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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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 Bed Occupancy Rate (BOR)  Average Length of Stay (ALOS)  Turn Over Interval (TOI)  Bed Turn over (BTO)  Emergency Response Time  Proportion of Deaths in the ER (%)  Net Death Rate (NDR)  Gross Death Rate (GDR)  According to the MoH standard, number of health care-associated infections should be 1.5%    Waiting time for prescription drug service should be less than 30 minutes   Waiting time for preoperative should be no more than two days Results are reported in Table 12. Some hospitals have incomplete data on performance indicators either because hospitals did not include medical services standard into their annual report, or because they have no annual report.

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B = Baseline; M =Midline 22 HAPIE Midline Assessment There are ten composite domains made from more than 80 elements in the hospital review instrument. The domains are: 1) hospital governance, 2) patient orientation, 3) human resources, 4) clinical practice and patient care, 5) health care associated infection, 6) transfusion, 7) facilities management, 8) medication safety, 9) surgery, interventional procedures and accompanying anesthesia, and 10) documentation and records. Each element of the domains was scored 0 to 4, with 4 being the highest, then averaged across all elements in the domain.

1) Hospital Governance consists of:

 Annual safety strategy/action plan in the hospital  Reporting on quality and safety  Clinical performance reports  Designated leader for Quality Improvement (QI) and safety  Multi-disciplinary group for QI and safety  Internal/external emergency preparedness plan  Certified laboratory and diagnostic radiology  External validation of laboratory and radiology The score of hospital governance domain ranged from 1.8 to 3.7 (mean 3.0) in the baseline and 2.4 to 3.9 (mean 3.2) in the midline (Figure 2). Hospitals A, E, and G showed increases from baseline to midline period while Hospital C had a slight decrease.

Figure 2. Summary for Hospital Governance in Nine Hospitals by Phase by Group

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2) Patient Orientation domain was comprised of the followings:

 Informed consent attached in medical records  Children separated from adults  Privacy for undressing/changing  Patient complaints are investigated and responded to  Annual report on complaints handling is published JCI hospitals showed an increases as did Hospitals C and G (KARS). Only Hospital H among NHA hospitals showed an increase (Figure 3). Average scores for all hospitals increased from 2.8 to 3.0.

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3) Human Resources domain elements are:

 Verification of professional credentials  Cardio-pulmonary resuscitation training according to international guidelines  Continuing professional development recorded for all relevant staff  Defined blood borne exposure control policy  Annual staff satisfaction survey As shown in Figure 4, Hospital B (JCI) showed a decrease while KARS hospitals showed an increase or were unchanged. Among NHA hospitals, only Hospital I showed an increased. The average score for all was 2.9 at baseline and increased to 3.1.

Figure 4. Summary for Human Resources in Nine Hospitals by Phase by Group

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4) Clinical Practice and Patient Care

The nine elements in this domain are:

 There is a defined mechanism for medical staff accountability for the quality and safety of medical care  Clinical guidelines (medical service standards) in each departments are agreed upon and implemented  The clinical group that exists coordinates the use of pharmaceuticals and therapeutics across the hospital (hospital formulary, prescribing, usage, etc)  There are guidelines on the use of antibiotics to reduce risk of resistance  There are guidelines on the use of prophylactic antibiotic  There are specialists designated as responsible for resuscitation services and training 24 HAPIE Midline Assessment  Resuscitation equipment is in order and diagrammatic instructions are available in resuscitation areas  There is a documented protocol for transferring patients within or outside of the hospital Scores for clinical practice and patient care criteria ranges from 1.7 to 3.1 (mean 2.5) at baseline and generally increased from 2 to 3.6 (mean 2.7) (Figure 5). All JCI hospitals increased and all KARS hospitals except Hospital C also increased. All hospitals NHA decreased. Those hospitals were decreasing due to a lack of resuscitation equipment and diagrammatic instructions and guidelines on antibiotics use.

Figure 5. Summary for Clinical Practice and Patient Care in Nine Hospitals by Phase by Group 4.

0 3.0 2.0

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5) Health care-associated infections domain has 14 elements:

 Multi-disciplinary infection control committee  Accessible infection control manuals  Team responsible for daily infection control activities  All staff trained on infection control appropriate to their risks in workplace  Gloves worn when needed  Single-use injections and safety boxes available  Laboratory perform susceptibility training  Medical screening of food handlers  Exclusive signs for food preparation areas  Separate hand-washing areas for food-handling areas  Non-food items not stored in food fridges  Food handling staff adhere to dress code  Staff have adequate access to alcohol-based hand-rub  Analysis of hospital-acquired infection data The average scores for all nine hospitals increased by 0.2 with only Hospitals F and G (KARS) showing a decrease (Figure 6).

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6) Transfusion domain was made up of the following elements:

 Blood stored in lockable designated refrigerator  Refrigerator temperature records are kept for reference  Written guidelines for prescription and administration of blood were used Overall, transfusion criteria had increased from 3.7 to 3.8. Two of three JCI hospitals decreased while two KARS hospitals improved and two remained unchanged and there was no change in the NHA hospitals (Figure 7).

Figure 7. Summary for Transfusion in Nine Hospitals by Phase by Group 4.

0 3.0 2.0

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7) Facilities Management domain has the following 11 elements:

 Disabled access to all patient areas,  Clear, coherent signs posted throughout  Fume cabinets, extractor fans and ventilation systems in place  Compressed gas cylinders secured and gas stocks securely stored  Radiation danger signs for women and ionizing radiation monitors for staff in place  Defibrillators maintained and calibrated  Emergency generators tested on full load  Firefighting equipment tested annually and appropriate pictogram fire exit signs  Cigarette smoking not allowed in hospital  Waste is segregated and treated appropriately, color-coded waste bags used appropriately  Waste-handling staff trained and using correct equipment.

