Gansu Province Basic Health Clinic Survey

Gansu Province Basic Health Clinic Survey Township Hospital Questionnaire Interviewer’s Name: Verifier’s Name: Verification Time: Month Day Name of Person Completing Form: Time Form was Filled: Starting Time: Year Hour Month Minute　 Day　 Ending Time: Hour Minute　 The objective of this questionnaire is to understand local health and township hospital situations Please have the person familiar with the township hospital complete this form If there is more than one person familiar with any facet of the questionnaire, we welcome multiple people to answer the different portions of the questionnaire Below are questions regarding the basic hospital situation and survey form It includes questions about the present staff, annual income and expenditures, standard service fees, equipment There are also questions about local township immunization rates and infectious disease prevalence, local immunization rates from 1988 to present, infectious disease rates, infant mortality rates, and technical health workers The answers to these questions are strictly confidential Please answer and complete the form in accordance to this township hospital’s annual records If you are unsure of the exact answers to any of these questions, please refer to the relevant records If there are no records to refer to, please use your knowledge to make an educated estimate If there is any portion that is unclear, ask the CDC survey staff to clarify, and then answer as accurately as you can, according to your best understanding of the question Please fill the form item by item and not leave any blank spaces A Basic Information A1.County: A2.Township: □□ Township code:□□ County code: A． Hospital Basic Conditions The questions below concern basic equipment, patient admissions, staff, education backgrounds, and positions If there are none for the indicated year, please mark “0” B1 Please fill in the quantity for each item for the years 2003 and 1999 If none, please indicate with “0” Item Unit 2003 1999 How many patient beds does this hospital have? Beds What is the total number of staff at this hospital? Person(s) 2.1Techinical health staff Person(s) 2.1.1 Professional doctor Person(s) 2.1.2 Professional doctor’s assistant Person(s) 2.1.3 Registered nurse Person(s) 2.1.4 Pharmacist Person(s) 2.1.5 Lab technician Person(s) 2.1.6 Other technical health worker Person(s) 2.2 Other technical worker Person(s) 2.3 Managerial staff Person(s) 2.4 Support staff Person(s) Retired Staff 　　　　　 Person(s) What is the total area of the hospital building(s)? m2 4.1 Of which: How much area is used directly for m2 hospital operation? Equipment worth between 5,000-10,000 Yuan 　 　 Equipment worth over 10,000 Yuan 6.1 Of which: Equipment worth over 50,000 Yuan 　 Total Assets 10,000 Yuan Fixed assets 10,000 Yuan Total number of outpatients seen/year Person(s) 10 Number of inpatients/year Person(s) B2 Local township hospital 2003 technical health worker education level and position If none, please indicate with “0” Education or Position/ranking Unit 2003 Technical health worker Person(s) Of College graduate, Bachelor’s degree (centralized) Person(s) which College graduate (self-study, adult college entrance exam, Person(s) night school, correspondence school) Technical College (centralized) Person(s) Technical College (self-study, adult college entrance exam, Person(s) night school, correspondence school) 10 Technical High School (centralized) Person(s) 12 Technical High School (self-study, adult high school entrance Person(s) exam, night school correspondence school) 14 Below technical high school Person(s) Of 15 High level job title Person(s) which 17 Mid-level job title Person(s) 19 Assistant job title Person(s) 21 No professional technical title Person(s) C．Annual Income and Expenditure The questions below pertain to this township hospital’s economic status C1 Annual income and expenditure If none, please indicate with “0” Income or Expenditure type Unit Total income 10,000 Yuan 1.1 Of which: Financial subsidy income/year 10,000 Yuan 1.2 Higher level subsidy income 　　　　　　 10,000 Yuan 1.3 Operational income 10,000 Yuan 1.3.1 Of which: Medical treatment income 10,000 Yuan 1.3.2 Drug sale income 10,000 Yuan 1.3.3 Other income 10,000 Yuan Total expenditure 10,000 Yuan 2.1 Of which: Operational expenditure 10,000 Yuan 2.1.1 Of which: Medical treatment expenditure 10,000 Yuan 2.1.2 Drug purchasing 10,000 Yuan 2.1.3 Other expenditures 10,000 Yuan 2.2 Specific programming expenditure 　　　　　　 10,000 Yuan 2.3 Of total expenditures: Staff salary expenditure 10,000 Yuan Total patients’ accumulated non-payment deficit 10,000 Yuan Doctor’s average monthly salary Yuan Percentage of township hospital’s salaries that come from % county level funding Construction investment 10,000 Yuan 2003 1999 D．