Final Ideal Clinic Manual - Version 17

Ideal Clinic Manual
Version 17
1 April 2017
ACKNOWLEDGEMENT
The purpose of a health facility is to promote health and to prevent
illness and further complications through health promotion, early
detection, treatment and appropriate referral. The success of South
Africa’s National Health Insurance will depend on a well functioning
Primary Health Care (PHC) system. Community based services must
be complimented by PHC facilities that will provide equitable access to
South Africans, prioritising health services to those most in need. To
achieve this, PHC should function optimally thus requiring a
combination of elements to be present in order to render it IDEAL. To
achieve this the national Department of Health started the Ideal Clinic
programme.
An Ideal Clinic is a clinic with good infrastructure, adequate staff,

adequate medicine and supplies, good administrative processes and sufficient bulk supplies that use
applicable clinical policies, protocols, guidelines to ensure the provision of quality health services to
the community. An Ideal Clinic will cooperate with other government departments as well as with the
private sector and non-governmental organisations to address the social determinants of health.
The Ideal Clinic programme defines ten components, 32 sub components and 206 elements that
must be green, which means that they are present and optimally functional. This Ideal Clinic
realisation and maintenance manual has been developed to provide guidance on how to achieve
Ideal Clinic status and to maintain such status. The manual is also a tool to assist progressive
discipline.
Jeanette Hunter led the development and completion of this manual. The AURUM Institute
genereously invested resourses to complete the first draft of the first version of the Ideal Clinic
framework. Messrs R Morewane, K Mahlako, D Matsebula, Dr K Taole and Mesdames Y
Mokgalagadi, M Dichaba and E Shivambu reviewed this draft. Mesdames J Hunter, R Steinhobel, A
Jautse and Dr S Asmall sacrificed precious personal time over weekends to complete the final draft.
My sincere gratitude to the national Department of Health programme managers, provincial

department of health managers, district managers, PHC facility managers and non -govermental
organisations who provided insightful comments and direction to the final draft.
I express special appreciation to Ronel Steinhobel for taking the initiative to transform the checklists
into score calculation tools and merging them as electronic tools into the monitoring and evaluation
software. My special thanks to Dr Shaidah Asmall for meticulously providing the information for the
checklists.
I sincerely thank the European Union(EU), the United States Agency for International Development
(USAID) and Centers for Disease Control and Prevention (CDC) for their continued support of the
Ideal Clinic programme.
MP MATSOSO
DIRECTOR-GENERAL
Date: 2017/07/31
TABLE OF CONTENTS
INTRODUCTION AND BACKGROUND 1

THE PURPOSE OF THIS MANUAL 2
HOW TO USE THE MANUAL 3
COMPONENT 1: ADMINISTRATION 4
1. SIGNAGE AND NOTICES 4
Commitment for Ideal Clinic elements 1-3 4
Commitment for Ideal Clinic elements 4-7 5
2. STAFF IDENTITY AND DRESS CODE 6
Commitment for Ideal Clinic elements 8 - 10 6
3. PATIENT SERVICE ORGANISATION 7
4. MANAGEMENT OF PATIENT RECORD 8
Commitment for Ideal Clinic element 21 10
COMPONENT 2: INTEGRATED CLINICAL SERVICES MANAGEMENT (ICSM) 11
5: CLINICAL SERVICE PROVISION 11
Commitment for Ideal Clinic elements 22 11
6. ACCESS TO MEDICAL, MENTAL HEALTH, ALLIED HEALTH PRACTITIONERS 19
7. MANAGEMENT OF PATIENT APPOINTMENTS 22
8: COORDINATION OF PHC SERVICES 24
9. CLINICAL GUIDELINES AND PROTOCOLS 27
Commitment for Ideal Clinic element 50 - 53 27
COMMITMENT FOR IDEAL CLINIC ELEMENT 58 - 60 30
COMMITMENT FOR IDEAL CLINIC ELEMENT 61 31
10. INFECTION PREVENTION AND CONTROL 33
11. PATIENT WAITING TIME 39
12. PATIENT EXPERIENCE OF CARE 41
Commitment for Ideal Clinic elements 86 and 89 42
COMPONENT 3: MEDICINES, SUPPLIES AND LABORATORY SERVICES 44
13: MEDICINES AND SUPPLIES 44
Commitment for Ideal Clinic element 94-97 45
14. MANAGEMENT OF LABORATORY SERVICES 56
Commitment for Ideal Clinic element 106 – 110 56
COMPONENT 4: HUMAN RESOURCES FOR HEALTH 57
15: STAFF ALLOCATION AND USE 57
Commitment for Ideal Clinic element 115- 116 60
16: PROFESSIONAL STANDARDS AND PERFORMANCE MANAGEMENT DEVELOPMENT
(PMDS) 61
Commitment for ideal Clinic elements 121 - 122 64
Commitment for Ideal Clinic elements 123- 124 65
COMPONENT 5: SUPPORT SERVICES 67
17. FINANCE AND SUPPLY CHAIN MANAGEMENT 67
18: HYGIENE AND CLEANLINESS 69
19: SECURITY 77
20: OUTBREAK AND DISASTER PREPAREDNESS 81
Commitment for Ideal Clinic element 150 -151 82
COMPONENT 6: INFRASTRUCTURE AND SUPPORT SERVICES 85
21. PHYSICAL SPACE AND ROUTINE MAINTENANCE 85
22. ESSENTIAL EQUIPMENT AND FURNITURE 88
Commitment to Ideal Clinic elements 159 - 164 88
Commitment to Ideal Clinic elements 164 - 167 90
Commitment to Ideal Clinic element 171 93
23. BULK SUPPLIES 94
24. ICT INFRASTRUCTURE AND HARDWARE 97
COMPONENT 7: HEALTH INFORMATION MANAGEMENT 99
25. DISTRICT HEALTH INFORMATION SYSTEM (DHIS) 99
COMPONENT 8: COMMUNICATION 101
26. INTERNAL COMMUNICATION 101
27. COMMUNITY ENGAGEMENT 104
COMPONENT 9: DISTRICT HEALTH SYSTEM SUPPORT 107
28. DISTRICT HEALTH SUPPORT 107
Commitment for Ideal elements 192 - 193 107
29. EMERGENCY PATIENT TRANSPORT 108
30. REFERRAL SYSTEM 109
COMPONENT 10: PARTNERS AND STAKEHOLDERS 110
31. PARTNERS SUPPORT 110
32. MULTI-SECTORAL COLLABORATION 111
List of Annexure
ANNEXURE 1: COMPONENTS AND SUB-COMPONENT OF IDEAL CLINIC DASHBOARD, VERSION 17 ............ 123
ANNEXURE 2: IDEAL CLINIC REALISATION AND MAINTENANCE DASHBOARD, VERSION 17 ....................... 124
ANNEXURE 3: CHECKLIST FOR ELEMENT 1 - EXTERNAL SIGNAGE IN PLACE ........................................... 133
ANNEXURE 4: PATIENTS’ RIGHTS CHARTER ........................................................................................ 134
ANNEXURE 5: CHECKLIST FOR ELEMENT 7 - ALL SERVICE AREAS WITHIN THE FACILITY ARE CLEARLY
SIGNPOSTED ............................................................................................................................. 135
ANNEXURE 6: EXAMPLE OF A DRESS CODE FOR STAFF ........................................................................ 137
ANNEXURE 7: CHECKLIST FOR ELEMENT 9 - ALL STAFF MEMBERS COMPLY WITH PRESCRIBED DRESS CODE
................................................................................................................................................ 139
ANNEXURE 8: CHECKLIST FOR ELEMENT 10 - ALL STAFF MEMBERS WEAR AN IDENTIFICATION TAGS ........ 140
ANNEXURE 9: NOTICE OF PRIORITISATION OF VERY SICK, FRAIL AND ELDERLY PATIENTS ........................ 141
ANNEXURE 10: EXAMPLE OF A TEMPLATE FOR TRAINING REGISTER FOR STAFF..................................... 142
ANNEXURE 11: CHECKLIST FOR ELEMENT 15 - PATIENT RECORDS ADHERES TO ICSM PRESCRIPTS ...... 143
ANNEXURE 12: CHECKLIST FOR ELEMENT 17 - GUIDELINE FOR ACCESSING, TRACKING, FILING, ARCHIVING
AND DISPOSAL OF PATIENT RECORDS IS ADHERED TO .................................................................. 146
ANNEXURE 13: CHECKLIST FOR ELEMENT 21 - PRIORITY STATIONERY IS AVAILABLE AT THE FACILITY IN
SUFFICIENT QUANTITIES ............................................................................................................. 147
ANNEXURE 14: TRAINING REGISTER FOR STAFF TRAINED ON INTEGRATED CLINICAL SERVICE MANAGEMENT
................................................................................................................................................ 148
ANNEXURE 15: QUALITY IMPROVEMENT PLAN ..................................................................................... 149
ANNEXURE 16: POSTER PROMOTING ADOLESCENT AND YOUTH SERVICES ............................................ 150
ANNEXURE 17: PROFILE FOR ADOLESCENT AND YOUTH IN THE CATCHMENT AREA ................................. 151
ANNEXURE 18: CHECKLIST FOR ELEMENT 43 - ADOLESCENT AND YOUTH FRIENDLY SERVICES ARE
PROVIDED ................................................................................................................................. 152
ANNEXURE 19: APPOINTMENT SCHEDULING PROCESS ......................................................................... 153
ANNEXURE 20: PRE-DISPENSING OF CHRONIC MEDICATION................................................................. 156
ANNEXURE 21: EXAMPLE OF A TOOL FOR ACKNOWLEDGING RECEIPT OF CHRONIC MEDICATION BY PATIENT
................................................................................................................................................ 159
ANNEXURE 22: SCHOOL HEALTH SERVICE REFERRAL LETTER AND FOLLOW -UP ASSESSMENT FORM....... 160
ANNEXURE 23: EXAMPLE OF A REGISTER OF LEARNERS REFERRED FROM SCHOOL HEALTH TEAMS......... 162
ANNEXURE 24: REFERRAL AND BACK REFERRAL FORM FOR WBPHCOT .............................................. 163
ANNEXURE 25: CHECKLIST FOR ELEMENT 49 - FACILITY REFERS ENVIRONMENTAL HEALTH RELATED RISKS
TO ENVIRONMENTAL HEALTH SERVICES ....................................................................................... 165
ANNEXURE 26: CHECK LIST FOR ELEMENT 50 - THE ICSM COMPLIANT PACKAGE OF CLINICAL GUIDELINES IS
AVAILABLE IN ALL CONSULTING ROOMS ....................................................................................... 166
ANNEXURE 27: CHECK LIST FOR ELEMENT 51 - NATIONAL GUIDELINES ON PRIORITY HEALTH CONDITIONS
ARE AVAILABLE IN THE FACILITY .................................................................................................. 167
ANNEXURE 28: EXAMPLE OF A REGISTER FOR NURSES TRAINED ON BASIC LIFE SUPPORT ..................... 168
ANNEXURE 29: PATIENT SAFETY INCIDENT REPORTING FORM .............................................................. 169
ANNEXURE 30: PATIENT SAFETY INCIDENT (PSI) REGISTER ................................................................. 173
ANNEXURE 31: RECORDS FOR STATISTICAL DATA ON PATIENT SAFETY INCIDENT .................................. 174
ANNEXURE 32: CHECKLIST FOR ELEMENT 57 - PATIENT SAFETY INCIDENT MANAGEMENT RECORDS SHOW
COMPLIANCE TO THE NATIONAL GUIDELINE FOR PATIENT SAFETY INCIDENT REPORTING AND LEARNING
................................................................................................................................................ 179
ANNEXURE 33: EXAMPLE OF A REGISTER TO SUMMARISE CLINICAL RECORD AUDITING ........................... 180
ANNEXURE 34: NOTIFIABLE MEDICAL CONDITIONS .............................................................................. 181
ANNEXURE 35: KEY ELEMENTS OF INFECTION CONTROL STANDARD PRECAUTIONS ................................ 182
ANNEXURE 36: CHECKLIST FOR ELEMENT 65 - ALL STAFF HAS RECEIVED IN-SERVICE TRAINING ON
INFECTION CONTROL STANDARD PRECAUTIONS THAT IS IN-LINE WITH THE SOP IN THE LAST TWO YEARS
................................................................................................................................................ 185
ANNEXURE 37: POSTER – HOW TO HAND WASH.................................................................................. 186
ANNEXURE 38: POSTER – HOW TO HAND RUB .................................................................................... 187
ANNEXURE 39: FIVE MOMENTS FOR HAND HYGIENE ............................................................................ 188
ANNEXURE 40: POSTER – COUGH ETIQUETTE .................................................................................... 189
ANNEXURE 41: CHECKLIST ELEMENT 69 - STAFF WEAR APPROPRIATE PERSONAL PROTECTIVE CLOTHING
................................................................................................................................................ 190
ANNEXURE 42: W ASTE SEGREGATION AND COLOUR CODING ............................................................... 191
ANNEXURE 43: W AITING TIME SURVEY TOOL ...................................................................................... 192
ANNEXURE 44: W AITING TIME CALCULATION TOOL .............................................................................. 193
ANNEXURE 45: TEMPLATE TO DISPLAY RESULTS OF PATIENT EXPERIENCE OF CARE .............................. 194
ANNEXURE 46: TEMPLATE FOR COMMITMENT OF THE FACILITY TO IMPROVE/SUSTAIN THE RESULTS OF THE
PATIENT EXPERIENCE OF CARE ................................................................................................... 195
ANNEXURE 47: COMPLAINTS, COMPLIMENTS AND SUGGESTION REGISTERS .......................................... 196
ANNEXURE 48: STATISTICAL DATA ON COMPLAINTS, COMPLIMENTS AND SUGGESTIONS ......................... 199
ANNEXURE 49: CHECKLIST FOR ELEMENT 87- THE COMPLAINTS/ COMPLIMENTS /SUGGESTIONS RECORDS
SHOW COMPLIANCE TO THE NATIONAL GUIDELINE TO MANAGE COMPLAINTS/COMPLIMENTS/
SUGGESTIONS ........................................................................................................................... 202
ANNEXURE 50: EXAMPLE OF SPECIFICATIONS FOR A COMPLAINT, COMPLIMENT AND SUGGESTION BOXES203
ANNEXURE 51: COMPLAINTS, COMPLIMENTS AND SUGGESTION FORM .................................................. 204
ANNEXURE 52: COMPLAINTS, COMPLIMENTS AND SUGGESTIONS POSTER ............................................. 205
ANNEXURE 53: EXAMPLE OF A SCHEDULE FOR ACKNOWLEDGEMENT OF POLICIES/ GUIDELINES/PROTOCOLS
/SOP/NOTIFICATIONS ................................................................................................................ 206
ANNEXURE 54: EXAMPLE OF A SYSTEM TO ORGANISE MEDICINE IN THE MEDICINE ROOM ........................ 207
ANNEXURE 55: CHECKLIST FOR ELEMENT 94 - MEDICINE ROOM/DISPENSARY IS NEAT AND MEDICINES ARE
STORED TO MAINTAIN QUALITY ................................................................................................... 209
ANNEXURE 56: EXAMPLE OF A TEMPERATURE CONTROL CHART FOR MEDICINE ROOM/DISPENSARY ........ 210
ANNEXURE 57: TEMPERATURE CONTROL CHART FOR MEDICINE REFRIGERATOR ................................... 211
ANNEXURE 58: CHECKLIST FOR ELEMENT 98 - COLD CHAIN PROCEDURE FOR VACCINES IS MAINTAINED . 212
ANNEXURE 59: CHECKLIST FOR ELEMENT 99 - MEDICINE CUPBOARD OR TROLLEY IS NEAT AND ORDERLY
................................................................................................................................................ 213
ANNEXURE 60: REGISTER FOR SCHEDULE 5 AND 6 MEDICINES ............................................................. 214
ANNEXURE 61: CHECKLIST FOR ELEMENT 101 - ELECTRONIC NETWORKED SYSTEM FOR MONITORING THE
AVAILABILITY OF MEDICINE IS USED EFFECTIVELY ......................................................................... 215
ANNEXURE 62: ESSENTIAL MEDICINES LIST FOR PRIMARY HEALTH CARE FACILITIES ............................ 216
ANNEXURE 63: CHECKLIST FOR ELEMENT 102 - 90% OF THE MEDICINES ON THE TRACER MEDICINE LIST ARE
AVAILABLE ................................................................................................................................ 220
ANNEXURE 64: CHECKLIST FOR ELEMENT 105 - BASIC SURGICAL SUPPLIES (CONSUMABLES) ARE AVAILABLE
................................................................................................................................................ 222
ANNEXURE 65: CHECKLIST FOR ELEMENT 107 - REQUIRED FUNCTIONAL DIAGNOSTIC EQUIPMENT AND
CONCURRENT CONSUMABLES FOR POINT OF CARE TESTING ARE AVAILABLE .................................. 224
ANNEXURE 66: CHECKLIST FOR ELEMENT 108 - REQUIRED SPECIMEN COLLECTION MATERIALS AND
STATIONERY ARE AVAILABLE ...................................................................................................... 225
ANNEXURE 67: CHECKLIST FOR ELEMENT 109 - SPECIMENS ARE COLLECTED, PACKED, STORED AND
PREPARED FOR TRANSPORTATION ACCORDING TO THE PRIMARY HEALTH CARE LABORATORY
HANDBOOK ............................................................................................................................... 228
ANNEXURE 68: CHECKLIST FOR ELEMENT 110 - THE LABORATORY RESULTS ARE RECEIVED FROM THE
LABORATORY WITHIN THE SPECIFIED TURNAROUND TIMES ............................................................ 230
ANNEXURE 69: EXAMPLE OF A WORK ALLOCATION SCHEDULE FOR STAFF ............................................. 231
ANNEXURE 70: ANNUAL LEAVE SCHEDULE .......................................................................................... 232
ANNEXURE 71: EXAMPLE OF A STAFF SATISFACTION SURVEY ............................................................... 234
ANNEXURE 72: OCCUPATIONAL HEALTH AND SAFETY REGISTER ......................................................... 237
ANNEXURE 73: EXPENDITURE REPORT ............................................................................................... 239
ANNEXURE 74 : CLEANING SCHEDULE .......................................................................................... 240
ANNEXURE 75: CHECKLIST FOR ELEMENT 131 - DISINFECTANT, CLEANING MATERIALS AND EQUIPMENT ARE
AVAILABLE ................................................................................................................................ 243
ANNEXURE 76: CLEANING EQUIPMENT ............................................................................................... 244
ANNEXURE 77: REGULATIONS FOR MATERIAL SAFETY DATA SHEETS..................................................... 245
ANNEXURE 78: CONTROL SHEET FOR SIGN-OFF FOR CLEANLINESS ...................................................... 249
ANNEXURE 79: CHECKLIST FOR ELEMENT 132 – ALL SERVICE AREAS ARE CLEAN .................................. 259
ANNEXURE 80: CHECKLIST FOR ELEMENT 133 - CLEAN RUNNING WATER, TOILET PAPER, LIQUID HAND
WASH AND DISPOSABLE HAND PAPER TOWELS ARE AVAILABLE ...................................................... 261
ANNEXURE 81: CHECKLIST FOR ELEMENT 135 - SANITARY AND HEALTH CARE WASTE ARE MANAGED
APPROPRIATELY ........................................................................................................................ 262
ANNEXURE 82: CHECKLIST FOR ELEMENT 136 - GENERAL WASTE IS MANAGED APPROPRIATELY ............ 263
ANNEXURE 83: CHECKLIST FOR ELEMENT 137 – ALL TOILETS ARE CLEAN, INTACT AND FUNCTIONAL....... 264
ANNEXURE 84: CHECKLIST FOR ELEMENT 138 - THE EXTERIOR OF THE FACILITY IS AESTHETICALLY
PLEASING AND CLEAN ................................................................................................................ 265
ANNEXURE 85: STANDARD OPERATING PROCEDURE FOR WASTE MANAGEMENT ................................... 266
ANNEXURE 86: SCHEDULE FOR PEST CONTROL .................................................................................. 270
ANNEXURE 87: CHECKLIST FOR ELEMENT 145 - THERE IS A STANDARD SECURITY GUARD ROOM OR THE
FACILITY HAS AN ALARM SYSTEM LINKED TO ARMED RESPONSE .................................................... 271
ANNEXURE 88 : REGISTER FOR SECURITY BREACHES .......................................................................... 272
ANNEXURE 89: CHECKLIST FOR ELEMENT 149 – FUNCTIONAL FIREFIGHTING EQUIPMENT IS AVAILABLE... 274
ANNEXURE 90: CONTROL SHEET FOR INSPECTION OF FIREFIGHTING EQUIPMENT.................................. 275
ANNEXURE 91: EVACUATION PLAN ..................................................................................................... 276
ANNEXURE 92: EVACUATION DRILL REPORT ........................................................................................ 277
ANNEXURE 93: CHECKLIST FOR ELEMENT 155 - CLINIC SPACE ACCOMMODATES ALL SERVICES AND STAFF
................................................................................................................................................ 278
ANNEXURE 94: CHECKLIST FOR ELEMENT 156 – THERE IS ACCESS FOR PEOPLE WITH WHEELCHAIRS ..... 279
ANNEXURE 95: CHECKLIST FOR ELEMENT 157 - THE BUILDING/S IS MAINTAINED ACCORDING TO SCHEDULE
................................................................................................................................................ 280
ANNEXURE 96: EXAMPLE OF A RECORD TO TRACK MAINTENANCE WORK ............................................... 284
ANNEXURE 97: CHECKLIST FOR ELEMENT 158 - BUILDING IS COMPLIANT WITH SAFETY REGULATIONS .... 285
ANNEXURE 98: CHECKLIST FOR ELEMENT 159 - FURNITURE IS AVAILABLE AND INTACT IN SERVICE AREAS
................................................................................................................................................ 286
ANNEXURE 99: CHECKLIST FOR ELEMENT 160 - ESSENTIAL EQUIPMENT IS AVAILABLE AND FUNCTIONAL IN
CONSULTING AREAS .................................................................................................................. 288
ANNEXURE 100: EXAMPLE OF A MAINTENANCE SCHEDULE FOR EQUIPMENT .......................................... 290
ANNEXURE 101: CHECKLIST FOR ELEMENT 165 - RESUSCITATION ROOM IS EQUIPPED WITH FUNCTIONAL
BASIC EQUIPMENT FOR RESUSCITATION ...................................................................................... 293
ANNEXURE 102: CHECKLIST FOR ELEMENT 166 - RESTORE THE EMERGENCY TROLLEY DAILY AND OR AFTER
EVERY TIME IT WAS USED ........................................................................................................... 294
ANNEXURE 103: CHECKLIST FOR ELEMENT 167 – THERE IS AN EMERGENCY STERILE OBSTETRIC DELIVERY
PACK ........................................................................................................................................ 297
ANNEXURE 104: CHECKLIST FOR ELEMENT 168 – THERE IS A STERILE PACK FOR MINOR SURGERY ........ 298
ANNEXURE 105: CHECKLIST FOR OXYGEN SUPPLY .............................................................................. 299
ANNEXURE 106: CHECKLIST FOR ELEMENT 170- UP TO DATE ASSET REGISTER AVAILABLE .................... 300
ANNEXURE 107: EXAMPLE OF AN ASSET DISPOSAL FORM .................................................................... 301
ANNEXURE 108: SCHEDULE FOR MEETINGS ........................................................................................ 302
ANNEXURE 109: TEMPLATE FOR AGENDA ........................................................................................... 303
ANNEXURE 110: TEMPLATE FOR ATTENDANCE REGISTER FOR MEETINGS ............................................. 304
ANNEXURE 111: CHECKLIST FOR ELEMENT 189 – THERE IS A FUNCTIONAL CLINIC COMMITTEE .............. 305
ANNEXURE 112: EXAMPLE OF SERVICES AND ACTIVITIES FOR AN OPEN DAY ......................................... 307
ANNEXURE 113: EXAMPLE OF A TEMPLATE FOR AN OPERATIONAL PLAN ................................................ 308
ANNEXURE 114: STATUS DETERMINATION CYCLE ............................................................................... 322
ANNEXURE 115: EXAMPLE OF A REGISTER FOR AMBULANCE TURNAROUND TIMES ................................. 323
ANNEXURE 116: REFERRAL PATHWAYS .............................................................................................. 324
ANNEXURE 117: GENERAL PRIMARY HEALTH CARE REFERRAL AND FEEDBACK FORM ........................... 327
ANNEXURE 118: EXAMPLE OF A REGISTER FOR PATIENT REFERRALS.................................................... 329
ANNEXURE 119: REPORTING TEMPLATE FOR IMPLEMENTING PARTNERS ............................................... 330
ANNEXURE 120: TEMPLATE FOR MEMORANDUM OF UNDERSTANDING ................................................... 331
LIST OF ACRONYMS
ANC Antenatal Care

ART Antiretroviral treatment
BANC Basic Antenatal Care
CCMDD Central Chronic Medicine Dispensing and Distribution
CHW Community Health Worker
CoGTA Cooperative Governance and Traditional Affairs
DCST District Clinical Specialist Team
DHIS District Health Information System
DHMT District Health Management Team
DHS District Health System
DoH Department of Health
DPSA Department of Public Service and Administration
EML Essential Medicine List
EPI Expanded Program on Immunization
HIV Human Immunodeficiency Virus
HRH Human Resource for Health
ICSM Integrated Clinical Services Management
IPC Infection Prevention and Control
MCWH Maternal Child Women’s Health
Min / max minimum / maximum
MOU Maternal Obstetric Unit
MRHS Male Reproductive Health Services
NCD Non-communicable diseases
NGO Non-Governmental Organisation
NMC Notifiable Medical Conditions
NHLS National Health Laboratory Services
PACK Practical Approach to Care Kit
PDoH Provincial Department of Health
PEC Patient Experience of Care
PHC Primary Health Care
PMDS Performance Management and Development System
PNC Prenatal Care
PPTICRM Perfect Permanent Team for Ideal Clinic Realisation and Maintenance
PSI Patient Safety Incident
RTHC Road to Health Chart
SANC South African Nursing Council
SLA Service Level Agreement
SOP Standard Operating Procedure
TB Tuberculoses
WBPHCOT Ward Based Primary Health Care Outreach Team
WISN Workload Indicator Staffing Needs
INTRODUCTION AND BACKGROUND
The ‘Ideal Clinic’ (IC) programme is an initiative started by South Africa’s National
Department of Health (NDoH) in July 2013 as a way of systematically improving and
correcting deficiencies in Primary Health Care (PHC) clinics in the public sector. These
deficiencies were picked up by the NDoH facilities audit completed in 2012.
An Ideal Clinic is a clinic with good infrastructure, adequate staff, adequate medicine and
supplies, good administrative processes and adequate bulk supplies that use applicable
clinical policies, protocols, guidelines as well as partner and stakeholder support, to ensure
the provision of quality healthcare services to the community. An Ideal Clinic cooperates
with other government departments as well as with the private sector and non-governmental
organisations to address the social determinants of health.
Integrated Clinical Services Management (ICSM) is a key focus within an Ideal Clinic. ICSM
is a health system strengthening model that builds on the strengths of the HIV programme
to deliver integrated care to patients with chronic and/or acute diseases or who come for
preventative services by taking a patient-centric view that encompasses the full value chain
of continuum of care and support.
A standardised questionnaire which is translated into a dashboard (Ideal Clinic components,

sub-components and elements) is used for tracking progress in PHCs over time. Since 2013
there has been substantial consultation on the dashboard. Feedback from health
professionals and managers working at facility, district, provincial and national level
improved the dashboard effecting changes from version 1 onwards. This version of the
dashboard, version 17, is comprised of 10 components, 32 sub-components and 206
elements. See Annexure 1. Version 17 and thus this manual prescribe the minimum
elements that should be present in a well-functioning PHC facility. See Annexure 2.
Each element is scored according to the performance of the facility; green indicating that
performance is achieved, amber indicating that the performance is partially achieved, and
red indicating that performance is not achieved. The method of measurement (indicated
with symbols), level of responsibility (facility, district, province or national) and weight (vital,
essential and important) is indicated for each element. See Annexure 2.
Ideal Clinic Manual version 17 1|Page

The average score according to the weights assigned to the 207 elements determines
whether Ideal Clinic status is achieved or not. The elements are weighted as Vital (10
elements), Essential (86 elements), and Important (110 elements). In order for a facility to
obtain Ideal Clinic status, the facility must at a minimum score 90 percent for elements
weighted as Vital, 70 percent for elements weighted as Essential, and 68 percent for
elements weighted as Important. This will give the facility silver status. Depending on how a
facility performs in a status determination, it will be scored and subsequently categorised as
no category achieved, silver (70-79 percent), gold (80-89 percent) and platinum (90-99
percent). The category will only be achieved when the minimum average percentages for
Vital, Essential and Important elements have also been achieved. It is therefore important to
note that a facility can obtain a high average score (70 to 99 percent) but still fail to obtain
an Ideal Clinic category as they have failed to obtain the minimum average score for per
weight category.
Over time, as the quality of the conditions of PHC facilities improve, we may add more
elements and more specifications for certain elements.
THE PURPOSE OF THIS MANUAL
The Ideal Clinic manual has been developed to assist managers at various levels of
healthcare service provision to correctly interpret and understand the requirement for
achieving the elements as depicted in the Ideal Clinic dashboard. It can therefore be
regarded as a reference document which guides the managers to determine the status of
Ideal Clinic dashboard elements in a facility. The manual is envisaged to be of particular use
to the facility manager. Responsibility on the dashboard has been assigned to the facility
manager in areas that the facility manager may believe is out of his/her control. However,
for these areas it will be the facility manager who knows that the element is not green and it
is the facility manager who should initiate processes through the district office to turn these
elements green.
The manual is also a useful tool for managers at sub-district, district, provincial and national
level to ensure progressive discipline of those reporting to them. Facility managers must
receive orientation to the IDEAL CLINIC REALISATION AND MAINTENANCE process
using this manual. The content of the manual could then guide counseling sessions and
further steps of discipline when weaknesses in clinics persist.

HOW TO USE THE MANUAL
The Ideal Clinic Manual is comprised of detailed steps that should be followed to achieve
every element. The numbering of the steps is aligned to the numbering in the dashboard. In
some instances, a step refers the reader to a specific annexure. This implies that the
relevant annexure should be used for further guidance to achieve of the element.
Documents, policies, guidelines and standard operating procedures referenced as being

available on the national Department of Health’s website (www.health.gov.za) can be
obtained by selecting the ‘Ideal Clinic’ tab on the website. The tab will direct the user to the
Ideal Clinic website. On the Ideal Clinic website there is a tab named ‘Documents’ where
the relevant documents can be downloaded from.

COMPONENT 1: ADMINISTRATION
1. Signage and notices
Commitment for Ideal Clinic elements 1-3
Monitor whether there is communication about the facility and the services provided.
1 All external signage in place

2 Facility information board reflects the facility name, service hours, physical
address, contact details for facility and emergency service and service
package details is visibly displayed at the entrance of the premises
3 Sign indicating NO WEAPONS, NO SMOKING, NO ANIMALS (except for service
animals), NO LITTERING and NO HAWKERS, is clearly sign posted at the
entrance of the facility
Process
Step 1: Familiarise yourself with the specifications for external signs. See Annexure 3
Step 2: Do inspection every six months to check that all external signs for the facility
are present and in good condition.
Step 3: In the event of having to replace new, damaged or missing signs, order signs
from the sub-district/district manager through supply chain following the
relevant provincial protocol.
Step 4: The signs will be installed either by the supplier or district maintenance staff
depending on order specifications.
Note to reviewers:
• Facility information board must be on the wall next to the main entrance of the facility
building OR on a free standing board approximately 500mm to 2000 mm before the main
entrance to the facility building (entrance of the premises)
• It is not ideal but is acceptable if the information on the Facility information board is
displayed on two separate boards (additional panel to main board) as the Ideal Clinic
Programme did add additional information to the board since the first version was
published.
• Emergency service contact numbers must include the contact numbers for ambulances
and fire brigade.
• External signage must be formally manufactured signage.

Commitment for Ideal Clinic elements 4-7
Signs and notices are clearly placed throughout the facility.
4 Vision, mission and values of the district are visibly displayed
5 Facility organogram with contact details of the facility manager is displayed on

a central notice board
6 Patients' Rights Charter is displayed in all waiting areas in at least two local
languages
7 All service areas within the facility are clearly signposted
Process
Step 1: Ensure that the mission, vision and values of the district as well as the
organogram with contact details of the managers are visibly displayed on a
central notice board.
Step 2: Obtain the Patient’s Rights Charter from www.health.gov.za.
Step 3: Visibly displayed Charter in all main waiting areas in at least two local
languages. See Annexure 4.
Step 4: Conduct an inspection of the facility every six months to ensure that all internal
signs for the facility are present and in a good condition. See Annexure 5
Step 5: In the event of having to buy new or replace damaged or missing signs, order
signs through supply chain management following the relevant provincial
protocol.
Step 6: The signs will be installed either by the supplier or district maintenance staff.
Step 7: All notices like the vision, mission, values and organogram must be attached
firmly to a notice board surface. Notices may only be attached to notice boards
and to no other surface e.g walls and windows.
Note to reviewers:
• Verify that organogram is up to date by comparing it with an updated list of the staff
establishment of the facility.
• All internal signage must ideally be manufactured. Neatly typed and laminated signage is
acceptable where the facility is still in the process of obtaining manufactured signage.

2. Staff Identity and Dress Code
Commitment for Ideal Clinic elements 8 - 10
Monitor whether staff uniform, protective clothing and mode of staff identification are in
accord to policy prescripts.
8 There is a prescribed dress code for all service providers
9 All health care professional staff members comply with prescribed dress code
10 All staff members wear an identification tag
Process
Step 1: Obtain the Staff Dress Code and Insignia specifications from the district. See
Annexure 6 as an example of a Staff Dress Code.
Step 2: Share the contents of the Staff Dress Code with all staff members.
Step 3: All new staff must be inducted, including an orientation to the prescribed dress
code.
Step 4: Compliance to dress code must be included in the staff performance

agreements.
Step 5: Randomly check that the healthcare professional staff members on duty are
dressed correctly according to the dress code. Check that all staff is wearing
prescribed dress code (Annexure 7) and identification tags (Annexure 8).

3. PATIENT SERVICE ORGANISATION
The facility must be user friendly for the very sick, frail and elderly patients.
11 Help desk/reception services are available
12 There is a process that prioritises the very sick, frail and elderly patients
13 A functional wheelchair is always available
Process
Step 1: Schedule a monthly duty roster to assign staff to the help desk/reception.
Ensure that the various languages spoken by staff at the facility are
documented and available at the helpdesk/reception so that staff can be
called to interpret when necessary.
Step 2: Develop a SOP that describes how the facility will ensure that the very sick,
frail and elderly patients are prioritised.
Step 3: Display notice in at least two local languages in the waiting area indicating the
prioritisation process for very sick, frail and elderly patients. See Annexure 9.
Step 4: Schedule in-service training for ALL staff on prioritisation process. Keep a
record of attendance in the in-service training book. See Annexure 10 as an
example.
Step 5: Delegate the function of prioritisation process to a designated staff member
on a daily basis.
Step 6: Conduct random spot checks during the day to determine if the very sick, frail,
and elderly patients are prioritised.
Step 7: Ensure that functional wheelchairs are available at the facility for use if and
when needed.
Step 8: On a weekly basis, monitor the condition of the wheelchairs and order repairs
if required
Step 9: If there are no functional wheelchairs available at the facility, order them using
the standard provincial protocol.
Step 10: Schedule in-service training for all staff on safety procedures when
transporting a patient in a wheelchair. Make a record of attendance in in-
service training book. See Annexure 10 as an example.
Note to reviewers:
• For element 11, to be compliant the facility must have a SOP as well as a notice
displayed. To verify that the SOP is implemented ask one of the staff members to
explain how they go about to ensure that the very sick, frail and elderly patients are
prioritised.

4. Management of Patient Record
Every patient has a single record containing correctly captured personal and clinical
information.
14 There is a single patient record irrespective of health conditions
15 Patient record content adheres to ICSM prescripts
Process
Step 1: All new patients will have a patient record opened for them using the National
Adult or Child Record for Clinics and Community Health Centres.
Step 2: Allocate a file number using the Standard Operating Procedure for accessing,
tracking, filing, archiving and disposal of patient records that has been
approved for the province/district/.
Step 3: Every patient must have a single patient record that contains all clinical
information including laboratory results, copies of referral letters and
prescription charts as per ICSM prescripts. See Annexure 11

The patient records will be filed in a single location close to reception using a standard filing
SOP to enable quick access of records.
16 District/provincial standard operating procedure/guideline for accessing,
tracking, filing, archiving and disposal of patient records is available
17 Guideline for accessing, tracking, filing, archiving and disposal of patient

records is adhered to
18 There is a single location for storage of all active patient records
19 Patient records are filed in close proximity to patient registration desk
20 Retrieval of a patient’s file takes less than ten minutes
Process
Step 1: Obtain the provincial or district SOP for accessing, tracking, filing, archiving
and disposal of patient’s records.
Step 2: Adhere to contents of the SOP. See Annexure 12.
Step 3: Identify a secure and lockable storage area in or near reception for the filing of
patient records.
Step 4: If needed, procure a bulk storage system according to the approved provincial
protocol.
Step 5: Schedule in-service training for administrative staff on patient record filing,
archiving and disposal procedures. Record attendance in the in-service
training book/file. See Annexure 10 as an example.

Commitment for Ideal Clinic element 21
Priority stationery for the facility is available at all times in sufficient quantities.
21 Priority stationery (clinical and administrative) is available at the facility in

sufficient quantities
Process
Step 1: Determine the clinic specific minimum quantity for each item of stationery
required.
Step 2: Using the stationery checklist (Annexure 13), the facility admin clerk must, on
a weekly basis; check that there is sufficient stationery.
Step 3: Order the required quantity using the standard provincial procurement
protocol.
Note to reviewers:
Check what the minimum levels are for the various stationery items (if the minimum levels
for stationery has not been determined by the facility, the facility will be non-compliant to this
element). Verify that the minimum required are present on the shelves. The facility will not
be compliant if the minimum levels are not present. If the facility has already placed an
order but the order has not arrived yet the facility is non-compliant.
Ideal Clinic Manual version 17 10 | P a g e

COMPONENT 2: INTEGRATED CLINICAL SERVICES MANAGEMENT (ICSM)
5: Clinical service provision
Commitment for Ideal Clinic elements 22
The facility has organised patient flow to provide patients with appropriate clinical care.
22 Facility has been reorganised with designated consulting areas and staffing for
acute, chronic health conditions and preventative health services
Process
Step 1: Obtain the ICSM manual from www.health.gov.za.
Step 2: Determine the process flow in the facility. See process flow mapping in ICSM
manual.
Step 3: Flow plan for facility must provide for an area for monitoring vital signs for the
three streams of care.
Step 4: Schedule in-service training for all staff on the Integrated Clinical Services
Management (ICSM). Record attendance in the in-service training book/file.
See Annexure 14 as an example.
Step 5: Implement process flow as per plan.
Step 6: Mark out flow using colour coding to direct patients.
Name of Stream Colour Description of colour

Minor ailments Orange
Chronic Services Blue
Maternal and Child Health Deep green

Note to Reviewers:
Facilities that are too small (daily headcount of less than 170 patients per day (3 350 per
month) to be segregated into three streams will not be expected to have dedicated
consulting areas for acute, chronic health conditions and preventative health services but
should still adhere to ICSM principles. This means that patients should be treated holistically
and not be sent from one section to another because of co-morbidities. Small facilities that
adhere to ICSM principles should be scored green for this element.

Facility staff must ensure that patients’ privacy is respected at all times in all service areas.
23 Patients are consulted, examined and counselled in privacy
Process
Step 1: The induction programme for new staff must include the importance of
securing patients’ privacy while being consulted or counseled.
Step 2: Patients should at all times be consulted and counseled behind closed
doors/curtains/ screens.
Step 3: Do spot-checks to determine whether staff members respect patients’ privacy

while providing services and correct identified weaknesses.

Improvements in PHC service environment must lead to improved service and population
health outputs and outcomes.
24 TB treatment success rate is at least 85% or has increased by at least 5% from

the previous year
25 TB (new pulmonary) defaulter rate < 5%
26 Ante-natal visit rate before 20 weeks gestation is at least 67% or has increased
by at least 5% from the previous year
27 Ante-natal patient initiated on ART rate is at least 96% or has increased by at
least 5% from the previous year
28 Immunisation coverage under one year (annualised) is at least 87% or has
increased by at least 5% from the previous year
Process
Step 1: The record-keeping process (data collection) in the facility must feed into the
DHIS data or relevant electronic patient information system required to
calculate the values of the above indicators.
Step 2: The record-keeping process (data collection) must be accurate, complete and
validated to ensure good quality health management information.
Step 3: Calculate and analyse the data to determine whether the facility is achieving
the above targets, see note below on how to conduct the status determination
for elements 24 to 28.
Step 4: Should the clinic not reach the above targets, investigate to find reasons and
implement corrective actions.
NOTE:
HOW TO CONDUCT THE STATUS DETERMINATION FOR ELEMENT 24
• If the facility obtained the target of 85% the facility scores green (achieved) for the
element.
• If the facility did not obtain the target of 85%, there should be at least a 5% increase
from the previous financial year:
The TB programme use the calendar year (January to December) for reporting. The
score for element 24 is determined by comparing the outcome of 1 year and 1
quarter ago with the outcome of 2 years and 1 quarter ago.

For example:
If you conduct the status determination of a clinic on 10 November 2016 (4th quarter
of the year) you compare the TB success rate of the 3rd quarter of 2015 with the TB
success rate of the 3rd quarter of 2014. See table below for examples with values and
scores.
Status determination TB success rate of 1 TB success rate of 2 Score

conducted year and 1 quarter ago years and 1 quarter
ago
10 November 2016 = 4th 3rd quarter 2015 = ≥85% Green
quarter
10 November 2016 = 4th 3rd quarter 2015 = 35% 3rd quarter 2014 = 30% Green
quarter
10 November 2016 = 4th 3rd quarter 2015 = 30% 3rd quarter 2014 = 33% Red
quarter
HOW TO CONDUCT THE STATUS DETERMINATION FOR ELEMENT 25
The TB programme use the calendar year (January to December) for reporting. The score
for element 25 is determined by looking at the TB defaulter rate of 6 months (2 quarters)
back because the average TB patient is on treatment for 6 months.
For example:
If you conduct the status determination on 10 November 2016 (4th quarter) you look at the
TB defaulter rate of the 1st quarter of 2016 (January to March 2016). See table below for
examples with values and scores.
Status determination conducted TB defaulter rate Score

10 November 2016 = 4th quarter 1st quarter 2016 = <5% Green
10 November 2016 = 4th quarter 1st quarter 2016 = ≥5% Red
HOW TO CONDUCT THE STATUS DETERMINATION FOR ELEMENT 26 to 28
• If the facility obtained the target as described for the specific element the facility
scores green (achieved) for the element.
• If the facility did not obtain the target as set, there should be at least a 5% increase
from the previous financial year:
a) When conducting the status determination during April to June (1st quarter) of a
financial year, use the outcome of two financial years ago, comparing it with the
outcome of three financial years ago if necessary.
b) When conducting status determination during July to March (2nd to 4th quarter) of
a financial year, use the outcome of the previous financial year, comparing it with
the outcome of two financial years ago if necessary.

For example:
a) When conducting the status determination during April to June 2016, use the
outcome of 2014/15 financial year and compare it with the outcome of 2013/14.
b) When conducting the status determination during July 2016 to March 2017, use
the outcome of 2015/16 financial year and compare it with the outcome of
2014/15. See table below for examples with values and scores.
Status Outcome of indicator one or Outcome of indicator two Score
determination two financial years ago or three financial years
conducted ago
10 July 2016 Outcome of 2015/16 = ≥ target Green
set
10 May 2016 Outcome of 2014/15 financial Outcome of 2013/14 Green
year = 40% financial year = 35%
10 July 2016 Outcome of 2015/16 financial Outcome of 2014/15 Red
year = 50% financial year = 47%

Quality Improvement plans are developed and implemented
30 Quality Improvements plans are signed off by the facility manager and updated
quarterly
Process
Step 1: Obtain the National Quality Improvement Guideline from www.health.gov.za

that will assist facility managers to understand and implement quality
improvements.
Step 2: Generate the “Quality Improvement Report” from the Ideal Clinic software
once the first facility status determinations has been conducted at the end of
May every year. See Annexure 15.
Step 3: Add any additional areas in need for improvement that has been identified in
addition to the Ideal Clinic elements that were failed, for example, gaps
identified in clinical audits, patient safety incidents, patient experience of care
surveys, complaints, staff satisfaction surveys, security breaches, infection
control risk assessment.
Step 4: Complete the columns for “Activity, By whom and When”.
Step 5: The facility manager must meet with all staff to discuss the content of the draft
quality improvement plan and to obtain inputs. Keep record of this meeting.
Step 6: Update the quality improvement plan with inputs received from staff.
Step 7: Facility manager to sign and date the quality improvement plan.
Step 8: Fill in at the end of every quarter the column for “Results” at each area where
the “When” column was indicated for completion in that specific quarter.
Note to reviewers:
Facilities should only have one collated Quality Improvement Plan that is updated quarterly.

