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Session 07: Questionnaire review. Section 12

HHFA

Data Collection Training

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By the end of this session, you will be able to:

summarize questionnaire section 12

identify sources of water, health care waste management practices, and sterilizing equipment in a facility

describe how the general structure of the questionnaire applies to section 12

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Session 07 content

Questionnaire review: Section 12: Basic infrastructure and systems

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Sub-sections

12.1 Infrastructure

12.1.1 Communications
12.1.2 Power supply
12.1.3 Water availability

12.2 Conditions for infection prevention and control

12.2.1 Health care waste management
12.2.2 Central reprocessing of medical equipment

12.3 Referral and emergency transportation systems

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Kind of responses

One option

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Kind of responses

Several options + observation

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Categories of information

12.1 Infrastructure

12.1.1 Communications

Means for external communication (one option)
Functioning computer (one option)
Internet access (one option)
Internet consistency (several options)
Connectivity paid by management (one option)

COMMUNICATIONS

Means for external communication

Eligible means for external communication include the following:

Landline phone: A telephone that is inside the facility must be able to call outside the facility to be considered as having external communication.
Shortwave radio: This can receive and send voice communications on radio transmission frequencies. The shortwave radio for communications has a speaker and receiver. The facility personnel use a phone type apparatus or a microphone to communicate with persons at other locations who have the same frequency shortwave radio. The short-wave radio must be located within the facility.
Cellphone supported by facility: A cell phone supported by the facility requires that the facility either provide the phone and a sim card or that there be some mechanism for ensuring that personal cell phone users are reimbursed for time used for official calls. Make sure that on the day of the assessment there is a functioning cell phone. Functioning requires that there be sufficient time on the phone card that calls can be made.

Computers and access to internet

Functional computer: Computers have become quite common in many health facilities. Please ask if there is a functioning computer within the facility. The computer must be functional on the day of the survey.

Access to internet or email: Ask if there is access to internet/email within the facility today. This may be via wireless, broad band, phone-up, or a mobile modem connection. Clarify if the device is a facility or a private device.

Payment for internet access: Clarify who pays for the internet access time. Sometimes the facility internet does not function well, so even if the facility pays for internet access at the facility, staff will use their personal accounts, without reimbursement, so that they can complete facility business (e.g., transmitting reports in a timely manner). The options are that

The facility reimburses at sufficient levels—this is required for a “YES” response.
The staff, in practice, supplement the internet use for facility business with their own accounts and are not reimbursed, and this is necessary to complete the required work—this is a “NO” response.
The internet use for business purposes is not reimbursed by the facility—this is a “NO” response.

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Categories of information

12.1 Infrastructure

12.1.1 Communications

Means for external communication (one option)
Among communication other than cell phones or landlines are short-wave radios that require a power source (batteries or electricity).

The following example shows power source for radio is solar.

Radio

Satellite for radio

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Categories of information

12.1 Infrastructure

12.1.2 Power supply

Electricity from any source, main source, backup source, recent availability (all one option)

Backup solar for radio

POWER SUPPLY

Electricity

Electricity from any source: This can include generator, solar, grid, or even battery generated.

Uses of electricity: This is capturing how widespread the availability of electricity is and how strong the current is.

Stand alone devices: This may be found in situations where there is a small solar panel, battery, or generator that is only used to provide electricity for specific needs (e.g., vaccine refrigerator).
Electric lighting and communications: This may be found when the electric power is weak so that lights and radios may function, but not equipment that requires more electricity. This is sometimes found where small batteries or solar panels are used. The facility may be fully wired or this may be available in only parts of the facility.
Electric lighting, communications, a few devices: This usually implies a stronger supply of electricity such as a larger battery, solar panel, or generator than available in (02).
All electric needs of the facility: This means that when electricity is available all equipment and lighting can be used and that all rooms where electricity is needed are wired.

Main source of electricity: There may be multiple sources of electricity. Indicate the main source for the majority of the facility during normal working hours.

