HARAMAAYAA YUUNIVERSITII

HARAMAYA UNIVERSITY

COLLEGE OF HEALTH AND MEDICAL SCIENCE DEPARTMENT OF MIDWIFERY

[Clinical Midwifery Specialist (CMS)]

COURSE: CLINICAL AUDIT

TASK: CLINICAL AUDIT PROJECT PROPOSAL

TITLE OF MY PROJECT:

CRITERIA BASED CLINICAL AUDIT TO IMPROVE MATERNITY REFFERAL

SYSTEM IN HIWOT FANA SPECIALIZED UNIVERSITY HOSPITAL, OROMIA,
ETHIOPIA 2022.

By: Tofik Mohammad Muse (BSc , MSc fellow @ HU )

Id number: sgs/1109/14

Submitted to: Abera Kenay ( PhD)

Submission date: 15/1/2015 E.Ci

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 Stake Holders
This study will include all necessary participant including Nurses, Midwives, Clients, liaison
office coordinators, hospital quality office director and others.

Acknowledgements
First I would like to thanks my Allah for giving me opportunity to study this program and enable
me to prepare this clinical audit project proposal. Then my deepest thanks to Dr. Abera Kenney
for his teaching clinical audit course and guiding us to do clinical audit project proposal. Finally
would like thanks Hiwot Fana Specialized University Hospital liaison office staff for guiding me
and providing me all necessary information for this proposal.

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Table of Contents
Stake Holders ................................................................................................................................................ 2
Acknowledgements................................................................................................................................... 2
Acronyms and Abbreviations .................................................................................................................... 4
Introduction .............................................................................................................................................. 5
Aims and Objectives.................................................................................................................................. 7
Objectives ................................................................................................................................................. 7
Criteria and standard of referral system for maternity service ................................................................ 8
Methodology............................................................................................................................................. 9
Study setting and period ........................................................................................................................... 9
Study Design ............................................................................................................................................. 9
Exclusion criteria ....................................................................................................................................... 9
Inclusion criteria........................................................................................................................................ 9
Study population ....................................................................................................................................... 9
Sample size................................................................................................................................................ 9
Sampling Procedure ................................................................................................................................ 10
Statistical Instruments/ study analysis ................................................................................................... 10
Ethical approval....................................................................................................................................... 10
Table 1: Work plan .................................................................................................................................. 11
Annexes 1: reference .............................................................................................................................. 12
Annexes 2: Questionaries’ ...................................................................................................................... 13
Table 2: Standard national referral form check list ............................................................................... 14
National Patients referral Format ........................................................................................................... 15

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Acronyms and Abbreviations
BP blood pressure

DOH department of health

EDD expected date of delivery

FHB Fetal heart beat

GA Gestational age

HFSUH Hiwot Fana Specialized University Hospital

IMR Infant mortality rate

LNMP last normal menstrual period

MCH Maternal child health

MOH Minister of health

MMR Maternal mortality rate

PR Pulse rate

RR Respiratory rate

WHO World health organization

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Introduction
Ethiopia made a striding change in maternal death over the last decades, the MMR decreased
from 871 per 100,000 in 2000 to 401 per 100,000 in 2017; this is death of about 12,000 mothers
every year. Direct obstetric complications account for 85% of the deaths. (1)

The 2019 WHO maternal mortality fact sheet reported that approximately 810 women die every
day from pregnancy related complications. The vast majority of these deaths (94%) occurred in
low-resource settings and most could have been prevented.(2) Sub-Saharan Africa alone
accounted for roughly two-thirds (196 000) of maternal deaths, and Ethiopia is among these
countries. (2, 3)

In Ethiopia, liaison and referral systems across the various levels of care are not strong enough
that influences the overall accomplishment of the health system and contributes to poor health
outcomes of emergency patients. According to different assessment conducted by MOH the
following challenges were identified; poor referral documentation, weak feedback mechanism,
no operational guideline for referral catchment, very weak communication among health care
facilities and uneven distribution of number of patients between health facilities.(4)

A patient or client referral is defined by the World Health Organization (WHO) as a process in
which a health worker at a one level of the health system, having insufficient resources (drugs,
equipment, skills) to manage a clinical condition, seeks the assistance of a better or differently
resourced facility at the same or higher level to assist in, or take over the management of, the
client’s case.

