DECISION

PROMULGATING QUALITY INDICATORS FOR EYE-CARE SERVICES

MINISTER OF HEALTH

Pursuant to Decree No.75/2017/ND-CP dated June 20, 2017 of the Government on functions, duties, rights and organizational structure of the Ministry of Health;

Pursuant to Decision No.4518/QD-BYT dated July 16, 2018 of the Minister of Health on functions, duties, rights and organizational structure of the Medical Service Administration affiliated to the Ministry of Health;

Pursuant to Decision No.4276/QD-BYT dated October 14, 2015 approving the national action program on improvement of capacity for management of medical examination and treatment quality up to 2025;

At the request of the Director of Medical Service Administration

HEREBY DECIDES

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Article 2. Quality indicators for eye-care services in Vietnam apply to ophthalmology specialist medical facilities.

Article 3. Assignment given to the Medical Service Administration

The central eye specialist hospital shall cooperate with relevant departments and entities in providing guidelines for application of quality indicators for eye-care services and evaluate such application and send reports to the Minister of Health.

Article 4. This Decision comes into force from the day on which it is signed for promulgation.

Article 5. Chief of the Ministry Office, Director of the Medical Service Administration, Chief of Ministry Inspectorate, Director General of relevant departments, Directors of hospitals affiliated to the Ministry of Health, Directors of Health Departments of provinces and centrally-affiliated, Health Agencies affiliated to relevant ministries and Directors of relevant entities shall take responsibility to implement this Decision./.

PP. MINISTER
DEPUTY MINISTER




Nguyen Viet Tien

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MEDICAL SERVICE ADMINISTRATION

QUALITY INDICATORS FOR EYE-CARE SERVICES

 (Issued together with Decision No.5066/QD-BYT dated August 16, 2018 of the Minister of Health)

GUIDELINE FOR QUALITY INDICATORS FOR EYE-CARE SERVICES IN VIETNAM

1. Definition:

Hospital quality indicator means a tool used to measure various dimensions of healthcare service quality which is presented in forms of numbers, ratios or rates as the basis for improvement of healthcare service quality and comparison of service quality among hospitals. Quality indicators for eye-care services are established upon consideration of the hospital quality indicators which is issued together with Decision No.7051/QD-BYT dated November 29, 2016 of the Minister of Health on guidelines for pilot establishment of a number of hospital quality indicators. And for the purpose of applying 10 quality indicators for eye-care services, eye specialist medical facilities shall select additional quality indicators according to the quality indicators issued together with Decision No.7051/QD-BYT.

2. Principles for establishment of hospital quality indicators

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- Hospital quality indicators are used for measuring elements including structure (input), the process and the output of the healthcare services.

- Such indicators are calculated through data collection and analysis.

- Selected indicators shall tightly relevant to the healthcare service quality, the feasibility and the value and orient to the improvement of service quality.

-  Hospital quality indicators are the basis for hospitals to select suitable indicators for periodic assessment depending on their actual capacity and conditions.

3. Dimensions of healthcare service quality

Professional capacity: the assessment of provision of healthcare services according to medical advices and regulations on technical classification.

Safety: the harm of risks to patient, health workers and community during provision of healthcare services.

Efficiency: the assessment of optimal use of available resources for providing healthcare services with the lowest charges and the best effect.

Clinical effectiveness: the assessment to see whether medical service provision achieves desired outcomes.

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Patient-oriented indicators: the assessment of patients’ satisfaction relating to non-medical dimensions including living facilities, hygiene of patient wards and employees' behaviors

LIST OF EYE CARE SERVICE QUALITY INDICATORS

Dimension

Indicator

Type of indicator

Professional capacity

1) Ratio of medical procedures approved and applied to total medical procedures according to the healthcare level

Input

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2) Rate of health workers continuously receiving professional training as regulated

Input

Safety

3) Rate of satisfactory medical records

Process

Safety

4) Rate of surgeries following instructions provided in the surgical safety checklist

Process

Safety

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Output

Safety

6) Number of serious medical errors

Output

Effectiveness

7) Rate of patients having good sight after cataract surgery alone

Output

Efficiency

8) Serviceability of hospital beds

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Patient-oriented indicators

9) Rate of patient's satisfaction with healthcare services (inpatient and outpatient)

Output

Staff-oriented indicators

10) Rate of health workers’ satisfaction

Output

INDICATOR NO.1: Ratio of medical procedures approved and applied to total medical procedures according to healthcare level

NAME OF INDICATOR NO.1: Ratio of medical procedures approved and applied to total medical procedures according to healthcare level

DEFINITION AND ACCEPTABLE SCORE

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Such ratio is identified to assess the professional capacity of a hospital and capacity to comply with regulations issued by the Ministry of Health.

Acceptable score: > 70%

1

Applicable areas

The whole hospital

2

Quality property

Professional capacity

3

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Input

4

Reasons

Application of medical procedures is an indicator used for assessing professional capacity of a hospital, a basis for assessing the capacity to meet the healthcare service demand of citizens in an area as well as a basis for investment and development of such hospital.

5

Calculation method

5.1

Numerator

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5.2

Denominator

Total number of eye care procedures according to healthcare level of the hospital

5.3

Required parameters

Number of eye care procedures being applied and those being applied and those included in the list of eye care procedures according to healthcare level of the hospital (such list issued together with Circular No.43/TT-BYT dated December 11, 2013 of the Ministry of Health on healthcare levels in medical facility network; Circular No.21/2017/TT-BYT dated May 10, 2017 of the Minister of Health on amendments to the list of medical procedure which is issued together with Circular No.43/2013/TT-BYT) Not include number of medical procedures of superior hospital being applied

5.4

Sampling method

Whole selection

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Included criteria

Eye care procedures being run and those being approved and those included in the list of medical procedures according to the healthcare level

5.6

Excluded criteria

Medical procedures of superior hospitals

Medical procedures applied to other departments

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Data sources

The list of medical procedure issued together with Circular No.43/2013/TT-BYT dated November 11, 2013 and Circular No.21/2017/TT-BYT dated May 10, 2017

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The list of available medical procedures

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Data collection, aggregation and analysis

Data collection method

Data is collected from the list of medical procedures approved by competent authorities and the list of medical procedures issued together with Decisions of equivalent supervisory authority

Data clarification

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Analysis method

Percentage calculation

Data presentation

Data is presented in a table or pie chart at one time or column or line chart in multiple times for comparison purpose.

Data collector

General Planning department

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Data collection supervisor

Quality control department/team

Data entry clerk

General planning department

Analyser

Quality control department/team

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High accuracy and reliability

9

Reporting

Reporting frequency

Once every year (the first month of December)

Report preparer

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Approver

Board of Directors

INFORMATION COLLECTION FORM FOR INDICATOR NO.1

RATIO OF MEDICAL PROCEDURES APPROVED AND APPLIED TO TOTAL MEDICAL PROCEDURES ACCORDING TO HEALTHCARE LEVEL

A. GENERAL INFORMATION

A1. NAME OF THE HOSPITAL: …………………………………………………………..

A2. DEPARMTENT (OF GENERAL HOSPITAL PROVIDING OPHTHALMOLOGY SERVICE) ……………………….

