Decision No. 5066/QD-BYT dated August 16, 2018 on promulgating quality indicators for eye-care services

MINISTRY OF HEALTH
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SOCIALIST REPUBLIC OF VIETNAM
Independence - Freedom - Happiness
----------------

No.5066/QD-BYT

Hanoi, August 16, 2018

PP.MINISTER
DEPUTY MINISTER




Nguyen Viet Tien

Dimension

Indicator

Type of indicator

Professional capacity

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

Input

Professional capacity

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

5) Rate of post-surgery endophthalmitis

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

Output

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

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

DEFINITION AND ACCEPTABLE SCORE

Definition: Such indicator is used to assess the ratio of medical procedures applied and approved by the supervisory authority or competent authority tototal medical procedures according to healthcare level

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

Type of indicator

Input

4

Reasons

Application of medical proceduresis an indicator used for assessing professionalcapacity 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

Number of eye care procedures being applied and approved by competent supervisory authorities

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-BYTdated 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

5.5

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

6

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

The list of medical procedures approved by competent authorities

The list of available medical procedures

7

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

Compare lists of medical procedures of the hospital with those issued together with Circular No.43/2013/TT-BYT dated November 11, 2013 and Circular No.21/2017/TT-BYT dated May 10, 2017. Check probability of several medical procedures to ensure the hospital is able to carry out such procedures.

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

Data collection supervisor

Quality control department/team

Data entry clerk

General planning department

Analyser

Quality control department/team

8

Data value

High accuracy and reliability

9

Reporting

Reporting frequency

Once every year (the first month of December)

Report preparer

Quality control department/team

Approver

Board of Directors

B1

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

…………

B2

Number of eye care procedures approved by the supervisory authority

………………

B2.1

Total number of eye care procedures approved by the supervisory authority

…………

B2.2

Approval Decision No.

……………..

B3

Number of eye care procedures applied of total procedures approved

…………

B4

Number of eye care procedures of superior hospitals applied and approved

…………

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 inCircular 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

Technical competence

3

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.

5

Calculation method

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

Number of health workers receiving professional training in 2 consecutive years at the data collection date, training duration (number of periods), and professional lessons (attached with information collection form)

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

Health workers who are practicing or who are not issued with physician’s certificate

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.

6

Data sources

Personnel department or continuous training management department

7

Data collection, aggregation and analysis

Data collection method

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

Staff of personnel department or continuous training management department

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

8

Data value

Average accuracy and reliability

9

Reporting

Reporting frequency

Once every year (the first month of December)

Report preparer

Quality control department/team

Approver

Director

B1

Qualification

1. Doctor

2. Nurse

3. Optometrist

4. Others:

(specify)…………….

B2

Mode of training (in the last 2 years)

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

…………

B2.1b

Total periods (Sum of periods of each course)

…………

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

…………

B2.2b

Total periods (Sum of periods of each course)

…………

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

……….

B2.3b

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

…………….

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

…………..

B2.4b

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

…………….

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

……….

B2.5b

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

…………….

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

…………

B2.6b

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

…………….

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

……….

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)

…………….

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

…….

B2.8b

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

…………….

B2.9

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

1. Yes

2. No

B2.9a

Number of courses taught

………

B2.9b

Total periods (According to actual teaching periods)

…………….

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

………

B2.10b

Total periods (According to actual teaching periods)

…………….

B2.11

Have you participated in scientific events or thematic events?

1. Yes

2. No

B2.11a

Number of event joined

………

B2.11b

Total periods (3 accumulated events equals 4 periods)

…………….

B3

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

…………….

B4

Is your training duration conformable with the regulations?

1. Yes

2. No

NO.

MODE OF TRAINING

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.

2

Health workers enrolling on domestic and overseas short-term extensive practicing courses, technique transfer courses or professional training courses

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

Hosting a thematic conference/seminar or scientific talk

Hosting/Attending Certificate

8 periods

4

Reporting a thematic conference/seminar or scientific talk

Attending Certificate and reports

8 periods

5

Being a principle investigator or secretary of a local project at the acceptance date

Certificate

8 periods

6

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

7

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

9

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

Training Certificate

According to actual teaching periods

10

Scientific events and thematic events

Attending Certificate

3 accumulated events equals 4 periods

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 recordsthat meet the criteria provided in the checklist (attached) to total number of recordsundergoing inspection in the assessment period.

Acceptable score: > 80%

1

Applicable areas

The whole hospital

1

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.

