Haramaya General Hospital

Improvement plan-based
protocols utilization

Prep. By Harif A(M.Sc.)

Maya
 Improvement plan-based protocols utilization

no Identified gap Possible solution By whom Time rem

fram ark
e
1 • No interdepartmental • Prepare Interdepartmental protocol By EBC Until
consultation protocols • Avail consultation format in all service area Team 1st
• No interdepartmental special FFA EBC Q
consultation formats • Insert in personal file scope-based practice Team,
• No all personal file has • Assign GP to triage HR, MD
scope-based practice
2 • No STG adherence given to ✓ Give orientation to staff on STG special for Pharm Until
Staff, special for FFA FFA Dep’t, 1st
• No generic name drug ✓ Avail STG on booklet for FFA EBC team, Q
prescribed as STG ✓ Assess STG by DUE all senior
• No drug prescribed per ✓ Give orientation Evidence based clinical physician,
encounter as STG service protocol SMT
✓
3 • No Chart Audit Team and ✓ Assign Chart audit team with TOR SMT, Until
TOR ✓ Perform chart audit as TOR EBC Team 1st
• No chart audited performed ✓ Prepare data triangulation protocol with CQI dep’t Q
• No data triangulation report M&E
report ✓ Prepare MR completeness check tracking dep’t
• No medical record mechanism MRU
completeness check ✓ Prepare QIP on data utilization
 mechanism
• No QIP on Data Utilization
4 • No OPD service at launch ✓ Open OPD at launch time SMT, MD, Until
time ✓ Prepare register for patient no seen on the EBC team 1st
• No patient identified that same day OPD Q
no seen on the same day ✓ Prepare AMR guideline coordinat
• No antibiotic with correct ✓ Prepare maintenance protocol with or
dose, frequency, route, notification work order Pharmacy
duration was prescribed as ✓ Make senior physician consistently ,
STG engaged in all clinical care activities and Biomedic
• No maintenance protocols decisions which necessitate their al Dep’t,
• No weekly senior chart involvement. FG, All
round performed ✓ Prepare senior weekly chart round Senior
improvement plan physician,
CQI
5 • No hospital health care ✓ Prepare hospital health care efficiency Finance, Until
system efficiency identified assessment mechanism and make assess HR, EBC 1st
• No incentive guideline for source of inefficiency of health care system team, CQI Q
staff ✓ Prepare incentive guideline and make dep’t
• No priority mitigation adhere SMT
measures are not ✓ Prepare priority mitigation measurement
developed
6 • No nursing shift handover ✓ Avail nursing shift handover Nurse Until
protocol and format ✓ Prepare daily round table package Directory, 1st
• Round package and ✓ Avail emergency preparedness table All ward, Q
 emergency table ✓ Prepare ICU nurse package OPD,
preparedness protocol ✓ Avail INP format for DVT prop, GI prop, Emergenc
• Prepare emergency table at Nutrition and fluid balance format, med y service,
ward adm format ICU
• No ICU nurse package ✓ Perform nursing care audit Nurse
• No skill lab room ✓ Open skill lab staff,
✓ Prepare plan on need-based capacity SMT
building with performance
✓
7 • No OR schedule ✓ Avail OR Schedule such have start time, EBC team, Until
• No elective surgery TAT, finishing time, Category of surgery OR, 1st
protocol ✓ Prepare and avail pre and post-operative SOPD, Q
• No peri operative protocol anesthesia Surg W,
