Accreditation Manual 2nd Edition

NATIONAL HOSPITAL INSURANCE FUND
ACCREDITATION MANUAL FOR HEALTH FACILITIES 2ND EDITION - 2007
NHIF ACCREDITATION MANUAL 2ND EDITION
FORWARD This is the second edition of the NHIF accreditation manual for Kenya Hospitals. The development of this manual was a collaborative effort of representatives from all health sectors, including the Ministry of Health, University of Nairobi Medical School, the Kenya Medical Association, and the Private Hospitals. The manual is based on the Kenyas Ministry of Health minimum standards as spelt out in the Norms and Standards for Health Service Delivery (2006), The Standards Benefit Package & The Kenya Essential Package for Health (KEPH). Although this manual is specific to Kenya, the contents therein have been compared to International Standards and found to meet basic intent of most international standards that apply to Kenyan laws, Public Health Act, and the National Hospital Insurance Fund (NHIF) regulations, vision and mission. It is expected that this manual will be a catalyst for change and improvement in both the culture and practice of health care in all NHIF accredited hospitals and guide in the implementation of the Kenya Essential Package for Health services appropriate for every tier level of facilities. NHIF was established in 1965 by an Act of Parliament as a Department in the Ministry of Health. The main objective was to help in financing health care for those in formal employment. In 1998, by another Act of Parliament, it became a parastatal in the Ministry of Health. Today, NHIF is the biggest and the oldest social health insurance institution in Africa, supporting the financing of healthcare to both those in formal and informal employment. This manual, therefore, aims at enhancing NHIFs ability to define objectively the system and scope of awarding rebates, and encouraging Quality Improvement of healthcare services in hospitals. It is designed to help Health Providers be aware of Standards expected of them by NHIF as an accrediting institution and Standards set by Ministry of Health. This shall help in assuring that the quality of health services accessed by contributors is acceptable. Through this manual, NHIF now has an objective quantitative tool for accurately awarding rebates and assuring her members of quality health care provision. As an accreditation tool, this manual shall be used to accredit health facilities every two (2) years.
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ACKNOWLEDGEMENTS
We wish to appreciate the following persons for their active participation in the conceptualization, development and authoring of this manual: 1. The Board of NHIF, for providing leadership and direction towards development this manual. 2. The Chief Executive NHIF-Mr. Richard Kerich, for his support and leadership. 3. Dr. Stephen Ochiel Chairman Kenya Medical Association. 4. Dr. George J. Midiwo, General Manager, Standards and Quality Assurance Department. 5. Mr. Martin Ngari, Manager, Accreditation and Contracting, Quality Assurance Department. 6. Dr. James Njoroge, Manager, Standards and Quality Assurance, NHIF. 7. Mrs. Judith Karimi Otele, Standards and Quality Assurance Officer , NHIF Headquarters. 8. Ms. Naomi Choge, Standards and Quality Assurance Officer, NHIF Headquarters. 9. Mr. Joseph Githinji, Standards and Quality Assurance Officer, NHIF Headquarters. 10. Mr. Erastus Masinde, Standards and Quality Assurance Officer, NHIF Headquarters. 11. Mrs. Julia Ouko, Standards and Quality Assurance Officer, NHIF Headquarters
Special gratitude to Dr. Stephen Ochiel, Chairman, Kenya Medical Association for his valuable suggestions and input towards development of this manual.
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USERS GUIDE 1. The Area Manager is the overall in-charge of this exercise and should notify the Health Facility In-Charge on the intent of NHIF staff to visit the facility for assessment two weeks in advance , using the NHIF accreditation notification form and alongside, avail a clean Accreditation manual to the health facility. 2. The Quality Assurance Officer is the technical in-charge and the team leader to the exercise. 3. On the day of the assessment, the team shall present itself to the facilitys In-Charge. Introduce themselves and explain to him/her the objectives of their visit and request for a hospital staff to be assigned to them during the accreditation exercise. 4. They must at all times wear their clinical white coat and a well-displayed NHIF identification badge. They should observe professionalism throughout the assessment exercise. 5. The assessment scores will be based on all or none principle. For example, for secure fence with a gate the score can only be 3 for YES or 0 for NO fence, fence with a missing gate, etc. Note that there are no intermediate scores. 6. Scores awarded to the facility are confidential and must not be disclosed to the health facility by the team. The NHIF Board of Management shall convey results of the assessment to the facility. 7. Ensure you put your remarks about your observations in the remarks column and share these with the hospital representative/management. These remarks are also useful for our reference. 8. Ensure you use a separate assessment manual for each health facility. 9. The hospital representative accompanying you MUST sign the accreditation manual alongside you, upon completion of the exercise. 10. Upon completion, the accreditation manual must be signed, stamped, sealed in envelop marked confidential and forwarded to the General Manager, Standards and Quality Assurance Department through the respective Area Manager. 11. The accreditation assessment MUST be carried out by at LEAST THREE NHIF staff. 12. The NHIF management Board reserves the right to order for a reassessment of the facility, and the right to accredit or deny accreditation to a health facility. 13. Note that all pages must be officially stamped using the hospital stamp.
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LAYOUT OF THE MANUAL

This manual has been designed to include levels of care as outlined in the Kenya Essential Package for Health. For each level of care mandatory services have been spelt out viz a viz the other convenient services. NHIF is currently accrediting hospitals from level III and above. The levels of care as spelt out in the Kenya Essential Health Package are as shown below: o LEVEL I Private Single Practice Clinics. o LEVEL IIDispensaries. o LEVEL III...Health Centers, Small Nursing Homes & Private Facilities. o LEVEL IVDistrict Hospitals, Medium Sized Private & Medium Sized Faith based Facilities. o LEVEL V.Provincial Hospitals & Big Private & Faith based Facilities with all Specialists (Paediatricians, Surgeons, Physicians, Gynaecologists, Anaesthetists, etc) o LEVEL VI. National Teaching & Referral Hospitals. Note that the entire manual gives a total score of a level VI facility, while levels III, IV and V have the applicable areas clearly stated. At the end of each dimension please state clearly the marks scored by the facility at the appropriate column. Ensure that the sub-totals scores combined tally with the grand total stated at end of the manual tallies.
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TABLE OF CONTENTS
FORWARD.. 2 ACKNOWLEDGEMENTS..3 USERS GUIDE....4 LAYOUT OF MANUAL. 5 HOSPITALS PARTICULARS7 PHYSICAL INFRASTRUCTURE...8 EXAMINATION/CONSULTATION ROOM.....10 EMERGENCY ROOM.11 LABORATORY SERVICES. ..12 RADIOLOGY....14 PHARMACY.....17 FOOD & NUTRITION......25 THEATRE SERVICES..... 26 PHYSIOTHERAPY.. 28 OCCUPATIONAL THERAPY.29 ORTHOPAEDICS.29 STERILE PREPARATION UNIT....30 INTENSIVE CARE UNIT30 LABOUR WARD..............30 HUMAN RESOURCE......... 32 WARDS.... 41 GOOD HOUSE KEEPING... 42 MOURTUARY...43 OTHER SERVICES...44 RECORDS......... 45 FUNCTIONAL COMMITTEES....... 45 HOSPITALS IN DISADVANTAGED REGIONS .. 46 MEDICAL TRAINING INSTITUTIONS....... 47 ENGRAVEMENT OF HOSPITAL EQUIPMENTS. .. 47 USE OF ICT.. 47 TABULATION OF POINTS.47 CERTIFICATION OF ASSESMENT...48 REFERENCE LIST...49
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NATIONAL HOSPITAL INSURANCE FUND (NHIF)
ACCREDITATION ASSESSMENT MANUAL (Criteria for Assessing and Grading of Health or Hospital Care Providers for the Approval of Benefits Package Standards) NAME OF INSTITUTION:.. P.O.BOX . E-MAIL .. TEL.NO PROVINCE:....
DISTRICT:...
LICENSED BY REGISTRAR M.P & D.B. /DMS TO OPERATE AS:....
TYPE/CATEGORY:..(I.E. MISSION, GOK, PRIVATE, COMMUNITY)
WHEN THE HOSPITAL STARTED:...
BED CAPACITY:COTS:..
NUMBER OF FULL-TIME STAFF: NO. OF STAFF ON LOCUM:
NEAREST NHIF OFFICE:.
HOSPITAL ASSESED AT LEVEL: ..
STATE WHETHER NEW OR RE-ACCREDITATION:
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N.H.I.F ACCREDITATION STANDARDS
POINTS AWARDED POINTS (MAXIMUM OR ZERO)
REMARKS
1.0 PHYSICAL INFRASTRUCTURE.

