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SECONDARY HEALTH FACILITY ASSESS

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					SECONDARY HEALTH FACILITY ASSESSMENT FORM (DRAFT)
1. GENERAL INFORMATION
Date of assessment (d/m/y) Facility name Ownership (public, private, for- and notfor-profit) Type (RHC/ GH/ Other) Interviewer name Respondent name Respondent job title Respondent contact information (telephone, fax, email, other) Original building In-patient

HOSPITAL FORM

Type of structure

Pre-fabricated Unit New permanent building Other (specify)

No of beds

Emergency Maternity Delivery

Room Available OPD MCH/EPI Lab Pharmacy Male 4-beds ward Female 4-beds ward Operation theater Patient load

Yes/No

Room Available Delivery room with 2 beds X-Ray room Reception and waiting areas Laundry Kitchen Female staff residence Male staff residence

Yes/No

Out-patients, previous month In-patients, previous month

Main Referral facility Number of Ambulances Reporting to DEWS

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2. EQUIPMENT GYN/OBS Instruments Normal Delivery set D&C set E&C set Vacuum suction apparatus Baby resuscitation apparatus Baby weighing scale Adult weighing scale Electric suction machine Electric sterilizer 3. EQUIPMENT EMERGENCY # Available # Functional Comments

Instruments

# Available

# Functional

Comments

Electric sterilizer Operation light Oxygen cylinder Ambu bad (pediatric) Ambu Bag (adult) Suction machine heavy duty Laryngoscope Stretchers Wheelchairs

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4. EQUIPMENT OPEARTION THEATER Equipment Hydraulic Operation table Shadow less lamps with 9 illuminators Megills Forceps Patients trolley Oxygen cylinder large with regulator Oxygen cylinder medium with regulator Trolley instruments SS Dressing drums large size Stand for dressing Basin S S Basin stands Towel clips BP handle BP blades Dissecting Forceps Plane Needle holder Large Sponge holding forceps large Stand for drip Bucket El Aircushion rubber Hot water bottles # functional Equipment Stomach tube Small skin retractor Metallic catheter 1-12 Dilator complete set Scissors surgical various sizes Nose speculum Proctoscope Themes Splint VS Rubber sheet Scalpels 6” Allies Forceps Long Allies Forceps 6” Cheatle Sterilized forceps 10” Arm splints different sizes Instruments cabinet Spot light Nail brush Thermometer Kidney tray S.S Urine collection bags # functional

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5. HUMAN RESUORCES Staff cadre Senior Medical Officer Woman Medical officer Lady health Visitor EPI technician/vaccinator Lab technician Malaria supervisor TB supervisor Nurse Drug dispenser/medical technician X-Ray technician Operation technician Driver Support staff Mental Health Personnel 1. Psychiatrist 2. Psychologist 3. Social worker/ Social Welfare Officer 4. Occupational Therapist Posted Available/ present Comments

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6. SERIVCES PROVIDED Service Activities Ante-natal care Delivery care MCH Post partum care Family Planning Care of new born Immunization Child Survival IMCI Micro-nutrient supplementation Nutrition Growth monitoring Feeding assessment DOTS Communicable disease control Malaria control Other (specify) Integration with PHC Mental Health Identification/management and referral CVS Yes and/or Refer Non-communicable disease (Yes and/or Refer) Selective outreach services (specify) M&E of health workers Diabetes Mellitus Chronic Respiratory illness Provision Y/N Comments

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PHYSICIAN SATISFACTION

PHYSICIAN FORM

Please grade according to the scale given where 1=extreme dissatisfaction and 7= extreme satisfaction 1 2 3 4 5 6 7 1 Satisfaction with physical working condition 2 Satisfaction with freedom to choose own method of working 3 Satisfaction with your colleagues and fellow workers 4 Satisfaction with recognition you get for good work 5 Satisfaction with the amount of responsibility you are given 6 Satisfaction with your remuneration 7 Satisfaction with your opportunities to use your abilities 8 Satisfaction with your hours of work 9 Satisfaction with amount of variety in your job 10 Overall satisfaction with your job

What is your opinion is the best thing about your job? ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ What is your opinion is the worst thing about your job? ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ How in your opinion can health services be made more efficient and effective in Pakistan? ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Any other comments: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________

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CLIENT SATISFACTION

CLIENT FORM

Strongly disagree

Disagree

Unsure

Agree

Strongly agree

It takes more than 30 minutes to get to the hospital It costs more than Rs.50 to get to the hospital The hospital is in good condition The hospital is clean The OPD hours are convenient The toilets are dirty I had to wait a long time to see a doctor There was a bench to sit while I waited The person who gave me a ticket was helpful The person who saw me was polite The person who treated me listened to my problems I was pleased the way I was treated at the hospital The person who treated me explained to me what was wrong with me I received free drugs I did not have to wait a long time to receive my drugs Next time I will come back here For clients who have spent at least one night in the hospital: The ward was clean The bedding was clean The food was good It was not cold Visiting hours were not long enough The staff at the hospital answered all my questions I was bored at the hospital There was always someone at night to help me I did not feel safe at night I could avail the ambulance to get home If my friends are sick I will tell them to come to this hospital

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