• No day care surgery ✓ Prepare and avail pre and post-operative ObsGyn,
• No SaLTS committee nurse staff,
established ✓ Avail patient transfer format CQI dep’t
• No SaLTS Committee ✓ Prepare WHO SSC Audit format
performance reviewed ✓ Avail perioperative conference format
• No SSC audit protocol ✓ Prepare on every peri operative conference
• No SSI register brief and debriefing feedback and action
• No WHO SSC utilization plan
monitoring mechanism ✓ Prepare SSI Tracking at admission and after
discharge format
• No peri operative
✓ Prepare QIP on surgical efficiency and
conference schedule
productivity and Cancelation reduction
 ✓ Make clinical audit on priority health
condition at Surgical service
8 • No national NICU leveling ✓ Avail national NICU leveling and define EBC team, Until
document NICU NICU 1st
• No all staff work at NICU ✓ Assign trained nurse on NICU staff, Q
that trained on NICU ✓ Avail family counseling corner CQI dep’t
service ✓ Give orientation
• No family counseling corner ✓ Prepare QIP on neonatal mortality
• No orientation given on ✓ Make clinical audit on priority health
NICU manual condition at NICU
9 • No national emergency and ✓ Avail national leveling document EBC team, Until
ICU leveling document and ✓ Prepare report based on national leveling ED staff 2nd
assessed document ICU staff Q
• No BEC training ✓ Prepare capacity building plan based on CQI dep’t
• No trauma protocol and gap assessed for both ED and ICU dep’t
registry ✓ Avail WHO BEC toolkit
• No capacity building plan ✓ Give orientation on trauma, burn,
both at Emergency and ICU poisoning, ICU manual
✓ Prepare trauma registry and WHO trauma
format
✓ Prepare WHO medical format
✓ Avail emergency triage format
✓ Prepare BEC training performance
✓ Prepare QIP on EICC
✓ Make clinical audit on priority health
 condition at EICC
10 • No health literacy unit ✓ Prepare and open health literacy unit with HLU focal Until
• No hospital care leaflet, assign focal person person, 2nd
poster for client and HCP ✓ Proved comprehensive information and Pain Mgt Q
• No patient orientation prepare clinical information material such focal
protocol as leaflet, posters, person,
• No patient discharge ✓ Avail zero tolerance pain poster SMT, EBC
planning protocol ✓ Avail pain mgt protocol team,
• No pain mgt protocol ✓ Perform pain assessment Staff
• No social service unit ✓ Avail patient orientation and discharge Client
• No client awareness and planning protocol
knowledge audit ✓ Avail Patient orientation format
• ✓ Avail patient discharging planning
✓ Give orientation on patient orientation and
patient discharge planning
✓ Prepare social services unit
✓ Assess client awareness and knowledge,
prepare report
✓ Prepare QIP on client awareness and
knowledge from identified gap when
assessed client awareness and knowledge
✓ Prepare QIP on pain mgt from identified
gap when assessed pain
11 • No MOU b/n hospital and ✓ Make MOU b/n Hospital and Lead HC SMT, CQI Until
leading health center ✓ Perform community forum EBC 2nd
• No community forum ✓ Prepare action plan on community forum Team, Q
conducted gap identified Pharmacy
• No mentorship for ✓ Conduct mentorship for lead health center Dep’t
catchment area with lead ✓ Support lead health with human resource,
HC medical equipment, supply
• ✓ Prepare mentorship report with action plan
Haramaya General Hospital