There is a functioning district/sub-district clinical leadership team that oversees clinical care
and patient safety in facilities
31 Six monthly district/sub-district clinical performance review report with action

plan from clinical quality supervisors are available
Process
Step 1: The district/sub district clinical quality supervisors compile a six monthly report
on the performance of facilities in clinical areas. Obtain a template as an
example of such a report on www.health.gov.za.
Step 2: The performance report must be tabled at the quarterly facility performance
review meetings.
Step 3: The clinical performance report must be shared with ALL facilities in the
district/sub-district to enable learning.
Step 4: The facility manager must table the report at the facility’s quarterly staff
meetings.
Note to reviewers:
Clinical quality supervisors can include but are not limited to District Specialist Clinical
Teams and District Quality Assurance Units.

6. Access to Medical, Mental Health, Allied Health Practitioners
Access to a full range of health professionals to deliver a comprehensive health service

either at the facility or through appropriate referral.
32 Patients that require consultation with a medical practitioner have access to a

medical practitioner at the facility at least once a week
33 Patients have access to oral health services
34 Patients have access to occupational therapy services
35 Patients have access to physiotherapy services
36 Patients have access to dietetic services
37 Patients have access to social work services
38 Patients have access to radiography services
39 Patients have access to ophthalmic service
40 Patients have access to mental health services
41 Patients have access to speech and hearing services
42 Staff dispensing medicine have access to the support of a pharmacist
Process
Step 1: Map the facility’s service provision against the approved PHC package of
services.
Step 2: Document gaps differentiating between services to be provided on-site and

those to be referred to other health facilities.
Step 3: Improve, in cooperation with sub-district/district manager, conditions at the

facility (physical space, equipment, human resources, etc.) to initiate those
services that are to be provided on-site.
Step 4: Describe in the facility’s Standard Operating Procedure (SOP) for patient
referrals the various referral paths (as mapped out in step 1) to be followed to
allow access for patients to the services at other facilities that cannot be
provided by the facility as described in elements 32 to 41. Make suitable

arrangements for patients that must be referred to other health facilities to
receive the services that are not provided by the facility itself.
Step 5: Keep a register of the patients that are referred to other facilities. Refer to
element 199 “There is a referral register that records referred patients”
Step 6: Ensure that the contact details of the pharmacy that is supporting the facility is
available for healthcare professionals to enable them to contact the pharmacy
if required.
Note to reviewers:
• To assess elements 33 to 41, check the Facility’s SOP for referral to other health
facilities. The SOP must indicate the names and contact details of the health facilities
where the patients will be referred to if the facility does not provide the services at the
facility as set out in element 33 to 41. The contact details of the pharmacy that will give
support to the facility must also be listed.
• Check that the register for referral of patients is available and completed. Where a
facility had no referrals for the month the first line of the register must indicate “no
referrals made for the month”.

Services to adolescents and youths are provided in a manner that promotes their health,
prevents illness and support their development.
43 Adolescent and Youth Friendly Health Services are provided
Process
Step 1: Obtain the national policy for providing Adolescent and Youth Friendly
Services (AYFS) from www.health.gov.za.
Step 2: Posters promoting AYFS that is in-line with the policy is visibly posted at the
reception and in consulting room where AYFS is provided. See Annexure 16.
Step 3: Include training on AYFS for all healthcare professionals on the facility’s staff
development plan.
Step 4: Schedule in-service training for health professionals for providing adolescent
and youth friendly services through the regional training centers. Record
attendance in the in-service training book/file. See Annexure 10 as an
example.
Step 5: Ensure that the Clinic Committee includes a representative of the adolescent
and youth sector aged 16-24 years
Step 6: When conducting the annual patient experience of care survey, ensure that at
least 10% of the sample include adolescent and youth aged 10 to 24 years.
Step 7: Complete the profile for adolescents and youth in the catchment area which
includes their challenges, see Annexure 17.
Step 8: Verify that the facility provides adolescent friendly services, see Annexure 18.

7. Management of Patient Appointments
All planned streams of care are efficiently organised and properly managed through a
proper patient appointment system for patients with stabilised chronic health conditions and
MCWH patients.
44 ICSM compliant patient appointment system for patients with chronic health
conditions and MCWH patient is in use
45 Records of booked patients are retrieved not later than the day before the
appointment
Process
Step 1: Schedule in-service training for clinical and administration staff on patient
appointment scheduling. See Annexure 19. This will be included in the ICSM
training that staff should undergo. Record staff attendance in the in-service
training register/book/file. See Annexure 14 as an example.
Step 2: Ensure communication and engagement with community to orientate all

stakeholders about the clinic booking system.
Step 3: Assign appointment dates and times to patients.
Step 4: As per the patient appointment, the administration staff must retrieve patient
records not later than the day before to the appointment.
Step 5: Administration clerk must retrieve patient record and tick off in the scheduling
book that the record has been retrieved in the appropriate column. A cross
should be made in red pen if the record is not found and measures must be
taken to ensure that it is found before the patient arrives.
Step 6: Retrieve any outstanding results for laboratory investigations conducted during
previous visits and place the results in the records.

Clinically stable patients with chronic conditions are able to collect pre-dispensed
medication.
46 Pre-dispensed medication for clinically stable chronic patients is prepared for

collection not later than the day before collection date or patients are enrolled
on the CCMDD programme
Definition of terms used in this section
Pre-dispense means the interpretation and evaluation of the prescription and the
preparation and labelling of the prescribed medicine (Phases 1 and 2 of dispensing as
defined in the Pharmacy Act, 1974 (Act 53 of 1974))
Process
If the facility does not have a CCMDD programme, follow the steps below:
Step 1: Refer to Annexure 20 on pre-dispensing of chronic medication.
Step 2: Use Annexure 21 (as an example) for recording receipt of chronic medication
when delivered to a patient to their home by a Community Health Worker
(CHW).
Note to reviewers:
If the facility does have a CCMDD programme follow the steps in the CCMDD Standard
Operating Procedure.

8: Coordination of PHC Services
PHC manager and staff will cooperate with schools and school health teams to assist with
the removal of health related barriers to learning.
47 Facility does referrals to and receive referrals from school health services in its
catchment area
Process
Step 1: The facility manager and staff must be familiar with and have a relationship
with all schools in the facilities’ catchment area.
Step 2: Referrals from the school health team to the facility must be managed
appropriately.
Step 3: Make provision for consulting learners referred from school health in the
afternoons in line with the policy on adolescent friendly services.
Step 4: The school health team will refer learners on the prescribed form. Provide
feedback to the school health team on the prescribed form. See Annexure 22.
Step 5: Keep record of learners that were referred and feedback that was provided.
Note to reviewers:
If the facility did not make or receive any referrals from school health services the
register/record as indicated in step 5 must indicate “no referrals received or made”.

The clinic must have functional home- and community-based services.
48 The facility refers patients with chronic but stable health conditions to home-
and community-based services for support
Process
Step 1: With the support of the district manager ensure that a home- and community-
based teams services the catchment population of the facility.
Step 2: Refer patients who need follow-up in their homes to the home- and
community-based teams on the prescribed form. See Annexure 24 as an
example.
Step 3: Keep record/register of patients referred to home- and community-based

teams.
Step 4: Include the home- and community-based teams in the facility’s quarterly
meetings to receive feedback and to give guidance in regard to possible
challenges.
Step 5: Avail yourself to meet with home- and community-based teams on an ad hoc
basis to assist with problems that arise during the course of work.
Note to reviewers:
If the facility did not make any referrals to home- and community-based services the
record/register as indicated in step 3 must indicate “no referrals made to home- and
community-based services”.

Environmental health risks affecting the facility are attended to by environmental health
services
49 Facility refers environmental health related risks to environmental health

services
Process
Step 1: Obtain and record the contact details to report environmental health related
risks to environmental health services in the facility’s telephone list.
Step 2: Do frequent checks and report any environmental health related risk to the
environmental health services as soon as it is noted, see Annexure 25.
Step 3: Follow-up with the district/sub-district office to assist if the reported risks have
not been attended to.
Note to the reviewer:

The area to be assessed for the measures on Annexure 25 (Checklist for element 49) that
relates to whether there are stagnant water, overgrown vegetation and litter on the outside
perimeters of the facility is 100 meters from the perimeter fence/outside parameter,

9. Clinical Guidelines and protocols
Commitment for Ideal Clinic element 50 - 53
Ensure quality clinical care is delivered to patients by using relevant national clinical
guidelines.
50 ICSM compliant package of clinical guidelines is available in all consulting

rooms
51 National guidelines on priority health conditions are available in the facility
52 80% of professional nurses have been fully trained on Adult Primary Care OR
Practical Approach to Care Kit
53 80% of professional nurses have been fully trained on Integrated Management
of Childhood illness
Process
Step 1: Do an audit of consulting rooms to check availability of ICSM compliant

package of clinic guidelines (soft OR hard copy OR Cell phone APP). Use
Annexure 26.
Step 2: If all guidelines are not available, access from www.health.gov.za or order
from Government Printing Works catalogue or download the APP.
Step 3: Do an audit to check availability of the National guidelines on priority health
conditions (soft OR hard copy OR Cell phone APP). A copy of the guidelines
must be available in one office that is accessible to healthcare professionals.
Use Annexure 27.
Step 4: If all guidelines are not available, access from www.health.gov.za or order
from Government Printing Works catalogue or download the APP.
Step 5: Identify an ICSM champion to be trained as a facility trainer by the district
master trainers on the Adult Primary Care Guideline OR Practical Approach to
Care Kit as well as on Integrated Management of Childhood illnesses.
Step 6: Schedule training for healthcare professionals quarterly on the Adult Primary
Care OR Practical Approach to Care Kit as well as the Integrated
Management of Childhood illnesses and keep attendance registers of the
training conducted. See Annexure 10 and 14 as examples.
Note to reviewers:
For element 52: Staff must be trained on ALL the modules to be compliant.

Nurses are able to resuscitate and provide basic life support to patients with a sudden
onset of a condition manifesting itself by acute symptoms of sufficient severity such that
the absence of immediate medical attention (including resuscitation) could reasonably be
expected to result in serious impairment to bodily function or death.
54 Resuscitation protocol is available
55 80% of professional nurses have been trained on Basic Life Support
Process
Step 1: Check that the protocol on resuscitation is available at the facility.
Step 2: Draft a schedule of nurses who have been trained on Basic Life Support by an
accredited provider.
Step 3: Schedule training for nurses for those who have not been trained as well as
for those who are due for their two yearly updates in Basic Life Support.
Step 4: File a copy of the certificates obtained by the staff in Basic Life Support as
proof that staff did complete it.
Step 5: Update register of nurses who have been trained or have updated their Basic
Life Support certificate. See Annexure 28 as an example.

The facility manages patient’s safety incidents effectively to ensure that harm to patients is
reduced.
56 National Guideline for Patient Safety Incident Reporting and Learning is

available
57 Patient safety incident records comply with the National Guideline for Patient
Safety Incident Reporting and Learning
Process
Step 1: Obtain the national Guideline for Patient Safety Incidents Reporting and
Learning from www.health.gov.za.
Step 2: Develop a facility/district specific Standard Operating Procedure (SOP) using
the National Guideline for Developing a Facility Specific SOP for Patient
Safety Incidents Reporting and Learning.
Step 3: Assign a staff member to ensure compliance with the facility’s SOP to manage
Patient Safety Incidents.
Step 4: Complete the Patient Safety Incident Management form when a patient safety
incident occurs. See Annexure 29 as an example.
Step 5: Keep the following records as stipulated in the national policy up to date:
• patient safety incidents register. See Annexure 30
• monthly statistics on patient safety incidents. See Annexure 31
o data on classifications of agents (contributing factors) involved
o data on classifications of incident type
o data on classifications of incident outcome
o indicators for patient safety incidents
Step 6: Identify trends in system failures. To identify system failures analyse the data
on classification of contributing factors and incident type to determine trends in
cause/s of the incidents as well as frequently occurring incidents. Add to the
facility’s quality improvement plans areas where gaps in patient safety have
been identified.
Step 7: Do quarterly checks to verify that the facility complies with the Guideline. See
Annexure 32.
Note to reviewers:
The Patient Safety Incident Management forms, forms for statistical data as well as
registers do not need to be exactly in the same format/layout as set out in the National
Guideline. The contents must however provide the data to enable the facility to report on
the indicators and categories for patient safety incidents as set out in the National
Guideline.

Commitment for ideal clinic element 58 - 60
Quality clinical care is maintained by conducting regular clinical audits.
58 National Clinical Audit guideline is available
59 Clinical audits are conducted quarterly on priority health conditions
60 Clinical audit meetings are conducted quarterly in line with the guidelines
Process
Step 1: Obtain National Clinical Audit guideline from www.health.gov.za
Step 2: Obtain the National Clinical Audit Implementation Guideline for PHC facilities
from www.health.gov.za. Conduct quarterly clinical record audits on the files of
patients diagnosed with priority health conditions that is in-line with the,
Guideline.
Step 3: Collate results of all records audited and analyse results.
Step 4: Where there is a need, seek guidance of an expert from the district.
Step 5: Add to the facility’s quality improvement plan areas identified for improvement.
Step 6: Provide feedback to relevant staff members.
Step 7: Implement improvements as per agreed time frame on the quality

improvement plan.
Step 8: Keep a collated summary of the results of all clinical record audits conducted.
Step 9: Discuss the facility’s results of the clinical record audits on the quarterly
Clinical audit meetings. Keep records of the meetings held.

Commitment for ideal clinic element 61
Notifiable medical conditions (NMC) are reported in-line with the national guidelines.
61 National guidelines are followed for all notifiable medical conditions
Process
Step 1: Ensure that all staff know the following in regard to NMC:
• why staff must report all NMCs
• Who should notify
• NMC that falls within category 1 and 2 NMC, see Annexure 34.
Step 2: Report all category 1 NMCs immediately to the relevant focal person at the health
establishment or Sub-District level using the most rapid means available.
Step 3: Obtain the SOP with flow chart, case definitions and case investigation forms
from www.health.gov.za
Step 4: Obtain the NMC Notification booklet from the NMC focal person at Sub-
District/District
Step 5: Report category 1 and 2 NMCs using the paper based or the electronic
notification system:
• Paper based notification

o Complete the NMC Case Notification Form.
o Send the NMC Case Notification Form to
NMCsurveillanceReport@nicd.ac.za or fax to 086 639 1638
o Send a copy to the NMC focal person at Sub-District/District (details given
on the NMC Notification booklet cover page).
o Form(s) can be sent via sms, whatsapp, email, fax or transported via
health department shuttle/transport services to the NMC focal person at
Sub-District/District.
o The NMC Focal Person at health establishment level or Sub-District must
ensure that the forms are captured electronically.
OR

• Electronic notification
o Capture the NMC case details onto the NMC electronic system (web
address available on the NMC notification SOP).
o The notification will automatically be sent to all relevant focal people at
facilities, Sub-District, District, Province & National levels.
Note to reviewers:
• The facility must have the NMC Notification booklet OR have access to the web-based
application to report NMC to be compliant
• Ask the staff member responsible for reporting NMC to explain:
o the NMCs that must be reported (category 1 and 2 NMC) and
o the process to be followed to report category 1 and 2 NMC

10. Infection Prevention and Control
Prevent and control infection
62 National Policy on Infection Prevention and Control is available

63 Facility has a designated staff member who is responsible for infection
prevention and control
64 Standard Operating Procedure on infection control is available
65 All staff have received in-service training in the past two years on infection
control standard precautions that is in line with the standard operating
procedure.
66 Poster on hand washing is displayed above the hand wash basin in every
consulting room
67 Awareness day on hand hygiene is held annually
68 Poster on cough etiquette is displayed in every waiting area
69 Staff wear appropriate protective clothing
Process
Step 1: Obtain the national policy on Infection Prevention and Control (IPC) from
www.health.gov.za
Step 2: Assign a staff member to ensure compliance with the national policy on
Infection Prevention and Control. The staff member must be trained on
infection prevention and control. This training can be provided by the district or
the province, it does not need to be formal training provided by a specialized
service provider.
Step 3: Ensure that all staff know the key elements pertaining to infection control
standard precautions. See Annexure 35.
Step 4: Obtain the National Cleanliness Guideline from www.health.gov.za that

contains guidelines on some of the elements for infection control standard
precautions (Hand washing and hand hygiene, Personal Protective
Equipment, Waste management and disposal, Environmental cleanliness,

Handling of linen).
Step 5: Obtain the National Infection Prevention and Control Guidelines for TB, MDR-
TB and XDR-TB from www.health.gov.za that contains guidelines on
respiratory hygiene.
Step6: Obtain the National Guideline for the management of sharps, safe injection
practices, patient care equipment and wound care from www.health.gov.za .
Step 7: The Guidelines in Steps 4 to 6 can be used to compile the SOP.
Step 8: Schedule training for all staff on the infection control standard precautions, see
Annexure 36. Repeat training every two years to ensure that staff is kept up to
date. Keep attendance registers of the training conducted. See Annexure 10.
Step 9: Ensure that the poster on hand washing is displayed above the hand basin in
every consulting room, see Annexure 37 as an example. These posters
should be laminated to avoid damage by water. In facilities where alcohol
hand rub is used, the poster to use alcohol hand rub must also be displayed
on the notice board (or wall where there is no notice board) in every consulting
room. See Annexure 38 as an example. A copy of the posters can be obtained
from www.health,gov.za.
Step 10: Plan and host an annual awareness day on hand hygiene to raise awareness
with staff and patients. The awareness day can coincide with the Open day of
the facility. The World Health organization’s drives an annual hand wash
campaign. Each year the SAVE LIVES: Clean Your Hands campaign of the
WHO selects a specific topic for the year. Facilities can access the WHO’s
website (http://www.who.int/infection-prevention/campaigns/clean-hands/en/)
to assist them in the planning of the awareness day as they publish
promotional material every year in the form of pamphlets, posters and videos.
Activities can include but are not limited to:
• Signing up the facility in support of world hand hygiene on the WHO’s
website at http://www.who.int/gpsc/5may/register/en/
• Displaying posters on the annual theme in the facility
• Show health promotion videos on hand hygiene to staff and patients
• Host short information sessions for staff and patients on the importance of
hand hygiene, method and opportunities for hand washing (5 moments for

hand hygiene, see annexure 39). Keep attendance registers of staff and
patients that attended the sessions.
Step 11: Ensure that the poster on cough etiquette is displayed in every waiting area.
See Annexure 40 as an example. A copy of the poster can be obtained from
www.health,gov.za.
Step 12: Conduct spot checks to determine if staff are complying with personal
protective clothing requirements. See Annexure 41.

70 The linen in use is clean
71 The linen is appropriately used for its intended purpose
Process
Step 1: Orientate all staff on the appropriate use of all linen to ensure that linen is
used for its intended purpose at all times. Obtain the National Cleanliness
Guideline from www.health.gov.za that has a chapter on the management of
linen.
Step 2: Determine the stock levels required by a facility and comply with it.
Step 3: In large facilities dedicate a well ventilated room solely for storage of clean
linen. In small facilities store linen on a clean and neat rack in store with other
supplies and consumables or in a separate lockable cupboard.
Step 4: Keep linen store locked.
Step 5: Order linen as soon as the stock reaches a minimum level.

72 Waste is properly segregated
73 Sharps are disposed of in impenetrable, tamperproof containers
74 Sharps containers are disposed of when they reach the limit mark
75 Sharps containers are placed on work surface or in wall mounted brackets
Process
Step 1: Train all staff including cleaning staff on the infection control standard
precautions that included waste management (refer to SOP of element 65).
Step 2: Place waste segregation poster in a prominent position at all waste

generation points. See Annexure 42.
Step 3: Ensure that there is enough stock of impenetrable, tamperproof containers to

dispose of sharps.
Step 4: Ensure that all sharps containers are placed on work surfaces or placed in a
wall mounted bracket while still in use.
Step 5: Store all sealed containers for sharps that had reached the limit mark in the
designated area for storing healthcare waste.
Step 6: Designate specific waste storage areas that caters for the different types of
waste without cross contamination. These areas must be lockable.
Step 7: Conduct regular spot checks at the facility’s waste generation and waste
storage areas to determine that correct waste handling and segregation is
taking place.

Risks are identified and attended to that can compromise infection control compliance
76 An annual risk assessment for infection prevention and control compliance is

undertaken by the staff member assigned to infection prevention and control
Process
Step 1: Conduct an annual risk assessment for infection prevention and control
compliance. Obtain the risk assessment tool from www.health.gov.za. Risk
assessment can also be conducted by the provincial or district office.
Step 2: Analyse the results of the risk assessment.
Step 3: Add to the facility’s quality improvement plan areas identified for improvement.
Step 4: Provide feedback to relevant staff members.
Step 5: Implement improvements as per agreed time frame on the quality

improvement plan.
Step 6: Keep records of the collated summary of the results of the risk assessment.
Step 7: Discuss the facility’s results for the risk assessment for infection prevention
and control on one of the sub-district/district quarterly facility performance
review meetings.

11. Patient waiting time
Patients are offered treatment in the quickest possible time.
77 National Policy for the Management of Waiting Times is available
78 National target of not more the three hours for time spent in a facility is visible
displayed
79 Waiting time is monitored using the prescribed tool
80 Average time that a patient spends in the facility is no longer than 3 hours
81 Patients are intermittently informed of delays and reasons for delays in service
provision
Process
Step 1: Obtain the national policy on waiting time from www.health.gov.za.
Step 2: Visibly display the national target of not more than three hours for time spend
in a facility at the reception and waiting areas of the facility.
Step 3: Patients should be informed intermittently of any delays daily and mitigating
measures that are being instituted.
Step 4: Waiting time must be monitored quarterly. Select a day in the month of the
quarter in which the waiting time will be monitored (pre-determined for specific
clinic) e.g. 2nd Monday of the month. (Do not select the least busy day of a
week!).
Step 5: Select the first 100 patients attending the facility, irrespective of diagnosis, on
the day that the quarterly waiting time survey will be conducted. In small
facilities (headcount of less than 170 patients per day) survey 50 patients.
Step 6: Place the Waiting Time Survey Tool, see Annexure 43, in the records of those
patients that were selected and record the times as set out in the Waiting Time
Monitoring Tool for each of the patients selected.

Step 7: Analyse the waiting time data in Annexure 44 - Waiting Time Calculation Tool.
Step 8: Compare the waiting time for each quarter with the previous quarter to
establish trends and need for improvement.
Step 9: If the facility’s average time spend in the facility exceeds three hours, establish
which service areas are causing the bottle-neck.
Step 10: Address deficiencies in bottle-neck areas.
Note to reviewers:
For element 81:
• Ask patients in the facility whether they have been informed of any delays and
mitigating measures that are being instituted if there are delays.
• If on the day of review there is no delays, the facility can score “green” OR
alternatively seek chronic patients and ask them whether they are informed of delays
if there were delays.

12. Patient Experience of Care
All patients are afforded the opportunity to voice their experience of care to guide service
delivery improvement.
82 National Patient Experience of Care Guideline is available
83 Results of the yearly Patient Experience of Care Survey are visibly displayed at
reception
84 An average overall score of 70% is obtained in the Patient Experience of Care

Survey
85 The results obtained from the Patient Experience of Care Survey are used to
improve the quality of service provision
Process
Step 1: Obtain the National Patient Experience of Care (PEC) Guideline from
www.health.gov.za.
Step 2: Conduct the survey as stipulated in the National PEC Guideline.
Step 3: Publish and display the results of the survey at the reception area. See
Annexure 45.
Step 4: Develop the operational plan to respond to the results of the survey.
Step 5: Sign and date the commitment. See Annexure 46.
Step 6: Implement the plan.

Commitment for Ideal Clinic elements 86 and 89
Ensure that patient’s complaints/compliments/suggestions are attended to within the

prescribed time frame.
86 The National Guideline to Manage Complaints/Compliments/Suggestions is

available
87 The complaints/compliments/suggestions records compliance with the
National Guideline to Manage Complaints/Compliments/Suggestions
88 90% of complaints received are resolved
89 90% of complaints received are resolved within 25 working days
Process
Step 1: Obtain the national policy to manage complaints, compliments and

suggestions from www.health.gov.za.
Step 2: Develop a facility/district specific Standard Operating Procedure (SOP) using
the National Guideline for Developing a Facility Specific SOP to Manage
Complaints, Compliments and Suggestions.
Step 3: Assign a staff member to ensure compliance with the facility’s SOP to manage
complaints, compliments and suggestions.
Step 4: Follow the procedure to manage complaints/compliments/suggestions
whenever complaints/compliments/suggestions are received.
Step 5: Keep the following records as stipulated in the National Policy up to date:
• letters of complaint
• redress letters and/or minutes of redress meeting
• complaints, compliment and suggestion registers. See Annexure 47.
• monthly statistics on complaints, compliments and suggestions. See
Annexure 48
o data on classifications of complaints
o indicators for complaints.
Step 6: Identify trends in system failures making use on statistical data on categories
of complaints. Add to the facility’s quality improvement plans areas where
gaps have been identified.
Step 7: Do quarterly checks to verify that the facility comply with the policy. See
Annexure 49.
Note to reviewers:
The forms for statistical data as well as registers do not need to be exactly in the same
format/layout as set out in the National Guideline. The contents must however provide the
data to enable the facility to report on the indicators and categories for complaints,
compliments and suggestions as set out in the National Guideline.

All patients will be afforded the opportunity to lodge a complaint, give a compliment or make
a suggestion at the facility.
90 Complaints/compliments/suggestions boxes are visibly placed at main

entrance/exit
91 Official complaint/compliment/suggestion forms and pen are available
92 A standardised poster describing the process to follow to lodge a complaint,

give a compliment or make a suggestion is visibly displayed next to the
complaints/compliments/suggestions box, in at least two local languages
Process
Step 1: Familiarise yourself with specifications for the complaints, compliment and
suggestion box. See Annexure 50 for an example of the specifications.
Step 2: Order the box if there is not one available.
Step 3: Identify a visible and accessible location at the entrance and or exit of the
facility for placement of the box. Install the box at the identified location.
Step 4: A pen and sufficient copies of the complaints, compliments and suggestions
forms must be available from the person managing complaints, compliments
and suggestions or next to the box. See Annexure 51.
Step 5: Obtain the national poster, See Annexure 52 that describes the process to
follow when a patient wants to lodge a complaint, give a compliment or make
a suggestion from www.health.gov.za.
Step 6: Visibly display the poster in at least two local languages at the main
entrance/exit of the facility next to the complaints/compliments/suggestion box.
Note to reviewers:
If the forms and pen are not placed next to the box, a clear notice must be placed on or next
to the box that directs patients and family/support persons to the helpdesk/reception to ask
for a pen and or forms.

COMPONENT 3: MEDICINES, SUPPLIES AND LABORATORY SERVICES
13: Medicines and supplies
Good Pharmacy Practice principles are followed for the management and administration of
medicine
93 Standard Operating Procedure for the management and safe administration of

medicines is available
Process
Step 1: Ensure that the facility has a SOP for the management and safe
administration of medicines.
Step 2: Staff to sign acknowledgment indicating that they are aware and know the
content of the SOP and its application. See Annexure 53.
Step 3: Staff must at all times follow the procedures as set out in the SOP when
managing and administering medicines.
Note to reviewers:
The SOP for the management and safe administration of medicines can be a SOP
developed by the facility or the district or the province. It is also acceptable if the facility has
separate SOPs dealing with the management of medicine and the administration of
medicine to patients.

CCommitment for Ideal Clinic element 94-97
Ensure quality of medicine in the medicine room is maintained through appropriate storage
and temperature control.
94 Medicine room/dispensary is neat and medicines are stored to maintain quality
95 There is at least one functional wall mounted room thermometer in the

medicine room/dispensary
96 The temperature of the medicine room/dispensary is recorded daily
97 The temperature of the medicine room/dispensary is maintained within the

safety range
Definition of terms used in this section:
Dispensary is a room in a clinic where medicines are stored and prescriptions are
dispensed for patients attending the facility. In clinics where there is no dispensary,
dispensing is done in the consulting room/s.
Medicine room is a room in a clinic where medicines are stored but no dispensing takes
place.
Process
Step 1: Medicines in the medicine room must be organised according to the system as
stipulated in the facility/district/provincial SOP for the management and safe
administration of medicines. See Annexure 54 as an example of how
medicines can be organised in a medicine room.
Step 2: Ensure that the medicine room/dispensary is neat and medicines are stored to
maintain quality and availability at all times, see Annexure 55.
Step 3: Check availability and functioning of air conditioner in the medicine

room/dispensary. If there is no air conditioner in medicine room/ dispensary, or
the air conditioner is not in good working order, place an urgent

procurement/works order for procurement/repair using the applicable
procurement procedure.
Step 4: Mount the room thermometer on the wall in the medicine room/dispensary
away from the direct flow of air from the air conditioner.
Step 5: Ensure availability of monthly temperature record charts to record the

temperature of the medicine room, see Annexure 56.
Step 6: Allocate a staff member to record temperatures for the room daily using the
temperature record charts.
Step 7: Maintain a file with all the completed monthly room temperature charts.
Step 8: Review the room temperature record chart weekly to ensure the temperature
range for the medicine room/dispensary is within the safety range (below
25ºC) at all times.
Step 9: If the air conditioner is not working use a fan to keep the room cool.
Note to reviewers:
• For element 94, for the measure “There is sufficient space in the dispensary/medicine
room to store medicines needed in the facility”:
The criteria used to gauge whether there is sufficient space in the dispensary/medicine
room to store medicines are that -
• all medicines are stored in the medicine room and/or dispensary and not in
sub-stores, passages or other areas in the facility; and
• there is no medicine stored on the floor in the medicine room or dispensary
• For element 97: When conducting a status determination, check records for temperature
control charts for the previous month.

Ensure quality of medicine in the vaccine/medicine refrigerator is maintained through

appropriate storage and temperature control.
98 Cold chain procedure for vaccines is maintained
Process
Step 1: Check availability and functioning of vaccine/medicine refrigerator for the

storage of thermolabile medicines. If there is no vaccine/medicine refrigerator
in medicine room/dispensary, or the vaccine/medicine refrigerator is not in
good working order, place an urgent procurement/works order for
procurement/repair using the applicable procurement procedure.
Step 2: For a medicine refrigerator, without a built-in temperature monitor and alarm
system hang/place the refrigerator thermometer in the center of the fridge.
Step 3: Check that the fridge is not over full and that medicines and vaccines are
packed appropriately in the refrigerator with enough space for air to circulate
between containers, and that no stock is touching the back of the refrigerator/
condenser which could expose it to freezing.
Step 4: Ensure availability of monthly temperature record charts to record the

vaccine/medicine refrigerator temperatures, see Annexure 57.
Step 5: Allocate a staff member to record temperatures for the vaccine/medicine

refrigerator twice daily (at least seven hours apart) using the temperature
record charts. In clinics which are not open every day of the week and do not
have a monitoring device with an SMS alarm for out of range temperatures,
check on temperature on departure and on arrival at the clinic.
Step 6: Check that there are no non-medicine items (such as food) kept in the
refrigerator.
Step 7: Maintain a file with all the completed refrigerator temperature charts.

Step 8: Review the refrigerator temperature record chart daily to ensure the
temperature range for the refrigerator is within the safety range (between 2 -
8ºC) at all times.
Step 9: Check that any out-of-range temperature recordings were immediately

reported, have a dated signed-off record of corrective actions taken and that
temperatures have remained within range thereafter. Temperatures below 0ºC
may cause freezing and must also be corrected as this is critical to the viability
of many vaccines.
Step 10: If refrigerator is not working follow contingency plan to ensure quality of
medicines.
Step 11: Check availability of cooler box/es with suitable capacity, and ice packs for
use in consultation rooms and in the case of emergencies.
Step 12: The cold chain for vaccines must be maintained at all times, see Annexure 58.
Note to reviewers:
When conducting a status determination, check records for temperature control charts for
the previous month. If out of range temperatures were recorded during the previous month,
confirm that corrective actions were taken and recorded.

Ensure quality of medicine in the medicine cupboard or trolley is maintained through

appropriate storage and temperature control.
99 Medicine cupboard or trolley is neat and orderly
Process
Step 1: Ensure that the medicine in the medicine cupboard or trolley is neat and
orderly
Step 2: Ensure that medicine cupboard or trolley is locked when not in use
Step 3: Check daily that the medicine cupboard or trolley in the consultation room/s
are neat and orderly. Use Annexure 59.
C
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Ensure quality of medicine is maintained through appropriate storage and temperature

control.
100 The register for schedule 5 and 6 medicine is completed correctly
Process
Step 1: Check that there is a SOP for the handling of schedule 5 and 6 medicines.
Step 2 Ensure that schedule 5 and 6 medicines are stored in a lockable cupboard
and access to the keys is restricted.
Step 3 Check that there is a register to record the receipt and issuing of schedule 5
and 6 medicines (separate registers for schedule 5 and 6 medicines may be
kept).
Step 4 Verify that all receipts of schedule 5 and 6 medicines are checked against
invoices and entered in the register in accordance with the SOP.
Step 5 Record all issues of schedule 5 and 6 medicines to outpatients in the register
in accordance with the SOP.
Step 6 Record the administration of schedule 5 and 6 medicines to patients in the

facility in the register in accordance with the SOP. See Annexure 60 as an
example of a register to record schedule 5 and 6 medicines.
Step 7 Check balances in the register weekly against physical stock.
Note to reviewers:
Verify that the receipt, issuing and administration of schedule 5 and 6 medicines are
recorded in the register according to the guidelines as set out in the facility’s SOP.

Ensure consistent availability of essential PHC medicines.
101 Electronic networked system for monitoring the availability of medicines is

used effectively
Process
Step 1: Apply to the district pharmacist for the installation of an electronic networked
system for monitoring the availability of medicines
Step 2: Ensure that the SOP/Guideline for monitoring the availability of medicines is
available.
Step 3: Staff responsible for managing the electronic networked system to sign
acknowledgment indicating that they are aware and know the content of the
SOP/Guideline and its application. See Annexure 53.
Step 4: Verify that the principles for managing and using the electronic networked
system for monitoring the availability of medicines are adhered to, see
Annexure 61.

Ensure consistent availability of essential PHC medicines.
102 90% of the tracer medicine list are available
103 Re-ordering stock levels (min/max) are determined for each item on the
district/facility formulary
Definitions of terms used in this section:
Formulary
A formulary is a list of medicines extracted from the PHC Standard Treatment Guidelines
and Essential Medicine List (PHC STGs/EML) approved for use by the Provincial/District
Pharmaceutical and Therapeutics Committee (PTC) for a specific province/ district, category
of facilities or even a single facility.
Essential medicine list

The South African PHC STGs/EML, see Annexure 62, provides a list of medicines, together
with guidelines to support guiding rational medicine use. It provides a foundation for
supporting preventative and curative healthcare services at primary healthcare level.
Essential medicines are those that satisfy the priority healthcare needs of a population.
They are selected with respect to disease prevalence and public health importance, with
selection decisions made through the review of clinical evidence considering efficacy,
safety, quality and comparative cost-effectiveness
Tracer medicines list

A tracer medicine list is a list of medicines which is extracted from the PHC STGs/EML,
taking into account the most common morbidities and health needs within a particular
setting. The list is used as a monitoring tool within PHC facilities as a proxy for measuring
the availability of a basket of essential medicines within a particular setting. An electronic
networked system can be used to monitor the availability of tracer medicines

Process
Step 1: The facility manager or nurse designated to manage medicine in the facility
must:
• ensure that all medicines on the formulary (extracted from the PHC
STGs/EDL) applicable to the facility are available;
• ensure all tracer medicines are monitored weekly, see Annexure 63;
• check the medicine room/dispensary, and medicine trolleys/cupboards
to ensure stock is stored according to best practice following First
Expired First Out (FEFO) stock rotation principles.
Step 2: Determine reorder levels for stock items as per SOP.
Step 3: Check stock in the medicine room and/or dispensary weekly to ensure stock
levels are maintained within the minimum/maximum range for replenishment.
Step 4: For facilities with an electronic networked system for monitoring availability of
medicine, report stock levels as per the approved schedule and standard
operating procedure.
Step 5: Place a replenishment order to maintain medicine stock levels using the
applicable SOP.
Step 6: If an order is not received in full or in accordance with the pre-determined

schedule, follow up in writing and telephonically immediately with the
supervising pharmacist and/or supplier of stock (depot, sub-depot or hospital).
Step 7: Follow local procedures if the stock is not delivered within seven days.
Note to reviewers:
For provinces that use the stock visibility system (SVS): When conducting a status
determination the results for elements 102 must be obtained from the web-based SVS
application. Obtain the standard operating procedure for Facility Tracer Medicine Availability
from www.health.gov.za that provides guidance on how to obtain the reports from the
application.

Ensure that expired medicines are removed from the facility and disposed of safely,
minimising the risk of harm to the environment and people.
104 Expired medicine is disposed of according to prescribed procedures
Process
Step 1: Check the medicine room/dispensary, and medicine trolleys/cupboards to

ensure that expired stock is removed.
Step 2: Return medicines that will expire within three months or are unlikely to be
used before expiry to the immediate supplier of stock or make arrangements
for stock to be rotated to other facilities that could use the medicines before
expiry.
Step 3: Record details of medicine that have expired before they are sent for
destruction. See national guideline for destruction and disposal of medicines
and scheduled substances for the forms to be completed.
Step 4: Maintain all records in a file.
Step 5: After recording expired stock seal the expired medicine securely in an
appropriate container as per SOP and include a copy of the record.
Step 6: Store all expired stock items separately from usable stock in accordance with
the applicable SOP.
Step 7: It is the responsibility of the pharmacist’s assistant or professional nurse

designated to manage medicine in the facility to ensure that expired medicine
is removed from the facility.
Step 8: The supervising pharmacist must ensure that the expired medicine is
destroyed and disposed of in accordance with applicable legislation and
supply chain procedures. See national guideline for destruction and disposal
of medicines and scheduled substances available at www.health.gov.za.
Note to reviewers:
When conducting a status determination, ask the facility manager or nurse designated to
manage medicine to explain the process to be followed at facility level for disposal of
expired medicines. The element is scored green if he/she explains the process correctly.

Manage minor injuries at Primary Health Care facilities.
105 Basic medical supplies (consumables) are available
Process
Step 1: Determine re-order levels for each item on the list for basic surgical supplies.
Verify that all medical supplies are available, see Annexure 64.
Step 2: Monitor stock of basic surgical supplies weekly.
Step 3: Place a replenishment order to maintain the minimum/maximum surgical

supply levels using the prescribed procurement procedure.
Step 4: If order was not received on schedule follow up immediately with district
pharmacy.

14. Management of Laboratory Services
Commitment for Ideal Clinic element 106 – 110
The facility uses laboratory technology to ensure that patients’ health conditions are
managed appropriately.
106 Primary Health Care Laboratory Handbook is available
107 Required functional diagnostic equipment and concurrent consumables for

point of care testing are available
108 Required specimen collection materials and stationery are available
109 Specimens are collected, packaged, stored and prepared for transportation
according to the Primary Health Care Laboratory Handbook
110 Laboratory results are received from the laboratory within the specified
turnaround times
Process
Step 1: Obtain the Primary Health Care Laboratory Handbook from
www.health.gov.za.
Step 2: Where there is no electronic access, obtain hard copies from the sub-district
or district manager.
Step 3: Ensure that all required functional diagnostic equipment and concurrent
consumables for point of care testing are available. See Annexure 65.
Step 4: Ensure that required specimen collection materials and stationery are
available. See Annexure 66.
Step 4: Induct all new staff on the NHLS process on handling specimens correctly as
outlined in the manual. Conduct spot checks to make sure the process is
being followed correctly. See Annexure 67.
Step 5: Using the manual or electronic tracking form check if patient laboratory results
have been received within the specified time frame. See Annexure 68.
Step 6: If the results have not been received within the specified turnaround times,
follow up with the laboratory.
Step 7: File all abnormal results appropriately in patient record within 24 hours of
receipt, all other results to be filed within 5 working days.

COMPONENT 4: HUMAN RESOURCES FOR HEALTH
15: Staff allocation and use
The facility has adequate number of staff in place with the correct skills mix for the services
provided.
111 Staffing needs have been determined in line with WISN
112 Staffing is in line with WISN
113 The facility has a dedicated manager
Process
Step 1: Contact the sub-district/district to arrange a date for the human resource staff
to conduct the WISN assessment.
Step 2: Prepare all the information on the staff and clinic services that will be needed
during WISN assessment. The Implementation Guideline of Health Workforce
Normative Guides and Standards for fixed PHC facilities will give guidance in
this regard and can be obtained from www.health.gov.za.
Step 3: Inform your staff of the planned date, provide necessary information and
orientate them on the expected procedure for that day.
Step 4: If the report has not been received after one week of completion of the WISN
assessment, follow up with the sub-district/district manager.
Step 5: After receiving the report, develop the Ideal Organogram for your facility using
the WISN assessment findings.
Step 6: Obtain approval of the Ideal Organogram from the district manager.
Step 7: Should there be surplus staff in your facility, plan with district manager for
redeployment.

Step 8: Should there be a need for additional staff, write a request to the district
manager for the posts to be created, funded and filled.
Step 9: Participate in the recruitment and selection process as required.
Step 10: District manager to appoint a facility manager for facilities that have a
headcount of more than 170 patients per day. In facilities that have a
headcount of less than 170, a staff member must be dedicated as the facility
manager. The suggested split between management and clinical functions
should be 60% management and 40% clinical (rural) and 80% management
and 20% clinical for facilities with a workload of more than 170 patients.
Content of the job description and performance agreement must be in line with
the approximately 60/80 per cent management and 40/20 per cent clinical
work principle.
Note to reviewers:
If the facility manager’s post is vacant for less than three months and the facility has a
formal letter from the sub-district/district that designate a staff member as the acting
manager, the facility can score green.

Staff members are aware of work allocations and perform as scheduled.
114 Work allocation schedule is signed by all staff members
Process
Step 1: Complete the work allocation schedule daily, weekly or monthly as appropriate
for your clinic. See Annexure 69.
Step 2: Each staff member must sign the schedule confirming that they are aware of
their duty allocation.
Step 3: Place the schedule on the staff notice board for easy access to all staff
members.

Commitment for Ideal Clinic element 115- 116
All staff understands the leave policy and a leave schedule have been developed to suit
service needs. Every staff member has an individual staff file that contains up to date staff
records.
115 Leave policy is available
116 An annual leave schedule is available
Process
Step 1: Obtain the public service leave policy from the district office.
Step 2: Share the contents of the public service leave policy with all staff members
• Explain the policy contents clearly to the staff so that they understand the
leave process, emphasising the need for approval prior to going on
leave, unless in an emergency situation.
• Staff to sign acknowledgment indicating that they are aware of the policy
and its application. See Annexure 53.
Step 3: Draw up an annual leave schedule for all staff members taking into account
the service needs of the facility. See Annexure 70.
Step 4: Print and place the annual leave schedule on staff notice board.

16: Professional Standards and Performance Management Development(PMDS)
Staff is inducted to make them feel welcome, that they understands core information about
their job and help them to settle into their new job and work environment.
117 Record of staff induction is available
Process
Step 1: Schedule induction training for all newly appointed staff. Staff should receive
induction training within the first three months of being appointment.
Step 2: Training must cover at a minimum the following:
• Vision and mission of the district

• Batho Pele Principles
• Operational policies and procedures
• Health and Safety of patients and staff (non clinical risk)
• Quality improvement methodology
• Infection Prevention and Control
• Patient safety (clinical risk)
Step 3: Keep attendance registers of the training conducted. See Annexure 10 as an

example
Note to reviewers:
Obtain the list with the facility’s staff establishment. Verify which staff members have been
appointed in the past 12 months. Check on the training register whether these staff
members have received induction training.

