Base line Assessment

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.