Merile 2

Quality Improvement Plan
Facility: ec Maclear Hospital Date: 31- Jan- 01 Feb

2017
C01 Blood Services
Problem Item Activity By Whom By When (Date) Status / Result

Risk Rating: V
Standard: 3.3.1 Accessible and effective blood
and blood product services enhance patient
management and outcomes
Measure: 3.3.1.1.1 CHECKLIST - 2 staff members
interviewed are able to explain how the cold
chain is ensured for all blood products including
ordering / storage / issuing
Notes: 2 staff members interviewed were not
able to explain how the cold chain is ensured for
all blood products including ordering/ storage/
issuing
C03 Health technology Services

Risk Rating: V
Standard: 3.4.3 Medical devices are maintained to
Private and Confidential | etc. Maclean Hospital

DHIS 1.4 Software Version: 1.4.1.12 | Software Last Updated: 30 May 2014 | Database Version: 17 Nov 2014Software Version: 1.4.1.9 | Software Last Updated: 06 Nov 2013 | Database Version: 1 May 2013
C03 Health technology Services

ensure safety / availability / functionality
Measure: 3.4.3.1.3 A report (from within the last
12 months) shows that adverse events involving
medical equipment are reported and that actions
taken to prevent recurrence have been
implemented
Notes: There was no report for adverse events
involving medical equipment and no zero
reporting
C04 Pharmacy

Risk Rating: X
Standard: 3.1.2 The provision of medicines and
medical supplies (including disposables) supports
the delivery of care
Measure: 3.1.2.1.1 CHECKLIST - Tracer medicines
as per applicable Essential Drugs List or formulary
are available in the pharmacy/medicine room
Notes: Tracer medicines as per EDL such as

C04 Pharmacy

prednisone and Abacavir 20mg/ml were not
available
Risk Rating: V
Standard: 2.4.3 Specific safety protocols are in
place for patients undergoing high risk
procedures
Measure: 2.4.3.4.1 A protocol regarding the safe
administration of medicines to patients is
available including a protocol for the safe
administration of medicines to children
Notes: A protocol regarding the safe
administration of medicines to patients including
children was not available
Risk Rating: V
Standard: 3.1.3 Medicines and medical supplies
are managed in compliance with relevant
legislation and principles of medicine supply
management
Measure: 3.1.3.3.1 A standard operating
procedure is available which indicates how
schedule 5 and 6 medicines are stored /
controlled / distributed in accordance with the
Medicines and Related Substances Act 101 of
1965

C04 Pharmacy

Notes: SOP regarding how schedule 5&6
medicines are stored, controlled was not available
Risk Rating: V
Standard: 3.1.4 The prescribing and dispensing of
medicines comply with relevant regulations and
protocols and promote the quality use of
medicine
Measure: 3.1.4.2.3 CHECKLIST - Dispensing is
done in accordance with applicable policies and
legislation including labelling
Notes: Dispensing was not done in accordance
with applicable laws e.g. patients were not given
opportunity to ask question
Risk Rating: V
medicine
Measure: 3.1.4.3.1 CHECKLIST - A random
selection of 3 patients receiving medicine indicate
that they have a clear understanding of how and
when to take their medication and any other
relevant information - Generic outpatient
checklist

C04 Pharmacy

Notes: Three patients interviewed indicated that
the side effects of medicines were not explained
to them
Risk Rating: E
Standard: 2.3.1 Health professionals in the
establishment champion improvements in patient
centred / quality care
Measure: 2.3.1.2.2 Healthcare professionals
specifically pharmacists and radiographers
indicate that they have access to adequate
supervision
Notes: Pharmacist indicated that HE had no
adequate supervision
Risk Rating: E
Measure: 3.1.2.4.2 A document outlining the
delivery schedule for medical supplies is available
Notes: A document outlining the delivery
schedule for medical supplies was not available
Risk Rating: E

C04 Pharmacy

procedure is available which indicates how health
care professionals can access medicines when the
pharmacy / medicine room is closed
Notes: SOP indicating how health care
professionals can access medicines when the
pharmacy is closed was not available
Risk Rating: E
Measure: 3.1.2.6.2 The name and contact details
of the pharmacist on duty for the provision of
services after hours is available
Notes: The name and contact details of the
pharmacist on duty after hours was not available
for the provision of service
Risk Rating: E

C04 Pharmacy

terms of agreement for the supply of medical
supplies (consumables) is available and there is
evidence that compliance with the agreement is
being monitored and appropriate action taken
Notes: Document outlining the terms of
agreement for the supply of medical supplies was
not available
Risk Rating: E
delivery schedule for medicine is available
Notes: A document outlining the delivery
schedule for medicines was not available
Risk Rating: E
terms of agreement for the supply of medicine is
available and there is evidence that compliance
with the agreement is being monitored and
appropriate action taken

C04 Pharmacy

Notes: The document outlining the terms of
agreement for supply of medicines was not
available
Risk Rating: E
Measure: 3.1.2.2.1 CHECKLIST - Tracer medical
supplies are available in the area where medical
supplies are stored
Notes: Tracer medical supplies such as size 5mls
and 10mls syringes were not available
Risk Rating: E
management
Measure: 3.1.3.2.1 The stock control system
shows minimum and maximum or re-order levels
for medicines
Notes: The stock control system did not show
minimum and maximum re-order levels for
medicines

C04 Pharmacy

Risk Rating: E
management
Measure: 3.1.3.5.2 CHECKLIST - Physical stock
corresponds to stock on the inventory
management system as per Checklist 31221
Notes: There were no bin cards for medical
supplies to verify the correspondence
Risk Rating: E
management
shows minimum and maximum or re-order levels
for medical supplies/devices
Notes: The stock control system for medical
supplies was not available to verify re-order levels
Risk Rating: E

C04 Pharmacy

management
Measure: 3.1.3.4.2 CHECKLIST - Medical supplies
are stored correctly
Notes: Medical supplies were not correctly stored
e.g. leaking ceiling and damaged door handle
Risk Rating: E
management
Measure: 3.1.3.3.3 The entries in the schedule 6
drug register are complete and correct Check that
physical stock of one S6 medicine corresponds to
the quantity in the register
Notes: The entries in the schedule 6 drug register
were not correct e.g. severance 5mg recorded as
310 while in stock 300
Risk Rating: E
management
Measure: 3.1.3.2.2 CHECKLIST - Physical stock
corresponds to the stock reflected in the

C04 Pharmacy

inventory management system (as per checklist
31211)
Notes: Physical stock did not correspond to stock
in the inventory system e.g. Nevirapine 10mg/ml
recorded as 60 while in stock 74
Risk Rating: E
management
Measure: 3.1.3.1.1 CHECKLIST - Medicine is stored
correctly as per Good Pharmacy Practice
Notes: Medicines were not stored correctly as per
GPP e.g. floor tiles chipping and leaking ceiling
Risk Rating: E
management
Measure: 3.1.3.4.1 There is a procedure relating
to the management of medical supplies/devices
Notes: The procedure for the management of
medical supplies was not available

C04 Pharmacy

Risk Rating: E
management
Measure: 3.1.3.1.2 CHECKLIST - Procedures
relating to the management of medicine as
required by Good Pharmacy Practice are followed
in the pharmacy/medicine room
Notes: Procedure relating to the management of
medicines as required by GPP was not followed
e.g. staff responsible for the stock of medicine
was not aware of what the budget was
Risk Rating: E
medicine
Measure: 3.1.4.1.1 A document is available which
details the membership and terms of reference of
the multidisciplinary Pharmacy and Therapeutics
committee (PTC) to optimise quality use of
medicine in the health establishment

C04 Pharmacy

Notes: A document detailing the membership and
terms of reference of the PTC was not available
Risk Rating: E
medicine
selection of 3 prescriptions audited shows that
prescribing is done to facilitate rational use of
medicine and in accordance with prescribing
guidelines and policies
Notes: Three prescriptions audited showed that
prescribing was not done in accordance with
prescribing policies e.g. qualification and practice
number, not recorded
Risk Rating: E
medicine
Measure: 3.1.4.1.2 The minutes of the Pharmacy
and Therapeutics committee or relevant forum
demonstrate that actions have been taken to

C04 Pharmacy

optimise the quality use of medicine
Notes: The minutes of the PTC were not available
Risk Rating: E
medicine
procedure is available which outlines the
dispensing of medicines according to the
Pharmacy Act 53 of 1974 and Medicines and
Related Substances Act 101 of 1974
Notes: SOP outlining the dispensing of medicines
was not available
Risk Rating: E
medicine
procedure is available for the compounding of
medicines including extemporaneous compounds
/ cytotoxic and TPN as applicable

C04 Pharmacy

Notes: SOP for the compounding of medicines
was not available
Risk Rating: E
Standard: 3.1.5 An effective pharmacovigilance
and monitoring system ensures adverse drug
reactions are reported and appropriate actions
taken timeously
Measure: 3.1.5.1.1 There are standard operating
procedures for the monitoring of adverse drug
reactions
Notes: SOP for the monitoring of adverse drug
reactions was not available
Risk Rating: E
Standard: 4.4.1 Environmental controls are
implemented to limit environmental damage and
public health risks
Measure: 4.4.1.3.1 The establishment has a
service level agreement for the safe disposal of
toxic chemicals / radioactive waste and expired
medicines with an accredited service provider and
the service levels are monitored for compliance
Notes: The SLA for the safe disposal of toxic

C04 Pharmacy

chemicals and expired medicines was not
available
Risk Rating: E
Standard: 7.1.3 Waiting areas are appropriately
located and provide adequate shelter and seating
for patients
Measure: 7.1.3.1.1 The waiting area has adequate
space / heating / number of chairs to
accommodate all patients in the area
Notes: The waiting area was not having adequate
space and number of chairs
C05 Radiology

Risk Rating: E
Standard: 1.5.1 Waiting times in busy areas are
managed to improve patient satisfaction and care
Measure: 1.5.1.1.2 Patients are informed of how
long they will wait in the queue

C05 Radiology

Notes: Patients not informed of how long they
will wait in the queue
Risk Rating: E
Standard: 3.2.2 Accessible and effective radiology
services enhance patient diagnosis
Measure: 3.2.2.2.4 Each X-ray machine is
provided with a log book which includes quality
control information on the device
Notes: X-ray machine did not have a log book
which include quality control information on the
device
Risk Rating: E
Measure: 3.2.2.2.1 A clearly visible warning notice
regarding the importance of pregnant women
notifying the radiographer before an X-ray is done
is posted outside the X-ray rooms
Notes: Warning notice regarding the importance
of pregnant women notifying the radiographer
before x-ray is done not posted outside x-ray
rooms

C05 Radiology

Risk Rating: E
Measure: 3.2.2.2.2 All radiation workers wear
valid registered dosimeters and there is evidence
that these are monitored on a daily basis for
radiation exposure
Notes: One of the workers in radiology
department did not wear a dosimeter and there
was no evidence of daily monitoring of radiation
exposure
Risk Rating: E
Measure: 3.2.2.2.5 Each X-ray room is provided
with an exposure chart
Notes: X-ray room not provided with exposure
chart
Risk Rating: E
Measure: 3.2.2.2.6 Protective clothing is available
i.e. gonad shields / rubber aprons / gloves /
thyroid shields

C05 Radiology

Notes: Protective clothing such as gloves and
thyroid shields not available
Risk Rating: E
Standard: 3.4.1 Medical equipment for safe and
effective patient care is available and functional
Measure: 3.4.1.1.2 CHECKLIST - Functional
essential equipment as listed in the checklist is
available in the Radiology Department
Notes: Functional essential equipment e.g.
screening unit, drip stand, x-ray mobile, x-ray
units not available
Risk Rating: E
for patients
Notes: Waiting area not having adequate space,
heating and chairs

M01 CEO or Hospital Manager

Risk Rating: V
Standard: 5.2.1 The health establishment`s
management structure and delegations of
authority is at the appropriate levels to ensure
efficient service delivery at the establishment
Measure: 5.2.1.2.2 There is evidence that the
manager complies with clinical practice law in
relation to custodianship of minors/Mental Health
Act (re admission for obs) and consent in
emergency surgery when a patient is unable or
has no next of kin
Notes: Evidence to prove that clinical practice law
is complied with was not available
Risk Rating: V
Measure: 5.2.1.1.2 An up-to-date copy of the
delegations of authority for the manager of the
health establishment or district details the
manager’s authority in terms of financial supply
chain and human resource management
Notes: Functional delegation not available


Risk Rating: V
Standard: 5.4.1 An active programme to assure
and improve quality is implemented and its
effectiveness is monitored and evaluated
Measure: 5.4.1.1.3 Minutes of the relevant forum
reviewing quality (from within the last quarter)
indicate that all quality aspects are regularly
discussed / analysed and actions have been taken
to improve quality
Notes: Minutes for quality forum not signed
Risk Rating: E
Standard: 1.1.2 Patient opinions inform quality
improvements in the health establishment
Measure: 1.1.2.2.2 The patient satisfaction survey
results show that there has been improvement
over time in the results
Notes: Patient satisfaction survey results available
are only for EDS determination of improvement
was not made
Risk Rating: E
Standard: 1.1.3 Health establishment meets the
patients’ expectations of cleanliness / hygiene /
accommodation
Measure: 1.1.3.1.1 Patient satisfaction survey


results show that patients are satisfied with
cleanliness of health establishment
Notes: Patient satisfaction survey results
regarding cleanliness were not available
Risk Rating: E
accommodation
results show that patients are satisfied with linen
services of the health establishment
Notes: Patients satisfaction survey results
regarding linen not available
Risk Rating: E
accommodation
results show that patients are satisfied with food
Notes: Patients satisfaction survey results
regarding food not available