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B. INDICATOR ASSESSMENT

B1

Total number of eye care procedures according to the healthcare level of the hospital

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B2

Number of eye care procedures approved by the supervisory authority

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B2.1

Total number of eye care procedures approved by the supervisory authority

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B2.2

Approval Decision No.

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B3

Number of eye care procedures applied of total procedures approved

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B4

Number of eye care procedures of superior hospitals applied and approved 

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NAME OF INDICATOR NO.2: Rate of health workers receiving continuous professional training as regulated

DEFINITION AND ACCEPTABLE SCORE

Definition: The rate of health workers receiving continuous professional training as regulated is provided in Circular No.22/2013/TT-BYT dated August 09, 2013 of the Ministry of Health on guidelines for continuous training provided for health workers (each health worker issued with a physician's certificate must enroll in continuous training course of at least 48 periods in 2 consecutive years from the day on which such physician's certificate is issued.)  

Acceptable score: > 85%

1

Applicable areas

The whole hospital

2

Quality property

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Type of indicator

Process

4

Reasons

Continuous training consists of short-term training courses including training for knowledge and professional skills; re-training, training according to instructions of superior hospital, training in technique transfer and other professional medical training courses not included in the national education program.         

Health employees working in medical facilities are required to enroll in continuous training course in order to achieve technical competence in their working filed.

This is one of the indicators used for assessing the task completion and job development of health workers; any health worker not enrolling in training for 2 consecutive years as prescribed in this Circular shall have his/her physician's certificate revoked as per provisions of the law on medical examination and treatment.

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Numerator

Number of health workers who were issued with physician’s certificate and have worked in medical facilities for a period of time (the number of serving years is an even number counted from the year of certificate issuance) and have received continuous training of 48 periods in the last 2 consecutive years. (according to the data reporting date)

Denominator

Total number of health workers who were issued with physician’s certificate and have worked in medical facilities for a period of time (the number of serving years is an even number counted from the year of certificate issuance) (according to the data reporting date)

Required parameters

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Sampling method

Included criteria

Health workers who were issued with physician's certificate and have worked for medical facilities.

Continuous training courses provided for health workers are suitable for professional requirements of their job

Excluded criteria

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Continuous training courses provided for health workers are not suitable for professional requirements of their job

Number of working year is an odd number counted from the year in which the physician’s certificate is issued to the assessment year.

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Data sources

Personnel department or continuous training management department

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Data collection, aggregation and analysis

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Data is collected from quarterly or annual reports.

Analysis method

Percentage calculation

Data presentation

Data is presented in a column chart or pie chart.

Data collector

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Data collection supervisor

Staff of quality control department/team

Data entry person

Staff of personnel department or continuous training management department

Analyser

Staff of quality control department/team

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Data value

Average accuracy and reliability

9

Reporting

Reporting frequency

Once every year (the first month of December)

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Quality control department/team

Approver 

Director

INFORMATION COLLECTION FORM FOR INDICATOR NO.2

RATE OF HEALTH WORKERS RECEIVING CONTINUOUS PROFESSIONAL TRAINING AS REGUALTED 

A. GENERAL INFORMATION

CODE

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A2. FULL NAME OF HEALTH WORKER: ..............................................

A3. DEPARTMENT: ……………………………………………………………………

A4. AGE:

A5. GENDER                   Male * Female *

A6. PHYSICIAN’S CERTIFICATE INFORMATION

- Certificate No. ...................................................;

- Issuance date: ……………………………………..;

- Issuer:  ……………………………………………….;

- Field of work: ....................................;

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B1

Qualification

1. Doctor

2. Nurse

3. Optometrist

4. Others:

 (specify)…………….

B2

Mode of training (in the last 2 years)

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B2.1

Have you enrolled in continuous training courses inside and outside the hospital?

1. Yes

2. No

B2.1a

Number of training courses taken

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B2.1b

Total periods  (Sum of periods of each course)

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B2.2

Have you taken domestic and overseas short-term extensive practicing courses, courses in technique transfer or professional training courses?

1. Yes

2. No

B2.2a

Number of training courses taken

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B2.2b

Total periods  (Sum of periods of each course)

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B2.3

Have you attended thematic conference/seminar or scientific talks?

1. Yes

2. No

B2.3a

Total number of thematic conference/seminar or scientific talks joined

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B2.3b

Total periods  (Total number of thematic conference/seminar or scientific talks multiplied by 4 periods)

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B2.4

Have you ever hosted a thematic conference/seminar or scientific talk?

1. Yes

2. No

B2.4a

Total number of thematic conference/seminar or scientific talks hosted 

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B2.4b

Total periods  (Total number of thematic conference/seminar or scientific talks multiplied by 8 periods)

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B2.5

Have you reported any thematic conference/seminar or scientific talk?

1. Yes

2. No

B2.5a

Total number of thematic conference/seminar or scientific talk that you reported 

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B2.5b

Total periods  (Total number of thematic conference/seminar or scientific talks multiplied by 8 periods)

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B2.6

Have you ever been a principle investigator or secretary of any local project at the acceptance date?

1. Yes

2. No

B2.6a

Number of projects of which you are the principle investigator or secretary at the acceptance date

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B2.6b

Total periods   (Total number of projects multiplied by 8 periods)

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B2.7

Have you written any domestic and overseas scientific journal which was already published?

1. Yes

2. No

B2.7a

Number of scientific journals written

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B2.7b

Total periods  (Total number of scientific journal multiplied by 8 periods for 2 chief authors and multiplied by 4 periods for co-author or author assistant)

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B2.8

Have you ever planned medical curriculum (clinical protocol, clinical guidelines or clinical pathways) which is published by the hospital?

1. Yes

2. No

B2.8a

Total number of curriculum

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B2.8b

Total periods  (Total number of curriculums multiplied by 8 periods)

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B2.9

Have you teaching any continuous training course for health workers? (excluding lecturers of education institutions)

1. Yes

2. No

B2.9a

Number of courses taught

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B2.9b

Total periods  (According to actual teaching periods)

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B2.10

Have you enrolled on training courses for improving medical knowledge and professional skills offered in the hospital?

1. Yes

2. No

B2.10a

Number of training courses taken

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B2.10b

Total periods  (According to actual teaching periods)

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B2.11

Have you participated in scientific events or thematic events?

1. Yes

2. No

B2.11a

Number of event joined

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B2.11b

Total periods  (3 accumulated events equals 4 periods)

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B3

Total number of training periods converted (Total periods of courses taken in the last 2 years)

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B4

Is your training duration conformable with the regulations?

1. Yes

2. No

Training duration conversion table

NO.

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MODE OF CERTIFICATION

NUMBER OF PERIOD (or converted)

NOTE

1

Health workers enrolling in continuous training course inside and outside the hospital

Diploma/ Certificate of Continuous Training

According to number of periods specified in the Certificate/Certificate of Continuous Training

Training programs and material are appraised and approved by the competent authority.

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Diploma/Certificate

According to number of hours specified in the Diploma/Certificate

Training programs and material are appraised and approved by the competent authority.

