for the following SRH components: perinatal obstetrics, (Reference Text for SRH), family planning services, surveillance system for cervix-uterine and breast cancer, STDs and prevention of infections. The policlinic has consolidated reports on the coverage of SRH components, these are analyzed and decisions are taken at least every three months to improve their coverage as well as the quality thereof. The staff is familiar with all the components of sexual and reproductive health norms and protocols, and these are applied. When users enter the examination room they are greeted kindly and in a friendly way by the attending physician and/or nurse. The Base Perinatal Medical History (BPMH) is adequately filled out with an error margin of less than 80%, and it can be observed if prenatal controls are completed. At the end of the visit the user is informed about her health conditions and the evolution of her pregnancy in an adequate and comprehensible language. In compliance with the norms, she receives a prescription for iron sulfate. PROCESS Level 1 Initial Technical Quality Human Quality Decontamination norms for used instruments are observed in all examination rooms. The educational material handed Group talks and orientation out for each component is sufficient sessions are offered to the to meet the users' needs. policlinic's users. Level 2 Intermediate Technical Quality Human Quality Level 3 Maturity Technical Quality Human Quality RESULT New users: pills, IUDs, condoms and vaginal ovules. At least 3 users are able to identify two variables related to the correct use of modern contraceptive methods. At least 3 users are able to identify two different symptoms and signs associated to STDs. Percentage of new users of contraceptive pills, IUDs, condoms, vaginal ovules and natural methods, in comparison to the target. Inputs distributed: pills, IUDs, condoms and vaginal ovules. Active users: pills, IUDs, condoms and vaginal ovules. Continuing users: pills, IUDs, condoms and vaginal ovules. At least 3 users are able to identify two different symptoms and signs associated to high risk pregnancies as well as pregnancy alarm. PAP smear coverage among women aged between 25 and 59 years. Inputs distributed: Pills, IUDs, condoms and vaginal ovules. At least three users received orientation about family planning during their post partum or post abortion perinatal control. Prenatal control - Number of new consultations before the 5th month of pregnancy. It must be determined if pregnant women who consult for the first time, have a high risk pregnancy. PAP smear coverage among women aged between 25 and 59 years. Number of new consultations prior to the 5th month of pregnancy. Proportion of pregnant women who had four control visits. Coverage of tetanus toxoid in pregnant women. Prenatal control coverage with four control visits. Coverage of the tetanus toxoid in pregnant women. Total Number of Questions Human Quality Questions Technical Quality Questions 35 10 25 Quality Surveillance Map Standard : Referral and Counter-referral Level 1 Initial Technical Quality Human Quality STRUCTURE Referral and counter-referral norms are available to transfer cases that exceed the policlinic's capacity to other facilities which can handle more complex cases. The policlinic has its own ambulance or vehicle or it hires transport services to transfer patients as required. Level 2 Intermediate Technical Quality Human Quality The policlinic has lists of reference facilities where complementary studies may be carried out as well as the provision of more complex health care services. Their telephone numbers, addresses, working hours and persons in charge are posted in a visible Ambulance use is subject to regulations which are known to the person in charge of this service as well as his(her) immediate superiors. Level 3 Maturity Technical Quality Human Quality At reference hospitals and policlinics, the professional staff involved may participate in scheduled health care activities for users and implement practices based on an integrated health care concept in networks. The policlinic's staff is familiar with the socioeconomic characteristics of its target population as well as the potential demand and the required demand for referrals. The competence of the policlinic is clearly defined, as regards the level of care and complexity of the services it offers. There must be a document detailing all the referrals. A fully operational communications system is in place at the policlinic (telephone, radio or both). PROCESS Verify the list and compliance in at least three cases that required the referral and counter-referral system through the review of a random sample. The referral norm for pregnant women states that the user must take with her the base perinatal medical history. The procedures are clear and There is a follow up mechanism in simple, and at the policlinic there is place for referrals and transfers an officer on a permanent basis and the timeliness and adequacy who authorizes the use of the of the treatment sought by these ambulance for the transportation referrals is evaluated. of patients. There is a procedure and a person in charge of providing information by telephone to the higher level facility concerning emergency transfers at the time the user heads for said facility. The policlinic carries out all the procedures necessary to submit pertinent medical information, medical histories and other material upon the request of the attending physician at the more complex facility. The user receives adequate information, which is stated simply and clearly regarding the reasons for his/her transfer. The counter-referral norm for post partum users must sate that when they go back to the facility they must have their perinatal card. The user is informed that once he(she) has received care elsewhere, he/she must return to the assigned family practice facility. The percentage of transfers to other levels of care or to another specialist in relation to family practice visits ranges between 8% and 10%. RESULT The percentage of transfers to higher levels of care in relation to family practice visits ranges between 4% and 8%. 