Risk Rating: E
Standard: 1.8.2 Complaints are used to improve
service delivery
Measure: 1.8.2.4.1 Terms of reference of a forum
reviewing complaints (or RELEVANT complaints
for district office) is available which details the
interdisciplinary membership / roles and
responsibilities and strategy to manage
complaints
Notes: Terms of reference of the complaints
forum not available
Risk Rating: E
service delivery
Measure: 1.8.2.3.1 CHECKLIST - Letters to the last
five complainants whose cases have been
completed are in their files and include the
findings and actions
Notes: Copy of response letters of
acknowledgement not found in patients file
Risk Rating: E
Standard: 2.1.1 The basic care and treatment of
patients contributes to positive health outcomes


establishment monitors its morbidity and
mortality statistics and implements improvement
programmes to address concerns
Notes: Evidence that mobility and mortality are
monitored including statistics not available
Risk Rating: E
Standard: 4.1.1 Public participation and
intersectoral collaboration support service
planning and delivery to improve population
health
Measure: 4.1.1.5.3 Minutes or correspondence
(from within the last 12 months) indicate contacts
made to remedy or improve signage and road
access where the health establishment is not
accessible
Notes: Minutes to inform road signage not
available
Risk Rating: E
Standard: 5.1.1 The national / provincial
department or parent company provide the
necessary oversight functions for the health
establishment
Measure: 5.1.1.1.1 The health establishment /
district has received an unqualified or emphasis of


matter audit result from the Auditor General
(qualified or disclaimer audits constitute a 0
score)
Notes: District Hospital received a qualified report
from Auditor General
Risk Rating: E
Standard: 5.1.2 A functional governance structure
is in place at the health establishment
Measure: 5.1.2.1.1 The governance structure has
clear terms of reference which details the
membership / stakeholder representation/
responsibilities and lines of accountability for the
structure
Notes: Terms of reference of governance
structure not available
Risk Rating: E
Standard: 5.1.3 The governance structure
provides appropriate oversight to assure the
quality / accountability / good management of all
business processes
Measure: 5.1.3.6.3 A written organogram of the
health establishment management structure is


available / up to date and displayed
Notes: Organogram not available
Risk Rating: E
business processes
Measure: 5.1.3.6.5 There is documented evidence
that the health establishment adheres to the
appropriate delegations of authority for financial
/ HR / other management control processes
Notes: Delegation for HR not available
Risk Rating: E
business processes
Measure: 5.1.3.6.4 A copy of the delegations of
authority for the manager of the health
establishment details the manager’s authority in
terms of expenditure / procurement and staff
appointments
Notes: Delegations for procurement not available


Risk Rating: E
business processes
Measure: 5.1.3.6.2 All managers have signed
disclosures of financial interest
Notes: Proof that management signed financial
disclosures not available
Risk Rating: E
business processes
Measure: 5.1.3.6.1 Minutes of the governance
structure (from within the last quarter)
demonstrate that management performance is
regularly discussed and monitored and failures in
performance are addressed
Notes: Meeting last held in May 2016
Risk Rating: E


business processes
structure (from within the last quarter) indicate
that human resource management and
development reports of the establishment are
regularly discussed and monitored and remedial
actions are implemented
Risk Rating: E
business processes
that financial reports (including external and
internal audit report of the health Est) are
action is taken
Risk Rating: E


business processes
that quality of care in the health establishment is
actions are implemented
Notes: Meeting last held in 2016
Risk Rating: E
business processes
that organisational risks in the health
establishment are regularly discussed and
monitored and remedial actions are implemented
Risk Rating: E
business processes


that the strategic plan and direction of the
establishment are regularly discussed and
monitored and remedial actions are implemented
to ensure delivery
Notes: Meeting last held in May
Risk Rating: E
Measure: 5.2.1.1.1 A written organogram of the
health establishment management structure is
available/ up to date and displayed at the
entrances of establishments and waiting areas
Notes: Written organogram not available
Risk Rating: E
Standard: 5.2.2 Strategic and operational plans
support the delivery of services according to clear
objectives
Measure: 5.2.2.1.3 Strategic plans reflect
management responsibilities and accountabilities


and detail targets for all action areas
Notes: Strategic plan for 2009/12 was produced
Risk Rating: E
objectives
Measure: 5.2.2.2.2 The operational plans contain
clear service delivery requirements for Finance /
HR / Operations and clinical service components
including targets
Notes: AOP could not be assessed service
alignment was not available
Risk Rating: E
objectives
Measure: 5.2.2.2.1 The operational plans of the
health establishment are aligned with the
provincial APP (annual performance plan) or DHP
(district health plans) targets as relevant
Notes: DHP not available
Risk Rating: E
Standard: 5.2.3 Strategic plans align with national


/ provincial / parent company priorities
Measure: 5.2.3.1.2 The strategic plan is aligned to
national DOH or provincial office/parent company
priorities and considers stakeholder needs and
local priorities
Notes: Provincial strategic plan was outdated
2009/12
Risk Rating: E
Standard: 5.2.3 Strategic plans align with national
/ provincial / parent company priorities
Measure: 5.2.3.1.1 The health establishment has
an up-to-date strategic plan for the current 3-year
period which has been agreed upon by the
governance structures
Notes: Strategic plan for 3 years’ period not
produced
Risk Rating: E
Standard: 5.2.4 Operational plans support the
delivery of services according to clear objectives
Measure: 5.2.4.1.3 The operational plans include
detailed risk assessments of each critical
component in delivering the service against the


plan
Notes: Operational plan was not available
Risk Rating: E
Standard: 5.2.6 Senior managers monitor and
evaluate operational plans to ensure targets are
met
Measure: 5.2.6.2.3 Minutes of management
meetings (from within the last quarter)
demonstrate that internal and external audit
reports are considered and actions are in place to
address concerns
Notes: Minutes of internal and external audits
reports are discussed were not available
Risk Rating: E
Standard: 5.3.1 An effective risk management
system ensures risks identified are management
effectively
Measure: 5.3.1.1.1 The health establishment risk
management strategy document includes
evidence of monitoring and mitigation actions
plans
Notes: HE had no risk management strategy
which includes monitoring and mitigation


Risk Rating: E
Measure: 5.4.1.1.2 There is a
designated/competent person who coordinates
the quality assurance system/programme
Notes: There was no designated person to
coordinating quality
Risk Rating: E
established to review quality for purposes of
quality improvement is available
Notes: Terms of reference for quality
improvement not available
Risk Rating: E
Standard: 5.5.1 The senior managers are held
accountable for implementing the service delivery
objectives of the health establishment against the
strategic and operational plans
Measure: 5.5.1.3.2 Performance management


agreements of the managers are aligned with the
strategic and operational plans and contain
targets and due dates
Notes: Performance agreement not signed
Risk Rating: E
Measure: 5.5.1.3.3 All senior managers have
comprehensive performance reviews of their
performance against targets on a quarterly basis
with plans for remedial action being taken if
necessary
Notes: Performance reviews not produced
Risk Rating: E
Measure: 5.5.1.3.1 A up-to-date signed copy of
the performance management agreement or SLA
between the manager and the supervisor is


available and reflects performance targets
Notes: Performance agreement not signed
Risk Rating: E
Standard: 5.5.2 Senior managers display the
leadership values of the health establishment
Measure: 5.5.2.1.1 Results of staff satisfaction
surveys in the last 12 months shows that
managers are perceived as role models and
leaders in the health establishment
Notes: Staff satisfaction survey results not
available
Risk Rating: E
Measure: 5.5.2.1.2 Results of the staff satisfaction
survey conducted in the last 12 months shows
that staff feel motivated and engaged in their
work
available
Risk Rating: E
Standard: 5.6.1 Internal communication activities
facilitate staff involvement in the health


establishment’s aims and improvement initiatives
Measure: 5.6.1.2.1 The health establishment can
demonstrate that it has used various
communication channels to provide information
to the their staff on quality related issues such as
imbizos / newsletters / emails / staff forums
Notes: Proof for communication with HE not
available
Risk Rating: E
Measure: 5.6.1.2.2 Staff satisfaction survey
results indicate that staff feel are able to actively
participate in decision making and that their
views are taken into consideration on issues
related to quality
available
Risk Rating: E
Standard: 6.6.2 Data is processed and analysed to
provide reports used by management for
decision-making and planning
Measure: 6.6.2.2.2 There is evidence that reports


generated from the Information systems are used
to assist management in decision making and
planning
Notes: Evidence that information generated is
used for planning was not available
Risk Rating: E
Standard: 7.1.1 The buildings and units are
appropriately licensed
an authorisation notice in line with R42 and the
Mental Health Act regulations
Notes: There was no authorisation notice
Risk Rating: D
Measure: 1.5.1.2.1 A document reflecting agreed-
upon local targets or benchmarks for waiting
times is available
Notes: Document for benchmarks on local targets
for waiting times not available
Risk Rating: D


health
Measure: 4.1.1.2.2 Management has a plan in
which the health outcomes and needs of the
community are addressed including an
engagement program with relevant
stakeholders/NGOs
Notes: Plan with health outcomes and needs of
the community not available
Risk Rating: D
health
an up to date map of the catchment population
including the population numbers and
demography in each region
Notes: Map did not include population numbers
Risk Rating: D
health


a health service plan for the current financial year
in which the health outcomes and needs of the
community are addressed
Notes: HE service plan not produced
Risk Rating: D
health
Measure: 4.1.1.2.4 Management has an
understanding of the disease burden (including
psychiatric illnesses) in the catchment population
Notes: Management did not understand HE
diseases burden
Risk Rating: D
health
Measure: 4.1.1.2.5 Management monitors the
presenting complaint/disease being seen at the
establishment


Notes: Proof of monitoring disease seen in the HE
not available
Risk Rating: D
health
Measure: 4.1.1.4.1 Evidence shows that
integrated / intersectoral collaboration in
addressing policies and practices in relation to
environmental hygiene / adolescent health /
nutrition / health promotion / school health
Notes: Integrated meetings not attended
Risk Rating: D
health
Measure: 4.1.1.1.1 Evidence that management
representatives have attended meetings with the
public within the last 12 months
Notes: Evidence that management attended
meetings with public not produced


Risk Rating: D
Standard: 4.1.2 Effective partnerships and
collaboration between different health
authorities enhance service delivery to a defined
catchment population
Measure: 4.1.2.2.2 There is evidence that
different service providers co-ordinate their
outreach programmes to prevent duplication but
ensure coverage of all households
Notes: Outreach programme not in place
Risk Rating: D
Measure: 4.1.2.1.1 Minutes of meetings or
correspondence within the past year indicate
joint planning with other health services in
relation to health service delivery
Notes: minutes for past planning with other
services not available
Risk Rating: D


Measure: 5.6.1.1.1 Communication strategy
within the health establishment is structured to
ensure that all staff are kept informed of that
which impacts on them and the health
establishment
Notes: Communication strategy not available
Risk Rating: D
Standard: 5.6.2 Public relations are actively
managed to provide accurate and appropriate
information on the health establishment’s
services / programmes / policies
Measure: 5.6.2.1.1 An up to date communication
strategy is available in the health establishment
which includes formal and informal mechanisms
for communicating with the public and the
correct authorisation procedure to follow in line
with policy
Notes: Up-to-date communication strategy not
available

M03 Communications/PRO

Risk Rating: V
a policy or protocol for the obtaining of patient
consent if patient identifiable information needs
to be communicated to a 3rd party
Notes: Policy or protocol for obtaining patients
consent for identifiable information needs to be
communicated to 3rd party not available
Risk Rating: E
Standard: 4.2.2 Opportunities to advocate for the
promotion of healthy lifestyles and prevention of
disease and complications are pursued to
improve the health of the population
Measure: 4.2.2.1.2 The establishment has
evidence indicating that it has participated in
health promotion activities with the last 12
months
Notes: HE has not participated in the health
promotion activities


Risk Rating: E
to the their staff on quality related issues such as
imbizos / newsletters / emails / staff forums
Notes: HE could not demonstrate that they have
used proper channels for communication
Risk Rating: E
results indicate that staff feel are able to actively
participate in decision making and that their
views are taken into consideration on issues
related to quality
Notes: Staff satisfaction survey results were not
available
Risk Rating: E


to the public such as Open days/ imbizos /
newsletters / adverts / TV-radio snips or
interviews / queries letters
Notes: Health establishment has not
communicated with TV and media
Risk Rating: E
Measure: 5.6.2.4.1 Contact details of responsible
person for customer care in the health
establishments are visibly displayed
Notes: Contact details of customer care was not
displayed
Risk Rating: E


Measure: 5.6.2.2.1 There is a designated staff
member handling communication matters who is
competent to perform the function
Notes: Designated member handling
communication not appointed
Risk Rating: D
health calendar and a programme indicating
activities in which it supports and/or participates
Notes: Health calendar indicating activities was
not available
Risk Rating: D
Measure: 5.6.1.1.1 Communication strategy
within the health establishment is structured to
ensure that all staff are kept informed of that


which impacts on them and the health
establishment
Notes: There was no communication strategy
Risk Rating: D
Measure: 5.6.2.6.1 A PROATIA manual is available
and accessible to patients in the health
establishment (promotion of access to
information Act)
Notes: PROATIA manual not available
Risk Rating: D
Measure: 5.6.2.1.1 An up to date communication
strategy is available in the health establishment
which includes formal and informal mechanisms
for communicating with the public and the
correct authorisation procedure to follow in line
with policy


Notes: Up-to-date communication strategy not
available
M04 Facility Infrastructure