1.1 ENVIRONMENT. *APPLICABLE FOR ALL LEVELS. i. Secure perimeter fence with a secure gate. ii. Well kept and clean compound. iii. a). Treated sewage is discharged into an approved public sewerage system, where a system is available, OR b). Sewage is collected, treated, and disposed off in an independent system that complies with appropriate laws and rules. iv. At least placenta pit is available where applicable. v. The health facility has a functional incinerator. vi. Waste is segregated into non-clinical and clinical refuse. vii. Clinical waste is labeled and can be traced back to its point of origin. viii. Clinical waste is kept in designated areas in lockable containers while awaiting disposal. ix. Availability of a composite pit. x. Availability of sharps disposal facilities/ safety boxes. xi. Presence of 5-10 flushable toilets. xii. At least 1-4 pit latrines. xiii. At least1- 4 stores. xiv. Consultation rooms 1 to 6. xv. Staff housing or available transport means for staff working late night shifts or those summoned for emergency cases. xvi. 1 Minor theatre at outpatient. xvii.1Waiting room with provision for health education. xviii At least one registration room. xix. 1Cash office. xx. 1 Records room. xxi. 1 Injection/ Treatment room.
3 3
3 3 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
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N.H.I.F ACCREDITATION STANDARDS
POINTS AWARDED POINTS (MAXIMUM OR ZERO)
REMARKS
APPLICABLE TO LEVEL IV UPWARD. xxii. 1 Plaster room. xxiii. 1 Dental unit room. xxiv. 1 ENT Services room. xxv. Administration unit. xxvi. Ablution block where applicable. xxvii. Medical Engineering Unit. xxviii. Composite pit for non-clinical waste. 1.2 BUILDING. APPLICABLE TO ALL LEVELS. i. Design approved to be a health facility by public works. ii. Facility approved to operate by Public Health Authority or another body like the National Environment Management Board. iii. Clean and well painted walls, with washable paint on the inside. iii. Floors are even/leveled and easy to clean with antiseptics. iv. Rooms are well ventilated allowing adequate natural light. v. Corridors are wide enough and well lit, allowing free movement. vi. Serviced fire fighting equipment is in place in every unit. 1.3 WATER SUPPLY. *APPLICABLE TO ALL LEVELS. i. Reliable source of water. ii Running water at point of use. iii. Water treatment system in place for alternative sources. iv. Facility has water storage facilities/reservoirs in place. 1.4 POWER SOURCE. *APPLICABLE TO ALL LEVELS. i. Electricity (connection to National Grid).
1 1 1 1 1 1 1
5 2
2 3 3 3 3
3 3 2 2
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NHIF ACCREDITATION STANDARDS ii. Generator or solar. 1.5 RELIABLE EMERGENCY COMMUNICATION CHANNELS. *APPLICABLE FOR ALL LEVELS. Landline; Mobile; Radio call; pager e.t.c.
POINTS AWARDED POINTS (MAX OR ZERO) 3
REMARKS
SUBTOTAL FOR LEVEL III. SUBTOTAL FOR LEVEL IV. SUBTOTAL FOR LEVEL V. SUBTOTAL FOR LEVEL VI.
73 80 80 80
2.0 EXAMINATION/CONSULTATION ROOMS. *APPLICABLE FOR ALL LEVELS. 2.1 QUALITY ASSURANCE IN EXAMINATION/CONSULTATION. a. The facility has clear guidelines for admitting patients. b. The health facility has clear guidelines regarding patients they cannot admit. 2.2 EQUIPMENT IN CONSULTATION ROOM. i. Examination coach/bed with a screen. ii. Thermometer. iii. BP machine with a stethoscope. iv. Gloves. v. Diagnostic set. vi. Availability of consultation rooms: a. LEVEL III.1 to 2 rooms. b. LEVEL IV.3 to 4 rooms. c. LEVEL V..5 to 6 rooms. d. LEVEL VI 6 and above. vii. Sink with running water and soap/antiseptic. viii. Clean and sterile swabs with antiseptic. ix. Examination light. x. Drip stand. xi. Relevant furniture.
2 2
1 1 1 1 1
1 1 1 1 1 15 15 15 15 JUNE 2007
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NHIF ACCREDITATION STANDARDS
POINTS AWARDED POINTS (MAX OR ZERO)
REMARKS
3.0 EMERGENCY ROOM. *APPLICABLE TO LEVEL IV UPWARD. 3.1 QUALITY ASSURANCE IN EMERGENCY ROOM. 1. There are clear guidelines to identify patients with emergency or immediate needs. 2. There is evidence of staff trained in emergency care. 3.2 RESCUSITATION ROOM. i. Suction machine. ii. Stretcher/wheelchair. iii. Adjustable bed. iv. Ambu bags/masks. v. Oxygen cylinder with oxygen or link to main oxygen line. vi. Daily updated emergency tray. vii. Defibrillator. viii. Emergency theatre annex or quick access to main facility theatre. ix. Well illustrated guidelines on how to handle various medical/surgical emergencies. x. Stocks consumables and protective gear (Gloves, sutures, sterile kits, dust coats, safety boots). xi. Air ways. xii. Equipment for performing emergency tracheostomy. 3.3 EMERGENCY STAFF. (As per the triage in emergency situation.) i. Trained Emergency Nurses (minimum three). ii. Anesthetist. iii. General Surgeon. iv. A General Medical Officer. v. Trained Emergency Clinical Officer. 3.4 OBSERVATION/RECOVERY ROOM. i. Minimum of 3 beds.
4 4
1 1 1 1 1 1 1 1 1 1 1 1
5 3 3 2 2 5
SUBTOTAL FOR LEVEL III. SUBTOTAL FOR LEVEL IV. SUBTOTAL FOR LEVEL V.
N/A 40 40
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REMARKS
SUB TOTAL FOR LEVEL VI.
40
4.0 LABORATORY.
*APPLICABLE FOR ALL LEVELS. 4.1 QUALITY ASSURANCE IN LABORATORY SERVICES. a. There is written safety program in place. b. Appropriate safety devices are in place and the laboratory staff is/are well oriented to safety procedures and practices. c. Evidence of continuous training on new procedures and newly acquired or recognized hazardous materials. d. Evidence of qualified and experienced laboratory staff. e. The facility has in place the expected report time for test results and that these results are reported within a period to meet patients needs. f. The laboratory has established reference ranges for each test performed, and the range is included in the clinical records at the time test results are reported. 4.2 LABORATORY TESTS. i. Hemoglobin test. ii. Differential white cell count. iii. Peripheral blood film. iv. Blood slide for malaria parasite. v. Stool for ova & cyst. vi. Stool for culture & sensitivity. vii. Gram stain. viii. ABO & RH grouping. ix. Urinalysis. x. Urine Microscopy. xi. Pregnancy Test. xii. Blood glucose. xiii. Widal Test. xiv. Brucella Test. xv. HIV Test.
xvi. Sickle Cell Test.
3 3
3 3
3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3
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REMARKS
*APPLICABLE TO LEVEL IV UPWARD. i. Full Haemogram. ii. Blood Screening & Storage. iii. Peripheral Blood Count. iv. Platlet Count. v. Clotting Time. vi. Bleeding Time. vii. Prothrombin Time. viii. Reticulocyte Count. ix. Rheumatoid Factor. x. Blood Culture & Sensitivity. xi. Packed Cell Volume. xii. ABO & RH Grouping. xiii. Urine Culture & Sensitivity. xiv. Hepatitis B Virus Screening xv. Hepatitis C Virus Screening. xvi. Syphilis Screening. xvii. PSA Determination. xviii. Pap Smear Analysis. xix. Bone Marrow Examination. xx. Compatibility Testing. xxi . Coombs Test. xxii. Antibody Screening. xxiii.Pus Swabs. xxiv.Cytological Examinations Of Fluids OR Aspirates. xxv.Blood Glucose. xxvi.CSF Culture. xxvii.Liver Function Tests. xxviii.Cholesterol Test. *APPLICABLE TO LEVEL V & VI. xxix. CD4/CD8. xxx.Viral Load. xxxi.Parasitology. xxxii.Histopathology. xxxiii. Blood gases. xxxiv. Virology. xxxv. Immunatosy. xxxvi. Lipid profile.
3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3
3 3 3 3 3 3 3 3
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NHIF ACCREDITATION STANDARDS xxxvii. Other tests (specify). 4.3 EQUIPMENTS & TOOLS. *APPLICABLE TO ALL LEVELS. i. Fluorescent microscopes. ii. Binocular microscope. iii. QBC cell counter. iv. Weighing balances. v. TB Screen. vi. Refrigerator and freezer. vii. Distillation machine. viii. Others e.g. test tubes, slides, flasks, stands, pipettes, burettes, thermometers, racks e.t.c. ix. Autoclave. *APPLICABLE TO LEVEL IV UPWARD. x. Haematology counter. xi. Tissue processor. xii. Incubator. xiii. Water bath. xiv. Calorimeter. xv. Coagulometer. xvi. Centrifuge machine. xvii. Spectrophotometer. xviii. Chemistry analyzer. xix. Immuno assay analyzer. xx. Hot air oven. xxi. Blood bank. xxii. Specialized laboratories, e.g. haematology, parasitology e.t.c.
REMARKS
1 1 1 1 1 1 1 1 1
1 1 1 1 1 1 1 1 1 1 1 1 2
SUBTOTAL FOR LEVEL III. SUBTOTAL FOR LEVEL IV. SUBTOTAL FOR LEVEL V. SUBTOTAL FOR LEVEL V.
75 173 200 200
5. 0 RADIOLOGY SERVICES. *APPLICABLE TO LEVEL IV UPWARD. 5.1 QUALITY ASSURANCE IN RADIOLOGY DEPARMENT. a. Certification by the Radiation Protection Board. 5
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NHIF ACCREDITATION STANDARDS b. Documented evidence of continuous (24 hrs) Imaging Services. c. A radiology safety program, which is coordinated with facilitys safety management program is in place and appropriate to the risks and hazards encountered in a Radiology Department. d. Evidence of continuous training on new imaging procedures and hazardous materials. e. The staff who perform and/or interprets testing or direct or supervise testing are identified, are appropriately trained and experienced. f. The health facility has established the expected report time for radiological results, and that the results are reported within the time frame to meet patients needs. g. There is a radiology equipment management program that includes the selection and acquisition; inventorying, inspecting and testing; calibrating and maintenance; monitoring and follow-up; and documentation of all processes. h. Essential radiological reagents and supplies are identified, available, are appropriately stored and dispensed according to guidelines; are periodically evaluated for accuracy and results; and are completely and accurately labeled. i. Quality control procedures are in place for validating test methods; daily surveillance of test results; ensuring quick response to a deficiency; testing reagents and solutions; and documenting results and corrective actions. 5.2 RADIOLOGICAL SERVICES. i. Hand And Finger-AP/LAT. ii. Wrist Joint - AP/LAT. iii. Forearm - AP/LAT.
REMARKS
2 2 2