50% of the referrals go back to the facility with a counter-referral form. Total Number of Questions Human Quality Questions Technical Quality Questions 20 8 12 Quality Surveillance Map Standard : Clinical Laboratory Level 1 Initial Technical Quality Human Quality STRUCTURE There is a clinical laboratory capable of processing all the tests listed in Annex A without delegating them to another laboratory. Level 2 Intermediate Technical Quality Human Quality The policlinic has all the necessary equipment and reagents. There are use and reordering procedures in place. Regular and special methods used to prepare patients and obtain samples are defined in writing and reviewed on a yearly basis, as well as the precautions to be taken, and the identification, storage and preservation of samples. Level 3 Maturity Technical Quality Human Quality The laboratory has a waiting room, an area for administrative activities, clinical tests, and one area where samples are obtained. There is a permanent education program in place for laboratory technicians and professionals, which includes at least quality technical procedures and results, as well as bio-safety principles. The laboratory has technicians or biochemists on duty at least 6 hours per day. There are folders with calibration curves and/or standards for the techniques used at the lab as well as for the respective equipment. In a survey of three users these have received adequate information concerning the procedures to follow to bring samples, as well as food and time requirements. The laboratory processes biochemical tests within 24 hours after obtaining the sample. Users do not require more than 30 minutes to obtain or deliver material for testing. All samples are identified by a bar code. PROCESS The laboratory has all the required material available such as culture media, glassware as well as cleaning materials. The Policlinic has manuals and statistics available for all biochemical procedures. The lab is open to obtain or receive samples 3 hours per day or longer. The lab is open to obtain samples at least 2 hours. Request the person in charge of the laboratory to furnish the latest statistical reports and measures adopted. In a survey of three laboratory users, none spent more than 15 minutes to obtain samples or deliver the material to be tested. RESULT At the Family Practice unit the The laboratory takes less than 48 average number of laboratory tests hours to deliver test results. per person ranges between 2 and 3.5. The percentage of laboratory tests performed in relation to the number of family practice visits ranges between 20% and 35%. At least one continuous quality improvement action is taken every month at the laboratory during a three- month period. The laboratory takes less than 36 hours to deliver test results. A minimum of three continuous quality improvement actions are adopted in the laboratory during a three-month period. The laboratory takes an average of less than 24 hours to deliver test results. At least two continuous quality improvement actions are taken in the laboratory every month during a three-month period. Total Number of Questions Human Quality Questions Technical Quality Questions 25 13 12 Quality Surveillance Map Standard : X Rays Level 1 Initial Technical Quality Human Quality STRUCTURE The X- Ray unit is open at least 6 hours per day and there is a specialized physician and/or laboratory technicians available during working hours. The temperature in the users dressing rooms is adequate. Level 2 Intermediate Technical Quality Human Quality The unit has an area to develop xray films, an area to prepare reports and filing cabinets. Regular and special methods to prepare users for X ray studies are defined in writing and are reviewed on a yearly basis. Level 3 Maturity Technical Quality Human Quality The X- Ray unit has a specialized physician and/or X- ray technicians available during the policlinic's working hours . There is a permanent education program for technicians and/or professional staff at the X-Ray Unit, which includes at least quality technical procedures, results and safety principles. All the staff at the X-ray unit, except the secretaries has a dosimeter to measure radiation and a lead apron as well as basic protection for the staff that most exposed. There is enough film and film processing material available, and the staff is familiar with use and reordering procedures. There is a preventive maintenance system and plan for x-ray equipment. PROCESS The unit has written norms and procedures that regulate its activities. Surveying three users, they have received adequate verbal or written information regarding the preparation for special procedures. The staff of the X-ray unit meets on a regular basis in adherence to a schedule, to analyze and discuss the information available. The X-ray unit takes an average of less than 24 hours to deliver X-ray films and their corresponding reports. Available statistics may be verified as regards all the procedures carried out at the X-ray unit. The CQI team or teams meet on a regular basis to adopt measures for the X-ray unit. RESULT The average number of X-ray diagnostic procedures per person required by the family practice unit ranges between 1 and 1.5. In a survey of three users who had an appointment, waiting time to obtain their X-rays was not longer than 15 minutes. The percentage of x-ray diagnostic procedures in relation to family practice visits ranges between 5 and 9%. The X-ray unit adopted at least two continuous quality improvement actions during the last semester. Total Number of Questions Human Quality Questions Technical Quality Questions 19 7 12 Quality Surveillance Map Standard : Nursing Level 1 Initial Technical Quality Human Quality STRUCTURE The policlinic assigned an area or office to the head nurse. The nursing staff is familiar with the shifts, working hours and other administrative aspects as well as professional