Central supply refers to electricity from a grid, a wired form of electricity from an external source usually managed by local authorities or a private company.
A generator requires fuel or battery to function.
A solar source converts sun light to energy for electricity using solar panels. The connections between the solar panels may be wired into the building, or may be connected to single pieces of equipment (e.g., vaccine refrigerators)
Battery may be connected to light bulbs or to specific equipment. This refers to a large battery (such as a car battery) that can be turned on for the evening and at least provides electricity for light bulbs or specific equipment.

Secondary or back-up sources of electricity: This refers to a source of power or electricity that can be used when the primary source is not available. Most often this is a generator.

Q. 2508: Electricity available during the past 7 days: Ask the respondent if electricity has been available during the past 7 days during all times the facility was open or interrupted for less than two hours at a time. If the respondent is uncertain (i.e., the respondent was not present the past week) ask if there is someone else who can be asked to verify the response.

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Categories of information

12.1 Infrastructure

12.1.3 Water availability

Water source (one option)
Availability on the facility grounds today (one option + observation)
Recent water availability (one option)

WATER AVAILABILITY

Water source

This question attempts to identify the main source of water that is used in the facility and if it comes from an improved source.

“Improved water sources (WHO/UNICEF definitions) are those which, by nature of their design and construction, have the potential to deliver safe water (JMP definition). Improved sources include: piped water, boreholes or tubewells, protected dug wells, protected springs, rainwater, and packaged or delivered water. Unimproved sources include unprotected dug wells or springs and surface water (e.g. lake, river, stream, pond, canals, irrigation ditches).”

Protected means that the water from the source is protected (e.g., by a fence, or a cement base) so that it is unlikely to be contaminated by animal or human waste or other unclean sources

Piped into facility: Pipe is connected with facility plumbing to one or more taps. This response is only applicable if the water source is from a central source. (Considered safe). If the facility water source is a well that is pumped to a tank and then piped into the facility, the source is the well (protected or not protected).
Piped onto facility grounds. Pipe is connected to a tap outside the facility in the yard or plot (sometimes called a yard connection). (Considered safe).
Public tap or standpipe: Public water point off facility grounds from which facility may collect water. A standpipe may also be known as a public fountain or public tap. Public standpipes can have one or more taps and are typically made of brickwork, masonry, or concrete. (Considered safe).
Tube well or borehole. A deep hole that has been driven, bored, or drilled with the purpose of reaching ground water supplies. Boreholes/tubewells are constructed with casing or pipes, which prevents the small diameter hole from caving in and protects the water source from infiltration by run-off water. Water is delivered from a tubewell or borehole through a pump, which may be powered by human, animal, wind, electric, diesel or solar means. Boreholes/tubewells are usually protected by a platform around the well, which leads spilled water away from the borehole and prevents infiltration of run-off water at the well head. (Considered safe).
Protected dug well. A dug well that is 1) protected from runoff water through a well lining or casing that is raised above ground level and a platform that diverts spilled water away from the well and 2) covered so that bird droppings and animals cannot fall down the hole. Both conditions must be present for a dug well to be considered as protected. (Considered safe).
Unprotected dug well: This is a dug well for which one of the following conditions is true: 1) the well is not protected from runoff water; or 2) the well is not protected from bird droppings and animals. If at least one of these conditions is true, the well is unprotected. (Not considered safe).
Protected spring: A spring protected from runoff, bird droppings, and animals by a “spring box” which is typically constructed of brick, masonry, or concrete and is built around the spring so that water flows directly out of the box into a pipe without being exposed to outside pollution. (Considered safe).
Unprotected spring: A spring that is subject to runoff and/ or bird droppings or animals. Unprotected springs typically do not have a “spring box”. (Not considered safe).
Rainwater collection: Rain that is collected or harvested from surfaces by roof or ground catchments and stored in a container, tank, or cistern. (Considered safe).
Bottled water: Water that is bottled and sold in bottles. (UNICEF considers that this source cannot be available in sufficient amounts to be considered a safe water source. In addition, the water source for bottled water may not be known).
Cart with small tank: Water is obtained from a provider who transports water into a community using a cart and then sells the water. The means for pulling the cart may be motorized or non-motorized. (Not considered safe since the source is not known).
Tanker truck: Water is obtained from a provider who uses a truck to transport water into the community. Typically, the provider sells the water. (Not considered safe since the source is not known).
Surface water: Water located above ground and includes rivers, dams, lakes, ponds, streams, canals, and irrigation channels. (Not considered safe).
If water is kept in tanks, Veronica tap buckets, or basins, you must ask where the water comes from. If water is obtained from several sources, probe to determine the source from which the facility obtains the majority of its water. If the source varies by season, record the main source used at the time of interview. If no water is available on the day of the visit, ask about the most common source during the past month. Marking no source of water means that there is never water in the facility. If patients need to bring water from home because water is not available at the facility, “no water source” should be selected. Response options and terminology should be modified to reflect the local context.