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In Ethiopia, there is a three-tier health service delivery that aims at improving the quality and
accessibility of health service by means of maintaining continuum of care though the entire level.
Hence, to achieve this effective referral system was in a place for which a national referral
guideline was developed and implemented since 2013 that helped to organize hospitals’ liaison
(Bed management, Admission and discharge) and referral services.( 4)

Though stated intervention there are still gaps in the country's referral system which arise due to
different reasons. Today only 28% of the patients are referred with the formal referral format,
70% of referral by passes the level of the facility, and 39% of the referral is made without stating
even the vital sign of the patients, most importantly only 10% of patients are. (4)

Improving referral system in maternal services means improving maternal mortality rate (MMR)
and infant mortality rate.(5) quality referral system is a component in health program
implementation and in providing quality healthcare services.(6) So by using criteria based
clinical audit I am going to improve maternity referral system in Hiwot Fana Specialized
University Hospital, oromia, Ethiopia.

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Aims and Objectives
This study aims to assess and improve maternity referral system in Hiwot Fana specialized
university hospital, by conducting criteria based clinical audit on maternity referral forms, from
august 15,2022 to September 15, 2022.

Objectives

1. To improve referral system of women in reproductive age using standard Referral Form.

2. To assess the compliance of the health care professionals on the use of standard referral
forms using the 12 criteria.

3. To enhance the utilization of the national standard referral forms based on 12 criteria for
maternal services.

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Criteria and standard of referral system for maternity service

12 Criteria (elements) of standard national referral form obtained from national referral guide
line (MOH, Ethiopia 2013)

1) Information of referring health facility should be recorded, including name of the facility
and liaison office telephone
2) Information of receiving health facility should be recorded, including name of the facility
and liaison office telephone
3) Patients’ identification information should be recorded, including name of the patients,
age and sex of the patients
4) Chief complaints of the patients(mother) should be stated and recorded
5) Condition of the patients (women) should be recorded, it may be emergency, critical or
stable condition
6) History of present illness or pregnancy should be shortly written, it includes gravida,
para, LNMP, EDD of the mother and other complain from mother at presenting time
7) Finding from vital sign measurement (BP, RR, PR, T) and from physical examination
(GA, FHB, weight and etc.) should be recorded shortly and briefly
8) Diagnosis should be written
9) Treatment given should be recorded
10) Reason of referral should be clearly written
11) Profession of Recommended Health Professional to escort the patients should be written
12) Finally, information of Referring liaison officer should be recorded including his/her
name, Phone, and Sign.

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Methodology

Study setting and period

This baseline study will take place from 15 august, 2022 to 15 September, 2022 in HFSUH, a
major referral center for hospitals located in eastern Ethiopia. HFSUH receives patients from
district hospitals which are linked with a large number of health centers in the region. The
majority of women with severe obstetric complications are referred to HFSUH due to shortage of
blood for transfusion, equipment, and treatment options in nearby health centers and district
hospitals.(7)

Study Design
This is a retrospective-document review designed to improve maternity referral system by
auditing based on national standard referral form among randomly selected referred women in
Harar from August 15, 2022 to September 15, 2022 to the HFSUH.

Exclusion criteria
All forms except referral form on maternity service

Inclusion criteria
Referral form only from the Labor and Delivery, Gynecology and MCH ward

Study population
All referred women from district hospital and its tier health Centre to HFUSH in the previous six
months

Sample size
Sample size will be estimated based on available time and resource to collect data, so
conveniently total sample size of this study will be 40 referred women of reproductive age to
Hiwot Fana Specialized university hospital from all women of reproductive age recorded as
referred during past six months

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Sampling Procedure
I decided my sample size conveniently; I will collect May data by using simple random sampling
which is lottery method to select adequate sample size from previously documented referred
mother to HFUSH

Statistical Instruments/ study analysis

Data will be collected and entered to SPSS 26 version; Descriptive statistics will be used such as
frequency, mean and percentages to present collected data representing the characteristics of
maternal referral system in HFSUH. Quality of the randomly selected Referral forms will be
assessed based on the minimum elements of a standard Referral form as required by national
referral guide line, MOH, Ethiopia 2013. Completely utilized or recorded Referral forms refer to
a score of 12/12 based on 12 criteria with 100% recommended standard of referral form record.
In comparison with the standard Referral form, the compiled Referral forms will be assessed as
compliant (100%, 12/12 criteria) based on the entries filled upon. referral form Based on the
12criteria (compared to the standard Referral form), non-compliant Referral forms were
categorized as follows; 0-25% compliant (0-3 entries), 26-50% compliant (4-6entries), 51-75%
compliant (7-9entries), and 76-99% compliant (10-12 entries).