Township Hospital’s General Background The following are questions regarding this township hospital’s general situation, including services provided, basic laboratory capabilities, training, and most commonly seen diseases Please circle the number next to the corresponding answer　○　 D1 What are this hospital’s average daily hours of operation? Hours D2 What are this hospital’s average weekly days of operation? Days D3 In 2003, aside from weekends or holidays, how many days was this hospital closed? D4 What year was this hospital established? Days Year D5 Is this hospital taking part in any rural cooperative medical insurance program? Yes No D6 Please estimate, of the patients who seek care at this hospital, the percentage that have residency in this township? % D7 Of the patients with residency in this township, what percentage has medical insurance? D8 Of the patients with rural residency, what percentage has medical insurance? D9 Does this hospital keep patient medical records? Yes % % No D10 Hospital services and standard fees Please circle the number corresponding with your answer　○　 If the service is free, please write “0” Service Is this service available? 2003 (Yuan) Registration fee Health check-up examination Yes No 　go to next row　 Basic health exam (physical) Yes No 　go to next row　 Non-infectious TB treatment Yes No 　go to next row　 Yes No 　go to next row　 X-ray image fee X-ray fee Yes No 　go to next row　 5mL single-use needle syringe Yes No 　go to next row　 Yes No 　go to next row　 10mL single-use needle syringe Yes No 　go to next row　 Injection fee 10 Stitches for a wound Yes No 　go to next row　 11 Hospital bed fee Yes No 　go to next row　 12 Ultrasound exam Yes No 　go to next row　 13 Routine blood test Yes No 　go to next row　 14 Routine urine test Yes No 　go to next row　 15 Routine stool test Yes No 　go to next row　 Yes No 　go to next row　 16 Liver function lab test Yes No 　go to next row　 17 Hepatitis B blood panel 18 Electrocardiogram Yes No 　go to D11　 D11 Does this hospital have the capacity to realign and dress broken bones? D12 What is the average cost for treating a broken bone? Yes Yuan No D13 Does this hospital provide oral rehydration salt (ORS) solution for diarrhea treatment? Yes No D14 Does this hospital provide families with instructions on how to make their own oral rehydration salt solutions? Yes No D15 Does this hospital provide direct observed therapy-short course (DOTS) for tuberculosis patients? (DOTS) therapy? Yes No　if no, go to C17　 D16 Starting which year did this hospital begin to offer this service? Year D17 Is this hospital capable of providing the following laboratory tests? Please circle the number for the corresponding answer　○　 Yes No Stool analysis 2 Sputum analysis Blood analysis Urine analysis D18 In the year 2003, how many times did this township hospital hold training events for village health workers? Times D19 Year 2003 Township hospital level training program topics for village health workers (number of times) If there were none, please write “0” Program topic Number of times in 2003 Mother and Child health education Epidemic prevention 2.1 Immunization planning 2.2 Health education training 2.3 Program training Program topic Number of times in 2003 Clinical skills training 3.1 SARS training 3.2 3.3 TB-DOTS training Other clinical skills training In the following sections, please fill in most commonly seen diseases D20 Please choose from the list of disease types below the top three types most commonly encountered for the different age brackets at this hospital For the most common, please fill in the row labeled “first type”, then fill in the rows for “second type” and “third type” Age Males Females Age 61 Age 5-11 Age 18Age 26Age 41years and age 12age 12years and years 25 years 40 years 60 years under 17 years 17 years over First type Second type Third type Disease type list: Diseases of the respiratory organs, Diseases of the nervous system, Diseases of the skin