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NHIF ACCREDITATION STANDARDS iv. Elbow Joint - AP/LAT. v. Humerus - AP/LAT. vi. Shoulder AP & AXIAL. vii. Chest PA & LAT. viii. Clavicle PA/AXIAL. ix. Scapula - AP/LAT. x. Sternum PA & LAT. xi. Sterno Clavicular. xii. Foot And Toes - AP/LAT. xiii. Ankle Joint - AP/LAT. xiv. Leg - AP/LAT. xv. Knee Joint - AP/LAT. xvi. Patella AP/ASKYLINE. xvii. Femur - AP/LAT. xviii. Hip Joint - AP/LAT. xix. Sacro-Iliac Joint AP/AXIAL. xx. Pelvis AP. xxi. Abdomen (PLAIN/ERECT). xxii. Skull - AP/LAT. xxiii. Facial Bones - AP/LAT. xxiv. Orbits OM & LAT. xxv. Mandible- AP & OBLIQUES. xxvi. Sinuses 3 VIEWS. xxvii. Optic Foramina OM & OBLIQUE. xxviii. Mastoids OM & OBLIQUES. xxix. Cervical spine - AP/LAT. xxx. Cervical 3 VIEWS. xxxi. Thoracic spine - AP/LAT. xxxii. Lumbar spine AP/LAT. xxxiii. Lumbosacral spine - AP/LAT. xxxiv. Barium meal. xxxv. Barium swallow. xxxvi. Barium enema. xxxvii. Intravenous Urography. xxxviii. Hysterosalpingogram. xxxix. Cholecystograms. xl. Ultrasound. xli. Mammography. *APPLICABLE TO LEVEL V& VI. xlii. Angiography.
POINTS AWARDED POINTS (MAX OR ZERO) 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 5 5 5 5 5 5 5
REMARKS
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NHIF ACCREDITATION STANDARDS xliii. Venograms. xliv. Myelograms. xlv. Mobile Radiography. xlvi. MRI + Contrast. xlvii. CT Scan. xlviii. Cystography. xlix. Fluoroscopy.
POINTS AWARDED POINTS (MAX OR ZERO) 5 5 5 30 20 5 5
REMARKS
SUBTOTAL FOR LEVEL III. SUBTOTAL FOR LEVEL IV. SUBTOTAL FOR LEVEL V. SUBTOTAL FOR LEVEL V.
N/A 136 216 216
6.0 PHARMACY SERVICES *APPLICABLE TO ALL LEVELS. 6.1 QUALITY ASSURANCE IN PHARMACY DEPARTMENT. a. The facility operates its own duly licensed pharmacy, which complies with requirements of the Pharmacy and Poisons Board. b. There is a written medicines policy and procedure, accessible to staff, covering all aspects of medicines systems in the facility including ordering, procurement, receipt, storage prescription, administration and disposal of medicines and other pharmaceutical products. c. Records of ordering, receipt, supply, administration and disposal of all medicines and medical supplies in order to maintain an audit trail are kept. d. Lockable cupboard is provided for all controlled drugs (Dangerous Drug Act) and properly kept register. e. There are policies and procedures in place to govern the documentation and management of any medication brought into the facility for or by the patient. f. Pharmacist /Technologist licensed by pharmacy and poison board supervises the storage, preparation, and dispensing of medications.
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NHIF ACCREDITATION STANDARDS g. Medications prescribed and administered to the patient are written in the patients records. 6.2 DRUGS/PREPARATIONS. * APPLICABLE TO LEVEL III & IV ONLY. (As per MoH Essential Drugs List). 6.2.1 General Anaesthetics & Theatre Agents. Diazepam Inj.5mg/mi (ampoule). Oxygen Inhalation (Cylinder). 6.2.2 Local Anaesthetics. Lignocain HCL Inj 2% (50ml bottles). Ethyl Chloride Spray (100 ml. Bottle). 6.2.3 Non-Opioids, NSAIDS & Antimigraine. Aspirin Tabs 100mg / 300 mg. Indomethacin Caps 25 mg. Paracetamol Paediatric Oral Suspension 120 mg/ml (100 ml bottle). Paracetamol Tabs 500 mg. Ibuprofen Tabs 200mg. Ibuprofen Syrup 100mg / 5ml / 60ml (bottle). Liniments. 6.2.4 Anti-Allergies & Drugs Used In Anaphylaxis. Adrenaline Tart Inj 1mg / 1ml (ampoule).
Chlorpheniramine Maleate Inj 10mg / ml (ampoule). Chlorpheniramine Maleate syr 2mg / 5ml (bottle). Chlorpheniramine Maleate Tabs 4mg. Hydrocortisone Sodium Succinate Inj 100 mg Base (vial).
POINTS
POINTS AWARDED (MAX OR ZERO)
REMARKS
2 2
2 2
2 2 2 2 2 2 2
2 2 2 2 2
6.2.5 Non-Specific Antidotes & Other Substances Used In Poisoning. Charcoal Tabs 125 mg.
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NHIF ACCREDITATION STANDARDS 6.2.6 Specific Antidotes & Other substances Used In Poisoning. Atropine Sulphate Inj 1 mg/ml (IV&IM / vial). Pralidoxine Mesylate (PAM) Inj. 6.2.7 Antiepileptics/Anticonvulsants. Diazepam Inj 10gm / 2ml (IV & IM per vial). Phenobarbitone Tabs 30 mg. 6.2.8 Anti-Infective drugs Anthelminthics. Mebendazole Suspension 100 mg / 5ml (bottle). Mebendazole Tabs 100 mg. Niclosamide Tabs 500mg. Albendazole Chewable Tabs 400 mg. Albendazole Syrup 400 mg / 10 ml (bottle). Levamisole Hydrochloride Tabs 50 mg. Levamisole Hydrochloride Syrup 40 mg/5ml (bottle). Praziquantel Tabs 600 mg. 6.2.9 Antibacterial Oral Liquids. Amoxycillin Suspension 125 mg / 5 ml (100 ml bottle). Co-trimoxazole Suspension 240mg / 5ml(50 ml bottle). Erythromycin Ethyl Succinate, dry 200mg/ 5ml. Ampiclox Neonatal drops 60 mg/ 30mg. 6.2.10 Antibacterial Oral Tabs/Caps. Amoxycillin Caps 250 mg. Amoxycillin Caps 500 mg. Amoxycillin 250 mg + Clavulanic Acid 125 mg Tabs. Co-trimoxazole Tabs 480mg. Doxycline HCI Caps 100mg. Nitrofurantoin Sodium Tabs 100mg.
POINTS
REMARKS
2 2
2 2
2 2 2 2 2 2 2 2
2 2 2 2
2 2 2 2 2 2
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NHIF ACCREDITATION STANDARDS Nalidixic Acid Tabs 500 mg. Tetracycline Caps 250 mg. Norfloxacin 400 mg tablets.
POINTS 2 2 2
REMARKS
6.2.11 Antibacterials Injectables. Benzathine Penicillin Inj 2.4 MU IV (vial). Benzyl Penicillin Inj 5MU / 1 IMU (vial). Fortified Procain Penicillin Inj. 4.0 MU (vial). Triple Penicillin Inj 6:3:3 (Vial). Gentamycin 80 mg / 2ml. Gentamycin 20 mg / 2ml. 6.2.12 Antifungals. Clotrimazole Cream 1% 15gms. Clotrimazole Vaginal Pessaries 100 mg. Clotrimazole Ear Drops 1% 20 gms. Benzoic acid 6% + Salicylic acid 3% Ointment. Nystatin Oral Suspension 100,000 Units/ml (24ml). Nystatin Ointment. 6.2.13 Antiprotozoal Drugs. Metronidazole Tabs 200 mg. Amodiaquine 200 mg tabs. Amodiaquine susp. 50mg/5ml. Sulfadoxine 500 mg + Pyrimethamine 25 mg Tabs / Drops 10 mg. ACT (AntiMalaria-Combined Therapy). 6.2.14 Dermatological Drugs. Benzyl Benzoate Emulsion 25% x 100mls. Compound Benzoic Acid 6%+Salicylic Acid3%. Calamine Lotion 100ml. Gentian Violet Crystals Powder 10 gms. Hydrocortisone Skin Ointment 1% 10g.
2 2 2 2 2 2
2 2 2 2 2 2
2 2 2 2 2
2 2 2 2 2
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NHIF ACCREDITATION STANDARDS 6.2.15 Gastrointestinal Drugs. Compound Magnesium Trisilicate Tabs. Compound Magnesium Trisilicate Mist (100mls bottle). Oral Rehydration Salts Powder (WHO Formulation). 6.2.16 Hormones, Endocrine Drugs and Contraceptives. Adrenal Hormones and Substitutes Hydrocortisone Sodium Succinate Inj 100 mg Base. Hormonal Contraceptives Ethinylestradiol + Levonorgestrel Tabs (30mcg + 150mcg packet). Ethinylestradiol + Norethisterone Tabs (35mcg + 1.0mg packet). Oxytocics & Antioxytocics Ergometrine Maleate Inj 500mcg / ml. 6.2.17 Immunologicals (Vaccines). BCG Vaccine Dried Powder (per 10 dose vial). Hepatitis B Vaccine. Measles Vaccine. Poliomyelitis Oral Vaccine (per 10 dose vial). Rabies Vaccine. Tetanus Toxoid Vaccine. Pentavalent Vaccine. Anti-snake venom (10ml ampoule). 6.2.18 Opththalmologicals & ENT Preparations Tetracycline Eye Ointment 1% 3.5gms. Zinc Sulphate 0.25% Eye Drops. Oxytetracyline 3% + Hydrocortisone 1% Ear Suspension. 6.2.19 Psychotherapeutic Drugs. Chlorpromazine HCI Inj 50 mg / 2ml.
POINTS
REMARKS
2 2 2
2 2 2 2
2 2 2 2 2 2 2 2
2 2 2
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NHIF ACCREDITATION STANDARDS Chlorpromazine HCI Tabs 100 mg (sc). Chlorpromazine HCI Tabs 25 mg (sc). Fluphenazine Decanoate Inj 25 mg / 1ml.
POINTS 2 2 2
REMARKS
6.2.20 Respiratory Tract Drugs. Aminophylline Inj 25mg/ml IV (10ml). Salbutamol Syrup 2mg/5ml (100mls). Salbutamol Tabs 2 mg/4mg. 6.2.21 Cardiovascular Drugs. Frusemide Tabs 40mgs. Propanolol 40mg. 6.2.22 Solutions for Water, Electrolyte & Acid Base Disturbance. Darrows Solution Strength (500ml). Dextrose Inj 50% W/V (50 ml). Dextrose Inj 10% W/V (500ml). Dextrose Inj 5% W/V (100ml). Normal Saline Inj 0.9% (500ml). Water for Inj (10ml). 6.2.23 Vitamins and Minerals. Ferrous Sulphate Tabs 200 mg. Folic Acid Tabs 5 mg. Vitamin B Complex Tabs. Multivitamin Tabs. Multivitamin Syrup 100 ml. 6.2.24 Pharmaceutical Dressings. Sterile Medicated (Antimicrobial). Paraffin Gauze 10cm x 10cm (pkt). Sterile Medicated (Antimicrobial) Paraffin Gauze 15cm x 20 cm) (pkt). * APPLICABLE TO LEVEL V & VI ONLY. A. Gastro Intestinal Tract. i. Antacids. ii. Laxatives/purgatives. iii Anthelminthics.
2 2 2
2 2
2 2 2 2 2 2
2 2 2 2 2
2 2 2
5 5 5 Page 22 of 49 JUNE 2007
NHIF ACCREDITATION STANDARDS iv. Anti diarrhoeals. v. Hepatic preparations. vi. Lubricants. vii. Suppositories. B. Central Nervous System. i. Analgesics and antipyretics. ii. Anti- inflammatory agents. iii. Anti-convulsants. iv. Sedatives and tranquilizers. v. Hypnotics. vi. Anti-histamines. vii. Anti-depressants. viii. Stimulants. ix. Antiemetics, anti-nauseants. x. Muscle relaxatants. C. Ear, Nose And Throat. i. Nasal preparations. ii. Oro-pharyngeal preparations. iii. Nasopharyngeal preparations. D. Cardio-Vascular System. i. Anticoagulants. ii. antihypertensives. iii. Clotting agents. E. Genito-Urinary. i. Urinary antiseptics. ii. Diuretics and anti-diuretics. iii. Anti-spasmodics. iv. Preparations acting on the uterus. v. Pessaries. F. Endocrines. i. Steroids hormones. ii. Corticosteroids. iii. Trophic hormones. G. Respiratory System. i. Cough expectorants.
POINTS AWARDED (MAX OR ZERO REMARKS 5 5 5 5
5 5 5 5 5 5 5 5 5 5
5 5 5
5 5 5
5 5 5 5 5
5 5 5
Page 23 of 49
JUNE 2007
NHIF ACCREDITATION STANDARDS ii. Cough suppresants. iii. Inhalations. iv. Bronchial spasms relaxants. v. Respiratory stimulants. H. Infections. i. Antibiotics. ii. Sulphonamides. iii. Sulphonamides and Trimethoprim. iv. Anti-TB preparations. v. Anti amoebics. vi. Anti leprotics. vii. Anti malarials. viii. Anti virals including ARVS. ix. Anti schistosomiasis and Filiariacides. x. Anti trichomonal agents. xi. Anti-fungals. xii. Vaccines, serums and immunoglobulins. I. Opthalmic Preparations. i. Antibacterial preparations. ii. Steroid preparations. iii. Anti allergic preparations. iv. Anti viral preparations. v. Local anesthetics. vi. Mydriatics, myotics drugs used in glaucoma. vii. Miscellaneous ophthalmic preparations. J. Dermatological Preparations. i. Anti pruritics. ii. Locally acting sedatives. iii. Dermatological stimulants. iv. Dermatological antiseptics. v. Topical preparations for muscular disorder. vi. Topical corticosteroids with/without antibiotics. vii. Anti parasitics. viii. Keratolitics. ix. Fungicides. x. Cleansing agents.
