11.23 Ringers lactate 1L 1 0 11.23.1 Min stock = 5L; MAC applies only when higher than 5L 11.24 Dextrose 5% 1L 1 0 11.24.1 Min stock = 5L; MAC applies only when higher than 5L 11.25 IV colloids 500 ml 1 0 11.25.1 Min stock = 5 bags; MAC applies only when higher than 5 bags 11.26 Syringe 5ml 1 0 11.27 Syringe 10ml 1 0 11.28 Needle 18G 1 0 11.29 Needle 22G 1 0 11.30 ITN 1 0 Total Points (30) ../30 xxxx Remarks 12 Maternity [max 21 points] YES NO 12.1 Sufficient water with soap in delivery room 1 0 12.1.1 A functioning water source or at the least 20L 12.2 Light in delivery room 24 hours 1 0 12.2.1 Electricity, solar light or rechargeable battery lamp or kerosene lamp filled with kerosene 12.3 Waste from Maternity correctly handled 1 0 12.3.1 Bin with lid and safe needle disposal container, specific for the maternity room use only 12.4 Delivery room is well-maintained 12.4.1 Walls with durable materials and painted 1 0 12.4.2 Curtain between delivery bed and door 1 0 12.4.3 Delivery room smells of disinfectant 1 0 12.4.4 Floor level cement, without fissures and ceiling not damaged 1 0 12.4.5 Windows with curtains and functional door 1 0 12.5 Availability and use of the Partogram 1 0
15.2.2 Sterilizer in separate room from theater 15.2.3 Use of chemical heat indicators 15.2.4 Register for sterilizations used and completely filled 15.3 Minor surgery done in a separate room from the major surgical procedures 1 15.4 Functioning theater lamp 1 15.5 Functioning theater table 1 15.6 Preparedness 15.6.1 At the least one sterilized major surgery set available, with date of sterilization indicated on the pack 2 15.6.2 At the least one sterilized CS set available, with date of sterilization indicated on the pack 2 15.6.3 At the least 4 L of Ringers Lactate available in the theater 0.5 15.6.4 At the least 2 bags of Colloids available in the theater 0.5 15.6.5 Theater smells of disinfectant, and cleaning schedule is available 1 15.6.6 Nursing/technical Staff trained in anesthesia is presently on duty (at the least ketamine or spinal) 2 15.6.7 Nursing Staff trained in theater procedures presently on duty 2 15.6.8 Qualified Medical Doctor with experience doing CS presently on duty 5 Total Points (40) ../40 xxxx Remarks No Service Max P % 1 General Management 21 2 Business Plan 13 3 Finance 15 4 Indigent Committee 7 5 Hygiene & Med Waste Disp 32 6 OPD 27 7 Family Planning 21 8 Laboratory 10
9 Inpatient Wards 46 10 Essential Drugs Management 20 11 Tracer Drugs 42 12 Maternity 21 13 ANC 12 14 HIV/TB 10 15 Surgery 40 Total 337 Name Team leader Evaluation: Name Director GH: Date: Final Score: Annex 10: Monthly Health Facility Invoice HEALTH CENTER Monthly Provisory Invoice for MPA Services LGA: Month: Health Center: Year: Service Quantity Produced Unit Fee [In contract] Naira 1 New outpatient consultation 2 New outpatient consultation for an indigent patient 3 Minor Surgery 4 Referred patient arrived at the Cottage Hospital
Present the following quarterly consolidated PBF invoice for [Name] LGA, [Name] State, for the month of July [Year], for the sum total of twenty six million, two hundred forty seven thousand and five hundred forty six Naira (26,247,546); Invoice established in one original copy, of which a copy is kept at [Name] LGA PHC department, and the other at the [Name] SPHCDA Signed: ..................................., the....../......................../ Year Prepared by the Chairman of the LGA RBF Steering Ctee: Signed by the SPHCDA rep: Last name, first name: Last name, first name: Signature: Signature: Annex 12: Performance Framework for the LGA PHC department No Indicator/Performance Measure Primary/Secondary Data Sources Composite Criteria/Validation Criteria Weight 1 50% of Health Centers have been supervised at least once per quarter Supervision Report Travel Request Form approved and signed Travel form co-signed by the Head of visited facilities Supervision Report Exists and is readily available at LGA/PHC dept. At least 50% of all Health Centers have been supervised during the past quarter, and these should not include those Health Centers which have been supervised in the quarter preceding the evaluated quarter These supervisory visits are the formative visits and are not the same as the Quantity or Quality Audit visits. The reports should indicate the dates of visits and, at the least, summarize the findings/interventions of each 15
Annex 13: Business Plan for Health Centers PBF-Business Plan for Health Centers Version 28 October, 2011 Analysis of results Month 1 – Month 3 [Year] & plan for Months 4 – 6 [Year] GENERAL INFORMATION LGA……… Health center……………… Population [Year]: ……… Are there sub-contracted private clinics or health posts? Yes / no If yes, which? ………………… Qualified staff: ….. Non qualified staff: …. HEALTH CENTRE STATISTICS [Years] Months OPD Visits New cases Hospital bed days Assisted deliveries in health facility Nr of women using FP (new + re-attendants) oral (3 months) & Injectables Nr ANC visits (new) Nr ANC visits (standard visits) EXTERNAL CONSULTATIONS What is the monthly target for OPD consultations in your Ward: ...……………
