Planning & Coordination:Dr Md Aminul HasanDirector Hospitals & Clinics. DGHS& Focal PersonQuality Improvement SecretariatMinistry of Health of Family WelfareAdvisor:Director GeneralHealth Economics UnitMinistry of Health & Family WelfarePublished on 2019Network partner:UNICEF, UNFPA, SCI, USAID, WHODesign & Desktop Editing:QIS teamQuality Improvement SecretariatPrinting & Publishing:Jerin Efaz Enterprise8/3 (2nd floor), Katabon, Nilkhet, Dhaka.Cell : 01712713985E-mail : [email protected]

PrefaceA standard operating procedure (SOP) is a set of step-by-step instructionscompiled by an organization to help service providers carry out complexhospital routine operations. SOPs aim to achieve efficiency, quality output anduniformity of performance, while reducing miscommunication and failure tocomply with health service standard and clinical Quality.Many hospitals are currently providing quality clinical services, which is a newintervention in the practice of health service delivery in the country. However,the services are not being provided in a standardized and uniform manner.Therefore, this standard operating procedures (SOP) manual has beendeveloped to standardize and formalize the provision of Quality clinical servicesin the health service delivery. SOPs on how to provide clinical services for OPD,IPD, Emergency etc and to document and report the services provided areaddressed in this manual.It is a written procedure prescribed for repetitive use as a practice, inaccordance with agreed upon specifications aimed at obtaining a desiredoutcome.This document has developed after literature reviewed, then draft has develop,reviewed by the relevant stakeholder by holding series working group meetings& finalized in a national workshop.This SOP describes specific step by step procedures in clinical management likeOPD, IPD Housekeeping, Emergency services, OT services, Radiology Services &Pathology services. It should be used as a hands-on reference for serviceproviders providing services, thereby helping to standardize the practice in allhospitals, with the ultimate goal of optimizing the quality & standard patientcare. The manual may also be used as a reference for health service providersfor effective health management.Finally the SOPs will ensure that standardizedQuality clinical services areprovided in all health facilities and at all times, Clarify roles and responsibilities ofthe service providers for clinical care, Provide a detailed description of how toperform clinical activities, Improve the standards for clinical services on acontinual basis, at end it will ensure the client satisfaction in health servicedelivery.Dr Md Aminul HasanDirector Hospitals & Clinics. DGHS& Focal PersonQuality Improvement SecretariatMinistry of Health of Family Welfare

Table of Contents1Introduction052Standard Operating Procedure (SOP) for OPD Services093Standard Operating Procedure (SOP) for IPD Services194Standard Operating Procedure (SOP) for House keeping Services355Standard Operating Procedure (SOP) for Emergency Services416Standard Operating Procedure (SOP) for OT services497Standard Operating Procedure (SOP) for Pathology Services578Standard Operating Procedure (SOP) for Radiology Services63

IntroductionThe Standard Operating procedure (SOP) are developed for the healthcarefacilities based on the Health Care Standards involved in the health serviceproviders and experts. The SOPs include separate sets of procedures for thehealthcare facilities of various levels. SOPs reflect the difference in opportunities,capacity and vulnerability of the healthcare staff in different levels of thehealthcare system.The purpose of the Standard Operating Procedures is to provide clear anddetailed description of step by step routine actions of the service providersproviding services in the facilities.Many hospitals are currently providing quality clinical services, which is a newdevelopment in the practice of health care in the country. However, theservices are not being provided in a standardized and uniform manner.Therefore, this standard operating procedures (SOP) manual has beendeveloped to standardize and formalize the provision of Quality clinical servicesin the health service delivery. SOPs on how to provide clinical services for OPD,IPD, Emergency etc and to document and report the services provided areaddressed in this manual.SOP is a written procedure prescribed for repetitive use as a practice, inaccordance with agreed upon specifications aimed at obtaining a desiredoutcome.These are a specific set of practices that are required to be initiated andfollowed when specific circumstances arise. For example, emergency roomphysicians have SOPs for patients who are brought in an unconscious state;nurses in an operating theater have SOPs for the forceps and swabs that theyhand over to the operating surgeons; and laboratory technicians have SOPs forhandling, testing, and subsequently discarding body fluids obtained frompatients.In present day medicine, clinicians are familiar with SOPs in restricted contexts.Service providers are also aware of the use of SOPs in the context of clinical trials,either with regard to the functioning of ethics committees or with regard toscreening, consenting, assessing, and treating patients across the course of theclinical trial. An idea whose time has now come is the introduction of SOPs intoroutine clinical practice; that is, not for special patients (e.g. those who areunconscious) or for special circumstances (e.g. clinical trials), but for everypatient in everyday clinical care.Standard OperatingProcedure (SOP)05