POINTS 5 5 5 5
REMARKS
5 5 5 5 5 5 5 5 5 5 5 5
5 5 5 5 5 5 5
5 5 5 5 5 5 5 5 5 5
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JUNE 2007
NHIF ACCREDITATION STANDARDS K. Nutritive Preparations. i. Insulin. ii. Oral hypoglycaemics. iii. Vitamins. iv. Food products e.g. lipovenous, AKE. v. Iron and erythropoietics. vi. Minerals. vii. Anabolic agents. viii. Thyroid and antithyroid preparations. ix. Carcino chemotherapeutic agents. x. Drugs for metabolic disorders. L. Anaesthetics, Surgical Antiseptics. i. Anaesthetics (local and general). ii. Surgical antiseptics and applications. M. Contraceptives Agents. i. Oral. ii. Spermicidal. iii. Injectables. iv. Contraceptive devices. N. Others. i. Antiretrovirals (ARVs). ii. Post Exposure Prophylaxis (PEP) drugs.
POINTS
REMARKS
5 5 5 5 5 5 5 5 5 5
5 5
5 5 5 5
5 5
234 234 437 437
7.0 FOOD AND NUTRITION. * APPLICABLE TO ALL LEVELS. 7.1 QUALITY ASSURANCE ON FOOD AND NUTRITION. a. There is a qualified nutritionist/dietician involved in preparing patients menu.
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NHIF ACCREDITATION STANDARDS b. Guidelines on food appropriate for the patient and consistent with his/her clinical care is available, including orders for nil by mouth, a regular diet, a special diet, and parenteral or nasogastric tube nutrition. c. Food preparation, handling, storage, and distribution are safe and comply with laws, regulations, and current acceptable practices. d. The facility identifies patients at nutrition risk and commences them on nutrition therapy. e. Nursing staff assists patients unable to feed themselves to feed. f. Facility disposes off kitchen garbage and refuse properly. g. Persons handling patients food have appropriate uniforms and are medically examined every six months.
POINTS
REMARKS
3 3 3 3 21 21 21 21
8.0 THEATRE. * APPLICABLE TO ALL LEVELS. 8.1 QUALITY ASSURANCE STANDARDS FOR THEATRE. i. Written policies and procedures address compliance with applicable standards, laws and regulations, including maintenance of sterility and safety ii. There is a theatre equipment management program that includes the selection and acquisition; inventorying, inspecting and testing; calibrating and maintenance; monitoring and follow-up; and documentation of all processes. iii. Evidence of continuous training on new theatre procedures for theatre staff. iv. The theatre services are available for emergencies after normal working hours.
4 4
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NHIF ACCREDITATION STANDARDS v. Daily record of all surgeries performed in theatre, and by whom, is kept. vi. Availability of theatre trained nurses or theatre technicians. 8.2 SURGICAL SERVICES. I. Minor Incision and drainage of Cyst / Abscess. II. Circumcisions. III. POP Applications. IV. Removal of POP. V. Suture of cut small, medium wounds & arresting haemorrhage. VI. Removal of stitches. VII. Tongue-tie release. VIII. Catheterization. IX. Manual Vacuum Aspiration. X. Implants insertion & removal. XI. Minor Removal of FB nose, ear. XII. Ear syringing. XIII. Giving Enema. XIV. Surgical dressing (small & medium wounds). XV. Tonsillectomy. * APPLICABLE TO LEVEL IV UPWARD. i. General surgery. ii. Obstetric/gynecological surgeries. iii. Orthopedics operations. iv. Ear, Nose and Throat operations. v. Neuro-surgery. vi. Reconstructive surgery. vii. Urological surgeries. viii. Maxillo-facial surgeries. ix. Pediatric surgeries. x. Cardio-thoracic surgeries. xi. Endoscopic surgeries. xii. Endocrinological surgeries. 8.3 THEATRE EQUIPMENTS. i. At least 2 (two) standard operating tables. ii. Anesthetic machine. iii. Operating lamps/lights.
POINTS
REMARKS
4 4
3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 10 10 10 10 10 10 10 10 10 10 10 10 4 4 3 JUNE 2007
Page 27 of 49
NHIF ACCREDITATION STANDARDS iv. Suction machine. v. Oxygen supply. vi. Sterilizers/ autoclave. vii. Diathermy machine. viii. Cardio-pulmonary monitor. ix. Endoscopes. x. Extra anesthetic machine. xi. Drip stands. xii. Varied operating sets. xiii. Defibrillator. xiv. A minor theatre for day or uncomplicated cases. 8.4 THEATRE LAYOUT. i. Receiving area/reception. ii. Changing room. iii. Scrubbing room/area. iv. Operating room. v. Recovery room. vi. Sluice room. vii. Doctors room. viii Store. ix. Theatre sterile supply unit (TSSU).
POINTS 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3
REMARKS
69 260 260 260
9.0 PHYSIOTHERAPY SERVICES. * APPLICABLE TO LEVEL IV UPWARD. 9.1 Special Examination Assessment. 1.Electro diagnosis. 2. Manual muscle training (MMT). 3. Electromyography (EMG). 9.2 Heat Therapy. 1. Laser jet. 2. UVR (ultra violet radiation). 3. IRR (infra red radiation). 4. SWD (short wave diathermy).
2 2 2
1 1 1 1
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NHIF ACCREDITATION STANDARDS 5. MWD (micro wave diathermy). 6. Hot packs. 7. Hydrotherapy. 9.3 Exercise Therapy. 1. Pre and post natal exercises. 2. General exercises. 3. Pre and post operative exercises. 4. Specialized exercises training. 5. Keep fit/group exercises. 6. Pediatric physiotherapy. 9.4 Electrotherapy. 1. Ionization. 2. Stimulation. 9.5 Manipulative Therapy. 1. Therapeutic massage. 2. Passive stretching. 3. Active movements. 4. Firm/ pressure bandaging. 9.6 Chest Physiotherapy. 1. Postural drainage. 2. Nebulization. 3. Cryo-therapy. 4. Hydrotherapy. 5. Bedside physiotherapy. 6. Physiotherapy medical report. 7. Counseling.
POINTS 1 1 1 2 2 2 2 2 2 2 2 2 2 2 2 2 2 1 1 2 2 3
REMARKS
N/A 50 50 50
10.0 OCCUPATIONAL THERAPY SERVICES. * APPLICABLE TO LEVEL IV UPWARD. 1. Physical Disabilities. 5 2. Psychiatry Counseling. 5 3. Rehabilitation. 5
SUBTOTAL FOR LEVEL III. SUBTOTAL FOR LEVEL IV. SUBTOTAL FOR LEVEL V.
N/A 15 15
Page 29 of 49 JUNE 2007
POINTS
REMARKS
SUBTOTAL FOR LEVEL VI.
15
11.0 ORTHOPAEDICS * APPLICABLE TO LEVEL IV UPWARD. I. At least 1 Plaster room. 3 II. TRACTION. a. Intermittent 3 b. Continuous. 3 2. Electrotherapy and traction. 3 3. Reduction of joints, fractures and POP immobilization/splinting. 3
N/A 15 15 15
12. 0 STERILE PREPARARION UNIT (SPU) * APPLICABLE TO LEVEL IV UPWARD. QUALITY ASSURANCE IN SPU. 1. The facility has a sterilization room where sterile instruments are processed. 3 2. The facility has developed and implemented written policies and procedures for the cleaning, antimicrobial processing, and storage of supplies 3 and equipment to prevent the transmission of infection through their use. 3. The unit maintains a separate area for processing, decontamination, and storage of supplies, and is restricted to properly attired 2 authorized personnel. 4. Instructions for the operation of autoclaves are posted near the equipment. 2
* APPLICABLE LEVEL V & VI.
N/A 10 10 10
13.0 ICU ROOM.
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NHIF ACCREDITATION STANDARDS 1. Cardio pulmonary monitor. 2. Respirator. 3. Automatic blood pressure monitor. 4. Defibrillator. 5. Central Venous pressure monitor. 6. Blood Gas Analyzer. 7. Injection Pump. 8. I.C.U beds: a. 2 (two beds). b. 3-4 beds. c. 5-10 beds. d. Over 10 beds.
POINTS 5 5 5 5 5 5 5 5 10 15 20
REMARKS
N/A N/A 85 85
14. 0 LABOUR WARD. * APPLICABLE TO ALL LEVELS. 14.1 QUALITY ASSURANCE IN LABOUR WARD. 1. The department has in place policies and procedures for obtaining patients information and records of the patients care (including Partographing) and response to care is 5 documented and shared among medical, nursing and other care providers during each staffing shifts. 2. The department has in place guidelines and procedures for dealing with clients with obstetric emergency or immediate needs including 5 APH, PPH, PET, eclampsia, obstructed labor, cardiac disease, fetal distress, e.t.c. 3. The department has in place policies and procedures addressing use of analgesia in prenatal and past natal care of clients. 5 14.2 EQUIPMENT. 1. Standard Delivery Bed: a. At least 2 delivery couches. b. 2-4 delivery couches. 3 c. 5 and above delivery couches.
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NHIF ACCREDITATION STANDARDS 2. Vacuum Extractor. 3. Suction machine. 4. Resuscitation Kit. 5. Cord ligatures. 6. Baby labels. 7. Sterile delivery packs. 8. Ergometrine/syntocinon, fluids, syringes needles. 9. Maternity pads. 10. Baby weighing scale. 11. Clean floor and waste bins. 12. Source of clear overhead light. 13. Baby resuscitoir. 14 Quick access to nursery. 15. Labour acute room. 16. Sluice room. 17. Running water. 18. Quick access to theatre or annex maternity. 19. Provision for hot drink after delivery.
POINTS 1 1 2 1 2 3 2 1 2 2 1 2 2 2 2 2 2 2
REMARKS
* APPLICABLE TO ALL LEVELS. 15.1 QUALITY ASSURANCE FOR PERSONNEL. 1. There is a written policy on how the facility determines the number, types, and desired qualification of their staff. 2. There are procedures for orientation of all staff members to the facility and to their specific job responsibilities at the appointment of new staff. 3. There is a program to ensure each staff member receives ongoing in-service and continuous education to maintain or advance his/her skills and knowledge. 4. The facility has an effective job description policy.
50 50 50 50
15.0 PERSONNEL.
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NHIF ACCREDITATION STANDARDS B. CATEGORIES OF PERSONNEL (FULL TIME) IN THE STAFF LIST, PHYSICAL PRESENCE AND EVIDENCEOF QUALIFICATION. * APPLICABLE TO LEVEL III ONLY. Medical Officer (S); 1 And Above Clinical Officers; 1-2, 3 And Above. Nursing Staff; 6-10, 11 And Above. Laboratory Technician/ Technologist; At least 1, 2 And Above. Pharmaceutical Technologist; 1 And Above. Records Officer; 1 And Above. Cashier. Subordinate Staff; 2 And Above. Cooks; 1 And Above. Watchmen/Security Officers; 2 And Above. At Least 1 Public Health Technician. Oral Health Officers; 1 And Above. Drivers; 1 And Above. At Least 1 Plaster Technician. At Least 1 Hospital Secretary /Typist. At Least 1 Procurement Officer.
POINTS
REMARKS
15 10 20 20 30 10 15 10 5 3 5 3 5 5 5 3 5 3 3
SUBTOTAL FOR LEVEL III