Annex 15: Individual Performance Evaluation Template Individual Performance Evaluation for Health Staff Criteria 25% Score 50% Score 100% Score Max Score 1 Professional Awareness includes the following: (20 points) Timeliness Arrived frequently late (at the least four times past month) Arrived sometimes late (1 to 3 times per month) Was always on time 8 Availability Has been frequently absent from his/her service without any clear motive (at the least four times past month) Has been a few times absent from his service without clear motive (1 to 3 times per month) Was never absent from his/her service without known and valid motive 8 Uniform Did not wear a uniform during working hours (even once per month) Neglected uniform (dirty or torn or not ironed) Uniform always worn and proper (washed ; ironed and not torn) 4 2 Team spirit includes the following: (30 points) Interpersonal Relationship Frequently in conflict with colleagues (reported more than once to his/her superior during the past month) Sometimes in conflict with colleagues (reported once to his/her superior) Never in conflict with colleagues 8 Collaborative spirit Frequently refused to assist colleagues when asked Sometimes refused to assist colleagues Never refused to assist colleagues 8
(more than once per month) (even once) Dedication Frequently left work unfinished without somebody taking over under the argument that official working hours were up (more than 3 times past month) Sometimes left work unfinished without somebody taking over using the argument that official working hours were up (1 to 3 times per month) Never left work unfinished without somebody taking over 8 Initiative Has never done any additional work Has always awaited a command from higher up to carry out additional work Has at least once done additional work without supervisor asking him/her to do so 6 3 Technical Competency and flexibility during work: (40 points) Organization Never has a daily work schedule (assessed during internal work supervision) Not always has a daily work schedule (at least once during internal supervision) Always has a daily work schedule 10 Quality of work Never adheres to specific work related norms and standards (assessed during internal supervision) Not always adheres to work related norms and standards (found at least once during internal supervision) Always adheres to specific work related norms and standards 14
Quantity of work Never finishes his/her daily work based on his/her own daily work schedule (assessed during internal supervision) Not always finishes his/her work based on his/her own daily work schedule (found at least once during internal supervision) Always finishes his/her work according to his/her daily work schedule 16 4 Willingness and aptitude for personal development : (10 points) Takes into account advice and from previous internal and external supervisory visits Never takes care of such recommendations (concluded during internal and external supervisory visits) Not always takes care of such recommendations (if this happens once or more) Always takes into account recommendations of internal and external supervisory visits 10 TOTAL POINTS 100 5 Participation to Results and the Past Monthly Performance Score Participation to Results and the past monthly performance score (quantity and quality) through presence during working days during the past three months : NB: We take into account actual working days without taking into account any valid reasons for absence such as vacation, leave, sickness, absence through disciplinary action, Number of official working days = (N); number of days actually worked = (n); 100% P =
Annex 16: Column Headers for PBF Registers [Available as a separate draft document: not yet inserted as it is being finalized] Annex 17: Terms of Reference for the Health Center Health Committee/General Hospital Governing Board Health Center: Health Center RBF Committee SMOH/SPHCDA Version 111010 The Health Center RBF Committee has a strong link to the Ward Development Committee (WDC). Whereas the WDC has been created to oversee all health facilities at the Ward level, the Health Center RBF Committee, is put in place to function as the governing board of the contracted RBF facility. The General Hospital RBF Committee will function as the governing board for the general hospital. Membership of the Health Center RBF Committee: The Chair (who is the chairperson of the WDC) or his or her designate; elect members of the WDC; Officer in charge of the health center (non-voting member); One technical staff of the health center (non-voting member); Headmaster of the school. Functions of the Health Center RBF Committee: Discuss the quarterly quantity and quality performance of the Health Center and advice the Health Center management in areas of possible improvements; Ensure that the health center management can operate with a reasonable level of autonomy to reach the objectives agreed upon in the business plan; Appoint the Indigent committee of the Health Center among its members, and select community representatives;