Risk Rating: X
Standard: 7.2.1 Electrical power / water /
sewerage systems are functional and adequate
for the needs of the establishment
Measure: 7.2.1.3.1 Maintenance record reflects
that emergency generator is functional and
maintained and that the generator is started and
run for at least 15-20 minutes weekly
Notes: Maintenance records reflects that
generator was last maintained in 2015 and
started and run weekly last in 01/04/2016
Risk Rating: V
Standard: 7.1.4 Buildings are maintained to
provide safety and promote a positive image of
the establishment
Measure: 7.1.4.1.1 Maintenance records show


that recommendations of annual management
inspection reports on safety hazards and
maintenance needs are implemented
Notes: Maintenance records showing that
recommendations of annual management
inspection reports on safety hazards and
maintenance needs are implemented not
available
Risk Rating: V
the establishment
Measure: 7.1.4.1.2 No obvious safety hazards are
observed during the visit such as loose electrical
wiring / collapsing ceilings / unstable walls
Notes: Peeling floor tiles observed
Risk Rating: V
Standard: 7.3.1 People and property are actively
protected to minimise safety and security risks
Measure: 7.3.1.1.1 There is a security system
documented in the security policy and in place in
the establishment that covers the buildings and


premises/grounds
Notes: Security policy not available
Risk Rating: E
health
Measure: 4.1.1.5.3 Minutes or correspondence
(from within the last 12 months) indicate contacts
made to remedy or improve signage and road
access where the health establishment is not
accessible
Notes: Minutes indicating contacts made to
remedy road access were not available
Risk Rating: E
Standard: 4.4.1 Environmental controls are
implemented to limit environmental damage and
public health risks
service level agreement for the safe disposal of
toxic chemicals / radioactive waste and expired
medicines with an accredited service provider and
the service levels are monitored for compliance
Notes: The establishment has no SLA for the safe


disposal of toxic chemical/ radioactive waste and
expired medicines with an accredited service
provider
Risk Rating: E
Standard: 7.1.2 Available infrastructure is
appropriately used according to level of care
Measure: 7.1.2.1.1 Inspection records (from the
last 24 months) show that an evaluation has been
carried out to determine whether available
facilities are used as intended in the building
plans
Notes: Inspection records showing that an
evaluation has been carried out to determine
whether available facilities are used as intended
in the building plan not available
Risk Rating: E
Standard: 7.1.6 Grounds are maintained to be
safe and orderly
Measure: 7.1.6.2.1 All access routes are clearly
marked and safe
Notes: Entries from the main gate to OPD is
dilapidated and full of pot holes


Risk Rating: E
Measure: 7.3.1.6.1 The Fire Certificate for the
health establishment is available
Notes: The fire certificate for the HE not available,
however fire extinguisher certificate of
compliance produced
Risk Rating: E
Standard: 7.4.1 The buildings and grounds are
kept clean and hygienic to maximise safety and
comfort
Measure: 7.4.1.4.3 Smoking areas are provided
and identified for staff / visitors and patients
Notes: Smoking area not provided for staff/
visitors and patients
Risk Rating: D
Measure: 7.2.1.1.1 An up-to-date lay out plan of
all the electrical / mechanical / water / sewerage
for any manholes is available
Notes: An up-to-date layout plan of all electrical/


mechanical/ water/ sewerage for any man holes
not available
Risk Rating: D
comfort
Measure: 7.4.1.4.1 There is an anti-smoking policy
applicable to patients / visitors and the staff
Notes: Anti-smoking policy applicable to patients/
visitors and staff not available
M05 Financial Management

Risk Rating: V
Standard: 6.3.1 Expenditure is managed and
monitored to ensure efficiency within legal
frameworks
expenditure variance reports are compiled at
least quarterly and tabled at management


meetings where variances are addressed
Notes: There was no expenditure variance reports
Risk Rating: V
frameworks
exception reports are compiled where
expenditure on high risk / priority areas deviates
from budget by more than 5 percent
Notes: Evidence that exception reports are
compiled were not available
Risk Rating: E
Standard: 5.2.5 Resources are allocated to meet
the strategic and operational plans to ensure
service delivery
Measure: 5.2.5.1.1 There is a budget allocation
plan that includes key priority areas to be funded
which has been approved by the governing
structure
Notes: Budget was not signed by the governance
structure


Risk Rating: E
service delivery
that all relevant managers/unit heads have
provided input into the budget in order to ensure
they reflect the strategic plans of the health
establishment
Notes: Proof that all relevant mangers provided in
plans was not available
Risk Rating: E
met
Measure: 5.2.6.2.2 Annual external audits are
conducted and reports made available to the
management team and governance structures
(only applicable to those which are sampled)
Notes: Annual external reports were not available
Risk Rating: E
met


Measure: 5.2.6.2.3 Minutes of management
meetings (from within the last quarter)
demonstrate that internal and external audit
reports are considered and actions are in place to
address concerns
Notes: Minutes of internal and external reports
were no considered and no action plans taken
Risk Rating: E
met
Measure: 5.2.6.2.1 Internal audit reports of the
last financial year are available to the
management team and provided to the
governance structures
Notes: Proof that internal audits reports were
provided to the governance structure was not
available
Risk Rating: E
frameworks
Measure: 6.3.1.1.1 CHECKLIST - Financial
management systems show adherence to policy


and procedures as well as conform to the legal
requirements
Notes: Financial system did not reflect
segregation of functions and security of verifiable
documents
Risk Rating: E
Standard: 7.1.5 The establishment is organised /
furnished / equipped to meet patient needs and
comfort
Measure: 7.1.5.1.2 There is provision made in the
establishment budget to ensure purchasing and
maintenance of non-medical equipment eg Air
conditioners / Gas Bank / Patient Call system
Notes: The HE has no budget provision for non-
medical equipment
M06 HR Management

Risk Rating: X
Standard: 6.2.1 Staff health and welfare is actively
promoted to improve working lives

M06 HR Management

Measure: 6.2.1.1.3 Measures are in place to
prevent any incident of harm to staff
Notes: Measures to prevent harm or incident in a
documented form was not produced
Risk Rating: X
Measure: 6.2.1.1.2 Recent reports/stats within
the last 12 months show what remedial actions
have been taken in the event of an incident of
harm to a staff member
Notes: Reports/ stats zero reports were not
available however no remedial reports
Risk Rating: V
Measure: 5.5.1.1.2 There is evidence that exit
interviews are conducted with all managers who
have resigned and action plans are put in place
that address issues raised

M06 HR Management

Notes: There were no action plans in place
address issues
Risk Rating: V
Standard: 6.1.1 Human resources are managed in
accordance with documented human resource
policies to ensure safe and effective service
provision
agreements with staff who perform remunerated
work outside the establishment (where they are
permanently employed) are monitored
Notes: There was no monitoring of staff who
perform remunerated work outside HE
Risk Rating: V
provision
Measure: 6.1.1.2.1 Staff patient ratios in key
areas are in accordance with the approved
staffing plan for emergency unit / outpatients /
medical/ surgical / paediatrics / ICU / ECT /

M06 HR Management

psychiatric wards as applicable
Notes: Staff patient ratios were not available
Risk Rating: V
Standard: 6.1.2 Staff performance is reviewed
against defined roles and responsibilities to
ensure agreed outputs are delivered
Measure: 6.1.2.2.1 CHECKLIST - The files of
members of staff reflect that comprehensive
performance reviews are done based on their
performance plans and in accordance with the
human resource management policy
Notes: One Out of five files audited did not have
reviews and PMDS plan e.g. cleaner
Risk Rating: E
Standard: 2.6.1 An Infection Prevention and
Control Programme to reduce healthcare
associated infections is implemented
Measure: 2.6.1.6.2 The annual in-service
education and training plan includes infection
control education / prevention of respiratory
infections especially TB and universal precautions
Notes: Annual in-service education plans not
available

M06 HR Management

Risk Rating: E
Measure: 2.6.1.6.1 Evidence that at least 50% of
health professionals have been trained in
standard precautions in the previous financial
year
Notes: Evidence of at least 50% professional
trained on standard precautions not available
Risk Rating: E
Standard: 3.4.2 Staff are trained in the correct use
of medical equipment
Measure: 3.4.2.1.1 The orientation programme of
the establishment indicates that time has been
allocated for the training of staff in the use of
medical equipment
Notes: Orientation programme was not available
Risk Rating: E
Standard: 3.4.2 Staff are trained in the correct use
of medical equipment
Measure: 3.4.2.1.2 The staff development and in-
service training programme makes provision to
assess and update staff on the correct use of

M06 HR Management

medical equipment
Notes: Staff development plan to assess use of
equipment not available
Risk Rating: E
Standard: 3.5.1 The health establishment has an
effective decontamination process in place
Measure: 3.5.1.2.1 The sterilisation manager is
appropriately qualified in sterile services including
experience and training
Notes: There was no sterilisation manager
allocated to CSSD a health care worker is
allocated in the CSSD
Risk Rating: E
Measure: 3.5.1.2.2 Training records show that
staff working with sterilisation equipment receive
training within the last financial year in the
technical aspects of sterilisation and on use of the
equipment
Notes: There were no training records
Risk Rating: E
Standard: 4.3.1 Emergency plans protect public

M06 HR Management

safety in the event of significant disease
outbreaks or other health emergencies
Measure: 4.3.1.2.2 There is evidence that in-
service training was done on disease outbreaks as
they present
Notes: There were no in-service training records
for disease outbreaks
Risk Rating: E
service delivery
Measure: 5.2.5.3.1 The staff establishment and
related priorities such as MTP/APP ensures
sufficient staff in the required specialties are
available to deliver services as defined in the
strategic plan
Notes: Proof of availability of staff required in
specialist areas was not produced
Risk Rating: E
Measure: 5.5.1.1.1 CHECKLIST - All manager

M06 HR Management

positions are filled with individuals who have the
required qualifications / competencies and
experience
Notes: Not all manager’s positions were filled or
filled with qualified people e.g. HR & Finance
Risk Rating: E
Measure: 5.5.1.3.2 Performance management
agreements of the managers are aligned with the
strategic and operational plans and contain
targets and due dates
Notes: Operational plan not available to check
and verify alignment
Risk Rating: E
Measure: 5.5.2.2.1 Managers have had a
leadership and management competency
assessment performed within the last 2 years

M06 HR Management

Notes: Proof that management competency was
performed was not available
Risk Rating: E
Measure: 5.5.2.2.2 Managers have undergone
leadership and management development
courses within the last 2 years
Notes: Management have not under gone
leadership and management competency
assessment
Risk Rating: E
provision
Measure: 6.1.1.5.5 Staff working hours are
monitored to ensure that they comply with the
Basic Conditions of Employment Act in terms of
hours per week
Notes: There was no proof of monitoring staff
working hours

M06 HR Management

Risk Rating: E
provision
Measure: 6.1.1.1.1 A set of up to date provincial
and health establishment human resource
policies are available
Notes: HR National DPSA and provincial policy not
signed by relevant person
Risk Rating: E
provision
Measure: 6.1.1.4.1 A register / documentation is
available with up to date annual professional
body registration numbers for each category of
staff
Notes: Register for annual professional body
registration not available
Risk Rating: E
Standard: 6.1.2 Staff performance is reviewed
against defined roles and responsibilities to

M06 HR Management

ensure agreed outputs are delivered
Measure: 6.1.2.1.1 CHECKLIST - Job descriptions
outline expected responsibilities/ activities and
duties of the staff member and have been signed
/ accepted and dated
Notes: Out of six reviewed job description all
were not dated reviewed and others not signed
Risk Rating: E
Standard: 6.1.3 Labour Relations policies are
supported by sound employee relations to
protect employee and employer rights
Measure: 6.1.3.1.1 There is a joint
agreement/discussion forum between
management and unions for example on
conducting of disciplinary proceedings and codes
of conduct in the health establishment
Notes: There is no joint agreement between
management and unions
Risk Rating: E
Standard: 6.1.4 A comprehensive programme is
implemented to support staff training and
continuing professional development
Measure: 6.1.4.2.3 Records are kept for each
health care professional in terms of their current

M06 HR Management

status of continuing professional development /
and their further education needs
Notes: Not all files had records of educational
needs e.g. cleaners
Risk Rating: E
Measure: 6.1.4.1.1 The health establishment
provides induction/orientation for all new
members of staff which focuses on policies /
procedures / health and safety / clinical quality
care
Notes: There was no orientation and induction
programmes
Risk Rating: E
Measure: 6.1.4.1.2 A training record for the
Induction/Orientation Programme (from within
the last 12 months) is available and shows that all
new staff have undergone training

M06 HR Management

Notes: There was no orientation and induction
programmes
Risk Rating: E
results show that majority of staff are satisfied
with the education they have received in their
clinical technical areas
available
Risk Rating: E
Measure: 6.1.4.2.2 There is evidence available
that staff have undergone training in line with the
most recent Workplace Skills Plan
Notes: There was no evidence that staff
underwent training in line with skills development
plan

M06 HR Management

Risk Rating: E
Measure: 6.2.1.2.4 There is evidence to
demonstrate that staff participate in formal
initiatives planned within the Employee Wellness
programme such as wellness days and talks
Notes: Proof of participation in the wellness
program not available
Risk Rating: E
12 months) is available and demonstrates that
actions have been taken to improve on areas
identified in staff satisfaction survey
available
Risk Rating: E
results show that majority of staff are satisfied
with their working conditions

M06 HR Management

available to verify working conditions
Risk Rating: E
quarter) demonstrates that staff utilise the
Employee Assistance Programme
Notes: Report for utilisation of EAP was not
available
Risk Rating: E
Measure: 6.2.1.1.1 There is an annual report that
reflects incidence of harm to staff
Notes: Reports of incidences or zero report was
not produced
Risk Rating: D
Measure: 2.3.1.1.1 There are updated job
descriptions for departmental/section heads

M06 HR Management

which clearly indicate that posts are filled by
qualified healthcare professionals and describe
the responsibilities/lines of accountability
Notes: Not all Job descriptions were reviewed and
dated e.g. clinical head.
Risk Rating: D
Standard: 2.5.2 Adverse events are analysed and
managed in order to prevent recurrence and
reduce patient harm
Measure: 2.5.2.3.1 The annual in-service training
plan includes training on how to carry out safety
checks and prevent accidents in the environment
Notes: Annual in-service training not available
Risk Rating: D
Measure: 5.5.1.2.1 CHECKLIST - All managers have
up to date job descriptions (use previous
checklist)
Notes: Job description of filled in posts were