Entrench goal oriented performance by staff members through appropriate performance

agreements and reviews.
118 There is an individual Performance Management Agreement for each staff

member
Process
Step 1: Obtain the PMDS policy from the district.
Step 2: Explain the content of the PMDS policy clearly to all staff members.
Step 3: Ensure that each staff member has an approved and signed job description
available.
Step 4: Use the prescribed PMDS templates to develop an individual Performance
Management Agreement (PMA).
• ensure that the performance goals of the facility are reflected within the key
result areas of individual staff members’ PMAs
• PMA to be signed by the individual staff member and the facility manager
after discussion and agreement
• submit signed original copies to district office by 15 April of the relevant
financial year.
Step 5: Performance appraisal to be conducted quarterly using the PMDS evaluation
templates. Evaluation templates available on the DPSA website. Note: Even if
personnel records are kept at a central location, copies of staff PMAs and
performance review documents must be available at the facility. Good practice
prescribes that individual staff members and the facility manager refers to
these documents regularly to track performance and staff development needs.

Create an environment that supports the professional development of staff to ensure the
delivery of quality health services.
119 Continued staff development needs are determined for the current financial
year and submitted to the district manager
120 Training records reflect planned training is conducted as per the district
training programme
Process
Step 1: Develop a staff development and training plan based on the facility’s service
needs. This must be done in time to include training costs in the budget of the
financial year.
Step 2: Submit to district manager by 15 April of the relevant financial year.
Step 3: Staff members should be released for the identified training taking into
consideration the facility’s staffing and service needs.
Step 4: Record all training in a register. See Annexure 10 as an example.

Commitment for ideal Clinic elements 121 - 122
Staff is disciplined and committed to providing quality health services.
121 The disciplinary procedure is available

122 The grievance procedure is available
Process
Step 1: Obtain the public service disciplinary and grievance procedures from the
district office.
Step 2: Explain the contents of the disciplinary and the grievance procedures to all staff
members.
Step 3: All staff must sign acknowledgement that they have been informed of both
procedures and understand it. See Annexure 53.

Commitment for Ideal Clinic elements 123- 124
Staff work in a positive work environment.
123 Staff satisfaction survey is conducted annually
124 The results of the staff satisfaction survey are used to improve the work
environment
Process
Step 1: In cooperation with the sub district/district human resource management unit,
conduct the yearly staff satisfaction survey. As an example see Annexure 71.
Step 2: Sub district/district human resource unit must analyse the results and present
to sub district/district Health Management Team (DHMT) with
recommendations for improvement.
Step 3: Using recommendations from step 2, develop an action plan to address

relevant weaknesses highlighted in the staff satisfaction survey report.
Step 4: Implement action plans in cooperation with sub-district/district.
Step 5: Staff satisfaction survey report and action plan must be available for
inspection.

Occupational Health and Safety hazards are attended to.
125 Occupational Health and Safety incidents are managed and recorded in a
register
Process
Step 1: All occupational health and safety incidents must be reported by completing
the WCL1 or WCL 2 forms for all staff that was involved in an occupational
health and safety incident.
Step 2: Submit the forms to the sub-district/district office.
Step 3: Record all the occupational health and safety incidents in a register. See
Annexure 72 as an example.
Step 4: The actions taken to manage the incident must be recorded in the register.
Step 5: Annually analyse the register to establish trends.
Step 6: Where trends have been identified, add activities to the quality improvement
plan to prevent incidents from reoccurring.
Note to reviewers:
An occupational health and safety incident is any injury that staff has sustained while being
on duty. In cases where there is not clarity on whether the injury will qualify as an
occupational health and safety incident, the incident must still be reported. The determining
body will evaluate the case and make a finding.

COMPONENT 5: SUPPORT SERVICES
17. Finance and supply chain management
Ensure the availability of key resources at all times through the application of good financial
management
126 Facility has a dedicated budget
Process
Step 1: Sub district/district finance manager to set up the facility as a cost centre.
Step 2: Ensure that facility managers are part of the discussion at sub district/district
level that will result in the facility’s budget allocation.
Step 3: Allocate financial resources in line with the facility needs.
Step 4: Develop control measures for rational budget utilisation and expenditure.
Step 5: Using the monthly expenditure report as received from sub-district/district,

compare the report to the monthly commitment register you have in your
records for the relevant month. See Annexure 73.
Step 6: Participate in the quarterly sub-district/district expenditure review meetings.
Step 7: Query any differences/discrepancies in expenditure balances with the sub-

district/district and make relevant submission for correction of the
discrepancies. After the corrections have been authorised, reallocate the
funds according to budget pressures.

Ensure adequate replenishment of supplies through a supply chain management system.

Suppliers will be monitored through Service Level Agreements (SLAs) to ensure
compliance.
127 Facility has a standard operating procedure for obtaining general supplies
Process
Step 1: Ensure that the facility has a standard operating procedure for procuring
general supplies.
Step 2: Set a minimum and maximum value for each item procured based on the
facility’s use.
Formula to calculate minimum and maximum levels
Formula Min level = Lead Time (time it takes from the moment the item is
ordered until it is received and ready to be used) + Safety Stock (amount of
stock to hold because of something that could occur to delay the lead time)
If the process is working smoothly, you will receive the item you ordered right
as you get into the safety stock.
Formula Max level = Min + (Min/2)
Example:
Min = 30 days lead time + 15 days of safety stock = 45 days
Max = 45 + (45/2) = 67.5 round up to 68 days
The only other number that is needed is the quantity of the item that is used
per day. This is used to translate the number of days to a quantity of the item.
For example 50 surgical gloves are used daily
Min stock level = 45 days x 50 gloves = 2 250 gloves
Max stock level = 68 days x 50 gloves = 3 400 gloves
* the formulas can be adjusted to suite the circumstances in the facility to
ensure that stock do not run out.
Step 3: Replenish item once the minimum level of an item has been reached.
Step 4: Obtain a copy of the relevant item contracts and use the terms and conditions
of the contract to ensure acceptable turn-around times and to apply penalties
where necessary.
Step 5: Keep all source documents safely.

18: Hygiene and cleanliness
The entire facility is clean at all times.
128 All cleaners have been trained on cleaning
129 Cleaning schedules are available for all areas in the facility
130 All work completed is signed off by cleaners and verified by manager or
delegated staff member
131 Disinfectant, cleaning materials and equipment are available
132 All service areas are clean
Process
Step 1: Ensure that cleaners have been appropriately trained and are fully aware of
their duties.
• if you have contract cleaners, meet with the contractor and ensure
that the cleaners in your facility have been trained and have a clear
understanding of their duties.
Step 2: Identify, schedule and record additional training needs of cleaners.
Step 3: Maintain records of training of each cleaner. See Annexure 10 as an example
Step 4: Compile daily, weekly and monthly cleaning schedules for all areas in the
facility. File in cleanliness file. See Annexure 74 as an example.
Step 5: Obtain the National Ideal Clinic Health Commodities Specification Catalogue
that contains specifications for cleaning equipment from www.health.gov.za.
Verify that the facility has the prescribed list of non-negotiable disinfectant,
cleaning materials and equipment (Annexure 75) and ensure that facility has
disinfectant, cleaning materials and equipment (Annexure 76) at all times.
Step 6: Obtain material safety data sheets for all cleaning material used in the facility
from the sub-district/district office. The material safety data sheets must

comply with the Hazardous Chemical Substances Regulations, 1995, see
Annexure 77.
Step 7: Ensure that cleaning is in line with expected standards and that cleaners take
responsibility for their allocated areas through appropriate supervision and
sign-off on check lists for toilets. The manager or the professional health care
staff member delegated by the manager to supervise the cleanliness of areas
must also sign the checklist daily and indicate on the checklist whether he/she
is satisfied with the cleanliness of the areas. The checklist must be filed in the
cleanliness file and should be used to guide performance evaluation of
cleaners. See Annexure 78 as an example
• Conduct daily inspections of the service areas of the facility using

the Cleaning Inspection Checklist. See Annexure 79.
• If any areas are not clean, discuss with the relevant cleaner and get
them to clean again.
• Instruct cleaners to inform the facility manager immediately of any
repairs required.
Step 8: Instruct cleaners to close taps properly and switch off unnecessarily lights.

Staff and patients will be protected from communicable diseases through good hygiene
practices.
133 Clean running water, toilet paper, liquid hand wash soap and disposable hand
paper towels are available
Process
Step 1: District management to ensure that all clinics have running water
• if there is a break in the normal supply of clean running water, request

repairs using the local prescribed process.
Step 2: Conduct a weekly inspection of all consumables to ensure the correct quantity
is available. See Annexure 80.
Step 3: Ensure the availability of toilet paper, liquid hand wash soap and disposable
hand paper towels in the appropriate areas

Staff and patients will be protected from communicable diseases through good practice
disposal of general and health care risk waste.
134 Standard operating procedure for managing general and health care risk waste
is available
135 Sanitary and health care risk waste are managed appropriately
136 General waste is managed appropriately
Process
Step 1: Ensure that the facility has a SOP for managing general and health care risk
waste.
Step 2: Obtain checklist for the management of sanitary, healthcare and general
waste. See Annexure 81 and Annexure 82.
Step 3: Display on notice board in dirty utility room the instructions for the correct use
of coloured bin liners to be used for sanitary disposal and general waste
management.
• medical waste disposal bins//boxes must be lined with red plastic
• general bins and sanitary disposal bins/boxes must be lined with the
appropriate coloured bin liners
• all disposal bins/boxes must be clean and intact
• broken disposal bins/boxes must be replaced with new ones
Step 4: Place the sanitary, health care risk waste and general disposal bins in the
appropriate areas.
• disposal bins/boxed must never be more than three quarters full
• disposal bins/boxes must be emptied as needed.
Step 5: Conduct spot checks on the status of the sanitary and general disposal
bins/boxes to ensure compliance to the infection control measures. Non-
functional sanitary disposal bins and general waste bins (broken and/or
damaged) must be replaced by ordering new ones.
Step 6: Instruct the cleaners to inform the facility manager immediately if the bin liners
is getting close to the minimum level.
Step 7: Ensure that health care risk waste is stored in an access controlled area.
Note to reviewers:
The colour of the bin liners for general and sanitary bins is determined by the district
policy/guideline

Toilets are available and functional at all times to ensure staff and patient safety
137 All toilets are clean, intact and functional
Process
Step 1: Obtain checklist for functional toilet status.
Step 2: Conduct a spot check of the toilets in your facility to see that they are intact
and functional. See Annexure 83.
Step 3: If the toilets are not functional, put up a sign on the toilet door stating “Not
Working - Do Not Use”
Step 4: Ensure prompt repairs of broken toilets.

The facility environment must be aesthetically pleasing to contribute positively to the mental
health of patients and staff
138 Exterior of the facility is aesthetically pleasing and clean
Process
Step 1: Appoint the required number of groundsmen as per the approved organogram.
At facilities where groundsmen are shared with other facilities, ensure that a
schedule is drawn up that indicates the schedule of the groundsmen at the
different facilities.
Step 2: Ensure that groundsmen have been appropriately trained and are fully aware
of their duties. This includes orientation of new groundsmen.
• if you have contract groundsmen, meet with the contractor and

ensure that the groundsmen in your facility have been trained and
have a clear understanding of their duties.
Step 3: Maintain records of training of each groundsman. Annexure 10 as an example.
Step 4: Do spot checks of the exterior to check whether the facility is neat and clean.
See Annexure 84.
Step 5: Instruct groundsman to clean areas where weaknesses are identified.

Waste is stored and removed from the facility in line with acceptable standards to ensure
patient and staff safety
139 A signed waste removal service level agreement between the health
department and the service provider is available
140 Waste is removed in line with the contract
Process
Step 1: Obtain the SOP (hard or soft copy) for waste management. Annexure 85.
Step 2: Train all staff on the importance of waste handling, segregation and the
purpose of the colour categorisation.
Step 3: Maintain records of training of all staff. See Annexure 10 as an example.
Step 4: Place Waste Categorisation Schedule (Annexure 42) in the dirty utility room.
Step 5: Conduct spot checks at the facility waste generation points to determine that
correct waste handling and segregation is taking place.
Step 6: If the correct procedures for waste management are not adhered to, correct
weaknesses through instructions to relevant staff.
Step 7: Ensure that all waste are stored in an access controlled general and health
care risk waste storage areas
• if designated area is not available or conforming to required standard

(refer to checklist of element 135 and 136), place a works order.
Step 8: Obtain and keep a copy of the signed waste removal SLA from the sub-
district/district
Step 9: Read and understand the SLA so you are aware of the service delivery
requirements that the waste removal service provider must comply with.
Step 10: Monitor waste removal to ensure that the service provider complies with the
requirements of the SLA.
Step 11: Record each incident of non-compliance and escalate to the sub-
district/district office.

The facility is pests free to ensure that the environment is clean
141 Records show that pest control is done according to schedule
Process
Step 1: Compile a pest control schedule for the facility. The frequency will depend on
the current situation of the facility. If the facility is invested with pests, more
frequent pest control will be needed. The schedule can be changed from time
to time as the situation change in the facility. See Annexure 86 as an example.
Step 2: Monitor that pest control is conducted according to the set schedule. The
manager must sign the schedule once the pest control has been conducted.
Note to reviewers:
Pest control should be conducted by the district office or through an appointed company. In
rural areas and facilities where pests are not a big problem spraying with a high
performance residual insecticide spray is acceptable (example Fendona).

19: Security
Patient and staff safety is assured at all time.
142 Safety and security standard operating procedure is available
143 Perimeter fencing is intact
144 Parking for staff on the facility premises
145 There is a standard security guard room OR the facility has an alarm system
linked to armed response
146 There is a security guard on duty OR the facility has an alarm system linked to
armed response
Process
Step 1: Ensure that the facility has a safety and security SOP. The SOP must cover at
a minimum the following:
• High risk areas and the specific security needs for these areas
• Access control within the facility
• Reporting of security incidents (see register for security breaches)
• Training of personnel on the management of alarms (where applicable),
provision of guarding services and patrolling
• Equipment for personnel
• Maintenance and replacement of security equipment.
Step 2: Conduct a monthly walk about to ensure that perimeter fencing is intact, gates
are functioning and the guard room is neat and tidy.
Step 3: If the clinic does not have parking for staff this must be requisitioned through
the district/provincial infrastructure unit.

Step 4: The guard room must conform to the standards (see Annexure 87) or have an
alarm system that is linked to armed response. Facilities that have an alarm
system that is linked to armed response must ensure that the alarm is
serviced as prescribed by the company that has installed the alarm.
Step 5: Inform the district/provincial infrastructure unit in writing of identified

weaknesses in regard to fencing, parking and guard room.
Step 6: Keep a copy of correspondence with district infrastructure in this regard.
Step 7: Ensure that there is a duty roster for security officers where there is not an
alarm system that is linked to armed response.
Note to reviewers:
• Facilities with the structural make-up that render perimeter fencing and separate guard
house impossible/unnecessary e.g. in a multi story building in a city will score green on
element 143 and 145 even if they do not have a perimeter fence or a guard house.
• The parking area for staff can be outside the perimeter of the facility (example in a
building, area next to the facility). This parking area must however be within 500m
walking distance and the parking area must have specific allocated space for staff
working at the facility. Parking in the street is not acceptable as it is not allocated to staff.

Optimal security services are delivered at the facility to ensure safety and security of
patients and staff.
147 A signed copy of the service level agreement between the security company
and the provincial department of health is available
Process
Step 1: Obtain and keep a copy of the signed security SLA from the sub-district/district
Step 2: Read and understand the SLA so that you are aware of the service delivery
requirements that the security service provider must comply with. Ensure that
these services include the control of prohibited items.
Step 3: Orientate your staff on the terms of the SLA
Step 4: Monitor if security services complies with the requirements of the SLA.
Step 5: If weaknesses are identified discuss with the security officers working at your
facility to take corrective action.
Step 6: If weaknesses persist call a meeting with the management of the security
service provider. Keep records of these meetings.
Step 7: Escalate repeated incidents of non-compliance to the district office.
Note to reviewers:
In facilities where provincial/district/in house staff performs the security duties, the content of
the job description of the appointed staff must be reviewed. Check whether the job
description addresses the facility’s need in regard to security issues.

The safety of staff and patients are protected by managing security breaches appropriately.
148 Security breaches are managed and recorded in a register
Process
Step 1: Record all security breaches in a register or the security incident book. See
Annexure 88 as an example of a register.
Step 2: Record how the breach was managed and what measures were taken to
prevent the reoccurrence of the breach.
Step 3: Once the investigation of the breach has been finalised the security staff must
sign off in the register.
Note to reviewers:
Where no security breaches occurred in a month, a “Null” record must be entered in the
register and the register for that month must also be signed off.

20: Outbreak and Disaster preparedness
Patients and staff are protected against the risk of injury due to fire.
149 Functional firefighting equipment is available
Process
Step 1: Ensure that functional firefighting equipment (Annexure 89) that should be in
your facility is available.
Step 2: The district manager must ensure that there is a service level agreement with
a competent service provider for servicing the facility’s firefighting equipment.
Step 3: Conduct monthly inspections to ensure that equipment is present and intact.
Step 4: The service provider must service firefighting equipment at least yearly.
Step 5: A record must be kept of the services conducted. See Annexure 90 as an

example. The facility manager must remind the service provider in good time
of the next scheduled service date.
Step 6: If an item(s) of firefighting equipment has been used, immediately contact the
service provider to restore functionality for future use.
Step 7: Escalate to sub-district/district manager in writing if corrective action is not

timeously taken.

Commitment for Ideal Clinic element 150 -151
The clinic is at ready for emergency evacuation all times.
150 Evacuation plan is displayed in the manager’s office and the main entrance
151 Contact numbers of healthcare personnel required in emergencies are

available in the management offices and at reception
152 Emergency evacuation procedure is practiced annually
153 Deficiencies identified during the practice of the emergency evacuation drill
are addressed
Process
Step 1: Obtain a floor plan of the facility from the district office. Where there is no floor
plan available from the district office, draw a floor plan. Excel can be used or
neatly hand draw the floor plan.
Step 2: Use the floor plan to develop an emergency evacuation plan that visually
displays the evacuation paths.
Step 3: Indicate all emergency exists, assembly points, main electrical power switch,
main water shut off valve and firefighting equipment on the floor plan.
Step 4: Add in directional arrows to show the way to the various emergency exit points
as well as the emergency assembly point. See Annexure 91.
Step 5: Visibly display the evacuation plan in the manager’s office and the reception
area.
Step 6: Ensure that the contact numbers of healthcare personnel that will be required
in emergencies is in the file for contact details in the manager’s office and
reception. Where there is no manager’s office in the facility the contact
numbers must be available in the most accessible office in the facility.
Contact details of the following healthcare personnel must be included:
District outbreak team,

District Specialist Team OR General Medical Practitioner allocated to
the facility,
Local area manager,
Referring district hospital (casualty section),
District manager,
Facility manager,
Facility professional staff
Step 7: Conduct annually an evacuation drill. Note: No critical patient must be left
unattended during the evacuation practice. Allocate a trained staff member
to attend to them
• assign/designate roles to staff

• choose a date and time to practice evacuations that is not made known
to staff
• set the scene and commence the evacuation drill in line with the plan.
Step 8: Debrief and give feedback to staff.
Step 9: Draw up an emergency evacuation drill practice report (see Annexure 92 as

an example) and file. This report must include recommendations for
improvement if applicable.
Step 10: Plan and implement remedial action within two weeks.
Step 11: Rerun the evacuation practice if necessary.

The facility staff is prepared to manage outbreaks effectively
154 Standard Operating Procedure for outbreak notification and response are
available
Process
Step 1: Obtain the National Guidelines on Epidemic Preparedness and Response

from www.health.gov.za.
Step 2: Use the Guideline to develop a SOP for outbreak notification and response for
the facility. District offices should be guiding this process.
Step 3: All staff members to sign the acknowledgement form that they are aware of
the content of the SOP. Attach this to the back of the SOP and file the
document. See Annexure 53 as an example.

COMPONENT 6: INFRASTRUCTURE AND SUPPORT SERVICES
21. Physical space and routine maintenance
The physical space and environment is conducive to rendering quality health services.
155 Clinic space accommodates all services and staff
Process
Step 1: Determine if the size of the facility is sufficient to provide services based on
the population to be served and PHC package of services provided. Refer to
the size classification and facility reorganization sections in the ICSM manual
to determine the required number of rooms/areas etc.
Step 2: Once the appropriate size has been calculated according to the process as set
out in the ICSM manual, use Annexure 93 to determine whether the size of the
facility is sufficient.
Step 3: Prepare and submit a motivation to district office for additions/renovations if

needed.
Step 4: Make regular follow up with the district manager in this regard.

The facility is accessible for people in wheelchairs.
156 There is access for people in wheelchairs
Process
Step 1: Using the wheelchair access requirement checklist to check whether the
facility complies with the criteria. See Annexure 94.
Step 2: Should the facility not comply, apply for the relevant alterations through the
sub-district/district manager by following the relevant provincial protocol.

The facility infrastructure must be maintained to provide an environment conducive for

health service delivery.
157 Building(s) is maintained according to schedule
158 Building(s) complies with safety regulations
Process
Step 1: Using Annexure 95, compile a checklist of major infrastructure repairs and
maintenance work required.
Step 2: Log a request to have major repairs onto the district’s annual major
maintenance plan.
Step 3: Obtain the maintenance schedule for the current financial year for the facility
from the sub-district/district.
Step 4: Do regular follow-up to ensure that the maintenance is conducted according to

the schedule.
Step 5: Follow-up with the sub-district/district if maintenance is not done according to

schedule. Document all follow-ups. See Annexure 96.
Step 6: As soon as items for minor repair are identified, complete and submit a works
order. Keep record of orders submitted and track progress. See Annexure 96
as an example.
Step 7: If no action has been taken within one week, escalate to sub-district/district.
Step 8: Obtain the certificates from the sub-district/district that is required to ensure
that the facility is compliant with all safety regulations. File in the building
maintenance file. See Annexure 97.

22. Essential equipment and furniture
Commitment to Ideal Clinic elements 159 - 164
Appropriate furniture and essential equipment is available in every consulting room.
159 Furniture is available and intact in service areas
160 Essential equipment is available and functional in every consulting areas
161 Staff are trained on the use of essential equipment
162 Standard Operating Procedure for decontamination of medical equipment is

available
163 Standard Operating Procedure for reactive maintenance of medical equipment

is available
164 Maintenance plan for essential equipment is adhered to
Process
that contains a standardised list with specifications for furniture from
www.health.gov.za
Step 2: Obtain the list for the furniture and essential equipment required in the
consulting rooms
• consulting room furniture Annexure 98
• essential equipment Annexure 99
Step 3: Using the lists for furniture and essential equipment required in the consulting
room, conduct a quarterly stock taking and ensure that all the items are
available
Step 4: Ensure that missing items are budgeted for.
Step 5: Order missing items using the standard procurement procedure.
Step 6: Immediately follow up if items were not received on the indicated date.
Step 7: Schedule in-service training for all healthcare personnel on the equipment that
is used in the facility. If there is equipment that staff is not familiar with,
arrange through the sub district/district office that the supplier of the
equipment conducts training for the healthcare personnel. Keep a register of
all training conducted; see Annexure 10 as an example.
Step 8: Ensure that the facility has a SOP for decontamination of medical equipment.
The SOP must cover at a minimum:
• Decontamination of reusable devices and surgical instruments
• Procedures on single use device
• Handling of potentially infectious instruments and materials.
• Hazardous chemicals and their use
• Procedures of packing and assembly of instruments
• Testing and use of equipment for disinfecting
• Tracking system for product sterilization, identification, recording and
recalls
• Safe handling of used instruments, including their checking and
transport to CSSD
• When to perform manual cleaning
Step 9: Ensure that the reactive SOP for the maintenance of all medical equipment is
available.
Step 10: Compile a maintenance schedule for the following equipment (see Annexure
100 as an example):
• Automatic External Defibrillator (AED) OR ECG monitor and defibrillator
• Pulse oximeter with adult & paediatric probes (recalibrated)
• Non invasive electronic blood pressure monitoring device including
paediatric, adult & large adult cuff sizes (recalibration) (cuff bladders,
valves and tubing replaced)
• Scales (recalibration),
• Hemoglobin meter (recalibration)
Step 11: Sign off on the maintenance schedule when the maintenance for specific
equipment has been performed.
Step 12: Follow-up with the sub-district/district office if maintenance is not done
according to schedule.

Commitment to Ideal Clinic elements 164 - 167
Facilities must be able to successfully resuscitate patients as the need arise.
165 Resuscitation room is equipped with functional basic resuscitation equipment
166 Emergency trolley is restored daily or after each use
167 There is an emergency sterile obstetric delivery pack
168 There is a sterile pack for minor surgery
Process
that contains a standardised list with specifications for equipment and supplies
needed for the resuscitation room, emergency trolley, emergency sterile
obstetric delivery pack and sterile pack for minor surgery from
www.health.gov.za.
Step 2: Conduct regular audits on emergency equipment using the following schedule:
• resuscitation room: Annexure 101

• emergency trolley: Annexure 102
• emergency sterile obstetric delivery pack: Annexure 103
• sterile pack for minor surgery: Annexure 104
Step 3: Keep record of the completed audit lists for future reference.
Step 4: Designate a professional nurse to ensure on a daily basis that the emergency
equipment as stipulated in Step 2 are available, clean and functional.

Oxygen must be consistently available to patients when needed.
169 Oxygen cylinder with pressure gauge is available in resuscitation/ emergency

room
Process
Step 1: The facility’s mobile oxygen cylinder in the resuscitation/emergency room

must be fitted with a functional gauge at all times.
Step 2: The emergency oxygen cylinder has sufficient volume and pressure at all
times. Designate a staff member to check this on a daily basis.
Step 3: The designated staff member must complete the check sheet (See Annexure
105 as an example) on a daily basis to ensure that the oxygen level is as
prescribed.
Step 4: Should the oxygen in the cylinder be below the prescribed level contact the
service provider to have the cylinder refilled or exchanged with a full one.

Assets in the facility are controlled.
170 An up-to-date asset register is available
Process
Step 1: Obtain an updated asset register from the sub-district/district office.
Step 2: Do regular spot check to check whether the assets in the facility correspond
with the asset register of the sub-district/district office. See Annexure 106.
Step 3: Report any discrepancies to the sub-district/district office; keep record of the
communication done.
Step 4: Report any stock that is lost due to theft immediately to the sub-district/district
office to ensure that the asset register is kept up to date. Keep record of
reports sent.

Commitment to Ideal Clinic element 171
The facility uses space optimally.
171 Redundant and non-functional equipment is removed from the facility
Process
Step 1: If there are any items of equipment found to be redundant, inform the sub
district/district to reallocate this to another facility.
Step 2: If there are any items of equipment found to be beyond repair, have this
condemned and disposed of. Complete an asset disposal form for the
equipment. See Annexure 107 as an example.
Step 3: Update asset register accordingly.
Note to reviewers:
Check whether there is any redundant equipment or non-functional equipment in the facility.

23. Bulk supplies
Facilities must have clean, fresh running water and backup supply available at all times.
172 Facility has a functional piped water supply
173 Facility has access to emergency water supply when needed
Process
Step 1: In cooperation with the local municipality ensure that there is clean piped
water to the facility.
Step 2: Where there is no piped water ensure that the sub-district/district has planned
for the installation of piped water.
Step 3: The 24-hour contact number of the local municipality’s water supply
department must be prominently displayed on the facility’s notice board
together with other emergency numbers of essential services.
Step 4: Ensure that the facility has access to emergency water supply in the form of:
• water tanks that are regularly filled by the local municipality. The water
level of the tank should be checked at least every fortnight.
• tanks on trailers that are brought to the facility when there is a break in
piped water supply. A short SOP describing the process to follow to
arrange for the backup water supply must be available.
Note to reviewers:
Back up water supply must be available for facilities where the water supply is disrupted
more than three times in a year for more than 4 hours a day at a time. Facilities where
disruption is less frequent as described can score green for element 173 even if they have
no back-up water supply.

Facilities must have uninterrupted electricity supply.
174 Facility has access to a functional back-up electrical supply when needed
Process
Step 1: In cooperation with the district infrastructure unit ensure that functional back-
up electricity is available at the facility.
Step 2: Back-up electrical supply must be available in the form of:

• a generator permanently stationed at the facility OR
• a generator that are brought to the facility from the sub-district/district office
when needed. A short SOP describing the process to follow to arrange for
the generator must be available. OR
• Uninterrupted Power Supply (UPS) OR
• Solar power
Step 3: If back-up electricity to the facility is in the form of a generator, assign a staff
member to check the fuel levels on a monthly basis and after every use.
• report and correct any defects
• make sure that the emergency contact number for the generator
maintenance is prominently displayed on the facility notice board.

Removal of sewerage must be properly managed to ensure a safe and hygienic facility.
175 Sewerage system is functional
Process
Step 1: In cooperation with the local municipality, ensure that the facility is serviced by
a piped sewerage removal system or a septic tank system.
Step 2: Should the facility experience problems with the sewerage system log a call
for repairs with the district maintenance services.
Step 3: Make sure that the emergency contact number for the district maintenance
services and the local municipality is prominently displayed on the facility
notice board.
Note to reviewers:
When conducting a status determination observe that the sewerage system is functional,
drains must not be blocked, both inside as well as outside the facility. There must also be no
leaking drain pipes outside the building. Where the sewerage system is not functional,
check that works orders has been completed to report it and follow-ups have been done
where needed.

24. ICT infrastructure and hardware
A functional telephone system must always be available in the facility to allow proper
communication.
176 There is a functional telephone in the facility
Process
Step 1: Should the landline not be functional, contact the relevant service provider.
Step 2: If the fault persists for more than three days escalate it to the district.
Step 3: Keep record of all maintenance and repairs of telephone lines.

Functional Information Communication Technology (ICT) equipment (computer, printer and

e-mail) must be available.
177 There is a functional computer
178 There is functional printer connected to the computer
179 There is web access
Process
Step 1: If there is no computer with printer and e-mail in the facility, order the ICT
equipment using the ICT procurement order form. The ICT equipment
purchase agreement must include maintenance.
Step 2: Update the asset register accordingly
Step 3: In the event that the ICT equipment is not functional, order the repair by
logging a call with district ICT support.
Step 4: Using the district training plan, request training for relevant facility staff in
correct use of the ICT equipment.
Step 5: Ensure that the facility has internet/intranet (that allows access to all required
applications) access.

COMPONENT 7: HEALTH INFORMATION MANAGEMENT
25. District Health Information System (DHIS)
Facilities generate and record accurate information for their own use and submission to
district, provincial and national levels.
180 Facility performance in response to burden of disease of the catchment

population is displayed and is known to all clinical staff members
181 National District Health Information Management System policy available
182 Clinical personnel and data capturer trained on the facility level Standard
Operating Guidelines for data management
183 Relevant DHIS registers are available and are kept up to date
184 Facility submits all monthly data on time to the next level
185 There is a functional computerised patient information system
Process
Step 1: All clinical staff must be conversant with the burden of disease in their
catchment population.
Step 2: The PHC package of services provided at the facility must be based on the
burden of disease for the catchment area.
Step 3: Ensure that professional nurses and data capturers have been trained on the
District Health Management Information System Policy
Step 4: Ensure that professional nurses and data capturers have been trained on the
Facility Level Standard Operating Guidelines for Data Management
Step 5: Maintain records of training. See Annexure 10 as an example
Step 6: Data generated by the facility must be recorded in the approved PHC registers
and kept up to date.
Step 7: Verify that monthly data that was captured are correct.

Step 8: Ensure that graphs are updated to the last quarter's data.
Step 9: Sign off data report.
Step 10: Submit all monthly data on time to the next level.
Step 11: Discuss facility performance using data/information in facility’s monthly

meetings.
Step 12: Correct data based on the sub-district/district’s feedback where relevant.
Document all evidence of monthly data feedback received from sub-
district/district.
Step 13: In cooperation with national, provincial and districts offices, install and train
staff on the electronic Health Patient Registration Information System/Primary
Healthcare Information system
Step 14: Monitor that every patient is registered on the Health Patient Registration
Information System.

COMPONENT 8: COMMUNICATION
26. Internal communication
Recommendations from the district quarterly performance review meetings are used to
discuss the performance of the facility and plan corrective actions to improve facility
performance.
186 There are sub-district/district quarterly facility performance review meetings
Process
Step 1: In cooperation with the district manager and area managers set dates for the
quarterly performance review meetings as part of the sub-district/district
annual calendar.
Step 2: Review each programme’s performance against predetermined targets and

explain reasons for variations.
Step 3: The facility manager must schedule a meeting with the facility staff one week
before the quarterly performance review meetings to prepare the facility’s
presentation using the relevant provincial template.
Step 4: Deliver the facility’s presentation and answer all questions at the quarterly
performance review meetings.
• discuss what actions will be taken to achieve set targets and what changes
need to be made within the facility. Make notes during the discussion.
• record activities, challenges and any good practices that you could
replicate in your own facility from other facilities presentations
Step 5: File a copy of the presentation electronically and make sure that computer
content is backed up appropriately.

Staff in the facility is well informed about the facility’s current performance and future plans.
187 A staff meeting is held at least quarterly within the facility
Process
Step 1: Draw up a quarterly meeting schedule in consultation with all staff members.
Facilities are free to have more frequent meeting on an ad hoc basis.
Step 2: Include quarterly meeting dates on the Annual Facility Calendar. See
Step 3: Display quarterly meeting schedule for the year on the staff notice board.
Attendance of all staff is compulsory except those who are on leave.
Step 4: Develop an agenda for the meeting. See Annexure 109 as an example.
Step 5: All staff who attended the meeting must sign the attendance register. See
Step 6: Designate a staff member to take minutes.
Step 7: Minutes of the meeting will be available within three working days after the
meeting and will be filed electronically in date order. Minutes are available for
all staff to read.
Step 8: Review the action points after the meeting and ensure that all activities that
were agreed upon at the meeting, are executed.

Staff is knowledgeable about all relevant policies and notifications. This knowledge is used
to improve the facility’s functioning and services to the patients.
188 Staff members demonstrate that incoming policies and notices have been read
and are understood by appending their signatures on such policies and
notifications
Process
Step 1: When new policies and notifications are received, check if they replace
existing policies and notices.
Step 2: Discuss the new policies and notices with staff immediately.
Step 3: Check to see that the relevant staff members understand the changes and
determine if further training may be required. If training is required, request
this using the district training protocol.
Step 4: Staff members that must implement and/or have knowledge of the
policies/guidelines and notices must sign the acknowledgement form for the
specific policies/guidelines and notices. Attach this to the back of the new
policy/guidelines or notice and file the document. See Annexure 53 as an
example.
Step 5: If there are further questions regarding the policies and notices seek relevant
answers from the relevant source or your local area manager.

27. Community engagement
The community being served by the facility supports the facility management and staff by
being involved in service planning and taking ownership and pride of their facility and its
functioning.
189 There is a functional clinic committee
190 Contact details of clinic committee members are visibly displayed
Process
Step 1: Using the District Governance Structures Policy (www.health.gov.za)

understand the roles, responsibilities and activities of the clinic committee as
well as how to get a functional clinic committee established.
Step 2: Determine whether there is a clinic committee in place. If so, ascertain

whether it is functional. See Annexure 111.
Step 3: If clinic committee is not in place or not functional obtain guidance through the
district manager from the office of the MEC for Health.
Step 4: In cooperation with the office of the MEC obtain nominations of clinic
committee members and ensure that the appointment process is taken to
completion.
Step 5: Develop a clear and legible list of the names of clinic committee members and
all their contact details
• place this list on patient notice board in the waiting area

• update this list when there are changes to clinic committee members.
Step 6: In cooperation with the chairperson of the clinic committee:
• develop a schedule of monthly meetings

• request training for clinic committee members from the district

• attend clinic committee meetings, ensure that agenda is developed,
register is kept and minutes are taken. See Annexure 109 / Annexure
110 as an example
• follow up actions arising out of clinic committee meetings.

Promote community ownership of the facility and its functions while strengthening health
promotion and disease prevention in the community.
191 Facility has an annual open day
Process
Step 1: In consultation with facility staff and community leaders plan for open days.
See an example of suggested services and activities for an open day. See
Step 2: Log dates of the open day in the annual calendar to be displayed on the staff
notice board. See annexure 108 as an example.
Step 3: In cooperation with the clinic committee seek support from relevant sources.
Step 4: Ensure the necessary communication with stakeholders required for a

successful open day.
Step 5: On the day of the event oversee the setup and activities including various
health screening.
Step 6: Compile a report of the event including relevant statistics of screenings

conducted.
Step 7: Submit the report to the sub-district/district and file the report.

COMPONENT 9: DISTRICT HEALTH SYSTEM SUPPORT
28. District health support
Commitment for Ideal elements 192 - 193
The district supports the facility through Perfect Permanent Team for Ideal Clinic Realisation
and Maintenance (PPTICRM) to function in line with the national quality standards. The
district must provide comprehensive support on all aspects of the management of the
facility.
192 There is a health facility operational plan in line with district health plan
193 District PPTICRM visits all facilities at least once a year and those targeted to
be Ideal in the specific year at least twice a year to ensure that weaknesses
have been corrected and to record the Ideal Clinic Realisation status for the
end of year report
Process
Step 1: Develop a facility operational plan in line with the district health plan. See
Annexure 113 that gives guidance on how to develop an operational plan.
Step 2: The PPTICRM, in cooperation with the facility manager, plan and agree on the
dates for visits to provide the necessary support to the facility with regard to all
the components, sub components and elements of the Ideal Clinic. See
Annexure 114 for a schedule of when the various types of status
determinations must be conducted.
Step3: Conduct the status determination and capture the results on the Ideal Clinic
software.
Step 4: Using the generated quality improvement plan correct the weaknesses
immediately.
Step 5: The status of the facility as well and the corrective actions must be presented
at the quarterly district performance review meetings.
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Ideal Clinic manual version 17
29. Emergency patient transport
The facility must have access to emergency medical services (EMS) transport.
194 There is a pre-determined EMS response time to the facility
195 EMS response complies with the pre-determined response time
196 Emergency contact numbers (fire, police, ambulance) are displayed in areas
where telephones are available
Process
Step 1: Obtain the norm for the response time relevant to the facility from the sub-
district/district Emergency Medical Services (EMS) manager.
Step 2: Keep a register of actual emergency transport response time. See Annexure
115 as an example.
• the staff member requesting patient emergency transport must record

the patient name, date and time patient transport was requested,
referral destination, and date and time of patient collection in the
ambulance response time
• calculate and record the response times in the register
• on a monthly basis monitor the trend in response time to determine
whether the EMS complies with the norm.
Step 3: Escalate to the sub-district/district office if there are consistently long response
times or for serious incidents where response time was poor. The district
management must communicate the course of redress to the facility.
Step 4: If no response to the follow-up has been received from the sub-district/district
office within seven days then escalate the query to the next level.
Step 5: Visibly display the contact details of the fire brigade, police station and
ambulance in all areas where there are telephones.
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30. Referral system
Facility must have access to a rational and responsive referral system to ensure continuity
of care between different levels of health service.
197 National Referral Policy is available
198 Facility's Standard Operating Procedure for referrals is available and sets out
clear referral pathways to required service providers
199 There is a referral register that records referred patients
Process
Step 1: Obtain a copy of the National Referral Policy (www.health.gov.za).
Step 2: Develop the facility’s SOP including referral path ways for your facility that is in
line with the National Referral Policy.
Step 3: Schedule orientation and training for all healthcare professionals so they know
how to refer patients.
Step 4: Make a list of all the available referral pathways and display it. See Annexure
116 as an example.
Step 5: Keep sufficient stock of standardised referral forms. See Annexure 117 as an
example.
Step 6: Complete the patient referral form when a patient is referred. Hand a copy to
the patient and keep a copy in the patient record.
Step 7: Keep record of all referred patients in the referral register. See Annexure 118
as an example.
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COMPONENT 10: PARTNERS AND STAKEHOLDERS
31. Partners support
Implementing partners must support the activities of the facility.
200 An up to date list (with contact details) of all implementing health partners that
support the facility is available
201 The list of implementing health partners shows their areas of focus and
business activities
Process
Step 1: Obtain a list of implementing partners that are operating in the sub-
district/district. The list must include their focus and business activities.
Step 2: Compile a list of implementing partners whose focus and business activities is
needed by the facility. The list must be updated when details of the health
partners change.
Step 3: The sub-district/district schedules an annual meeting in November with all

identified health partners to discuss and agree on their contribution to support
the facility in the next financial year.
Step 4: The sub-district/district develops and signs a memorandum of understanding

on how the support is going to be carried out.
Step 5: The sub-district/district establishes a reporting framework for all implementing

partners to the facility and district. See Annexure 119 as an example.
Step 6: The quarterly district review meeting could be used for implementing partners
to present their support progress.
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32. Multi-sectoral collaboration
There is continued cooperation and communication between the Provincial Department of

Health and the South African Police Service and facilities
202 There is an official memorandum of understanding between the PDOH and

SAPS
Process
Step 1: Provincial office to develop the memorandum of understanding with SAPS.
Step 2: The responsibilities of SAPS and PDoH must be clearly outlined in the
memorandum of understanding. These responsibilities could include but are
not limited to:
Responsibilities of the PDoH:
• Ensure that its facilities are secure by providing proper fencing, perimeter
lightning, and security guard houses with security guards.
• Ensure that all health facilities have the contact detail of the local SAPS for
their respective areas.
• Inform SAPS of any matter that may or have cause a risk to the patients,
staff or property of the Department.
• Work together with the SAPS when any matter at the facility need to be
investigated.
• Ensure regular communication with the SAPS on a local level through the
attendance of multisector forums in respective areas.
Responsibilities of SAP
• To assist the PDoH to ensure the safety of patients, staff and the property
of the PDoH when called upon.
• To assist where necessary, if practically possible to monitor security and
safety at health facilities by way of regular patrols near health facilities
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such as clinics, community health centers and mobile clinics in high risks
crime areas.
• To inform the PDoH where security risks have been identified and where
necessary advise on measures that would improve the security.
• To investigate reported crime at facilities and to provide feedback to the
PDoH in accordance with internal police prescripts.
• To engage the PDoH and relevant stakeholders forums on issues of safety
and security at health facilities.
• To provide reasonable access to the SAPS at the workplace without
compromising service delivery in order for the PDoH to promote health
activities and health service delivery to the employees.
• To invite the SAPS where reasonably possible when organizing internal
health promotions and other relevant programmes to ensure maximum
benefit to employees.
Step 3: Draft the memorandum of understanding on the province’s approved template

for memorandum of understandings. See Annexure 120 as an example. The
same template can be used for all the memorandum of understanding listed in
elements 202 to 207. Replace the purpose and responsibilities of both parties
that pertains to the specific memorandum of understanding.
Step 4: Once both parties have agreed on the content of the memorandum of
understanding, sign the memorandum of understanding.
Step 5: Distribute memorandum of understanding to district offices and facilities.
Step 6: Orientate facility staff to the contents of the memorandum of understanding.
Step 7: Staff to sign acknowledgment indicating that they are aware of the
memorandum of understanding and its application. See Annexure 53.
Step 8: The facility must keep record and provide regular feedback to the sub-
district/district on implementation of the memorandum of understanding
including consistent lack of cooperation.
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Health and Department of Education
203 There is an official memorandum of understanding between the PDOH

Department of Education
Process
Step 1: Provincial office to develop the memorandum of understanding with

Department of Education.
Step 2: The responsibilities of Department of Education and PDoH must be clearly

outlined in the memorandum of understanding. These responsibilities could
include but are not limited to:
• Ensure that school health services are rendered to the quantile 1 and
quantile 2 schools and that the relevant grades are covered by the school
health policy.
• Together with Department of Education agree on a roster on when
services will be delivered at the relevant schools.
• Provide health promoting activities during school visits or in case of
outbreaks
• Keep a record of every child that was assessed at a school.
• Provide feedback to the school after assessments have been completed.
• Refer a child to another level/ service where services cannot be rendered
at the school.
• Ensure regular communication with Department of Education through
meetings to ensure that services are rendered as required.
• Health facilities to receive and treat referrals from schools.
• In case of outbreaks at schools, visit the school, investigate and ensure
that the relevant activities take place to address the matter.
• Ensure that confidentiality is adhered to with regard to the health condition
of learners.
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Responsibilities of Department of Education
• Provide possible dates for visits to schools and communicate these dates
to PDoH, district offices and facilities.
• Provide working space for the school health services to be rendered at a
school.
• Ensure that the necessary approval forms were signed by parents prior to
visits to school.
• Ensure that the services are arranged in such a manner that the
maximum services can be rendered by the team during visits.
• Refer children with problems to the school health service or the local
clinic.
• Secure the files of children that were seen by the school health services.
• Inform the local clinic in the event of any outbreak of any disease in the
school and provide access to further investigations and treatments.
• Meet with the PDoH and stakeholders to plan for joint activities.
• Ensure confidentiality of health records.
• Organise health promotion and other programmes in conjunction with
Department of Health to ensure maximum benefit to staff and
communities

for memorandum of understandings.
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Health and Department of Social Services.

the Department of Social Development
Process

Department of Social Services.
Step 2: The responsibilities of Department of Social Services and PDoH must be

clearly outlined in the memorandum of understanding. These responsibilities
could include but are not limited to:
• Render services in line with the Primary Health care re-engineered

approach where ward base teams will be the extension of health services
at a community level.
• Quality health services to be delivered at the health facility in line with the
Ideal clinic standards.
• Refer patients to Social development where aspects are identified by the
clinic or ward based services which need intervention from Social
development.
• Meet on a regular basis at Provincial and local level to ensure a smooth
working relationship with Department of Social Development.
Department of Social Development to ensure maximum benefit to the
communities.
• Monitor and communicate with Social development population health
indicators that are affected by the mandate of social development.
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Responsibilities of Department of Social Services
• Cooperate with the PDoH to ensure a coordinated community based

service.
• Will meet with the PDoH regularly to ensure that there is cooperation
between the facility and Social Services.
• Social Development to ensure staff that services the respective area
follow-up on referrals from the clinic.
• Channel health related referrals to the relevant ward base team or clinic.
• Work with PDoH to ensure a coordinated approach regarding programmes
to enhance the service/
• Co-operate with PDoH in an annual joint quality assurance assessment of
Old Age Homes and Children Homes.
• Train health staff on relevant Social Development programs.
• Provide access to support grants.
• Provide access to the PDoH for health promotion activities and health
service delivery to staff where applicable.
PDoH to ensure maximum benefit to staff and communities.