2

Health workers attending thematic conference/seminar or scientific talk

Attending Certificate

4 periods

3

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Hosting/Attending Certificate

8 periods

4

Reporting a thematic conference/seminar or scientific talk

Attending Certificate and reports

8 periods

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Certificate

8 periods

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Writing a domestic and overseas scientific journal which was already published

Certificate of report

+ 8 periods for 2 chief authors

+ 4 periods for co-author and author assistant

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Writing medical textbook (clinical protocol, clinical guidelines or clinical pathways) which is published by the hospital

Certificate or books published

8 periods/book/author

8

Teaching the continuous training course or participating in the teaching process (excluding lecturers of education institutions)

Teaching Certificate and textbook

According to actual teaching periods

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Training courses for improving medical knowledge and professional skills offered in the hospital 

Training Certificate

According to actual teaching periods

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Scientific events and thematic events

Attending Certificate

3 accumulated events equals 4 periods

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NAME OF INDICATOR NO.3: Rate of satisfactory medical records

DEFINITION AND ACCEPTABLE SCORE

Definition:

A completed medical record is a record of disease development, treatment and care of a patient during medical treatment in a health facility, including all documents and information relating to such patient and healthcare service.

Rate of satisfactory medical records is determined by number of medical records that meet the criteria provided in the checklist (attached) to total number of records undergoing inspection in the assessment period.

Acceptable score: > 80%

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Applicable areas

The whole hospital

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Quality property

Safety

3

Type of indicator

Process

4

Reasons

Medical record is considered a scientific document concerning medical procedure, a financial document as well as a forensic document. A medical record must be completed in an instant, objective, careful, accurate and scientific manner.

Decision No.4069/2001/QD-BYT dated September 28, 2001 of the Ministry of Health issuing medical record templates.

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Calculation method

Numerator

Number of medical record meeting the criteria in the checklist

Denominator

Number of medical record undergone inspection

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Required parameters

Inspection according to instructions in the checklist

Sampling method

All medical records of patients discharged from the hospital shall be selected at any time (in 1 or 2 days or 1 or 2 weeks) in an assessment period to make sure there are at least 100 medical records selected. 

Included criteria

All medical records of patients discharged from the hospital from clinical department sent to the general planning department before submitted for approval and storage purpose

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Secret medical records

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Data sources

- Direct assessment

- Following-up books, or book for medical record management of the general planning department

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Data collection, aggregation and analysis

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Medical records are collected and compared with the medical record assessment checklist.

Analysis method

Percentage calculation

Data presentation

Data is presented in table, column chart or line chart for the purpose of time comparison.

Data collector

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Data collection supervisor

Quality control department/team

Data entry person

General planning department

Analyzer

Quality control department/team

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Data value

High accuracy

9

Report

Reporting frequency

Every quarter

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Quality control department/team

Approver 

Director

INFORMATION COLLECTION FORM FOR INDICATOR NO.3

RATE OF SATISFACTORY MEDICAL RECORDS

A. GENERAL INFORMATION

A1. CODE

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A3. FULL NAME OF PATIENT: ..............................................

A4. DEPARTMENT: ……………………………………………………………………

A5. AGE:

A6. GENDER                  Male * Female *

A7. STORAGE NO.:………..

A8. MEDICAL CODE

B. INDICATOR ASSESSMENT

B1

Is the medical record completed as required by the checklist?

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2. No

B2

Uncompleted tasks

B2.1

Medical record form and storage mode

1. Correct form

2. Intact, clean, not erased or patchy 

B2.2

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1. Sufficient administrative information (Section I)

2. Sufficient information on patient administrator (Section II)

B2.3

Medical examination and diagnosis

1. Hospital admission causes

2. Disease development

3. Disease history

4. Whole-body examination

5. Organ examination

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B2.4

Consultation record

1. Use of drugs indicated by a asterisk (*)

2. Referral

3. Surgery (attached with surgery agreement)

4. Medical procedure (**)

5. Disease characteristics 

B2.5

Nursing report sheet

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2. Vital sign monitoring sheet

3. Medical prescription

4. Surgical safety checklist (for patients undergoing surgery)

B2.6

Disease development monitoring and doctor’s medication order

B2.6a

Treating physician

1. Monitor daily disease development (specify time)

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3. Give clinical instruction provided in the treatment report sheet

4. Give clinical instruction after an inpatient code is received  

5. Give instructions for caring regime and diet 

B2.6b

The head of the department

1. Examine and record judgment in the medical record at least once for patients undergoing treatment in 5 or more than 5 days

B2.7

Nursing and caring department

1. Prepare and implement the caring plan

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B2.8

Compliance with prescription making regulations

B2.8a

Drug numbering regulations

1. Radioactive drugs

2. Mental health-related drugs

3. Antibiotics

4. Tuberculosis drugs

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B2.8b

Drug prescription regulations

1. Concentration (content)

2. Drug dose

3. Number of dose/day

4. Drug taking time      

5. Drug route

6. Instruction

B3

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1. A medical record is reviewed after days of treatment.

B4

Review of medical record

1. Columns

2. Signatures 

INDICATOR NO.4: Rate of surgeries following instructions provided in the surgical safety checklist

NAME OF INDICATOR NO.4: Rate of surgeries following instructions provided in the surgical safety checklist

DEFINITION AND ACCEPTABLE SCORE

Definition: Such rate is the ratio of surgeries following instructions provided in the surgical safety checklist under the guidance of the World Health Organization to total surgeries undergoing inspection. (A surgical safety checklist is a tool used for checking and supervising actions taken before, during and after a surgery in order to minimize medical errors and complications during the surgery.)       

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Applicable areas

Surgery

2

Quality property

Patient safety

3

Type of indicator

Process

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Reasons

Restrict medical errors during the surgery to ensure patient safety

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Calculation method

Numerator

Number of surgeries following instructions provided in the surgical safety checklist (checklist attached)

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Total number of surgeries undergoing inspection in the reporting period

Required parameters

Carry out cross sectional assessment at a time of each surgery and verify whether the checklist is properly applied at such time

Sampling method

Random selection of surgeries in the assessment time

Based upon number of patients undergoing surgery in the assessment period (at least 30 surgeries/assessment period)

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Surgeries performed at the operating room.

Excluded criteria

- Patients receiving surgical appointment but delaying the surgery

- Patients not undergoing surgery in the operating room of the hospital 

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Data sources

Direct observation through surgical safety checklist provided by the World Health Organization (WHO) and under the guidance of the Ministry of Health or he checklist recorded in the medical record  (Excluding pre-surgical safety checklist or the note of transfer of patients having surgery)

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Data collection method

Direct observation at the operating room

Analysis method

Data is inputted by Epidata software and processed by SPSS statistics software.

Data presentation

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Data collector

Nursing department

Data collection supervisor

Quality control department/team

Data entry person

Quality control department/team

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Analyser

Quality control department/team

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Data value

Average accuracy and reliability

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Report

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Twice a year; 6-month and 12-month reports (reporting time: the first week of June and December)

Data collected from December 01 of a year to May 31 of the next year ( the first 6 months of a year); data collected from June 01 to November 30 of a year (the last 6 months of a year)

Report preparer

Quality control department/team

Approver 

The head of the hospital

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RATE OF SURGERIES FOLLOWING INSTRUCTIONS PROVIDED IN THE SURGICAL SAFETY CHECKLIST

A. GENERAL INFORMATION

A1. CODE

A2.NAME OF THE HOSPITAL: …………………………………………………………..

