EBC Mentorship Findings

& Audit Results

Dila General hospital

10/03/17 E.C
 Team members
Team members

• Mr Tsion
Markos
• Dr Akalu Adifa
• Mr Eyasu
Estiphanos
• Mr Joshua Ayele
 Methodology
• During entry to facility:
– Discussion with MD and QI team

• Approach:
– Mentoring and coaching

– Audit the EBC score for internal use

• During exit;
– Presentation for all SMT & Case team
members by PPT on finding
 Introduction
• EHAQ was first introduced in 2012 and this is
the 4th cycle
• The pervious cycles were focused on
1. Improving client satisfaction,
2. CASH & MNCH services
3. CATCH –IT
 The 4th cycle: Evidence Based Practice
(EBC)
Focus areas:
1. Surgical services
2. Neonatal intensive care unit/NICU services
3. Outpatient service (NCD focused)
4. Emergency services.
EBC AUDIT TOOL
Assesse five major Components with a number of standards and
verification criteria.
S.No Focus area initiative Score 100% (Percentage)

1. Mechanism to Avail High-Quality Evidence 60 20.00

2. Evidence Generation and Utilization 84 28.00

3. Focus Service Areas 102 34.00

4. Patient Preferences and Value (Person-centered 30 10.00

Care)
5. Cluster Activity (EHAQ Networking and 24 8.00
engagement)
Total Score 300 100%
1. Mechanism to Avail High-Quality Evidence (60/20%)

Protocols (scope based and standard based clinical practice protocols)

Strength
 The hospital has established protocols defining the scope of practice for

different healthcare professionals (physicians, nurses, midwives….) based on

their specialty.
 Sampled personal files contained scope of practice attachments

 Clinical Practice Protocols are available at service delivery points

 Ex: Consultation protocol, Admission and discharge protocol, Nursing round

protocol, Bad news breaking,

 The Interdepartmental Consultation Protocol clearly specifies consultation

response times (30-40min). And there are consultation request form

Standard based Protocols
 1. Mechanism to Avail High-Quality Evidence…

Areas to be improved
 No monitoring system for the implementation of the scope of

practice.

 There's no documentation proving healthcare workers received

training on the protocols.

 Consultation request forms are poorly filed, and response

times have not been analyzed.

 No mechanism to monitor utilization of the clinical protocols
2. Evidence generation and utilization (84/28%)

Health information management system

Strength

• The hospital has begun implementation of electronic

medical record system (EMRS) in some service

areas, (full implementation is required).

• Availability of data collection tools ( registers, tally

sheet, and reporting format) but not adequate number

 2. Evidence generation and utilization…

Areas to be improved

• No functional chart audit team (no TOR, no chart audit report)

• No mechanism to check the completeness of medical records before

returning to the medical record room

• Report completeness and timeliness not regularly monitored

• PMT meeting not conducted regularly

• Data quality assurance mechanisms are not in place.

– LQAS not conducted by the HMIS Team

– No data quality triangulation between units

• No records found that indicate training on EMRS was provided.

– No staff capacity building Plan/schedule, No standardized manual for staff training
2. Evidence generation and utilization….

Triage

Strength
 There is a central triage equipped with necessary supplies and equipment.

 Triage protocol is available at central triage

 Triage is done by G.P assigned by letter

Areas to be improved

 Pre-triage set up is available but not functional

 No system for patient channeling to the cough clinic

 2. Evidence generation and utilization….
OPD

Strength
 OPDs are well ventilated, well-furnished and well equipped (no glucometer)

 Functional hand washing facilities are available in OPDs (no ABHR solution)

 Out patient departments are directed by senior physician (Clinical head)

 Adequate OPD waiting area for patients

 Patients not seen in the same day are regularly assessed. (SBFR)

Areas to be improved
 Outpatient clinics not Open at lunch time

 No Block-based appointment system

2. Evidence generation and utilization….

Pediatric Ward

 The Hospital has separate Pediatric Wards composed of

o HDU and Therapeutic feeding room for SAM
 But lack procedure room
 The HDU should be next to the nursing station

 All ward rooms are child friendly

 National guidelines, job aids and clinical protocols are available

 V/s, Growth monitoring and pain management practiced

accordingly
 2. Evidence generation and utilization….
Human Resources
Strength
• The Hospital establishes Human Resources Information Management Systems
(HRIS)
• H.R. Management Manual is in place
• The Hospital has a human resource development plan that addresses staff
numbers, skill mix, and staff training and development.
• Transparent staff incentive and recognition system is in place
• Staff training need assessment was done
Areas to be improved
• Human resource development plan not approved by governing board
• need assessment findings were not used for the human resource development plan
2. Evidence generation and utilization….