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Health and Department of Public Works.

Department of Public Works
Process

Department of Public Works.
Step 2: The responsibilities of Department of Public Works and PDoH must be clearly
• Provide information to Department of Roads and Public works where new

facilities are planned, upgrades and refurbishment are required.
• Inform Department of Roads and Public Works when the condition of roads
makes it impossible to deliver services.
• Communicate with Department of Roads with relation to the need for road
signage to health facilities from major access routes.
• Ensure that properties are well maintained and report shortcomings to
public works.
Responsibilities of Department of Public Works
• Ensure that there are proper roads to health facilities.

• Ensure that roads are in good condition for health personnel and
community to have health facility access.
• Ensure the safety of roads to limit motor vehicle accidents.
• Provide signage to health facilities from major access roads.
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• Oversee capital building projects of the Department to ensure that it is in
line with the needs of the Department.
• Ensure quality in the building process of facilities for the PDoH.
• Keep an immovable asset register of all properties of the PDoH
• Do the payments of all rates and taxes on PDoH’s buildings
• Ensure regular maintenance of buildings.
• Ensure land acquisition for new facilities
PDoH to ensure maximum benefit to staff and communities.

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Health and Cooperative Governance and Traditional Affairs.
206 There is an official memorandum of understanding between the district

management and Cooperative Governance and Traditional Affairs (CoGTA)
Process

Cooperative Governance and Traditional Affairs.
Step 2: The responsibilities of Cooperative Governance and Traditional Affairs and

PDoH must be clearly outlined in the memorandum of understanding. These
responsibilities could include but are not limited to:
• Inform the Department on trends in the disease pattern to be integrated

in an integrated plan for a certain area.
• Provide inputs to the Intergovernmental Development plan to allow
integrated planning targeted for development.
• To plan for new health facilities in areas where there are development.
• Ensure that health services are delivered in Traditional land areas.
• To engage through Department of Co-operative Governance and
Traditional affairs with traditional leaders in their respective areas.
• Work in collaboration with traditional leaders and healers e.g. with male
medical circumcision.
Responsibilities of Cooperative Governance and Traditional Affairs:
• Work with the PDoH to ensure integrated planning.

• Inform the PDoH of new settlements that will be developed that may
need health services or new health facilities.
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• Engage with the PDoH regarding traditional leaders and healers that may
play a role in health service delivery.
• Ensure that the PDoH understands the role of Department of traditional
affairs.

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Health and Department of Transport.

Department of Transport
Process

Department of Transport.
Step 2: The responsibilities of Department of Transport and DoH must be clearly

• Work with the Department of Transport, Safety and Liaison to ensure

campaigns preventing injuries and accidents.
• Liaise closely with the Department of Transport, Safety and Liaison to
assist with crime prevention and control in and around the health facilities.
• Take all health vehicles on a regular base for Road worthy testing to
ensure safe vehicles.
• Ensure that all PDoH vehicles are licensed.
• Provide information to Department of Transport on areas where public
transport may be needed to make health facilities more accessible.
Responsibilities of Department of Transport:
• Facilitate and coordinate social crime prevention and road safety

programmes and thus reduce accidents and injury.
• Coordinate crime prevention and community safety partnerships and thus
influencing safety at health facilities.
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• Coordinate licensing and road worthiness of vehicles and thus also
ensuring safety of PDoH vehicles.
• Communication and awareness of Road safety Campaigns.
• Organise health promotion and other programmes

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Annexure 1: Components and sub-component of Ideal Clinic dashboard, version 17
10 Components and 32 Sub-Components
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Annexure 2: Ideal Clinic Realisation and Maintenance Dashboard,
version 17
ELEMENTS
responsibility
National Core
Performance
Component
component
Standards
Check list
Level of
Weight
Sub-
MM
1. Signage and notices: Monitor whether there is communication about the facility and the services
provided
1 All external signage in place I P Y
Facility information board reflects the facility name, service hours, physical
2 address, contact details for facility and emergency service and service I D
package details is visibly displayed at the entrance of the premises
Sign indicating NO WEAPONS, NO SMOKING, NO ANIMALS (except for
3 service animals), NO LITTERING and NO HAWKERS is clearly sign I D
posted at the entrance of the facility
DOMAIN 1: PATIENT RIGHTS
4 Vision, mission and values of the district are visibly displayed I D

Facility organogram with contact details of the facility manager is displayed
5
on a central notice board
I HF
Patients' Rights Charter is displayed in all waiting areas in at least two
6
local languages
I HF
7 All service areas within the facility are clearly signposted HF Y I
2. Staff identity and dress code: Monitor whether staff uniform, protective clothing and mode of staff
identification are according with policy prescripts
8 There is a prescribed dress code for all service providers I P
1. Administration
All healthcare professional staff members comply with prescribed dress

9
code
I
? HF Y
10 All staff members wear an identification tag HF I Y
3. Patient service organisation: Monitor the processes that enable responsive patients service
11 Helpdesk/reception services are available HF I
12 HF
?
There is a process that prioritises the very sick, frail and elderly patients I
13 A functional wheelchair is available HF
? E
4. Management of patient record: Monitor whether patient records content is organised according to
DOMAIN 6: OPERATIONAL MANAGEMENT
Integrated Clinical Services Management (ICSM) prescripts, whether the prescribed stationery is used and
whether patient records are managed appropriately
14 There is a single patient record irrespective of health conditions I HF
15 Patient record content adheres to ICSM prescripts E HF Y
District/provincial standard operating procedure/guideline for accessing,
16
tracking, filing, archiving and disposal of patient records is available
I P
Guideline for accessing, tracking, filing, archiving and disposal of patient
17
records is adhered to
I HF Y
18 There is a single location for storage of all active patient records I HF
19 Patient records are filed close to patient registration desk I
? HF
20 Retrieval of a patient’s file takes less than 10 minutes I
? HF
Priority stationery (clinical and administrative) is available at the facility in
21
sufficient quantities
I HF Y
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5. Clinical service provision: Monitor whether clinical integration of clinical care services allowing for three
discrete streams (acute, chronic and MCWH) of service delivery is adhered to as per service package and
whether this results in improvements in key population health and service indicators
Facility has been reorganised with designated consulting areas and
22 staffing for acute, chronic health conditions and preventative health E HF
services.
23 Patients are consulted, examined and counselled in privacy I HF
TB treatment success rate is at least 85% or has increased by at least 5%
24
from the previous year
E HF
25 TB (new pulmonary) defaulter rate < 5% E HF
Antenatal visit rate before 20 weeks gestation is at least 67% or has
26
E HF
DOMAIN 2: PATIENT SAFETY AND CLINICAL GOVERNANCE AND CLINICAL CARE
Antenatal patient initiated on ART rate is at least 96% or has increased by

27
at least 5% from the previous year
E HF
Immunisation coverage under one year (annualised) is at least 87% or has

28
E HF
Quality Improvements plans are signed off by the facility manager and
30
updated quarterly
I HF
2. Integrated Clinical Services Management (ICSM)
Six monthly district/sub-district clinical performance review report with

31
action plan from clinical quality supervisors are available
E D
6. Access to medical, mental health, allied health practitioners, pharmacists and adolescent friendly
services: Monitor patient and staff access to clinical expertise at PHC level
Patients that require consultation with a medical practitioner have access
32
to a medical practitioner at the facility at least once a week.
E HF
33 Patients have access to oral health services D I
34 Patients have access to occupational therapy services D I
35 Patients have access to physiotherapy services D I
36 Patients have access to dietetic services I D
37 Patients have access to social work services I D
38 Patients have access to radiography services I D
39 Patients have access to ophthalmic service I D
40 Patients have access to mental health services E D
41 Patients have access to speech and hearing services I D
42 Staff dispensing medicine have access to the support of a pharmacist I D
43 Adolescent and Youth Friendly Health Services are provided I D Y
7. Management of patient appointments: Monitor whether an ICSM patient appointment system is
adhered to
ICSM compliant patient appointment system for patients with chronic
44
health conditions and MCWH patient is in use
I HF
Records of booked patients are retrieved not later than the day before the
45
appointment
I HF
Pre-dispensed medication for clinically stable chronic patients is prepared
46 for collection not later than the day before collection date or patients are E ? HF
enrolled on the CCMDD programme
8. Coordination of PHC services: Monitor whether there is coordinated planning and execution between
PHC facility, School Health Team, community-based and environmental health services
Facility does referrals to and receives referrals from school health
47
services in its catchment area
I D
Facility refers patients with chronic but stable health conditions to home-
48
and community-based services for support
E HF
Facility refers environmental health related risks to environmental health Y
49
services
I D
125 | P a g e
9. Clinical guidelines and protocols: Monitor whether clinical guidelines and protocols are available,
whether staff have received training on their use and whether they are being appropriately applied
ICSM compliant package of clinical guidelines is available in all consulting

50
rooms
E HF Y
National guidelines on priority health conditions are available in the

51
facility
I HF Y
80% of professional nurses have been fully trained on Adult Primary Care
52
OR Practical Approach to Care Kit
E D
80% of professional nurses have been fully trained on Integrated
53
Management of Childhood Illness
E D
54 Resuscitation protocol is available E HF

DOMAIN 2: PATIENT SAFETY AND CLINICAL GOVERNANCE AND CLINICAL CARE
55 80% of professional nurses have been trained on Basic Life Support E D

National Guideline for Patient Safety Incident Reporting and Learning is
56
available
E NDoH
Patient safety incident records comply with the National Guideline for
57
Patient Safety Incident Reporting and Learning
E HF Y
58 National Clinical Audit Guideline is available E NDoH

59 Clinical audits are conducted quarterly on priority health conditions E HF
60 Clinical audit meetings are conducted quarterly in line with the guidelines E HF
61 National guidelines are followed for all notifiable medical conditions HF

? I
10. Infection prevention and control: Monitor adherence to prescribed infection prevention and control
policies and procedures
62 National Policy on Infection Prevention and Control is available E NDoH
Facility has a designated staff member who is responsible for infection
63
E HF
64 Standard operating procedure on infection control is available I HF

All staff have received in-service training in the past two years on
65 infection control standard precautions that is in line with the standard E HF Y
operating procedure
Poster on hand washing is displayed above the hand wash basin in every
66
consulting room
I HF
67 Awareness day on hand hygiene is held annually I HF
68 Poster on cough etiquette is displayed in every waiting area I HF
69 Staff wear appropriate protective clothing E
? HF Y
70 The linen in use is clean E HF
71 The linen is appropriately used for its intended purpose E ? HF
72 Waste is properly segregated E HF
73 Sharps are disposed of in impenetrable, tamperproof containers V HF
74 Sharps containers are disposed of when they reach the limit mark V HF
Sharps containers are placed on work surface or in wall mounted
75
brackets
E HF
An annual risk assessment for infection prevention and control
76 compliance is undertaken by the staff member assigned to infection I HF
126 | P a g e
11. Patient waiting time: Monitor adherence to the facility's prescribed waiting times
77 National Policy for the Management of Waiting Times is available I NDoH

DOMA IN 2: PATIENT SAFETY AND CLINICAL GOVERNANCE AND CLINICAL CARE
National target of not more than three hours for time spent in a facility is
78
visible displayed
I HF
79 Waiting time is monitored using the prescribed tool E HF
80 Average time that a patient spends in the facility is no longer than 3 hours E HF
Patients are intermittently informed of delays and reasons for delays in
81 I ? HF
service provision
12. Patient experience of care: Monitor whether an annual patient experience of care survey is conducted
and whether patients are provided with an opportunity to complain about or compliment the facility and
whether complaints are managed within the prescribed time
82 National Patient Experience of Care Guideline is available E NDoH
Results of the yearly Patient Experience of Care Survey are visibly
83
displayed at reception
E HF
An average overall score of 70% is obtained in the Patient Experience of
84
Care Survey
E HF
The results obtained from the Patient Experience of Care Survey are
85
used to improve the quality of service provision
E HF
The National Guideline To Manage Complaints/Compliments/Suggestions

86
is available
E NDoH
The complaints/compliments/suggestions records complies with the

87
National Guideline to Manage Complaints/Compliments/Suggestions
E HF Y
88 90% of complaints received are resolved E HF

89 90% of complaints received are resolved within 25 working days E HF
Complaints/compliments/suggestions boxes are visibly placed at main
90
entrance/exit
E HF
91 Official complaint/compliment/suggestion forms and pen are available E HF

A standardised poster describing the process to follow to lodge a
complaint, give a compliment or make a suggestion is visibly displayed
92
next to the complaints/compliments/suggestions box in at least two local
E HF
languages
13. Medicines and supplies: Monitor consistent availability of required good quality medicines and
supplies
3. Pharmaceuticals and Laboratory Services
DOMAIN 3: CLINICAL SUPPORT SERVICES
Standard operating procedure for management and safe administration of

93
medicines is available
I HF
Medicine room/dispensary is neat and medicines are stored to maintain
94
quality
I HF
Y
There is at least one functional, wall-mounted room thermometer in the
95
medicine room/dispensary
V HF
96 The temperature of the medicine room/dispensary is recorded daily V HF

The temperature of the medicine room/dispensary is maintained within
97
the safety range
V HF
98 Cold chain procedure for vaccines is maintained V HF Y

99 Medicine cupboard or trolley is neat and orderly I HF Y
100 The register for schedule 5 and 6 medicines is completed correctly E HF
Electronic networked system for monitoring the availability of medicines is
101
used effectively
E HF
Y
102 90% of the medicines on the tracer medicine list are available V HF Y
127 | P a g e
Re-ordering stock levels (min/max) are determined for each item on the
103 E HF
3. Pharmaceuticals and Laboratory Services
district/facility formulary
104 Expired medicine is disposed of according to prescribed procedures E ? HF

105 Basic medical supplies (consumables) are available E
HF Y
14. Management of laboratory services: Monitor consistent availability and use of laboratory services
106 Primary Health Care Laboratory Handbook is available E NDoH

Required functional diagnostic equipment and concurrent consumables
107
for point of care testing are available
E HF
Y
108 Required specimen collection materials and stationery are available E HF Y
Specimens are collected, packaged, stored and prepared for
109 transportation according to the Primary Health Care Laboratory E HF
Handbook Y
Laboratory results are received from the laboratory within the specified
110
turnaround times
E HF
Y
15. Staff allocation and use: Monitor whether the PHC facility has the required HRH capacity and whether
staff are appropriately applied
111 Staffing needs have been determined in line with WISN I
? D
112 Staffing is in line with WISN I D

113 Facility has a dedicated manager E D
114 Work allocation schedule is signed by all staff members I HF
DOMAIN 6: OPERATIONAL MANAGEMENT
115 Leave policy is available I HF

4. Human Resources for Health
116 An annual leave schedule is available HF I

16. Professional standards and Performance Management Development System (PMDS): Monitor
whether staff are managed according to Department of Public Service Administration (DPSA) and
Department of Labour prescripts
117 Record of staff induction is available I HF
There is an individual Performance Management Agreement for each
118
staff member
I HF
Continued staff development needs are determined for the current

119
financial year and submitted to the district manager
I HF
Training records reflect planned training is conducted as per the district

120
training programme
I HF
121 The disciplinary procedure is available I HF

122 The grievance procedure is available I HF
123 Staff satisfaction survey is conducted annually I D
The results of the staff satisfaction survey are used to improve the work
124
environment
I HF
Occupational Health and Safety incidents are managed and recorded in a

125
register
E HF
17. Finance and supply chain management: Monitor the consistent availability of a functional supply chain
DOMAIN 3:
5. Support
SUPPORT
CLINICAL
Services
management system as well as the availability of funds required for optimal service provision
126 Facility has a dedicated budget I D
127 Facility has a standard operating procedure for obtaining general supplies E HF
128 | P a g e
18. Hygiene and cleanliness: Monitor whether the required systems and procedures are in place to ensure
consistent cleanliness in and around a facility
128 All cleaners have been trained on cleaning procedures E HF
129 Cleaning schedules are available for all areas in the facility I HF
All work completed is signed off by cleaners and verified by manager or
130
delegated staff member
I HF
131 Disinfectant, cleaning materials and equipment are available E

? HF
Y
132 All service areas are clean E HF
Y
Clean running water, toilet paper, liquid hand wash soap and disposable
133
hand paper towels are available
E HF
Y
Standard operating procedure for managing general and health care risk
134
waste is available
I HF
135 Sanitary and healthcare risk waste are managed appropriately E

? HF
Y
136 General waste is managed appropriately E HF
Y
137 All toilets are clean, intact and functional E
? HF
Y
Y
138 Exterior of the facility is aesthetically pleasing and clean E HF
A signed waste removal service level agreement between the health
139
department and the service provider is available
E P
140 Waste is removed in line with the contract E
? HF
5. Support
141 Records show that pest control is done according to schedule I HF

19. Security: Monitor whether systems processes, procedures are in place to protect the safety of assets,
infrastructure, patients and staff of the PHC facility
142 Safety and security standard operating procedure is available I HF
143 Perimeter fencing is intact I HF
144 Parking for staff is provided on the facility premises I HF
There is a standard security guard room OR the facility has an alarm
145
system linked to armed response
I D Y
There is a security guard on duty OR the facility has an alarm system
146
linked to armed response
I D
A signed copy of the service level agreement between the security

147 I
? D
company and the provincial department of health is available
148 Security breaches are managed and recorded in a register I
HF
20. Outbreak and Disaster preparedness: Monitor whether firefighting equipment is available and whether
staff know how to use it and whether disaster drills are conducted
149 Functional firefighting equipment is available E

HF Y
Evacuation plan is displayed in the manager’s office and the main
150
entrance
I HF
Contact numbers of healthcare personnel required in emergencies are
151
available in the management offices and at reception
I HF
152 Emergency evacuation procedure is practised annually E HF

Deficiencies identified during the practice of the emergency evacuation
153
drill are addressed
E HF
Standard operating procedure for outbreak notification and response are
154
available
E ? HF
129 | P a g e
21. Physical space and routine maintenance: Monitor whether the physical space is adequate for the PHC
facility workload, disabled persons and whether timely routine maintenance is undertaken
155 Clinic space accommodates all services and staff E HF Y
156 There is access for people in wheelchairs E D Y
157 Building(s) is maintained according to schedule I D Y
158 Building(s) complies with safety regulations E D Y
22. Essential equipment and furniture: Monitor whether essential equipment and required furniture are
available
159 Furniture is available and intact in service areas I HF Y
160 Essential equipment is available and functional in consulting areas E HF Y
161 Staff are trained on the use of essential equipment E HF
Standard operating procedure for decontamination of medical equipment
162
is available
E HF
DOMAIN 7: FACILITIES AND INFRASTRUCTURE
Standard operating procedure for reactive maintenance of medical

163
equipment is available
I HF
164 Maintenance plan for essential equipment is adhered to E HF

Resuscitation room is equipped with functional, basic resuscitation
165
equipment
V HF Y

6. Infrastructure
166 Emergency trolley is restored daily or after each use V HF Y

167 There is an emergency sterile obstetric delivery pack E HF Y
168 There is a sterile pack for minor surgery E HF Y
Oxygen cylinder with pressure gauge is available in resuscitation/
169
emergency room
V HF
170 An up-to-date asset register is available I HF Y

171 Redundant and non-functional equipment is removed from the facility HFI
23. Bulk supplies: Monitor whether the required electricity supply, water supply and sewerage services are
constantly available
172 Facility has a functional piped water supply E ? HF
173 Facility has access to emergency water supply when needed E HF
174 Facility has access to a functional back-up electrical supply when needed E
? HF
175 Sewerage system is functional E HF

24. ICT infrastructure and hardware: Monitor whether systems for internal and external electronic
communication are available and functional
176 There is a functional telephone in the facility E ? HF
177 There is a functional computer I ? HF
178 There is functional printer connected to the computer I ? HF
179 There is web access I ? D

25. District Health Information System (DHIS): Monitor whether there is an appropriate information
7. Health Information
DOMAIN 4: PUBLIC
system that produces information for service planning and decision making
Management
Facility performance in response to burden of disease of the catchment

HEALTH
180 I
? HF
population is displayed and is known to all clinical staff members
181 National District Health Information Management System policy available I HF
Clinical personnel and data capturer trained on the facility level Standard
182
Operating Guidelines for Data Management
I HF
183 Relevant DHIS registers are available and are kept up to date I
? HF
130 | P a g e
184 Facility submits all monthly data on time to the next level I HF
185 There is a functional computerised patient information system ? D I
26. Internal communication: Monitor whether the communications system required for improved quality
DOMAIN 4: PUBLIC HEALTH
for service delivery is in place

There are sub-district/district quarterly facility performance review
186
meetings
I D
8. Communication
187 A staff meeting is held at least quarterly within the facility I HF

Staff members demonstrate that incoming policies and notices have been
188 read and are understood by appending their signatures on such policies I HF
and notifications
27. Community engagement: Monitor whether the community participates in PHC facility activities through
representation in a functional clinic committee
189 There is a functional clinic committee I P Y
190 Contact details of clinic committee members are visibly displayed I HF
191 Facility has an annual open day I HF
28. District Health Support (DHS): Monitor the support provided to the facility through guidance from
district management, regular Ideal Clinic status measurement by the PPTICRM as well as through visits from
the district support and health programme managers
192 There is a health facility operational plan in line with district health plan I HF
9. District Health System Support
District PPTICRM visits all facilities at least once a year and those
targeted to be Ideal in the specific year at least twice a year to ensure that
193
weaknesses have been corrected and to record the Ideal Clinic
E
? D
Realisation status for the end of year report
29. Emergency response: Monitor the effectiveness of emergency responses
DOMAIN 5: LEADERSHIP AND CORPORATE GOVERNANCE
194 There is a pre-determined EMS response time to the facility I

? D
195 EMS response complies with the pre-determined response time I D
Emergency contact numbers (fire, police, ambulance) are displayed in
196
areas where telephones are available
I HF
30. Referral system: Monitor whether patients have access to appropriate levels of healthcare
197 National Referral Policy is available I NDoH
Facility's standard operating procedure for referrals is available and sets
198
out clear referral pathways to required service providers
I HF
199 There is a referral register that records referred patients HF I
31. Implementing partners support: Monitor the support that is provided by implementing partners
An up to date list (with contact details) of all implementing health partners
200 I HF
10. Implementing Partners and Stakeholders
that support the facility is available

The list of implementing health partners shows their areas of focus and
201 I HF
?
business activities
32. Multi-sectoral collaboration: Monitor the systems in place to respond to the social determinants of health
There is an official memorandum of understanding between the PDOH
202
and SAPS
I P
203
Department of Education
I P
204
and the Department of Social Development
I P
205
and Department of Public Works
I P
There is an official memorandum of understanding between the district
206 management and Cooperative Governance and Traditional Affairs I P
(CoGTA)
207
and Department of Transport
I P
131 | P a g e
Summary of Ideal Clinic categories
Weights Silver Gold Platinum

Vital (10 elements) 90% 100% 100%
Essential (86 elements) 70% 80% 90%
Important (110 elements) 68% 78% 89%
AVERAGE 70%-79% 80%-89% 90%-100%
DEFINITIONS AND KEYS USED
Definition of weight categories:

Vital
Extremely important (vital) elements that require immediate and full correction. These are
elements that affect direct service delivery and clinical care to patients and they may have
immediate and long-term adverse effects on the health of the population.
Essential
Very necessary (essential) elements that require resolution within a given time period. These
are process and structural elements that indirectly affect the quality of clinical care given to
patients.
Important
Significant (important) elements that require resolution within a given time period. These are
process and structural elements that affect the quality of the environment in which health care
is given to patients.
Performance is scored in line with three colours as follows:
Green (G) = achieved
Amber (A) = partially achieved
Red (R) = not achieved
Key and description for method of measurement
Key Method of measurement (MM)

a) Check applicable documents e.g. policies, guidelines, SOP, data, etc.
? b) Ask staff members and/or clients for their views or level of understanding
c) Objective observations and/or conclusion
d) Test the functionality of equipment/systems
Key and description for level of responsibility Key and description for weights
Key Description Key Description
NDoH national Department of Health V Vital
P Province E Essential
D District I Important
HF Health facility
132 | P a g e
Annexure 3: Checklist for element 1 - External signage in place
Use the checklist below to check the facility’s external signage
Scoring – in column for score mark as follows:
Y (Yes) = present; N (No) = not present; NA (Not applicable) = for small facilities or where certain
services are not rendered
External signage Score
Geographical location signage from main roads

a. Both directions on each main road
b. Within 1 km of clinic
c. No obstructions to visibility
Facility gate entrance signage
a. Vehicles and persons will be searched
b. Entry and parking are at own risk
Specific external locations:
a. Emergency Assembly Point
Waste storage:
a. Healthcare Risk Waste (medical waste)
b. Healthcare General Waste
At or near to main entrance of building:
a. Ambulance parking sign OR Ambulance parking area marked on paving
Total score
Total maximum possible score (sum of all scores minus those marked NA)
Percentage (Total score ÷ Total maximum possible score) x 100 %
Score calculation:
Y = 1, N = 0, NA = NA
Percentage obtained Score

80% Green
40-79% Amber
<40% Red
133 | P a g e
Annexure 4: Patients’ Rights Charter
The Patients' Rights Charter

For many decades the vast majority of the South African population for services or a particular health facility for treatment provided
has experienced either a denial or violation of fundamental human that such choice shall not be contrary to the ethical standards
rights, including rights to health care services. To ensure the applicable to such health care providers or facilities, and the
realisation of the right of access to health care services as choice of facilities in line with prescribed service delivery guide
guaranteed in the Constitution of the Republic of South Africa (Act lines.
No 108 of 1996), the Department of Health is committed to Be treated by a named health care provider
upholding, promoting and protecting this right and therefore Everyone has the right to know the person that is providing
proclaims this PATIENTS' RIGHTS CHARTER as a common health care and therefore must be attended to by clearly
standard for achieving the realisation of this right. identified health care providers
This Charter is subject to the provisions of any law operating within
Confidentiality and privacy
Information concerning one’s health, including information
the Republic of South Africa and to the financial means of the
concerning treatment may only be disclosed with informed
country.
consent, except when required in terms of any law or an order of
A healthy and safe environment the court.
Everyone has the right to a healthy and safe environment that will
ensure their physical and mental health or well-being, including
Informed consent
Everyone has the right to be given full and accurate information
adequate water supply, sanitation and waste disposal as well as
about the nature of one’s illnesses, diagnostic procedures, the
protection from all forms of environmental danger, such as pollution,
proposed treatment and the costs involved, for one to make a
ecological degradation or infection.
decision that affects anyone of these elements.
Participation in decision-making Refusal of treatment
Every citizen has the right to participate in the development of
A person may refuse treatment and such refusal shall be verbal
health policies and everyone has the right to participate in decision-
or in writing provided that such refusal does not endanger the
making on matters affecting one’s health
health of others.
Access to healthcare Be referred for a second opinion
Everyone has the right of access to health care services that
Everyone has the right to be referred for a second opinion on
include:
request to a health provider of one’s choice.
i. receiving timely emergency care at any health care facility that
is open regardless of one's ability to pay; Continuity of care
ii. treatment and rehabilitation that must be made known to the No one shall be abandoned by a health care professional worker
patient to enable the patient to understand such treatment or or a health facility which initially took responsibility for one’s
rehabilitation and the consequences thereof; health.
iii. provision for special needs in the case of newborn infants, Complain about health services
children, pregnant women, the aged, disabled persons, patients Everyone has the right to complain about health care services
in pain, person living with HIV or AIDS patients; and to have such complaints investigated and to receive a full
iv. counselling without discrimination, coercion or violence on response on such investigation
matters such as reproductive health, cancer or HIV/AIDS; Every patient or client has the following
v. palliative care that is affordable and effective in cases of
incurable or terminal illness;
responsibilities:
vi. a positive disposition displayed by health care providers that • Advise the health care providers on his or her wishes with
demonstrate courtesy, human dignity, patience, empathy and regard to his or her death.
tolerance; and • Comply with the prescribed treatment or rehabilitation
vii. health information that includes the availability of health procedures.
services and how best to use such services and such • Enquire about the related costs of treatment and/or
information shall be in the language understood by the patient. rehabilitation and to arrange for payment.
Knowledge of one’s health insurance/medical aid • Take care of health records in his or her possession.
• Take care of his or her health.
scheme
A member of a health insurance or medical aid scheme is entitled to • Care for and protect the environment.
information about that insurance or medical aid scheme and to • Respect the rights of other patients and health providers.
challenge, where necessary, the decisions of such health insurance • Utilise the health care system properly and not abuse it.
or medical aid scheme relating to the member. • Know his or her local health services and what they offer.
Choice of health services • Provide health care providers with the relevant and accurate
Everyone has the right to choose a particular health care provider information for diagnostic, treatment, rehabilitation or
counseling purposes
National Department of Health: Private Bag X828, Pretoria. 0001. Telephone: 012 395 8264/3 www.health.gov.za
134 | P a g e
Annexure 5: Checklist for element 7 - All service areas within the facility
are clearly signposted
Use the checklist below to check whether all service areas within the facility are clearly
signposted

Y (Yes) = if present; N (No) = if not present; NA (Not applicable) = signage is NA to the specific
facility due to the services rendered or the size of the facility (small facilities) or type of services
rendered
Internal branding Score

Help Desk/Reception
Complaints/suggestions/compliments box
Medicine storage room/dispensary/pharmacy
Chronic Medicine Collection (CCMDD)
Emergency room
Facility Manager – door identifier
Emergency exit(s)
Exit(s)
Stairs (if applicable)
Patient Toilets
a. Directional arrows to toilets
b. Disabled toilet pictogram
c. Female toilet pictogram
d. Male toilet pictogram
Directional signs for service areas - Colour-coded signage for each of the 3 streams of
care service areas
a. Acute/minor ailments (orange)
b. Chronic Diseases (blue)
c. MCWH (deep green)
d. Health Support Services (Allied health services) (yellow)
e. Medicine storage room/ dispensary/pharmacy
Functional room signage (each area/room should be labelled)
Vital signs
Counselling room/s
Fire-fighting signs :
a. At each hose, fire hose pictogram
135 | P a g e
At each extinguisher, fire extinguisher pictogram
Support/admin areas ( room name sign on each door )

a. Storeroom(s)
b. Sluice room
c. Laundry
d. Kitchen
e. Patient records storage room
f. Community Outreach Service
g. Staff toilet(s)
h. Staff room/boardroom
Total score
Maximum possible score (sum of all scores minus those marked NA)
Note: Facilities with fewer than three consulting rooms are too small to be segregated into three
streams and are not be expected to have dedicated consulting areas for acute, chronic health
conditions and preventative health services with accompanying signage. However, healthcare
offered at these facilities should still adhere to ICSM principles. This means that patients should be
treated holistically and not sent from one section to another because of co-morbidities. Signage for
the three streams should therefore be marked as NA.
Score calculation:
Y = 1, N = 0, NA = NA

80% Green
40-79% Amber
<40% Red
136 | P a g e
Annexure 6: Example of a dress code for staff
Dress code for staff

All staff members
• An identification tag must be visibly displayed at chest level. The tag shall include the
following information:
o emblem of the provincial Department of Health
o initial/full names and surname of the staff member
o staff designation eg: "professional nurse", “data capturer”, “general assistant"
• General appearance for all staff members
o clothing must be clean, neat and fit properly
o shoes must be clean and in good condition
o good personal hygiene principles must be adhered to at all times
o the following is not allowed:
clogs, crocs, slip-ons
t-shirts
jeans, leggings, tights
see through clothes
low-cut necklines
hats
• General appearance applicable for staff that provide direct patient care
o may not wear artificial nails or colored nail polish
o nails must be short, clean and neatly trimmed
o hair must be clean and long hair must be tied back
o minimal jewelry must be worn
o sleeves must be short (for infection control purposes)
Dress code for nursing staff
Prescribed uniform for females: Prescribed uniform for males:
• white blouses (no see- through type) • white collared shirts

• navy jersey/jacket in the winter season • navy jersey/jacket in the winter season
• navy skirt/slacks • navy trousers
• navy/black court/flat shoes - no clogs, crocs, • navy blue/black socks
slip-ons allowed • black shoes – no clogs, crocs, slip-ons
• skin colour stockings allowed
• South African Nursing Council (SANC) • SANC approved distinguishing devises
approved distinguishing devises (epaulettes) (epaulettes) must be worn at all times
must be worn at all times according to the according to the nursing staff’s professional
nursing staff’s professional qualifications qualifications
Dress code for doctors
• neat blouses (no see- through type) • neat collared shirts

• neat skirt/slacks • neat trousers
• neat dress with appropriate length (not shorter • jersey/jacket in the winter season
than 10cm from above the knee) • socks
• jersey/jacket in the winter season • closed shoes – no clogs, crocs, slip-ons
137 | P a g e
• court/flat shoes - no clogs, crocs, slip-ons • optional - white coat worn over clothes
• optional - white coat worn over clothes
Dress code for allied health workers
Allied groups Dress colours

Occupational Therapist green
Radiologist brown
Speech Therapist red
Physiotherapist light blue
Dieticians and Nutritionist navy
• neat blouses (no see- through type)
• skirt/slacks • neat collared shirts
• neat dress with appropriate length (not • trousers
shorter than 10cm from above the knee) • jersey/jacket in the winter season
• jersey/jacket in the winter season • socks
• court/flat shoes - no clogs, crocs, slip-ons • black shoes – no clogs, crocs, slip-ons
Dress code for administration staff, data capturers
• short or long sleeve shirt/blouse

• skirt/dresses of appropriate length, smart casual trousers
• cardigan, jersey or jacket in the winter season
Dress code for general assistants, community health workers and lay-councilors
• neat shirt or golf shirt (colours can be determined by district/province)

• neat trousers or skirts (colours can be determined by district/province)
• jersey or jacket in the winter season
• closed shoes and socks – no clogs, crocs, slip-ons allowed
138 | P a g e
Annexure 7: Checklist for element 9 - All staff members comply with
prescribed dress code
Use the checklist below to check that staff on duty are dressed according to prescribed
dress code
Check – randomly select five healthcare professional staff members to review
Y (Yes) = present and adhered to; N (No) = not present or not adhered to; NA (Not applicable) = if
there are not enough staff on duty/appointed to evaluate five staff members, check those on duty,
marking the remaining columns NA
Item Staff Staff Staff Staff Staff

member member member member member
1 2 3 4 5
Nails short
Jewellery minimal (plain wedding band,
small ear rings, no necklaces)
Dress/skirt OR pants (dress/skirt should not
be shorter than knee length)
No see-through clothes
Tailored clothes (not too tight nor too loose)
Distinguishing devices worn
Score
Maximum possible score (sum of all
scores minus those marked NA)
Total score (sum of scores for 5 staff
members)
Total maximum possible score (sum of
maximum possible minus those marked
NA)
Percentage (Total score ÷ Total maximum
possible score) x100
Score calculation:
Y = 1, N = 0, NA = NA
Percentage Score
obtained
90% Green
40-89% Amber
<40% Red
139 | P a g e
Annexure 8: Checklist for element 10 - All staff members wear an
identification tags
Use the checklist below to check that the staff on duty wear official identification tags
Check – randomly select five staff members to review
Y (Yes) = present and adhered to; N (No) = not present or not adhered to; NA (Not applicable) = if
there are not enough staff on duty/appointed to evaluate five staff members, check those on duty
and mark remaining lines NA
Staff member Score

Staff member 1
Staff member 2
Staff member 3
Staff member 4
Staff member 5
Total score
Total maximum possible score (sum of all scores minus those
marked NA)
Note: Identification tag must include the emblem of the facility/district or provincial department of
health, full names/initials and surname of the staff member
Score calculation:
Y = 1, N = 0, NA = NA
Percentage Score
obtained
90% Green
40-89% Amber
<40% Red
140 | P a g e
Annexure 9: Notice of prioritisation of very sick, frail and elderly patients
PLEASE NOTE
THE VERY SICK, FRAIL AND
ELDERLY PATIENTS
WILL BE GIVEN PRIORITY
AND MOVED TO THE FRONT OF
THE QUEUE
Page | 141
Annexure 10: Example of a Template for training register for staff
By signing against my name in the table below I acknowledge that I have undergone formal
training on how to................ (insert details on specific training e.g. clean the facility)
STAFF NAME PERSAL

DESIGNATION SIGNATURE DATE
AND SURNAME NUMBER
Page | 142
Annexure 11: Checklist for element 15 - Patient records adheres to ICSM
prescripts
Use the checklist below to check whether patient records comply with ICSM prescripts
Check – randomly select five records of patients who were seen in the past three months. Include
records for the following conditions: one adult acute/minor ailment, one adult chronic, one adult
maternal health, one sick child and one well baby record to cover records of patients consulted at all
three streams of care (Chronic, MCWH and Acute)
Y (Yes) = recorded; N (No) = not recorded; NA (Not applicable) = if patient did not receive relevant
treatment/measure does not apply to the particular type of record selected
Type of information/notes
minor ailment
Adult chronic
Adult acute/
Sick child
Well baby
maternal
(IMCI)
Adult
Administrative details (on cover of record)
Name and surname
Patient file number
Facility name
ID/Refugee/passport number OR date of birth
Demographic details
Residential address
Personal contact details
Name and surname of parents or guardian
Contact details of parents or guardian
Next of kin contact details
Employment contact details (if employed)
Marital status
Patient profile – 1st visit
Type of employment
Social (type of employment, living conditions, social assistance,
cooking method)
Social (school grade, social assistance, nutrition, where child
lives)
Health risk factors (alcohol, smoking, other substances, physical
activity, healthy eating, sexual behaviour)
Family history of chronic conditions
Known chronic conditions
Surgical history
Allergies
Clinical management
Length/Height of patient at 1st visit
Weight at every visit
Body mass index (BMI) calculated at 1st and 7th visits
Weight-for-height z score
MUAC (every 3 months)
Temperature
Blood pressure at every visit
Page | 143
Pulse rate at every visit
Blood sugar as per guidelines
Urine dipstick as per guidelines
Basic screening where indicated (HIV, TB, STI, Diabetes)
Current chronic condition
Adherence to medication
Reported side effects of medication
Other hospital/doctor visits
Presenting complaints
Examination
General (JACCOL)
Chest
Cardiovascular
Abdomen
Mental state
Diagnosis
Patient management
Investigation/tests requested
Date of investigation/test requested
Results of investigations/test recorded
Health education provided
Treatment prescribed
Rehabilitation (where applicable)
Referral (where applicable)
Date of next visit indicated (where applicable)
Health Care Practitioner’s name and surname
Health Care Practitioner’s signature
Date signed by Health Care Practitioner
SANC/HPCSA Number
Child health records
History of immunisations
Deworming treatment
Vit A supplementation
Developmental screening (6, 14 weeks and 6, 9, 18 months and
3, 5-6 years)
Growth charts completed
Basic screening completed according to Road to Health Charts
Maternal health records
BANC 1st visit
Obstetric history
Previous obstetric history and family
Gestational age
General examinations
Abdomen – FHH examination
Vaginal examination
HIV status
Pregnancy risk screening
BANC follow-up visits
General examination
Abdomen examination
Supplements
Gestational graph plotted per visit
Page | 144
Delivery summary
Birth date
Birth weight
Apgar score
Delivery mode
Pregnancy outcome
Postnatal Care visits
General examination (3-6 days post delivery)
General examination (6 weeks post delivery)
Health education
Prescription
Patient’s name and surname
ID number
Age
Allergies
Name of medication
Strength of medication
Quantity
Batch number
Prescriber’s name and surname
Prescriber’s signature
Date signed by prescriber
Dispenser’s name and surname
Dispenser’s signature
SANC/HPCSA number
Consent form (where applicable)
Patient’s full names and surname are written on the consent form
The exact nature of the operation/procedure/treatment is written
on the consent form
The consent form is signed by the patient or parent/guardian
The consent form is signed by the health care provider
The consent form is dated
The information is legible
Total score (sum of scores for 5 records)
Total maximum possible score (sum scores for 5 records
minus those marked NA)
Percentage (Total score ÷ Total maximum possible score) x %
100

Score calculation: 90% Green
40-89% Amber
Y = 1, N = 0, NA = NA <40% Red
Page | 145
Annexure 12: Checklist for element 17 - Guideline for accessing,
tracking, filing, archiving and disposal of patient records is adhered to
Use the checklist below to determine whether the facility adheres to the SOP for accessing,
tracking, filing, archiving and disposal of patient records
Y (Yes) = compliant; N (No) = not compliant
Item Score
Patient record storage room adheres to the following:

Lockable with a security gate OR electronically controlled entrance (tag)
Shelves OR cabinets to store files
Lowest shelf OR cabinets start at least 100 mm off the floor and the top of shelving
is not less than 320 mm from the ceiling to allow airflow
Aisle and shelves OR Cabinets labelled correctly according to SOP
Counter or sorting table or dedicated shelves to sort files
Light is functional and allows for all areas of the room to be well lit
Room is clean and dust free
Filing system for patient records adheres to the following:
Facility retained patient records in use
Standardised unique record registration number is assigned to files. One of the
following methods is consistently used : patient’s surname, identity document
number or date of birth, or a set of facility-assigned and recorded numbers)
Record registration number is clearly displayed on the cover of the patient record
All patient records are filed as per SOP
A tracking system is in place to check that all patient records issued for the day are
returned to the patient records storage room/registry by the end of the day
Annual register available of archived records

Annual register available of disposed records
Access for patient to their records
The SOP/guideline for filing, archiving and disposal of patient records describes the
process to follow for patients to access their patient record
Total score
Percentage (Total score ÷ 16) x 100 %
Score calculation:
Y = 1, N = 0
90% Green
40-89% Amber
<40% Red
Page | 146
Annexure 13: Checklist for element 21 - Priority stationery is available at
the facility in sufficient quantities
Use the checklist below to check stationery availability
Y (Yes) = present; N (No) = not present; NA (not applicable) = if stationery is not applicable to the
facility
Stationery type Facility minimum required Score

quantity (Record must be
available stipulating the
facility’s minimum required
quantities)
Goods and supplies order forms/books
Patient record for adults
Patient record for children
Road to Health Booklet for Boys
Road to Health Booklet for Girls
Appointment Cards - General
Patient information registers/Tick sheet
WBPHCOT referral forms
General referral forms
Sick note
Total score
Maximum possible score (sum of all scores minus those marked NA)
Percentage (Total score ÷ maximum possible score) x 100 %
Score calculation: Percentage obtained Score