Availability of water from the main source on the facility grounds today

This question refers to the location from where the water is accessed for use in the health facility (e.g. tap, borehole), rather than the source where it originates. Sometimes there is a main and a back-up source of water, but the water safety for these two sources may differ. We want to know if water from the main source is available today on the facility grounds. On premises means within the building or facility grounds.

Water availability the past 7 days

Ask the respondent if water has been available during the past 7 days during all times the facility was open or interrupted for less than two hours at a time. If the respondent is uncertain (i.e., the respondent was not present the past week) ask if there is someone else who can be asked to verify.

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Group knowledge check: Identification of water sources�(15’)

Group participants in tables and tell them to nominate a note-taker and a rapporteur
Refer participants to questionnaire sub-section 12.1.3 in the paper questionnaire
Display the next slide and ask participants to review the questionnaire, discuss internally, agree, and write down the team’s response
Ask rapporteurs to share responses as you display correct responses at the click
Discuss as appropriate
Continue doing the same for the other pictures

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Piped into facility
Piped to facility grounds
Public tap/standpipe
Tubewell/borehole
Protected dug well
Protected spring
Unprotected spring
Rainwater
Bottled water
Cart with small tank/drum
Tanker truck
Surface water

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Piped into facility
Piped to facility grounds
Public tap/standpipe
Tubewell/borehole
Protected dug well
Protected spring
Unprotected spring
Rainwater
Bottled water
Cart with small tank/drum
Tanker truck
Surface water

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Piped into facility
Piped to facility grounds
Public tap/standpipe
Tubewell/borehole
Protected dug well
Protected spring
Unprotected spring
Rainwater
Bottled water
Cart with small tank/drum
Tanker truck
Surface water

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Piped into facility
Piped to facility grounds
Public tap/standpipe
Tubewell/borehole
Protected dug well
Protected spring
Unprotected spring
Rainwater
Bottled water
Cart with small tank/drum
Tanker truck
Surface water

Categories:

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Sub-sections

12.2 Conditions for infection prevention and control

12.1.1 Health care waste management

Sharps waste disposal method (one option)
Condition of sharps waste disposal site (one option + observation)
Infectious waste disposal method (one option)
Condition of infectious waste disposal site (one option + observation)
Incinerator functionality (one option)
Incinerator fuel availability (one option)
Guidelines for health care waste management (one option + obs.)
Formal training in past 2 years (one option)

HEALTH CARE WASTE MANAGEMENT

Waste disposal methods

Following is a description of the methods of disposal:

Burn incinerator: This is an enclosed structure (brick or other) where waste can be burned at a higher temperature than is achieved in a site open to air such as a pit. Two potential types of burn incinerators: the 2-chamber industrial and the 1-chamber drum or brick.
Open burning: Open burning, the next most effective means of destroying contaminated waste, could take place on flat ground with no protection whatsoever, or this could take place in a pit or protected ground, with some degree of security so that people or animals cannot easily access the site.
Dump without burning: This is simply dumping the waste at a location within facility premises. This could take place on flat ground with no protection, or in a covered pit or pit latrine. This could also take place in an open pit or protected ground or pit.
Remove offsite: This means the waste is kept somewhere prior to removal; this could be stored in covered container, stored in another protected environment such as a closet or fenced area, or stored unprotected before it is moved to a place outside the facility for final disposal. Responses ‘1’ through ‘12’ refer to how the sharps are stored in the facility prior to removal offsite.