and subcutaneous fat, Diseases of the urogenital system, Diseases of the digestive system, Diseases of the osteal-muscular system, Infectious and parasitic diseases, Diseases of the blood circulation system, Diseases of the endocrine system 10 Other D21 Please choose from the list of common diseases below the top three types most commonly encountered for the different age brackets at this hospital For the most common, please fill in the row labeled “first type”, then fill in the rows for “second type” and “third type” Age Males Females Age 61 Age 5-11 Age 18Age 26Age 41years and age 12age 12years and years 25 years 40 years 60 years under 17 years 17 years over First type Second type Third type Disease list: Diarrhea, Trachoma, Ascariasis, Fluorosis, Iodine deficiency, Leishmaniasis, Dysentery, Cholera, Measles, 10 Anemia　11 Cold　12 Asthma　13 Chronic respiratory disease 　　　　　 　　　14 Pulmonary TB　15 Pneumonia　16 Acute respiratory infection (viral)　17 Accidental injury　18 Stroke　19 Dental caries　20 Coronary heart disease　21 Diabetes　22 Poisoning　22 Vision problems　23 Other 　Please specify: _　 E．Hospital Basic Equipment Status Below are questions and tables pertaining to this hospitals medical and laboratory equipment situation Please circle the number corresponding to the answer　○　 E1 Does this hospital have a freezer for storing vaccines? Yes　Cont.　 No　If no, jump to D4　 E2 Does this freezer have a thermometer inside for monitoring temperature? Yes　Cont.　 No　If no, jump to D4　 E3 What is the current temperature? E4 Does this hospital have a refrigerator for vaccinations? Yes　Cont.　 No　If no, jump to D7　 E5 Does this refrigerator have a thermometer inside for monitoring temperature? Yes　Cont.　 No　If no, jump to D7　 E6 What is the current temperature? degrees (C assumed) degrees (C) E7 Are the toilet and wash basin at this hospital separated? Yes No E8 This hospital uses which of the following types of syringe for injections? Glass syringe Single-use syringe Both E9 What are the most commonly used sterilization methods at this hospital? Boiled water Electric sterilizer Steam pressure Chemical sterilization Other(Please specify: _) E10.What is the sterilization time for the most commonly used type of sterilization? E11 How many rooms does this hospital have? Rooms E12.Of which, how many are laboratories? Rooms E13.Does this hospital have running water (indoor)? Yes Autoclave Minutes No E14.What is this hospital’s water source? Underground water (using a pump) Open well (using a bucket) Stream, river, lake Rain water, snow melt Water processing facility Other (Please specify: _ ) Don’t know E15.Can patients call the hospital for services using a designated phone? 　　　　　　　　　　　　　　　　　　　? Yes No E16.Is there a covered area to protect patients waiting to be seen from the elements? E17.Does this hospital have a computer? Yes E18.How many vehicles does this hospital have? Yes No No Cars The following are questions regarding township hospital level management of villages E19.Please answer the following questions about township hospital level management of villages Question Unit 2003 1999 How many villages does this township clinic manage? Villages Of which, how many have village clinics? Villages What is the total number of village clinic/private doctors Person(s) in all the villages managed by this township hospital? Person(s) What is the total population of the villages managed by this township hospital? How many private doctors are there in this township? 　 Person(s) 　　 E20.On the whole, how you feel about the quality of present village clinic health services managed by this township hospital compared to the year 2000? Better Same Not as good as in 2000 No way to compare Please answer the following questions about the head of this township hospital Please circle the number corresponding to the answer　○　 E21.What year was the township hospital head born? E22.Hospital head’s education level: Technical college College Year Middle school/technical high school High school E23.How many years has the hospital head been a doctor? Years E24.How many years has this hospital head been the hospital head at this hospital? Year(s) E25.How many years has the hospital head been hospital head at other hospitals? Year(s) E26.What was his/her ranking in last year’s year-end assessment test? Unqualified Basically qualified Qualified Good Excellent Please continue by answering