90% Green
Y = 1, N = 0, NA = NA 40-89% Amber
<40% Red
Page | 147
Annexure 14: Training register for staff trained on Integrated Clinical Service Management
By signing against my name in the table below I acknowledge that I have undergone formal training on indicated modules of ICSM.
Staff name Persal Desig- Module Module Module Module Module Module Module Module Module Module Module Module
and surname number nation 1 2 3 4 5 6 7 8 9 10 11 12
Signature
Signature
Signature
Signature
Signature
Signature
Signature
Signature
Signature
Signature
Signature
Signature
and date
and date
and date
and date
and date
and date
and date
and date
and date
and date
and date
and date
Page | 148
Annexure 15: Quality improvement plan
QUALITY IMPROVEMENT PLAN
Facility Name: ____________________________
Date Generated: ___________________________
Element Respon- By
# Element Weight sibility No Partial Comment Activity Whom When Results
ADDITIONAL AREAS FOR IMPROVEMENT AS IDENTIFIED TRHOUGH SURVEYS, RISK ASSESSMENTS, COMPLAINTS
By
Item Activity Whom When Results
Name and Surname of facility manager: ___________________
Signature: ___________________
Date: ___________________
Page | 149
Annexure 16: Poster promoting adolescent and youth services
ADOLESCENT AND YOUTH SERVICES
Service times: 14h00 to 17h00
These are service times dedicated to adolescent and youth

services. However adolescents will be assisted throughout
the day if a specific condition requires this.
Services will be provided in a friendly and supportive manner

and include health promotion and disease prevention as well
as curative interventions relating to sexual and reproductive
health, HIV/AIDS and TB, mental health/illness, drug and
substance abuse and violence and injury.
Page | 150
Annexure 17: Profile for adolescent and youth in the catchment area
Facility profile for adolescents and youth in the catchment area
Item Percentage/Rate
Percentage youth (ages 10 to 24 years) in province
(obtained from Stats SA’s data)
School dropout rate in the province (obtained from
Stats SA’s data)
Percentage of youth who obtained tertiary
qualifications in the province
Percentage of youth unemployment in the province
(obtained from Stats SA’s data)
Teenage pregnancies rate in the catchment area
(obtained from DHIS)
Description of strengths and challenges pertaining to youth in the catchment
area using the above statistics
Page | 151
Annexure 18: Checklist for element 43 - Adolescent and youth friendly
health services are provided
Use the checklist below to check whether the facility renders services that are adolescent
and youth friendly
Y (Yes) = if present and compliant; N (No) = if not present or not compliant
Item Score
The National Adolescent and Youth Health Policy is available
A poster indicating that the facility allocates dedicated time to consult

adolescents and youth after school hours is visibly posted in the reception
area and in consulting room(s) where AYFS are provided
Facility’s AYFS poster displays its comprehensive integrated package of
AYFS services provided
The facility’s staff development plan makes provision for all healthcare
professionals to be trained in AYFS
The training register/record reflect that the healthcare professionals providing
comprehensive integrated package of services to young people are trained on
AYFS
Facility’s clinic committee includes a representative of the adolescent and
youth sector aged 16-24 years
At least 10% of the sample of PEC survey include adolescent and youth aged
10-24 years
Facility has a brief profile of adolescents and youth in its catchment area,
including their challenges
Total score

Score calculation:
80% Green
Y = 1, N = 0, NA = NA 40-79% Amber
<40% Red
Page | 152
Annexure 19: Appointment scheduling process
1. PRE-APPOINTMENT RETRIEVAL OF CLINICAL RECORDS
Between 48 and 72 hours prior to the patient’s appointment
• The designated appointment clerk, together with the administrative clerk at the
front desk, should retrieve patients’ records for each of the planned services.
• The clinical records then need to be provided for the relevant professional nurse
who will be consulting planned patients for the various services.
• The relevant prescription and laboratory investigations should be updated where
necessary.
• Clinical records should then be submitted to the pharmacy, or the nurse should
pre-dispense the medication and store it appropriately.
• The patients’ clinical records should then be stored at the registration point.
2. SCHEDULING OF PATIENT APPOINTMENTS
Once the starting date for consulting patients according to a scheduling system has been
determined, the scheduling of patients should commence.
Who is responsible for scheduling the patients?
If only a single room is utilised to see patients with appointments for either chronic or
MC&SRH, then the professional nurse could schedule the patient’s next visit.
If more than one consultation room is used, then an appointment scheduling desk should be
established near the exit of the facility, or patients should return to reception to schedule the
next appointment.
How is the appointment date decided?
Depending on the patient’s condition (immunisation, family planning, well-baby, post natal
care, ANC, and chronic care) and availability of medication at the facility, the patient will
either return on a monthly basis, every 2nd or 3rd month or 6 monthly to the facility.
• The maximum number of patients to be consulted daily is pre-determined.
• At the beginning of each week, the professional nurses should determine and
provide a 5- day period on which returning patients should be scheduled.
• This should be calculated between 25 and 30 days after the current date.
• The patient should then be given a choice as to the exact date when they would like
to return within this period. The date should not be imposed on the patient.
Page | 153
Scheduling the appointment
Patients receiving an appointment will fall into various categories:

• Requiring a full clinical examination (6 month visit)
• Repeat visit (chronic, immunisation, family planning)
• Consultation by doctor
• Collection of medication – CCMDD facility based
The format chosen to schedule patients will be facility specific – a time format should be
used as this spreads the workload.
In order to avoid the batching of patients and prolonging the waiting times, patients should
be offered time slots for attending the appointment.
Patients requiring 6-month appointments should be distributed equally across the time slots
or scheduled in a specific time slot to avoid prolonging the waiting times for other patients.
The time slots should be per 2-hour session with 10 patients scheduled per two hour
session (see example on the following page). At the end of each slot, wo to three slots
should be left blank for patients that missed scheduled appointments but returned within the
96 hour grace period.
Note: Frail, elderly and high risk clients should be given priority.
Adolescents and youth should be scheduled after school hours.
Page | 154
Complete the consultation room number, day of the week and date.
Patients Details
MON TUES WED
Consultation Room: 5 Day of the week(circle) THUR FRI SAT Date:
DD/MM/YYYY
No. Record Full name and Comment Record Appointment Record
number surname of patient Retrieved Attended returned
Y N Y N Y N
07.30-10.00
1. 2468013579 Mary Saints CCMDD Y N Y N Y N

2. Y N Y N Y N
3. Complete Patient Y N Y N Y N
4. file number here. Indicate if the Y N Y N Y N
5. The unique patient patient’s file wasY N Y N Y N
6. record number pre-retrieved. ThisY N Y N Y N
generated by should be done 48- Indicate if the
7. Y N Y N
patient’s Y
record N
HPRS is 10 digits 72 hours before the
8. Y N Y N returned
was Y to N
scheduled
9. Y N Y N
reception Y
for N
10. 1234567890 James Doe FU Y N Y N
filing. Y N
10.15-12.45 (Tea time = 10.00-10.15)
11. Y N Y N Y N
12. Y reason
Indicate N for Y N Y N
13. Y e.g. laboratory
appointment, N Y N Y N
14. Y referred
results (LR), N for Y N Y N
15. Y N (DR), Y
doctor consultation N Y N
16. 2345678901 Polly Jacaranda LR collection
Y of medsN only Y N Y N
(CCMDD), regular follow-up
17. Y N Y N Y N
(6mth FU). This is done at
18. Y N
the time that the Y N Y N
19. appointment is being made.Y
Y N N Y N
20. Y N Y N Y N
Complete 13.30-16.00 (Lunch time= 12.45-1.30)
21. patient’s full Y N Y N Indicate
Y if N
name and the patient
22. Y N Y N Y N
surname attended the
23. Y N Y N Y N
appointment
24. Y N Y N Y N
25. Y N Y N Y N
26. Y N Y N Y N
27. Y N Y N Y N
Missed appointments (Record all patients who present with 5 working days of a missed appointment bellow.)
28. 5678901234 Zenthembe Ndlovu Y N Y N Y N
29. Y N Y N Y N
30. Y N Y N Y N
31. At the end of the day indicate how many patients attended
Y theirNappointments,
Y N Y N
32. Y
missed their appointments, records retrieved and records Nreturned
Y. N Y N
Total number of patients attended Total number of missed appointments
Total number of records retrieved Total number of records returned
Page | 155
PATIENT SCHEDULING TOOL
Date of appointment: This refers to a calendar date. You should label all the dates in the
forms to cater for operating calendar days for the facility for the year. Eg 9th April 2012,
10th April 2012
No: Number refers to the numerical order in ascending order. This will guide you as to when
you reach your target appointments for the respective date
Patient file number: This refers to the patient file number as on the patient record. This will
facilitate easy retrieval of patient record prior to the appointment
Name and surname: This should be as reflected in patient’s identity documents and or
patient records
Diagnostic condition: This refers to the chronic condition for which the patient is booked.
Eg: hypertension, diabetes, epilepsy, asthma, COPD, and ART
Investigations to be conducted or checked: Patients may require laboratory monitoring
and investigations need to be conducted and checked. In this column record the
investigations that need to be conducted on the following appointment or results that need
to be checked.
Nature of appointment: In this column reflect the nature of patient appointment that will
assist in triaging the patients as well as monitoring the patient in the process: eg.
• Patient defaulted – referred for tracing. You can add address and health tracer’s
name
• Requiring a full clinical examination (6 month visit)
• Repeat visit (chronic, immunisation, family planning)
• Consultation by doctor
• Collection of medication – CCMDD facility based
Attended: The last column should reflect if the patient attended (✓) of if the patient
defaulted (x)
What is the procedure when a patient misses their scheduled appointment date?
The patient should be informed that should they miss their scheduled date:
Their record will be filed back in the main filing area after five working days
Should they come within five working days after their scheduled date, they will be consulted
after all the patients allocated to that time slot have been consulted, even if they arrive first.
The patient will need to wait in the queues.
Should the patient arrive after five working days, they will need to follow the normal process
of retrieving their files, wait for vital signs and be consulted in a vacant time slot.
Page | 156
How will an appointment system work in a single room and single nurse clinic?
• Chronic stable patients for medicines collection should be scheduled between 07h30
and 08h30 or between 15h00 and 16h00.
• Well-baby clinic, immunisation, post natal visits and follow-up antenatal visits should
be scheduled for the 1st 2 hours (8h30-10h30).
• Patients with acute episodic illness, antenatal first visits and patients for chronic
prescription six month review should be scheduled between 10h30 and 14h00.
• Family planning and other preventive services should be offered between 14h30 and
16h00.
• Emergencies should be consulted at anytime.
Ensure co-ordination of appointments, for example, a mother coming for a chronic
appointment but also needing her baby to be immunised, should be given one appointment.
Patient defaulting on appointments
In order to improve the outcome of patients (chronic patients, ensure healthy mothers and
babies, reduce unwanted pregnancies and prevent childhood infections) it is important that
patients adhere to their appointment schedule.
Patients who miss appointments should be referred to the adherence counsellors to
encourage and motivate them.
• A patient who does not return to the facility without informing the clinic within seven
days of their scheduled appointment should be considered a defaulter.
• This patient’s medication should be unpacked and re-distributed within the
medication stock for supply to other patients.
• The patient’s name, surname, physical address and mobile number should be
retrieved from the patient’s file and entered into the home based carers register with
a comment- defaulter requiring follow-up.
• Home based carers should then visit the patient’s home to discover the reasons for
the default of the appointment and motivate the patient to return to the facility for
further assessment.
Page | 157
Annexure 20: Pre-dispensing of chronic medication
• Two days prior to the patient’s appointment, the patient’s clinical records and
scheduling list should be provided to the allocated professional nurse for chronic
patients or the pharmacist’s assistant, where available.
• The designated professional should pre-dispense (phase 1 and 2 of the dispensing
process) the chronic medicine according to the prescription.
• The medicine should be packed in a brown bag or opaque plastic bag, where
available.
• A sticker with the patient’s name and file number should be placed on the external
part of the bag.
• The bag should be sealed to avoid tampering. The bags can be opened when
validation takes place upon issuing the medicine to the patient.
• Once the medicine has been pre-dispensed (phase 1 and 2), depending on the
allocation of the patient, the medicine parcels should be placed in the medicine
cupboard in alphabetical order, in the relevant consultation room, or kept in the
dispensary if it is to be issued by a pharmacist’s assistant.
Page | 158
Annexure 21: Example of a tool for acknowledging receipt of chronic
medication by patient
TOOL FOR ACKNOWLEDGING RECEIPT OF CHRONIC MEDICATION BY PATIENT

Name and surname
Clinic file number
Identity number or date of birth
Month in schedule
Date of medicine delivery
Dispenser’s signature (to be

completed after checking,
packing and labeling packet)
Community health worker’s
signature upon receipt of
medicine (sealed bag)
Patient’s signature on opening of
sealed bag and checking
medicine
Medicine not delivered
Page | 159
Annexure 22: School health service referral letter and follow-up
assessment form
REFERRAL LETTER TO HEALTHCARE PROVIDER
Date: _____________________________
Dear colleague
Re: Referral for further assessment
During routine health screening it was found that ___________________________
may have a problem with _______________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
________________________________________________________________and may require
further assessment.
[Add findings in as much detail as possible from school health screening form e.g., Visual
screening left eye 6/18 - Severe visual problem in the space provided above]
Kindly complete the attached follow up form indicating the outcomes of the assessment for attention
of the school principal.
Yours sincerely
_______________________________ ____________________________
SIGNATURE (School Health Nurse) PRINT NAME
School Health Stamp
Page | 160
FOLLOW UP ASSESSMENT FORM
Date: __________________
Name of clinic: __________________
Name of health provider: __________________
Designation (e.g. Prof Nurse) __________________
Contact number: ___________________
Dear Sir / Madam

FOLLOW UP OF HEALTH ASSESSMENT
The following learner _________________________was referred for further assessment as a result of the
Integrated School Health Screening Programme.
Further assessment conducted Yes / No (tick whatever applicable).

The child must return to the clinic for further treatment on ____________ (add date).
Care and support at school level

The school can assist the child in the following ways:
[Add simple interventions e.g. sit at the front of the class for vision problems]
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______
Please do not hesitate to contact the clinic/private healthcare provider should you require additional
information at______________________ (add contact numbers)
Yours sincerely
____________________________________________
NAME AND SIGNATURE OF HEALTH PROFESSIONAL
School Health Stamp
Page | 161
Annexure 23: Example of a register of learners referred from school
health teams
REGISTER OF LEARNERS ASSESSED WHICH WERE REFREED BY SCHOOL HEALTH
Name of health facility: __________________________
Month and year: _____________________20_____
Name and Grade Name of Reason for Referral Date Date feedback
surname of school referral date learner provided to
learner seen at school health
facility teams
Page | 162
Annexure 24: Referral and back referral form for WBPHCOT
Referral Form (from outreach team to provider)
A person has been referred to your service by a member of the outreach team working
in your ward. Community healthcare workers are mandated by the National Department
of Health to identify community members in need of primary health and social services.
Thank you for seeing this client, we look forward to working together for improved health
and welfare for all South Africans.
Client referred to (facility name) Date referral is made Ward No
Name of CHW referring client Outreach team leader name
Contact number Team leader

for CHW contact number
Client details
Client address Client name and surname
Date of birth (dd/mm/yyyy) Age Gender

Client contact
telephone
number
Referred to clinic (Tick all that apply)

MCHW Under 5 Treatment related problems Other
Antenatal care Newborn care TM symptoms Other health problems
Postnatal care Low birth weight STI testing (specify below)
Pregnancy test Immunisation Mental health
Family planning Vitamin A Treatment adherence
Emergency contraception Persistent diarrhoea Chronic health problem
Cervical contraception Pneumonia Chronic health problem
PCR test for infants Nutritional/growth HCT
problems CD4 test
Ols
Referred to social services Referred for home-based care
(tick all that apply) (Please write condition that needs home care)
Child-headed household Protection services
Food support Grant support
Other (specify in box Mental health
below) Support groups
Housing
Vital documents
Provide a brief explanation for the referral (Include place client is being referred if not above and reason for referral)
Please complete Back-referral Form on the other side of this paper so we can ensure follow-up care. Please contact the
outreach team leader noted on this form if you have any further questions regarding this referral.
Signed_________________________________________________ Date______________________________
Page | 163
Back-referral Form
(from provider to outreach team)
This client was seen by (provider name) Date client seen (dd/mm/yyyy)
Facility name Facility telephone number
Name of referring CHW Name of team leader
Client details
Client name and surname Telephone number
Findings (include diagnosis with patient consent)
Actions taken (including medicines given/prescribed if relevant)
Follow-up actions to be monitored or completed by CHW
Please send client back to this provider on/by_____________________________________________ for further follow-up
(dd/mm/yyyy)
Signature Date (dd/mm/yyyy)
Page | 164
Annexure 25: Checklist for element 49 - Facility refers environmental
health related risks to environmental health services
Use the checklist below to check whether the facility has access to and refers environmental
health risks to environmental health services
Y (Yes) = if available and compliant; N (No) = if not available or not compliant
Item Score
Contact details of the environmental health services are available at the
facility
No stagnant water outside the perimeters of the facility
No overgrown vegetation outside the perimeters of the facility
No litter outside the perimeters of the facility
Total score
Score calculation:
Y = 1, N = 0

100% Green
40-99% Amber
<40% Red
Page | 165
Annexure 26: Check list for element 50 - The ICSM compliant package of
clinical guidelines is available in all consulting rooms
Use the checklist below to check the availability of ICSM compliant package of clinical
guidelines
Check – randomly select two consulting rooms
Y (Yes) = present; N (No) = not present; NA (not applicable) = at least one copy of EML for hospitals
must be in doctor’s room, therefore only one consulting room needs to have one; mark other
consulting room as NA
Score Score
Item Consulting Consulting
room 1 room 2
Adult Primary Care guide (APC) – 2016/17 or Practical Approach
to Care Kit (PACK), 2017
Integrated Management of Childhood Illness Chart Booklet, 2014
Standard Treatment Guidelines and Essential Medicines List for
Primary Health Care, 2014
Hospital Level, Adults, 2015 (only in consulting room used by
the doctor)
Hospital Level, Paediatrics, 2013 (only in consulting room used
by the doctor)
Newborn Care Charts Management of Sick and Small Newborns
in Hospital SSN Version 1,- 2014 (only in consulting room
used by the doctor)
Score
Maximum possible score (sum of all scores minus those
marked NA)
Total score for all 2 consulting rooms
Total maximum possible score (sum of all consulting rooms
Percentage (Total score ÷ Total maximum possible score) x %
100
* Guidelines can also be available electronically or via apps
Score calculation:
Y = 1, N = 0, NA 100% Green
40-99% Amber
<40% Red
Page | 166
Annexure 27: Check list for element 51 - National guidelines on priority
health conditions are available in the facility
Use the checklist below to check the availability of national guidelines
Check – whether a copy of the guidelines and policies are available in an office that is accessible to
staff
Y (Yes) = present; N (No) = not present
Item Score
HIV
National Consolidated Guidelines for the Prevention of Mother-to-Child
Transmission of HIV and the Management of HIV in Children, Adolescents
and Adults, 2015
TB
National Tuberculosis Management Guidelines, 2014
National Guidelines for the Management of Tuberculosis in Children, 2013
OR 2014
National Management of Drug-Resistant Tuberculosis. Policy Guidelines,
2013
Infection Prevention and Control Guidelines for TB, MDR-TB and XDR-TB,
2015
Maternal and child health
Guidelines for Maternity Care in South Africa, 2016

Sexually Transmitted Infections
Sexually Transmitted Infections Management Guidelines,2015

Diabetes
National Management of Type 2 Diabetes at Primary Care Level, 2014
Hypertension
National Clinical Guidelines for management of hypertension, 2006
Score
*Guidelines can also be available electronically or via apps

100% Green
Y = 1, N = 0, NA 40-99% Amber
<40% Red
Page | 167
Annexure 28: Example of a register for nurses trained on Basic Life
Support
Record all the staff members’ names and surnames in the register. Record the date the first
training was conducted. Ensure that follow-up training is conducted every two years.
Keep a copy of the certificate obtained in a file together with the register
Date of Date of Date of

Staff name and Persal Date of
Designation update in 2 update in 2 update in 2
surname number training
years years years
Nursing staff
Page | 168
Annexure 29: Patient Safety Incident reporting form
Section A (notification) - to be completed by manager of section where incident took place. Submit section A and B to next level for notification
for SAC 1 incidents
Section B(Statement by staff, patient or significant other)– to be completed by staff, patients or significant other that were directly involved
while the incident took place
Section C(investigation) - to be completed by investigator(s) of the incident, in most cases this would be the manager(s) of section where the
incident took place
SECTION A – notification
Ref no:
1. Type of Patient Safety Incident (PSI): Mark with an X
No Harm Near miss Harmful (Adverse Event)
2. Patient information 3. Staff involved

Patient Name and surname Name and Surname Contact detail Department
Patient file number
Location (department/ward)
Age
Gender
Final Diagnosis
4. Date of PSI 5. Time of PSI
6. SAC rating: mark 1 2 3 7. Date reported to 8. No of days to report

with an X next level if SAC = 1 PSI with SAC = 1
9. Method of Reported by Research Surveys on Inpatient Review of External sources Safety Focused Use
detecting PSI: mark health studies patient medical record on walk teams of
with an X professional experience review follow-up Complaints Media Public rounds data
of care
Page | 169
10. Short description of Patient Safety Incident (detailed information available under section B as reported by staff)
11. Immediate resulting action taken to minimise harm
12. Short description of Initial disclosure
Compiled by: Designation: Signature: Date:
SECTION B- Statement by staff, patient or significant other

1. Statement by staff, patient or significant other: (Add sections for additional statements and information as needed)
Statement 1:
Page | 170
SECTION C - Investigation
1. Category according to type – mark appropriate one with an X
1.Clinical 2. Clinical process/ 3. Health Care associated 4. Medication / 5. Blood and blood products 6. Medical device
Admini- procedure infections IV fluids
stration
Medical Central Line Associated Lack of availability
Not performed when indicated Wrong dispensing Acute transfusion reactions
procedure Blood Stream Infection
performed Omitted medicine or Delayed transfusion reactions/ events Failure / malfunction
without Performed on wrong patient Peripheral Line Infection
dose (including Transfusion Transmitted Infections)
valid
consent Wrong process/ procedure/ 8. Patient Accidents
Surgical site Medicine not available Errors- wrong blood/ blood products
treatment performed
Hospital Acquired
Adverse Drug Reaction 7. Behaviour Falls
Retention of foreign object Pneumonia
Pressure ulcers acquired Ventilator Associated 9. Infrastructure/ Buildings/ Fixtures
Wrong medicine Suicide
during admission Pneumonia
Performed on wrong body Catheter Associated Urinary
Wrong patient Attempted suicide Non-Existent/ inadequate
part/ site/side Tract infection
Maternal death Communicable diseases Wrong frequency Self inflicted injury Damaged/ faulty/ warn
Neonatal death Wrong route Sexual assault by staff member 10. Other
Any other incident that does not fit into
Fresh still born Prescription error Sexual assault by fellow patient or visitor
categories 1 to 9
Wrong dose/ strength
Physical assault by staff member
administered
Physical assault by fellow patient or visitor
Exploitation, abuse, neglect or degrading
treatment by fellow patient or visitor
Exploitation, abuse, neglect or degrading
treatment by staff member
Wandering/ Abscond
Refusal of hospital treatment
2. Framework for Root Cause Analysis and implementation of action plans
a. Contributing factors – Mark with an X
1. Staff Cognitive Performance Behaviour Communication Patho-Physiological/ Disease
2. Patient Cognitive Behaviour Communication Patho-Physiological/ Disease Emotional Social
3. Work / Environment Physical Remote/ long Equipment Consumables Environmental Current Code/ Security/safety
Environmental distance from risk Specifications/ Regulations
/ Infrastructure service
4. Organisational/Service Protocols/Policies/ procedures Processes Organisational Organisation of Staff
Management/Decisions/Culture teams establishment
5. External Natural Environment Equipment, Products, Services, systems and policies
6. Other
Page | 171
b. Root Cause Analysis
Contributing Factor Describe the factor that contributed to the Describe the action Person responsible for Date for
event plan to rectified the implementing the action plan implementation
identified problem
3. Findings and recommendations by Patient Safety Committee
4. Conclusion
Type of behaviour according to Just Culture: mark with a X No error Human Error At – Risk Behaviour Reckless Behaviour
5. Summary of Final disclosure to patient/family
6. Date of closure of 7. No days to 8.

Type of closure: PSI case Litigation Referred to
PSI case close PSI case mark with an X concluded Labour relations
9. Patient Outcome according to degree of harm: Mark with an X None Mild Moderate Severe Death
10. Organisational Outcome: Property Increase in required resource Media Formal Damaged Legal Othe
Mark with an X damage allocation for patient attention complaint reputation ramifications r

Page | 172
Annexure 30: Patient Safety Incident (PSI) register
HEALTH ESTABLISHMENT NAME: ______________________________________ MONTH/YEAR_______________
Ref Patient’s Type of # of Summary of Finding (all incidents)
department/area
Patient outcome
Date and time of
Class according
Class according
Date PSI closed

to Incident type
Type of closure
Location (ward/
Organisational
No. Name& PSI working incident and recommendations
days to close
Reporting date
# of working
SAC score
Behaviour
outcome
to agent
Incident
Surname days to by Patient Safety
Type of
PSI
report Committee
of SAC 1
incidents
)
SAC 1
incident
Page | 173
Annexure 31: Records for statistical data on Patient Safety Incident
Statistical data on classification for agents (contributing factor)
Establishment Financial Year: Q=Quarter
Name/Province: A B C D E F G H I J K L M N O P Q R S
Sept
AVG
TOT
May
Aug
Nov
Dec
Mar
Jun
Feb
Apr
Jan
Oct
%*
Jul
Q1
Q2
Q3
Q4
1.Staff Factors
Cognitive factors
Performance
Behaviour
Communication factors
Patho- Physiologic/
Disease related Factors
Emotional factors
Social factors
2. Patient factors
Cognitive factors
Behaviour
Communication factors
Patho- Physiologic/
Disease related factors
Emotional factors
Social factors
3. Work/ Environment
factors
Physical environment/
infrastructure
Security/Safety
Remote/long distance
from service
Environmental risk
Current code/
specifications/ regulations
Equipment
Consumables
4.Organisational/
Service factors
Protocols/Policies/
Procedures/
Processes
Organisational management
/Decisions/ culture
Organisation of teams
Staff establishment
5. External Factors
Natural environment
Equipment, Products,
Services,systems & policies
6. Other
Other
GRAND TOTAL
Total of agent in Column Q ÷ Grand Total of Column Q

Page | 174
Statistical data on classification according to type of Incident
Financial Year:*Q=Quarter
Establishment A B C D E F G H I J K L M N O P Q R S
Name/Province:
Sept
AVG
TOT
May
Aug
Nov
Dec
Mar
Jun
Feb
Apr
Jan
Oct
%*
Jul
Q1
Q2
Q3
Q4
Type
1.Clinical
Administration
Medical procedure
performed without
consent
2. Clinical process/
procedure
Not performed when
indicated
Performed on wrong
patient
Wrong
process/procedure/trea
tment performed
Performed on wrong
body part/ site/ side
Retention of foreign
object during surgery
Pressure sores
acquired during
admission
Maternal death
Neonatal death
Fresh still born
3. Health care
associated infections
Central Line
Associated Blood
Stream Infection
Peripheral Line
Infection
Surgical site
Hospital Acquired
Pneumonia
Ventilator Associated
Pneumonia
Catheter Associated
Urinary Tract Infection
Communicable
diseases
4. Medication/ IV
Fluids
Wrong dispensing
Omitted medicine or
dose
Medicine not available
Adverse Drug Reaction
Wrong medicine
Wrong dose/ strength
administered
Page | 175
Wrong patient
Wrong frequency
Wrong route
Prescription Error
5. Blood or blood
products
Acute transfusion
reactions
Delayed transfusion
reactions/ events
(including Transfusion
Transmitted Infections)
Errors- wrong blood/
blood products
6. Medical devises/
equipment/ property
Lack of availability
Failure / malfunction
7. Behaviour
Suicide
Attempted suicide
Self inflicted injury
Sexual assault by staff
Sexual assault by
fellow patient or visitor
Physical Assault by
staff
Physical assault by
fellow patient or visitor
Exploitation, abuse,
neglect or degrading
treatment by fellow
patient or visitor
Exploitation, abuse,
neglect or degrading
treatment by staff
member
Wandering/Absconding
Refusal of hospital
treatment
8. Patient accidents
Falls
9. Infrastructure/
Buildings/ fixtures
Damaged/ Faulty/
Worn
Non-Existent/
Inadequate
10. Other
Any other incident that
does not fit into
category 1 to 9
GRAND TOTAL
* Total of type in Column Q ÷ Grand Total of Column Q
Page | 176
Statistical data on classification according to incident outcome
PATIENT OUTCOME

Name/Province:
A B C D E F G H I J K L M N O P Q R S
Sept
AVG
TOT
May
Aug
Nov
Dec
Mar
Jun
Feb
Apr
Jan
Oct
Jul
Q1
Q2
Q3
Q4
%*
None
Mild
Moderate
Severe
Death
GRAND
TOTAL
ORGANISATIONAL OUTCOME

Name/Province:
A B C D E F G H I J K L M N O P Q R S
Sept
AVG
TOT
May
Aug
Nov
Dec
Mar
Jun
Feb
Apr
Jan
Oct
Jul
Q1
Q2
Q3
Q4
%*
Property
damage
Increase in
required
resource
allocation for
patient
Media attention
Formal
complaint
Damaged
reputation
Legal
ramifications
Other
GRAND
TOTAL
* Total of outcome in Column Q ÷ Grand Total of Column Q
Page | 177
Statistical data on Indicators for Patient Safety Incidents (PSI)
Name of establishment/province: _____________________________
Financial year: _______________________________
Column
A B C D E F G H
Name
# PSI cases #PSI cases % PSI cases # PSI cases % of PSI # PSI SAC 1 # SAC 1 %of SAC 1
closed closed closed cases incidents incidents
Month: (Column B/ within 60 closed reported reported
Column A) working within 60 within 24 within 24
days working hours hours
days (Column F/
(Column D/ Column G)
Column B)
April
May
June
Quarter 1
July
Aug
Sept
Quarter 2
Oct
Nov
Dec
Quarter 3
Jan
Feb
March
Quarter 4
TOTAL
AVG
Page | 178
Annexure 32: Checklist for element 57 - Patient safety incident
management records show compliance to the national guideline for
patient safety incident reporting and learning
Use the checklist below to check the availability of records required for the effective
management of /Patient Safety Incidents
Check – patient safety records for the past three months. Note: in cases where no incidents
occurred in the past three months, records should still be completed indicating a ‘0’ on statistical
forms for the relevant months. Register must also be present indicating in first line of register ”No
incidents reported”
Y (Yes) = available; N (No) = not available
Item Score
The facility/district Standard Operating Procedure for Patient Safety

Incident Reporting and Learning is available
Patient Safety Incident Register
Statistical data on classifications of agents involved
Statistical data on classifications of incident type
Statistical data on classifications of incident outcome
Indicators for patient safety incidents
Total score
Score calculation:
Y = 1, N = 0

100% Green
40-99% Amber
<40% Red
Page | 179
Annexure 33: Example of a register to summarise clinical record auditing
Priority areas % Score % Score % Score % Score Average

obtained obtained obtained obtained
Quarter 1 Quarter 2 Quarter 3 Quarter 4
HIV/TB
Non communicable
diseases (diabetes and
hypertension)
Maternal (ANC and PNC)
Well baby
Sick child (IMCI)
AVG per Quarter
Page | 180
Annexure 34: Notifiable Medical Conditions
a) Why do I notify?
• International Health Regulations (IHR) and the South African National Health Act
require rapid detection, notification and prompt risk assessment of public health risks to
enable timely and targeted public health response.
• Notifications serve as early warning signs for possible outbreaks hence enable efficient
public health actions to contain or prevent such outbreaks.
• Notifications provide empirical data required to monitor disease distribution and trends
and identify populations at risk, and for policy decisions.
b) Who should notify?

Every doctor or nurse (health care provider) who diagnoses a patient with any one of the
NMC.
c) Categories of Notifiable Medical Conditions (NMC)

Category 1 NMC are conditions that require immediate reporting by the most rapid means
available upon clinical or laboratory diagnosis followed by a written or electronic notification
to the Department of Health within 24 hours of diagnosis by health care providers.
Category 2 NMC are conditions that must be notified through a written or an electronic
notification to the Department of Health within 7 days of diagnosis.
Category 1 NMC Category 2 NMC
Acute flaccid paralysis Agricultural or stock remedy poisoning
Acute rheumatic fever Bilharzia (schistosomiasis)
Anthrax Brucellosis
Botulism Congenital rubella syndrome
Cholera Congenital syphilis
Food borne illness outbreak Diphtheria
Malaria Enteric fever (typhoid or paratyphoid fever)
Measles Haemophilus influenzae type B
Meningococcal disease Hepatitis A
Plague Hepatitis B
Poliomyelitis Hepatitis C
Rabies (human) Hepatitis E
Respiratory disease caused by a
novel respiratory pathogen** Lead poisoning
Rift valley fever (human) Legionellosis
Smallpox Leprosy
Viral haemorrhagic fever diseases* Maternal death (pregnancy, childbirth and puerperium)
Waterborne illness outbreak Mercury poisoning
Yellow fever Pertussis
Soil-transmitted helminth infections
Tetanus
Tuberculosis: pulmonary
Tuberculosis: extra-pulmonary
Tuberculosis: multidrug-resistant (MDR-TB)
Tuberculosis: extensively drug-resistant (XDR-TB)
Page | 181
Annexure 35: Key elements of infection control standard precautions
Standard precautions are meant to reduce the risk of transmission of blood borne and other
pathogens from both recognized and unrecognized sources. They are the basic level of
infection control precautions which are to be used, as a minimum, in the care of all patients.
Hand hygiene is a major component of standard precautions and one of the most effective
methods to prevent transmission of pathogens associated with healthcare. In addition to
hand hygiene, the use of personal protective equipment should be guided by risk
assessment and the extent of contact anticipated with blood and body fluids, or pathogens.
In addition to practices carried out by health workers when providing care, all individuals
(including patients and visitors) should comply with infection control practices in health-care
settings. The control of spread of pathogens from the source is key to avoid transmission.
Among source control measures, respiratory hygiene/cough etiquette, developed during the
severe acute respiratory syndrome (SARS) outbreak, is now considered as part of standard
precautions.
Worldwide escalation of the use of standard precautions would reduce unnecessary risks
associated with health care. Promotion of an institutional safety climate helps to improve
conformity with recommended measures and thus subsequent risk reduction. Provision of
adequate staff and supplies, together with leadership and education of health workers,
patients, and visitors, is critical for an enhanced safety climate in health-care settings.
1. Hand hygiene
Summary technique:
Hand washing (40–60 sec): wet hands and apply soap; rub all surfaces; rinse hands
and dry thoroughly with a single use towel; use towel to turn off faucet.
Hand rubbing (20–30 sec): apply enough product to cover all areas of the hands; rub
hands until dry.
Summary indications:
Before and after any direct patient contact and between patients, whether or not
gloves are worn
Page | 182
Immediately after gloves are removed.
Before handling an invasive device.
After touching blood, body fluids, secretions, excretions, non-intact skin, and
contaminated items, even if gloves are worn.
During patient care, when moving from a contaminated to a clean body site of the
patient.
After contact with inanimate objects in the immediate vicinity of the patient
2. Gloves
Wear when touching blood, body fluids, secretions, excretions, mucous membranes,
non-intact skin.
Change between tasks and procedures on the same patient after contact with
potentially infectious material.
Remove after use, before touching non-contaminated items and surfaces, and before
going to another patient. Perform hand hygiene immediately after removal.
3. Facial protection (eyes, nose, and mouth)

Wear a surgical or procedure mask and eye protection (face shield, goggles) to protect
mucous membranes of the eyes, nose, and mouth during activities that are likely to
generate splashes or sprays of blood, body fluids, secretions, and excretions.
4. Gown
Wear to protect skin and prevent soiling of clothing during activities that are likely to
generate splashes or sprays of blood, body fluids, secretions, or excretions.
Remove soiled gown as soon as possible, and perform hand hygiene.
5. Prevention of needle stick injuries

Use care when:
handling needles, scalpels, and other sharp instruments or devices
cleaning used instruments
disposing of used needles.
Page | 183
6. Respiratory hygiene and cough etiquette
Persons with respiratory symptoms should apply source control measures:
cover their nose and mouth when coughing/sneezing with tissue or mask, dispose of
used tissues and masks, and perform hand hygiene after contact with respiratory
secretions.
Health care facilities should:

place acute febrile respiratory symptomatic patients at least 1 meter (3 feet) away from
others in common waiting areas, if possible.
post visual alerts at the entrance to health-care facilities instructing persons with
respiratory symptoms to practice respiratory hygiene/cough etiquette.
consider making hand hygiene resources, tissues and masks available in common
areas and areas used for the evaluation of patients with respiratory illnesses.1
1
World Health Organization 2006 - Infection control standard precautions in health care
Page | 184
Annexure 36: Checklist for element 65 - All staff has received in-service
training on infection control standard precautions that is in-line with the
sop in the last two years
Use the checklist below to check whether staff has received in-service training on infection
prevention and control in the past 2 years
Check – randomly select two health care professional and two cleaners from the facility’s staff
establishment. If the facility has less than four staff members on their staff establishment, check all
the staff
Y (Yes) = staff member was trained; N (No) = staff member was not trained; NA (Not applicable) = if
there are fewer than 4 staff members
Professional
Professional
Healthcare
Healthcare
Cleaner 1
Cleaner 2
Topics included in training
2
Healthcare professionals received training on:
• Hand washing and hand hygiene
• Personal Protective Equipment
• Prevention of respiratory infections
• Safe injection practices
• Sharps safety
• Waste management and disposal
• Environmental cleanliness
• Patient Care equipment
• Handling of linen
• Wound care
Cleaners received training on:
• Hand washing and hand hygiene
• Personal Protective Equipment
• Prevention of respiratory infections
• Waste management and disposal
• Environmental cleanliness
• Handling of linen
Score
Maximum possible score (sum of all scores
Percentage (Total score ÷ maximum possible %
score) x 100

100% Green
Y = 1, N = 0, NA= NA 40-99% Amber
<40% Red
Page | 185
Annexure 37: Poster – How to Hand wash
Page | 186
Annexure 38: Poster – How to Hand rub
Page | 187
Annexure 39: Five moments for Hand Hygiene
Page | 188
Annexure 40: Poster – Cough Etiquette
Page | 189
Annexure 41: Checklist element 69 - Staff wear appropriate personal
protective clothing
Use the checklist below to check whether protective clothing is available and worn
Y (Yes) = available and worn; N (No) = not available or not worn; NA (not applicable) = if staff is not
in a situation where they need to wear protective clothing at the time of the audit
Score -stock Score - worn

Item
available by staff
Gloves – non sterile

Gloves – sterile
Disposable gowns OR aprons
Protective face shields OR goggles with surgical face

masks
Score
Maximum possible score (sum of all scores minus
the ones marked NA)
Total score for all stock available and worn by staff
Total maximum possible score (sum of stock
available and clothing worn by staff minus those
marked NA)
Percentage (Total score ÷ maximum possible score) %
x 100
Score calculation:
Y = 1, N = 0, NA = NA

100% Green
40-99% Amber
<40% Red
Page | 190
Annexure 42: Waste segregation and colour coding
A universal colour-coding system has been developed which emphasises linkage of colour to the
type and risk of the waste contained or is expected to contain. There should be clearly visible
charts showing what goes into which colour bag or container. If a container and a plastic bag are
used then both must be of the same colour.
Colour coding of waste containers

CATEGORY EXAMPLES COLOUR DESTINATION
Category A Paper, cardboard, yard clippings, wood or Black/transparent Recycling
similar materials, fruit and food containers.
Office papers, wrapping papers.
Leftover food from patients and kitchen and White Compost/
this includes peels from vegetables and fruits. animal feed
It excludes all containers thereof.
Category B Discarded syringes, needles, cartridges, Yellow, shatterproof, Incineration
broken vials, blades, rigid guide wires, penetration and
trochars, cannulae. leakage resistant
Category C Human tissues, placentas, human Red, leakage Incineration
organs/limbs, excision products, used wound resistant
dressings, used catheters and tubing,
intravenous infusions bags, abdominal swabs,
gloves, masks, linen savers, disposable caps,
theatre cover shoes and disposable gowns.
Sanitary towels, disposable baby napkins
Category D Empty aerosol cans, heavy metal waste and Shatterproof, Incineration
discarded chemical disinfectants. penetration and and landfill
leakage resistant
designated with a
“Flammable” sign
Category E Contaminated radio-nuclide’s whose ionizing High lead density Radio-active
radiation have genotoxic effects. Also material waste storage
chemical waste, cytotoxics waste materials. – hot-laboratory
– lab pots then
landfill.
Category F Pharmaceutical products Green Incineration
With the use of the correct plastic bag colour, each container is automatically labeled as clinical
waste, non-clinical waste, kitchen waste, etc. When the bag is three quarters full, each bag or
container must be labeled with the name of the ward/service area, and be dated then b e closed
and secured and indicate the name of the person that closed it. Each new container or sharps
container should be labeled when replaced.
Page | 191
Annexure 43: Waiting time survey tool
Record the patient
number (e.g. 1 to 100):
Mark the condition for which patient is attending with an “X”
Acute Chronic Mother and Child

Children (IMCI) ANC
Minor Ailments /PNC
Adult Well-
Mental Family
HIV TB NCD baby/
24 hour Emergency health planning
24 hour MOU EPI
Unit
Area Enter time
Time patient enters clinic 1 Hours Minutes
Time patient registers at reception desk Hours Minutes
Time patient is allocated patient record Hours Minutes
Time patient completes vital signs Hours Minutes
Start time End time

1st consultation Hours Minutes Hours Minutes
2nd consultation (2 if referred) Hours Minutes Hours Minutes
3rd consultation (if referred) Hours Minutes Hours Minutes
The Pharmacy (if applicable) Hours Minutes Hours Minutes
Time patient departs clinic 3 Hours Minutes
1
When the patient enters the door of the facility, the queue marshall (or designated staff
member) should record the time
2
If referred from doctor or nurse to lay counsellor or allied health services (Rehab, social
worker, nutritionist, etc)
3
The last point of contact with service provision
Page | 192
3
2
1
Pt No
Diagnostic information
HIV
MOU
Minor
- Adult
24 Hour
Ailments
Total time
TIME
Average time
Time patient enters clinic
Date:
7:40
7:30
7:30
Time patient registers at reception
7:55
7:40
7:40
desk
Time patient is allocated patient

Name of Facility:
8:05
7:46
7:50
record
Time patient completes vital signs
8:12
7:58
8:00

1st
Start time
8:20
8:12
8:15
End time
8:26
8:20
8:18
Consultation
Start time
2nd
8:23
8:30
End Time
8:30
8:35
Consultation
Start time
3rd
Annexure 44: Waiting time calculation tool
Time spent in facility

End time
4:07
01:22
Consultation
Start time Waiting time in
9:00
9:02
8:40
facility
2:44
00:54
End time
applicable)
___________________________
___________________________
9:02
9:05
8:45
Pharmacy (if
12.Time the patient departs clinic Consultation time

spent in facility
9:05
9:06
8:46
00:09
00:28
Total time spent in facility
1:25
1:36
1:16
Waiting time for

registration
00:10
00:30
Total waiting time spent in facility

0:42
0:48
1:02
Waiting time for

Total consultation time spent in patient record
00:09
00:28
0:06
0:15
0:08
facility
Waiting time for registration Waiting time at

Pharmacy
0:15
0:10
0:10
00:04
00:12
Waiting time for patient record Waiting time spent in

0:10
0:06
0:10
MINOR AILMENTS
00:28
00:28
stream in facility
Waiting time at Pharmacy
0:02
0:03
0:05
Waiting time spent in

Number of patients surveyed
Total waiting time spent in MINOR

CHRONIC stream in
00:37
00:37
AILMENTS stream in facility facility

0:15
0:00
0:00

4
Total waiting time spent in CHRONIC

stream in facility MOTHER &CHILD
0:00
0:00
0:37
stream in facility
Total waiting time spent in MOTHER
&CHILD stream in facility Waiting time spent in
0:00
0:00
0:00
24 Hour Emergency
Total waiting time spent in 24 Hour Unit
Emergency Unit
0:00
0:00
0:00
Page | 193