M06 HR Management

available while other posts were not filled in and
no job descriptions e.g. clinical Head
M07 Infection Control

Risk Rating: X
Standard: 2.6.3 Universal precautions are applied
to prevent health care associated infections
Measure: 2.6.3.4.3 CHECKLIST - Appropriate
isolation accommodation exists for patients with
communicable diseases - as a minimum for viral
haemorrhagic disease
Notes: Appropriate isolation accommodation did
not exist for patients with communicable disease
Risk Rating: X
Measure: 2.6.3.4.2 CHECKLIST - Appropriate
isolation accommodation exists for patients with
communicable diseases - as a minimum for
hazardous diarrheal diseases


Notes: Appropriate isolation for patients with
communicable diseases was available but did not
have a parties required for patient with
communicable diseases
Risk Rating: V
Measure: 2.6.1.4.2 Minutes of the forum
reviewing infection control (from within the last
quarter) indicate that infection control
surveillance data and control measures are
regularly discussed / analysed and actions taken
to reduce infections
Notes: Minutes of forum reviewing infection
control were not available
Risk Rating: V
Measure: 2.6.1.4.3 Statistics on common health
care associated infections demonstrate that they
are being monitored monthly


Notes: Minutes of the forum reviewing infection
prevention and control were not available
Risk Rating: V
Measure: 2.6.3.3.1 There is evidence that a hand
washing drive or campaign is held at least
annually in the establishment
Notes: Evidence that a hand washing drive or
campaign was held annually was not available
Risk Rating: E
Measure: 2.6.1.6.4 There is educational material
available for the public / patients on specific
healthcare associated infections that require
additional precautions such as swine flu / MRSA /
cholera
Notes: Educational materials on the specific
health care associated infections such as swine flu
and MRSA were not available to the public


Risk Rating: E
Measure: 2.6.1.4.4 Minutes/documentation of
the forum reviewing infection prevention and
control demonstrate that recommendations on
antibiotic usage based on the organism’s
sensitivity profiles are adhered to where available
Notes: Statistics on common health care
associated infections were not available
Risk Rating: E
Measure: 2.6.1.4.1 Terms of reference of the
forum reviewing infection prevention and control
is available which details the interdisciplinary
membership / roles / responsibilities and strategy
to manage healthcare associated infections
Notes: Terms of reference of the forum reviewing
infection prevention and control were not
available


Risk Rating: E
Measure: 2.6.1.6.3 There is educational material
available for staff on universal precautions
including hand washing / respirator use / the safe
use and disposal of sharps / use of personal
protective equipment / cough etiquette
Notes: Educational materials on use of PPE was
not available to staff
Risk Rating: E
establishment records all notifiable disease and
reports them to the appropriate public health
agency
Notes: There was no evidence that the HE reports
and records all notifiable diseases to the
appropriate public health agency
Risk Rating: E


Measure: 2.6.3.4.1 A policy and procedure is
available that details how infectious patients are
isolated / which isolation facilities are used and
the manner in which these facilities and
equipment are disinfected
Notes: Policy and procedure that details how
infectious are isolated was not available
Risk Rating: E
Measure: 2.6.3.3.2 The results of hand washing
audits show compliance within the health
establishment of at least 80 percent
Notes: Results of hand washing audits were not
available
Risk Rating: E
Measure: 2.6.3.1.1 CHECKLIST - A comprehensive
policy and procedure covering standard
precautions is available


Notes: Comprehensive policy and procedure
covering standard precaution was not available
Risk Rating: D
reports information on health care associated
infections to the appropriate public health
agencies View recent submission within 6 months
Notes: The HE did not report information on
health care associated infections to relevant
public health agencies
M08 Management information system

Risk Rating: E
Standard: 6.6.1 A health management
information system collects / stores and provides
data to meet the needs of management
Measure: 6.6.1.3.2 Proof of testing of contingency


plan is available and includes backup of data /
alternative facilities / power contingencies etc
Notes: Proof of testing contingency plan was not
available
Risk Rating: E
Standard: 6.6.2 Data is processed and analysed to
provide reports used by management for
decision-making and planning
Measure: 6.6.2.2.2 There is evidence that reports
generated from the Information systems are used
to assist management in decision making and
planning
Notes: Evidence that reports generated from
information system is used to assist in planning
was not available
Risk Rating: E
Standard: 6.6.3 Policies and legislation on data
protection ensure confidential information is
properly handled
Measure: 6.6.3.2.1 A written policy regarding
disposal of confidential waste is available
Notes: Policy regarding disposal of confidential
waste was not available


Risk Rating: E
Standard: 6.6.3 Policies and legislation on data
protection ensure confidential information is
properly handled
Measure: 6.6.3.1.1 All confidential records are
archived in a secure / access controlled
environment that is fire proof
Notes: Records area for confidential records is not
safe and fire proofed
M10 Procurement

Risk Rating: E
Standard: 6.4.1 All procedures for the acquisition
of assets are transparent and reflect planned
needs and budgets
show evidence that acquisition of assets within
the last 3 months was in line with procurement
plan
Notes: There was no signed procurement plan

M10 Procurement

Risk Rating: E
Standard: 6.4.1 All procedures for the acquisition
of assets are transparent and reflect planned
needs and budgets
demonstrates that the health establishment
follows procurement policies and procedures
Notes: Evidence demonstrating that HE follows
procurement policies was not produced
Risk Rating: E
Standard: 6.4.2 Assets are managed effectively
and efficiently to maximise use / maintain
adequate levels / reduce losses
Measure: 6.4.2.2.1 Records show that the
manager in charge of assets monitors the service
level agreements for maintenance of the assets
on a regular basis and addresses any concerns
directly with the supplier of services
Notes: Proof that assets are monitored and
condemns directly auctioned not available
Risk Rating: E
Standard: 6.4.3 Contracts for the supply of goods
and services are managed and monitored to
ensure performance / quality / value-for-money

M10 Procurement

Measure: 6.4.3.2.1 Documentary evidence (from
within the last quarter) show that the
performance of a sample of two current
outsourced contracts are monitored monthly
according to the specifications in the contract and
SLA
Notes: Proof of monitoring contract of current
outsourced contracts not available
Risk Rating: E
Standard: 6.4.3 Contracts for the supply of goods
and services are managed and monitored to
ensure performance / quality / value-for-money
Measure: 6.4.3.3.1 There are records showing
that any areas of failure or non-performance are
addressed and taken up with the contractor for
correction A stipulated period is given in which
the failures must be corrected
Notes: Proof of addressing failures or taken up
with contractor was not available
Risk Rating: E
Standard: 6.4.4 Efficient management of stock
ensures that supplies meet planned service needs
at all times
Measure: 6.4.4.2.2 Physical stock corresponds to

M10 Procurement

stock on the inventory management system
Notes: Verification of correspondence could not
be done, no stock cards
Risk Rating: E
at all times
shows minimum / maximum / re-order levels
Notes: Up-to-date stock control system with
minimum and maximum re-order levels not
available
Risk Rating: E
at all times
terms of agreement for the supply of stock is
available and there is evidence that compliance
with the agreement is being monitored and
appropriate action taken
Notes: Document outlining terms of agreement
for supply of stock was not available

M12 Occupational health and safety

Risk Rating: V
Standard: 6.2.2 Staff are protected from exposure
to workplace hazards through effective
Occupational Health and Safety systems
Measure: 6.2.2.3.3 Evidence shows that medical
examinations are performed for all health care
workers who are exposed to potential
occupational hazards when performing their
duties (e.g. radiation / infectious diseases
including TB / chemicals)
Notes: Evidence showing that medical
examinations are performed for health care
workers exposed to potential occupational
hazards when performing their duty was not
available
Risk Rating: V
Measure: 6.2.2.4.2 Records of needle stick
injuries show that those staff have received post
exposure prophylaxis and have been re-tested


Notes: Records of needle stick injuries showing
that staff has received post exposure prophylaxis
Risk Rating: V
Measure: 6.2.2.2.2 Minutes of the occupational
health and safety committee / forum (from within
the last 6 months) indicate that occupational risks
are regularly discussed / analysed and actions
implemented to reduce significant risks
Notes: Minutes of occupational health and safety
committee/ forum were not available as there
was no health and safety committee
Risk Rating: E
Measure: 6.2.2.3.1 A pre-placement examination
is performed before commencement of duty or
within 14 days of employment if relevant
Notes: Pre-placement examination was not


performed before commencement of duty or
within 14 days of employment
Risk Rating: E
Measure: 6.2.2.3.2 Health risks assessments are
conducted on all areas in the health
establishment and monitored regularly
Notes: Health risk assessment were not
conducted in the HE
Risk Rating: E
Measure: 6.2.2.2.1 The terms of reference of the
occupational health and safety committee /
forum is available and details the interdisciplinary
membership / roles / responsibilities and strategy
to manage occupational risks
Notes: Terms of reference of occupational health
and safety committee/ forum were not available


Risk Rating: E
Measure: 6.2.2.1.1 CHECKLIST - Responsible
persons are designated as specified in the OHS
Act with signed letters which outline their
responsibilities
Notes: The responsible persons were not
designated as specified in the OHS Act
Risk Rating: E
Measure: 6.2.2.4.1 Records show that healthcare
workers have been given prophylactic
immunisations for high risk infections such as
hepatitis B
Notes: Records showing that health care workers
have been given prophylactic immunisations were
not available

M14 Clinical Management Group

Risk Rating: X
place for patients undergoing high risk procedures
Measure: 2.4.3.3.1 CHECKLIST - The establishment
has a formal policy for handling emergency
resuscitations
Notes: Policy for handling emergency
resuscitation not available
Risk Rating: V
Standard: 1.4.1 Management of referrals
preserves the quality of patient care
Measure: 1.4.1.1.1 CHECKLIST - There is an up to
date patient referral policy and protocol available
in the health establishment/unit which includes
all critical aspects
Notes: Referral policy excluded protocol
responsibility of referring doctor and feedback to
family not available
Risk Rating: V
Standard: 1.6.1 The management of emergency
patients arriving at or referred from the health
establishment preserves the quality of patient
care
Measure: 1.6.1.4.2 Procedure emphasises the


speedy handover of patients to reduce handover
time from EMS to hospital staff
Notes: Procedure for speedy handover to reduced
time from EMS not available
Risk Rating: V
care
Measure: 1.6.1.4.1 There is a procedure
governing the handover of patients from EMS to
hospital staff
Notes: Procedure for handover of patients from
EMS not available
Risk Rating: V
health establishment participates in monthly
maternal/perinatal morbidity and mortality
meetings
Notes: Presented mobility and mortality minutes
were not signed


Risk Rating: V
Standard: 2.2.1 The establishment provides
clinical care so as to ensure positive outcomes in
identified priority initiatives including meeting the
Millennium Development Goals
Measure: 2.2.1.3.2 The report on health initiatives
or programmes shows that quality improvement
plans have been implemented in order to address
shortcomings and improve outcomes
Notes: Report on initiatives and programme had
no QIP
Risk Rating: V
Measure: 2.2.1.2.1 CHECKLIST - The establishment
conducts clinical audits of each priority
programme/health initiative Review the clinical
audit reports - checklist provided If no clinical
audits conducted review 3 patient files per
priority program
Notes: Clinical audits not conducted and reviews
not performed


Risk Rating: V
Standard: 2.4.1 There is a structured approach to
the management of clinical risk in the
establishment
reviewing clinical risks (from within the last
quarter) indicate that clinical risks and adverse
events are regularly discussed / analysed and
actions have been taken to reduce significant risks
Notes: Minutes for reviewing clinical risks not
available
Risk Rating: V
Standard: 2.4.2 The care rendered to patients
with special needs contributes to their recovery
and well-being
procedure for the care of the terminally ill which
addresses the needs of the patients and their
family
Notes: Procedure for terminally ill was not
approved
Risk Rating: V


and well-being
procedure for conducting and acting on risk
assessments of patients with reduced mobility
Notes: Procedure for conducting risk assessment
did action plans not available
Risk Rating: V
and well-being
procedure for conducting and acting on risk
assessments of frail and aged patients
Notes: Procedure for conducting risk assessment
not appointed by relevant authority
Risk Rating: V
Measure: 2.4.3.4.1 A protocol regarding the safe
administration of medicines to patients is
available including a protocol for the safe
administration of medicines to children