Decision No.3443/QD-BYT dated September 22, 2011 providing for additional medical record templates and a number of ophthalmology case report forms

5

Calculation method

Numerator

Number of medical record meeting the criteria in the checklist

Denominator

Number of medical record undergone inspection

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

Excluded criteria

Secret medical records

6

Data sources

- Direct assessment

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

7

Data collection, aggregation and analysis

Data collection method

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

General planning department

Data collection supervisor

Quality control department/team

Data entry person

General planning department

Analyzer

Quality control department/team

8

Data value

High accuracy

9

Report

Reporting frequency

Every quarter

Report preparer

Quality control department/team

Approver

Director

B1

Is the medical record completed as required by the checklist?

1. Yes → end

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

Administrative information

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

6. Diagnosis of the treatment department

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

1. Nursing report sheet

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)

2.Give daily prescription

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

2. Follow the doctor’s medication order

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

5. Corticosteroid drugs

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

Preliminary review of medical record

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

B4

Review of medical record

1. Columns

2. Signatures

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

DEFINITION AND ACCEPTABLE SCORE

Definition: Suchrate 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.(Asurgical 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.)

Acceptable score: 100%

1

Applicable areas

Surgery

2

Quality property

Patient safety

3

Type of indicator

Process

4

Reasons

Restrict medical errors during the surgery to ensure patient safety

5

Calculation method

Numerator

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

Denominator

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)

Included criteria

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

6

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 checklistrecorded in the medical record (Excluding pre-surgical safety checklist or the note of transfer of patients having surgery)

7

Data collection, aggregation and analysis

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

Data is presented in a statistical table or chart.

Data collector

Nursing department

Data collection supervisor

Quality control department/team

Data entry person

Quality control department/team

Analyser

Quality control department/team

8

Data value

Average accuracy and reliability

9

Report

Reporting frequency

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

B1

Operating room No.

………………

B2

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

Have tasks mentioned in the surgical safety checklist been done before the patient leaves the operating room?

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?

3. Is the pulse oximeter on patient and functioning?

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

2. Confirm the surgical dossier number

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 ofthe site

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

11. Are drugs for surgical infection prevention used?

B5.3

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

B6.1

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 thechecklist

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

DEFINITION AND ACCEPTABLE SCORE

Definition: Rate of post-ocular surgery endophthalmitisis the ratio ofpatients getting post-ocular surgery endophthalmitisto totalpatients having ocular surgery in the reporting and assessment period.

ACCEPTABLE SCORE: < 0.08% (Recommended by WHO)

1

Applicable areas

Surgery

2

Quality property

Safety

3

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)

5

Calculation method

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)

Number of patients diagnosed with endophthalmitis and recorded in the medical record (except for patients having surgery for ocular trauma)

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)

6

Data sources

Medical records or medical error reporting book

7

Data collection, aggregation and analysis

Data collection method

Data is collected from medical histories and reporting sheets.

Analysis method

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

Quality control department/team

Data entry person

Quality control department/team

Analyser

Quality control department/team

8

Data value

High accuracy and reliability

9

Report

Reporting frequency

Once every 6 months

Report preparer

Quality control department/team

Approver

Board of Directors

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

…..

B2

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): …………….

2. No

B3.1

Treatment given to the patient

B3.2

Is the hospital infection control procedure reviewed?

1. Yes (specify): …………….

2. No

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

DEFINITION AND ACCEPTABLE SCORE

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

Safety

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 onpatient 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 collection method

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

Departments in charge of collecting reports from the medical error reporting system

General quality control department/team

Data collection supervisor

Quality control department/team

Data entry person

Quality control department/team

Analyser

Quality control department/team

8

Data value

Average accuracy and reliability

9

Reporting

Reporting frequency

Every quarter

Report preparer

Quality control department/team

Approver

Board of Directors

SURGICAL ERRORS

1.

Performing an operation on the wrong body part of the patient:

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.

Performing an operation not following the medical procedure:

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.

B. The surgical instrument is inserted before the surgery and is intentionally remained in the patient's body.

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 biologicsprovided widelyDetection of contamination in medicine, medical instruments and biologics irrespective of contamination origin or specimen origin

7.

Deathor 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

B. Surgical drain or other tubes with special function

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

11.

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

E. Number of dose 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.

Death or complication due to hypoglycemia in inpatients

16.

Not applicable

17.

Not applicable

18.

Not applicable

19.

Not applicable

ENVIRONMENTAL ERRORS

20.

Death or serious complication due to electrical injuryExcept 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 mistakenOr

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

24.

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.

Causing death or severe injury to patients or health workers by weapons in the hospital campus

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

2. No

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”?

1. Yes

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

Is the serious medical error related to “Performing an operation not following the medical procedure”?

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

B5

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

5. > 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

4. Fourth 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

3. Third time

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

2. Twice

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?

1. Once

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

If yes, how many times has such error occurred?

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

B11.1

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

2. No

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"?