Total waiting time spent in 24 Hour 24 Hour MOU
00:29
00:29
MOU
0:00
0:29
0:00
Annexure 45: Template to display results of patient experience of care
RESULTS OF THE PATIENT EXPERIENCE OF CARE SURVEY _____(year) (can also be

presented in a graph format)
SERVICE AREA
TARGET (%) SCORE OBTAINED
Access to services
87
Availability of medicines
83
Patient safety
57
Cleanliness and infection
prevention and control 65
Values and attitudes

65
Patient waiting time

65
Overall Patient Experience of
>70%
Care survey results
Page | 194
Ideal Clinic manual version 16 (1 April 2016)
Annexure 46: Template for commitment of the facility to improve/sustain the results of the patient
experience of care
OPERATIONAL PLAN
PERSON
POSSIBLE SOLUTIONS RESPONSIBLE FOR DUE MANAGER’S COMMENT
PRIORITY AREA INTENTION
(OPERATIONAL ACTIVITIES) SOLUTION (NAME AND DATE (OUTCOME)
AREA OF WORK)
Access
Availability of
medicine
Safety
Cleanliness and IPC
Values and attitudes
Patient waiting time
Signed commitment
Facility manager: ____________________ Sub-district manager: _________________________
Date: _________________________ Date: _________________________
Page | 195
Annexure 47: Complaints, compliments and suggestion registers
Complaints Register
Health establishment’s name: ______________________________________ Month/year: _____________________
Ref No. Patient/ Patient's Service Summary Information on Category Severity of Type of Date Number of
family/ name and area where description of of Complaint Resolution Resolved working
Date Received
(Column supporting surname complaint the complaint i.) Action taken, Complaint (Risk (Column days to
A) person’s was ii) Outcome, Rating) B) resolve
name and lodged iii) Remedial action Complaint
surname (Column
D)
Column name (e.g. A, B and D) in the heading of the complaints register refer to the columns to be completed in Annexure G:
• To obtain column A of Annexure G count the number of reference numbers for the month
• To obtain column B of Annexure G count the number of complaints resolved (count the rows where dates have been entered). Very important: also check previous month’s
registers for complaints that have been resolved for the current month and add all the complaints that have been resolved for the current month. In some instances you can
have more complaints resolved than received for a specific month because complaints of previous months were resolved in that specific month.
• To obtain column D of Annexure G count the number of complaints resolved within 25 days only. Same principle applies as previous bullet; therefore check previous month’s
registers.
Page | 196
REGISTER FOR COMPLIMENTS
Ref No. Date Name & surname Patient's Name Service area where compliment Summary description of Information on
Received of person who & Surname originated from the compliment
recorded the action taken
compliment
Page | 197
REGISTER FOR SUGGESTIONS
Ref No. Date Name & surname Patient's Name Service area where suggestion Summary description of Information on
Received of person who & Surname originated from the suggestion
recorded the action taken
suggestion
Page | 198
Annexure 48: Statistical data on complaints, compliments and suggestions
Statistical data on Complaints
Name of establishment/province: _____________________________ Financial year: ______________________________
Column INDICATORS CATEGORIES
name A
# Complaints
B C D E F G H I J K L M N O P
# Complaints
% Complaints
% Complaints
(Column B÷A)
Waiting times
Availability of
working days
working days
of Columns F
# Complaints
Staff attitude
environment
Hygiene and
Month:
month (Sum
Patient care
information
cleanliness
Waiting list
medicines
Access to
within 25
within 25
Total per
Safe and
resolved
resolved
resolved
resolved
Physical
received
access
secure
Other
(D÷B)
to O)
April
May
June
Tot Q1
Jul
Aug
Sept
Tot Q2
Oct
Nov
Dec
Tot Q3
Jan
Feb
March
Tot Q4
TOTAL
AVG
(Tot/12)
% for financial year (Total of Column F/G/H/I/J/K/L/M/N/O÷Total Column P)
Page | 199
Statistical data on Compliments
Column INDICATOR CATEGORIES
name A B C D E F G H I J K L
# Compliment
Waiting times
of Columns B
Availability of
Staff attitude
environment
Hygiene and
Month:
month (Sum
Patient care
information
cleanliness
Waiting list
medicines
Access to
Total per
Safe and
Physical
received
access
secure
Other
to K)
April
May
June
Tot Q1
Jul
Aug
Sept
Tot Q2
Oct
Nov
Dec
Tot Q3
Jan
Feb
March
Tot Q4
TOTAL
AVG
(Tot/12)
% for financial year (Total of Column
B/C/D/E/F/G/H/I/J/K÷Total Column L)
Page | 200
Statistical data on Suggestions
Column INDICATOR CATEGORIES
name A B C D E F G H I J K L
# Suggestions
Waiting times
of Columns B
Availability of
Staff attitude
environment
Hygiene and
Month:
month (Sum
Patient care
information
cleanliness
Waiting list
medicines
Access to
Total per
Safe and
Physical
received
access
secure
Other
to K)
April
May
June
Tot Q1
Jul
Aug
Sept
Tot Q2
Oct
Nov
Dec
Tot Q3
Jan
Feb
March
Tot Q4
TOTAL
AVG
(Tot/12)
% for financial year (Total of Column
B/C/D/E/F/G/H/I/J/K÷Total Column L)
Page | 201
Annexure 49: Checklist for element 87- the complaints/ compliments
/suggestions records show compliance to the national guideline to
manage complaints/compliments/ suggestions
Use the checklist below to check the availability of records required for effective
Complaint/Compliment/Suggestion Management
Check – complaints/compliments/suggestion records for the past three months for statistical data.
For complaint letters and redress letter/minutes, check the last five resolved complaints for evidence
Note: in cases where no complaints, compliments and suggestions were recorded in the past three
months the records should still be completed indicating a ‘0’ on statistical forms for the particular
months. Registers must also be present indicating in first line of register “No
complaints/compliments/suggestions reported”
Item Score
The facility/district Standard Operating Procedure to Manage

Complaints/Compliments/Suggestions is available
Complaints letters (check the last 5 complaints resolved)
Complaints redress letters/minutes (check the last 5 complaints resolved)
Complaints register
Compliments register
Suggestion register
Statistical data on classifications of complaints
Statistical data on indicators for complaints, compliments and suggestions
Total score
Percentage (Score ÷ 8) x 100 %
Score calculation:
Y = 1, N = 0, NA = NA

100% Green
40-99% Amber
<40% Red
Page | 202
Annexure 50: Example of specifications for a complaint, compliment and
suggestion boxes
Complaint, compliment and suggestion box

280mm
Note: this box will be opened weekly
530mm
113m
70mm
230mm Storage space for

complaints,
153mm compliments and
suggestion forms
210mm 210mm
Specifications
Material Perspex, 5mm thick

Colour White, frosted
Hinges and Stainless steel
hook and eye
Label Perspex print on box itself (no labels) in colour as determined by the
province (Colour model CMYK: specify colours)
Text and font size:
“Complaint, compliment and suggestion box” – Arial 72
Repeat text translated into two other languages according to most
prevalent language in the province
“Note: this box will be opened weekly” – Arial 32
Lock Lock with number sequence to lock
Mounted Must be mounted onto the wall, 1.2m above the ground.
Page | 203
Annexure 51: Complaints, compliments and suggestion form
FORM TO LODGE A COMPLAINT OR RECORD A COMPLIMENT OR SUGGESTION
Date completed Ref no

(office
use)
Do you want to: Complaint Give a compliment Make a suggestion

(mark the applicable box with an X)
Details of the person lodging a complaint or recording a compliment or suggestion

Surname
First Name
Contact details Cell number
Postal address
Physical address
E-mail address
Service area (e.g ward no, reception,
pharmacy)
Hospital or clinic file number
If you are submitting on behalf of someone else, please complete the following:
Relation to the patient, e.g. mother, etc.
Patient’s Surname
Patient’s First Name
Contact details of Cell number
the patient Postal address
Physical address
E-mail address
Service area (e.g ward no, reception,
pharmacy)
Patient’s hospital or clinic file number
Please describe the complaint or give a compliment or make a suggestion.

* Where possible also record the staff involved and department where the incident took place.
Date on which the complaint took place:
_______________________________ ________________________________
Signature of person lodging the complaint Signature of patient
Page | 204
Annexure 52: Complaints, compliments and suggestions poster
Page | 205
Annexure 53: Example of a schedule for acknowledgement of policies/
guidelines/protocols /SOP/notifications
Facility name: __________________________________
Document name: ____________________
NAME AND PERSAL DESIGNATION DATE SIGNATURE

SURNAME NUMBER
Page | 206
Annexure 54: Example of a system to organise medicine in the medicine
room
1. Pharmaceutical stock may be arranged according to the provincial clinic order list, by
dosage form (e.g. tablets/capsules, liquids, injections, topical preparations etc) or in
categories per disorder (e.g. diabetes, asthma, epilepsy, TB, HIV).
2. The applicable SOP and space available in the medicine room must be taken into
consideration when deciding which approach to use.
3. Store items by generic name.
4. Label brazier bins or shelves neatly.
5. A colour coding system may be used to assist in the identification of medicines. The
same colour coding used in the medicine room should be used in the organization of
medicine stored in the consulting room/s. Refer Table 1 for an example of a colour
coding system.
6. Pack stock in the designated storage location (brazier bin) for the item.
7. Stock must be stored and rotated using FEFO/FIFO principles.
8. Expired, damaged and obsolete stock must be removed from the shelves and stored in
a separately designated area and disposed of according to approved procedures
Table 1: colour coding for brazier bins
CATEGORY COLOUR COLOUR

INDICATION
ANTIBIOTICS ORANGE ORANGE
ACUTE AILMENTS NEON YELLOW NEON YELLOW
ANTENATAL NEON PINK NEON PINK
ASTHMA BLUE BLUE
DIABETES LIGHT BLUE LIGHT BLUE
EPILEPSY LIGHT PURPLE LIGHT PURPLE
FAMILY PLANNING LIGHT PINK LIGHT PINK
HEART & RED
RED
HYPERTENSION
HIV GREEN GREEN
TB YELLOW YELLOW
PAIN PINK PINK
NOTE: These colour indications are for the various categories of medicine, as per the
provincial ordering list.
Page | 207
Example of a medicine
room/dispensary with a colour
coding system to organise the
medicine
Page | 208
Annexure 55: Checklist for element 94 - Medicine room/dispensary is
neat and medicines are stored to maintain quality
Use the checklist below to check how the facility stores medicine to ensure that quality
medicines are available
Y (Yes) = if present and compliant; N (No) = if not present or not compliant
Item Score
Access to the dispensary/medicine room is controlled at all times
There are no cracks, holes or signs of water damage in the
dispensary/medicine room
There is sufficient space in the dispensary/medicine room to store
medicines needed in the facility
There are no medicines stored in direct contact with the floor
The dispensary/medicine room is clean
There is no evidence of pests in the dispensary/medicine room
Medicines are stored neatly on shelves
Medicines are stored according to a classification system
Brazier bins (storage organisers) are neatly labelled
Medicines are packed according to FEFO (First Expired, First Out)
principles
No expired medicines observed in the dispensary/medicine room.
There is evidence that a medicines stock-take was carried out in the last
12 months
Access to the dispensary/medicine room is controlled at all times
Total score
Score calculation:
Y = 1, N = 0, NA = NA
90% Green
40-89% Amber
<40% Red
Page | 209
Annexure 56: Example of a temperature control chart for medicine
room/dispensary
DAILY MEDICINE ROOM/DISPENSARY TEMPERATURE RECORD
FACILITY DISTRICT
MONTH/YEAR
RECORD TEMPERATURE DAILY
DAY TEMPERATURE COMMENT* DAY TEMPERATURE COMMENT*

(°C) (°C)
1 17
2 18
3 19
4 20
5 21
6 22
7 23
8 24
9 25
10 26
11 27
12 28
13 29
14 30
15 31
16
______________________
Signature of supervisor Date:
* Indicate action taken when the temperature recorded exceeds 25 °C under the comments section.
Action to take when the room temperature exceeds 25 °C:
1. Check that the air conditioner is on. If not, check the electricity supply to the air
conditioner and switch the air conditioner on.
2. If there are no challenges with the electricity supply but the air conditioner is not on
OR if the air conditioner is on but not in good working order, place an urgent
works/procurement order for repairs/replacement using district procurement
procedures.
3. Open windows and use electrical fans where available to reduce the temperature
until air conditioner is functional
Page | 210
Annexure 57: Example of a temperature control chart for medicine refrigerator
DAILY REFRIGERATOR TEMPERATURE RECORD
FACILITY MONTH/YEAR DISTRICT
Record temperature at 08:00 and 15:00 daily
Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Deg. °C AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM
22
20
UNSAFE
18
16
14
12
10
8
SAFE
6
4
2
0
UNSAFE
-2
-4
-8
-10
T
OS
FR
DE
* Indicate in the ‘Defrost’ section of the temperature chart the date and time when the fridge is defrosted.
______________________
Signature of supervisor Date:
Action to take when the temperature moves into the “UNSAFE” range:
1. Check the electricity supply connection. Check the gas supply – is there a spare gas cylinder?
2. Check that the door closes properly. Check that the door has not been left open for a while. Check how often the fridge door is opened. Make sure that the fridge
is not overloaded.
3. Check how thick the ice build-up is in the freezing compartment. DEFROST IF THE ICE IS MORE THAN 0.5CM THICK – CLEAN THE FRIDGE REGULARLY.
4. Implement your contingency plan if the fridge is malfunctioning. Notify your supervising pharmacist, sub-district and/or district pharmacy and PHC managers of the
challenge.
Page | 211
Annexure 58: Checklist for element 98 - Cold chain procedure for
vaccines is maintained
Use the checklist below to check whether the cold chain for vaccines is maintained
Y (Yes) = compliant;, N (No) = not compliant
Item Score
There is a standard operating procedure for the maintenance of cold chain for
vaccines
Facility has a vaccine or medicine refrigerator with a thermometer
The temperature of the refrigerator is recorded twice daily, 7 hours apart (check one
month’s record)
The temperature of the refrigerator is maintained between 2-8 ºC (check one

month’s record)
There is a cooler box for storage of vaccines if needed
Ice packs are available for use as needed
Total score for all
Score calculation: Percentage Score

obtained
Y = 1, N = 0 100% Green
40-99% Amber
<40% Red
Page | 212
ANNEXURE 59: Checklist for element 99 - Medicine cupboard or
trolley is neat and orderly
Use the checklist below to check whether the medicine cupboard or trolley is neat and
orderly
Check – randomly select two consultation rooms (if the facility has only one, score this) and check
whether the medicine cupboard or trolley complies with measures
Score Score
Item Consultation Consultation
room 1 room 2
Surfaces inside the cupboard/trolley are clean
Medicines are neatly grouped together according to a

classification system e.g. by dosage form (tablets/capsules,
liquids, ointments, drops etc.) in alphabetical order and by
generic name
Medicine packets/bottles are clean and dust free
There are no loose tablets or vials lying around
There are no used unsheathed needles lying around or

placed in open vials
Total Score
Total Maximum possible score (sum of all scores minus

the ones marked NA)
Percentage (Total score ÷ Total maximum possible %

score) x 100

obtained
Y = 1, N = 0, NA = NA 100% Green
40-99% Amber
<40% Red
Page | 213
ISSUED AND RECEIVED
Medicine Quantity Strength Signature of Signature of Requisition/
Date
issued registered pharmacist order
nurse number
Medicine
Balance

Name of
patient
*Note: Does not have to be completed if issued by a pharmacist

Patient
Strength
No
Annexure 60: Register for schedule 5 and 6 medicines
Date
Schedule 5 and 6 Medicine Register
Time
Dose
given
Prescriber
Signature
Rank of
person
Pack size
administer
ing
Signature
Page | 214
Rank of
person
checking*
ANNEXURE 61: Checklist for element 101 - Electronic networked
system for monitoring the availability of medicine is used
effectively
Use the checklist below to check whether the electronic networked system for monitoring the
availability of medicines is used appropriately
Item Score
The facility has functional electronic networked system for monitoring the availability of
medicines
The approved list of medicines to be updated is visible in the medicine room
The facility updates the electronic networked system at least weekly
The capturing device and its accessories are in good working order
The capturing device and its accessories are stored in a lockable unit
Access to the keys for the unit where the capturing device is kept is restricted
The facility has not been marked as non-reporting for two weeks (10 working days) or
more (at the point of assessment)*
Total score for all
* Source for this information will be the website used to view captured medicine availability data and
the Primary Health Care Facility Dashboard associated with it.
Score calculation: Y = 1, N = 0

> 80 % Green
50 – 79 % Amber
< 50 % Red
Page | 215
Annexure 62: Essential Medicines List for Primary Health Care Facilities
ATC MEDICINE ATC MEDICINE

A02BC Proton-pump inhibitor, oral B05XA05 Magnesium sulphate, parenteral
A02BC03 Lansoprazole, oral C01CA24 Epinephrine (adrenaline), parenteral
A03BA01 Atropine, parenteral C01DA Nitrates, short acting, oral
A03BB01 Hyoscine butylbromide, oral C01DA08 Isosorbide dinitrate, oral
A03FA01 Metoclopramide, oral C01DA14 Isosorbide mononitrate, oral
A03FA01 Metoclopramide, parenteral C02AB01 Methyldopa, oral
A06AB06 Sennosides A and B, oral C03AA Thiazide Diuretic
A06AD11 Lactulose, oral C03AA03 Hydrochlorothiazide, oral
A07AA02 Nystatin, oral C03C Loop Diuretic, oral
A07BA01 Charcoal, activated C03C Loop Diuretic, parenteral
A07CA Oral rehydration solution (ORS) C03CA01 Furosemide, oral
A07DA03 Loperamide, oral C03CA01 Furosemide, parenteral
A10AB Insulin, short/rapid acting C03DA01 Spironolactone, oral
A10AC Insulin, intermediate acting C05AX02 Bismuth subgallate compound, topical
A10AD Insulin, biphasic C07A ß-blocker, oral
A10BA02 Metformin, oral C07AB11 Atenolol, oral
A10BB Sulphonylureas, oral C07AG Alpha 1 and non-selective ß blocker, oral
A10BB01 Glibenclamide, oral C07AG02 Carvedilol, oral
A10BB12 Glimepiride, oral C08CA Calcium channel blocker, long acting, oral
A11B Multivitamin, oral C08CA01 Amlodipine, oral
A11CA01 Vitamin A (retinol), oral C08CA05 Nifedipine, short-acting, oral
A11DA01 Thiamine (vit B1), oral C09A ACE-Inhibitor, oral
A11EA Vitamin B Complex, oral C09AA02 Enalapril, oral
HMGCoA reductase inhibitors (statins),
A11HA01 Nicotinamide (vitamin B3), oral C10AA oral
A11HA02 Pyridoxine (vit B6), oral C10AA01 Simvastatin, oral
A12AA04 Calcium carbonate, oral D01AC Imidazole, topical
A12CB Zinc, elemental, oral D01AC01 Clotrimazole, topical
B01AC06 Aspirin, oral D01AE12 Salicylic Acid, topical
B01AD01 Streptokinase, parenteral D01AE13 Selenium sulphide, topical
Vitamin K1 (phytomenodione),
B02BA01 parenteral D02A Emollient
B03A Iron, oral D02AB Zinc and caster oil ointment
B03AA Ferrous lactate, oral D02AC Petroleum Jelly
B03AA02 Ferrous fumarate, oral D02AX Aqueous cream (UEA)
B03AA03 Ferrous gluconate, oral D02AX Emulsifying ointment
B03AD03 Ferrous sulphate compound (BPC), oral D04AB01 Lidocaine, topical
B03BB01 Folic Acid, oral D04AB06 Tetracaine, topical
B05BA03 Dextrose, I.V. solution D04AX Calamine lotion
B05BB01 Sodium Chloride 0.9%, I.V. solution D05AA Coal Tar (LPC), topical
B05CB01 Sodium Chloride 0.9%, irrigation D07AA02 Hydrocortisone, topical
Page | 216
D07AC01 Betamethasone, topical H03AA01 Levothyroxine, oral
D08AC02 Chlorhexidine, topical J01AA02 Doxycycline, oral
D08AG02 Povidone iodine, topical J01CA01 Ampicillin, parenteral
D08AG03 Iodine tincture BP, topical J01CA04 Amoxicillin, oral
D09AA Bismuth iodoform paraffin paste (BIPP),
topical J01CE02 Phenoxymethylpenicillin, oral
Benzathine benzylpenicillin (depot
D09AX Paraffin gauze dressings J01CE08 formulation), parenteral
D10AD Retinoids, topical J01CF05 Flucloxacillin, oral
D10AD01 Tretinoin, topical J01CR02 Amoxicillin/Clavulanic Acid, oral
D10AE01 Benzoyl peroxide, topical J01DB01 Cephalexin, oral
G01AF02 Clotrimazole, vaginal J01DD04 Ceftriaxone, parenteral
Trimethoprim/Sulfamethoxazole
G02AB03 Ergometrine, parenteral J01EE01 (Cotrimoxazole), oral
G02AD06 Misoprostol J01FA Macrolide, oral
G02BA02 Copper IUD J01FA01 Erythromycin, oral
Contraceptives. Hormonal for systemic
G03A use J01FA10 Azithromycin, oral
Contraceptives, monophasic: combined
G03AA estrogen/progestin pill J01GB04 Kanamycin, parenteral
Ethinyloestradiol/levonorgestrel
G03AA07 30mcg/150 mcg, oral J01MA Fluoroquinolone, oral
Contraceptives, triphasic: combined
G03AB estrogen/progestin pill J01MA02 Ciprofloxacin, oral
G03AB03 Levonorgestrel/Ethinyl oestradiol, oral J01MA14 Moxifloxacin, oral
G03AC Contraceptives, levonorgestrel, implant J01XD01 Metronidazole, oral
Contraceptives, monophasic: progestin
G03AC only pill J02AC01 Fluconazole, oral
G03AC Contraceptives, progestin only pill J04AB02 Rifampicin (R), oral
Contraceptives, progestin-only
G03AC injectable, parenteral J04AC01 Isoniazid (H/INH), oral
Contraceptives, progestin-only
G03AC subdermal implant H03AA01 Levothyroxine, oral
G03AC03 Levonorgestrel pill J01AA02 Doxycycline, oral
Contraceptives, medroxyprogesterone
G03AC06 acetate depot, parenteral J01CA01 Ampicillin, parenteral
G03AC08 Etonogestrel, implant J01CA04 Amoxicillin, oral
Progestin-only, emergency
G03AD contraceptive, oral J01CE02 Phenoxymethylpenicillin, oral
Levonorgestrel, emergency Benzathine benzylpenicillin (depot
G03AD01 contraceptive, oral J01CE08 formulation), parenteral
G03C Estrogen, oral J01CF05 Flucloxacillin, oral
G03CA03 Estradiol valerate, oral J01CR02 Amoxicillin/Clavulanic Acid, oral
G03CA57 Estrogens conjugated, oral J01DB01 Cephalexin, oral
G03DA02 Medroxyprogesterone acetate, oral J01DD04 Ceftriaxone, parenteral
Trimethoprim/Sulfamethoxazole
G03DC02 Norethisterone acetate, oral J01EE01 (Cotrimoxazole), oral
G03HA01 Cyproterone acetate, oral J01FA Macrolide, oral
H01BB02 Oxytocin, parenteral J01FA01 Erythromycin, oral
H01BB02/
G02AB03 Oxytocin/ergometrine, parenteral J01FA10 Azithromycin, oral
H02AB01 Betamethasone, parenteral J01GB04 Kanamycin, parenteral
H02AB07 Prednisone, oral J01MA Fluoroquinolone, oral
H02AB09 Hydrocortisone, parenteral J01MA02 Ciprofloxacin, oral
Page | 217
J01MA14 Moxifloxacin, oral M02AC Methyl Salicylate Ointment
J01XD01 Metronidazole, oral M04AA01 Allopurinol, oral
J02AC01 Fluconazole, oral N01AX13 Nitrous Oxide, general anesthetic
J04AB02 Rifampicin (R), oral N01BB02 Lidocaine 1%, parenteral
J04AC01 Isoniazid (H/INH), oral N01BB02 Lidocaine 2%, parenteral
Lidocaine with epinephrine
J04AD03 Ethionamide, oral N01BB52 (adrenaline), parenteral
J04AK01 Pyrazinamide (Z), oral N02AA01 Morphine, parenteral
J04AK02 Ethambutol (E), oral N02AA01 Morphine, oral
J04AK03 Terizidone, oral N02AB02 Pethidine, parenteral
J04AM02 Rifampicin/Isoniazid (RH), oral N02AX02 Tramadol, oral
Rifampicin/Isoniazid/Pyrazinamide/Et
J04AM06 hambutol (RHZE), oral N02BE01 Paracetamol, oral
Phenobarbital (phenobarbitone),
J05AB01 Aciclovir, oral N03AA02 oral
J05AE03 Ritonavir, oral N03AB02 Phenytoin, oral
J05AE08/
J05AE03 Atazanavir/ritonavir, oral N03AE Benzodiazepines (antiepileptics)
J05AF01 Zidovudine, oral N03AF01 Carbamazepine, oral
J05AF05 Lamivudine, oral N03AG01 Valproate, oral
J05AF06 Abacavir, oral N03AX09 Lamotrigine, oral
J05AF07 Tenofovir, oral N04A Anticholinergic agents, oral
J05AF09 Emtricitabine, oral N04A Anticholinergic agents, parenteral
J05AG01 Nevirapine, oral N04AA02 Biperiden, parenteral
J05AG03 Efavirenz, oral N04AB02 Orphenadrine, oral
J05AR10/J05AE03 Lopinavir/ritonavir, oral N05AA01 Chlorpromazine, oral
J06BB01 Fluphenazine decanoate,
Anti-D immunoglobulin N05AB02 parenteral
J06BB05 Rabies Immunoglobulin (RIG) N05AD01 Haloperidol, parenteral
J07AG01 Haemophilus Influenzae Type B (Hib)
vaccine N05AD01 Haloperidol, oral
Pneumococcal conjugated vaccine
J07AL02 (PCV) N05AF01 Flupenthixol decanoate, parenteral
J07AM01 Tetanus toxoid (TT) N05AF05 Zuclopenthixol acetate, parenteral
J07AM51 Zuclopenthixol decanoate,
Tetanus and diptheria (Td) vaccine N05AF05 parenteral
J07AM51 Diptheria, tetanus and pertussis(DTP)
vaccine N05AX08 Risperidone, oral
J07BB Influenza vaccine N05BA Benzodiazepines (anxiolytics)
J07BC01 Hepatitis B (HepB) vaccine N05BA01 Diazepam, oral
J07BD01 Measles vaccine N05BA01 Diazepam, parenteral
J07BF Oral polio vaccine (OPV) N05CD Benzodiazepines (sedatives)
J07BG01 Rabies vaccine N05CD08 Midazolam, parenteral
J07BH Rotavirus vaccine N06AA Tricyclic antidepressants, oral
Hexavalent - diptheria, tetanus,
acellular pertussis, inactivated polio,
hepatitis B, haemophilus influenza
J07CA09 type b vaccine N06AA09 Amitriptyline, oral
Bacillus Calmette-Guerin (BCG) Selective serotonin reuptake
L03AX03 vaccine N06AB inhibitors (SSRIs), oral
M01A NSAID, oral N06AB03 Fluoxetine, oral
M01AE01 Ibuprofen, oral N06AB04 Citalopram, oral
Page | 218
P01AB01 Metronidazole, oral
P01BC01 Quinine dihydrochloride, parenteral
P01BE03 Artesunate, parenteral
P01BF01 Artemether/lumefantrine, oral
P02BA01 Praziquantel, oral
P02CA01 Mebendazole, oral
P02CA03 Albendazole, oral
P03AC04 Permethrin, topical
P03AX01 Benzyl benzoate, topical
R01AA05 Oxymetazoline, nasal
R01AA14 Epinephrine (adrenaline), inhalation
R01AD Corticosteroid, nasal
R01AD05 Budesonide, nasal
R03AC ß2 agonist, short acting, inhaler
Long-acting beta2 agonist/corticosteroid
R03AK combination, inhaler
R03AK06 Salmeterol/fluticasone, inhaler
R03BA Corticosteroids, inhaled
R03BA01 Beclomethasone, inhaler
R03BB01 Ipratropium Bromide, inhaler
R03AC02 Salbutamol, inhaler
R05 Cough Syrup
R06AB04 Chlorphenamine, oral
R06AD02 Promethazine, parenteral
R06AE07 Cetirizine, oral
S01AA01 Chloramphenicol, opthalmic
S01EC01 Acetazolamide, oral
S01FA01 Atropine, opthalmic
S01GA04 Oxymetazoline, opthalmic
S01GX01 Sodium Cromoglycate, opthalmic
S01HA03 Tetracaine (amethocaine), opthalmic
S01XA03 Sodium Chloride, hypertonic, I.V.
solution
S02AA10 Acetic acid in alcohol 2%, otological
V03AB15 Naloxone, parenteral
V03AN01 Oxygen
V06DC01 Dextrose, oral
Water for injection/ sterile water,
V07AB parenteral
Page | 219
Annexure 63: Checklist for element 102 - 90% of the medicines on the
tracer medicine list are available
Availability of tracer medicines listed below should be measured on an electronic networked
stock availability monitoring system
Scoring – where an electronic networked stock availability monitoring system is not available, use
the scoring columns in the list below to score availability as follows:
Check – available stock in the medicine room/dispensary
MEDICINE ROOM/DISPENSARY
Oral formulations/inhalers
Score Score
Abacavir 20mg/ml (240 ml) syrup Lopinavir, Ritonavir 200/50mg tablets
Abacavir 60mg tablets Lopinavir, Ritonavir 80/20mg/ml (60 ml)
Amlodipine 5mg tablets Metformin 500mg OR 850mg tablets
Amoxicillin 250mg OR 500mg capsules Methyldopa 250 mg tablets
Amoxicillin suspension 125mg/5ml OR Metronidazole 200mg OR 400mg tablets
250mg/5ml
Aspirin 300mg tablets Nevirapine 200mg tablets
Azithromycin 250mg OR 500mg tablets Nevirapine 50mg/5ml suspension
Beclomethasone 100mcg or 200 mcg Oral rehydration solution
inhaler
Carbamazepine 200mg tablets OR Paracetamol 120mg/5ml syrup
lamotrigine 25mg tablets
Co-trimoxazole 200/40mg per 5ml 50ml Paracetamol 500mg tablets
OR 100ml suspension
Co-trimoxazole 400/80mg tablets Prednisone 5mg tablets
Efavirenz 200 mg capsules Pyrazinamide 500mg tablets
Efavirenz 50mg capsules Pyridoxine 25mg tablets
Enalapril 10mg tablets Rifampicin + Isoniazid (RH) 300mg/150mg
OR 150/75mg tablets
Ferrous lactate/gluconate suspension Rifampicin + Isoniazid (RH) 60/60 tablets
Ferrous sulphate/fumarate tablets Rifampicin + Isoniazid + pyrazinamide +

providing ± 65mg elemental iron ethambutol (RHZE) (150/75/400/275)
tablets
Folic acid 5 mg tablets Salbutamol inhaler
Hydrochlorothiazide 12.5mg OR 25mg Simvastatin 10mg tablets
tablets
Ibuprofen 200 mg OR 400mg tablets Tenofovir, Emtricitabine 300/200 mg
tablets
Isoniazid 100mg OR 300mg tablets Tenofovir/emtricitabine/efavirenz
300/200/600mg tablets
Lamivudine 10mg/ml (240ml) syrup Vitamin A 50 000U OR 100 000U OR 200
000U capsule
Page | 220
Lamivudine 150mg tablets Zidovudine 50mg/5ml, 200 mlsuspension
Injections
Score Score
Medroxyprogesterone acetate 150mg/ml
Benzathine benzylpenicillin 2.4MU vial
injection OR norethisterone 200mg/ml
Ceftriaxone 500mg OR 1g ampoules
Topicals
Score Score
Chloramphenicol 1%, ophthalmic
ointment
Fridge
Score Score
BCG vaccine Pneumococcal Conjugated Vaccine (PCV)
Insulin, short acting Polio vaccine (oral)
Measles vaccine Rotavirus vaccine
Hexavalent: DTaP-IPV-HB-Hib vaccine Tetanus toxoid (TT) vaccine
Oxytocin 5 OR 10 IU/ml OR oxytocin/
ergometrine combination)
Emergency trolley
Score Score
Adrenaline Injection 1mg/ml Magnesium sulphate 50%, 2ml ampoule
(Epinephrine)
Amlodopine 10mg tablets Midazolam (1mg/ml OR 5mg/ml) OR
Diazepam 5mg/ml
Dextrose 10% OR 50% intravenous Nifedipine 10mg capsules
solution
Furosemide 20mg ampoule Promethazine HCl 25mg ampoule
Hydrocortisone sodium succinate Sodium chloride 0.9% 1L
100mg/ml
Isosorbide dinitrate, sublingual, 5 mg
tablets
Total score /35 Total score /32
Percentage (Sum of 2 Total scores ÷ 67) x 100 %
Score calculation:
Y = 1, N = 0 > 90% Green
80 - 89% Amber
< 80% Red
Page | 221
Annexure 64: Checklist for element 105 - Basic surgical supplies
(consumables) are available
Use the checklist below to check availability of medical and dressing supplies
Check – available stock in storage room
Y (Yes) = available; N (No) = not available; NA (not applicable) = if the facility uses consumables for
older HB models, AEDs and for the section named “Only applicable if the facility have a permanent
doctor”
SURGICAL SUPPLIES
Item Item
Score
Score
Admin set 20 drops/ml 1.8m /pack Gloves exam n/sterile large /box
Admin set paeds 60 drops/ml 1.8m /pack Gloves exam n/sterile medium /box
Blade stitch cutter sterile/pack Gloves exam n/sterile small /box
Blood collecting vacutainer (holding Gloves surg sterile latex sz 6 OR 6.5 OR
barrel/bulldog) small/box
Blood lancets (haemolance) Gloves surg sterile latex sz 7 OR 7.5 OR
medium/box
Urinary (Foley’s) catheter silicone/latex 14f Gloves surg sterile latex sz 8 OR large/box
Urinary (Foley’s) catheter silicone/latex 18f Intravenous cannula (Jelco) 18g green/box
Urine drainage bag Intravenous cannula (Jelco) 20g pink/box
Simple face mask OR reservoir mask OR Intravenous cannula (Jelco) 22g blue/box
nasal cannula (prongs) for oxygen, adults
Simple face mask OR reservoir mask OR Intravenous cannula (Jelco) 24g yellow/box
nasal cannula (prongs) for oxygen,
paediatric
Face mask for nebuliser OR face mask Needles: 18 (pink) OR 20 (yellow)/box
with nebuliser chamber for adult
Face mask for nebuliser OR face mask with Needles: 21 (green)/box
nebuliser chamber for paediatric
Nasogastric feeding tube 600mm fg8 Needles: 23 (blue)/box OR 22 (black)/box
Nasogastric feeding tube 1000mm fg10 OR
12 * Syringes 3-part 2ml/box
Disposable aprons * Syringes 3-part 5ml/box
Eye patches (disposable) * Syringes 3-part 10 or 20ml/box
Disposable razors Insulin syringe with needle/box
Suture chromic g0/0 or g1/0 1/2 75cm
Suture nylon g2/0 or g3/0 3/8 45cm
Suture nylon g4/0 3/8 45cm
Only applicable if the facility uses older HB model
Haemolysis applicator sticks HB chamber glass-grooved
HB meter clip HB cover glass-plain
Only applicable if facility uses an Automatic External Defibrillator (AED)
Replacement pads for AED - adult Replacement pads for AED – paediatric
Only applicable if facilities have a permanent doctor
Disposable Amnihook Dental syringe and needle for LA
Page | 222
Ultrasound gel medium viscosity
Sub-total 1 for surgical supplies Sub-total 2 for surgical supplies
Sub-total 1 Maximum score (sum of all Sub-total 2 Maximum score (sum of all
scores minus those NA) scores minus those NA)
DRESSINGS SUPPLIES
Item Pack Item Pack size
Score
Score
size
Plaster roll 1 Sanitary towels maternity /pack 12

Bandage crepe 1 Stockinette 100mm 1
OR150mm/roll
Gauze paraffin 100x100 /box 1 Adhesive micro-porous 1
surgical tape 24/25mm or
48/50mm
Gauze swabs plain n/s 100 70% isopropyl alcohol prep
200
100x100x8ply/pack pads 24x30 1ply OR 2 ply /box
Basic disposable dressing pack 1 Gauze abs grade 1 burn /pack
(should contain a minimum of:
cotton-wool balls, swabs, 2
forceps, disposable drape)
Cotton wool balls 1g 500`s 1
Sub-total 1 for dressing supplies Sub-total 2 for dressing supplies
Total score for surgical and dressing supplies
Total maximum score for surgical supplies (sum of all scores minus those marked NA)
and dressing supplies
Percentage (Total scores ÷ Total maximum score) x 100
Score calculation:
Y = 1, N = 0, NA = NA Percentage obtained Score
90% Green
40-89% Amber
<40% Red
* Syringe three part consists of the barrel, the plunger and the rubber piston
Page | 223
ANNEXURE 65: Checklist for element 107 - Required functional
diagnostic equipment and concurrent consumables for point of
care testing are available
Use the checklist below to check the availability of laboratory equipment and consumables
in the various areas where they are used
Y (Yes) = available; N (No) = not available; NA (not applicable) = only for malaria rapid strips – in
areas where malaria is not prevalent, malaria rapid strips to be marked NA
Item Score
Laboratory equipment and consumables
Hb meter
Blood glucometer
Spare batteries for blood glucometer
Glass slides for cervical smears
Lancets
Blood glucose strips
Urine dipsticks
Urine specimen jar OR flask
Malaria rapid test (where applicable in facilities in KZN, GP, MP and LP)
Rapid HIV test
Rh ‘D’ (Rhesus factor) test
Total score for all (Total score laboratory equipment + consumables +

stationery)
Total maximum possible score (sum of all scores minus those marked NA)

obtained
Y = 1, N = 0, NA = NA 100% Green
40-99% Amber
<40% Red
Page | 224
ANNEXURE 66: Checklist for element 108 - Required specimen
collection materials and stationery are available
Use the checklist below to check whether specimen collection materials and stationery are
available
Y (Yes) = available; N (No) = not available; NA (Not applicable) = as indicated
Item Score
Vacutainer tube: Blue Top (Sodium Citrate)
Vacutainer tube: Red OR Yellow Top (SST)
Vacutainer tube: Yellow Top (SST-Paeds)
Vacutainer tube: Grey Top (Sodium Fluoride)
Vacutainer tube: White Top
Vacutainer tube: Purple Top (EDTA)
Vacutainer tube: Purple Top (EDTA Paeds)
Sterile specimen jars
Swabs with transport medium (Score NA if there is not a permanent doctor)
Sterile Tubes (without additive) for MCS (Microscopy, culture and sensitivity) (Score
NA if there is not a permanent doctor)
Venipuncture needles (Green)
Specimen Plastic Bags
Pap smear collection materials

Fixative
Wooden spatula
Slide holder OR brown envelope
Microscope slides
Early Infant diagnosis (EID) collection material
DBS PCR Kit OR EDTA Microtainer tube
NHLS stationery
Request forms
PHC Request Form
Cytology Request Form
PHC Order Book Material for specimen collection
PHC Facility Specimen Register
Total Score
Percentage (Score ÷ 21) x 100

obtained
Y = 1, N = 0 100% Green
40-99% Amber
<40% Red
Page | 225
Illustration of NHL specimen collection materials
Use the correct specimen collection material as per specimen key next to each test
Page | 226
KEY
Specimen collection material
Vacutainer tube: Red Top R
BL
Vacutainer tube: Blue Top (Sodium Citrate)
Y
Vacutainer tube: Yellow Top (SST) and (SST-Paeds)
G
Vacutainer tube: Grey Top (Sodium Fluoride)
W
Vacutainer tube: White Top
P
Vacutainer tube: Purple Top (EDTA) and (EDTA Paeds)
SJ
Sterile specimen jars
DBS
Dried blood spot
Specimen Specimen
collection collection
Test material Test material
CHEMICAL PATHOLOGY
ALP (Alkaline Phosphatase) Y Phenytoin Y
ALT(Alanine Transaminase) Y Pleural effusion Protein R
Amylase/Lipase Y Potassium (serum) Y
Calcium (serum) Y Prostate-Specific Ag (PSA) Y
Cholesterol Y Sodium (serum) Y
Creatinine (eGFR) (serum) Y Total Bilirubin Y
CRP (C-reactive protein) Y Triglycerides Y
Folate (serum) P TSH (Thyroid-stimulating hormone) Y
FT4 (Free Throxine 4) Y Uric Acid (serum) Y
Gamma GT (GGT) (Serum) Y Urine albumin:creatinine ratio SJ
Glucose G Urine protein:creatinine ratio SJ
HbA1c (Glycated Haemoglobin) Y Vitamin B12 Y
LDL-Cholesterol (LDL-C) Y
Haematology Microbiology
Differential count P CRAG (Cryptococcal Antigen test) Y
Full Blood Count (FBC) P Hepatitis A IgM Y
Haemoglobin P Hepatitis B Surface Ab Y
INR (International Normalized Ratio) B HIV Elisa (discordant rapids) Y
Platelets P Stool parasites SJ
Red Cell Antibody screen (Coomb’s Y
Test) P Syphilis Serology
White Blood Cell (WBC) P MCS (Microscopy, culture band sensitivity)
HIV viral load TB testing
HIV Viral Load W/P Xpert MTB/RIF SJ
HIV DNA PCR TB Smear microscopy SJ
HIV DNA PCR DBS/P TB Culture SJ
HIV CD4 Count TB Drug Susceptibility SJ
CD4 Count P TB Line Probe Assay (Hain MTBDR) SJ
Blood grouping
ABO (Blood grouping) Y
Rhesus Factor (Rh) Y
Page | 227
Annexure 67: Checklist for element 109 - Specimens are collected,
packed, stored and prepared for transportation according to the primary
health care Laboratory Handbook
Use the checklist below to check whether specimens are handled according to the PHC
Laboratory Handbook
Check – three samples from each of the groups of specimens (A to C) as listed in Table 1 and
check whether they comply with the guidelines provided
Y (Yes) = handled correctly; N (No) = not handled correctly; NA (not applicable) = NA if the facility
does not have the specific group of specimen listed in Table 1 in storage.
Table 1: Grouping of specimens
Group A Group B Group C

Blood Pap smear MCS (Microscopy, culture
Pleural effusion band sensitivity)
Sputum
Stool
Urine
Group A Group B Group C
Item
sample 1
sample 2
sample 3
sample 1
sample 2
sample 3
sample 1
sample 2
sample 3
Score
Score
Score
Score
Score
Score
Score
Score
Score
General
Specimens are clearly labelled
Each laboratory request form is

correctly completed
There is at least one functional
wall mounted thermometer in
area where lab specimens are
stored for courier collection
The temperature of the storage
area for lab specimens is
recorded daily
Group A specimens
Samples are kept away from
direct sunlight
Where the room temperature
exceeds 25°C, samples are
stored in the fridge (at +- 5°C)
Page | 228
Length of storage does not
exceed 24 hours, stored at room
temperature (+- 20-25°C)
Group B specimens
Stored at room temperature
Stored inside a slide carrier
(envelope)
Group C specimens
Samples placed into the transport
medium provided (where
appropriate)
Samples kept away from direct
sunlight
Where room temperature
exceeds 25°C, samples are
stored in the fridge (+- 5°C)
Length of storage does not
exceed 24 hours, stored at room
temperature (+-20-25°C)
Score
Maximum possible score (sum
of all scores minus those
marked NA)
Total score for all samples

Total maximum possible score
(sum of all sample scores
Percentage (Total score ÷ Total
maximum possible score) x
100 %
Score calculation:
Y = 1, N = 0, NA = NA

100% Green
40-99% Amber
<40% Red
Page | 229
Annexure 68: Checklist for element 110 - The laboratory results are
received from the laboratory within the specified turnaround times
Use the checklist below to check whether the turnaround times for laboratory results are in
line with specifications
Check – register for sending and receiving laboratory results, check three records
Y (Yes) = results received within specified turnaround time; N (No) = results NOT received within
specified turnaround time; NA (not applicable) = if the specific result (listed under point 1 to 9) is not
in the record
No
Score record
Score record
Score record
Item
3
Turnaround time
1 All blood results except those listed in number 2 24 hours

and 3
2 Blood results: Cholesterol, CRP (C-reactive 24-48 hours
protein), FT4 (Free Throxine 4), HbA1c (Glycated
Haemoglobin), Phenytoin, lipase, PSA (Prostate
specific hormone), Red Cell Folate, Triglycerides,
TSH (Thyroidstimulating hormone), Vitamin B12,
CD4 Count, RPR(Rapid Plasma Reagin test for
syphilis), Hepatitis A, B or C
3 Blood results: HIV PCR for infants, viral load 48-120 hours
4 Pap smear Variable depending
on result (4-6
weeks)
5 MCS (Microscopy, culture band sensitivity) 24-72 hours
6 Sputum: TB 5 days-6 weeks
7 Sputum: Xpert MTB/RIF 24 hours