Notes: Protocol regarding administration of
medicine not available
Risk Rating: V
reviewing resuscitations (from within the last
quarter) indicates that resuscitations are regularly
discussed / analysed and actions have been taken
to reduce significant risks
Notes: Minutes of the forum reviewing
resuscitations not available
Risk Rating: V
Standard: 2.5.1 Adverse events are identified and
promptly responded to reducing patient harm
and suffering
Measure: 2.5.1.1.2 CHECKLIST - Adverse event
reports reflect that immediate actions are taken
at the time of incident and a root cause analysis
was done to prevent recurrence
Notes: Files of adverse events not found
Risk Rating: V


reduce patient harm
reviewing adverse events (from within the last
quarter) indicates that adverse events are
regularly discussed / analysed and actions are
taken to prevent recurrence
Notes: Minutes for adverse events not available
Risk Rating: V
Measure: 2.6.1.2.1 There is a qualified and or
experienced healthcare professional with
designated responsibilities for infection control in
the health establishment
Notes: There was no dedicated person to manage
responsibilities for infection control
Risk Rating: V
management


procedure is available which indicates how
schedule 5 and 6 medicines are stored /
controlled / distributed in accordance with the
Medicines and Related Substances Act 101 of
1965
Notes: SOP for schedule 5&6 was not available
Risk Rating: V
Standard: 3.1.5 An effective pharmacovigilance
and monitoring system ensures adverse drug
reactions are reported and appropriate actions
taken timeously
Measure: 3.1.5.1.2 The minutes of the forum
which deals with adverse drug reactions
demonstrates that actions have been taken to
report / analyse and take appropriate action
regarding adverse drug reactions
Notes: Minutes which deal with drug adverse
events not available
Risk Rating: V
Measure: 3.3.1.1.2 All adverse blood reactions are
documented and reported to the forum dealing


with adverse events on a monthly basis
Notes: Documentation for adverse events blood
reactions not available
Risk Rating: E
Measure: 1.1.2.2.2 The patient satisfaction survey
results show that there has been improvement
over time in the results
Notes: Patients satisfaction survey not available
Risk Rating: E
Measure: 1.1.2.1.1 A report of the annual patient
satisfaction survey indicates that a survey was
done in the last 12 months
Notes: Report of annual patient’s satisfaction
survey not available
Risk Rating: E
accommodation


results show that patients are satisfied with food
Notes: Patients satisfaction survey regarding food
not available
Risk Rating: E
accommodation
results show that patients are satisfied with linen
Notes: Patients satisfaction survey regarding linen
not available
Risk Rating: E
accommodation
results show that patients are satisfied with
cleanliness of health establishment
Notes: Patients satisfaction survey not available
Risk Rating: E
Standard: 1.2.1 Patients are provided with


information to enable them to make informed
decisions regarding their care
Measure: 1.2.1.2.1 There are up to date written
policies or guidelines relating to informed consent
including consent for HIV and clinical trials
Notes: Policy relating to informed consent not
available
Risk Rating: E
reviewing referrals (from within the last quarter)
indicates that referral data is regularly discussed /
analysed and actions have been implemented to
improve the referral system
Notes: Minutes of the referral forum not available
Risk Rating: E
Measure: 1.5.1.2.2 A report on measured waiting
times (from within the last 6 months) is available
and demonstrates that waiting times have been


analysed and improved over time
Notes: Report for waiting times not available
Risk Rating: E
Standard: 1.5.2 Waiting times for patients to
access elective care are managed to improve
efficiency in the delivery of healthcare
Measure: 1.5.2.1.1 A report shows that waiting
times for elective procedures are monitored on a
regular basis and have improved over time
Notes: Report of waiting time for elective
procedures was not available
Risk Rating: E
care
Measure: 1.6.1.3.1 A written policy is available
regarding health establishment closures and
ambulance diversions
Notes: Policy regarding diversions and closure of
ambulance not available
Risk Rating: E
Standard: 1.7.1 The package of services offered at


the health establishment are in accordance with
national guidelines or licensing specifications
Measure: 1.7.1.1.1 CHECKLIST - The defined
package of service is available for the type of
health establishment/unit or level of care
Notes: Other relevant service in the service
package are not rendered e.g. mental health,
surgery and mortuary
Risk Rating: E
Standard: 1.8.1 Patients complaints are managed
systematically and to patient’s satisfaction
Measure: 1.8.1.1.1 CHECKLIST - The health
establishment has an up to date procedure for
the management of complaints which includes
acknowledgement / investigation/ response and
timelines and mitigation strategy
Notes: Produced complaints guidelines were from
national
Risk Rating: E
service delivery
Measure: 1.8.2.2.1 Complaints relating to serious
adverse events are managed via the adverse
events management system and noted as such in


the complaints register
Notes: Complaints relating to address events not
sent to the forum
Risk Rating: E
service delivery
Measure: 1.8.2.3.1 CHECKLIST - Letters to the last
five complainants whose cases have been
completed are in their files and include the
findings and actions
Notes: Letters did not contain action plans taken
Risk Rating: E
service delivery
reviewing complaints (or RELEVANT complaints
for district office) is available which details the
interdisciplinary membership / roles and
responsibilities and strategy to manage
complaints
Notes: Terms of reference for forum reviewing
complaints not available


Risk Rating: E
service delivery
reviewing complaints (from within the last
quarter) indicates that complaints statistics are
regularly discussed / analysed and actions
implemented to address concerns
Notes: Minutes of the forum reviewing
complaints not available
Risk Rating: E
service delivery
Measure: 1.8.2.1.2 Complaints are classified by
order of severity
Notes: Complaints not classified in order of
severity
Risk Rating: E
Measure: 2.2.1.1.1 CHECKLIST - The most up to
date guidelines on the national strategic priority


programmes or health initiatives are available
Notes: Not all national strategic priority
programmes were available e.g. cervical cancer
and choice of TOP
Risk Rating: E
Measure: 2.2.1.3.1 CHECKLIST - Evidence is
available that health outcomes of the priority
programmes or health initiatives are monitored
against the relevant targets
Notes: Health outcomes of priority programmes
conductions are not monitored
Risk Rating: E
Measure: 2.3.1.4.1 A recent quality improvement
plan/programme within the last 6 months shows
that healthcare professionals / nurses /
pharmacists and doctors / are responsible for
implementing relevant improvements to patient


care
Notes: QIP produced was date May 2015 with no
progress
Risk Rating: E
establishment
Measure: 2.4.1.1.1 There is an up to date clinical
risk policy and protocol which highlights the
establishments approach to the management of
clinical risk
Notes: Clinical risk policy was not available
Risk Rating: E
establishment
reviewing clinical risk is available which details the
interdisciplinary membership / responsibilities /
accountability / strategy to manage clinical risks
Notes: Terms of reference of a forum reviewing
clinical risk was not available


Risk Rating: E
establishment
Measure: 2.4.1.2.2 Clinical risk assessments are
conducted in each service/department of the
establishment according to relevant policy and/or
guidelines
Notes: Clinical risk assessment are not conducted
by each department
Risk Rating: E
Measure: 2.4.3.3.2 An appropriate forum to
review all resuscitations is formally constituted
with terms of reference and appropriate
multidisciplinary membership
Notes: Forum that reviews resuscitation not
available
Risk Rating: E
and suffering
Measure: 2.5.1.2.2 There is a procedure in place


to support staff affected by adverse events
Notes: Procedure to support staff affected by
adverse events not available
Risk Rating: E
and suffering
Measure: 2.5.1.1.1 There is an up to date adverse
events policy available which details the
establishments/units approach to the
management of clinical risk including risk
identification methods
Notes: An up-to-date adverse event policy not
available
Risk Rating: E
reduce patient harm
Measure: 2.5.2.1.2 The forum reviewing clinical
risk strategy has clear terms of reference which
details the interdisciplinary membership /
responsibilities / lines of accountability and
strategy to manage clinical risks


Notes: Forum reviewing clinical risks not
appointed
Risk Rating: E
reduce patient harm
Measure: 2.5.2.4.1 There is evidence that adverse
events for the health establishment are
monitored against relevant targets including falls
/ pressure sores / injuries / medication errors
Notes: Evidence that adverse events against
targets are monitored not available
Risk Rating: E
reduce patient harm
Measure: 2.5.2.1.1 Establishment has a reporting
system for adverse events indicating severity /
categorisation and actions taken
Notes: HE has no system to report adverse events
Risk Rating: E


Measure: 2.6.1.1.1 CHECKLIST - A policy regarding
infection control in the health establishment/unit
covers all aspects of infection prevention and
control
Notes: IPC Policy not available instead a WHO IPC
Guidelines produced for infection prevention and
control outdated 2003
Risk Rating: E
a system for monitoring health acquired
infections
Notes: HE has no system to monitor HAI
Risk Rating: E
medicine
Measure: 3.1.4.1.1 A document is available which
details the membership and terms of reference of
the multidisciplinary Pharmacy and Therapeutics


committee (PTC) to optimise quality use of
medicine in the health establishment
Notes: PTC terms of reference not available
Risk Rating: E
medicine
Measure: 3.1.4.1.2 The minutes of the Pharmacy
and Therapeutics committee or relevant forum
demonstrate that actions have been taken to
optimise the quality use of medicine
Notes: Minutes of PTC not available
Risk Rating: E
Measure: 4.1.2.2.1 There is a structured outreach
programme providing services and supporting the
community
Notes: Outreach programme not available


Risk Rating: E
Measure: 4.2.2.1.2 The establishment has
evidence indicating that it has participated in
health promotion activities with the last 12
months
Notes: Proof of participation in health promotion
not produced
Risk Rating: E
Measure: 4.3.1.3.1 An annually updated disaster
management plan is available and displayed at
strategic points
Notes: Annually disaster management plan
available but not displayed
Risk Rating: E


Measure: 4.3.1.1.1 An intersectoral plan for
management of possible health emergencies and
disease outbreaks is available and has been
updated in the last 12 months
Notes: Diseases outbreak not available
Risk Rating: E
conducts at least yearly drills to test the
preparedness of their disaster plan including
emergency / disease outbreak / fire / natural
disaster
Notes: Drills have not been conducted
Risk Rating: E
Measure: 4.3.1.2.1 CHECKLIST - Staff members in
management are aware of the disease outbreak
plans and of their roles in this plan (e.g. for a
cholera / diarrheal / influenza outbreak)


Notes: Staff members in management was not
aware of management of disease outbreak
Risk Rating: E
Standard: 7.2.4 A functional public
communication system allows communication
throughout the establishment in the event of an
emergency
Measure: 7.2.4.1.1 There is a functional alerting
system in the establishment that sounds
throughout staffed areas
Notes: Alerting system not functional
Risk Rating: E
Measure: 7.3.1.7.1 There are quarterly
emergency drills
Notes: Drills not conducted
Risk Rating: D
Measure: 1.1.2.2.1 Minutes of the forum which
considers patient satisfaction surveys (from
within the last 12 months) shows that results are


regularly discussed/analysed and actions are
taken to address concerns
Notes: Report of PSS not available and minutes of
the forum not available
Risk Rating: D
Measure: 1.2.1.4.1 There is an up to date ethical
research policy and protocol available in the
health establishment
Notes: Policy compiled by head of nursing not
approved and did not include research
Risk Rating: D
reviewing referrals is available which details the
interdisciplinary membership / roles /
responsibilities and strategy to manage and
improve the referral system
Notes: There were no terms of reference for the
committee


Risk Rating: D
Measure: 1.5.1.2.1 A document reflecting agreed-
upon local targets or benchmarks for waiting
times is available
Notes: Document for benchmark on local target
for waiting time not available
Risk Rating: D
reduce patient harm
Measure: 2.5.2.3.1 The annual in-service training
plan includes training on how to carry out safety
checks and prevent accidents in the environment
Notes: Annual in-service training plan not
produced

M16 Case Management

Risk Rating: E
Measure: 1.2.1.1.3 There is a process by which
patients who have 3rd party funders of their care
are informed if they are self liable for portions of
the cost of their admission
Notes: There is no process specific for informing
patients if they are liable for portions of cost of
their admission
Risk Rating: E
Standard: 3.7.1 Efficiency management systems
ensure that the entire patients clinical event is
managed in such a manner that they receive
adequate safe quality healthcare
Measure: 3.7.1.3.3 There is evidence to show that
quality improvement programmes are in place to
improve the accuracy of coding
Notes: Quality improvement programme to
improve accuracy of coding not in place
Risk Rating: E

M16 Case Management

Measure: 3.7.1.3.1 There is evidence that audits
are conducted to ensure efficient and accurate
billing for healthcare services
Notes: Audits to ensure efficient and accurate
billing are not conducted
Risk Rating: E
to monitor and mitigate against patient’s medical
aid funds being exhausted and them not having
access to care
Notes: Mitigation against medical Aid funds from
exhaustion is not done
Risk Rating: E

M16 Case Management

quality improvement plans have been
implemented to address shortcomings in length
of stay and level of care
Notes: There were no QIPs to address length of
stay
Risk Rating: D
Measure: 3.7.1.2.1 There is evidence that types of
funder rejections on claims are monitored to
ensure appropriate care is being delivered to
patients - rejections on Compliance to funder
rules for authorisations / benefits / limits /
predictable
Notes: Funders rejection are not monitored
Risk Rating: D
Measure: 3.7.1.1.1 The case management
department is staffed adequately based on

M16 Case Management

workload as shown by patient admissions/
consultations and procedures
Notes: There was no dedicated person for case
management
Risk Rating: D
Measure: 3.7.1.1.6 There is a system in place to
measure average cost per patient day / monitor
outliers and develop improvement plans to
address shortcomings
Notes: There was no system to measure cost per
patient’s day
Risk Rating: D
the establishment monitors the average Length of
Stay and Level of Care for the top 10 Diagnoses
against standard norms and targets

M16 Case Management

Notes: Evidence of monitoring level of case and
top 10 Diagnoses was not available
Risk Rating: D
Measure: 3.7.1.1.3 Case management systems
allow for the pre-authorisation of procedures and
for regular updates and final verification
information to be sent to funders
Notes: Regular updates are not done
Risk Rating: D
Measure: 3.7.1.1.2 Case managers receive
appropriate formal training and in-service
updates in efficiency management topics
Notes: Case managers have not been trained on
management topics

M16 Case Management

Risk Rating: D
Measure: 3.7.1.2.2 There are procedures to
mitigate against cost of healthcare being passed
onto the patient unnecessarily such as
motivations for clinically appropriate services /
LOC management/utilisation and case
management/co-payment monitoring
Notes: There are no procedures to integrate
against cost of health care passed on the patient
P01 Accident and Emergency Unit

Risk Rating: X
Measure: 1.2.1.2.2 CHECKLIST - Forms used for
informed consent are completed correctly by the


health professionals
Notes: Forms used for informed consent not
correctly completed e.g. consent not signed by
patient and not signed by two witnesses
Risk Rating: X
Measure: 2.4.3.5.1 CHECKLIST - Patient files
demonstrate that the protocol on administration
of blood has been adhered to
Notes: Protocol for administration of blood not
adhered to e.g. consent not signed
Risk Rating: X
Measure: 2.4.3.3.4 CHECKLIST - Emergency
trolleys are standardised/ appropriately stocked
and regularly checked (Part 1)
Notes: Emergency trolley not stocked
appropriately with non-functional larynges scopes
and expired medicines
Risk Rating: X