A3. PATIENT CODE (OR FULL NAME OF PATIENT): ..............................................

B. MEDICAL PROCEDURE APPLICATION

B1

Operating room No.

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Action taken at the assessment time

1. Before induction of anesthesia  

2. Before skin incision

3. Before patient leaves operating room  

B3

Have the surgical safety checklist been followed?

1. Yes → end of question

2. No

B4

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1. Yes → end of question

2. No

B5

Tasks uncompleted

B5.1

Uncompleted tasks in the part “Before induction of anesthesia” (Multiple choices)

1. Has the patient (or guardian) confirmed identity, site, procedure and consent?

2. Is the site marked?

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4. Is the anesthesia machine and medication check completed?

5. Has the patient signed the surgery agreement?

6. Does the patient have a known allergy? (including Latex)

7. Fasting before surgery?

8. Difficult airway/aspiration risk?

9. Risk of >500ml blood loss (7ml/kg in children)

B5.2

Uncompleted tasks in the part “Before skin incision" (Multiple choices)

1. Confirm the patient’s name

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3. Confirm the surgical procedure

4. Is the eye undergoing operation marked?

5. Are the intraocular lens placed?

6. Confirm protection of the eye not undergoing operation

7. Is surgical instruments check completed?

8. Confirm sterility of surgical instruments

9. Confirm sterility of the site

10. Has the surgical team informed of the surgical procedure?

11. Are drugs for surgical infection prevention used?

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Uncompleted tasks in the part “Before the patient leaves operating room” (Multiple choices)

1. Surgical instruments and suture count correct           

2. Morbid anatomy/microbiology testing

3. Specimen labeled

4. Equipment issues addressed

5. Requirements for post surgery rehabilitation and caring

B6

Signatures of surgical team's members

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Is the checklist signed by all members?

1. Yes

2. No

B6.2

Who does not sign the checklist? (Multiple choices)

1. Surgeon 

2. Anesthetist

3. Nurse, surgical assistant

4. Person filling in the checklist

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NAME OF INDICATOR NO.5: Rate of post-ocular surgery endophthalmitis

DEFINITION AND ACCEPTABLE SCORE

Definition: Rate of post-ocular surgery endophthalmitis is the ratio of patients getting post-ocular surgery endophthalmitis to total patients having ocular surgery in the reporting and assessment period.

ACCEPTABLE SCORE: < 0.08% (Recommended by WHO)

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Applicable areas

Surgery

2

Quality property

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Type of indicator

Output

4

Reasons

Infection and endophthalmitis are serious complications in cataract surgery as well as other ocular surgeries.

Such diseases may be caused by eye diseases, whole-body diseases or non-compliance with infection control procedure during the surgery or the procedure for post surgery eye treatment and care (eye dropping, drug taking)

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Calculation method

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Numerator

Number of patients getting post-ocular surgery endophthalmitis (except for patients having surgery for penetrating ocular trauma)

Denominator

Total number of patients having ocular surgery in the reporting period (except for patients having penetrating ocular trauma surgery)

Required parameters

Number of patients getting post-ocular surgery endophthalmitis (except for patients having surgery for ocular trauma)

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Sampling method

Medical records of all patients undergoing ocular surgery in the assessment period are selected.

Included criteria

Patients diagnosed with post-ocular surgery endophthalmitis (within 1 month from the surgery date)

Excluded criteria

Other infections not caused by surgery (e.g. surgery for penetrating ocular trauma)

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Data sources

Medical records or medical error reporting book

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Data collection, aggregation and analysis

Data collection method

Data is collected from medical histories and reporting sheets.

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Analysis of percentage, number of endophthalmitis case or case analysis

Data presentation

Data is presented in a table, column chart or pie chart.

Data collector

General planning department

Data collection supervisor

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Data entry person

Quality control department/team

Analyser

Quality control department/team

8

Data value

High accuracy and reliability

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Report

Reporting frequency

Report preparer

Quality control department/team

Approver 

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INFORMATION COLLECTION FORM FOR INDICATOR NO.5

RATE OF POST-OCULAR SURGERY ENDOPHTHALMITIS

A. GENERAL INFORMATION

A1. CODE

A2. NAME OF THE HOSPITAL: …………………………………………………………..

A3. FULL NAME OF PATIENT: ..............................................

A4. DEPARTMENT/ROOM: ………………………………………………………………

A5. AGE:

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A6. PRE-SURGERY DIAGNOSIS: ………………………………………………………….

B. INDICATOR ASSESSMENT

B1

Does the patient get post-ocular surgery endophthalmitis?

1. Yes

2. No

B1.1

The day on which post-ocular surgery endophthalmitis is detected

…..

...

...

...

Does the patient have another eye-related disease?

1. Yes

2. No

B2.1

If yes, specify the name of the disease

…..

B3

Is any post-endophthalmitis treatment provided?

1. Yes (specify): …………….

...

...

...

B3.1

Treatment given to the patient

B3.2

Is the hospital infection control procedure reviewed?

1. Yes (specify): …………….

2. No

INDICATOR NO.6: Number of serious medical errors

NAME OF INDICATOR NO.6: Number of serious medical errors

...

...

...

Definition:

A medical error is a unanticipated risk or mistake during healthcare process (including medical diagnosis, care and treatment) and unexpected impacts of medical supporting factors (including drugs, devices, medical environment or social environment)  which are not caused by disease development or host factor and produce effects on the patient's health according to injury levels from trivial to serious.

Medical errors that must be reported are serious errors categorized as severe injuries or death (hereinafter referred to as NC3/Risk - issued thereto).

Acceptable score: No serious medical error is committed

1

Applicable areas

The whole hospital

2

Quality property

...

...

...

3

Type of indicator

Output

4

Reasons

Medical errors cause tremendous impact on health of patients, medical staff and community due to medical and non-medical mistakes. Although not many medical errors are reported, early detection, treatment and prevention are required. Medical error reporting is aimed at identifying, analyzing and realizing errors caused by machines and human to work out method for treatment and prevention.

Decision No.56/BYT-K2DT dated May 16, 2014 of the Minister of Health on patient safety guidelines.

5

Calculation method

...

...

...

Required parameters

Number of serious medical errors listed in the table (attached) in the reporting and assessing period

Sampling method

All reported medical errors are selected.

Included criteria

NC3 group errors in the attached list

...

...

...

Excluded criteria

Reported medical errors not in the attached list

6

Data sources

Number of serious medical error report, voluntary error reporting sheets, online reporting system and medical histories

7

Data collection, aggregation and analysis

...

...

...

Data is collected from quarterly or annual reports.

Analysis method

Calculation of absolute number

Data presentation

Data is presented in a table, column chart or line chart for the purpose of time comparison.

Data collector

...

...

...

General quality control department/team

Data collection supervisor

Quality control department/team

Data entry person

Quality control department/team

Analyser

...

...

...

8

Data value

Average accuracy and reliability

9

Reporting

Reporting frequency

Every quarter

...

...

...

Report preparer

Quality control department/team

Approver 

Board of Directors

TABLE OF SERIOUS MEDICAL ERRORS

SURGICAL ERRORS

1.

