OHB

EBC MIDTERM EVALUTIONACTION PLAN GAPS IDENTIFIED FOR

BUSHOFTU GENERAL HOSPITAL

DATE 16/5/2015

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Sec 1.SCOPE BASED PRACTICE AUDIT
# Gaps identified Intervention to be Made Responsible Body Time Frame Remark
1 The hospital hasn’t facility To develop facility CEO Starting from
level/specific scope of practice level/specific scope of practice NOW
protocol protocol
2 No use consultation according to Should be started CCO,QU and Starting ftom
protocol at 4 focus area matron nurse NOW
SUBTOTAL SCORE FOR SCOPE BASED PRACTICE AUDIT
2.STANDARD BASED CLINICAL SERVICE AUDIT
1 Protocol is not printed and given in Avail protocol at booklet form MD 15/05/15
booklet form to clinical staff at each focused area Matron
2 Staffs not trained on protocol Should conduct staff training QIU 15/09/15
CCO
Directors
Coordinators
3 Facility didn’t designed Should be designed OPD head &QU 01/06/15
improvements plan based on
protocol utilization findings
SUB-TOTAL SCORE FOR EVIDENCE BASED CLINICAL SERVICE AUDIT
# 3.EVIDENCE GENERATION & UTILIZATION
1 The hospital doesn’t implement To implement automation of SMT 01/07/15
automation of medical records medical records
2 No chart audit team TOR Avail chart audit team TOR HMIS &plan Starting ftom
NOW
3 No QI project designed at HMIS Should be started HMIS &plan 01/07/15
room based on findings
2
4 No gap oriented research and budget Should be started finance 17/10/15
allocation
SUB-TOTAL SCORE FOR EVIDENCE GENERATION & UTILIZATION
# 4.SYSTEM REDESIGN & EHSTG BOOSTERS AUDIT
1 NO cash audit report at opd Do cash audit IPC Focal Starting from
Now
2 The hospital hasn’t functional block To establish functional block OPD Director 1/5/15
based appointment system based appointment system OPD Nurse
Coordinator
3 Specialty Clinics services aren’t To arrange specialty clinics to CCO 22/5/15
arranged work hours based work hours based as Morning &
Afternoon
4 OPD clinics are not functional Should be functional SMT with GB Starting from
Now
during lunch time
5 Growth Monitoring isn’t conducted To conduct growth monitoring IPD Nurse Starting from
for admitted children for all U-5 children Coordinator Now
IPD Director
6 Pain management isn’t practiced To assess, score & manage pain IPD Coordinator, Starting from
as per protocol Head nurse & Now
matron
7 No rehabilitation and palliative care Avail rehabilitation and Matron & QU Starting from
protocol palliative care protocol Now
8 The hospital hasn’t General To establish General SMT &QU 1/7/2015
Maintenance Center & protocol Maintenance Center
11 The hospital doesn’t conduct regular To conduct regular preventive Facility Manager 21/6/15
preventive maintenance for facilities maintenance for facilities &
& operating system like Electrical, operating system like Electrical,
Water, sanitation & sewerage Water, sanitation & sewerage
12 There isn’t plan for inspection & To develop plan for inspection Facility Manager 21/5/15
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 preventive maintenance at GM & preventive maintenance of Head
ME, with prioritized list of ME
13 No quality monitoring protocol Avail quality monitoring Environmental Starting from
protocol health Now
14 No patient feed back analyze Give patient feedback analyze Environmental Starting from
health Now
15 The hospital hasn’t Biomedical To establish Biomedical SMT 1/7/2015
Workshop Workshop
16 MEMIS isn’t implemented To implement MEMIS SMT 1/6/15
SUB-TOTAL SCORE FOR SYSTEM REDESIGN & EHSTG BOOSTERS AUDIT
# 5.EFFICIENT UTILIZATION HEALTHCARE RESOURCE AUDIT
1 No outsourced clinical service Outsource clinical service like E SMT and GB 30/5/15
ENT & dialysis etc

2 No Transparent staff incentive

Prepare staff incentive HRM Dept Within 1
system is in place procedure/guide and Avail the SMT month
source documents for staff
incentive guide (Benchmarking)
SUB-TOTAL SCORE FOR EFFICIENT UTILIZATION HEALTHCARE RESOURCE AUDIT