SOPs are more specific than guidelines and are defined in greater detail. Theyprovide a comprehensive set of rigid criteria outlining the management steps fora single clinical condition or aspects of organization.Guidelines are rigorously developed using evidence-based medicine criteriaand consist of two distinct components: the evidence summary and thedetailed instructions for the application of that evidence to patient care. For thecommon health care provider, guidelines require local adaptation to suit localcircumstances and to achieve a feeling of ownership, both of which areimportant factors in guideline uptake and use. SOPs therefore, help bridge thegap between evidence-based medicine, clinical practice guidelines, and thelocal realities at the point-of-care.SOPs are necessary to remind clinicians of the need for medical evaluationssuch as ultrasonography of the ovaries in young women advised valproate,physical and metabolic monitoring in patients advised olanzapine, and thyroidassessments in patients with mood disorders. Incorporating reminders in the formof SOPs can improve the rate of compliance with the relevant guidelines.SOPS are necessary to incorporate aspects of treatment which are nothighlighted in guidelines or which are parts of different guidelines. This will ensurethat attention is paid to areas as diverse as problem-solving, communication,social support, family burden, and caregiver stress. SOPs are necessary to ensurethat easily implemented strategies that benefit mental health are notneglected; examples of behavioral targets are diet, exercise, sleep, stressmanagement, and the pursuit of leisure and pleasure activities. SOPs arenecessary to monitor medication compliance, a variable that can make orbreak the success of a psychopharmacological treatment plan.The use of SOPs will have the added advantages of utilizing an aleducation,medicine,improvedinduction of new hospital staff, integrated quality control, transparency andenhanced protection from malpractice. When all these SOPs are in place, thequality of patient care will substantially improve.Scope of the ManualThis SOPs manual describes the specific steps providingclinical services to thepatients . It contains SOPs for the provision of clinical services to the patient infacility level, with the necessary documentation and reporting systems.06Standard OperatingProcedure (SOP)

Purpose of the ManualThis manual describes specific procedures in clinical care practice. It should beused as a hands-on reference for service providers providing services, therebyhelping to standardize the practice in all hospitals, with the ultimate goal ofoptimizing patient care. The manual may also be used as a reference for healthsystem managers, policymakers, health care providers, academicians,researchers, and pharmacy students.Objectives of the ManualGeneral Objective: The general objective of these clinical SOPs is to standardizethe provision of Quality clinical services, thereby optimizing patient outcomesby ensuring the rational use of medicines.Specific Objectives Ensure that standardized Quality clinical services are provided in all hospitalsand at all times. Clarify roles and responsibilities of the service providers for clinical care. Provide a detailed description of how to perform clinical activities. Serve as a source of guidance for new service providers. Improve the standards for clinical services on a continual basis. Provide evidence of commitment to improvements in the quality of patientcare.Standard OperatingProcedure (SOP)07

08Standard OperatingProcedure (SOP)

Chapter-11. SOP for OPD Services1.a. Introduction:Out patient departments (OPD) provide Medicare services to theambulatory patients. Acute and seriously ill patients must not bereferred to the OPD. Majority of the patients received services from theOPD. So it is of maximum importance to serve the people with highest possiblequality services to fulfill their need and reduce their sufferings. Efficient OPDservice can greatly reduce the burden to the other sections of the hospitalservices. Out patient services are rendered through the Male / Female / Children/ Dental & Family planning out patient departments.As majority of the people come in contact with the OPD services of the hospitalsso it is the area of importance to satisfy and address the people demandaccordingly and in an effective way.Rural peoples come to the Government Hospitals with high expectations and inmany situations it was observed that peoples expectations superset the realsituation which gives raise to many problems and often confrontation with theservice providers. So the mentioning of standard operating procedure withsetting up of norms and standards for the OPD will be helpful for both the clientsand service providers to be realistic. It will also help the supervisors to measuretheir institutional service standards.Standard OperatingProcedure (SOP)09

