Baseline (Facility Assessment) Tool for Quality Improvement (QI) in Bangladesh
Objective:
This tool aims to assess healthcare facilities across three key dimensions—Structure, Process, and Outcome—to identify gaps, ensure compliance with quality standards, and drive continuous improvement.
Scoring Criteria for Facility Assessment Indicators
To ensure an objective and standardized evaluation, a scoring system (1 to 5 scale) is applied to each indicator. This allows healthcare facilities to identify gaps, prioritize interventions, and track progress over time.
Scoring Scale Explanation:
Score
Description
Action Required
1 - Poor
The indicator
is not met at all or is completely inadequate
Immediate
corrective action required with high priority
2 - Needs
Major Improvement
The indicator
is partially met, but major deficiencies exist
Significant
improvement needed with a structured improvement plan
3 -
Average/Needs Improvement
The indicator
is moderately met, but some gaps remain
Improvement
required with monitoring & minor adjustments
4 - Good
The indicator
is mostly met, with minor deficiencies
Sustain
and enhance existing practices
5 -
Excellent/Best Practice
The indicator
is fully met with optimal performance
Maintain
& use as a model for best practice
Detailed Scoring Criteria by Domain & Indicator
1. Facility Information
Indicator
Description
Facility Name
Name of the
healthcare facility
Facility Type
Primary,
Secondary, or Tertiary Care
Ownership
Public / Private
/ NGO
Location
Urban / Rural
Catchment
Population
Approximate
population served
Date of
Assessment
DD/MM/YYYY
Assessor Name
& Designation
Name and role
of the assessor
A. Structure Assessment (Inputs & Readiness) Table
Indicator
1 - Poor
2 - Needs Major Improvement
3 - Average
4 - Good
5 - Excellent
Infrastructure
(Water, Sanitation, Electricity, Waste Disposal, Internet)
No clean
water, sanitation, electricity, or waste disposal
Partial
utilities available but unreliable
Most
utilities available but require maintenance
Fully
functional utilities with minor gaps
All utilities
fully available & well maintained
Workforce
Availability (Doctors, Nurses, Midwives, Technicians, Support Staff)
Severe
shortage, <50% positions filled
50-70%
positions filled, many critical shortages
70-85%
positions filled, some key gaps
85-95%
positions filled, minimal gaps
100%
positions filled, well-staffed
Training
& Competency Development
No training
programs for staff
Occasional
training, but no structured plan
Training
programs exist but not regularly updated
Regular
training with minor gaps
Continuous
professional development (CPD) with certification & tracking
Equipment
& Supplies
Essential
equipment missing or non-functional
Most
essential equipment available but poorly maintained
Equipment
available but occasional shortages
Equipment
available & well-maintained
Equipment
available, functional & regularly maintained
Essential
Medicines & Consumables Availability
Frequent
stockouts of essential medicines
Medicines
available but irregular supply
Medicines
mostly available with occasional shortages
Essential
medicines consistently available with minor stockouts
Full availability
of essential medicines with stock monitoring
Policy
& Governance (SOPs, Guidelines, Compliance Mechanisms)
No SOPs,
protocols, or QI mechanisms
Some SOPs
exist but not implemented
SOPs exist
but weak compliance
SOPs
implemented with minor gaps
SOPs fully
implemented with strong compliance
Health
Information System (HIS) & Digital Record-Keeping
No patient
records or data system
Paper-based
records with missing data
Partial
digitalization, data inconsistencies
Functional
HIS with minor gaps
Fully
digitalized system with data analytics & real-time monitoring
Referral
& Emergency Transport System
No referral
or ambulance services
Referral
system exists but not functional
Referral
system partially functional with delays
Referral
system functional with minor delays
Fully
functional, timely referral & ambulance system
Facility
Safety & Security
No fire
safety, disaster preparedness, or security measures
Some safety
measures exist but not implemented
Safety
protocols in place but gaps in training
Facility
meets safety standards with minor lapses
Facility
fully meets safety, disaster preparedness & security standards
Financial
Resources & Funding Availability
No dedicated
funding for QI & operational needs
Some funding
available but inconsistent
Funding
available but not well-managed
Sufficient
funding with minor gaps
Adequate,
sustainable funding with financial transparency
B. Process Assessment (Service Delivery & Quality)
Process Assessment (Service Delivery & Quality)
Patient Safety Domain
Indicator
1 - Poor
2 - Needs Major Improvement
3 - Average
4 - Good
5 - Excellent
Infection
Prevention & Control (IPC)
Compliance
with standard IPC guidelines (e.g., hand hygiene, PPE usage, waste disposal)
No IPC
measures in place
Some IPC
measures exist but weak enforcement
IPC measures
in place, but compliance varies
IPC well
implemented with minor lapses
Full
compliance with IPC, regular monitoring & audits
Hand hygiene
compliance among healthcare workers
<20%
compliance
20-50%
compliance
50-75%
compliance
75-90%
compliance
>90% compliance
Proper waste
segregation & disposal (biohazard, sharps, general waste)
No
segregation of waste
Partial
segregation, but improper disposal
Waste
segregated but occasional lapses in disposal
Waste
segregation and proper disposal with minor lapses
Fully
compliant waste management system
Medication
Safety
Availability