Implementation of Improvement
plan on Protocol Utilization for last
six-month
th st
(4 Q2015 efy and 1 Q 2016 efy)
Prep. By Harif A(M.Sc.)
Maya
Implementation of Improvement plan on Protocol Utilization for last three-month
2016 efy

No Activities Plan Achiev Remark

Meas
’ t
1 • Prepare Interdepartmental protocol # 4 4
• Avail consultation format in all service area special FFA Ss 4 4
• Insert in personal file scope-based practice special FFA # 180 160
• Assign GP to triage # 1 1
2 ✓ Give orientation to staff on STG special for FFA # 120 120
✓ Avail STG on booklet for FFA # 4 4
✓ Assess STG by DUE # 4 2
✓ Give orientation Evidence based clinical service protocol # 320 320
3 ✓ Assign Chart audit team with TOR # 1 1
✓ Perform chart audit as TOR specially FFA # 6 12
✓ Prepare data triangulation protocol with report # 4 2
✓ Prepare MR completeness check tracking mechanism # 12 6
✓ Prepare QIP on data utilization # 1 1
4 ✓ Open OPD at launch time # 1 1
✓ Prepare register for patient no seen on the same day # 1 1
✓ Prepare AMR guideline # 1 1
 ✓ Prepare maintenance protocol with notification work # All All me
order ME
✓ Make senior physician consistently engaged in all clinical # 5 5
care activities and decisions which necessitate their
involvement.
✓ Prepare senior weekly chart round review improvement # 52 24
plan
5 ✓ Prepare hospital health care efficiency assessment # 4 2
mechanism and make assess source of inefficiency of
health care system
✓ Prepare incentive guideline and make adhere # 80 80
✓ Prepare priority mitigation measurement # 2 1
6 ✓ Avail nursing shift handover # 9 9
✓ Prepare daily round table package # 2 4
✓ Avail emergency preparedness table # 1 1
✓ Prepare ICU nurse package # 1 1
✓ Avail INP format for DVT prop, GI prop, Nutrition and # 5 5
fluid balance format, med adm format
✓ Perform nursing care audit # 3 3
✓ Open skill lab # 1 1
✓ Prepare plan on need-based capacity building with # 40 35
performance
7 ✓ Avail OR Schedule such have start time, TAT, finishing # 1 1
time, Category of surgery
 ✓ Prepare and avail pre and post-operative anesthesia # 1 1
format
✓ Prepare and avail pre and post-operative nurse format # 1 1
✓ Avail patient transfer format # 1 1
✓ Prepare WHO SSC Audit format and perform SSC audit wk 12 12
✓ Avail perioperative conference format Wk 12 12
✓ Prepare on every peri operative conference brief and Wk 12 12
debriefing feedback and action plan
✓ Prepare SSI Tracking at admission and after discharge # 1 1
format
✓ Prepare QIP on surgical efficiency and productivity , # 4 3
Cancelation reduction, SSI, ….
✓ Make clinical audit on priority health condition at # 2 3
Surgical service
8 ✓ Avail national NICU leveling and define NICU 1 1
✓ Assign trained nurse on NICU 10 10
✓ Avail family counseling corner 1 1
✓ Give orientation on standard clinical service of NICU Sess 3 3
✓ Prepare QIP on neonatal mortality, ….. 1 1
✓ Make clinical audit on priority health condition at NICU # 2 3
9 ✓ Avail national leveling document Prepare report based on # 1 1
national leveling document
✓ Prepare capacity building plan based on gap assessed for # 30 45
both ED and ICU dep’t
 ✓ Avail WHO BEC toolkit # 1 1
✓ Give orientation on trauma, burn, poisoning, ICU manual # 4 4

✓ Prepare trauma registry and WHO trauma format # 1 1

✓ Prepare WHO medical format # 1 1
✓ Avail emergency triage format # 1 1
✓ Prepare BEC training performance # 3 3
✓ Prepare QIP on EICC # 2 1
✓ Make clinical audit on priority health condition at EIC # 2 2
10 ✓ Prepare and open health literacy unit with assign focal # 1 1
person
✓ Proved comprehensive information and prepare clinical # 500 320
information material such as leaflet, posters,
✓ Avail zero tolerance pain poster # 50 45
✓ Avail pain mgt protocol # 1 1
✓ Perform pain assessment # 12 12
✓ Avail patient orientation and discharge planning protocol # 1 1
✓ Avail Patient orientation format # 1 1
✓ Avail patient discharging planning # 1 1
✓ Give orientation on patient orientation and patient # 320 230
discharge planning
✓ Prepare social services unit # 1 1
✓ Assess client awareness and knowledge, prepare report # 2 2
 ✓ Prepare QIP on client awareness and knowledge from # 1 1
identified gap when assessed client awareness and
knowledge
✓ Prepare QIP on pain mgt from identified gap when # 1 1
assessed pain
11 ✓ Make MOU b/n Hospital and Lead HC # 1 1
✓ Perform community forum
✓ Prepare action plan on community forum gap identified
✓ Conduct mentorship for lead health center
✓ Support lead health with human resource, medical
equipment, supply
✓ Prepare mentorship report with action plan
12 ✓ Give orientation on EBC # 350 325
✓ Make assessment on EBC # 5 5
✓ Make supportive supervision on EBC # 6 6
✓ give orientation on QI and Clinical Audit # 350 280
✓ Give feedback on EBC assessed # 5 5
✓ Prepare report and action plan on CA and present to staff # 8 12
special for FFA
✓ Prepare QIP on identified gap with QI committee and # 10 9
with engagement of senior physicians
13 ✓ Make audit on protocol utilization special FFA # 3 3
14 ✓ Prepare action plan on identified gap with
implementation