...

...

...

It means that operation is performed on the patient's body part inconsistent with the one specified in the medical record of such patient.

Except for the following emergencies:

A. Decision on changing site made during operation

B. Approval for such change

C. Both

2.

Performing an operation on the wrong patient:

It means that the operation is performed on the patient inconsistent with patient's identity specified in the medical record.

3.

...

...

...

It means the medical procedure for performing surgery is inconsistent with the one specified in the surgery consultation record.

Except for the following emergencies:

A. Decision on changing surgical method made during operation

B. Approval for such change

C. Both

4.

Leaving a surgical instrument inside the patient's body or performing other unnecessary invasive procedures

Except for the following cases:

A. The surgical instrument is inserted into the patient’s body under instructions.

...

...

...

C. The surgical instrument is not inserted before the surgery but intentionally remained inside the patient's body as the removal may cause harm to the patient. For example: Very tiny needles or debris of screws.

5.

Death during surgery and post-surgery in case the physical status of the patient before surgery is grouped into class I include deaths by anesthesia or surgery plans that can or cannot not be performed. 

MACHINE ERRORS

6.

Death or serious complication relating to contaminated drugs or medical equipment or biologics provided widely Detection of contamination in medicine, medical instruments and biologics irrespective of contamination origin or specimen origin

7.

Death or complication related to machine use or function of medical instruments for patient care in which such use or function is different from the anticipated one. Medical instruments include (not limited):

A. Catheter

...

...

...

C. Infusion pump

D. Mechanical ventilator

8.

Death or serious complication related to venous air embolism during inpatient caring and treatment  Except for neurosurgery procedures with high risk of venous air embolism

PATIENT MANAGEMENT-RELATED ERRORS

9.

Not applicable

10.

Death or complication due to hospital leaving without any permission 

...

...

...

Suicide or serious complication due to suicide committed at the medical facility

These errors are indentified as incidents caused by the patient's actions after such patient is admitted to the medical facility for treatment.

CARE-RELATED ERRORS

12

Death or serious complication due to medication errors:

A. Drug’s name

B. Drug dose

C. Patient

D. Time for drug taking

...

...

...

F. Drug blending

G. Drug route

Except for abnormal reasons for selection of drug and dose in clinical treatment

For example: Giving the patient a drug despite knowing that the patient has an allergy to such drug and drug interaction may lead to death or serious complications.

13.

Death or serious complication related to hemolysis due to transfusion of the wrong blood type or blood products

14.

Not applicable

15.

...

...

...

16.

Not applicable

17.

Not applicable

18.

Not applicable

19.

Not applicable

ENVIRONMENTAL ERRORS

...

...

...

Death or serious complication due to electrical injury Except for medical errors due to electrotherapy (synchronized and unsynchronized cardioversion)

21.

Accidents due to airway design or other gases provided to the patient:

A. Gas mistaken  Or

B. Gas contained hazardous substances

22.

Death or complication due to burn during caring process at the medical facility irrespective of causes

23.

Death or complication due to falling during caring process in the medical facility

...

...

...

Death or serious complication due to tools used for fixing the patient or bed barrier

MEDICAL ERRORS CONSIDERED CRIMINAL VIOLATIONS

25.

Impersonating health workers to give the patient treatment

26.

Kidnapping (or enticing) patients irrespective of age

27.

Sexual harassment of patients in the hospital campus

28.

...

...

...

 (*) There are 6 errors, which are errors no.9, 14, 16, 17, 18 and 19 not applicable to ophthalmology specialist medical facilities.

INFORMATION COLLECTION FORM FOR INDICATOR NO.6

SERIOUS MEDICAL ERRORS

A. GENERAL INFORMATION

A1. CODE

A2. NAME OF THE HOSPITAL: …………………………………………………………..

A3, NAME OF CONSOLIDATED REPORT PREPARER: …………………………………………

A4. DEPARTMENT/ROOM: ………………………………………………………………

...

...

...

A6. GENDER                 Male * Female *

B. INDICATOR ASSESSMENT

B1

Has the serious medical error been reported?

1. Yes

2. No serious medical error

B2

Is the serious medical error related to “Performing an operation on the wrong body part of the patient”?

1. Yes

...

...

...

B2.1

If yes, how many times has such error occurred?  

1. Once

2. Twice

3. Third time

4. Fourth time

5. > fourth time

B3

Is the serious medical error related to “Performing an operation on the wrong patient”?

...

...

...

2. No

B3.1

If yes, how many times has such error occurred? 

1. Once

2. Twice

3. Third time

4. Fourth time

5. > fourth time

B4

...

...

...

1. Yes

2. No

B4.1

If yes, how many times has such error occurred? 

1. Once

2. Twice

3. Third time

4. Fourth time

5. > fourth time

...

...

...

Is the serious medical error related to “Leaving a surgical instrument inside the patient's body or performing other unnecessary invasive procedures"?

1. Yes

2. No

B5.1

If yes, how many times has such error occurred? 

1. Once

2. Twice

3. Third time

4. Fourth time

...

...

...

B6

Is the serious medical error related to “Death during surgery or post-surgery in case the patient’s physical status before the surgery is grouped in class I"?

1. Yes

2. No

B6.1

If yes, how many times has such error occurred? 

1. Once

2. Twice

3. Third time

...

...

...

5. > fourth time

B7

Is the serious medical error related to “Death or serious complication relating to contaminated drugs or medical equipment or biologics provided widely”?

1. Yes

2. No

B7.1

If yes, how many times has such error occurred? 

1. Once

2. Twice

...

...

...

4. Fourth time

5. > fourth time

B8

Is the serious medical error related to “use of medical machine or function of medical instruments for patient care"?

1. Yes

2. No

B8.1

If yes, how many times has such error occurred? 

1. Once

...

...

...

3. Third time

4. Fourth time

5. > fourth time

B9

Is the serious medical error related to “venous air embolism during the process of caring and treating inpatients”?

1. Yes

2. No

B9.1

If yes, how many times has such error occurred? 

...

...

...

2. Twice

3. Third time

4. Fourth time

5. > fourth time

B10

Is the serious medical error related to “hospital leaving without any permission”?

1. Yes

2. No

B10.1

...

...

...

1. Once

2. Twice

3. Third time

4. Fourth time

5. > fourth time

B11

Is the serious medical error related to “suicide committed at the medical facility"?

1. Yes

2. No

...

...

...

If yes, how many time has such error occurred? 

1. Once

2. Twice

3. Third time

4. Fourth time

5. > fourth time

B12

Is the serious medical error related to “medication error"?

1. Yes

...

...

...

B12.1

If yes, how many times has such error occurred? 

1. Once

2. Twice

3. Third time

4. Fourth time

5. > fourth time

B13

Is the serious medical error related to “hemolysis"?

...

...

...

2. No

B13.1

If yes, how many times has such error occurred? 

1. Once

2. Twice

3. Third time

4. Fourth time

5. > fourth time

B14

...

...

...

1. Yes

2. No

B14.1

If yes, how many times has such error occurred? 

1. Once

2. Twice

3. Third time

4. Fourth time

5. > fourth time

...

...

...

Is the serious medical error related to “electrical injury"?

