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«SEPTEMBER 2015 This report was prepared by University Research Co., LLC (URC) for review by the United States Agency for International Development ...»

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1.11M Hospital following the certification of quality assurance from the external parties

4.10M Criteria and procedure of early transfer for patient to the referral was determined

6.4M Availability and accessibility to the Blood Bank 24/7.

6.5M Procedure for collection, identification, storage, transport, and blood disposal can be accessed by all staff.

6.6M Mechanism of blood services for patients from outside the hospital.

7.12M Implementation of the smoking ban was monitored in the hospital.

7.16M Emergency room (ER) divided by triage, consist of resuscitation room, therapy room, and observation room.

7.17M Out-stationed laboratory equipment (e.g., blood gas analysis) is calibrated, standardized and maintained by technicians from the main laboratory using the same procedures.

HAPIE Midline Assessment 7 Hospital Review

8.11 M There is a policy of how drugs are brought by patient, was identified and stored by the hospital.

8.12 M Compliance of prescription drugs is based on formulary standards at the hospital, reported January-December 2013

9.8M Hospital established the filling process for surgical report completion to be done before the patient leaves the operative recovery area.

10.11M Availability of policy about medical record removal.

10.12M Hospital policy differentiates medical record between active and non-active Deletions Number Data Captured 5.11 Non-food items (drugs, specimens or blood) not stored in food fridges.

7.3 Staff are protected by fume cabinets, extractors and ventilation systems in areas using hazardous substances e.g., ethylene oxide, nitrous oxide, glutaraldehyde, cytotoxic drugs 11. Financing Related to Quality and Safety 11.1 There is a system of patient financing using the case-mix costing, for example, Diagnostic Related Group or CBG 11.2 There is a budget for quality and safety improvement in hospitals (e.g., in-house or outside training related to the quality and safety improvement)  The budget assigned for improvement activities?

 How many the budgets? (for each activity if possible)  What percentage of the budget compared to the total budget? (In the last 3 years)?

11.3 a. How the cost to get hospital accreditation (before last accreditation earned) excluding routine cost have been budgeted?

b. How the cost to get hospital accreditation (cost for next accreditation) excluding routine cost has been budgeted?

c. For JCI hospitals, how the details of the costs incurred?

11.4 Is there a compensation system for quality and safety coordinator?

11.5 In improving the quality and safety, are consultants used within last 3 years?

 If so, for what activities? (e.g., mentoring accreditation, ISO, quality improvement training, etc.)  What cost for the consulting services?

11.6 What cost for certification to improve quality and safety (excluding consulting services)?

11.7 What costs to human resources and/or infrastructure investment to improve quality and safety?

Organizational Audit Additions and deletions in the organization audit instrument are summarized in Table 3.

Table 3. Additions and Deletions of Organizational Audit Instrument A.

Organizational Audit – AMI Additions Number Data Captured AMI 8aM Patient informed about their rights and obligations when admitted AMI 8bM Patients given access to their management plan on the ward/unit AMI 12M Adverse event reporting policy and system to patient safety committee AMI 24M All patient rooms allow privacy and dignity to be maintained.

AMI 31M Resuscitation equipment (and access for a team) available on site at the wards AMI 39M a. Number of specialist doctor in one department, standby / on call when weekdays / weekend 8 HAPIE Midline Assessment b. Number of specialist doctors who practice during the data collection process AMI 40M a. Number of residents in one department b. Number of residents who practice during the data collection process Deletions AMI 21 Outstationed laboratory equipment (e.g., blood gas analysis) is calibrated, standardized and maintained by technicians from the main laboratory using the same procedures AMI 23 Criteria and procedures are defined for early transfer of appropriate patients to a referral centre AMI 38 During 2011 clinical review included analysis of reported events adverse to patients B. Organizational Audit – Delivery Additions Number Data Captured D8aM Patient informed about their rights and obligations when admitted D8bM Patients given access to their management plan on the ward/unit D10M Adverse event reporting policy and system to patient safety committee

D13 Baseline:

During 2012, clinical review included analysis of routine clinical indicators on the management of maternity care

Midline:

During 2013, clinical review included analysis of structured medical audit on the management of maternity care D17M There is policy about emergency obstetric care in emergency room D19M All patient rooms allow privacy and dignity to be maintained.

D21M Resuscitation equipment (and access for a team) available on site at the wards D24aM There is separation room from sick and healthy newborn D24bM The separation room for newborns with intensive medical needs D31M Each emergency "crash cart" has a completed checklist of equipment and supplies D32M a. Number of specialist doctors in one department b. Number of specialist doctors who practice during the data collection process D33M a. Number of residents in one department b. Number of residents who practice during the data collection process D34M There is a policy about episiotomy D35M All delivery patients educated about the treatment of exclusive breastfeeding D36M Written policy regarding the implementation of Early Initiation of Breastfeeding and management of award of exclusive breastfeeding D37M Hospital has a policy about of recording the baby’s medical record into mother’s medical record status D32M a. Number of specialist doctors in one department b. Number of specialist doctors who practice during the data collection process D33M a. Number of residents in one department b. Number of residents who practice during the data collection process D34M There is a policy about episiotomy D35M All delivery patients educated about the treatment of exclusive breastfeeding HAPIE Midline Assessment 9 D36M Written policy regarding the implementation of Early Initiation of Breastfeeding and management of award of exclusive breastfeeding D37M Hospital has a policy about of recording the baby’s medical record into mother’s medical record status C. Organizational Audit- Hip Fracture Additions Number Data Captured Hip 18M Adverse event reporting policy and system to patient safety committee Hip 20aM Patient was informed about their rights and obligations when admitted Hip 20bM Patients are allowed access to their management plan on the ward/unit Hip 25M All of patient rooms allow privacy and dignity to be maintained.





