Minimum Service Delivery Standards for Hospitals

V1: 26 July 2018

MINIMUM SERVICE DELIVERY STANDARDS (MSDS)

FOR HOSPITALS IN SINDH PROVINCE

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 Minimum Service Delivery Standards for Hospitals
V1: 26 July 2018

SSDS
Measurable Criteria
Clause No.
6.5.2 Policies and procedures guide the care of high-risk patients, such as:
- emergency patients
- those who are comatose or on life support
- those with communicable diseases or Immuno-suppressed
- patients on dialysis
- vulnerable elderly and children
- seriously ill patients.

6.6 Documentation of Care

The patient record contains sufficient information to identify the patient, support the
diagnosis, justify the treatment and care, document the course and results of the treatment
and care, and promote continuity of care.
SSDS
Measurable Criteria
Clause No.
6.6.17 There is a hospital policy, which allows patients access to their records.
6.6.17

6.7 Discharge, Transfer and Referral

Safe and appropriate discharge, transfer or referral of patients is based on the patient’s
health status and need for continuing care.
SSDS
Measurable Criteria
Clause No.
6.7.1 A written procedure including criteria to determine readiness for discharge, transfer or
referral of patients is used and specifies who is authorised to use it.

7. OPERATION THEATRE DEPARTMENT

7.1 Service Management

Operating Theatres provide safe, hygienic and appropriate services for patients and are
coordinated with other services of the hospital to provide continuity of care.

SSDS
Measurable Criteria
Clause No.
7.1.3 & 7.1.4 Anaesthetic services are provided by qualified, registered and experienced
7.1.3

anaesthetists.
An anaesthetist is present for all surgical procedures 24 hours a day.
7.1.4

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 Minimum Service Delivery Standards for Hospitals
V1: 26 July 2018

7.1.9 Coded data available to OT staff from audits includes:

- Admissions and discharges by specialty
- Diagnosis-specific bed utilisation
- Procedure-specific operating rates
- Post-operative infections
- Post-operative deaths
- Unplanned return to theatre
- Post-operative pulmonary embolism
- Post-operative CVA
- Post-operative cardiac myocardial infarction
- Unplanned re-admission within 28 days of discharge
- Unplanned transfer to ICU
- Unplanned transfer to another unit
- Unplanned second operation within 6 weeks of surgery
- Damaged organs following surgical procedure.

7.2 Policies, Procedures and Records

Operational policies and procedures clearly describe the key processes of the operating
theatre and/or department, the responsibility of the staff and expected results. Records
provide accurate information for analysis and evaluation.

SSDS
Measurable Criteria
Clause No.
7.2.1 & 7.2.2 Rules for visiting hours, number and kind of visitors/attendants are clearly defined
and visibly posted. Wherever needed, facilities are provided for relatives to sit at
7.2.1

the bedside and to stay overnight.

Documented policies and procedures for the following processes are developed
and followed by the staff:
- Prioritizing patients with emergency needs
- Examination and treatment of emergency patients and elderly patients
- Management of patients when bed space is not available on the desired ward
- Patient referral mechanism
- Managing waiting time
- Support to disadvantaged patients, such as unaccompanied and poor patients.
6.1.9

-Mechanism of user charges waivers and local purchase sanctions

7.2.8 & 7.2.10 There is a separate fully functioning and equipped recovery room.
7.2.8

Sufficient, qualified and experienced staff monitors patients in the recovery room to
7.2.10

ensure individual patient supervision at all times.

7.3 Facilities and Equipment

Safe and adequate facilities and equipment are provided to meet the needs and volume of
patients undergoing procedures in the operating theatre(s).

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