standards in effect at the policlinic. Level 2 Intermediate Technical Quality Human Quality All medical records in the nursing unit are systematically and carefully filed, registered, kept and organized. These are considered a legal instrument. There are written nursing policies and procedures concerning health care and education for users and staff members which include: Confidentiality of information, the functions of the nursing staff in the area of education. Level 3 Maturity Technical Quality Human Quality There is a motivation and incentive There is a permanent educational system in place for the policlinic's development program for the nursing staff implemented through nursing staff. instruments such as: congratulations memoranda, attendance to events, promotions. PROCESS Verify if the head nurse was appointed to her(his) post based on a merits contest and whether she(he) has the respective titles to fully accredit her(his) professional expertise. The head nurse keeps updated records of the staff under her supervision. The nursing staff has organized working groups to support the staff's human and professional development (these can be informal talks). The nursing staff meets as often as necessary, but no fewer than 6 times a year, to identify problems in this area. There must be records of the documentation, recommendations and proposed actions. Verify if written performance evaluations are carried out periodically and if the staff's activities are monitored at least once a year. The head nurse in conjunction with the nursing staff have elaborated an educational program for patients which is implemented on a regular basis (see minutes of the meetings). Verify through consultation with three nurses about their awareness concerning the policlinic's goals, projects and achievements. At least four talks are offered to the users every month by the nursing aids. The nursing aid and/or nurse assigned to each examination room take the users' vital signs . There must be a nursing manual or a document on nursing procedures which should include: the assignment of duties and nursing care responsibilities to the policlinic's staff. At least six meetings are held by The number of lost medical records At least nine meetings are held by the CQI team or teams every year must be 0% at the family practice the CQI teams every year to deal concerning nursing-related matters. unit during the month. with nursing topics. CQI teams hold at least twelve meetings per year on nursing matters. RESULT The number of lost medical records is below 1% at the family practice unit during the month. Total Number of Questions Human Quality Questions Technical Quality Questions 21 10 11 Quality Surveillance Map Standard : Social Work Level 1 Initial Technical Quality Human Quality STRUCTURE There is at least one social worker at the policlinic and appropriate facilities to carry out his/her duties. Level 2 Intermediate Technical Quality Human Quality Services are offered to users in morning and afternoon shifts. Level 3 Maturity Technical Quality Human Quality The policlinic has a private room available, which is adequate for interviews and meetings guaranteeing the users' privacy and intimacy. Social workers make regular house The functions manual must clearly calls to the affiliates supporting the specify that a social and evolution work of the family practice unit. card must be completed to follow up those cases that require treatment. There is a written functions Manual available to carry out Social Work tasks. There are statistics of social work activities, and these are analyzed within the group and with the director. There are work plans and Social Work activities are organized by the unit, including support to the policlinic's workers and the staff is familiar with these activities. PROCESS Norms are updated and the rest of the health team is familiar with them. It is possible to check the users' socioeconomic reports. It is possible to verify the There are social statistics for the participation of the Social Work unit policlinic's area of influence. in the meetings held by the health team and/or CQI teams . A social history is attached to the medical history prepared in the examination rooms, and it is periodically updated. The staff of the Social Work unit carries out socio-sanitary research with the policlinic's assigned population, which allows them to learn more about their activities, habits and practices (at least one every year). It is possible to verify at least one socio-cultural research in one year, whose recommendations are applied. RESULT At least two house calls are made every month, which may be verified in the unit's records, and there are specific reports concerning said visits. It is possible to identify at least two users per month who returned for treatment as a result of the work performed by the Social Work staff. It is possible to identify at least two group activities carried out with the user(s) and or family members per month. The year's statistics show an improvement in the quantity and quality of social work care in comparison to the previous semester or year. Total Number of Questions Human Quality Questions Technical Quality Questions 19 9 10 Quality Surveillance Map Standard : Eligibility and Admission Level 1 Initial Technical Quality Human Quality STRUCTURE There is a procedures manual available for the activities of the Eligibility unit and the entire staff is familiar with it. Level 2 Intermediate Technical Quality Human Quality Verify the existence of a list of health professionals posted in a visible place inside the facility. Level 3 Maturity Technical Quality Human Quality The Eligibility section depends from There is visible information at the the Policlinic's Director and this Eligibility unit which clearly states function is fully exercised. that no medical records are ever lost in the policlinic, and the can file a complaint if this occurs. Verify the existence of a map of the area. Verify the existence of current records of companies that failed to pay their