Duty rooms
 Duty rooms are near to the service units
 Gender based/not profession-based
 Duty bed available to half duty team
Areas to be improved
Necessary facilities not available
Computer (reference books loaded )
Functional T.V.
water boiler
 2. Evidence generation and utilization….
Food and beverage service

Strength

• The hospital provides a food and beverage service

• The kitchen is visibly clean, well ventilated and has adequate space

• The hospital establish facility-specific menu

• Patient feedback monitoring tool is available

Areas to be improved

• There is team that monitor the quality of food but;-

– No quality monitoring protocol/checklist

– No quality monitoring schedule

– No quality monitoring report

2. Evidence generation and utilization….
Medical equipment

• Medical Equipment maintenance center established

• Medical equipment Management information system/ MEMIS is in place

• There is a notification and work order system for medical equipment

maintenance

• Medical equipment inventory regularly conducted

• Medical equipment maintenance workshop has sufficient space, and

adequate ventilation to conduct maintenance and repair of Medical
equipment

• History files for medical equipment well organized.

Medical equipment Hx files
2. Evidence generation and utilization….
General maintenance
Strength
– The Hospital has a general maintenance center(but no
workshop)
– Tools and technical personnel are available to perform
repairs
• Plumping (water), Metal and wood work shops but no
electrical workshop
– There is a notification and work order system for
Areas to be improved
– No general maintenance workshop
– No maintenance protocol
– preventative maintenance schedule for major equipment
 2. Evidence generation and utilization….
Pharmacy
• Strategy in place that addresses prioritized drug lists
for monitoring and problem identification
• Prioritized drug list (Top 20) available that include 3rd
line antibiotics, narcotic drugs, other expensive drugs
• Scope based prescription protocol is in place

• Antibiotics Stewardship committee is established and

functional.
 2. Evidence generation and utilization….
Senior engagement
Strength
– Daily senior led multi-disciplinary round that
addresses
– Senior physicians are assigned on duty, including
weekends and holidays (but no posted schedule)
– Senior physicians participate clinical auditing and in
QI projects
– There are QI projects led by senior physicians
Areas to be improved
– New admissions are not audited and co-signed
– No handover protocol/practice for Senior physicians
QI projects
 5. CLUSTER ACTIVITY (24/8%)
Strength
• There is approved TOR shared with all members of the cluster
• Best practices are documented and shared among member hospitals
• Support to primary hospitals and HCs
– Material: Oxygen support to PHs
– HR: Senior physicians support PHs and Wonago HCs two times/week

Areas to be improved
• Cluster meeting not regularly conducted
• Mentorship to member hospitals only conducted once last year.
• Member hospitals cluster performance not monitored regularly
• Community forum is not conducted regularly
 Section IV: Focus Service Areas

(a) Quality Nursing Care

(b) Surgical service efficiency & safety
(c) Neonatal intensive care
(d) Emergency, trauma and critical care

and
(e) Patient preference
 Strength on Quality Nursing Care
 Nursing care protocol and nursing round protocol are
availed
 Nursing audit team established with ToR and active
 Carry out daily nursing care audit and quarterly chart
audit for nursing care
 Presence of QIPs on nursing care quality
 Nursing round regularly conducted
 Nursing station available and easily accessible
 Presence of shift handover with protocol
 Presence of orientation protocol
 Identified gaps on Quality Nursing Care
• Absence of prepared emergency table at medical ward
• KAP assessment was not done on key nursing
procedures
• Absence of ICU nursing care package/protocol & ICU
client chart audit
• Patients are oriented on their care, but deatailed patient
orientation needs to be strengthened at wards based on
few patients interviews
• Absence of training materials for ward TV
• Absence of capacity building protocol, plan, and
schedule at skill Lab
 Strength on surgical service
 Presence of 05 OR tables with 02 more tables near to
be used for Obs (C/S)
 Presence of OR schedule, elective surgery protocol,
pre and post operative hospital stay protocol
 Presence of daily OR briefing and debriefing
 Execution of QIP on operation cancelation
 Adherence of preadmission evaluation protocol
 Incision time is before 8:00 AM
 Utilization of WHO safe surgery checklist
 Better surgical productivity (>90% plan performance)
& absence of surgical backlog
 Identified gaps on surgical service
• Major surgical service KPIs and performances need to be
monitored regularly in tables and charts including trend
analysis
• Absence of day care surgery with protocol
• Absence of peri-operative conference
• SaLTS committe needs involvement of seniors and
performance should be monitored biweekly by SaLTS
• There is SSI capturing mechanism, but absence of SSI
protocol & SSI surveillance
• Post discharge SSI capturing mechanism need to be
strengthened
• Absence of SSC audit protocol & SSC audit
 Strength on NICU