8 Stool 24 hours
9 Urine 24 hours
Score
Maximum possible score (sum of all scores minus those marked
NA)
Total score for all 3 samples checked
Total maximum possible score (sum of all samples checked minus

those marked NA)
Score calculation:
Y = 1, N = 0, NA = NA 100% Green
40-99% Amber
<40% Red
Page | 230
Annexure 69: Example of a work allocation schedule for staff
Date from Date to
Name and Designation Service area Date Signature

surname of
staff member
Page | 231
Annexure 70: Annual leave schedule
ANNUAL LEAVE SCHEDULE (First 6 months)
Facility name: ____________________
Year: ____________________________
Month January February March April May June
Name and surname of

staff member
Week 1
Week 2
Week 3
Week 4
Week 1
Week 2
Week 3
Week 4
Week 1
Week 2
Week 3
Week 4
Week 1
Week 2
Week 3
Week 4
Week 1
Week 2
Week 3
Week 4
Week 1
Week 2
Week 3
Week 4
Example: Mr Xy
Example: Ms DB
Example: Mr TT
232 | P a g e
ANNUAL LEAVE SCHEDULE (Second 6 months)
Facility name: ____________________
Year: ____________________________
Month July August September October November December
Name and surname of

staff member
Week 1
Week 2
Week 3
Week 4
Week 1
Week 2
Week 3
Week 4
Week 1
Week 2
Week 3
Week 4
Week 1
Week 2
Week 3
Week 4
Week 1
Week 2
Week 3
Week 4
Week 1
Week 2
Week 3
Week 4
Example: Mr FF
Example: Ms DG
Example: Mr DT
233 | P a g e
Annexure 71: Example of a staff satisfaction survey
Rate the below questions as follows:
Disagree =1, Slightly disagree = 2, Slightly agree = 3, Agree = 4, Strongly agree = 5
ID Question Score
1 Staff Satisfaction Survey 1 2 3 4 5
1.1 Personal profile
1.1.1 Facility name:
1.1.2 Occupational class:
1.1.3 Occupational band:
1.1.4 Race:
1.1.5 Gender:
1.1.6 Age group:
1.1.7 Years of service:
1.1.8 Language:
1.2 Survey questions (score ranges from 0 to 5)
1.2.1 Direction/strategy/integration
I am clear on what the Department of Health's strategies and goals
1.2.1.1 are and my role in supporting their attainment
The Department of Health's strategies and goals directly supports
1.2.1.2 those of the National Department of Health
I am aware of the initiatives to create better integration of policies and
1.2.1.3 coordination across units
The implementation of integration policies will optimise use of
1.2.1.4 resources and enhance efficiencies
1.2.1.5 Management actively supports the integration initiatives
1.2.2 Morale
1.2.2.1 I feel valued as an employee
1.2.2.2 I enjoy being a part of this organisation
1.2.2.3 Employees have a good balance between work and personal life
1.2.2.4 Morale is high across the organisation
1.2.2.5 Employees speak highly about this organisation
1.2.3 Workload
There is enough staff employed to meet work demands in the
1.2.3.1 organisation
1.2.3.2 I am given enough time to do my job well
1.2.3.3 Sufficient time is available to work on agreed high priority activities
1.2.4 Wellbeing and security
1.2.4.1 I feel in control and on top of things at work
1.2.4.2 I feel emotionally well at work
1.2.4.3 I am able to keep my job stress at an acceptable level
1.2.4.4 I feel safe in my work environment
1.2.5 Job satisfaction
1.2.5.1 My work gives me a feeling of personal accomplishment
1.2.5.2 I like the kind of work I do
1.2.5.3 Overall I am satisfied with my job
1.2.6 Organisation commitment
1.2.6.1 I feel a sense of loyalty and commitment to the organisation
1.2.6.2 I am proud to tell people that I work at DoH
1.2.6.3 I feel emotionally attached to the organisation
1.2.6.4 I am willing to put in extra effort for the organisation
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1.2.7 Diversity
1.2.7.1 Diversity among staff is valued
1.2.7.2 Sexual harassment is prevented and discouraged at the organisation
1.2.7.3 Discrimination is prevented and discouraged at the organisation
Bullying and abusive behaviours are prevented and discouraged at
1.2.7.4 the organisation
1.2.7.5 There is equal opportunity for all staff in the organisation
The organisation has effective procedures for handling employee
1.2.7.6 grievances
Management provides support to staff in reporting any discrimination
1.2.7.7 or harassment
1.2.8 Change and innovation
1.2.8.1 Change is handled well in the organisation
1.2.8.2 The way the organisation is run has improved over the last year
1.2.8.3 The organisation is innovative
1.2.8.4 The organisation is good at learning from its mistakes and successes
1.2.9 Comments
Please provide any suggestions or recommendations you have to
1.2.9.1 improve performance across the organisation
1.2.10 Client orientation and quality of service
We understand the specific needs of our clients (people we provide
1.2.10.1 service to)
We are focused on delivering high-quality and timeous services to our
1.2.10.2 clients
We have sufficient facilities equipment and supplies to deliver quality
1.2.10.3 service
1.2.10.4 Our services meet our clients' needs
1.2.10.5 Department of Health's services are accessible to the community.
Department of Health's services are well known and appreciated in
1.2.10.6 the community.
1.2.11 Employee/management relations
1.2.11.1 Management sets high standards of excellence
Management creates an environment where employees are enabled
1.2.11.2 to perform their jobs well
1.2.11.3 Management values the role that unions play in the organisation
1.2.11.4 Management and unions engage in constructive conflict resolution
1.2.11.5 Management encourages collaboration across the organisation
1.2.11.6 Management treats employees fairly
1.2.12 Respect
1.2.12.1 I feel my input is valued by my peers
Knowledge and information sharing is a group norm across the
1.2.12.2 organisation
1.2.12.3 Employees consult each other when they need support
1.2.12.4 Individuals appreciate the personal contributions of their peers
When disagreements occur they are addressed promptly in order to
1.2.12.5 resolve them
1.2.13 Role clarity
1.2.13.1 The organisation’s goals and objectives are clear to me
Employees have a shared understanding of what the organisation is
1.2.13.2 supposed to do
1.2.13.3 Roles and responsibilities within the group are understood
1.2.13.4 Clear reporting structures have been established
Employees at this organisation have the right skill sets to perform their
1.2.13.5 job functions
1.2.13.6 My role has a clearly defined performance expectation
235 | P a g e
1.2.14 Performance/reward systems
1.2.14.1 People are involved in setting their own performance goals
1.2.14.2 People are recognised for achieving their goals
1.2.14.3 People are rewarded for the quality of their work
1.2.14.4 There is a clear link between performance and rewards
Management gives feedback that is specific enough to be used for
1.2.14.5 improving their performance
When people do not perform up to their potential action is taken to
1.2.14.6 help them improve and grow
1.2.14.7 People are rewarded for team efforts not only individual performance
1.2.15 Communication
1.2.15.1 I receive the information I need to perform my job well
When I need help I can ask others in my work group for suggestions
1.2.15.2 or ideas
Interpersonal communication and relationships contribute to
1.2.15.3 organisational performance
1.2.15.4 Our face-to-face meetings are productive
The organisation uses effective methods to communicate important
1.2.15.5 information
1.2.16 Career development
When a position needs to be filled in this organisation the best person
1.2.16.1 for the job is the one who gets it
The organisation continuously invests in developing the skills of its
1.2.16.2 employees
The organisation has effective training and education programmes to
1.2.16.3 assist people to do their jobs effectively
My responsibilities include challenging goals that encourage personal
1.2.16.4 growth
The organisation actively retains scarce talent required for efficient
1.2.16.5 quality care
1.2.17 Decision-making/management structures
The structure of the organisation supports cooperation between
1.2.17.1 functions and departments
1.2.17.2 I believe that the organisation manages its finances responsibly
The organisation supports the implementation of Batho Pele principles
to ensure that poor people are not further disadvantaged by the
1.2.17.3 system
1.2.17.4 There are clear policies and procedures for how work is to be done
SUB TOTAL SCORE (add the scores in each column)
TOTAL (add subtotal scores

AVERAGE PERCENTAGE (total/(109*5)
%
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Annexure 72: Occupational Health and Safety Register
OCCUPATIONAL HEALTH AND SAFETY REGISTER
NAME OF FACILITY:______________________
FINACIAL YEAR:___________________________
Date of Time Name and Designation Persal Nature of injury Official forms Outcome of investigation
Injury of surname of number submitted to (include cause and
Injury employee of district correctional actions taken
employee (Yes/No) to prevent reoccurrence)
APRIL
MAY
JUNE
JULY
AUGUST
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SEPTEMBER
OCTOBER
NOVEMBER
DECEMBER
JANUARY
FEBRUARY
MARCH
Verified at end of financial year by: Name and Surname___________________ Signature:____________________ Date:______
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Annexure 73: Expenditure report
NAME OF FACILITY:______________________ FINANCIAL YEAR:___________________________
SUBJECT: EXPENDITURE REPORT
MAIN ITEM COMPENSATION GOODS AND MACHINERY & PROV & LOCAL HOUSEHOLDS TOTAL
OF EMPLOYEE SERVICES EQUIPMENT GOVERNMENT
BUDGET R 5,301,000 R6,491,000 R 1,251,000 R 259,000 R 13,302,000
APRIL'15 R 345,650 R 79,427 R 425,107
MAY'15 R 300,845 R 1,161,304 R 1,462,149
JUNE'15 R 399,783 R 464,126 R 863,909
JULY'15 R -
AUGUST'15 R -
SEPTEMBER'15 R -
OCTOBER'15 R -
NOVEMBER'15 R -
DECEMBER'15 R -
JANUARY'16 R -
FEBRUARY'16 R -
MARCH'16 R -
ACTUAL R 1,046,308 R 1,704,857 R - R - R - R 2,751,165
VARIANCE R 4,254,692 R 4,786,143 R 1,251,000 R - R 259,000 R 10,550,165
% SPENT 20 26 21
PROJECTION R 1,395,077 R 2,273,143 R - R - R - R 3,668,220
EXPECTED MONTHLY EXPENDITURE

COMPENSATION OF EMPLOYEES R 44,175,000
GOODS AND SERVICES R540,917
MACHINERY & EQUIPMENT
TOTAL R 982,667
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Annexure 74 : CLEANING SCHEDULE
Key:
NAME OF FACILITY:______________________
Area to be cleaned
DAILY DUTIES Cleaning not applicable to that areas
Daily duties Consultation General and Toilets Staff

rooms waiting areas kitchen
Wash floor
Damp dust counter tops
Wipe door handles
Wash hand wash basin including taps Where applicable
Wash toilets (seats, urinals)
Wipe soap and paper towel dispensers Where applicable
Replenish paper towels
Replenish toilet paper
Replenish liquid soap dispensers Where applicable
Wash kitchen basin with taps
Damp dust kitchen equipment
Spot clean dirty wall surfaces
Damp dust dressing trolleys
Damp dust examination lamp
Damp dust chairs
General waste bins cleaned and lined with bag
Medical waste bins/boxes remove when full
Sharps containers, sealed and removed when 3 quarter full
Sanitary bins/boxes remove when full
Remove waste from all service areas to temporary storage area.
Tie and close all the general waste bags in the temporary storage area.
240 | P a g e
WEEKLY DUTIES
Weekly Duties Consultation General service Toilets Medicine room/ All other store
rooms and waiting areas dispensary rooms
Damp dust window sills
Wash mirrors
Damp dust wall skirtings
Wash floors
MONTHLY DUTIES
Monthly Duties All areas Consulting/ Toilets Staff kitchen Medicine All other
vital rooms room/ storage areas
dispensary
Wash and wipe signage boards
Wash inside-out when soap
dispensers are empty wash
inside and out
Clean refrigerator
Wipe out kitchen unit/cupboards
Damp dust shelves
QUATERLY DUTIES
Quarterly duties All areas

Strip all floors and apply polish
Damp dust light fixtures
Damp dust ceiling fans
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SIX MONTHLY DUTIES
Six monthly duties All areas

Wash all the walls from top to bottom
Wash windows
Remove, wash and replace all curtains
Cleaners to report any

dysfunctional/missing cleaning
equipment immediately to the
facility manager or healthcare
professional assigned to
supervise cleanliness
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ANNEXURE 75: Checklist for element 131 - Disinfectant, cleaning
materials and equipment are available
Use the checklist below to check whether the disinfectant, cleaning materials and equipment
are available
Y (Yes) = available; N (No) = not available; NA = Not applicable e.g.:

• Mop for exterior areas for facilities that do not have exterior areas to clean.
• Polish, stripper and floor polisher in facilities where the floor surface does not require
polishing.
Disinfectant and cleaning Material Score

High-level disinfection for medical equipment (e.g sodium perborate powder OR
phthalaldehyde)
Chlorine compounds (e.g Biocide D or Clorox)
Sanitary all-purpose cleaner
Detergent-based solutions
Wet polymer (floor polish)
Protective polymer (strippers)
All cleaning materials clearly labelled
Materials Safety Data Sheets for all cleaning products
Cleaning equipment Score
Two-way bucket system for mopping floors (bucket for clean water and bucket
for dirty water) OR Janitor trolley
Colour labelled mop – Red for toilets and bathrooms
Colour labelled mop – Blue for clinical areas and non-clinical service areas
Mop labelled for cleaning exterior areas
Green bucket and cloths for bathroom and consulting room basins
Red bucket and cloths for toilet
White cloths for kitchen
Blue bucket and cloths for clinical areas and non-clinical service areas
Spray bottle for disinfectant solution
Window cleaning squeegee
Mop sweeper or soft-platform broom
Floor polisher
Total score
Total maximum possible score (sum of total scores minus those marked
NA)
Percentage (Total score ÷ Total maximum possible score) x 100
Score calculation:
Y = 1, N = 0, NA = NA 100% Green
40-99% Amber
<40% Red
243 | P a g e
Annexure 76: Cleaning equipment
The following cleaning equipment must be available in the facility.
Double bucket mop Colour coded mops
Two way bucket system Janitor trolley

For mopping
Colour coded cleaning cloths
Colour coded Window squeegee Mop sweeper Spray bottle

buckets
244 | P a g e
Annexure 77: Regulations for material safety data sheets
Hazardous Chemical Substances Regulations, 1995
The Minister of Labour has under section 43 of the Occupational Health and Safety Act,
1993 (Act No. 85 of 1993), after consultation with the Advisory Council for Occupational
Health and Safety, made the regulations in the Schedule.
9A (1) Subject to section 10(3) of the Act, every person who manufactures, imports, sells
or supplies any hazardous chemical substance for use at work, shall, as far as is
reasonably practicable, provide the person receiving such substance, free of charge, with a
material safety data sheet in the form of Annexure 1, containing all the information as
contemplated in either ISO 1 1014 or ANSIZ400.1.1993 with regard to-
(a) product and company identification;

(b) composition/information on ingredients;
(c) hazards identification;
(d) first-aid measures;
(e) fire-fighting measures;
(f) accidental release measures;
(g) handling and storage;
(h) exposure control/personal protection;
(i) physical and chemical properties;
(j) stability and reactivity;
(k) toxicological information;
(l) ecological information;
(m) disposal considerations;
(n) transport information;
(o) regulatory information; and
(p) other information:
Provided that, where it is not reasonably practicable to provide a material safety data sheet,
the manufacturer, importer, seller or supplier shall supply the receiver of any hazardous
chemical substance with sufficient information to enable the user to take the necessary
measures as regards the protection of health and safety.
(2) Every employer who uses any hazardous chemical substance at work, shall be in
possession of a copy of Annexure 8 or a copy of sufficient information, as contemplated in
subregulation (1).
245 | P a g e
(3) Every employer shall make Annexure 8 or sufficient information, as contemplated in
subregulation (1), available at the request of any interested or affected person.
ANNEXURE 8
Material safety data sheet
No:
Date issued:
MATERIAL SAFETY DATA SHEET Page of
COMPANY DETAILS
Name: Emergency telephone no.:
Address: Telex:
Tel: Fax:
1) Product and Company Identification:
(Page 1 may be used as an emergency safety data sheet)
Trade name : Chemical abstract no. :
Chemical family : NIOSH no.:
Chemical name: Hazchem code:
Synonyms: UN no.:
2) Composition
Hazardous components:
EEC classification:
R Phrases:
3) Hazards Identification
Main hazard:
Flammability:
Chemical hazard:
Biological hazard:
Reproductive hazard:
Eye effects: eyes:
Health effects - skin:
Health effects - ingestion:
Health effects - inhalation:
Carcinogenicity:
Mutagenicity:
Neurotoxicity:
4) First-aid Measures
Product in eye:
Product on skin:
Product ingested:
Product inhaled:
5) Fire-fighting Measures
Extinguishing media:
Special hazards:
Protective clothing:
6) Accidental Release Measures
Personal precautions:
Environmental precautions:
Small spills:
Large spills:
246 | P a g e
7) Handling and Storage
Suitable material:
Handling/storage precautions:
8) Exposure Control/Personal Protection
Occupational exposure limits:
Engineering control measures:
Personal protection - respiratory:
Personal protection - hand:
Personal protection - eye:
Personal protection - skin:
Other protection:
9) Physical and Chemical Properties
Appearance:
Odour:
pH:
Boiling point:
Melting point:
Flash point:
Flammability:
Auto flammability:
Explosive properties:
Oxidizing properties:
Vapour pressure:
Density:
Solubility - water:
Solubility - solvent:
Solubility - coefficient
10) Stability and Reactivity
Conditions to avoid:
Incompatible materials:
Hazardous decomposition products:
11) Toxicological Information
Acute toxicity:
Skin and eye contact:
Chronic toxicity:
Carcinogenicity:
Mutagenicity:
Neurotoxicity:
Reproductive hazards:
12) Ecological Information
Aquatic toxicity - fish:
Aquatic toxicity - daphnia
Aquatic toxicity - algae
Biodegradability:
Bio-accumulation:
Mobility:
German wgk:
13) Disposal Considerations
Disposal methods:
Disposal of packaging:
14) Transport Information
UN no.
Substance indentity no.
ADR/RID class:
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ADR/RID item no.
ADR/RID hazard identity no.:
IMDG - shipping name:
MDG - class:
IMDG - packaging group:
IMDG - marine pollutant:
IMDG - EMS no.
IMDG - WAG tabel no.:
IATA - shipping name:
IATA - class:
IATA - subsidiary risk(s):
ADNR - class:
UK - description:
UK - emergency action class:
UK - classification:
Tremcard no.:
15) Regulatory Information.
EEC hazard classification:
Risk phases:
Safety phases:
National legislation:
16) Other Information
248 | P a g e
Annexure 78: Control sheet for sign-off for cleanliness
DAILY CHECKLIST FOR TOILETS
Facility name: _____________________
Date: _______
Area Mon Tuesday Wednesday Thursday Friday

day
Time Time Time Time Time
AM PM AM PM AM PM AM PM AM PM
Wash Floor
Clean basins
Wash mirrors
Wipe door handles
Clean toilets
Clean urinals
Clean sanitary
bins
Clean general bins
and line with bag
Remove bins that
are full
Replenish
disposable towels
Replenish soap
Replenish toilet
paper
Verification by manager OR delegated healthcare professional that areas are clean
Signature of
manager
Satisfied (Y)/Not
satisfied (N)
The cleaner and manager/delegated healthcare professional must sign/initial in the

appropriate space. Manager/delegated healthcare professional must also indicate the
level of satisfaction.
249 | P a g e
WEEKLY CHECKLIST FOR TOILETS
Facility name:______________________
Month:____________________ Year:___________________
Area WEEK 1 WEEK 2
Wednes--
Thursday
Thursday
Wednes-
Tuesday
Tuesday
Monday
Monday
Friday
Friday
day
day
Date

Wash mirrors
Damp dust wall skirting’s
Signature of manager
Satisfied (Yes)/Not
satisfied (N)
Area WEEK 2 WEEK 3

Wednes--
Thursday
Thursday
Wednes-
Tuesday
Tuesday
Monday
Monday
Friday
Friday
day
day
Date

Wash mirrors
Satisfied (Yes)/Not
satisfied (N)

appropriate space. Manager/delegated healthcare professional must also indicate the level of
satisfaction.
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MONTHLY/QUARTERLY/SIX MONTHLY CHECKLIST FOR TOILETS
Facility name:______________________
Year:___________________
Duties Jan Feb Mrt Apr May Jun Jul Aug Sept Oct Nov Dec
Wash inside-
out when
soap
dispensers
are empty
Damp dust
light fixtures
Wash all the
walls from
top to
bottom
Wash
windows
Signature of
manager
Satisfied
(Yes)/Not
satisfied (N)

satisfaction.
251 | P a g e
DAILY AND WEEKLY CHECKLIST FOR CONSULTATION/VITAL ROOMS
Facility name:______________________
Month:____________________ Year:___________________
Area WEEK 1 WEEK 2
Wednes--
Thursday
Thursday
Wednes-
Tuesday
Tuesday
Monday
Monday
Friday
Friday
day
day
Date
Wash floor
Wipe door handles
Wash handwash basin
including taps
Wash toilets (seats,
urinals)
Wipe soap and paper
towel dispensers
Replenish liquid soap

dispensers
Spot clean dirty wall
surfaces
Damp dust dressing
trolleys
Damp dust examination
lamp
Damp dust chairs
General waste bins

cleaned and lined with
bag
Medical waste bins/
boxes remove when full
Sharps containers,
sealed and removed
when 3 quarter full
Wash mirrors
Satisfied (Yes)/Not
satisfied (N)
satisfaction.
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DAILY AND WEEKLY CHECKLIST FOR CONSULTATION/VITAL ROOMS
Facility name:______________________
Month:____________________ Year:___________________
Area WEEK 3 WEEK 4
Wednes--
Thursday
Thursday
Wednes-
Tuesday
Tuesday
Monday
Monday
Friday
Friday
day
day
Date
Wash floor
Wipe door handles
Wash handwash basin
including taps
Wash toilets (seats,
urinals)
Wipe soap and paper
towel dispensers
Replenish liquid soap

dispensers
Spot clean dirty wall
surfaces
Damp dust dressing
trolleys
Damp dust examination
lamp
Damp dust chairs
General waste bins

cleaned and lined with
bag
Medical waste bins/
boxes remove when full
Sharps containers,
sealed and removed
when 3 quarter full
Wash mirrors
Satisfied (Yes)/Not
satisfied (N)
satisfaction.
253 | P a g e
MONTHLY/QUARTERLY/SIX MONTHLY CHECKLIST FOR CONSULTATION/VITAL
ROOMS
Facility name:______________________
Year:___________________
Wash inside-
out when
soap
dispensers
are empty
Strip all
floors and
apply polish
Damp dust
light fixtures
Damp dust
ceiling fans
Wash all the
walls from
top to
bottom
Wash
windows
Remove,
wash and
replace all
curtains
Signature of
manager
Satisfied
(Yes)/Not
satisfied (N)

satisfaction.
254 | P a g e
WEEKLY AND DAILY CHECKLIST FOR MEDICINE ROOM/DISPENSARY
Facility name:______________________
Month:____________________ Year:___________________
Area WEEK 1 WEEK 2
Wednes--
Thursday
Thursday
Wednes-
Tuesday
Tuesday
Monday
Monday
Friday
Friday
day
day
Date
Wash floors
Satisfied (Yes)/Not
satisfied (N)
Area WEEK 3 WEEK 4

Wednes--
Thursday
Thursday
Wednes-
Tuesday
Tuesday
Monday
Monday
Friday
Friday
day
day
Date
Wash floors
Satisfied (Yes)/Not
satisfied (N)
255 | P a g e
satisfaction.
Checklist for medicine/dispensing room for monthly/quarterly/six monthly cleaning

duties
Facility name:______________________
Year:___________________
Wash inside-
out when soap
dispensers are
empty
Damp dust
shelves
Strip all floors
and apply
polish
Damp dust
light fixtures
Damp dust
ceiling fans
Wash all the
walls from top
to bottom
Wash
windows
Remove,
wash and
replace all
curtains
Clean
refrigerator
Signature of
manager
Satisfied
(Yes)/Not
satisfied (N)

satisfaction.
256 | P a g e
DAILY AND WEEKLY CHECKLIST FOR STAFF KITCHEN
Facility name:______________________
Month:____________________ Year:___________________
Area WEEK 1 WEEK 2
Wednes--
Thursday
Thursday
Wednes-
Tuesday
Tuesday
Monday
Monday
Friday
Friday
day
day
Date
Wash floors
Satisfied (Yes)/Not
satisfied (N)
Area WEEK 3 WEEK 4

Wednes--
Thursday
Thursday
Wednes-
Tuesday
Tuesday
Monday
Monday
Friday
Friday
day
day
Date
Wash floors
Satisfied (Yes)/Not
satisfied (N)

satisfaction.
257 | P a g e
MONTHLY/QUARTERLY/SIX MONTHLY CHECKLIST FOR STAFF KITCHEN
Facility name:______________________
Year:___________________
Strip all floors
and apply
polish
Damp dust
light fixtures
Damp dust
ceiling fans
Wash all the
walls from top
to bottom
Wash
windows
Clean
refrigerator
Wipe out
kitchen unit/
cupboards
Signature of
manager
Satisfied
(Yes)/Not
satisfied (N)

satisfaction.
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Annexure 79: Checklist for element 132 – All service areas are clean
Use the checklist below to check whether the various service areas are clean
Check – randomly select two service areas as indicated in the column for the score
Y (Yes) = compliant; N (No) = not compliant; NA (not applicable) = if there are fewer areas in the
clinic than listed
Area and measures Score Score
CONSULTING ROOMS: Consulting Consulting

room 1 room 2
Windows clean
Window sills clean
Floor is clean
Wall skirting are free of dust
The countertops are clean
The door handles are clean
Mirrors are clean
Walls are clean
Bins are not overflowing
Bins are clean
The areas are odour-free
All areas free of cobwebs
Score for consultation rooms
Maximum possible score for consultation rooms (sum of all
scores minus NA)
Percentage for consulting rooms (Score ÷ Total maximum %
possible score) x100
VITAL SIGNS ROOMS: Vital signs Vital signs
room 1 room 2
Windows clean
Window sills clean
Floor is clean
Mirrors are clean
Walls are clean
Bins are not overflowing
Bins are clean
259 | P a g e
Score for vital signs rooms
Maximum possible score for vital rooms (sum of all scores
minus NA)
Percentage for vital signs rooms (Score ÷ Total maximum %
possible score) x 100
WAITING AREAS: Waiting Waiting
area 1 area 2
Windows clean
Window sills clean
Floor is clean
Walls are clean
Bins are not over flowing
Bins are clean
Score for waiting areas
Maximum possible score for waiting areas (sum of all scores
minus NA)
Percentage for waiting rooms (Total score ÷ Total maximum %
Summary for cleanliness of service areas
AREA Score Maximum possible

score
Consultation rooms
Vital signs rooms
Waiting areas
Total score ÷ Total maximum possible score
PERCENTAGE (Total score ÷ Total maximum possible score) x %
100
Score calculation:
Y = 1, N = 0, NA = NA 90% Green
40-89% Amber
<40% Red
260 | P a g e
Annexure 80: Checklist for element 133 - Clean running water, toilet
paper, liquid hand wash and disposable hand paper towels are available
Use the checklist below to check whether there is running water, toilet paper, liquid hand
wash soap and disposable hand paper towels
Check – randomly select two toilets, two consulting rooms and two vital signs room to review
Y (Yes) = available; N (No) = not available; NA (not applicable) if the facility has fewer areas than
listed for review, score available areas
Item Area 1 Area 2

Toilet Toilet 1 Toilet 2
Running water
Toilet paper
Liquid hand wash soap
Disposable hand paper towels
Consultation room Consultation Consultation
room 1 room 2
Vital signs room Vital signs Vital signs
room 1 room 2
Score

the ones marked NA)
Total score for all areas
Total maximum possible score (sum of all 3 areas
Percentage (Total score ÷ Total maximum possible %
score) x 100

Score calculation:
100% Green
Y = 1, N = 0, NA = NA 40-99% Amber
<40% Red
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Annexure 81: Checklist for element 135 - Sanitary and health care waste
are managed appropriately
Use the checklist below to check whether sanitary and healthcare waste are managed
appropriately
Check – randomly select two toilets and two consulting rooms
Y (Yes) = available/with lid and appropriately lined; N (No) = not available or no lid or not
appropriately lined; NA (not applicable) = if the facility has fewer than listed areas
SANITARY BINS
Score Score Score Score

Item Toilet 1 Toilet 2 Consulting Consulting
rooms 1 rooms 2
Sanitary disposal bins with functional

lids OR healthcare risk waste box
Sanitary disposal bins/boxes lined
with appropriate colour plastic bags
Sanitary disposal bins/boxes are clean
and not overflowing
Healthcare risk waste disposal bins
with functional lids OR healthcare risk
waste box
Healthcare risk waste disposal
bins/boxes lined with red plastic bags
bins/boxes contain only healthcare
waste
bins/boxes are not overflowing
Item Health care waste storage area
Healthcare risk waste is stored in an

controlled-access area
Healthcare waste storage area is
clean and free from rodents
Total score
Total maximum possible score

(sum of all minus those marked NA)
Percentage (Total score ÷ %
maximum possible score) x 100

obtained
100% Green
Y = 1, N = 0, NA = NA
40-99% Amber
<40% Red
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Annexure 82: Checklist for element 136 - General waste is managed
appropriately
Use the checklist below to check whether general waste is managed appropriately
Check – randomly select three consulting rooms to review
Y (Yes) = available and with lid and appropriately lined; N (No) = not available or no lid or not
appropriately lined; NA (not applicable) = if the facility has fewer than the listed areas
Item
Score Score Score

Bins Service area Service area Service area
1 2 3
Bins with functional lids
Lined with appropriate coloured bags
General storage area
General waste is stored in a designated

area
General waste is stored in appropriate
containers which are neatly packed or
stacked
Maximum possible score (sum of all
Total score for bins and general
Total maximum possible score (sum of

bins and general minus those marked
NA)
Percentage (Total score ÷ Total
maximum possible score) x 100
Score calculation:
Y = 1, N = 0, NA = NA

100% Green
40-99% Amber
<40% Red
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Annexure 83: Checklist for element 137 – All toilets are clean, intact and
functional
Use the checklist below to check whether the toilets are functional
Check – randomly select three toilets to review
Y (Yes) = intact; N (No) = not intact; NA (not applicable) = if the facility has fewer than three toilets
or has no urinals
Score Score Score

Item
Toilet 1 Toilet 2 Toilet 3
Cleanliness of toilets
Windows clean
Window sills clean
Floor is clean
Basins are clean
Walls are clean
Toilets/urinals are clean
Sanitary bins clean and not overflowing
Intact and functional
The toilet bowl seat and cover/squat pan is intact
The toilet bowl is stain free
The toilet flush/sensor flush is functional
The toilet cistern cover is complete and in place
The urinals are intact and functional
The urinal/flush sensor is functional
Score
thosemarked NA)
Total score for all 3 toilets
Total maximum possible score (sum of all 3 toilets (minus
those marked NA)
Percentage (Total score ÷ Total maximum possible score)
x 100
Score calculation:
Y = 1, N = 0, NA = NA 100% Green
40-99% Amber
<40% Red
Page | 264
ANNEXURE 84: Checklist for element 138 - The exterior of the
facility is aesthetically pleasing and clean
Use the checklist below to check whether the exterior of the facility is aesthetically pleasing
and clean
Check – observe the general exterior environment of the facility
Y (Yes) = compliant; N (No) = not compliant; NA (not applicable) = if the facility’s structural make-up
does not allow for gardens e.g. in a multi-storey building in a city, at least one prompt must be
scored, e.g. “There is no dirt and litter around facility premises”
Prompts Score
The facility’s premises are clean (e.g. free from dirt and litter)
Exterior walls of the facility are clean
Corridors are clean
Grass is cut
Paving is free of weeds
Flower beds are well kept and free of weeds
Total score
Total maximum possible score (sum of all scores minus

NA)
Percentage (Total score ÷ Total maximum possible score) %
x 100
Score calculation:
Y = 1, N = 0, NA = NA

90% Green
40-89% Amber
<40% Red
Page | 265
Annexure 85: Standard Operating Procedure for waste management
In terms of the national Departments Health’s draft regulations
(1) All health establishments that generate health care waste shall:
(a) have a duty of care to dispose of the waste safely in terms of the National
Environmental Management Act, 1998 (Act No. 107 of 1998) as amended;
(b) be legally and financially responsible for the safe handling and environmentally
sound disposal of the waste they produce in terms of the polluter pays principle;
(c) be precautious by always assuming that the waste is hazardous until

shown to be safe;
(d) have a cradle to grave responsibility of the waste from the point of generation until its
final treatment and disposal; and
(e) minimise, re-use, recycle and recover health care general waste in terms of the
National Waste Management Strategy, 2011 and any amendments thereof.
(2) Each minor and major generator of a health establishment shall take all
reasonable measures to ensure that:
(a) once health care risk waste is placed in a healthcare risk waste container, the
health care risk waste is not removed from that container for the purposes of
decanting it into another container; sorting it or; any other purpose; until such
health care risk waste is received by the licensed waste treatment or disposal
facility;
(b) re-usable containers are effectively cleaned and disinfected before reuse;
(c) all persons who manually handle containers of untreated health care risk waste
are provided and required to wear clean, protective gloves and overalls,
changeable laboratory coats or other appropriate personal protective equipment;
(d) all medical and non-medical staff shall be immunised for hepatitis and other
transmittable diseases prior to handling the waste; and
(e) the necessary equipment to deal with spillages and emergency incidents are readily
available and conform to the requirements as stipulated in the Occupational Health
and Safety Act, 1993 (Act No. 85 of 1993) as amended.
(3) All major and minor generators of a health establishment shall:
(a) identify and classify all healthcare risk waste generated in accordance with the
provisions of SANS 10248-1:2008: Management of health care waste – Part 1:
Page | 266
Management of health care risk waste from a health care facility and SANS 10229-
1:2010: Transport of dangerous goods – Packaging and large packaging for road and
rail transport, Part 1: Packaging; and the Waste Classification and Management
Regulations, 2013 and any amendments thereof.
(b) identify and classify all healthcare risk waste transported in accordance with the
provisions of SANS 10228:2012: The identification and classification of
dangerous goods for transport by road and rail modes;
(c) train employees on an ongoing basis in the correct identification and
classification of health care waste; and
(a) keep records of all training.
(4) All major and minor generators of a health establishment shall:
(a) segregate all health care waste generated at the point of generation and
containerise it to minimise the risk of contamination or pollution to human
health and the environment;
(b) take reasonably practicable measures to minimise the volume of healthcare

waste at source;
(c) separate health care general waste from health care risk waste;
(d) train employees on an ongoing basis in the correct segregation and
minimisation of health care waste; and
(e) keep records of all training.
(5) All major and minor generators of a health establishment shall ensure that:
(a) all health care risk waste to be transported be packaged and labeled in
accordance with the provisions of SANS 10229-1:2010: Transport of dangerous
goods Packaging and large packaging for road and rail transport, Part 1:
Packaging, SANS 452:2008: Non-reusable and reusable sharps containers
and Waste Classification and Management Regulations, 2013 and any
amendments thereof;
(b) all healthcare risk and health care general waste generated be packaged
and labelled in accordance with the provisions of SANS 10248-1:2008:
Page | 267
Management of health care waste – Part 1: Management of health care risk
waste from a healthcare facility; and Waste Classification and Management
Regulations, 2013 and any amendments thereof;
(6) All major and minor generators of a health establishment shall ensure that:
(a) all health care risk waste be stored in accordance with the provisions of the
Norms and Standards for Storage, 2013 under the Waste Act;
(b) All major generators of a health establishment must have dedicated intermediate
and central storage areas for health care risk waste storage.
(c) All minor generators of a health establishment shall designate appropriate
intermediate or central storage areas for health care risk waste.
(d) All health care general waste shall be stored in refuse receptacles as stipulated in
the provisions of the National Domestic Waste Collection Standards, 2011 and any
amendments thereof, under the Waste Act.
(7) (i) All major and minor generators of a health establishment shall ensure that the
collection and transportation of healthcare waste on and off site be in accordance
with the provisions in the SANS 10248-1:2008: Management of healthcare waste
– Part 1: Management of healthcare risk waste from a healthcare facility; and the
National Domestic Waste Collection Standards, 2011 and any amendments
thereof, under the Waste Act;
(ii) All major generators of a health establishment shall ensure that all
healthcare risk waste be weighed on site prior to collection at all times.
(iii) All minors generators of a health establishment shall ensure that all health
care risk waste be weighed at all times.
(iv) All vehicles used for health care risk waste collection and transportation must:
(a) conform to the requirements of the National Road Traffic Act, 1996 (Act No.
93 of 1996); SANS 10232-1:2007: Transport of dangerous goods –
Emergency information systems; Part 1: Emergency information system for
road transport; SANS 10231:2010: Transport of dangerous goods –
Operational requirements for road vehicles; SANS10229-1:2010: Transport
of dangerous goods– Packaging and large packaging for road and rail
transport, Part 1: Packaging and SANS 10228:2012: The identification and
Page | 268
classification of dangerous goods for transport by road and rail modes and
any amendments thereof;
(8) (a) All major and minor generators of a health establishment shall ensure that the on
and off site waste treatment and disposal facilities for health care risk waste shall
conform to all relevant legislation.
(b) The waste treatment facilities, combustion technologies, that treat health care risk
waste in operation, must have a valid atmospheric emission license and waste
management license in place in terms of the Air Quality Act and Waste
Act respectively.
(c) The waste treatment facilities, non-combustion technologies, that treat health care
risk waste and waste disposal facilities in operation, must have a valid waste
management license in place in terms of the Waste Act.
(d) The waste residues generated from health care risk waste treatment facilities’
combustion and non-combustion technologies must be disposed off in terms
of the relevant norms and standards under the Waste Act.
Page | 269
Annexure 86: Schedule for pest control
PEST CONTROL SCHEDULE

Name of facility: __________________
Year:_______________________
Key: Pest control scheduled to take place
ITEM
MAR
MAY
AUG
NOV
OCT
APR
DEC
SEP
JAN
FEB
JUN
JUL
Pest control
schedule
Date completed
Comments
(where
applicable)
Facility
manager’s
signature
Page | 270
ANNEXURE 87: checklist for element 145 - There is a standard
security guard room OR the facility has an alarm system linked to
armed response
Use the checklist below to check whether facility security adheres to standard guidelines
Y (Yes) = compliant; N (No) = not compliant; NA (not applicable) = if the facility’s structural make-up
does not allow for its own security guard room e.g. in a multi-storey building in a city or at very small
facilities. Security services should, however, still be available therefore measures listed under
equipment and stationery must be scored.
Item Score
Does the facility have an alarm system linked to armed response (if Yes,
checklist for security guardroom and security equipment must not be
assessed. If No, assess checklist for security guardroom and security
equipment)
Security guard room
Kitchenette – sink with cupboard underneath

Table
Chair
Functioning lights
Security equipment for security officer(s) and accompanying stationery
Baton
Handcuffs OR Cable ties
Incident book
Metal detector
Telephone OR two-way radio OR dedicated cellphone
Total score
Total maximum possible score (sum of all scores minus NA)
Percentage Score
Score calculation: obtained
100% Green
Y = 1, N = 0, NA = NA 41-99% Amber
<40% Red
Page | 271
Ideal Clinic manual Version 17
Annexure 88 : Register for security breaches
Name of facility: __________________
Year:_______________________
Date of Name of Name and surname Short description of Short description Actions taken to Signature
breach surname of of staff and or the breach of how the breach prevent of staff
staff managing patients involved in was managed reoccurrence managing
the breach the breach (where the breach
applicable)
January
February
March
April
May
Page | 272
June
July
August
September
October
November
December
Page | 273
Annexure 89: Checklist for element 149 – Functional firefighting
equipment is available
Use the checklist below to check whether firefighting equipment is available
Y (Yes) = available and intact; N (No) = not available and intact; NA (not applicable) = for fire hose if
the facility has less than 250 m2 floor area OR the facility has no water supply
Item Score
Fire extinguishers
Fire hoses and reels unless it is a single-storey building of less than 250
m2 in floor area OR the facility has no water supply
Two 9 kg or equivalent fire extinguishers where the facility has no water
supply
Firefighting equipment is maintained according to schedule
Total score
Percentage (Total ÷ 4) x 100 %
Score calculation:
Y = 1, N = 0

100% Green
41-99% Amber
<40% Red
X
Page | 274
Annexure 90: Control sheet for inspection of firefighting equipment
Facility name:
Date inspected:
Type of Location Date of Date of Condition of equipment

firefighting last next
equipment service service
Page | 275
Annexure 91: Evacuation plan
Name of facility:___________________________ Key: Exit routes
Page | 276
Annexure 92: Evacuation drill report
Date of Staff member Findings of evacuation drill (short Corrective action taken Date of repeating
evacuation responsible for falls) drill to establish if
drill arranging and shortfalls were
conducting drill corrected
Page | 277
Annexure 93: Checklist for element 155 - Clinic space accommodates all
services and staff
Use the checklist below to check whether internal and external areas offer sufficient space for task
performance
Check – whether the following areas are present and sufficient
Y (Yes) = available; N (No) = not available; NA (not applicable) = for small facilities that cannot
accommodate all recommended areas
Item Score
INTERIOR SPACE
General
Main waiting area
Help desk/Reception/patient registration
Toilets
Clinical Service Areas
Sub-waiting area
Vitals area /room
Consulting room
Counseling room
Emergency/resuscitation room
Health Support services (Allied health)
Treatment room
Support /administration areas
Multipurpose meeting room
Facility manager office
Staff tea room with kitchenette
Medicine store room /dispensary/Pharmacy
Shelves available
Medicine collection kiosk (CCMDD)
Surgical stores store-room
Lockable cleaning material store room OR cupboard
Laundry
Dirty utility room
Linen room OR cupboard
Exterior space
Parking spaces
a. Staff
b. Disabled
c. Ambulance
Waste storage room
a. Domestic/general waste area
b. Medical/bio-hazardous waste area
Garden store room
Drying area (for mops, etc.)
Total score
Total maximum possible score (sum of all scores minus NA)
Percentage (Total score ÷ Total maximum possible score) x 100
Score calculation: 100% Green
Y = 1, N = 0, NA=NA 41-99% Amber
<40% Red
Page | 278
Annexure 94: Checklist for element 156 – There is access for people with
wheelchairs
Use the checklist below to check accessibility for users in wheelchairs
Item Score
Terrain must be compacted and smooth from gate to main entrance
At least one main entrance has a ramp to allow access for persons in
wheelchairs unless the entrance to the facility has no incline
Ramp at one main entrance has handrails unless the entrance to the facility
has no incline
Elbow taps in toilet with access for persons in wheelchairs
At least one toilet has access for persons in wheelchairs
In the toilet/s with access for persons in wheelchair, door handles are at the
height of a wheelchair s
In the toilet/s with access for persons in wheelchairs handrails are installed
Total score
Percentage (Total score ÷7) x 100 %
Score calculation: has no incline
Y = 1, N = 0,

100% Green
40-99% Amber
<40% Red
Ideal Clinic manual version 17 Page | 279

Annexure 95: Checklist for element 157 - The building/s is maintained
according to schedule
Use the checklist below to check whether the various internal and external areas are in good
condition
Check – randomly select the number of areas to review as indicated in the column for scores
Y (Yes) = available; N (No) = not available; NA (not applicable) = if the facility has fewer than the
listed areas or measure is not applicable to the specific facility because of the structural make-up of
the facility e.g. in a multi storey building in a city
Area and measures Scores