1. Yes

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

Is the serious medical error related to “hypoglycemia in inpatients"?

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

B15

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

5. > 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

4. Fourth 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

3. Third time

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

2. Twice

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?

1. Once

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

If yes, how many times has such error occurred?

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

B21.1

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

2. No

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”?

1. Yes

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

NAME OF INDICATOR NO.7: Rate of patient having good sight after cataract surgery alone

DEFINITION AND ACCEPRABLE SCORE

Definition: The rate of patient having good sight aftercataract 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 totalpatients having eyesight test.

ACCEPRABLE SCORE: > 80% (Recommended by WHO)

1

Applicable areas

The whole hospital

2

Quality property

Clinical effectiveness

3

Type of indicator

Output

4

Reasons

Assessing and improving treatment service quality

5

Calculation method

Numerator

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 ofcataract 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)

Sampling method

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

6

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.

Analysis method

Percentage calculation

Data presentation

Data is presented in a chart.

Data collector

A nurse - optometrist

Data collection supervisor

Quality control department/team

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

9

Reporting

Reporting frequency

Every year

Report preparer

Quality control department/team

Approver

Director

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)

NAME OF 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

3

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 operationis used to determine more accurately the overload level of a hospital and keep a watch on changes in the hospital operation.

5

Calculation method

Numerator

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

The whole hospital

Included criteria

Excluded criteria

6

Data sources

Medical record retaining department and general planning department

7

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 presentation

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

General planning department

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

NAME OF INDICATOR NO.9: Rate of patient's satisfaction with healthcare services (inpatients and outpatients)

DEFINITION AND ACCEPTABLE SCORE

Definition: Such rate is the ratio ofpatients 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

3

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

Denominator

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)

Provided healthcare services (inpatient or outpatient), accessibility, transparency of healthcare information and procedures, facility and instruments, behaviors and professionalcapacity of health workers and service provision result

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

Patients who refuse to communicate or cooperate with health workers or patients under 18 years old or patients undergoing treatment

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 SPSSsoftware.

Data presentation

Data is presented in a statistical table or in chart.

Data collector

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

Quality control department/team

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

MINISTRY OF HEALTH
FORM NO.1

(REDUCED FORM)

INPATIENT QUESTIONNAIRE

A1 Gender: 1.Male 2. Female

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

A3. Mobilephone number (required):

A4. Total hospitalized days: ............. days

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

refers to

refers to

refers to

refers to

refers to

Strongly disagree

Disagree

Neutral

Agree

Strongly agree

or Very poor

or Poor

or Average

or Good

or Very good

A. Accessibility

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.

A4.

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.

B2.

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

B3.

Iwas 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.

Information on drug use and treatment charge is publicly informed and updated.

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.

Toilets and bathroomsare clean and have convenient facilities.

C4.

When being hospitalized, I wassafe 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.

D. Behaviors and professional capacity of health workers

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.

D4.

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.

Health workers did not show any sign of tip asking.

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.

The treatment result satisfied my desire.

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?

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

…………………%

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): …………….

H

Please add other comments(If any)

MINISTRY OF HEALTH
FORM NO.2

A1.

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

refers to

refers to

refers to

refers to

refers to

Strongly disagree

Disagree

Neutral

Agree

Strongly 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.

A10.

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.

B8.

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 screeningwere done in order.

B11.

Give your comment on the time waiting for registration of examination

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.

C15.

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

D8.

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.

The professional capacity of doctors and nurses satisfiedmy expectation.

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.

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

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

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 may come back here.

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

5. Others (specify): …………….

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.

ACCEPTABLE SCORE: > 75%

1

Applicable areas

The whole hospital

2

Quality property

Staff-oriented indicators

3

Type of indicator

Output

4

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.

5

Calculation method

Numerator

Number of health workers satisfying with their current job

Denominator

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

Health employees who have worked in the hospital for more than 6 months

Excluded criteria

Health employees who work under seasonal employment contracts and trainees

6

Data sources

The questionnaire for health workers’ satisfaction measurement

7

Data collection, aggregation and analysis

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.

Data presentation

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

Quality control department/team

Analyser

Quality control department/team

8

Data value

High accuracy and reliability

9

Reporting

Reporting frequency

Once every year (in the first month of December)

Report preparer

Quality control department/team

Approver

The head of the hospital

MINISTRY OF HEALTH
FORM NO.3

A1.

A1 Gender: 1.Male 2. Female

A2.

Age: ………………………………..

A3.

Major

1. Doctor

2. Pharmacist

3. Nurse, midwife

4. Technician

5: Others (specify): …………….

A4.

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?: .......................

A6.

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): …………….

A8.

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.)

9. Departments not directly related to healthcare services

10. Pharmacy

11. Backup