Notes: Emergency trolley not appropriately
stocked with expired K Y jelly and and or
pharyngeal airways
Risk Rating: X
that in the event of a power disruption
emergency power supply is available in critical
clinical areas such as ICU / Theatre / Accident and
Emergency / ECT
Notes: Evidence that in the event of power
failure/ disruption power supply is available not
available
Risk Rating: X
Measure: 7.2.1.7.12 There is a functional system


to supply piped suction/vacuum to all clinical
areas
Notes: Functional system to supply of piped
vacuum not available
Risk Rating: X
to supply piped medical gas to all clinical areas
Notes: Functional system to supply of piped
medical gas not available
Risk Rating: V
accommodation
Measure: 1.1.3.1.2 CHECKLIST - 6 Areas are
checked for the state of cleanliness
Notes: Areas checked for state of cleanliness such
as toilet not clean and cotton wool disposed with
sharps
Risk Rating: V


care
Measure: 1.6.1.1.1 CHECKLIST - Patient records
demonstrate that the correct handover procedure
was followed between EMS staff and
establishment staff
Notes: Handover procedure not followed
between EMS and establishment staff e.g. vital
signs not monitored during transportation and
method of transfer not recorded
Risk Rating: V
care
Measure: 1.6.1.2.1 CHECKLIST - Patient records or
files indicate that the guidelines regarding
examination and stabilisation have been adhered
to
Notes: Guidelines regarding examination and
stabilisation not adhere to e.g. patients not
triaged complete history not taken, vital signs not
monitored during stay in hospital


Risk Rating: V
essential medical equipment as listed in the
checklist is available in the Trauma/Accident and
Emergency room/ECT room
Notes: Functional essential equipment not
available e.g. Tourniquet, lockable medicine
cupboard
Risk Rating: V
comfort
Measure: 7.4.1.2.1 CHECKLIST - Cleaning materials
cloths / dusters / scourers and chemicals and
equipment are available and stored in an
appropriate safe lockable area / with clear labels
for equipment used internally and externally
Notes: Cleaning materials such as protective
polymer and wet vacuum pick up not available
Risk Rating: E
Standard: 1.1.1 Patient are treated in a caring and
respectful manner by staff with the appropriate


values and attitudes
Measure: 1.1.1.2.1 Patients can be consulted in a
room/cubicle or receive treatment in a ward in a
manner which allows for privacy either through
closed doors / screens or curtains
Notes: Document which allows privacy when
consulting patients not available
Risk Rating: E
accommodation
Measure: 1.1.3.4.1 There is clean water and
disposable cups for patients in waiting
areas/court yards
Notes: Clean water and disposable cups not
provided
Risk Rating: E
a procedure/protocols in place by which referrals
and bookings for patients requiring specialist
interventions are done
Notes: Protocol by which referrals and bookings


for patients requiring specialist interventions not
available
Risk Rating: E
Measure: 1.4.1.1.4 CHECKLIST - The files of the
last patients transferred into the health
establishment contain copies of a referral letter
from the referral health establishment
Notes: Copy of referral letter not in file and two
other files not produced
Risk Rating: E
Measure: 1.4.1.1.3 A written procedure for
accessing patient transport services is available
Notes: Procedure for accessing patient transport
services not available
Risk Rating: E
last patients transferred out of the health


sent to the receiving health establishment
Notes: Copy of referral letter for patients
transferred out not in file
Risk Rating: E
Measure: 1.4.1.1.2 A map/list of catchment areas
and service providers in the referral chain with
contact details is available in patient care areas
Notes: Map of catchment areas and service
providers with contact details not in placed
Risk Rating: E
Measure: 1.5.1.1.1 There is a person/s
responsible for the management of queues and
patient flow
Notes: There is no person responsible for the
management of queues and patient flow
Risk Rating: E


Notes: Patients are not informed of how long they
Risk Rating: E
Measure: 1.5.1.4.3 Observe whether special
queues are designated for specific groups of
patients
Notes: Special queues for specific groups of
patients not designated
Risk Rating: E
reduce waiting time for files
Notes: System to reduced waiting time not in
place
Risk Rating: E
systematically and to patients satisfaction
Measure: 1.8.1.2.1 Information on the procedure


for complaints is clearly displayed in all service
areas
Notes: Information on procedure for complaints
not displayed
Risk Rating: E
management
Measure: 3.1.3.1.3 CHECKLIST - Medicines in the
wards or consultation rooms are appropriately
stored and managed
Notes: Medicines in the ward not appropriately
stored and managed e.g. cupboard not locked,
some expired medicine found on it e.g. folic acid
Risk Rating: E
management
and/or 6 drug register are complete and correct
and include date/ name of person who
administered it and balance in stock


Notes: Entries in the schedule 5&6 drug register
incorrect e.g. no witness for medicines
administered
Risk Rating: E
medicine
Notes: Prescribing not done to facilitate rational
use of medicine e.g. practice number and dosage
forms not recorded
Risk Rating: E
available in the Outpatient department and
consulting rooms
Notes: Functional essential equipments such as


aneroid BP apparatus with cuffs for obese
patients, metal glass door cabinet with shelves for
instruments not available
Risk Rating: E
Measure: 4.3.1.3.3 CHECKLIST - 3 Staff members
are interviewed to evaluate their awareness of
the disaster management plan including health
emergencies and their role in the plan
Notes: Staff not aware of where disaster
management document is, no CPR posters, one
not able to explain triaging
Risk Rating: E
strategic points
Notes: Disaster management plan not available


Risk Rating: E
Measure: 6.6.1.1.1 CHECKLIST - Hardware /
software and network connectivity supports local
needs and staff have the skills to use them
Notes: N/A no computer in the department
Risk Rating: E
for patients
Measure: 7.1.3.1.2 Waiting areas are located in
the areas where the service takes place
Notes: Waiting area not located where service
takes place
Risk Rating: E
for patients


Notes: Waiting area has inadequate space and
number of chairs
P02 Outpatient department

Risk Rating: X
appropriately, has larynges scope blades non
functional, expired emergency medicine such as
cyclokapron, lanoxin
Risk Rating: X


appropriately e.g. gloves, BP cuffs not available
Risk Rating: X
areas
Notes: There is no functional system to supply
piped suction/ vacuum to all clinical areas
Risk Rating: X
Notes: There is no functional system to supply
pipes medical gas to all clinical areas
Risk Rating: V
accommodation


Notes: Areas checked for state of cleanliness not
clean toilet has bad odour, spider webs in storage
room and cotton wool in sharps containers
Risk Rating: V
comfort
Notes: Cleaning materials such as paper towels
protective polymer not available
Risk Rating: E


Notes: Document which allows patients to be
consulted in a manner that promote privacy not
available
Risk Rating: E
accommodation
areas/court yards
Notes: Clean water and disposable cups for
patients in waiting area not provided
Risk Rating: E
Notes: Map of catchment areas and service
providers in the referral chain not available
Risk Rating: E


a procedure/protocols in place by which referrals
and bookings for patients requiring specialist
interventions are done
Notes: Procedure by which referrals and booking
for patients requiring specialist interventions are
done not available
Risk Rating: E
patient flow
Notes: There is no person responsible for the
management of queues
Risk Rating: E
Notes: System to reduce waiting time for files not
in place


Risk Rating: E
patients
Notes: Special queues are not designated for
specific groups of patients
Risk Rating: E
Notes: Patients are not informed of how long they
Risk Rating: E
systematically and to patients satisfaction
areas
Notes: Information on the procedure for
complaints not displayed in all areas


Risk Rating: E
Standard: 2.6.2 Specific precautions are taken to
reduce or prevent respiratory infections
Measure: 2.6.2.3.1 CHECKLIST - Staff responsible
for transportation of patients follow the protocol
for the safe transport of infected patients in
terms of reducing the risk of transmission
Notes: Staff did not mention not transporting
patients with other health problems
Risk Rating: E
medicine
Notes: Audited prescription did not show that
prescribing was done to facilitate rational use of
medicine e.g. practice number, number of doses
and illegible scripts not recorded


Risk Rating: E
strategic points
Notes: Disaster management plan not displayed
and not available
Risk Rating: E
Notes: Staff was not aware of the location of
disaster management document CPR posters not
in place and unit not having enough equipment to
be used in disaster
Risk Rating: E


Notes: N/A no computer in the department
Risk Rating: E
for patients
Measure: 7.1.3.1.2 Waiting areas are located in
the areas where the service takes place
Notes: Waiting areas not located where service
takes place
Risk Rating: E
for patients
Notes: Waiting area has inadequate space and
chairs to accommodate all patients


Risk Rating: D
Measure: 1.2.1.1.1 Detainees for forensic
ward/Patient rights posters or leaflets are
available in the common local languages of the
geographic area
Notes: Patients rights posters/ leaflets not
available
P03 Maternity Ward incl maternity theatres

Risk Rating: X
and well-being
Measure: 2.4.2.6.1 Security measures are
adequate to safeguard newborns and
unaccompanied children including restricted
access and exit monitoring in wards/
identification of newborns/ children and their


parents
Notes: Security measures are inadequate to safe
guard new born, access not restricted, new born
and parents not identified
Risk Rating: X
and well-being
Measure: 2.4.2.5.1 CHECKLIST - Initial
assessments of high risk maternity patients reflect
the identification of specific risk factors
Notes: Initial assessments of high risk maternity
patients reflected that specific factors were not
identified e.g. labour graph was not used
Risk Rating: X
procedures
Notes: Emergency trolley was not appropriately


stocked e.g. eye protecting mask, laryngeal mask,
airway and scissors not available
Risk Rating: X
procedures
Notes: Emergency trolley was not appropriately
stocked and regularly checked e.g. defibrillator,
tracheal tubes not available, expired medicines
observed
Risk Rating: X
areas
Notes: There was no functional system to supply
piped suction to all clinical areas


Risk Rating: X
piped medical gas to all clinical areas
Risk Rating: X
that in the event of a power disruption
emergency power supply is available in critical
clinical areas such as ICU / Theatre / Accident and
Emergency / ECT
Notes: Documented evidence that in the event of
a power disruption emergency power supply is
available not available
Risk Rating: V


patients/detainees recently discharged show that
a comprehensive clinical assessment and
diagnosis has been done
Notes: The recently discharged patient files show
that clinical assessment and diagnoses has not
been done comprehensively e.g. there was no
evidence that patients were informed about
health education
Risk Rating: V
available in the Maternity ward
Notes: Essential equipment listed were not all
available as listed in the checklist e.g. infusion
pump, glucose meter, HB meter were not
available
Risk Rating: V
Measure: 7.3.1.2.1 Security systems are
positioned at vulnerable patient areas such as
maternity / paediatric / psychiatric and


emergency units and access and egress points
Notes: Security system were not positioned in
maternity
Risk Rating: V
comfort
Measure: 7.4.1.2.1 CHECKLIST - Cleaning
materials cloths / dusters / scourers and
chemicals and equipment are available and stored
in an appropriate safe lockable area / with clear
labels for equipment used internally and
externally
Notes: Cleaning materials and chemical and
equipment such as protective polymer, plain
liquid soap, paper towels, surgical masks were not
available
Risk Rating: E
Standard: 2.6.4 Strict infection control practices
are observed in the designated feed preparation
areas to prevent infection
Measure: 2.6.4.1.3 Appropriate hand washing
facilities are available in the feed preparation area


with appropriate disinfectant solutions
Notes: No feed preparation area
Risk Rating: E
Measure: 2.6.4.1.1 There is a feed preparation
area available and functional within the health
establishment (if they admit infants)
Notes: A feed preparation area was not available
within the Health establishment
Risk Rating: E
Measure: 2.6.4.1.7 The storage cupboard for
babies formula is clearly marked and locked
Notes: No babies formula- but reported to be out
of stock
Risk Rating: E


Measure: 2.6.4.1.5 Information is displayed on
the walls in the feed preparation area about
disinfectant solutions and frequency of
replacement
Notes: There is no feed preparation area
Risk Rating: E
Measure: 2.6.4.1.2 Personnel working in the feed
preparation area wear protective clothing
including gowns/plastic aprons/ gloves/ masks
and hair protection
Notes: There is no personnel and no feed
preparation area
Risk Rating: E
Measure: 2.6.4.1.4 Appropriate facilities and
equipment to clean and disinfect utensils in the
feed preparation area are available and functional


Risk Rating: E
Measure: 2.6.4.1.6 There is a clear signage on the
door to limit all unnecessary entry
Risk Rating: E
Standard: 6.7.1 Individual patient information is
accurately and completely recorded according to
clinical / legal / ethical requirements
Measure: 6.7.1.2.1 Patient records in the service
areas wards / consultation rooms / record rooms
are kept in a suitable place that maintains the
patient`s confidentiality
Notes: Patient records in the ward were not kept
in a suitable place and patient’s confidentiality
not maintained
Risk Rating: E
Standard: 6.7.1 Individual patient information is
accurately and completely recorded according to
clinical / legal / ethical requirements
Measure: 6.7.1.1.1 CHECKLIST - Patient files
comply with legal and statutory requirements for


record keeping
Notes: Patients files did not comply with legal and
statutory requirements for record keeping e.g.
home language, time against entries not recorded
Risk Rating: D
Standard: 1.2.2 Patients have access to
information on the services provided by the
Measure: 1.2.2.3.2 A signage board at the
entrance of the unit indicates the visiting/service
hours specifically for the unit
Notes: A signage board at the entrance of the unit
indicating visiting/ service hours specifically for
the unit not available
P06 Paediatric ward

Risk Rating: X
and well-being

P06 Paediatric ward

Measure: 2.4.2.6.1 Security measures are
adequate to safeguard newborns and
unaccompanied children including restricted
access and exit monitoring in wards/ identification
of newborns/ children and their parents
Notes: Security measures to safe guard new born
and unaccompanied children were inadequate
e.g. access and exit not monitored, children and
parents not identified
Risk Rating: X
stocked e.g. blood pressure cuffs, scissors,
glucometer not available
Risk Rating: X

