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  Prepare data triangulation protocol with CQI dep’t Q
performed report M&E
 No data triangulation  Prepare MR completeness check tracking dep’t
report mechanism MRU
 No medical record  Prepare QIP on data utilization
 completeness check
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 assessment mechanism and make assess HR, EBC 1st
identified source of inefficiency of health care system team, CQI Q
 No incentive guideline for  Prepare incentive guideline and make dep’t
staff adhere SMT
 No priority mitigation  Prepare priority mitigation measurement
measures are not
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
 No peri operative after discharge format
 conference schedule  Prepare QIP on surgical efficiency and
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  Prepare QIP on neonatal mortality
corner  Make clinical audit on priority health
 No orientation given on condition at NICU
NICU manual
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 poisoning, ICU manual
ICU  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 Ses 3 3
s
 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 # 1 1
on 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