1.b. Standard Operating Procedure (SOP)of OPDActivitiesGENERALSTEP-1STEP-2a) Time tabledisplay, signposting & Displayaroundregistration desk.b) Registrationcounter remainclosed-c) Ticket will bemarked-- by colour pen orprovidingcolourdeticket/seal foreach areaA. Registrationcounter/Deskx Registration inwaiting placeof OPD areax Ticket will beprovided topatient asx Patient can besent to ORTcomer oremergencydirectly ifnecessaryWaiting Placea) ntendentRMO*1.00 ntRMO*1 MinutesClerkresponsible forregistrationSecond clerk*9-00 AMClerk assignedfor registrationSecond clerk*2 MinutesClerk assignedfor registrationSecond clerk*Male-10Femel-10(for 20person 5Accordingto monthlySuperintendentRMO*DoRMO*c) Sputum boxTwoDoRMO*d) Safe drinkingwater facilitiesOneDoRMO*e) Toilet facilitiesone formale onefor female9.00 AM to2.00 PMDoRMO*DoRMO*b) Waste basketF) Healtheducation’s---- Audio---- Video---- Poster10Time/NoStandard OperatingProcedure (SOP)

STEP-3ActivitiesTime/Nog) Sign markingwith same colourticket/seal orroom/area numbertowards respectiveOPDConsultation/Examination rooma) Privacyarrangementb) Examinationfacilities—---- BP. instrument---- Stethoscope---- Tonguedepressor---- Thermometerwithantiseptic lotion---- Weightmachine---- Height tape---- Torch light---- Hammer---- Aural speculum---- Gloves---- VaginalspeculumExamination whitetable covered withClean white clothc) Sittingarrangement forDoctor, chair &table covered withclothd) Dental surgeon- Dental chair &instrumente) Sittingarrangement forpatientf) other facilities—--- Waste basket--- Basin--- Soap--- LightExamination :a) Secondregistration with slno, name, age, sex,address, timing of in& exit dateAll activitieswill be entRMO*One foreachSuperintendentRMO*clearlywritten 2MinConcernedphysicianRMO*Standard OperatingProcedure (SOP)11

ActivitiesSTEP-4STEP-512b) Filled up historiessheety Chief complaintsy History of presentillness-- History of pastillnessy Family Historyy Physicalexaminationy Investigationy ProvisionalDiagnosisy Treatment &y Advice clearlywritteny Counseling byproviders(A) X-ray Servicesa) Registration &code number isproperly filled oninvestigation slipwith brief historyb) First come firstservec) Maintain Que.Dispensing ofDrugh:a) First come Firstserveb) Patient will be inQueue by sexc) Pharmacistcollect ticket &Register the ticketnumberd) Dispense drugs &with dose writtenclearlye) Propercounselingd) Reports are sentback to respectiveDoctor:* Plain X-ray,--- Chest--- abdomen--- Bone & joint--- Special X-ray--- Others* Emergency X-rayStandard OperatingProcedure egularlyNext dayWithin 6hoursWithin 30minutes

ActivitiesSTEP-6(B) Pathologya) First come firstserveb) Maintain Que.c) Registration withcode number witharrival timed) Routine Exam:--- Stool R/E--- Urine R/E--- Blood for TC. DC.ESR & Hb %--- Sputum AFB--- MP--- Blood group andcross matchingA. Admissiona) All patients isrespective of theirincome are eligiblefor admissionb) Acutely ill.patients areadmitted on prioritybasisc) Admission boardwill admit thepatientB. Referrals fromOPDa) Exact problemfor which thepatient is beingreferred, writeproperly the areaof referral includingthe documents &short e/NoResponsiblePersons4 Hours aftercollectingsampleMedicalTechnologist(Senior person)Other MTSame dayAdmissionboard/RMO/MO on dutySuperintendent*Same dayAdmissionboard/RM/MOon dutySuperintendent*after 72hoursSame day* Compliance rate:Quality of care will be measure by Compliance rate isExcellent: 91—100%Very Good : 76—90%Good: 50—76%Bad: 50%Standard OperatingProcedure (SOP)13

1.c. Patinet Flow Chart In OPD chargeNeedfurthermanagementORTProvisionYesInNeed ofORTNoWaitingYesHistory &physical ementYesYesDischargeManagementavailablein IPDReferral14Standard OperatingProcedure (SOP)DiagnosticProceduresLab / X-ray