* APPLICABLE TO LEVEL IV ONLY. Clinical Officers; At Least 2 And Above. Specialized Clinical Officers:
150
10
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JUNE 2007
NHIF ACCREDITATION STANDARDS Anesthesiologist; 1 And Above. Paediatrics; 1 And Above. At Least 1 Psychiatrist. At Least 1 Dermatologist. At Least 1 ENT Specialist. At Least 1 Ophthalmologist. Nursing Staff: Nurses; 10-20, 21 And Above. Specialized Nurses: Midwives. Theater. Psychiatry. Emergency. Any Other Speciality. Radiographer; At Least 1, 2 And Above. Laboratory Technicians; At Least 1, 2 And Above, Laboratory Technologists; At Least 1, 2 And Above. Pharmacists; At Least 1, 2 And Above. Pharmaceutical Technologist; At Least 1, 2 And Above. Health Records Officer; At Least 1, 2 And Above, At Least 1 Statistical Clerk. At Least 1 Cashier. At Least 1 Accountant. At Least 1 Health Administrative Office. At Least 1 Oral Health Officers.
POINTS
REMARKS
10 5 5 5 5 5
10 20 5 5 5 5 5 5 10 5 10 5 10 5 10 5 10 5 10 3 3 3 3 3 Page 34 of 49 JUNE 2007
NHIF ACCREDITATION STANDARDS Dental Technologists; At Least 1, 2 And Above. Dentists; At Least 1, 2 And Above. Medical Officers; 4 10, 10 And Above. Interns Qualified As General Medical Officers. Visiting Specialists: Physicians. Obstetric & Gynaecologists. Paediatricians. Surgeons. Any Other (Specify). Physiotherapists; At Least 1, 2 And Above. Security. Cooks. Occupational Physiotherapists; At Least 1, 2 And Above. Nutritionist; At Least 1, 2 And Above. Radiographer; At Least 1, 2 And Above. Public Health Officers; At Least 1 2 And Above Public Health Technician At Least 1, 2 And Above. Subordinate Staff; At Least 1, 2 And Above. Plaster Technician. Mortuary Attendants.
POINTS
REMARKS
5 10 5 10 15 20 10 30 30 30 30 30 5 10 3 3 5 10 5 10 5 10 5 10 5 10 5 10 3 3 Page 35 of 49 JUNE 2007
NHIF ACCREDITATION STANDARDS Drivers; At Least 1, 2 And Above. Hospital Secretary /Typist. Procurement Officers; At Least 1, 2 And Above.
POINTS
REMARKS
5 10 3 5 10
SUBTOTAL FOR LEVEL IV.