1. Yes

2. No

B15.1

If yes, how many times has such error occurred? 

1. Once

2. Twice

3. Third time

4. Fourth time

...

...

...

B16

Is the serious medical error related to “Accidents due to airway design or other gases provided to the patient”?

1. Yes

2. No

B16.1

If yes, how many times has such error occurred? 

1. Once

2. Twice

3. Third time

...

...

...

5. > fourth time

B17

Is the serious medical error related to “burn during caring process at the medical facility irrespective of causes”?

1. Yes

2. No

B17.1

If yes, how many times has such error occurred? 

1. Once

2. Twice

...

...

...

4. Fourth time

5. > fourth time

B18

Is the serious medical error related to “falling during caring process at the medical facility"?

1. Yes

2. No

B18.1

If yes, how many times has such error occurred? 

1. Once

...

...

...

3. Third time

4. Fourth time

5. > fourth time

B19

Is the serious medical error related to “tools used for fixing the patient or bed barrier”?

1. Yes

2. No

B19.1

If yes, how many times has such error occurred? 

...

...

...

2. Twice

3. Third time

4. Fourth time

5. > fourth time

B20

Is the serious medical error related to “impersonating the health worker to give the patient treatment"?

1. Yes

2. No

B20.1

...

...

...

1. Once

2. Twice

3. Third time

4. Fourth time

5. > fourth time

B21

Is the serious medical error related to “kidnapping (or enticing) patients irrespective of age”?

1. Yes

2. No

...

...

...

If yes, how many times has such error occurred? 

1. Once

2. Twice

3. Third time

4. Fourth time

5. > fourth time

B22

Is the serious medical error related to “sexual harassment of patients in the hospital campus”?

1. Yes

...

...

...

B22.1

If yes, how many times has such error occurred? 

1. Once

2. Twice

3. Third time

4. Fourth time

5. > fourth time

B23

Is the serious medical error related to “causing death or severe injury to patients or health workers by weapons in the hospital campus”?

...

...

...

2. No

B23.1

If yes, how many times has such error occurred? 

1. Once

2. Twice

3. Third time

4. Fourth time

5. > fourth time

INDICATOR NO.7: Rate of patients having good sight after cataract surgery alone

...

...

...

DEFINITION AND ACCEPRABLE SCORE

Definition: The rate of patient having good sight after cataract surgery alone is the ratio of patients who could see at least 2 more lines in the eyesight testing chart without changing their glasses at the time of latest eyesight test (at least 1 week after the surgery) to total patients having eyesight test.

ACCEPRABLE SCORE: > 80% (Recommended by WHO)

1

Applicable areas

The whole hospital

2

Quality property

Clinical effectiveness 

...

...

...

Type of indicator

Output

4

Reasons

Assessing and improving treatment service quality

5

Calculation method

...

...

...

Number of patients who could see at least 2 more lines in the eyesight testing chart without changing their glasses after the cataract surgery alone in the reporting and assessing period

Denominator

Total number of cataract surgery alone in the reporting and assessing period

Required parameters

Eyesight before the surgery

Eyesight after the surgery without glass changing at the time of the latest eyesight test (at least 1 week after the surgery)

...

...

...

All patients undergoing cataract surgery alone in the reporting and assessing period.

Included criteria

Patients undergoing cataract surgery alone in the reporting and assessing period

Excluded criteria

Patients having eyesight test prior to 1 week after the surgery

Children or patients who refuse to cooperate with health workers or whose post-surgery eyesight cannot be determined

Patient suffering from cataract along with other eye-related diseases

...

...

...

Data sources

Medical record retaining room, examination department and other relevant clinical departments.

7

Data collection, aggregation and analysis

Data collection method

Data is collected from medical records or treatment assessment.

...

...

...

Percentage calculation

Data presentation

Data is presented in a chart.

Data collector

A nurse - optometrist

Data collection supervisor

...

...

...

Data entry person

General planning department

Analyser

Quality control department/team

8

Data value

Average accuracy and reliability due to low rate of patients undergoing post-surgery eyesight test

...

...

...

Reporting

Reporting frequency

Every year

Report preparer

Quality control department/team

...

...

...

Director

INFORMATION COLLECTION FORM FOR INDICATOR NO.7

RATE OF PATIENTS HAVING GOOD EYESIGHT AFTER CATARACT SURGERY ALONE

A. GENERAL INFORMATION

A1. CODE

A2. NAME OF THE HOSPITAL: …………………………………………………………..

A3. FULL NAME OF PATIENT: ..............................................

A4. DEPARTMENT/ROOM: ………………………………………………………………

...

...

...

A5. GENDER                  Male * Female *

B. INDICATOR ASSESSMENT

B1

Eyesight of the patients before the surgery

B2

Eyesight of the patient after the surgery without glass changing at the time of the latest eyesight test (at least 01 week after the surgery)

INDICATOR NO.8: Serviceability of hospital beds

...

...

...

DEFINITION AND ACCEPATBLE SCORE

Definition:

ACCEPATBLE SCORE:

1

Applicable areas

The whole hospital

2

Quality property

Clinical Effectiveness

...

...

...

Type of indicator

Output

4

Reasons

Overloaded hospitals, especially central hospitals, are causing annoyance to the public. Although the number of hospital beds used is greater than the one estimated in the plan, the latter is used for determining the serviceability of hospital beds. The serviceability of hospital beds calculated by the number of hospital beds in operation is used to determine more accurately the overload level of a hospital and keep a watch on changes in the hospital operation.

5

Calculation method

...

...

...

Total number of inpatient treatment days in the reporting period

Denominator

Total number of hospital beds used during days of treatment in the reporting period

Required parameters

Number of patients, number of inpatient treatment day of each patient and number of hospital beds used

Sampling method

...

...

...

Included criteria

Excluded criteria

6

Data sources

Medical record retaining department and general planning department

...

...

...

Data collection, aggregation and analysis

Data collection method

Data is collected from medical records and hospital reports.

Analysis method

Determination of serviceability hospital beds

...

...

...

Data is presented in a table or chart.

Data collector

Staff of the general planning department

Data collection supervisor

General planning department

Data entry person

...

...

...

Analyser

General planning department

8

Data value

High accuracy and reliability

9

Reporting

...

...

...

Reporting frequency

Every quarter

Report preparer

General planning department

Approver 

The head of the hospital

INDICATOR NO.9: Rate of patients’ satisfaction with healthcare services (for inpatients and outpatients)

...

...

...

DEFINITION AND ACCEPTABLE SCORE

Definition: Such rate is the ratio of patients whose satisfaction with healthcare services provided in a hospital is at level 4 and 5 according to the Likert scale for measurement of patients’ satisfaction to total patients doing the questionnaire.  

ACCEPTABLE SCORE: >80%

1

Applicable areas

The whole hospital

2

Quality property

Patient-oriented indicators

...

...

...

Type of indicator

Output

4

Reasons

Patients’ satisfaction is the most important criteria used to assess the hospital service quality as well as a basis for determining shortcomings for improvement purpose.

According to Decision No.6858/QD-BYT dated November 18, 2016 which provides for a set of criteria for hospital assessment and requirement for regular measurement of patients’ satisfaction.

5

Calculation method

...

...

...