Working Procedures of1.d. Out Patient DepartmentRegistrationThere should be a central desk at the OPD where patients will be provided OPDslips after preliminary registration. This desk may also serve as the booth forhospital information and health education. One nurse/relevant staff with skill inhuman interactions may be deployed there. After taking brief history of patient'sillness he/she will direct them to the respective OPDs. Final registration of patientswill be done in the concerned OPDs.Working rulesThe patient treated in the OPD are usually ambulatory. Acutely ill patients mustnot be referred to the out patient department. They must be management inthe emergency. In OPD, a short clinical examination is done and documentedin the OPD slip. It must include a clearly written provisional or clinical diagnosis aswell as the advice and treatment given to the patient. A list of investigationplanned may also be written on the slip for convenience of the patients. Thepatients are given correctly and completely filled investigation forms. It must beexplained to the patients where Investigation Center is located for all the OPDinvestigations (blood, urine and stool etc.), and the time when samples arecollected, and also how the reports are distributed at the OPD. As in usualprocedure, a patient will require to wait till the next OPD day. A way should befound out in consultation with the clinical laboratory and radiology departmentso that reports of majority of investigations may be available on the same day.This will enable the clinicians to advice treatment to the OPD patients on thesame day without awaiting too much. for X-rays, the patients should be clearlydirected to communicate to the respective counter in the department and tofollow the preparatory instructions which will be given there.In case of an emergency arising in the OPD, the in charge should be providedwith necessary first aid, drugs and investigations. After the first aid given, it isadvisable to shift the patient to the emergency department immediately.To make things easy for the patients, it is advisable to fix a definite datementioning time & place for the next appointment which should be writtendown on the slip. It must be remembered that quality of care provided at theOPD should be comparable to in-patient care, and it should be the aim of thehospital to deliver significant medical care to the community through the OPD.Standard OperatingProcedure (SOP)15

Necessary patient information must be written in the CPO register andacceptable out-patient record with diagnosis be available.Referrals from OPDReminders for Unit Heads(RMO/Superintendent)For obtaining the opinion of TheConsultant the exact problemfor which the patient is beingreferred must be written downPlease.on the OPD slip and the patient"Display up-to-date organgramshould be directed to the"Display other information charts, viz.schedules general and visitors' policy,activity report Service data forguidance and transparency"Schedule for routine daily and weeklyactivities at fixed time"Monitorandsupervisestaffperformance, cleanliness, equipmentmaintenance and resources at the unitas per checklists"Send daily bed statement along withserious patients' list"Maintain staff morale, punctuality,interpersonal relationship, quest forsound professional knowledge &practice and their good behavior topatients and peoplefurther"Maintain records properlymanagement will be admitted"Applymechanismfeedback on users'complaints"Hold regular co-ordination meetingKeep minutes and ensure follow up"Send report to Director (Hospital),relevant OPD. While referringthepatienttoanyotherspecialty, please make surethattheresultoftheinvestigations done and-the atient. This will save repetitionoftheinvestigations,time,laboratories' time and also savefurtherdiscomforttothepatient.Admissionfrom OPDofpatientsA patient needing admission tothewardsforfrom the OPD through theadmission board and send thepatient to the respective ward.toreceivefeelings andDGHS & HCQA office by 6th day eachmonth as per specific report form.16Standard OperatingProcedure (SOP)

1.e. OPD Service Monitoring ChecklistSlNo.Services1Whether provided attention to patients and listedtheir complaints?2Whether given answers to present Question?3Whether asked chief complaints?4Whether asked present history of illness?5Whether asked past history of illness and relatedfamily history?6Whether patient checked for vitals signs?7Whether conducted related physical examinations?8Whether reached a provisional diagnosis?9Whether ordered condition related laboratory testsor X-rays?10Whether provided to the patients / relativesinformation about the condition and treatmentplan?11Whether discussed about the importance ofcompliance with drug?12Whether adequate time spent for patientconsultation?13Whether provider wash hands before and betweenpatient examination?14Whether soiled covers are removed and replacedbefore examining new patient?15Whether thermometer and tongue depressor arekept soaked in antiseptic solution before examiningnext patient?16Whether maintained patients discipline (Que)?17Whether patient counseling & health educationdone?18Whether admission procedure SOP followed?19Whether referral procedure SOP followed?As per SOPYesNoRemarksStandard OperatingProcedure (SOP)17