* APPLICABLE TO LEVEL V ONLY. Clinical Officers; At Least 2 And Above. Specialized Clinical Officers: Anesthesiologist; 1 And Above. Paediatrics; 1 And Above. At Least 1 Ophthalmologist. At Least 1 Psychiatric. At Least 1 Dermatologist. Ophthalmologist; 1 And Above. At Least 1 ENT. Reproductive Health; 1 And Above Nursing Staff: Nurses; 50-100. 101 And Above. Specialized Nurses: Midwives. Theater. Psychiatry. Emergency. ICU. Any Other Speciality. Radiographer; At Least 2, 3 And Above.
485
10
10 5 5 5 5 5 5 5
50 100 10 10 10 10 10 10 5 10
Page 36 of 49
JUNE 2007
NHIF ACCREDITATION STANDARDS Laboratory Technologists/Technicians; At Least 2, 3 And Above. Pharmacists; At Least 2, 3 And Above. Clinical Pharmacist; At Least 2, 3 And Above. Pharmaceutical Technologist; At Least 2, 3 And Above. Health Records Officer; At Least 2, 3 And Above. Cashier; At Least 2, 3 And Above. Accountant; At Least 1, 2 And Above. Health Administrative Officers. Oral Health Officers; At Least 2, 3 And Above. Dental Technologists; At Least 2, 3 And Above. Dentists; At Least 1, 2 And Above. Medical Officers; 4-10, 10 And Above. Interns Qualified As General Medical Officers. At Least 1 Physician. At Least 1 Obstetrician Gynecologist. At Least 1 Pediatrician. At Least 1 Surgeon. At Least 1 Psychiatrist. At Least 1 ENT Specialist.
POINTS
REMARKS
5 10 5 10 5 10 5 10 5 10 5 10 5 10 5 5 10 5 10 5 10 10 20 10 30 30 30 30 30 30 Page 37 of 49 JUNE 2007
NHIF ACCREDITATION STANDARDS POINTS At Least 1 Dermatologist. At Least 1 Anaesthetist . At Least 1 Pathologist. At Least 1 Radiologist. At Least 1 Orthopaedic Surgeon. Rehabilitative Therapists: Physiotherapists; At Least 2, 3 And Above. Occupational Therapists; At Least 2, 3 And Above. Orthopaedic Technologist; At Least 2, 3 And Above. Social Worker; At Least 2, 3 And Above. Counselor; At Least 2, 3 And Above. Nutritionist; At Least 2, 3 And Above. Security; 5-10, 10 And Above. Cooks; At Least 4, 5 And Above. Radiographer; At Least 2, 3 And Above. Drivers; 3 -6, 6 And Above. Public Health Technicians / Officers; At Least 2, 3 And Above. Subordinate Staff; 10-20, 20 And Above. 30 30 30 30 30
REMARKS
5 10 5 10 5 10 5 10 5 10 5 10 5 10 5 10 5 10 5 10 5 10 5 10 Page 38 of 49 JUNE 2007
POINTS NHIF ACCREDITATION STANDARDS Mortuary Attendants; At Least 2, 3 And Above. Plaster Technician; At Least 2, 3 And Above. Hospital Secretary /Typist; At Least 2, 3 And Above. Procurement Officers; At Least 2, 3 And Above. Medical Engineer; At Least 2, 3 And Above.
REMARKS
5 10 5 10 5 10 5 10 5 10
SUBTOTAL FOR LEVEL V