dues during the last three months. Verify the existence of a report of the total population's affiliation and registration by examination room corresponding to the last three months. Verify the adequate filing of AVC 04 forms according to the respective insurance number and whether these were assigned to a specific examination room. PROCESS The entire staff at the Eligibility Unit There is a procedure in place to received instructions with respect open new medical histories for new to the way they should treat users. users. The CQI team or teams hold There is a computerized system meetings to solve the problems that that handles the information arise at the Eligibility Unit. corresponding to the different processes involved at the Eligibility unit. Verify if there is a procedure in The staff has standards of care for place to guarantee the screening of users which emphasize friendly files and medical histories. manners when furnishing information concerning documents and requirements to receive care. All the procedures followed at the Eligibility unit are shown graphically (flowchart), as well as possible alternative routes and a description of the factors implied. RESULT In a random sample of 10 medical records the number of medical histories corresponds to the number registered on form AVC 04. In a survey of three users, verify if any of them experienced difficulties at the Eligibility Unit and if the waiting time was adequate, less than 15 minutes. At the Eligibility Unit the users' complaint rate does not exceed 5%. The staff at the Eligibility Unit is familiar with all the procedures carried out at the office. 100% of the admissions staff knows 100% of the procedures steps. The staff of the Eligibility unit has not been changed during the last 6 months. At the Eligibility unit the user complaints do not exceed 3%. Total Number of Questions Human Quality Questions Technical Quality Questions 22 8 14 Quality Surveillance Map Standard : Dentistry Level 1 Initial Technical Quality Human Quality The user may receive care from a professional dentist using a fully equipped and fixed dental chair that is completely operational, and has sufficient instruments and inputs to provide at least basic dental care and oral health services during 6 hours. The dentist carries out his/her activities wearing a uniform and protective gear which must include at least an apron, a mouthpiece and rubber gloves. Level 2 Intermediate Technical Quality Human Quality Level 3 Maturity Technical Quality Human Quality At the policlinic the dentistry equipment is outfitted with a silent compressor. PROCESS In the dentist's office there are: cloth towels, paper towels or disposable paper napkins for the users. At the dentist's office there is a sink It is possible to carry parawith hot and cold water taps. odonthological activities with natural light. Educational talks are offered at least once a month concerning oral health. At the dentist's office there are educational materials such as posters, tooth brushes and dental structure (macro-model). The dentist's office has a fully operational X-ray equipment as well as an additional system or equipment to process and develop the film, and a lead apron for the person in charge of taking X-rays. The dentist's office has a heater, or heating system or another system to keep the room temperature at adequate levels. PROCESS In a review of 10 medical records, all of them record dental treatments in the respective dental care cards. The policlinic has implemented an appointment system at the dentistry unit. Preventive maintenance of dental equipment is carried out once every three months. The dental assistant or office aid carries out preventive educational activities at least with five users during the week. After reviewing the medical records of three pregnant users, it can be verified that the procedures established in treatment protocols for pregnant or post partum women have been followed. The dental care unit has scheduled and is currently executing some type of research, survey or work approved by the policlinic's Director. At the dental office, the dentist treats users kindly and welcomes them with an initial greeting and after treating them he(she) bids them a courteous farewell. Care is provided in a coordinated fashion and based on protocols in the areas of dental surgery, extractions and emergencies, dentomaxillary surgery, radiology, pediatric dentistry, preventive dental care and periodontal care. The rate of compliance with previously scheduled appointments at the dentistry unit is 75%. The user is allowed to come with another person when required, and there must be a chair or armchair available for this person. The dentistry unit has an educational program on oral health and hygienic habits, which is currently being executed with the assigned population. It is implemented on a regular basis. RESULT The average number of patients seen by each dentist in one hour ranges between 1.5 and 2.5. The dentistry unit has more than five written dental care protocols corresponding to the most frequently diagnosed problems, as well as order forms for drugs, medications and other dental materials. Coordination activities are programmed between the dentistry unit and the following units: maternal-child care, CQI teams, traumatology and health education and research. Community-based educational activities are carried out. The average number of patients Fillings are completed in three seen by each dentist during one visits for adults and five sessions hour ranges between 2.6 and 4. for children. At the policlinic the ratio between fillings and extractions is 2 to 1. The conclusions of the CQI teams are applied to oral health. Two or more fillings are carried out for each extraction performed at the policlinic. At the policlinic three or more fillings are carried out for each extraction. The percentage of compliance with previously scheduled appointments in the dentistry unit is 85%. Total Number of Questions Human Quality Questions Technical Quality Questions 31 15 16