Guidelines on health care waste management

Healthcare waste (HCW) is a by-product of healthcare that includes sharps, non-sharps, blood, body parts, chemicals, pharmaceuticals, medical devices and radioactive materials. Management practices should include plans for waste minimization, segregation and containerization, intermediate storage, internal transport, centralized storage, external transport and treatment and final disposal of health care waste.

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Group knowledge check: Identification of waste management practices �(20’)

Group participants in tables and tell them to nominate a note-taker and a rapporteur
Refer participants to questionnaire sub-section 12.2.1 in the paper questionnaire
Display the next slide and ask participants to review the questionnaire, discuss internally, agree, and write down which waste disposal method they see in the picture
Ask rapporteurs to share responses as you display correct responses at the click
Discuss as appropriate
Continue doing the same for the other pictures

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Burn incinerator:

2-Chamber industrial – Protected
2-Chamber industrial – No protection
1-Chamber drum/brick – Protected
1-Chamber drum/brick – No protection

Open burning:

Open pit/flat ground – No protection
Open pit/flat ground - Protected

Dump without burning

Flat ground – No protection
Flat ground - Protected
Open-pit – No protection
Protected pit

Stored for removal offsite:

Stored in covered container
Stored in other protected environment
Stored unprotected

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Burn incinerator:

2-Chamber industrial – Protected
2-Chamber industrial – No protection
1-Chamber drum/brick – Protected
1-Chamber drum/brick – No protection

Open burning:

Open pit/flat ground – No protection
Open pit/flat ground - Protected

Dump without burning

Flat ground – No protection
Flat ground - Protected
Open-pit – No protection
Protected pit

Stored for removal offsite:

Stored in covered container
Stored in other protected environment
Stored unprotected

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Burn incinerator:

2-Chamber industrial – Protected
2-Chamber industrial – No protection
1-Chamber drum/brick – Protected
1-Chamber drum/brick – No protection

Open burning:

Open pit/flat ground – No protection
Open pit/flat ground - Protected

Dump without burning

Flat ground – No protection
Flat ground - Protected
Open-pit – No protection
Protected pit

Stored for removal offsite:

Stored in covered container
Stored in other protected environment
Stored unprotected

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Burn incinerator:

2-Chamber industrial – Protected
2-Chamber industrial – No protection
1-Chamber drum/brick – Protected
1-Chamber drum/brick – No protection

Open burning:

Open pit/flat ground – No protection
Open pit/flat ground - Protected

Dump without burning

Flat ground – No protection
Flat ground - Protected
Open-pit – No protection
Protected pit

Stored for removal offsite:

Stored in covered container
Stored in other protected environment
Stored unprotected

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Burn incinerator:

2-Chamber industrial – Protected
2-Chamber industrial – No protection
1-Chamber drum/brick – Protected
1-Chamber drum/brick – No protection

Open burning:

Open pit/flat ground – No protection
Open pit/flat ground - Protected

Dump without burning

Flat ground – No protection
Flat ground _ Protected
Open-pit – No protection
Protected pit

Stored for removal offsite:

Stored in covered container
Stored in other protected environment
Stored unprotected

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Burn incinerator:

2-Chamber industrial – Protected
2-Chamber industrial – No protection
1-Chamber drum/brick – Protected
1-Chamber drum/brick – No protection

Open burning:

Open pit/flat ground – No protection
Open pit/flat ground - Protected

Dump without burning

Flat ground – No protection
Flat ground - Protected
Open-pit – No protection
Protected pit

Stored for removal offsite:

Stored in covered container
Stored in other protected environment
Stored unprotected

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Burn incinerator:

2-Chamber industrial – Protected
2-Chamber industrial – No protection
1-Chamber drum/brick – Protected
1-Chamber drum/brick – No protection