& adherence to medication safety protocols
No protocols
available
Protocols
exist but not followed
Protocols
followed inconsistently
Protocols
followed with minor lapses
Strict adherence
with continuous monitoring
Medication
error tracking & reporting system
No system in
place
Informal
error tracking
Errors
tracked but no structured reporting
Errors
reported with action plans
Fully
functional reporting & prevention mechanism
High-risk
medication management (e.g., insulin, anticoagulants)
No monitoring
of high-risk drugs
Inadequate
monitoring with errors
Monitoring in
place but some gaps
Effective
monitoring with minor lapses
Highly
effective monitoring & prevention of errors
Surgical
Safety
Adherence to
WHO Surgical Safety Checklist
No checklist
used
Checklist
exists but not used
Checklist
used inconsistently
Checklist
used with minor lapses
Full
adherence, monitored, & audited
Post-operative
infection rates
High (>10%)
Moderate
(5-10%)
Acceptable
(3-5%)
Low (<3%)
Near-zero
infection rate
Incident
Reporting & Learning System
Presence of a
structured patient safety incident reporting system
No reporting
system
Informal
incident reporting
Reporting
system exists but underutilized
Reporting
system used with follow-up actions
Fully
functional reporting with root-cause analysis
Root-cause
analysis & corrective actions for adverse events
No
investigations conducted
Ad-hoc
investigations with no structured approach
Root-cause
analysis done occasionally
Root-cause
analysis done regularly with some follow-ups
Root-cause
analysis done for all incidents with strong action plans
Patient
Identification & Verification
Use of at
least two patient identifiers (e.g., name, DOB, ID number)
No
identification system
Identifiers
used inconsistently
Identification
system in place but occasional lapses
Strong
identification system with minor lapses
Fully
implemented system with 100% compliance
Emergency
& Disaster Preparedness
Availability
of emergency response protocols for disasters (fire, earthquake, mass
casualty events)
No protocols
exist
Some
protocols exist but not implemented
Protocols
exist but require updates
Protocols
implemented with minor gaps
Fully implemented,
tested, & regularly updated
Regular
emergency drills & staff training
No drills
conducted
Drills
conducted rarely
Drills
conducted yearly
Drills
conducted every 6 months
Drills
conducted quarterly with evaluations
Safe Blood
Transfusion Practices
Screening of
blood for infections (HIV, HBV, HCV, etc.)
No screening
conducted
Some
screening done but not standardized
Blood
screening done but occasional lapses
Blood
screening done with minor gaps
100%
screening with stringent monitoring
Adherence to
proper blood transfusion protocols
No protocols
exist
Protocols
exist but not followed
Protocols
followed inconsistently
Protocols
followed with minor lapses
Fully
compliant system with monitoring
Others Process Indicators
Others Process Indicators
Indicators
1 - Poor
2 - Needs Major Improvement
3 - Average
4 - Good
5 - Excellent
Waiting
Time
Patients wait
>4 hours for services
Patients wait
2-4 hours
Patients wait
1-2 hours
Patients wait
30 mins - 1 hour
Patients
receive services in <30 mins
Adherence
to Clinical Protocols
No protocols
followed
Protocols
exist but rarely followed
Protocols
followed inconsistently
Protocols
followed with minor lapses
Strict
adherence to all protocols
Patient-Centered
Care
No patient
engagement, disrespectful care
Some effort,
but patient satisfaction low
Moderate
patient engagement, occasional complaints
Strong
patient engagement, few complaints
Excellent
patient engagement, no complaints
C. Outcome Assessment (Impact & Performance)
Indicator
1 - Poor
2 - Needs Major Improvement
3 - Average
4 - Good
5 - Excellent
Maternal
Mortality Rate (MMR) (per 100,000 live births)
>250
deaths
150-250
deaths
100-150
deaths
50-100 deaths
<50 deaths
Neonatal
Mortality Rate (NMR) (per 1,000 live births)
>30 deaths
20-30 deaths
10-20 deaths
5-10 deaths
<5 deaths
Under-5
Mortality Rate (U5MR) (per 1,000 live births)
>50 deaths
30-50 deaths
20-30 deaths
10-20 deaths
<10 deaths
Hospital
Readmission Rate (within 30 days)
>30%
20-30%
10-20%
5-10%
<5%
Post-Surgical
Complication Rate
>20%
10-20%
5-10%
2-5%
<2%
Hospital-Acquired
Infection (HAI) Rate
>15%
10-15%
5-10%
2-5%
<2%
Average
Length of Stay (ALOS) (days)
>15 days
10-15 days
7-10 days
4-7 days
<4 days
Patient
Satisfaction Rate (based on surveys)
<40%
40-60%
60-75%
75-90%
>90%
Emergency
Service Response Time (minutes)
>60 min
45-60 min
30-45 min
15-30 min
<15 min
Referral Rate
for Preventable Conditions
>30%
20-30%
10-20%
5-10%
<5%
Equity in
Service Utilization (% of marginalized population receiving care)
<40%
40-60%
60-75%
75-90%
>90%
Financial
Protection (Catastrophic Health Expenditure Rate) (% of households spending
>10% of income on health)
>30%
20-30%
10-20%
5-10%
<5%
Provider
Compliance with Clinical Guidelines
<40%
40-60%
60-75%
75-90%
>90%
Final Facility Score & Performance Category
- 85-100% (4.5-5.0): Excellent – Best Practice Facility
- 70-84% (3.5-4.4): Good – Maintain and Improve Further
- 50-69% (2.5-3.4): Average – Needs Improvement
- 30-49% (1.5-2.4): Weak – Immediate Corrective Action Required
- <30% (1.0-1.4): Critical – Urgent Action Required
Conclusion:
This scoring framework ensures a structured, objective, and actionable evaluation of healthcare facilities. By using Donabedian’s model (Structure-Process-Outcome) and integrating WHO QI principles & 5S-CQI-TQM modalities, it enables a data-driven approach to continuous quality improvement.