Numerator

Number of patients satisfying with healthcare services (at level 4 and 5 according to the Likert scale)

Numerator No.1

Number of inpatients

Numerator No.2

Number of outpatients

...

...

...

Number of patients doing the questionnaire for patients' satisfaction

Denominator No.1

Denominator No.2

Number of inpatients

Number of outpatients

Required parameters

Patients (administrative information and patient information)

...

...

...

Sampling method

Random selection;

Sample size: According to regulations provided in the set of criteria for hospital assessment

Included criteria

Patients going through the hospital discharging process or those already left the hospital

Excluded criteria

...

...

...

6

Data sources

Questionnaire (template attached)

7

Data collection, aggregation and analysis

Data collection method

Interview

...

...

...

Data clarification

Data is clarified by the software provided by the Ministry of Health or Epidata software.

Analysis method

Data is analyzed by the software provided by the Ministry of Health or SPSS software.

Data presentation

Data is presented in a statistical table or in chart.

...

...

...

Social affair department/team or customer service department or quality control department (if there is no social affair department)

Data collection supervisor

Quality control department/team

Data entry person

Quality control department/team

Analyser

...

...

...

8

Data value

High accuracy and reliability

9

Reporting

Reporting frequency

Once every 3 months

...

...

...

Report preparer

Quality control department/team

Approver 

The head of the hospital

INFORMATION COLLECTION FORM FOR INDICATOR NO.9

 (The questionnaire is issued together with Decision No.6858/QD-BYT dated November 18, 2016 of the Minister of Health on promulgation of a set of criteria for hospital assessment)

MINISTRY OF HEALTH
FORM NO.1  

...

...

...

...

...

...

 (REDUCED FORM)

INPATIENT QUESTIONNAIRE

The purpose of this survey is to understand patients' desire for the purpose of improving healthcare services quality and gaining patients’ satisfaction.  These precious opinions will help the health industry to overcome difficulties and gradually improve quality in order to provide people with better services. The response will be kept confidential and not cause any impact on the treatment process. We do highly appreciate!

1. Name of the hospital: ………………………….. 2. Date of filling in the questionnaire: …………………..

3. Name of the department providing treatment service: ……………………………………. 4. Department code (provided by the hospital) …………………………….

PATIENT INFORMATION

A1 Gender: 1.Male 2. Female

A2. Age: ...........................

A3. Mobile phone number (required):

...

...

...

A5. Did you use your health insurance for this treatment? 1. Yes 2. No

HEALTHCARE SERVICE ASSESSMENT

Please rate how much you agree or disagree with the following statements on a scale from 1 to 5 by marking an "X" on a number in each line:

 refers to

refers to

 refers to

refers to

refers to

Strongly disagree

...

...

...

Neutral

Agree

Strongly agree

or Very poor

or Poor

or Average

or Good

or Very good

...

...

...

A1.

Diagrams or signs for directions to hospital departments or wards are easily found and read.

A2.

Time for patient visit is clearly informed.

A3.

Hospital buildings, stairs and wards are clearly numbered and easily found.

...

...

...

All surfaces of hospital passage are smooth and easy to walk on.

A5.

Health workers are always showed up when being asked by the patient

B. Transparency of healthcare information and procedures

B1.

The hospital admission procedure is clearly and publicly provided.

...

...

...

I was clearly and sufficiently informed of regulations and necessary information when being admitted to the hospital.

B3.

I was provided with clear and full explanation of the disease status, treatment method and expected day for treatment.

B4.

The doctor gave me clear explanation and advice before requesting me to undergo testing or screening by high-tech devices.

B5.

...

...

...

C. Facility and instruments for patients’ treatment

C1.

The hospital ward is clean and equipped with appropriate devices for regulating the temperature such as fan, heater or air conditioner.

C2.

The bed, bedspread and pillow given to each patient are safe and good for use.

C3.

...

...

...

C4.

When being hospitalized, I was safe and secured from theft acts.

C5.

Clean patient clothes are fully provided.

C6.

Hot and cold drinking water is fully provided.

...

...

...

C7.

Each bed is provided with a drape or wall or there is private room in order to ensure the patient's privacy (changing clothes, taking medical examination or urinating during best rest)

C8.

The hospital canteen provides enough qualified food and drinking as well as necessary tools for daily activities. 

C9.

The hospital environment is clean and unpolluted.

...

...

...

D1.

Doctors and nurses behave and communicate in a good manner.

D2.

The staffs (nurse assistant, security guard or accountant) behave and communicate in a proper manner.

D3.

I was fairly respected, cared and helped.

...

...

...

Doctors and nurses perfectly cooperated with each other in timely handling the work.

D5.

The doctor paid a visit and give encouragement to the patient in the hospital ward.

D6.

Advice on diet, physical exercise regime, complication monitoring and prevention was fully provided.

D7.

...

...

...

E. The service provision result

E1.

Drugs and drug instructions were fully provided.

E2.

Modern medical equipment and supplies were sufficiently provided to satisfy patients' desire.

E3.

...

...

...

E4.

I am confident about the quality of this hospital’s healthcare services

E5.

I satisfy with the healthcare service price.

G1

Generally, how would you rate your satisfaction with the hospital services compared to your expectation before hospitalization?

...

...

...

…………………%

G2

If requiring the same healthcare service, will you come to this hospital again or recommend other people this hospital?

1. I definitely will not come to this hospital again.

2. I don't want to come back here but I have other choices.

3. I want to be referred to another hospital.

4. I may come back here.

5. I definitely will come to this hospital again or I will recommend other people this hospital.

6. Others (specify): …………….

...

...

...

Please add other comments (If any)

MINISTRY OF HEALTH
FORM NO.2 

...

...

...

OUTPATIENT QUESTIONNAIRE

The purpose of this survey is to understand patients' desire for the purpose of improving healthcare services quality and gaining patients’ satisfaction.  These precious opinions will help the health industry to overcome difficulties and gradually improve quality in order to provide people with better services. The response will be kept confidential and not cause any impact on the treatment process. We do highly appreciate!

1. Name of the hospital: ……………………………………………………..

2. Questionnaire filling date: .....................................................

PATIENT INFORMATION

...

...

...

Gender: 1.Male 2. Female

A2.

Age: ………………………………..

Mobile phone number (required):

A3.

How far is it from your house to the hospital?: ................... km

A4.

Did you use your health insurance for this treatment? 1. Yes 2. No

HEALTHCARE SERVICE ASSESSMENT

...

...

...

 refers to

refers to

 refers to

refers to

refers to

Strongly disagree

Disagree

Neutral

Agree

...

...

...

or Very poor

or Poor

or Average

or Good

or Very good

A. Accessibility

A6.

Signs of directions to the hospital are easily found and read.

...

...

...

A7.

Diagrams or signs for directions to hospital departments or wards are easily to be found and read.

A8.

Hospital buildings, stairs and wards are clearly numbered and easily found.

A9.

All passage surfaces of the hospital are smooth and easy to walk on.

...

...

...

Hospital information can be found and doctor's appointment can be made over the phone or on the website of the hospital.

B. Transparency of healthcare information and procedures

B6.

The medical examination procedure is clearly and publicly provided.

B7.

Medical examination procedures are simplified.

...

...