18Standard OperatingProcedure (SOP)

Chapter-22. In Patient Department (IPD Services)2.a. Introduction:From Emergency and Out Patient Departments patients are admitted intothe In-Patient Department for further management by keeping thepatient under close monitoring. In Upazila Level Hospitals IPD is dividedmainly into male ward and female ward with 6 beds for MCH. All the malepatients 12 years age are admitted into the male ward and all the femalepatients and children age bellow 12 years are admitted into the female ward.At Upazila level hospitals the duty doctor, nurses and the supporting staffs in theIPD are accountable to RMO for their responsibilities and through RMO to TH &FPO.Usually the more sick, acute and seriously ill patients are admitted into the IPD forimmediate and supervised treatment protocol. They may also need to undergovarious diagnostic and or operative procedures and multiple inter relatedactivities are performed to serve an admitted patient. So, it is very muchimportant to coordinate and standardize these various components of IPDservices and also the various departments (i.e. doctors, nurses and supportservice staffs).During admission, patients and their relatives highly depend on the doctor andother hospital staffs for the well-being and comfort of the patient and they arepsychologically more sensitive and vulnerable to various emotional matters. So,beside clinical management of the patient, it is also important to look aftervarious behavioral aspects of the patient and their relatives for their satisfactionand confidence. All concern staffs should be well concern about their dealingswith the patients and their attendants by considering the psychological status ofthe respective person. They should be well tempered and skill in managingemotional and critical situations.Mention of standard operating procedure with norms and standards will be ofgreat importance to improve the IPD services as well as satisfy the patientsexpectation and make them more rational about the real situation of thehospital. By be informed about the available services and limitations will give amore harmonious relation between service providers and their clients. It willfurther improve human relationship, make people confident on the hospitalservices and also improve the providers satisfaction to serve.Standard OperatingProcedure (SOP)19

2.b. Standard Operating Procedures (SOP)For in Patient Services itiesTime/NoResponsiblePersonsA. House keepingy Mopped & Swept thefloor3 Times/24 hrsand whennecessaryCleaner/ Wardin-charge /Onduty SSNRMOy Clean toiletsy Fans, Walls, Roots,Doors & Windows arecleaned dusted.y Tap water supply 24 hy Attendant (Full time)for serious patienty Visitors as perschedule1/shift & whenrequiredWardboy/Sister /NursingSupervisorRMOA.Facilitiesy Doctors/Nurese/Ayawear their dress &badgesAll the timeAya / wardboy/ Sister /NursingSupervisorRMO y Investigationforms/Registers Report,Record in registrationHistory sheet.1/patientShouldmaintain fixedvisiting hourfor hospitalDoRMO y Discharge forms,Death certificates,Temp chart, intake &output chart, Height &Weight chart, Digoxinchart, Diabetic chart,Paragraph for labourPatientDuringworkingperiodSister incharge/ NursingSupervisorRMOAll timeSister in chargeRMOy Bed linen, pillow,pillow cover, Bedsidelocker, Mosquito net,Mosquito net standavailable according toneed.All the timeSister in charge/ Wardboy /Aya / NursingSupervisory Stock ledger &required register, likehandover & take overof charges (shift wise)made available.All the timey DietAll the timeStepsGENERAL20Standard OperatingProcedure (SOP)2 times / week

StepsSTEP-1STEP-2ActivitiesReception andRegistrationy First attend duty roomy Registration in IPDRegistery Bed allocation &Preparationy Health education &instruction sheety Send the Patient tobedy inform Doctor on dutyA. Examination* Check case sheetsupplied fromemergency / OPD* Ask chief complaints* History Present past Family Personal Menst. & Obsthistory of femalepatientsPhysical examination Pulse BP Temperature Dehydration Anaemia Cyanosis Oedema Jaundice Clubbing Koilonechia Height & Weight Heart Lung Liver Spleen Kidney Other systemicexaminations ifneeded. Obst &Gynaecologicalexaminationswhen mecessaryy Investigations.* Necessaryinvestigations: ponsiblePersonComplianceRate3-5 min:SSN8-10 ologist /Radiaologist/Medicaltechnologist/DoctorsRMO*10-15 minutes(Examinationto Diagnosis ithin 8 a.m12 noon-1p.m.Within 8 p.mSSNRMO(within Twohours)Same day(within 24 hrs)Standard OperatingProcedure (SOP)21