Open burning:

Open pit/flat ground – No protection
Open pit/flat ground - Protected

Dump without burning

Flat ground – No protection
Flat ground - Protected
Open-pit – No protection
Protected pit

Stored for removal offsite:

Stored in covered container
Stored in other protected environment
Stored unprotected

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Burn incinerator:

2-Chamber industrial – Protected
2-Chamber industrial – No protection
1-Chamber drum/brick – Protected
1-Chamber drum/brick – No protection

Open burning:

Open pit/flat ground – No protection
Open pit/flat ground - Protected

Dump without burning

Flat ground – No protection
Flat ground - Protected
Open-pit – No protection
Protected pit

Remove offsite:

Stored in covered container
Stored in other protected environment
Stored unprotected

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No sharp waste visible
Sharp waste visible, but protected area
Sharp waste visible, not protected
Sharp waste site not inspected

Categories:

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No sharp waste visible
Sharp waste visible, but protected area
Sharp waste visible, not protected
Sharp waste site not inspected

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No sharp waste visible
Sharp waste visible, but protected area
Sharp waste visible, not protected
Sharp waste site not inspected

Categories:

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No infectious waste visible
Infectious waste visible, but protected area
Infectious waste visible, not protected
Infectious waste site not inspected

Categories:

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Categories of information

12.2 Conditions for infection prevention and control

12.1.2 Central reprocessing of reusable medical equipment

Main equipment reprocessing site (one option), electric autoclave, electric dry heat sterilizer, non-electric autoclave, heat source for non-electric equipment (several options + observation)

CENTRAL PROCESSING OF EQUIPMENT FOR REUSE

Main equipment processing site

A facility may have one central location for processing equipment for reuse or it may have several different sites, with each site processing equipment for a different service area. The organization of equipment processing depends on facility specific decisions. Different sites may use different methods for processing equipment. For example, small dry heat sterilizers may be in some service sites to facilitate availability of sterile equipment for which there is high demand, but an autoclave may be used in other sites.

Probe to know where the main site is. If the respondent does not think there is a “main site” ask to see the most sophisticated or highest-level processing that is available. For facilities with surgery services, this will usually be where surgical equipment is processed. For those without surgery it may be where delivery equipment is processed.

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Non-electric autoclave (pressure and wet heat)	Electric dry heat sterilizer	Electric autoclave (pressure and wet heat)

Sterilizing or high-level disinfecting equipment

Ask participants to tell you which heading belongs to each equipment. Ask participants about differences. Provide clarifications

Autoclave: The autoclave uses pressurized wet heat—similar to a pressure cooker. To be functional there should be a functional pressure gauge. The autoclave may be electric or may have an external gas or wood burning heat sources. Autoclaves come in different sizes, which determines how much equipment can be sterilized at the same time.
Dry heat sterilizer: Often autoclaves and dry heat sterilizers look similar, but the dry heat sterilizer does not use pressure or wet heat. It requires a higher temperature and longer time to sterilize equipment.
Boiling or steaming: Boiling refers to the item being placed directly in a pot of water. Steaming refers to the item being on a tray that sits above boiling water so that the steam, but not the water, hits the items. Boiling and steaming equipment can be electric or may have an external gas or wood burning heat sources.
External heat source: This refers to the heat source for non-electric equipment. This may be a gas or wood stove, a gas burner, or any other source that can boil water. The fuel must be available or the electricity functional for the fuel source to be considered available today.

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Categories of information

12.3 Referral and emergency transportation systems

Out-referral site (one option)
Sending information with out-referrals (one option + observation)
Records maintained for out-referrals (one option + observation)
Feedback on out-referrals (one option + observation)
Access to emergency transportation (one option)
24-hour access to emergency transportation (one option)
Availability and functionality of vehicle (one option)

REFERRAL & EMERGENCY TRANSPORTATION SYSTEMS

Referrals are when a patient is sent by a provider to another provider or facility. There may be referral in—that is referrals to the facility; referrals out—that is referrals the facility makes to other facilities or providers, and internal referrals—that is referrals from one unit/provider to another within the same facility. When patients are referred, information on the reason for the referral and a history that includes any diagnostic tests or treatments that were provided prior to the referral should accompany the patient or be sent to the referred provider to facilitate rapid continuity of care. The following questions refer to referrals between facilities and not to internal referrals.