* APPLICABLE TO LEVEL VI ONLY. Specialized Clinical Officers: Anesthesiologist; 5 And Above. Paediatricians; 1 And Above. At Least 1 Ophthalmologist. At Least 1 Psychiatrist. At Least 1 Dermatologist. At Least 1 ENT. Ophthalmologist; 1 And Above. Nursing Staff: Nurses; 50-100, 101 And Above, Specialized Nurses; Midwives. Theater. Psychiatry. Emergency . ICU. Any Other Speciality.
875
10 5 5 5 5 5 5
20 30 10 10 10 10 10 10
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JUNE 2007
NHIF ACCREDITATION STANDARDS Reproductive Health; 1 And Above. Radiographer; At Least 4, 5 And Above. Laboratory Technicians; At Least 4, 5 And Above. Laboratory Technologists; At Least 4, 5 And Above. Pharmacists; At Least 4, 5 And Above. Clinical Pharmacist; At Least 4, 5 And Above. Pharmaceutical Technologist; At Least 4, 5 And Above. Health Records Officer; At Least 4, 5 And Above. Cashier; At Least 4, 5 And Above. Accountant; At Least 4, 5 And Above. Health Administrative Officer(s). Oral Health Officers; At Least 4. 5 And Above. Dental Technologists; At Least 4. 5 And Above. Dentists; At Least 4. 5 And Above. General Medical Officers: At Least 4. 5 And Above.
POINTS
REMARKS
5 5 10 5 10 5 10 5 10 5 10 5 10 5 10 5 10 5 10 5 5 10 5 10 5 10 10 20
Page 40 of 49
JUNE 2007
NHIF ACCREDITATION STANDARDS Interns Qualified As General Medical Officers. Anaesthetists. Physicians. Obstetrician Gynecologists. Pediatricians. Surgeons. Psychiatrists. Ophthalmologists. ENT Specialists. Dermatologists. Anesthetists. Pathologists. Radiologists. Orthopaedic Surgeons. Rehabilitative Therapists: Physiotherapists. Occupational Therapists. Orthopaedic Technologist. Social Workers. Counselors. Nutritionists. Security. Cooks. Radiographers. Public Health Officers. Public Health Technicians. Subordinate Staff. Drivers. Mortuary Attendants. Plaster Technicians. Hospital Secretary /Typist. Procurement Officers. Medical Engineers. SUBTOTAL FOR LEVEL VI.
POINTS 10 50 50 50 50 50 50 50 50 50 50 50 50 50 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10
REMARKS
1135
16.0 WARDS.
* APPLICABLE TO ALL LEVELS. 1. Male ward(s). 2. Female medical ward(s). 3. Isolation Ward.
2 2 2 Page 41 of 49 JUNE 2007
NHIF ACCREDITATION STANDARDS 4. Paediatric Ward. 5. Post Natal Ward 6. Ante-Natal Ward. 7. Labour Ward. * APPLICABLE TO LEVEL IV UPWARD. 8. Male surgical ward(s). 9. Male medical ward(s). 10. Male isolation ward(s). 11. Female medical ward(s). 12. Female surgical ward(s). 13. Female isolation ward(s). 14. Female obstetric ward(s). 15. Female gynecological ward(s). 16. Pediatrics medical ward(s). 17. Pediatrics surgical ward (s). 18. New born unit. * APPLICABLE TO LEVEL V- VI. 19. High dependency unit (at least 6 beds). 20. Burns unit. 21. Renal unit. 22. Cardio-thoracic ward. 23. Neurosurgical ward. 24. E.N.T. unit. 25. Eye unit. 26. Dental Unit.
POINTS 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2
REMARKS
2 2 2 2 2 2 2
2 14 36 52 52
17.0 GOOD HOUSE KEEPING. * APPLICABLE TO ALL LEVELS. 17.1 BED QUALITY. 1. Metallic. 3 2. Firm. 3 3. Adjustable. 3 4. Has wheels. 3 5. Of good height (30 inches from the floor). 3 6. At least 3 ft wide and 6ft long. 3
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NHIF ACCREDITATION STANDARDS 7. Spaces between beds at least 1.5 meters. 8. Number of beds: a. LEVEL III 5-50. b. LEVEL IV 51-100. c. LEVEL V 100-200. d. LEVEL VI 200 and above. 17.2 LINEN. QUALITY ASSURANCE IN LINEN PROVISIONS. 1. There are written guidelines on the cleaning and disinfection of linen and protection of the laundry staff. 2. There is enough stock of assorted linen (uniform, theatre, sheets, blankets, bed covers, mackintosh, pillow slips, mattresses, e.t.c) 3. The linen is clean and well pressed (ironed). 4. The linen is well labeled with facilitys name and department. 5. The linen is not torn. 6. There is a responsible person who controls the use of linen. 17.3 WHEEL CHAIR. One wheel chair per ward. Presence of wheel chairs but not in every ward. 17.4 STRETCHER. 13 4 or more.
POINTS 3
REMARKS
5 3 3 2 2 2 1 1 2
50 50 50 50
18. 0 MORTUARY * APPLICABLE TO LEVEL IV UPWARD. 18.1 QUALITY ASSURANCE IN THE MORGUE. 1. The facility has training program for the mortuary attendants on admission, identification/documentation, disinfection, 3 preservation and storage of bodies.
Page 43 of 49
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NHIF ACCREDITATION STANDARDS 2. There is a mortuary equipment management program that includes the selection and acquisition; inventorying, inspecting and testing; calibrating and maintenance; monitoring and follow-up; and documentation of all processes. 3. The facility has guidelines on disposal of unclaimed bodies. 4. The facility has enough stock of protective gear for the mortuary attendants. B. MORTUARY SERVICES. 1. Embalming facilities. 2. Refrigeration. 3. Other forms of preservation (formalin). 4. Prayer room. C. PROVISIONS FOR POSTMORTEM EXAMINATION. 1. Separate post mortem room. 2. Build-in post mortem table. 3. Running water with antiseptic. 4. Tissues disposal facilities. 5. Clean postmortem set.
POINTS
REMARKS
3 3 2 2 2 2
2 2 2 2 2
N/A 30 30 30
19. 0 OTHER SERVICES * APPLICABLE TO ALL LEVELS. 1. Well equipped, working ambulance. 3 2. MCH/FP (Maternal-Child Health/Family Planning). 3 3. K.E.P.I (Kenya Expanded Program on Immunization). 3 4. VCT (Voluntary Counseling and Testing). 3 5. PMTCT (Prevention of Mother To- ChildTransmission of HIV). 3 6. Infectious Diseases (TB, Leprosy e.t.c). 3 * APPLICABLE TO LEVEL IV UPWARD. 7. Palliative Care. 3 8. Dental unit. 3 9. Fertility Services. 3 Page 44 of 49 JUNE 2007
NHIF ACCREDITATION STANDARDS 10. Speech therapy.
POINTS 3
REMARKS
18 30 30 30
20. RECORDS & INFORMATION SYSTEMS. * APPLICABLE TO ALL LEVELS. A. QUALITY ASSURANCE IN RECORDS AND INFORMATION SYSTEMS 1. The facility has policy that identifies those authorized to make entries in the patient clinical 5 record& determines the records content&format. 2. The facility initiates and maintains a clinical record, which contains all information for every 5 patient assessed and/or treated (files). 3. The facility contributes to external databases in accordance with law or regulation (e.g. notifiable 5 diseases) and produces relevant reports (monthly, quarterly). 4. The facility has systems in place to ensure maintenance of confidentiality of patients data 5 and information. B. RECORDS. 1. Availability, usage and keeping of necessary records. 3 2. Qualified Records Officers. 2 3. Health Management Information systems in place and up-to-date. 3 4. In-patient/out patient registers. 2
30 30 30 30
21. 0 FUNCTIONAL COMMITTEES. * APPLICABLE TO ALL LEVELS. 1. INFECTION CONTROL.
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NHIF ACCREDITATION STANDARDS a. The committee is constituted of persons from all departments, with a Person qualified in infection control as the leader. b. The program is appropriate to the facilitys size and geographical location, services and patients. c. The facility has identified the procedures and processes associated with the risk of infection and the strategies to reduce infection risk. 2. MORTALITY REVIEW. a. The committee is constituted of persons from all concerned department(s), and a qualified doctor/ clinical officer/nurse is the leader. b. Monthly mortality meeting. 3. QUALITY IMPROVEMENT TEAM. a. There is a written plan for the facilitys quality improvement program. b. The hospital management participates in planning and monitoring a quality improvement and patient safety program. c. All departments collaborate in planning and carrying out the quality improvement program. d. Continuing Education (Professional Development). e. Evidence of certification by another quality certification body (e.g. ISO, KBS). 4. OTHER COMMITTEES. a. Hospital Management Board. b. Hospital Management Team. c. Executive Expenditure Committee.
POINTS
REMARKS
2 2
5 5
5 5 15 4 4 2
55 55 55 55
22.0 HOSPITALS IN DISADVANTAGED REGIONS. * APPLICABLE TO ALL LEVELS. Those in hardship areas, as recommended by the Government Notice.
100
Page 46 of 49
JUNE 2007
POINTS
REMARKS
23.0 MEDICAL TRAINING INSTITUTIONS. * APPLICABLE TO LEVEL III. 1. Rural Health Training Facilities * APPLICABLE TO LEVEL IV - VI. 1. Diploma Training Institutions 2. Degree Training / Referral Institutions
30 50 100
24. 0 ENGRAVEMENT OF ALL HOSPITAL EQUIPMENT *APPLICABLE TO ALL LEVELS. 25.0 USE OF ICT IN THE FACILITY *APPLICABLE TO ALL LEVELS.
30 150 150 150
20 20
FACILITY LEVEL
POINTS MAXIMUM SCORED ON POSSIBLE ASSESSMENT. SCORE.
REMARKS
GRAND TOTAL FOR LEVEL III
1024
GRAND TOTAL FOR LEVEL IV
2105
GRAND TOTAL FOR LEVEL V
2906
GRAND TOTAL FOR LEVEL VI
3146
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JUNE 2007
ACCREDITATION ASSESSMENT REPORT DONE BY THE FOLLOWING Assessment Certified by: 1. Name Signature.Date:
2.
Name. Signature..Date:
3.
Name:.. Signature. Date:..
I.the Area Manager of Area Office certifies that this assessment exercise took place.
Signature:Date:..
OFFICIAL NHIF STAMP
Hospital represented by:Designation.
Signature.Date..
OFFICIAL HOSPITAL STAMP
A need for re-assessment may arise if the NHIF Management/Board is not satisfied with the initial assessment. ENSURE THAT ALL PAGES ARE DULY STAMPED USING THE HOSPITAL STAMP BY THE HOSPITAL REPRESENTATIVE.
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JUNE 2007
REFERENCE LIST 1. JCI. (2003). Joint Commission International Accreditation Standards (2nd Ed). Oakbrook Terrace: U.S.A. 2. Omaswa F. G. and others. (1996. Quality Assurance for Health Workers in Uganda: A Manual of Quality Improvement Methods. Quality Assurance Program: Uganda. 3. The Kenya Public Health Act. 4. The Egyptian Accreditation Manual (2001). 5. Rudman, Willian J. (1997). Performance Improvement in Health Information Services. W.B Saunders Company: USA. 6. White, Alasdair. (1996). Continuous Quality Improvement: A Hands-on Guide to Setting up &Sustaining a Cost Effective Quality Programme. Performance Management Solutions Ltd: Great Britain.
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JUNE 2007