 All neccesary rooms are available with functional

medical equipments, except mobile X-ray
 Availabilty of NICU guidelines and protocols
 Majority of nurses are trained of NICU
 Presence of of Pediatrician
 Execution of QIP on reducing NICU mortality
 Presence of family counselling corner
 Identified gaps on NICU
• NICU Leveling was not done
• Four nurses and physician are not trained on NICU
• Absence of published NICU related QIP
• Absence of mechanism to ensure adeherence of
protocols and guidelines
• Number of clinical audit should be increased
• Strengthen family participation in care and clients’
orientation on the condition and discharge plan
 Strength on Emergency, trauma and
critical care

 Presence of different protocols and guidelines

 Presence of revised ICU, emergency, liason referral

and ambulance service registery

 Documentation of nursing care in the chart of ICU

clients

 Emergency department is at the right place (near to

gate) and labeled with red color
 Identified gaps on Emergency, trauma
and critical care
• The facility did not conduct regular emergency
assessment according to national emergency
leveling document
• The hospital should work on unmet standards
following the assessment
• The hospital should plan and document BEC
training performance
• Mechanisms to ensure adherence to protocols by
staff needs to be strengthened
 Identified gaps on Emergency cont...
• The hospital should assess the level of ICU
based on national ICU standards and plans to
meet standards
• Absence WHO trauma registry utilization
• Absence of clincal audit at EOPD and active
quality improvement project
• EOPD needs revision of path ways (process
map) to facilitate workflow
Strength on Patient Preferences and Value
 There is established health literacy unit with asigned
focal person
 Information provision try to address all major
perspectives (data)
 Presence of leaflets and flipchart for HE
 Presence of audio training materials at every corner
 Presence of social service protocol
 There is established pain clinic
 Pain is scored and managed accordingly at four focus
areas
 Identified gaps on Patient Preferences and
Value
• Audio visual training materials should be prepared and
TV at four focus areas should be used for mini-media
• Discharge plan implementation need to be strengthened
• Clients’ awarness assessment was not done, which
should be followed by improvement plan
• Absence of pallative care
• There should be regular and frequent performance report
review on pain management and health literacy which is
linked with quality improvement paln
• Absence of pain management protocol at pain clinic
 The way forward cont ...
 It all about loving clients ...

 We can improve exceedingly, if we use all

resources we have at hand

 We (hospital, University & RHB) need to deliver

quality of care; and make the hospital competent
with other national hospitals
 Character of EBC

1. All or none
2. Protocol and guideline adherence
3. Mechanism to ensure HCWs adherence
4. Linking quality improvement plan
5. A number of protocols and quality
improvement projects
 Assessment summary
No Section Score Weight
(300) (100%)

1 Mechanism to Avail High Quality 29/60 =29*20/60 9.7%

Evidence

2 Evidence Generation and 37/84 = 37*28/84 12.3%

Utilization
3 Focus Service Areas 58.5/102 =58.5*34/102 19.5%

4 Patient Preferences and 14/30 =14*10/30 4.7%

Value(Person-
centered Care )
5 Cluster Activity (EHAQ 6/24 =6*8/24 2%
Networking and engagement)

Total Score 143.5/300 =143.5*100/300 48%

 The way forward to hospital
• Showing KPI and or outcome indicators before and after
SBFR, EBC & or any other initiative
• SBFR versus EBC (give attention for both)
• Protocols, guidelines adherence mechanism
• System thinking/need creativity…
• Staff engagement, ownership and accountability
should be created
• Execution of Quality Improvement projects in all
departments
• Senior engagement in QI activities
Major areas demanding RHB Support

 The hospital need more support in capacity building like

NICU training, BEC for untrained HCWs, health literacy
for focal & etc.

 The hospital need support on missed documents like

EOPD assessment checklist, NICU leveling checklist
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Thank you All!