Out-referral site

An out-referral refers to a patient being sent from one facility to another—almost always so that they can receive care that is not available in the facility making the out-referral. Patients may be referred to different facilities depending on the problem, but there is usually a most commonly used site, which is the closest hospital that will receive the types of patients needing higher level care. Government systems will usually refer patients from a health center to a district hospital. The district hospital will usually refer patients to a provincial/regional hospital. If the respondent says they never refer patients elsewhere, probe for referrals for any reason, before marking ‘7’ that the facility never refers clients elsewhere.

Sending information with out-referrals

Referrals may follow an official process, using written referral forms, or may be informal (the patient is told to go to another service provider without any official help or transmission of information). When patients are referred, information on the reason for the referral and a history that includes any diagnostic tests or treatments that were provided prior to the referral should accompany the patient or be sent to the provider receiving the referral, to facilitate rapid continuity of care. First we want to know if there is a preprinted form that is used. A preprinted form will specify the type of information that should be sent with the patient (e.g., reason for referral, treatment provided prior to referral, any other notes to help the receiving facility provide care). A referral form may also include a part for the receiving facility to report back to the referring facility on the patient status. If the facility writes a referral note on a piece of paper or on a prescription form, this is not a preprinted referral form.

Records maintained for out-referrals

Ask to see any record that is maintained for patients who are referred out. Similar to the record for in-referrals, at minimum the number should be recorded. Ideally, the referral location and the reason for referral, as well as patient identification information will be recorded. The types of records often kept on out-referral made by this facility may be incorporated in the discharge registers, may be incorporated in unit registers or may be maintained copies of referral forms that are sent with the patient received.

Feedback on out-referrals

We are referring to feedback on patients who were sent elsewhere. Feedback on referrals usually includes information on the condition that was treated/diagnosis made at the referral site and services provided. This information helps a facility to evaluate if they are making appropriate and timely referrals and provides information for follow-up if the patient returns. If the facility says they ever receive feedback, clarify how frequently feedback is received, and then ask to see any evidence of the feedback. More than half time ‘1’ is considered routine, otherwise there is either no feedback ‘4’ or some feedback but not half time ‘2’. Evidence of feedback may be provided when part of a referral reform is completed and returned or may be a note written in a column in a register or a patient chart. If the facility reports they do receive feedback but they cannot provide any evidence (often the case), mark ‘3’.

Emergency transportation

This may be one of the following situations:

Ambulance owned by facility: The vehicle is based at the facility. An ambulance is a dedicated vehicle for patient transportation. The ambulance may have special equipment inside, or may simply be a vehicle for transporting patients. Some facilities may use a motorcycle with an attached patient transport wagon for emergency transportation. If this vehicle is used solely for emergency transportation, mark ‘1’.
Other type of official vehicle: This may be any type of official vehicle that is used for multiple purposes such as staff transportation, picking up supplies, but also can be used if needed for emergency transportation.
Access to vehicle based offsite but available on call for emergency transportation: This may an ambulance that is based elsewhere—such as at another facility or a civil government office, but that can be called for emergency transportation. This may also be a non-ambulance, official vehicle based elsewhere, and used for multiple purposes, but that can be called for emergency transportation. Often this would be the official vehicle of government officials or managers. This could also be a private vehicle available on call. This would refer to situations where there may be an agreement between the facility and private individuals to use individual’s private vehicle. For example, sometimes NGOs lend vehicles for emergency transportation.

24-hour access to emergency transportation

Vehicle available and functional

This means not only that the vehicle functions mechanically but also that fuel is available.

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You have now completed Session 07.

In the next session, we will look at the basics of the CSPro application, the user roles, and the tablet registration.