Hip 32M Resuscitation equipment (and access for a team) available on site at the wards Hip 35M a. Number of specialist doctors in one department b. Number of specialist doctors who practice during the data collection process Hip 36M a. Number of residents in one department b. Number of residents who practice during the data collection process Deletions Hip 15 Criteria and procedures are defined for early transfer of appropriate patients to a referral centre Hip 25 Average number of beds per room (total number of beds/ total number of rooms) D. Organizational Audit-Pneumonia Additions Number Data Captured P1M Patient was informed about their rights and obligations when admitted P13M Adverse event reporting policy and system to patient safety committee P18M There is written policy or procedure about administering oxygen to children P21M Monitoring mechanism or procedure of administering oxygen by nasal prongs or nasal catheter P22M Resuscitation equipment (and access for a team) available on site at the wards P25M All of patient rooms are enabled to privacy and dignity to be maintained.

Deletions Number Data Captured P24 Criteria and procedures are defined for early transfer of appropriate patients to a referral centre P25 Average number of beds per room (total number of beds/ total number of rooms)

–  –  –

A. Clinical Review-AMI Number Data Captured

2.25M Is patient diagnoses recorded completely?

10 HAPIE Midline Assessment

2.30M Was coronary angiography performed in the hospital?

3.1M Diagnosis

3.11M Was there any indication of antibiotic recorded?

B. Clinical Review-Delivery Number Data Captured

2.2aM Information of GPA (gestation, parity, abortion)

2.7aM Partograph completion

2.7bM Was the patient have complications during labor ?

2.7cM Specify the types of complications

2.7dM Was the inspection FHR (Fetal Heart Rate) performed during childbirth

2.18M How many times was Hemoglobin (Hb) checked during hospitalization?

2.19M Maximum Hb during hospitalized (gr/dl)

2.31M Adverse events:

3.11M Was medical summary or discharge summary for patient filled in?

3.12M Was there a link among the mother's medical record and the baby’s medical record C. Clinical Review-Hip Fracture Number Data Captured

2.5M Doctor state surgery indicated

2.17M Type of hip surgery

2.22T Were there any adverse events recorded:

3.1M Diagnose D. Clinical Review-Pneumonia Number Data Captured

4.8aM Temperature

4.8bM Respiratory rate (per minute)

4.8cM Pulse rate (per minute)

4.8dM Ronchi

4.8eM Wheezing

4.8fM Chest in drawing

7.1M Diagnose Patient Experience Additions to the patient experience instrument are summarized in Table 5.

Table 5. Additions to Patient Experience Instrument Patient Experience Number Data Captured 2aM Ward Class A.

9 Additional option for payment system B.15aM Was patient given explanation of breastfeeding? Reasons/Comments B.15bM During treatment in hospital, were you encouraged to breastfeed your baby?

Reasons/Comments

–  –  –

12 HAPIE Midline Assessment Data collection was conducted in the same manner for the midline phase as the baseline, often with the same data collection staff visiting the same hospitals and all data collectors were trained for three days using the new instruments. Visits at baseline took about one week in each of the nine hospitals, but two weeks were generally needed in the midline phase. For data on patient experience, the implementation of JKN resulted in fewer inpatients being discharged on any given day.

The period for the clinical review in the midline phase was one year (Jan-Dec 2013), but for hip fracture cases we considered for 18 months (July 2012-Dec 2013) in order to capture the required sample size. However, even with intensive searching in the medical records, there were three hospitals where the samples did not meet the target: Hospitals E, H and I.

During collection of qualitative data, questions were asked about accreditation as before, and questions about changes related to implementation of JKN were added. Questions explored additional topics such as hospital financing, information management system for recording and reporting and service mechanism related to implementation of JKN and how these may have related to accreditation and quality of services.

There were no significant constraints on data collection during the midline study. However, not all data collectors obtained all secondary data and supporting documents required for the ward audit and hospital reviews. This was because of document control policies or the absence of staff who could provide such documents not being present during data collection.

Hospital Review

In collecting data of hospital review, the following steps were taken:

 Key informants from the units involved in the study were identified and asked to be interviewed once informed consent was given. Informants were heads or managers of staff of wards, human resources, public relations, blood banks, occupational health and safety, medical services, pharmacy, medical records, laboratories, radiology or similar positions.

Official consent of the study was obtained from the Hospital Director. Hospitals issued letters internally to related units to participate in the study. Information from interviews was verified with secondary data (reports, hospital surveys, and SOP and meeting minutes).

 Observations of hospital facilities and operations were conducted to determine the current situation, and documented through photographs when appropriate.

This review was intended to cover the whole hospital and therefore included all active as follows:

 Management: medical services, education and training, human resources, finance, pharmacy, public relations unit.

 Heads of Units: emergency rooms, operating theatres, delivery wards, perinatal ward, intensive cardiac care units, waste management, food handling, intensive care, pharmacy maintenance, in-patient wards.

 Hospital committees: quality improvement and safety, infection control and prevention, pharmacy and therapy, occupational health and safety, medical committee.

In some cases, the primary relevant informants were not available during the data collection period. In those situations, data collectors sought alternative informants in related units who were likely to have the appropriate information. For example, when we could not meet the leader of the accreditation unit, we sought other accreditation team members. When alternative informants could not be interviewed, the information column was written “Not Available” and not included in the analysis. All information obtained from interviews were verified through documentations (reports, guidelines, regulations) and observation to all relevant unit (use of bracelet and safety boxes in patient wards). Scoring was based on SANITAS criteria, with maximum scores given when the information could be verified with appropriate documentation and was consistent with the actual findings of the data collectors. Data were then entered into an Excel data sheet in the field.



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