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# 6.QUALITY NURSING CARE AUDIT TOOL
1 NO capacity building plan and Shoud have regular capacity MD;METRON Starting from
performance at skill lab building plan and performance and HR 17/5/2015
2 No functional desktop and tv at To well equipped nursing SMT 1 months
nursing station stations
3 Patient not clearly understand the Strength patient orientation All staff at SDP Starting from
disease process 17/5/2015

# 7.SURGICAL SERVICE EFFICIENCY & SAFETY AUDIT

1 The hospital hasn’t minimum To avail minimum number(4) of SMT 3 months
number of OR table OR table
2 The hospital doesn’t conduct first To conduct first case incision OR Director 17/5/2015
case incision before 2 MLT for before 2 MLT for elective CCO
Elective Surgeries surgeries Matron
3 Difficult to comment on turnaround To document starting & ending OR Head Starting From
time b/n cases time for all cases on registration Now
4 The hospital hasn’t MDT To establish MDT preadmission SMT 1 months
preadmission patient evaluation patient evaluation Clinic
Clinic
5 Doesn;t conduct MDT per operative conduct MDT per operative OR Director 17/5/2015
conference a day before surgery to conference a day before surgery OR Head
finalize patient preparation plan to finalize patient preparation
before scheduling plan before scheduling

6 There isn’t culture of daily team To develop culture of daily OR Director 17/5/2015
briefing & debriefing at the team briefing & debriefing at OR Head
beginning & end of the OR day the beginning & end of the OR
day
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7 The hospital hasn’t day care surgery Should have day care surgery CCO 1 month
service service OR Director
8 There isn’t SSC utilization audit To develop SSC utilization OR Director 1 month
Protocol audit protocol
9 No WHO SSI surveillance Should have WHO surveillance IPD Director Starting from
tools ,wound assessment and tool,wound assessment and now
documentation on chart documentation
SUB-TOTAL SCORE FOR SURGICAL SERVICE EFFICIENCY & SAFETY AUDIT
# 8.IMPROVE NEONATAL INTENSIVE CARE AUDIT
1 Hospital NICU not Fulfill Standard Fulfill standard of service for SMT Starting from
requirement for Level 2 NICU for Infrastructure, Human resource ORHB 17/5/2015
General Hospital and Medical equipment as
defined by NICU National level
document

2 Some of important Equipment To avail all important SMT 3 months

aren’t available equipment as per level of NICU
as per National guideline
3 No family participation in decision Improve practice of engaging NICU head Starting from
making of new born parents now
SUB-TOTAL SCORE FOR IMPROVE NEONATAL INTENSIVE CARE AUDIT
# 9.IMPROVE EMERGENCY,TRAUMA & CRITICAL CARE AUDIT
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2 WHO BEC tool kit facilities aren’t To expand WHO BEC tool kit SMT Starting from
expanded in the hospital facilities now
3 The hospital hasn’t protocols for Avail protocol at EOPD EOPD Director 1 month
poisoning ,trauma ED ICU service & EOPD Head Nurse
burn at EOPD
4 The hospital doesn’t implement To implement WHO trauma EOPD Director Starting from
WHO trauma registry registry EOPD Head Nurse now
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5 EOPD doesn’t conduct Clinical audit To conduct Clinical audit EOPD Director Starting from
EOPD Head Nurse 17/5/2015
# 10.Patient Preference & Value Audit
1 Incomplete health literacy unit Medical director Within 1 week
register [no information provided  Should have full SMT
and contact number ] information in literacy
unit register
2 No Designed mechanism to assess Avail mechanism to assess CG&QIU Within 1
the patient awareness and knowledge awareness and knowledge of the month
client on their specific case
3 No regular performance report Review performance report at All Departments now and
review least every two weeks and onwards
Develop QIP based on gaps
4 Pain was assessed irregularly as 5th Assess pain regularly All HCP Starting from
V/S now and
onward
5 Pain was not managed According to Manage based on protocol or All HCP Starting from
protocol severity assessment now and
onward
6 No method to advocate pain prepare posters in all wards and Pain focal person Within 2
management rooms e.g.(“Zero tolerance for month
pain”)
7 No mechanism to address clients Avail chronic pain and Palliative PFHI committee Starting from
with chronic pain and those requiring care clinic SMT and GB now
palliative care

8 Audit for adequacy of pain control Have regular performance All departments Within 2
wasn’t performed report review at least every two Pain focal person weeks and
weeks involving key Clinical audit onwards
stakeholders and Develop QIP committee
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 AUDIT TEAM
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