the following questions about basic equipment Please circle the number corresponding to the answer　○　 E27.Does this hospital have the following laboratory equipment? Please circle the number corresponding to the answer　○　 Equipment Yes No Microscope 2 Centrifuge Incubator Spirit lamp 2 Balance Slides or ready-made glass slides Spectrophotometer 2 Ten-item urinalysis instrument Blood analysis instrument 10 Water bath E28.This hospital’s medical equipment If none, please fill in “0” in the “Unit” column Equipment Unit(s) Present Value　　　 800MA X-ray machine and below ECG machine Ultrasound diagnostic machine High pressure sterilizer Examination table General operating table Examination lamp Stethoscope Otoscope 10 Sphygmomanometer 11 Scale 12 Vision chart (backlit) 13 C-arm X-ray unit 　　 X-　　 14 Lung capacity machine 15 Dental chair 16 Operating kit 　　　 17 Gastric lavage instrument F Township Immunization Status The following section has tables on children’s immunization status Please use past records to fill them out F1 Immunization types at this township hospital Does this hospital presently offer this type of immunization? Please circle the number Immunization type corresponding to the answer　○　 Yes No BCG vaccine DPT combined vaccine Yes No Polio vaccine, pill form Yes No Measles vaccine Yes No Hep B vaccine Yes No Total vaccination injection fee.　　　 F2 Years 1988-2003 Immunization rates Year 10 11 12 13 14 15 16 BCG (%) DPT (%) Measles (%) 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 Hep B (%) Polio (%) Total (%) G．Infectious Disease Status The tables below pertain to infectious disease prevalence in this township Please use past records to complete this section G1 Year 1999-2003 Table for annual cumulative infectious disease cases If there were none, please indicate by filling with “0” Infectious disease type 1999 2000 2001 2002 2003 Pestis Cholera 3.1 Hep A Hepatitis 3.2 Hep B 3.3 Hep C 3.4 Hep D 3.5 Hep E Dysentery 4.1Bacillary 4.2Amoebic 5.Typhoid Fever 6.1 AIDS 6.2 HIV infected 7.Gonorrhea Syphilis 8.1Primary 8.2Secondary 8.3Congenital 9.Poliomyelitis 10.Measles 11.Pertussis 12.Diptheria 13.Meningitis 14.Scarlet fever 15.Hemorraghic fever 16.Rabies 17.Leptospirosis 18.Bu disease (endemic) 19.Anthrax 20.Typhus 21.Encephelitis B 22.Leishmaniasis Malaria 23.1Tertian (P Vivax) 23.2Pernicious (P Falciparum) 23.3 Undifferentiated 24.Dengue fever 25.Neonatal tetanus TB 26.1 Bacterial　+　 26.2 Bacterial　-　 26.3 No sputum test 10 G2 1988-1998 Annual cumulative infectious disease cases for four specific diseases In the table below, please fill in each year’s total cases for each disease in this township If there were none, please indicate by writing “0” Disease 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 Cholera Bacillary dysentery Amoebic dysentery Measles G3 1988-2003 Annual cumulative endemic disease cases If there were none, please indicate by writing “0” Disease 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 Pestis Leishma niasis Enhinococciasis Bu disease Kaschin-Beck disease Iodine deficiency Keshan disease Fluorosis 1998 1999 2000 2001 2003 H 1988-2003 Annual infant mortality and annual total technical health workers In the sections below, please fill in the infant mortality rate in this township and total number of technical health workers at this hospital for each year H1 The annual infant mortality rate is defined as the number of infants, born that year to one year of age, that have died, divided by the total number of infants born that year to one year of age 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2003 Infant mortality rate (%) Technical health workers (persons) This is the end of the questionnaire Please continue with the Village Clinic Status Questionnaire Thank you for your cooperation 12 ... “0” Service Is this service available? 2003 (Yuan) Registration fee Health check-up examination Yes No 　go to next row　 Basic health exam (physical) Yes No 　go to next row　 Non-infectious TB treatment... 2003 Mother and Child health education Epidemic prevention 2.1 Immunization planning 2.2 Health education training 2.3 Program training Program topic Number of times in 2003 Clinical skills training... 1999 How many villages does this township clinic manage? Villages Of which, how many have village clinics? Villages What is the total number of village clinic/ private doctors Person(s) in all the