Building exteriors
EXTERIOR OF BUILDING(S)
Walls – paint in good condition
Roof intact
Gutters
a. Intact
b. Paint in good condition
Doors and gates
a. Working condition
b. Handles working
c. Open and close
Lights
a. Present
b. Functional
Paving is intact
Score for exterior of buildings
Maximum possible score for exterior of building/s
(sum of all scores minus NA))
Percentage for exterior of building/s (Score ÷
Maximum possible score) x 100 %
INTERIOR OF BUILDING(S)
WAITING AREAS Score Waiting Score
area Waiting area
Ceiling
a. Paint in good condition
b. Intact
Lights
Ideal Clinic manual version 17 280 | P a g e

a. Present
b. Functional
Ventilation
Adequate natural (windows) OR mechanical ventilation (ceiling
fans/air conditioner)
Score for waiting areas
Maximum possible score for waiting areas (sum of all
scores minus NA)
Percentage for waiting areas(Score ÷ Maximum possible %
score) x 100
TOILETS Score Score
ablution 1 ablution 2
Wall-mounted paper towel dispenser(s)
Wall-mounted hand soap dispenser(s)
Wall tiles in good condition
Ceiling
b. Intact
Lights
a. Present
b. Functional
Windows
a. Window panes intact (glass not broken)
b. Handles working
c. Windows open and close
Doors
a. Intact
b. Handles working
c. Open and close
Hand wash basins
a. Intact
b. Taps functional (with running water)
Floor intact
Score for ablution facilities
Maximum possible score for ablution facilities (sum of all
scores minus (NA)
Percentage for ablution facilities (Score ÷ Maximum %
CONSULTATION ROOMS Score Score
Consultation Consultation

room 1 room 2
Floor in good condition
Ceiling
b. Intact
Lights
a. Present
b. Functional
Windows
a. Window panes intact (glass not broken)
b. Handles working
d. Window covering (curtains/blinds) clean and intact
(blinds)
Doors
a. Intact
b. Handles working
c. Open and close
Hand wash basins
a. Intact
b. Taps functional (with running water)
Ventilation
fans OR air conditioners)
Maximum possible score for consultation rooms (sum of
all scores minus NA)
Percentage for consultation rooms (Score ÷ Maximum %
VITAL SIGNS ROOMS: Score Vital Score Vital
signs room 1 signs room 2
Floor intact
Ceiling
a. Paint in good condition (not peeling/faded)

b. Intact (not broken)
Lights
a. Present
b. Functional
Windows
a. Glass not broken
b. Handles working
Doors
a, Intact
b. Handles working
c. Open and close
Hand wash basins
a. Intact
b. Taps functional
Ventilation
fans OR air conditioners)
Maximum possible score for vital signs rooms (sum of all
scores minus NA)
Percentage for vital signs rooms (Total score ÷ Maximum %

score
Exterior of building(s)
Interior of building(s)
Waiting areas
Ablution facilities
Vital signs rooms
Consultation rooms
Total Score
Total maximum possible score (sum of all
scores minus NA)

Score calculation:
80% Green
Y = 1, N = 0, NA = NA 40-79% Amber
<40% Red

Annexure 96: Example of a record to track maintenance work
Maintenance/ Date Name and Short Notes on Date

works order maintenance surname of description of dates on maintenance
number requested staff member maintenance which carried out
that requested follow-ups and finalised
requested the were made
maintenance

Annexure 97: Checklist for element 158 - Building is compliant with safety
regulations
Use the checklist below to check whether the building is compliant with safety regulations
Item Score
Fire compliance certificates
Electrical compliance certificates
Certificate of occupation
Total score
Score calculation:
Y = 1, N = 0
100% Green
40-99% Amber
<40% Red
Xx
X
X
X
X
Ideal Clinic Manual Version 17 Page | 285

ANNEXURE 98: Checklist for element 159 - Furniture is available and
intact in service areas
Use the checklist below to check whether facility service areas are equipped with sufficient
functional furniture
Check – randomly select the areas to review as indicated in the column for scores
Y (Yes) = available and intact; N (No) = not available or not intact; NA (not applicable) = where the facility
has fewer than the listed areas
Score Score
Item
Waiting areas Waiting area 1 Waiting area 2
Seating
a. Adequate seating for all patients
b. Chairs / benches intact
Notice boards available
Consultation Consultation
Consulting rooms
room 1 room 2
Desk
a. Available
b. Intact (including the drawers)
Chair (clinician)
a. Available
b. Intact
At least 1 chair (patient)
a. Available
b. Intact
Tilting examination couch
a. Available
b. Intact
Bedside footstool
a. Available
b. Intact
Wall-mounted or portable anglepoise-style examination lamp
a. Available
b. Intact
Lockable medicine cupboards
a. Available
b. Intact
Dressing trolley (at bedside for examination equipment)
a. Available
b. Intact (including the drawers)

Total score for waiting areas and consulting rooms
Total maximum possible score (sum of all waiting
areas and consulting rooms minus those marked NA)
Percentage (Total score ÷ Total maximum possible
score) x 100
Score calculation:
Y = 1, N = 0, NA = NA

90% Green
40-89% Amber
<40% Red

Annexure 99: Checklist for element 160 - Essential equipment is available and
functional in consulting areas
Use the checklist below to check whether essential equipment is available and functional in
consultation/vital signs and child health rooms
Check – randomly select the number of areas to review as indicated in the scoring columns
Y (Yes) = available and functional; N (No) = not available or not functional; NA (not applicable) = if the
facility has fewer than the listed areas
Score Score Score

Score
Consul- Consul- Child
Item Vitals
tation tation health
room
room 1 room 2 rooms
CONSULTATION ROOMS
Stethoscope
Non-invasive Baumanometer (wall
mounted/ portable)
Adult, paediatric and large cuffs (3)
for Baumanometer
Diagnostic sets including
ophthalmic pieces (wall mounted
or portable )
Patella hammer
Tuning fork (only required in one
consultation room)
Tape measure
Clinical thermometers
marked NA)
Percentage (Score ÷ Maximum %
VITAL SIGNS ROOM (Note if facility is too small to have a vital signs room, check for
equipment in consultation rooms)
Non-invasive electronic
Baumanometer (wall mounted/
portable)
Adult, paediatric and large cuffs (3)
for Baumanometer
Blood glucometer
Peak flow meter
Adult clinical scale up to 150 kg
Stethoscope
HB meter
Clinical thermometer
Height measure
Tape measure
Bin (general waste)

Urine specimen jars
marked NA)
possible score)x 100
CHILD HEALTH ROOM
Baby scale
Bassinet
Stethoscope
Blood glucometer
Non-invasive Baumanometer
(wall mounted/ portable)
Paediatric cuff for Baumanometer
Diagnostic sets including
ophthalmic pieces(wall mounted or
portable )
Patella hammer
Tape measure
Clinical thermometers
Score for child health room
marked NA)

score
Consultation rooms
Vital signs rooms
Child health rooms
Total score/Total maximum possible score
Percentage (Total score ÷ Total maximum %
Score calculation:
Y = 1, N = 0, NA = NA Percentage obtained Score

100% Green
40-99% Amber
<40% Red

Annexure 100: Example of a maintenance schedule for equipment
MAINTENANCE SCHEDULE FOR EQUIPMENT
Name of facility:_______________
Equipment/d Date Frequenc 1st 2nd 3rd 4th 5th 6th

etails of equipm y of service service service service service service
service ent maintena schedu schedu schedu schedu d schedu
procur nce led led led led schedu led
ed led
Automatic External Defibrillator (AED) OR ECG monitor and Serial number
defibrillator
Schedule of *1 Apr Annual 1 Apr 1 Apr 1 Apr 1 Apr 1 Apr 1 Apr
Service(exam 2017 2018 2019 2020 2021 2022 2023
ple)
Date serviced
Company or
health
technology
technician
that serviced
the
equipment
Facility
manager’s
Name &
surname that
signed off the
service
Signature of
facility
manager to
confirm that
the service
was
conducted
Pulse oximeter with adult & paediatric probes Serial number
Schedule of
Service
Date serviced
Company or
health
technology
technician
that serviced
the
equipment
Facility
manager’s
Name &
surname that
signed off the
service
Signature of
facility
manager to
confirm that
the service
was
conducted
Non invasive electronic blood pressure monitoring Serial number
device including paediatric, adult & large adult cuff
sizes (recalibration)
Schedule of
Service
Date serviced
Company or
health
technology
technician
that serviced
the
equipment
Facility
manager’s
Name &
surname that
signed off the
service
Signature of
facility
manager to
confirm that
the service
was
conducted
Scales (recalibration) Serial number
Schedule of
Service
Date serviced
Company or
health
technology
technician
that serviced
the
equipment
Facility
manager’s
Name &
surname that
signed off the
service
Signature of
facility
manager to
confirm that
the service
was
conducted
* If the facility has more than one of the equipment listed, add lines to include all equipment with its
serial number.
Add all the equipment that must be serviced on the schedule

Annexure 101: Checklist for element 165 - Resuscitation room is equipped
with functional basic equipment for resuscitation
Use the checklist below to check whether the emergency/resuscitation room complies with
measures for functional basic equipment
Check – room where resuscitation is performed
Y (Yes) = available and functional; N (No) = not available or not functional
Item Score
Emergency trolley with lockable medicine drawer and accessories
Examination couch/2-part obstetric delivery bed
Wall or ceiling mounted anglepoise-style examination lamp
Nebuliser OR face mask with nebuliser chamber for adult and paediatric
Functional electric powered OR manual suction devices and suction catheters
Drip stand
Dressing trolley
Cardiac arrest board
Bin (general waste )
Suture material
Thermal (space) blanket
Gloves exam n/sterile gloves: small, medium and large at least one pair of each
size
Gloves surgical sterile latex: 6 OR 6.5, 7 OR 7.5 and 8, at least one pair of each
size
Protective face shields OR Goggles with face mask
Disposable plastic aprons
Disposable non-sterile face masks
Resuscitation algorithms
Resuscitation documentation register
Wall-mounted liquid hand soap dispenser
Wall-mounted hand paper dispenser
Total score
Score calculation:
Y = 1, N = 0 100% Green
40-99% Amber
<40% Red

Annexure 102: Checklist for element 166 - Restore the emergency trolley daily
and or after every time it was used
Use the checklist below to check whether the emergency trolley is sufficiently stocked with
unexpired medication
Check – whether the equipment and medication are available on the emergency trolley (or on other
surfaces in the resuscitation room); and also check expiry date of medication. Mark expired medication
as “N”
Y (Yes) = available and functional or within expiry; N (No) = not available or not functional or expired
Item Score
Laryngoscope handle with functional batteries
Adult curved blades for laryngoscope size 2
Paediatric straight blades for laryngoscope size 1
Spare bulbs for laryngoscope
Spare batteries for laryngoscope sizes
Endotracheal tubes – uncuffed size 2mm OR 2.5mm
Endotracheal tubes – uncuffed size 3mm OR 3.5mm
Endotracheal tubes – uncuffed size 4.0mm OR 4.5mm
Endotracheal tubes – cuffed size 5.0mm
Water-soluble lubricant/lubricating jelly
Tape to hold tie endotracheal tube in place
Patella hammer
Oropharyngeal airways (Guedel) size 0
Adult-size introducer, intubating stylet or bougie for endotracheal tubes
Paediatricsize introducer, intubating stylet or bougie for endotracheal tubes
Magill’s forceps for adults
Magill’s forceps for paediatric
Laryngeal masks (supraglottic airways): adult
Manual bag valve mask/ manual resuscitator OR self-inflating bag with
compatiblemasks for adults
Manual bag valve mask/ manual resuscitator OR self-inflating bag with compatible
masks for paediatric
Simple face mask OR reservoir mask OR nasal cannula (prongs) for oxygen, adults
Simple face mask OR reservoir mask OR nasal cannula (prongs) for oxygen,
paediatric
Face mask for nebuliser OR face mask with nebuliser chamber for adult
Face mask for nebuliser OR face mask with nebuliser chamber for paediatric
Automatic External Defibrillator (AED) OR ECG monitor and defibrillator
Intravenous cannula 18g green and appropriate strapping
Intravenous cannula 20g pink and appropriate strapping
Intravenous cannula 22g blue and appropriate strapping
Intravenous cannula 24g yellow and appropriate strapping
Syringes 3-part: 2ml
Syringes 3-part: 5ml
Syringes 3-part: 10ml OR 20ml
Syringes: insulin syringes
Needles: 18 (pink) OR 20 (yellow)
Needles: 21 (green)
Needles: 23 (blue) OR 22 (black)
Sharps container
Admin set 20 drops/ml 1.8m /pack
Admin set paeds 60 drops/ml 1.8m /pack
Stethoscope
Haemoglobin meter
Blood glucometer with testing strips and spare batteries
Diagnostic set and batteries including opthalmic pieces (wall mounted or portable )
Rescue scissors (to cut clothing)
Paediatric Broselow tape OR Pawper tape
Wound care (gauze, bandages, cotton wools, plasters, alcohol swabs and antiseptic
solutions)
Urinary (Foley’s ) catheters: 14f
Urinary (Foley’s ) catheters: 18f
Urinary bag specified in the surgical supply list
Nasogastric tubes: 600mmfg8
Nasogastric tubes: 1000mmfg10 or 12
Medication/vaculitre stickers
Present individually or in combined multifunctional diagnostic monitoring set
Pulse oximeter with adult & paediatric probes
Non invasive electronic blood pressure monitoring device including paediatric, adult
& large adult cuff sizes
Clinical thermometer (in 0C, non-mercury)
Emergency medicines (also check expiry dates)
Activated Charcoal
Adrenaline injection 1mg/ml (Epinephrine)
Amlodipine 5mg OR 10mg tablets
Antihistamine e.g. promethazine 25mg injection
Aspirin tablets
Atropine 0.5mg OR 1mg injection
Benzodiazepine e.g. diazepam injection 5mg/ml injection

Calcium gluconate 10% injection
Furosemide 20mg ampoule
Hydrocortisone 100mg injection
Insulin, short acting (stored in the medicine fridge)
Ipratropium 0.25mg/2ml OR 0.5mg/2ml unit dose vial for nebulisation
Lidocaine/Lignocaine IV 1% OR 2%
Magnesium sulphate 50%, 1g/2ml ampoule (minimum of 14 ampoules required for
one treatment)
Nifedipine 10mg capsules
Short-acting sublingual nitrates e.g. glyceryl trinitrate SL OR isosorbide dinitrate
Short-acting β2 agonist solution e.g. Salbutamol OR Fenoterol
Thiamine 100mg injection
Water for injection
IV Solutions
Dextrose 10% OR 50%
Pediatric solutions e.g. ½ strength Darrows solution AND neonatalyte solution
Sodium Chloride 0.9%
Total score
Percentage (Total score ÷ 64) x 100
Score calculation:
Y = 1, N = 0 Percentage obtained Score
100% Green
40-99% Amber
<40% Red

ANNEXURE 103: Checklist for element 167 – There is an emergency
sterile obstetric delivery pack
Use the checklist below to check whether there is sterile emergency packs available.
Note: sterile packs must be labelled with the contents of the pack
Item Quantity Total score

NON-NEGOTIABLE
Stitch scissor 1
Episiotomy scissor 1
Cord scissor 1
Dissecting forceps non-toothed (plain) 1
Dissecting forceps toothed 1
Artery forceps, straight, long 2
Needle holder 1
Small bowl 2
Kidney dishes OR receivers (big) 2
EXTRAS (not part of sterilised pack)
Basin 1
Stainless-steel round bowl, large 1
Green towels 4
Disposable apron 2
Gauzes 5
Vaginal tampons 1
Sanitary towels 2
Round cotton wool balls 1 pack
Umbilical cord clamps 2
Total score
Score calculation:
Y = 1, N = 0, NA=NA 100% Green
40-99% Amber
<40% Red

Annexure 104: Checklist for element 168 – There is a sterile pack for minor
surgery
Use the checklist below to check whether equipment for minor surgery is available
Y (Yes) = available and functional; N (No) = not available or not functional
Note: sterile packs for minor surgery must be labelled indicating the contents of the pack
Item Quantity Score
MINOR STITCH / SUTURING TRAY
Small stitch tray 1
Stitch scissor 1
Toothed forceps 1
Non-toothed forceps 1
Bard-Parker surgical blade handle to fit
accompanying blades (blades do not form part of
1
sterilised pack but must be available)
Mosquito, straight 2
Mosquito, curved 2
Artery forceps, straight 2
Artery forceps, curved 2
Needle holder 1
Swab holder 1
Total score /12
Score calculation:
Y = 1, N = 0

100% Green
40-99% Amber
<40% Red

Annexure 105: Checklist for oxygen supply
Checklist for oxygen supply
Facility: Date from: Date to:
Day of the week Pressure gauge

Date checked Signature
reading
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

Annexure 106: Checklist for element 170- Up to date asset register available
Use the checklist below to check whether the asset register is up to date
Item Item 1 Item 2 Item 3
Randomly select three items from the asset

register and verify that each is present in the facility
Randomly select three items from the facility and
verify that each is present in the asset register
Total score
Score calculation:
Y = 1, N = 0

100% Green
40-99% Amber
<40% Red

Annexure 107: Example of an asset disposal form
Asset disposal form

This form is to be completed if any equipment/furniture within the facility is to be disposed of. This
form, once completed, must be sent to Supply Chain Management.
Region: ___________________________ Facility: ____________________________
Department: ______________________ Date: ______________________________
LIST OF EQUIPMENT/FURNITURE TO BE DISPOSED
Asset Location Description Purchase Original Disposal

number date cost value
REASON FOR DISPOSAL:

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________
METHOD OF DISPOSAL (please tick)
SCRAPPED
AUCTION
DONATED
Authorised by: ______________________ Date: ____________________

Annexure 108: Schedule for meetings
MEETING SCHEDULE
Facility name:_______________________
Month: ____________________________
Year: ______________________________
Weekday Date Week 1 Date Week 2 Date Week 3 Date Week 4

Monday
Tuesday
Wednesday
Thursday
Friday

Annexure 109: Template for agenda
FACILITY NAME: _______________________________
AGENDA FOR: _______________________
DATE: ______________
VENUE: ________________________
AGENDA POINTS:
1. Opening and welcome
2. Attendance and apologies
3. Finalisation of the agenda
4. Adoption of the previous meeting minutes
5. Matters arising from the previous meeting’s minutes
6. Standing items
7. Additional matters
8. Date of next meeting
9. Closure

Annexure 110: Template for attendance register for meetings
FACILITY NAME: _______________________________
ATTENDANCE REGISTER FOR: _______________________
DATE: ______________
VENUE: ________________________
Name and Rank Contact Organisation / Signature

surname number section

Annexure 111: Checklist for element 189 – There is a functional Clinic
committee
Use the checklist below to check whether the documents are available as evidence that the clinic
committee is functional
Item Score
Nomination process
Agenda
Attendance register
Clinic and Community Health Centre (CHC) Committee guidelines
Copy of submission to the sub-district
Formal Appointment
Signed appointment letters from Office of the MEC or delegated person
Adopted and signed constitution as per provincial guidelines
Code of conduct for Clinic/CHC Committee
Training
Attendance register for orientation and training conducted in the past 12 months
Services Planning, Monitoring, Evaluation and meetings
List of community needs as determined by the Clinic/CHC Committee in past 12 months
Agendas indicating that community needs and progress against operation plan was discussed
at least twice in the past 12 months
Signed minutes indicating that the Clinic/CHC Committee was informed on the progress
against the facility’s operational plan at least twice in the past 12 months
Current year plan indicating scheduled meetings (at least two within the next 12 months)
Attendance registers show that meetings held formed a quorum
Minutes of Clinic/CHC Committee meetings indicate that statistical data on population health
indicators are discussed
Minutes of Clinic/CHC Committee meetings indicate that the clinic’s human resources situation
is discussed
Minutes of Clinic/CHC Committee meetings indicate that situation relating to equipment and ,
supplies is discussed
Complaints, Compliments and Suggestion Management (check record of the past 6 months)
Proof that Clinic/CHC Committee took part in opening complaints boxes according to stipulated
schedule (signed register)
Minutes indicate that the management of complaints, compliments and suggestions are
discussed at Clinic/CHC Committee meetings
Accountability and Communication
Contact details of Clinic/CHC Committee members clearly displayed in reception area
Minutes of the Ward Committee meeting indicate that a member of the Clinic/CHC Committee
gave feedback at the Ward Committee meeting on health-related matters
Total score

100% Green
Score calculation: 40-99% Amber
<40% Red
Y = 1, N = 0,

Annexure 112: Example of services and activities for an open day
Theme: Immunisation/Child Health
Before the event: Use health promoters to inform community about the event. Request
community members to bring Road to Health Charts (RTHC).
MC: Facility manager: Purpose of open day
Welcome speech: Local Ward Counsellor
Opening speech: MCWH coordinator: The importance of immunisation
MC: Explain the activities offered
Activities: Check RTHC

Offer catch-up immunisation
Screening height and weight
Screening developmental milestones
Stations: 1. Screening
2. Immunisation
3. Facts and information about immunisation/ child health (with pamphlets)
4. Children’s activities (colouring, face-painting, clowns, magicians)

Annexure 113: Example of a template for an operational plan
Name of Facility__________________
Operational Plan ___________(year)
DATE OF SUBMISSION: _______________
SUBMITTED BY: ___________________ __________________

Title Signature

PURPOSE OF AN OPERATIONAL PLAN
An Operational Plan (OP) is created to assist you in meeting the aims and goals committed to in the District Health Plans/Annual Performance and Strategic
Plans through the development of strategic objectives. An OP is there to assist you in breaking down exact activities for each objective that are required to
meet your goals. By spending time on developing an accurate and useful OP, you can ensure that the objectives are achieved through regular monitoring.
Activities are broken down into Quarters to assist with planning and prioritising.
Guidelines to follow when writing your OP:
1. Stick to the template provided- it has been created to assist you in creating streamlined work plans
2. All goals, objectives and indicators that the Programme has committed to in the Annual Performance Plan (APP) and Strategic Plan (SP) should be in
the OP
3. Goals, objectives and indicators should appear in the same order in your APP, SP and OP to assist in alignment
4. Strategic objectives must be SMART (Specific, Measurable, Achievable, Realistic and Time bound)
5. NIDS must be used for all service delivery indicators.

HEALTH SECTOR PLANNING HORIZON
Provincial/Local Government Provincial/Local Government

Provincial/Local Government
5 Year Strategic Plans Annual Performance Plans and
Medium Term Strategic
District Health Plans
Framework
OPERATIONAL PLANS

The template in the following pages gives guidance on how to go about to develop an operational plan. The flow diagram below sets
out the process:
2. Develop
indicators for
1. Develop
each objective
objectives
(what is the
end product)
3. Develop
activities for
each indicator
Strategic objectives can be grouped in two categories:
1. Those objectives that are standard and will remain more or less the same for mostly every year to ensure that healthcare services are
delivered in the facility. These objectives relates to the specific services rendered at the facility. For example the facility
facili could set an
objective for each of the three streams of care (chronic, acute and mother and child health). Each ob objective
jective will then have various
indicators and each indicator will have a list of activities that needs to be performed to reach the objective
2. Those objectives that relates to the quality improvement plan of the facility. The quality improvement plan must be used to develop
objectives to close the gaps as identified in the quality improvement plan.

STRATEGIC OBJECTIVES:
NAME OF DISTRICT: SUB DISTRICT:

STRATEGIC OBJECTIVES (write down the strategic objectives for the facility, they can have more than 3)
1.
2.
3.
INDICATORS FOR INDICATOR 1: Write down the name of the NUMERATOR: DENOMINATOR:
STRATEGIC OBJECTIVE 1: indicator (add additional lines if there are more that
(Note an indicator does not 2 indicators set to achieve the specific objective)
have to have numeric values.
An indicator can for example .
be a SOP for ....., the
objective would then be to INDICATOR 2: NUMERATOR: DENOMINATOR:
develop an SOP for ....). If
this is the case at the field for
numerator and denominator
insert Not Applicable’ (NA)
INDICATOR 3: . NUMERATOR: DENOMINATOR:

INDICATORS FOR
STRATEGIC OBJECTIVE 2:
INDICATOR 4: NUMERATOR: DENOMINATOR:
INDICATORS FOR INDICATOR 5: NUMERATOR: DENOMINATOR:

STRATEGIC OBJECTIVE 3:
INDICATORS FOR INDICATOR 7: NUMERATOR: DENOMINATOR:

STRATEGIC OBJCTIVE 4:

ANNUAL TARGETS SET PER QUARTER FOR EACH INDICATOR
QUARTER 1 : TARGET / QUARTER 2 : TARGET / QUARTER 3 : TARGET/ QUARTER 4 : TARGET/

ANNUAL TARGET
MILESTONE MILESTONE MILESTONE MILESTONE
Indicator
Indicator #
name
INDICATOR
1:
INDICATOR
2:
INDICATOR
3:
INDICATOR
4:
INDICATOR
5:
INDICATOR
6:
INDICATOR
7:
INDICATOR
8:

ACTIVITIES SET TO ACHIEVE EACH INDICATOR
INDICATOR 1 Name of indicator:
PERSONS TIME FRAME

RESPONSIBLE
Mark with an ‘X’ the Quarter in which the activity will take ACTIVITY
ACTIVITIES OUTPUTS
The person place
BUDGET
These must be directly This is what is
actual activities, responsible for expected to happen
SOURCE AMOUNT
with only one ensuring activity Q1 Q2 should the activity take
activity per line happens (must Q3 place
(April-Jun (July-Sept Q4 Where the In South
be an actual (Oct-Dec (Jan-Mar
2017) 2017) money is African Rands
person) 2017)
2018) coming from

TIME FRAME
PERSONS
RESPONSIBLE Mark with an ‘X’ the Quarter in which the activity will take ACTIVITY
ACTIVITIES place OUTPUTS
The person BUDGET
with only one ensuring activity should the activity take SOURCE AMOUNT
Q1 Q2 Q3
be an actual (Oct-Dec (Jan-Mar Where the In South
(April-Jun (July-Sept
person) money is African Rands
2017) 2017)
2017) 2018) coming from

TIME FRAME
PERSONS
The person BUDGET
Q1 Q2 Q3
2017) 2017)

TIME FRAME
PERSONS
The person BUDGET
Q1 Q2 Q3
2017) 2017)

TIME FRAME
PERSONS
The person BUDGET
Q1 Q2 Q3
2017) 2017)

TIME FRAME
PERSONS
The person BUDGET
Q1 Q2 Q3
2017) 2017)

TIME FRAME
PERSONS
The person BUDGET
Q1 Q2 Q3
2017) 2017)

TIME FRAME
PERSONS
The person BUDGET
Q1 Q2 Q3
2017) 2017)

Annexure 114:: Status Determination Cycle
IDEAL CLINIC STATUS DETERMINATION CYCLE
• SD conducted by facility manager (SD Facility Manager)

• Completed and captured by 15 May 2017
• Facility manager to correct weaknesses where she/he is able
• Facility manager asks for assistance to correct weaknesses from PPTICRM where
• required
All facilities • District PPTICRM analyses status of facilities in their district on the software and
• effect the required interventions to address weaknesses
• SD conducted by District PPTICRM (SD PPTICRM)

• Completed and captured between July and September 2017 (4 -6 weeks before
• peer reviews are scheduled to take place)
• For facilities targeted to be IDEAL, district PPTICRM effects the intervention
All facilities required
• to ensure that targeted facilities will be found to be Ideal by the peer reviewers
• SD conducted by cross district PPTIRCM peer reviewers (SD PPTICRM PR)

• Completed and captured between October and November 2017
• Celebrate the achievements of clinics found to be Ideal (silver and higher status)
Facilities targeted • Facility management and district PPTICRM correct weaknesses in those still not
to be IDEAL in Ideal
the specific
financial year
• SD update conducted by district PPTIRCM peer reviewers (SD PPTICRM PRU)

• Completed and captured by 31 March 2018
• Effect final corrective interventions and capturing of final scores for financial year
Facilities targeted
to be IDEAL in the
specific financial
year that failed the
PEER REVIEWS

Annexure 115: Example of a register for ambulance turnaround times
Facility name:___________________
Name Signature Actual

Request Request Request Clinician Patient name Arrival Arrival
Patient number responding responding turnaround
date time clinician signature and surname date time
officer officer time

Annexure 116: Referral pathways
The referral pattern in districts are as follows:
1. Vertical referral
• vertical referral, i.e. patient referral from a lower to a higher level of healthcare facility, either
in the same district or another district, and vice versa, based on the role and responsibilities
of each category of healthcare facility.
• School Health Teams and the Nurse Team Leader of the ward-based PHC Outreach
Teams refer relevant cases to the PHC facility or to the Level 1 hospital in the catchment
area.
• PHC clinics refer all cases that cannot be managed at PHC level to the Level 1 hospital in
the catchment area, according to clinical guidelines.
• oral health outreach services refer cases for advanced oral health services to the fixed
clinics. For example severe maxilla-facial and orthodontic cases are referred to Tertiary
Hospital in the relevant province.
• Level 1 hospitals refer patients in need of specialist healthcare to the Level 2 hospital in the
catchment area.
• when there is a justifiable reason for deviation from the standard referral pattern, a Level 1
hospital may bypass the standard route of referral and send the patient directly to the Level
3 hospital. The Head of Clinical Services of the Level 2 hospital must give clearance for a
Level 1 hospital to bypass the standard referral route and send a patient directly to the
Level 3 hospital.
• Level 2 hospitals refer patients in need of specialist healthcare to the appropriate tertiary
facility.
All referred patients at all levels are to be referred back from the referral facility to the referring
facility.
2. Horizontal referral
• horizontal referral, i.e. patient referral to a healthcare setting with similar scope and
healthcare service package, for continuity of care, either in the same district or another
district.

• patients are referred from one PHC facility to another, e.g. referral of a patient who receives
monthly medication for a chronic condition at a PHC facility, who relocates to another area
in the same sub-district or another sub-district within the district or another district.
• a patient can be referred from one ward-based PHC setting to another, e.g. a patient on
ARVs who relocates from one ward to another within the district can be referred by the
Ward-based PHC Outreach Team leader to the care of the Ward-based PHC Outreach
Team operating in the ward into which the patient will be relocating.
3. Downward referral
• Patients who entered a certain level of care without referral, who require a lower level of
care after initial assessment, or who are in need of continuity of care, follow-up and
rehabilitation are down-referred to the appropriate level of care.
• Patients are referred from a PHC facility to the ward-based CHW for services rendered at
their level, e.g. a TB patient on clinic-based DOTS can be referred to community-based
DOTS by the CHW under the supervision of the nurse team leader.
C. Inter-sectoral referral
• patients are also referred to and from other organisations and government departments
which render services that are beyond the scope of the district healthcare service. These
entities refer clients in need of healthcare to PHC facilities where they will be managed
accordingly, e. g. Department of Social Development may refer a baby, who has not been
immunised and whom they have detected during their course of work, to the PHC facility in
the catchment area for immunisation.
• referrals from private healthcare practitioners. Private healthcare practitioners refer patients
who require healthcare services at PHC level or a higher level of healthcare, and who are
not financially capable to pay for private healthcare services, to a public healthcare facility
where they will be treated according to public health policies.

Flow diagram of referral pathways
Academic Hospitals Keys:
Preferred/
recommended two
way referral route
Central Hospitals
Exceptional one way

referral route
Tertiary Hospitals
Regional Hospitals
District Hospitals
Community Health
Centers
General Clinics Hospice/palliative care

Practitioners
Nurse, Doctor, District Clinic
Health Specialist Teams
Ward Based Primary Schools

Health Care Outreach
School Health Teams
Teams

Annexure 117: General Primary Health Care referral and feedback form
General PHC patient referral form
A patient has been referred to your facility/service by the Primary Health Care facility as
indicated below. Thank you for seeing this patient, we look forward to working together
for improved health and welfare for all South Africans.
REFERRED TO:
Name of facility
Department/doctor referred to (where applicable):
Patient details
Patient name and surname Patient address
Date of Birth (dd/mm/yyyy) Age Gender

Patient contact
telephone
number
Patient file/record
number
Clinical information on patient

History
Possible diagnosis
Relevant past
history
Current medication
and treatment given
Vital data and

examination
Reason for referral
REFERRED BY:
Name of facility
Contact details
Name and surname of healthcare professional
HPCSA/SANC NO
Signature of healthcare professional
Date

Page | 327
General PHC patient referral feedback form
A patient has been referred to your service as indicated on the attached referral form.
Please complete this form and give it to the patient so that he/she can bring it along with
them at their next visit to the facility
FEEDBACK TO:
Name of facility
Patient details
Patient name and surname Patient address
Date of Birth (dd/mm/yyyy) Age Gender

Patient contact
telephone
number
Patient file/record
number
Clinical information on patient

Examination
Diagnosis
Treatment
(medication, referral
ect.)
FEEDBACK FROM:
Name of facility
Contact details
HPCSA/SANC NO
Signature of healthcare professional
Date

Page | 328
Annexure 118: Example of a register for patient referrals
Name of facility
Facility manager Contact no.
Date Patient details Referral Reason for referral Date Feedback from
referred (name and destination feedback referral destination
surname, file received
record number)

Annexure 119: Reporting template for implementing partners
Name of organisation: ____________________________________
Person reporting: ____________________________________
Date of meeting: ____________________________________
Objective 1:
Activity Progress Challenges Mitigation actions
Planned activities for next quarter

_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________

Annexure 120: Template for memorandum of understanding
MEMORANDUM OF UNDERSTANDING
MADE AND ENTERED INTO BY AND BETWEEN
THE __________________ DEPARTMENT OF HEALTH
(herein after referred to as “the Department”)
Represented by _____________________
in his/her capacity as Head of Department.
AND
South African Police Service (SAPS)
Herein after referred to as the “other Department”
represented by __________________
in his/her capacity as Provincial Police Commissioner

A. PREAMBLE
Since the launch of the government's green paper on National Health Insurance, various
reforms and initiatives are underway to improve services to be provided under the future
National Health Insurance. This includes the three streams of re-engineering of primary
health care, strengthening management of health facilities, upgrading of infrastructure,
setting and monitoring national quality standards, and establishing norms for staffing
levels and skill-mix. The 'Ideal Clinic' (IC) programme is another initiative as a way of
systematically improving the deficiencies in Primary Health Care clinics in the public
sector and to correct the deficiencies in quality.
In order to implement these health reforms and specifically to realize the Ideal clinic
concept; the assistance and cooperation of other stakeholders are necessary. It is also
necessary to formalize this relationship formally.
It is therefore necessary that the two Departments agree on certain commonalities,

assistance and cooperation to be provided, to effect better service delivery priorities to
the community in the _______________
B. MEMORANDUM OF UNDERSTANDING
1. Preamble included in Memorandum of Understanding

The preamble of this understanding forms part hereof, as if specifically mentioned
herein.
2. Purpose of Memorandum of Understanding

The purpose of the Memorandum of Understanding is to ensure the continued
cooperation and communication exist between the Department of Health and the South
African Police Service.
3. INTERPRETATION
Unless inconsistent with the context, this agreement shall be interpreted as follows:
3.1 The head notes to the various clauses of this MOU and the index are inserted for
reference purposes only, and shall not take precedent in the interpretation of this
MOU;
3.2. This MOU shall be governed by the laws of the Republic of South
Africa;
3.3. Unless inconsistent with the context, an expression which denotes:

3.3.1 Any gender includes the other gender;
3.3.2 A person shall include both a natural person and/or a

juristic person and vice versa;
3.3.3 The singular includes the plural and vice versa;
3.3.4 “District Clinical Specialist Team” (DCST) means a team of

specialist comprising of a family Physician, an anesthetist, an obstetrician
and gynecologist, an advance midwife, a primary health care practitioner
and a pediatric nurse, placed in a health district to strengthen the clinical
services within the health district
3.3.5 “Department” means the Department of Health, a duly

constituted department of the Provincial Government in the
__________________ Province;
3.3.6 “Facilities” means the health facilities as agreed to by the

Parties;
3.3.7 “Ideal Clinic” means a primary health care facility with good
infrastructure, adequate staff, adequate medicine and supplies, good
administrative processes and adequate bulk supplies that use applicable
policies, protocols, guidelines as well as partner and stakeholder support ,
to ensure the provision of quality health services to the community
3.3.8 “National Health Insurance” is defined by the World Health

Organization as the progressive development of a health system
including its financing mechanisms into one that ensures that everybody
has access to quality health services and where everyone has accorded
protection from financial hardships linked to accessing these health
services
3.3.9 “Other Department“means the Department with whom the

Department of Health sought to have an understanding and is a
party of this MOU
3.3.10 “Primary Health Care” means the first level of contact of

individuals, the family and the community with the national health system,
care as close as possible to where people live and work, and constitutes
the first element of a continuing health care service
3.3.11 “Municipal Ward base outreach team” is a team of

community health workers based at a Primary Health Care facility and
offers integrated services to households and individuals within its
catchment area. The catchment area refers to the different Wards within
Municipalities. The team provides health care to families/ households;
community outreach services; preventative, promotive, curative, palliative
and rehabilitative services
3.3.12 “Upgrading of facility” means the improvement of the

physical infrastructure of the health facility
4. Commencement and duration of Memorandum of Understanding
4.1 This MOU shall commence from the date of the last signature effected hereto and
shall remain in force for a period of five (5) years.
4.2 The Parties may in writing agree to extend the period of this MOU.
4.3 Either Party may terminate this MOU by giving the other Party three (3) months
written notice.
5. Duties of the Department of Health
The Department shall:
• Ensure that its facilities are secure by providing proper fencing, perimeter lightning,
and security guard houses with security guards.
• Ensure that all health facilities have the contact detail of the local SAPS for their
respective areas
• Inform SAPS of any matter that may or have cause a risk to the patients, staff or
property of the Department.
• Work together with the SAPS when any matter at the facility need to be investigated.
• Ensure regular communication with the SAPS on a local level through the
attendance of multisector forums in respective areas.
6. Duties of the South African Police Service
• To assist the Department of Health to ensure the safety of patients, staff and the
property of the Department when called upon
• To assist where necessary, if practically possible to monitor security and safety at
health facilities by way of regular patrols near health facilities such as clinics,
community health centers and mobile clinics

• To inform the Department where security risks have been identified and where
necessary advise on measures that would improve the security
• To investigate reported crime at facilities and to provide feedback to the
Department in accordance with internal police prescripts
• To engage the Department and relevant stakeholders forums on issues of safety and
security at health facilities.
• To provide reasonable access to SAPS at the workplace without compromising
service delivery in order for the Department to promote health activities and health
service delivery to the employees.
• To invite SAPS where reasonably possible when organizing internal health
promotions and other relevant programmes to ensure maximum benefit to
employees.
7. Oversight Joint Committee
7.1 HOD’s of the respective Departments to meet at Provincial forums and address
issues pertaining both Departments that may hamper service delivery
7.2 Local coordination between the head of the facility and the local colleague from the
South African Police Service to meet and provide oversight at a local level
8. GOOD FAITH
In all their interactions the Parties shall display good faith, a spirit of co-operation,
show diligence, professionalism and commitment.
9. Breach and termination
9.1 Should any Party (Defaulting Party) commit any breach of the terms of this
MOU and fail to remedy such breach within fourteen (14) days of receiving a
written notice of breach.
9.2 A Notice of breach shall:-
9.2.1 Indicate clearly the nature and extent of such breach;
9.2.2 Contain a demand that the Defaulting Party remedies the breach within 14
days after receiving such notice; and

9.2.3 Draw the attention of the Defaulting Party to the remedies the Aggrieved Party
may use if such demand is not heeded.
10. Dispute resolution
10.1 The Heads of Department shall try to resolve any difference or dispute
relating to this Agreement which may arise between the Parties within
fourteen (14) days of becoming aware of its existence.
10.2 Where the Parties are unable to resolve any difference or dispute amicably
such difference or dispute shall be referred for arbitration in terms of the
Arbitration Act No 42 of 1965.
10.3 The findings of the arbitrator shall be final and binding on the Parties.
11. Variations
This MOU is the only understanding between the Parties and no amendments or
variations to this MOU shall be of any force or effect unless reduced to writing and
signed by both parties.
12. General
12.1 If any provision of this MOU is or becomes illegal, void or invalid it shall not
affect the legality of the other provisions, unless its illegality or otherwise
renders the whole MOU unenforceable.
12.2 Neither party shall assign or otherwise transfer any of its rights or obligations
under this MOU without prior written consent of the other party which shall not
be unreasonable withheld.
12.3 Neither party will be liable for any failure to meet any of its responsibilities in
terms of this MOU or any delay in meeting them to the extent to which the
failure or delay is caused by any circumstance what so ever which is beyond
its reasonable control, including but not limited to strikes, lockout, war, Civil
commotion or any order or regulation of any government or other lawful
authority meeting the above requirements

13. Domicilium Citandi et Executandi
13.1 The Parties choose as their Domicilia Citandi et Executandi their respective
addresses set out in this clause at which addresses all processes and notices
arising out of or in connection with this Agreement may validly be served
upon or delivered to the Parties.
13.2 The Parties respective addresses are as follows:
Department of Health, ____________________ Province:
Postal Address:
Street Address:
Tel:
South African Police Service: _________________ Province:
Postal Address:
Street Address:
Tel:
13.3 Any notice given in terms of this Agreement shall be deemed to have been received by the
addressee;
13.3.1 If delivered by hand on the date of delivery.
13.3.2 If posted be prepaid registered mail, on the eighth (8th) day following the date of such
posting.
13.4 Notwithstanding anything to the contrary contained or implied in this Agreement a written
notice or communication actually received by one of the Parties from another including by
way of facsimile transmission shall be adequate written notice or communication to such
Party.

13.5 Either Party is entitled to change the address to another address in South Africa as long as
it is not a post box (post restante) provided that such address shall be used fourteen (14)
days after the notice was sent to the other Party.
For the District health services: For the District Environmental Health
Services :
Full Names and Surname: Full Names and Surname:
Designation: Designation:
Signature: Signature:
Date: Date:
Place: Place:
AS WITNESSES (Full Names and AS WITNESSES (Full Names and

Surname): Surname):
1._______________________________ 1._______________________________
2. ______________________________ 2. ______________________________

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Ideal Clinic Manual

An Ideal Clinic is a clinic with good infrastructure, adequate staff,

My sincere gratitude to the national Department of Health programme managers, provincial

INTRODUCTION AND BACKGROUND 1

ANC Antenatal Care

A standardised questionnaire which is translated into a dashboard (Ideal Clinic components,

Ideal Clinic Manual version 17 1|Page

THE PURPOSE OF THIS MANUAL

Ideal Clinic Manual version 17 2|Page

Documents, policies, guidelines and standard operating procedures referenced as being

Ideal Clinic Manual version 17 3|Page

1. Signage and notices

Commitment for Ideal Clinic elements 1-3

1 All external signage in place

Ideal Clinic Manual version 17 4|Page

Signs and notices are clearly placed throughout the facility.

4 Vision, mission and values of the district are visibly displayed

5 Facility organogram with contact details of the facility manager is displayed on

7 All service areas within the facility are clearly signposted

Ideal Clinic Manual version 17 5|Page

Commitment for Ideal Clinic elements 8 - 10

8 There is a prescribed dress code for all service providers

10 All staff members wear an identification tag

Step 4: Compliance to dress code must be included in the staff performance

Ideal Clinic Manual version 17 6|Page

Commitment for Ideal Clinic elements 11 - 13

11 Help desk/reception services are available

13 A functional wheelchair is always available

Ideal Clinic Manual version 17 7|Page

Commitment for Ideal Clinic elements 14 - 15

14 There is a single patient record irrespective of health conditions

15 Patient record content adheres to ICSM prescripts

Ideal Clinic Manual version 17 8|Page

16 District/provincial standard operating procedure/guideline for accessing,

tracking, filing, archiving and disposal of patient records is available

17 Guideline for accessing, tracking, filing, archiving and disposal of patient

18 There is a single location for storage of all active patient records

19 Patient records are filed in close proximity to patient registration desk

20 Retrieval of a patient’s file takes less than ten minutes

Step 2: Adhere to contents of the SOP. See Annexure 12.

Ideal Clinic Manual version 17 9|Page

21 Priority stationery (clinical and administrative) is available at the facility in

Ideal Clinic Manual version 17 10 | P a g e

5: Clinical service provision

Commitment for Ideal Clinic elements 22

Step 1: Obtain the ICSM manual from www.health.gov.za.

Step 5: Implement process flow as per plan.

Step 6: Mark out flow using colour coding to direct patients.

Name of Stream Colour Description of colour

Chronic Services Blue

Maternal and Child Health Deep green

Ideal Clinic Manual version 17 11 | P a g e

Ideal Clinic Manual version 17 12 | P a g e

23 Patients are consulted, examined and counselled in privacy

Step 3: Do spot-checks to determine whether staff members respect patients’ privacy

Ideal Clinic Manual version 17 13 | P a g e

24 TB treatment success rate is at least 85% or has increased by at least 5% from

HOW TO CONDUCT THE STATUS DETERMINATION FOR ELEMENT 24