esponsiblePersonComplianceRateB. Diagnosis* Provisional diagnosis(Clinical diagonosis)* Dignosis written clearlyC. TreatmentTreatment will be givenafterSignature of DoctorD. Diet & NutritionBreak fastLunchSTEP-3DinnerA. Further treatment Counseling to thepatients needsurgicalinvestigation Inform patient /attendants wellahead of surgicalprocedureRespectivedoctor24 hoursbefore atonceRMO*RMO*RMO*-Routine Case-Emergency case atonceB. Labour Case Place in labourroom when painstartsFollow upMaintenance ofpantographC. Transfer If the patient isimproved theninform the patientregardingdischarge. Verbal adviceand explanationneeded forilliterate patient22 Follow up If the patientrequiresspecializedStandard OperatingProcedure (SOP)Boctors, SSN,Aya, DoContinuouslyRespectivedoctor24 hoursbeforeFollowingmorningAfter oneweek or ifneededRespectivedoctor6 hrs beforeAt once withinone hourISSN/Doctor ondutyRMO*

esponsiblePersonComplianceRateservices refer withinformation-----Routine case-----Emergency If death, sent tomortuary/deathhouse/isolationplace/handedover to relatives.Compliance rate:Quality of Care will be measured by compliance rate.The Rated is Excellent:91-100%Very Good:76-90%Good:50-75%Bad: 50%Standard OperatingProcedure (SOP)23

2.c. Flow Chart of IPD ServicePatient arrivalto nursingduty roomRegistrationFile preparationBed preparationMedical the physicianLab orX-ray /ImagingNeedforinvestigationYesNoManagement &progress zedhealthstatusNoMortuaryRelative24Standard OperatingProcedure (SOP)Discharge &follow upYesOperation

Working Procedure2.d. In-Patient WardUnder the new intervention program, the clinical in-patient units Male, female &Children at Thana Hospital, will play independent and broader role. RMO willhave to shoulder the responsibilities to co-ordinate the over all activities. Alldoctors, nurses and other staff will be accountable to TH & FPO.Case sheet maintenanceCase sheet is an importantdocument for patient care,medical records and medicolegalpurposes. Therefore, it should belooked after properly. The finalresponsibility for the case sheetupkeep is that of the statistician.Please note that it is important toadhere to the following sequencein arranging .the case sheet:Factors involved in good s into program and listed inward policy bookMaking a planned program foreach day’s work, in acquaintanceof allEncouraging everybody to plannext days work before leaving the"Case sheet: particulars ofpatient (including transfers)"Chief Complaints"History (present, past, familyand others)"Physical examination/Specialexaminationpolicies which enable easy and"InvestigationsOrienting new staff"Current treatment ordersMaintaining suitable environment:"Previous treatment orders"Progressnotestransfer notes)wardStarting day on timeDiscourage interruption while one is(including"Paretograph for labour patient"Consultant/Board"Opinion of consultant"Opinion of other consultant (s)engaged in a particular taskEstablishing of ward routine andefficient workprivacy, noise, proper , care of stores and utilityroomsProviding constant supplies andequipmentforefficientwork:adequate supply should be kept inhandalltimesconvenientlylocated and in good conditionStandard OperatingProcedure (SOP)25

"Progress report"Discharge summary"Morning and evening roundshould be ensured.Clean cut doctor's order: in clearlegible handwritings and completeAccurate and complete recordsEstablishinggoodworkingrelationship among all members ofwardDelegating certain responsibilitiesWell planned assignments of staff:interesting to staff, regarded aseducation experience to themPatient satisfaction: good care utpatients' and visitors' feelings andcomfort.Transparency: Display the forroutine activities and visitors' policyMonitoring and supervisionEvaluationProgress reportDescriptive progress report should be written at intervals. Abbreviations shouldbetter be avoided. Following guidelines are suggested for writing progressreport: Attending doctors should write his/her name distinctly. For acutely il

Advisor: Director General Health Economics Unit Ministry of Health & Family Welfare Published on 2019 Network partner: UNICEF, UNFPA, SCI, USAID, WHO Design & Desktop Editing: QIS team Quality Improvement Secretariat Printing & Publishing: Jerin Efaz Enterprise 8/3 (2nd floor), Katabon, Nilkhet, Dhaka. Cell : 01712713985 E-mail : jerinefaz .