P06 Paediatric ward

stocked and regularly checked e.g. defibrillator
and tracheal tubes not available
Risk Rating: X
piped medical gas to all clinical areas not available
Risk Rating: X
areas
piped suction/ vacuum to all clinical areas
Risk Rating: V

P06 Paediatric ward

Notes: The files of patients recently discharged
showed that comprehensive assessment and
diagnoses has not been done e.g. the past medical
history was not asked
Risk Rating: V
selection of clinical areas show that sharps are
safely managed and disposed of
Notes: Two clinical areas checked show that
sharps are not safely managed and disposed of
e.g. needle recapping
Risk Rating: V

P06 Paediatric ward

Notes: Security systems were not positioned in
paediatric unit
Risk Rating: V
comfort
Notes: Cleaning materials and chemicals and
equipment such as paper towels, goggles and face
shields not available
Risk Rating: E
policies or guidelines whereby provision is made
for parents or guardians to stay overnight when
children are receiving in-patient treatment
Notes: The HE did not have policies or guidelines
where by provision is made for parents or

P06 Paediatric ward

guardians to stay over night when children receive
in-patient treatment
Risk Rating: E
recliners/chairs or beds available for parents
staying with their children
Notes: The HE did not have recliners/ chairs or
beds available for parents staying with their
children
Risk Rating: E
and well-being
Measure: 2.4.2.6.2 In units where children are
cared for specific safety precautions are in place
to prevent harm e.g. covers on power
points/barriers/cotsides/child resistant
cupboards/safe water temperature/doors with
high handle/window safety catch

P06 Paediatric ward

Notes: Specific safety precaution not in place in
children unit
Risk Rating: E
Measure: 2.6.4.1.5 Information is displayed on the
walls in the feed preparation area about
disinfectant solutions and frequency of
replacement
Notes: Feed preparation area not available
Risk Rating: E
Measure: 2.6.4.1.6 There is a clear signage on the
door to limit all unnecessary entry
Risk Rating: E
Measure: 2.6.4.1.4 Appropriate facilities and

P06 Paediatric ward

equipment to clean and disinfect utensils in the
feed preparation area are available and functional
Risk Rating: E
Measure: 2.6.4.1.3 Appropriate hand washing
facilities are available in the feed preparation area
with appropriate disinfectant solutions
Risk Rating: E
Measure: 2.6.4.1.2 Personnel working in the feed
preparation area wear protective clothing
including gowns/plastic aprons/ gloves/ masks
and hair protection
Notes: Feed preparation area not available and
therefore no personnel specific for the area
Risk Rating: E

P06 Paediatric ward

Measure: 2.6.4.1.1 There is a feed preparation
area available and functional within the health
establishment (if they admit infants)
Risk Rating: E
Measure: 2.6.4.1.7 The storage cupboard for
babies formula is clearly marked and locked
Notes: Babies formula out of stock
Risk Rating: E
Standard: 4.2.1 The importance of health
promotion and disease prevention as part of
patient care is actively promoted and practiced
Measure: 4.2.1.1.1 CHECKLIST - 3 randomly
selected patient files for babies / HIV pregnant
mothers / Family Planning indicates that primary
prevention programmes were delivered
Notes: Primary prevention programme were not
delivered on a child e.g. child not weighed with

P06 Paediatric ward

visit, mebendazole and vitamin A not given as per
scheduled
Risk Rating: D
entrance of the unit indicates the visiting/service
hours specifically for the unit
Notes: A signage board at the entrance of the unit
indicating the visiting/ service hours specific, for
unit not available
P07_1 Generic wards / Measure is generic to any ward or day ward

Risk Rating: X
Measure: 1.2.1.2.2 CHECKLIST - Forms used for
informed consent are completed correctly by the


health professionals
Notes: Consent forms were not produced at the
time of inspection
Risk Rating: X
procedures
Notes: Emergency trolleys inappropriately
stocked as there was no thermometer,
glucometer, scissors and many more in the trolley
Risk Rating: X
procedures
Notes: Emergency trolleys not appropriately stock
as AED Defibrillator was not available


Risk Rating: X
essential equipment (as listed in the checklist) is
available in the general wards/clinics
Notes: Functional essential equipment was not
available such as diagnostic set
Risk Rating: X
areas
Notes: Functional system to supply piped suction/
vacuum to all clinical areas not available
Risk Rating: X


piped medical gas to clinical areas
Risk Rating: V
accommodation
Notes: Areas checked for state of cleanliness were
not clean as odour were there
Risk Rating: V
Notes: Files of recently discharged patients
showed that patients were not informed about
their treatment and were not given health
education
Risk Rating: V


Measure: 2.3.1.2.1 Healthcare professionals
indicate that they have access to adequate
supervision (excluding doctors for private sector)
Notes: Interviewed Health care professional
indicated that She had inadequate supervision
Risk Rating: V
Measure: 3.3.1.1.1 CHECKLIST - 2 staff members
interviewed are able to explain how the cold
chain is ensured for all blood products including
ordering / storage / issuing
Notes: Staff members interviewed were not label
to explain the optimum temperature for storage
of blood and for transportation of blood
Risk Rating: V
comfort
Measure: 7.4.1.2.1 CHECKLIST - Cleaning
materials cloths / dusters / scourers and


chemicals and equipment are available and stored
in an appropriate safe lockable area / with clear
labels for equipment used internally and
externally
Notes: Cleaning equipment such as janitor trolley
and colour coded cloths was not available
Risk Rating: E
Notes: Cubicle had n screens for privacy
Risk Rating: E
Measure: 1.2.1.1.2 CHECKLIST - Patients
interviewed know of their rights and
responsibilities
Notes: Patients interviewed did not know their


rights to refuse treatment and to a second
opinion
Risk Rating: E
Notes: Map/ list of services providers in the
referral chain with contact details was not
available
Risk Rating: E
last patients transferred into the health
from the referral health establishment
Notes: Files of the last patients transferred in to
the HE did not contain copies of referral letters
from the referral HE
Risk Rating: E


Measure: 1.8.1.2.2 The poster or pamphlet on
complaints is simple to read and available in the
local languages
Notes: Poster/ pamphlet on complaints was only
available in English
Risk Rating: E
and suffering
Measure: 2.5.1.2.1 CHECKLIST - Staff members
interviewed confirm the establishment
encourages the reporting of adverse events
Notes: Staff member interviewed verbalised that
they were not encourages to reports adverse
events
Risk Rating: E
management
Measure: 3.1.3.1.3 CHECKLIST - Medicines in the
wards or consultation rooms are appropriately
stored and managed


Notes: Medicines in the wards not appropriately
stored and managed as there was no system to
check expiry dates
Risk Rating: E
management
and/or 6 drug register are complete and correct
and include date/ name of person who
administered it and balance in stock
Notes: Entries in the schedule 5&6 drug register
were not counter signed or signed where the
checking health professional should sign
Risk Rating: E
Standard: 3.2.1 Accessible and effective
laboratory services enhance patient diagnosis
Measure: 3.2.1.1.3 CHECKLIST - Laboratory results
requested are available in the patients file
Notes: Laboratory results requested not available
in patient’s files


Risk Rating: E
Standard: 3.3.2 Therapeutic support services
contribute to the holistic care and rehabilitation
of patients
Measure: 3.3.2.1.2 Multidisciplinary meetings
occur on a regular basis in the unit and are
attended by the full range of clinical support
services staff Occupational therapist/
physiotherapists / dietician / social worker /
psychologist etc
Notes: Evidence of multidisciplinary meetings was
not available
Risk Rating: E
Notes: Staff members interviewed to evaluate
their awareness of the disaster management plan,
were not aware of their roles in the plan


Risk Rating: E
Standard: 7.1.5 The establishment is organised /
furnished / equipped to meet patient needs and
comfort
procedure for requisition of repairs indicates and
measures the timeframes between requisition
and finalisation of repairs
Notes: There was no evidence that the procedure
for requisition of repairs indicates and measures
the timeframes between requisition and
finalisation of repairs
Risk Rating: E
Standard: 7.2.4 A functional public
communication system allows communication
throughout the establishment in the event of an
emergency
Measure: 7.2.4.2.1 CHECKLIST - Staff members
know how to react to an emergency warning
Notes: Staff members interviewed did not know
how to react to an emergency warning
Risk Rating: D


Measure: 1.2.1.1.1 Detainees for forensic
ward/Patient rights posters or leaflets are
available in the common local languages of the
geographic area
Notes: Patient rights posters not available
Risk Rating: D
Standard: 1.3.1 All patients in the designated
catchment area are able to access the facility and
its services
Measure: 1.3.1.4.1 A policy is available at the
health care establishment regarding assistance
required for blind-impaired vision and hearing
patients
Notes: Policy regarding assistance required for
blind-impaired vision and hearing patients not
available
Risk Rating: D
comfort
Measure: 7.4.1.4.2 Notices are prominently
displayed prohibiting smoking inside the buildings


Notes: Notices prohibiting smoking inside the
building were not available
Risk Rating: D
Standard: 7.6.1 Linen and laundry services are
managed to meet the needs of the health
establishment and legislative requirements
Measure: 7.6.1.4.1 Linen rooms or storage
cupboards are locked / well organised/ and well
stocked proportionate to the requirements of the
Notes: Linen room not locked at the time of
inspection
S01 CSSD

Risk Rating: V
Measure: 3.5.1.4.2 All sterilisation equipment is
validated / licensed

S01 CSSD

Notes: There was no evidence of validation of
sterilising equipment
Risk Rating: V
monitor all incidents of sterilisation failure
whereby failures are documented with detailed
action plans where failures occurred
Notes: There was no system to monitor all
incidents of sterilisation failure
Risk Rating: E
Measure: 3.5.1.4.1 The department is designed so
as to allow the segregation / separation of clean
and dirty areas
Notes: The design of the department did not
allow the separation of clean and dirty areas
Risk Rating: E
Measure: 3.5.1.1.2 CHECKLIST - Staff are able to

S01 CSSD

explain the procedure by which used instruments
are sterilised from start to finish
Notes: Staff interviewed did not explain all aspect
of procedure by which used instruments are
sterilised e.g. autoclave indicators
Risk Rating: E
Measure: 3.5.1.3.1 A procedure detailing clear
responsibilities for the various aspects in the
decontamination cycle for the sterilisation
services is available
Notes: Procedure relating to the various aspects
in the decontamination cycle was not available
Risk Rating: E
Measure: 3.5.1.2.1 The sterilisation manager is
appropriately qualified in sterile services including
experience and training
Notes: The sterilisation manager was not
appropriately qualified e.g. the manager is a
health care workers

S01 CSSD

Risk Rating: E
Measure: 3.5.1.1.1 CHECKLIST - An up to date
decontamination policy is available
Notes: Decontamination policy was not available
Risk Rating: E
Measure: 3.5.1.4.3 There is a planned
maintenance schedule / a log and service history
for each machine
Notes: Autoclave machine was not serviced in
December 2016 as schedule
S02 Cleaning Services

Risk Rating: V
comfort


Measure: 7.4.1.2.5 There are records of the
mandatory pre-placement tests for cleaning staff
(hepatitis A and B) even if they are contracted-out
services
Notes: The records of the mandatory pre-
placement tests for cleaning staff was not
available
Risk Rating: V
comfort
Measure: 7.4.1.1.1 Records show that daily
inspections of cleanliness are carried out
Notes: The daily inspection for cleanliness was
last done in April 2016 and May 2016
Risk Rating: V
comfort
Measure: 7.4.1.1.23 The facility is observed to be
clean and hygienic
Notes: Facility was observed to be dirty


Risk Rating: V
comfort
Measure: 7.4.1.3.1 Records show that Pest
Control is done monthly in all areas
Notes: There were no records of monthly pest
control
Risk Rating: V
comfort
Notes: Cleaning materials such as paper towels
and wet vacuum pick up were not available
Risk Rating: V
comfort
Measure: 7.4.1.1.2 Toilets and bathrooms are


clean both on the floor and above the floor/door
handles/coutertops/toilets
Notes: Toilets and bathrooms were dirty with
spider webs and blocked showers
Risk Rating: E
comfort
Measure: 7.4.1.2.3 There is evidence of training of
cleaners on the use of cleaning equipment and
cleaning materials disinfectants and detergents
and infection control procedures
Notes: The 2015 minutes were produced instead
of the proof of training record
Risk Rating: E
comfort
Measure: 7.4.1.2.2 The maintenance plan record
shows that cleaning machines are regularly
serviced and in good repair
Notes: There was no maintenance plan to verify
the regular servicing cleaning machines

S03 Food Services

Risk Rating: V
Standard: 7.7.1 Food services are provided to
meet the needs of patients
Measure: 7.7.1.8.4 Documents show that
problems identified during health inspections
have been rectified
Notes: The health inspections was, not carried
out to verify problems identified
Risk Rating: E
Measure: 7.7.1.8.3 There are records of health
inspections carried out in the last 6 months which
show that the health establishment meets the
hygiene requirements
Notes: There were no records of health
inspections carried out in the last 6 months
Risk Rating: E
Measure: 7.7.1.8.2 Meals are delivered to the
wards using appropriate trolleys which are

S03 Food Services

hygienic and temperature controlled
Notes: Meals are delivered to the wards using
inappropriate trolley without temperature
control
Risk Rating: E
Measure: 7.7.1.8.5 There are no signs of visible
dirt in the kitchens or food storage areas
Notes: There was a bad odour in the kitchen
storage area
Risk Rating: E
Measure: 7.7.1.7.2 There are records of the
mandatory pre-employment tests for food-
handlers
Notes: Records of the mandatory pre-
employment test for food- handlers were not
available
Risk Rating: E

S03 Food Services

results show that more than 70 percent of
patients are satisfied with the quality and
presentation of the food
Notes: The recent patient satisfaction survey
results were not available the last survey was
conducted in October 2015
Risk Rating: E
Measure: 7.7.1.2.3 Serving time for meals are
clearly defined and adhered to and the time
difference between supper and breakfast is less
than 12 hours
Notes: The time difference between supper and
breakfast was 15 hours
Risk Rating: E
Measure: 7.7.1.2.2 Records demonstrate that the
food service managers monitors the distribution
of meals and receiving times of meals in the
wards and addresses causes of blockage