There was minimal change in the overall average in this domain (Figure 8). All JCI hospitals showed an increase.

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8) Medication Safety

The medication safety domain includes the following criteria:

 There is systematic monitoring and evaluations for addition of new medicines into the hospital formulary  Hospital policy requires the use of international non-proprietary names, not branded name drugs.

 High-risk medications are not included in floor stocks  Medication storage areas are regularly checked by pharmacists  High-Risk infusions are prepared by central pharmacy  Patients are given written medication information including adverse reactions  Full information is provided to patients on medication prescriptions  Patient information is verified and double-checked before administration  There is adherence to the rule that medications remain in packages until administration Medication errors and near-misses are reported and the data are used to improve medication safety.

Score for medication safety ranged from 2.2 to 3.5 (mean 2.5) in baseline to 2.5 to 3.8 in midline (mean 3.2) in the midline (Figure 9). Only Hospital H (NHA) did not shown an increase over the period.

Figure 9. Summary for Medication Safety in Nine Hospitals by Phase by Group

9) Surgery, Procedures and Anesthesia domain consisted of the following criteria:

 Formal guidelines for elective surgery pre-assessment are used to assess patients’ readiness for the procedure

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10) Documentation and Records domain was comprised of the following criteria:

 There is an approved policy on identification of patients.

 Basic information is available in medical records with only one set of case notes per-patient, case notes have up-to-date identification, and case notes are legible, dated, and signed  Admission notes are completed before surgical procedures (except in emergencies) and procedures recorded immediately and filed in the medical records appropriately,  All diagnoses/procedures are recorded two weeks post-discharge with International Classification of Diseases – Tenth Edition (ICD-10) discharge summaries completed  Case notes are retained according to the national guidelines.

Overall, the documentation and records criteria had decreased from 3.4 to 3.3. Two of three JCI hospitals increased while three KARS hospitals decreased and all NHA hospitals decreased (Figure 11).

Figure 11. Summary for Documentation and Records in Nine Hospitals by Phase by Group 4.

0 3.0 2.0

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28 HAPIE Midline Assessment C. Organizational Audit The Organizational Audit (OA) was based on 10 criteria determined from the four hospital

departments, obstetric, pediatric, internal medicine and surgery:

1. Patient information literature available on the unit/ward includes patient versions of national or local guidelines/standards.

2. Manual of policies and procedures to guide nursing care.

3. Clinical review included analysis of reported events adverse to patients.

4. Bracelet ID all patients.

5. Resuscitation equipment is accessible, complete, clearly organised and fully functional.

6. Safety boxes for disposal of injection devices are available in sufficient quantities for the number of injections administered.

7. There is no concentrated potassium chloride (KCl) stored in patient service areas.

8. Diagrammatic instructions for resuscitation are available in resuscitation areas.

9. Evidence-based clinical guidelines have been formally adopted, disseminated and implemented by the clinical staff.

10. Clinical teams meet regularly to evaluate and compare current practice against evidencebased guidelines for this service ("clinical review").

Composite results showed that the majority of hospitals improved from baseline to midline. There were major improvement in Hospitals A, E and G, while Hospital F experienced a slight decrease (Figure 12).

Figure 12. Comparison of Total Scores of 10 Keys OA Criteria between Baseline and Midline by Hospitals

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0 10 20 30 40 50 60 70 80 90 Most criteria in all departments increased in all hospitals except for bracelet IDs for all patients and adverse events analysed (Figure 13). However, the baseline assessment was based on observation during the visit by the data collectors while in the midline, results of the data collection instrument for patient interviews in each department were used. In order to improve the accuracy and validity of the study, the changes were made after the researchers added this question to the midline.

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No KCl in general ward stocks Resuscitation procedure posters Guidelines available to patients 0 20 40 60 80 100 All departments increased on 10 criteria assessed between baseline and midline periods by about 10% (Figure 14).

Figure 14. Total Scores of 10 Keys OA Criteria between Baseline and Midline by Departments D.

Clinical Chart Review Delivery Patient characteristics At baseline, out of pocket (OOP) was the most widely used payment method (35%), but at midline, the proportion using Jampersal was highest (33%) (Table 13). In JCI hospitals, the proportion of OOP payers was higher than the other two hospital categories in both periods while the proportion of Jampersal was decreasing and the proportion using Insurance for the poor increased 50% from baseline to midline. In NHA hospitals, the percentage of Jampersal was highest in baseline and midline period. However, the percentage of insurance for the poor increased 50%, while OOP and government insurance decreased.

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60 50 45 40 30

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60 50 40 30 20

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Clinical Practice of AMI Analysis used in the midline was only cardiac enzymes and EGC for primary diagnosis of AMI, while cholesterol, triglycerides, and LDL were predisposing factors. Hospitals generally increased by an insignificant margin (Table 25). By hospital category, there was also no differences between baseline and endline (Figure 20).

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There was a slight overall improvement in medications recorded at discharge from 36 to 47% (p = 0.156) (Table 26). There was no apparent difference between the three hospitals groups in the improvement seen (Figure 21).

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60 52 50 40 30 28

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Patient Experience with Nursing Services In Hospitals E, F, G, H, and I the proportion of patients with favorable perceptions of nursing care decreased while only Hospital C increased (Table 36). By hospital category, JCI hospitals experienced about half the decrease in overall perception of the nursing staff as the other two categories (Figure 26).

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