Ethical approval
Approval will be obtained from the authorities of the hospital, where the records will be
reviewed. Ethics of the audit will be protected, but for clinical audit no need to have ethical
approval

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Table 1: Work plan
Activity Responsible body Time period remark
S/No
1 Proposal Tofik Mohammad August 15 , 2022 to
development august 20,2022
2 Data collection Tofik and other stake August 21 ,2022 to
holders August 30, 2022
3 Data analysis Tofik September 3, 2022 to
September 10, 2022
4 Report writing Tofik September 11,2022
to September 14,
2022
5 Result Tofik September 15,2022
presentation
6 Re Audit Tofik After three months
of intervention
7 Improvement By all stake holders Continuously any
time

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Annexes 1: reference
1. Federal minister of health, Ethiopia
2. WHO. Maternal mortality; fact sheets, 2019. Available: https://www. who.int/news-
room/fact-sheets/detail/maternal-mortality
3. WHO. Trends in maternal mortality: 2000 to 2017. Geneva: WHO, 2019.
https://www.who.int/reproductivehealth/publications/maternalmortality-2000-2017/en/
4. ((National Referral Guideline, Ethiopian Ministry of Health, 2013
5. (IMR) (DOH AO No. 2016-0035).
6. Davidow et al. 2018; Blake-Lamb et al. 2016
7. [Tura, A.K.; Zwart, J.; Van Roosmalen, J.; Stekelenburg, J.; van den Akker, T.; Scherjon,
S. Severe maternal outcomes in eastern Ethiopia: Application of the adapted maternal
near miss tool. PLoS ONE 2018, 13, e0207350.].

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Annexes 2: Questionaries’
Socio demographic characteristics of referred women

1. Age

2. Marital status

a) Single c) Married
b) Divorced d) widowed

3) Residency a) urban b) rural

4) Income

Obstetric characteristic of referred women

5) Reason for referral

a) Lack of equipment’s and drugs for investigation and treatments
b) Lack of clinicians or experts
c) Lack of space for providing care
d) Client decision to be referred to
6) Pregnancy status of the women

a) Pregnant b) not pregnant

7) Condition of the women during referral

a) Stable b) emergency c) critical

8) Place Referred from

a) Health Centre b) district hospital c) other health facility

9) If mother was delivered, place of delivery

a) Home b) health center c) Hospital

10) Mode of delivery a) SVD b) C/S c) DVD

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Table 2: Standard national referral form check list
S/No Criteria of Recommended standard national referral form Response

1) Information of referring health facility should be recorded, including name of the 1) Yes
facility and liaison office telephone. 2) no

2) Information of receiving health facility should be recorded, including name of the 1) Yes
facility and liaison office telephone 2) no
3) Patients’ identification information should be recorded, including name of the 1) Yes
patients, age and sex of the patients 2) no
4) Chief complaints of the patients(mother) should be stated and recorded 1) Yes
2) No
5) Condition of the patients (women) should be recorded, it may be emergency, critical 1) Yes
or stable condition 2) no
6) History of present illness or pregnancy should be shortly written, it includes gravida, 1) Yes
para, LNMP, EDD of the mother and other complain from mother at presenting time 2) no
7) Finding from vital sign measurement (BP, RR, PR, T) and from physical examination 1) Yes
(GA, FHB, weight and etc.) should be recorded shortly and briefly 2) no
8) Diagnosis should be written 1) Yes
2) no
9) Treatment given should be recorded 1) Yes
2) no
10 Reason of referral should be clearly written 1) Yes
2) no
11 Profession of Recommended Health Professional to escort the patients should be 1) Yes
written 2) No
12 Finally, information of Referring liaison officer should be recorded including his/her 1) yes
name, phone and sign 2) no

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National Patients referral Format
Referring Health Facility

Name of facility _________________________Liaison office telephone_______

Receiving Health Facility

Name of facility _______________________________Liaison office telephone__________

Patients Identification

Name_______________________________________ Age __________________Sex ________

Chief Complaints of the patient________________________________________________

Condition of the patients (circle one)

Critical Emergency stable

History of present
illnes_________________________________________________________________________
_____

Finding BP __________PR _________RR _______Body T _________O2saturation________

P/E
______________________________________________________________________________

Diagnosis______________________________________________________________________

Treatment
given_________________________________________________________________________

Reason For Referral

______________________________________________________________________________

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Recommended Health Professions to escort the patients (state the profession not name)
___________________________________

Referring Health professional Name___________________ Cell phone______ Sign______

Escorting Health professional Name ____________________Cell phone_____________

Referring liaison officer ___________________Phone _______________Sign________

ii

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