S03 Food Services

Notes: The was no evidence produced that the
distribution of meals were monitored
Risk Rating: E
Measure: 7.7.1.1.1 Procedures for procurement /
storage and preparation of food services are
available and reviewed annually
Notes: National government of the Republic of
South Africa general procurement guidelines was
produced instead of the HE one
Risk Rating: D
Measure: 7.7.1.1.2 Guidelines for food
preparation are available and follow national
guidelines e.g. National guidelines on nutrition for
people living with HIV/AIDS / TB and chronic
diseases 2007 prevention and management of
overweight / obesity
Notes: Guidelines outdated 2001

S04 Laundry Services

Risk Rating: V
Measure: 7.6.1.2.2 Areas for receiving soiled linen
are separated from areas of clean linen
Notes: Areas for receiving soiled linen were not
separated from areas of clean linen
Risk Rating: E
Measure: 7.6.1.3.1 The machines in the laundry
are all in working order
Notes: All machine was last serviced in 2012
Risk Rating: E
Measure: 7.6.1.1.5 Linen stock sheets are
reconciled monthly to identify losses and
shortages

S04 Laundry Services

Notes: There was no evidence that linen stock
sheets are reconciled monthly
Risk Rating: E
Measure: 7.6.1.2.1 The policy indicates
procedures for handling of clean and
dirty/soiled/infectious linen
Notes: Policy indicating procedure for handling of
dirty and clean linen was not available
Risk Rating: D
Measure: 7.6.1.1.1 There is a policy/SOP for the
management of laundry service
Notes: Policy or SOP for the management of
laundry services was not available

S05 Maintenance services includes garden

Risk Rating: V
that water supplies are checked daily for
adequacy and availability from the main
reticulation system
Notes: Maintenance records showing that water
supplies are checked daily for adequacy and
availability from the main reticulation system not
available
Risk Rating: E
the establishment
Measure: 7.1.4.2.2 Repair requisitions are
reviewed monthly and outstanding items raised
with the responsible person/service provider
Notes: Document showing that repair requisitions
are reviewed monthly and outstanding items
raised write the responsible person/ service
provider not available


Risk Rating: E
the establishment
Measure: 7.1.4.2.1 There is an updated planned
maintenance programme available in the health
establishment which is monitored and reflects
that maintenance is carried out according to
schedule
Notes: An updated maintenance programme not
available in the HE
Risk Rating: E
Measure: 7.2.1.2.1 A up-to-date logbook or
inspection sheets for electrical power is available
Notes: A up-to-date logbook or inspection sheets
for electrical power not available
Risk Rating: E


the results of monthly water supply quality checks
bacteriological / chemical and residual chlorine
are within acceptable limits
Notes: Maintenance records showing the results
of monthly water supply quality checked
bacteriological/ chemical and residual chlorine
are within acceptable limits not available
Risk Rating: E
Standard: 7.2.2 Operational plant / machinery /
equipment is well maintained and fully functional
according to the needs of the health
establishment and complies with all regulatory
requirements
that maintenance and testing of systems and
installations is documented and in accordance
with regulations
Notes: Maintenance records showing that
maintenance and testing of system and
installations is documented and in accordance
with regulations not available
Risk Rating: E


comfort
Measure: 7.4.1.2.2 The maintenance plan record
shows that cleaning machines are regularly
serviced and in good repair
Notes: The maintenance plan record showing that
cleaning machines are regularly serviced not
available
Risk Rating: E
that on-site laundry machines are serviced
regularly
Notes: Maintenance records show that on-site
laundry machines were last serviced 26/02/2014
Risk Rating: D
Standard: 7.2.2 Operational plant / machinery /
equipment is well maintained and fully functional
according to the needs of the health
establishment and complies with all regulatory
requirements
Measure: 7.2.2.1.1 There is a policy and
procedures for the maintenance of plant /


equipment / installations for the health
establishment
Notes: A policy and procedure for the
maintenance of plant/ equipment/ installations
for the HE not available
S06 Record archive/department

Risk Rating: V
Standard: 6.7.2 An efficient system exists to
archive and retrieve medical records or patient
files
Measure: 6.7.2.2.3 Written standard operating
procedures exist for requests / retrieval / filing of
patient files
Notes: Written SOPs for requests, retrieval and
filing of patient files was not available
Risk Rating: E


patients
Notes: There was only one queue for all patients
observed
Risk Rating: E
Notes: Patients were not informed how long they
Risk Rating: E
Notes: There was no system in place to reduce
waiting times
Risk Rating: E


Notes: Hardware and software and not work
connectivity did not support local needs
Risk Rating: E
files
Measure: 6.7.2.2.1 Medical records room has
space for all records
Notes: Medical records room had insufficient
space for all records, records were observed in
boxes on the floor
Risk Rating: E
files
Measure: 6.7.2.2.2 The medical records room is
secure and only accessible to authorised staff
Notes: Medical records room was not secure and
was accessible to unauthorised staff
Risk Rating: D


files
Measure: 6.7.2.1.1 Records room staff have
received appropriate training in the management
of medical archives
Notes: Records room staff had not received
appropriate training in the management of
medical archives
S07 Waste Management

Risk Rating: V
Standard: 7.5.2 Health care risk waste (HCRW) is
handled / stored / disposed of safely to reduce
potential health risks and to protect the
environment
Measure: 7.5.2.3.2 Records show that the waste
manager monitors and manages the service level
agreements for waste removal and disposal
Notes: Records showing that the waste manager
monitors and manages the service level


agreements for waste removal, were not
available
Risk Rating: E
Standard: 7.5.1 Waste management in the
establishment and surrounding environment
complies with legal requirements / national
standards / with good practice
Measure: 7.5.1.1.1 The establishment has an up
to date waste management plan reviewed and
updated within the previous two years and
complies with the legal requirements and
national guidelines
Notes: Waste management plan was dated
2014/2015, not updated written the previous two
years
Risk Rating: E
environment
Measure: 7.5.2.1.1 The Health Care Risk Waste
management (HCRW) report undertaken in the
previous two years show management`s plan and
measures undertaken to address identified risks


Notes: Health care risk waste management report
was not available
Risk Rating: E
environment
for obtaining additional HCRW containers should
there be a need
Notes: Procedure for obtain additional HCRW
containers was not available
Risk Rating: E
environment
Measure: 7.5.2.3.1 There is a valid contract and
Service Level Agreement for waste removal which
is regularly monitored
Notes: Service level agreement for waste removal
was not monitored


Risk Rating: E
environment
Measure: 7.5.2.2.1 CHECKLIST - Policy for HCRW
management contain the procedure on collection
/ handling / segregation / storage / disposal /
training of staff
Notes: Policy for HCRW management containing
the procedure on collection, handling,
segregation, storage, disposal, training of staff
was not available
Risk Rating: D
Standard: 7.5.4 General waste (office / kitchen /
garden / household waste) is managed according
to protocols to protect the safety of staff and
patients
Measure: 7.5.4.2.2 General waste is stored in
appropriate containers which are neatly packed
or stacked
Notes: General waste not neatly packed

S08 Transport services-ambulances/Patient transport/Staff transport/Other vehicles

Risk Rating: E
Standard: 6.5.1 The availability and safety of
vehicles are assured through effective fleet
management
Measure: 6.5.1.1.1 There is a maintenance and
service plan for all vehicles including complete
records of all maintenance undertaken
Notes: Maintenance and service plans for all
vehicles not available and maintenance records
incomplete e.g. no record for 2016
Risk Rating: E
Standard: 6.5.1 The availability and safety of
vehicles are assured through effective fleet
management
Measure: 6.5.1.2.1 There is a list of drivers with
details of their valid Driver’s License and
Professional Drivers Permit
Notes: One driver for the hospital and his PDP has
expired 2016/09/29

S09 Security Services

Risk Rating: V
Notes: Security systems were not positioned at
vulnerable patient areas such as maternity and
paediatric wards
Risk Rating: V
Measure: 7.3.1.1.7 CHECKLIST - Security measures
are in place to ensure the safety of patients/
staff/ goods and assets in the health
establishment
Notes: Security measures were not in place to
ensure the safety of patient’s staff goods and
assets in the health establishment
Risk Rating: E
files


Measure: 6.7.2.2.2 The medical records room is
secure and only accessible to authorised staff
Notes: Medical records room not secure,
accessible to unauthorised staff
Risk Rating: E
Measure: 7.3.1.3.1 Records show nightly
inspections are done of the premises to ensure
lighting is functional and all areas are lit up
Notes: Records showing that nightly inspections
are done of the premises to ensure lighting is
functional in all areas, were not available
Risk Rating: E
Measure: 7.3.1.4.1 Records or minutes of
meetings show what actions have been taken to
address security incidents reported
Notes: Records or minutes of meeting showing
that actions have been taken to address safety
and security incidents reported were not
available


Risk Rating: D
Standard: 7.2.3 The telephone system enables
reliable internal and external communication for
routine communication and emergency back-up
Measure: 7.2.3.1.3 Access to the switchboard is
controlled
Notes: Access to the switch-board was not
controlled
Risk Rating: D
Measure: 7.3.1.5.1 Safety and security notices are
displayed in all areas
Notes: Safety and security notices were not
displayed in all areas
S10 Entrance/Reception and help desk

Risk Rating: E


Measure: 1.2.2.1.1 A help desk is situated in a
prominent position in the public area at the
entrance to the health establishment
Notes: Help desk not available
Risk Rating: E
areas
Notes: Information on procedure for complaints
not displayed in all service areas
Risk Rating: D
Measure: 1.2.2.1.2 Help desk staff demonstrate
that they are able to communicate in the
common local languages of the area
Risk Rating: D


Measure: 1.2.2.1.3 A spot check at a random time
during the visit shows that the helpdesk is
manned
Risk Rating: D
entrance of the health establishment indicates
the times when various services are offered
Notes: Signage board at the entrance of the HE
did not indicate times when various services are
offered
Risk Rating: D
Measure: 1.4.1.4.2 The staff member on duty at
the help desk is able to explain the booking
system

S11 Patient administration

Risk Rating: E
patient flow
Notes: There was no person observed managing
the queues
S13 Public Areas

Risk Rating: E
accommodation
areas/court yards

S13 Public Areas

Notes: Clean water and disposable cups for
patients not provided in waiting areas
Risk Rating: D
Standard: 7.1.6 Grounds are maintained to be
safe and orderly
Measure: 7.1.6.1.3 The records shows that nightly
inspections are done to ensure adequate lighting
on grounds for a safe environment for vehicles /
staff and visitors at night
Notes: Nightly inspections records did not ensure
adequate lighting on grounds


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Quality Improvement Plan

Facility: ec Maclear Hospital Date: 31- Jan- 01 Feb

C01 Blood Services

Problem Item Activity By Whom By When (Date) Status / Result

C03 Health technology Services

Problem Item Activity By Whom By When (Date) Status / Result

Private and Confidential | etc. Maclean Hospital

C03 Health technology Services

Problem Item Activity By Whom By When (Date) Status / Result

Problem Item Activity By Whom By When (Date) Status / Result

Private and Confidential | etc. Maclean Hospital

Problem Item Activity By Whom By When (Date) Status / Result

Private and Confidential | etc. Maclean Hospital

Problem Item Activity By Whom By When (Date) Status / Result

Private and Confidential | etc. Maclean Hospital

Problem Item Activity By Whom By When (Date) Status / Result

Private and Confidential | etc. Maclean Hospital

Problem Item Activity By Whom By When (Date) Status / Result

Private and Confidential | etc. Maclean Hospital

Problem Item Activity By Whom By When (Date) Status / Result

Private and Confidential | etc. Maclean Hospital

Problem Item Activity By Whom By When (Date) Status / Result

Private and Confidential | etc. Maclean Hospital

Problem Item Activity By Whom By When (Date) Status / Result

Private and Confidential | etc. Maclean Hospital

Problem Item Activity By Whom By When (Date) Status / Result

Private and Confidential | etc. Maclean Hospital

Problem Item Activity By Whom By When (Date) Status / Result

Private and Confidential | etc. Maclean Hospital

Problem Item Activity By Whom By When (Date) Status / Result

Private and Confidential | etc. Maclean Hospital

Problem Item Activity By Whom By When (Date) Status / Result

Private and Confidential | etc. Maclean Hospital

Problem Item Activity By Whom By When (Date) Status / Result

Private and Confidential | etc. Maclean Hospital

Problem Item Activity By Whom By When (Date) Status / Result

Private and Confidential | etc. Maclean Hospital

Problem Item Activity By Whom By When (Date) Status / Result

Problem Item Activity By Whom By When (Date) Status / Result

Private and Confidential | etc. Maclean Hospital

Problem Item Activity By Whom By When (Date) Status / Result

Private and Confidential | etc. Maclean Hospital

Problem Item Activity By Whom By When (Date) Status / Result

Private and Confidential | etc. Maclean Hospital

Problem Item Activity By Whom By When (Date) Status / Result

Private and Confidential | etc. Maclean Hospital

M01 CEO or Hospital Manager

Problem Item Activity By Whom By When (Date) Status / Result

Private and Confidential | etc. Maclean Hospital

M01 CEO or Hospital Manager

Problem Item Activity By Whom By When (Date) Status / Result

Private and Confidential | etc. Maclean Hospital

M01 CEO or Hospital Manager

Problem Item Activity By Whom By When (Date) Status / Result

Private and Confidential | etc. Maclean Hospital

M01 CEO or Hospital Manager

Problem Item Activity By Whom By When (Date) Status / Result

Private and Confidential | etc. Maclean Hospital

M01 CEO or Hospital Manager

Problem Item Activity By Whom By When (Date) Status / Result

Private and Confidential | etc. Maclean Hospital

M01 CEO or Hospital Manager