...

Healthcare service prices are quoted in a transparent and public manner.

B9.

Health workers welcome and instruct the patient to do medical procedures in a hospitable and dedicated manner.

B10.

Registration, payment, examination, testing and screening were done in order.

B11.

...

...

...

B12.

Give your comment on the time waiting for your examination

B13.

Give your comment on the time undergoing examination and receiving the doctor’s advice

B14.

Give your comment on the time waiting for testing or screening

...

...

...

B15.

Give your comment on the time waiting for testing or screening result

C. Facility and instruments for patients’ treatment

C10.

The waiting room or lounge is clean, cool in the summer and airtight and warm in the winter.

C11.

The waiting room has good chairs for all patients.

...

...

...

C12.

The waiting room is equipped with sufficient fans or air conditioners and such equipment is always in operation. 

C13.

The waiting room is equipped with facilities to help the patients feel comfortable such as televisions, pictures, leaflets or drinking water

C14.

Examination, screening or operation service was given privately to each patient. 

...

...

...

Restrooms are clean and have convenient facilities.

C16.

The hospital campus is clean and unpolluted.

C17.

The examination department is safe and secured from theft. 

D. Behaviors and professional capacities of health workers

...

...

...

Medical staff (doctors and nurses) behaved and communicated in a proper manner.

D9.

The staffs (nurse assistants, security guards or accountants) behaved and communicated in a proper manner.

D10.

I was respected, fairly treated, cared and helped.

D11.

...

...

...

E. Service provision results

E6.

The treatment result satisfied your desire.

E7.

Receipts, prescription and examination results were fully provided in a transparent manner with explanation if there is any question.

E8.

...

...

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E9.

I satisfy with the healthcare service price.

F

Generally, how would you rate your satisfaction with the hospital services compared to your expectation before you come to this hospital?

 (write from 0% to 100% or more than 100% if the healthcare service provided is beyond your expectation)

………………. %

G

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1. I definitely will not come to this hospital again.

2. I don't want to come back here but I have other choices.

3. I may come back here.

4. I definitely will come to this hospital again or I will recommend other people this hospital.

5. Others (specify): …………….

INDICATOR NO.10: RATE OF HEALTH WORKERS’ SATISFACTION

NAME OF INDICATOR NO.10: Rate of health workers’ satisfaction 

DEFINITION AND ACCEPTABLE SCORE

Definition: The rate of health workers’ satisfaction is the ratio of health employees and workers of a hospital satisfying with the benefits and working environment provided by such hospital to total number of medical staffs of the hospital.

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1

Applicable areas

The whole hospital

2

Quality property

Staff-oriented indicators

3

Type of indicator

Output

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Reasons

This is an important criteria used for assessing benefits and working environment of a hospital. This indicator is used for identifying and handling relevant unsolved issues, improving the working environment and efficiency and is a basis for strong attachment to the workplace of the workers and attracting new human resources. According to Decision No.6858/QD-BYT dated November 18, 2016 which provides for a set of criteria for hospital assessment and requirement for regular measurement of patients’ satisfaction.

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Calculation method

Numerator

Number of health workers satisfying with their current job

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Total number of health workers in a hospital doing the questionnaire

Required parameters

Staff information; benefits, employees’ income, working environment, administration method, personnel training and developing policies and promotion opportunities  

Sampling method

All health workers of the hospital are selected.

Included criteria

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Excluded criteria

Health employees who work under seasonal employment contracts and trainees

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Data sources

The questionnaire for health workers’ satisfaction measurement

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Data collection, aggregation and analysis

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Data collection method

Interview

Data collection method

Data is clarified by the software provided by the Ministry of Health or Epidata software.

Analysis method

Data is analyzed by the software provided by the Ministry of Health or SPSS software.

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Data is presented in a statistical table or chart.

Data collector

Quality control department/team or social affair department

Data collection supervisor

Quality control department/team

Data entry person

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Analyser

Quality control department/team

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Data value

High accuracy and reliability

9

Reporting

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Reporting frequency

Once every year (in the first month of December)

Report preparer

Quality control department/team

Approver 

The head of the hospital

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 (The questionnaire is issued together with Decision No.6858/QD-BYT dated November 18, 2016 of the Minister of Health on promulgation of a set of criteria for hospital assessment)

MINISTRY OF HEALTH
FORM NO.3 

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HEALTH WORKER QUESTIONNAIRE

The purpose of this survey is to understand opinions and desires of health workers for the purpose of improving healthcare service quality and working environment.   The response will be kept confidential. Please give your answers in a sufficient, objective and accurate manner. We do highly appreciate!

1. Name of the hospital: ……………………………………………………..

2. Questionnaire filling date: .....................................................

HEALTH WORKER INFORMATION

A1.

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A2.

Age: ………………………………..

A3.

Major

1. Doctor

2. Pharmacist

3. Nurse, midwife

4. Technician

5: Others (specify): …………….

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Your highest degree

1. Intermediate professional education diploma

2. College diploma

3. University diploma

4. Master's degree, Specialist Level I

5. Doctor’s degree, Specialist Level II

6. Others (specify): …………….

A5.

How many years have you worked in the medical industry?: .......................

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How many years have you worked in the current hospital?: .......................

A7.

Job position

1. Head of the hospital

2. Head of a department/division/center

3. Vice chief of a department/division

4. Employee under long-term contract

5. Employee under short-term contract

6. Others (specify): …………….

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Working field:

1. Administration department

2. Paraclinical

3. Internal medicine

4. Surgery

5. Obstetrics

6. Pediatrics

7. Infectious disease

8. Other specialties (Ophthalmology, Otolaryngology, Odonto Stomatology, etc.)

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10. Pharmacy

11. Backup

12. Others (specify): …………….

A9.

Do you concurrently take on more than one task?  

1. No

2. Yes, 2 tasks

3. At least 3 tasks

A10.

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SATISFACTION MEASUREMENT

Please rate how much you agree or disagree with the following statements on a scale from 1 to 5 by marking an "X" on a number in each line:

 refers to

refers to

 refers to

refers to

refers to

Strongly disagree

Disagree

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Agree

Strongly agree

or Very poor

or Poor

or Average

or Good

or Very good

A. Working environment

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The office is spacious, clean and cool.

A2.

The office is equipped with sufficient facilities (working devices, desk and chair) and old and outdated devices are timely replaced.

A3.

There is a room for employees on night shift.

A4.

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A5.

The personal protective equipment (clothes, surgical mask, and medical glove) is not worn out, crumpled or restricted.

A6.

The learning environment enables me to improve my knowledge and skills (library, reading room, information searching, internet access)

A7.

The working environment ensures my safety.

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A8.

The hospital ensures security and order for work. 

A9.

Patients and their family did respect and cooperated with me during the treatment.

B. Immediate supervisor and colleagues

B16.

My immediate supervisor has the capacity to handle work effectively.

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B17.

My immediate supervisor assigns tasks suitable for my professional capacity.

B18.

My immediate supervisor gave me care, respect and fair treatment.

B19.

My immediate supervisor welcomes and listens to my opinions.

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My immediate supervisor give me encouragement when I wonderfully completed my task or make progress in work.

B21.

My colleagues give great cooperation in common duties.

B22.