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NATIONAL HOSPITAL INSURANCE FUND

ACCREDITATION MANUAL FOR HEALTH FACILITIES 2ND EDITION - 2007

NHIF ACCREDITATION MANUAL 2ND EDITION

NHIF ACCREDITATION MANUAL 2ND EDITION

NHIF ACCREDITATION MANUAL 2ND EDITION

NHIF ACCREDITATION MANUAL 2ND EDITION

LAYOUT OF THE MANUAL

NHIF ACCREDITATION MANUAL 2ND EDITION

NHIF ACCREDITATION MANUAL 2ND EDITION

NATIONAL HOSPITAL INSURANCE FUND (NHIF)

LICENSED BY REGISTRAR M.P & D.B. /DMS TO OPERATE AS:....

TYPE/CATEGORY:..(I.E. MISSION, GOK, PRIVATE, COMMUNITY)

WHEN THE HOSPITAL STARTED:...

NUMBER OF FULL-TIME STAFF: NO. OF STAFF ON LOCUM:

NEAREST NHIF OFFICE:.

HOSPITAL ASSESED AT LEVEL: ..

STATE WHETHER NEW OR RE-ACCREDITATION:

NHIF ACCREDITATION MANUAL 2ND EDITION

N.H.I.F ACCREDITATION STANDARDS

POINTS AWARDED POINTS (MAXIMUM OR ZERO)

1.0 PHYSICAL INFRASTRUCTURE.

NHIF ACCREDITATION MANUAL 2ND EDITION

N.H.I.F ACCREDITATION STANDARDS

POINTS AWARDED POINTS (MAXIMUM OR ZERO)

NHIF ACCREDITATION MANUAL 2ND EDITION

POINTS AWARDED POINTS (MAX OR ZERO) 3

NHIF ACCREDITATION MANUAL 2ND EDITION

NHIF ACCREDITATION STANDARDS

POINTS AWARDED POINTS (MAX OR ZERO)

NHIF ACCREDITATION MANUAL 2ND EDITION

NHIF ACCREDITATION STANDARDS

POINTS AWARDED POINTS (MAX OR ZERO)

SUB TOTAL FOR LEVEL VI.

NHIF ACCREDITATION MANUAL 2ND EDITION

NHIF ACCREDITATION STANDARDS

POINTS AWARDED POINTS (MAX OR ZERO)

NHIF ACCREDITATION MANUAL 2ND EDITION

POINTS AWARDED POINTS (MAX OR ZERO) 3

75 173 200 200

NHIF ACCREDITATION MANUAL 2ND EDITION

POINTS AWARDED POINTS (MAX OR ZERO) 3

NHIF ACCREDITATION MANUAL 2ND EDITION

POINTS AWARDED POINTS (MAX OR ZERO) 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 5 5 5 5 5 5 5

NHIF ACCREDITATION MANUAL 2ND EDITION

POINTS AWARDED POINTS (MAX OR ZERO) 5 5 5 30 20 5 5

N/A 136 216 216

NHIF ACCREDITATION MANUAL 2ND EDITION

POINTS AWARDED (MAX OR ZERO)

NHIF ACCREDITATION MANUAL 2ND EDITION

POINTS AWARDED (MAX OR ZERO)

NHIF ACCREDITATION MANUAL 2ND EDITION

POINTS AWARDED (MAX OR ZERO)

NHIF ACCREDITATION MANUAL 2ND EDITION

POINTS AWARDED (MAX OR ZERO)

NHIF ACCREDITATION MANUAL 2ND EDITION

POINTS AWARDED (MAX OR ZERO)

5 5 5 Page 22 of 49 JUNE 2007

NHIF ACCREDITATION MANUAL 2ND EDITION

POINTS AWARDED (MAX OR ZERO REMARKS 5 5 5 5

NHIF ACCREDITATION MANUAL 2ND EDITION

POINTS AWARDED (MAX OR ZERO)

NHIF ACCREDITATION MANUAL 2ND EDITION

POINTS AWARDED (MAX OR ZERO)