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7/29/2019 Peer Review Monitoring
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VOLTA REGIONAL HEALTH
DIRECTORATE
REPORT ON THE FIRST ROUND OF
PEER REVIEWOF HOSPITALS IN THE VOLTA REGION
DECEMBER, 2011
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DECLARATION
This report is the result of the Peer Review monitoring by the Regional Clinical Care Division of the Volta
Regional Health Directorate, which was actively supported by the Medical Superintendents group. The
overriding objective of the exercise is to improve the quality and standards of service delivery for all the
twenty one hospitals and the only Polyclinic in the region to become centres of excellence.
We the undersigned hereby declare that, the findings and the recommendations made in this report
shall be used for the improvement in the quality of healthcare delivery in the Volta Region and not for
any other purpose apart from the stated objectives of the Peer Review Process.
Any person or group of persons wishing to use any part or whole of this report for any purpose or any
other objective should contact the undersigned persons of this declaration.
ROBERT KWAKU ADATSI
DEPUTY DIRECTOR CLINICAL CARE
VOLTA REGION
DR. KOFI GAFATSI NORMANYO
CHAIRMAN, MEDICAL SUPERINTENDENTS GROUP
VOLTA DIVISION
MR. SIMON YAO DZOKOTO
PEER REVIEW COORDINATOR FOR HOSPITALS,
VOLTA REGION
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ABBREVIATIONS AND ACRONYMS
CCD Clinical Care Division
CHPS Community-Based Health Planning System
GPRS Ghana Poverty Reduction Strategy
GHS Ghana Health Service
M &E Monitoring and Evaluation
MSG Medical Superintendents Group
MSG-VD Medical Superintendents Group- Volta Division
PR Peer Review
QA Quality Assurance
RDHS Regional Director of Health Services
RHD Regional Health Directorate
VRHD Volta Regional Health Directorate
WHO World Health Organization
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TABLE OF CONTENT
DECLARATION ............................................................................................................................................... ii
ABBREVIATIONS AND ACRONYMS ............................................................................................................... iii
TABLE OF CONTENT ..................................................................................................................................... iv
MESSAGE FROM HONOURABLE VOLTA REGIONAL MINISTER .................................................................... vi
MESSAGE FROM THE REGIONAL DIRECTOR OF HEALTH SERVICES ............................................................ vii
EXECUTIVE SUMMARY ............................................................................................................................... viii
ACKNOWLEDGEMENT ................................................................................................................................... x
CHAPTER ONE-INTRODUCTION..................................................................................................................... 1
1.1 Overview ................................................................................................................................................. 1
1.2 Review of the Check list .......................................................................................................................... 1
1.3 Progress and Limitation in Organization of Peer Review ........................................................................ 4
CHAPTER TWO- PERFORMANCE ................................................................................................................... 5
2.2 Performance Change in Thematic Areas ................................................................................................. 8
2.3 Comparing the Difference in Means and Standard Deviations of the Thematic Areas of the First
and Second Cycle Peer Reviews ............................................................................................................ 9
2.4 Performance Change in the Thematic Areas Based On Ownership...................................................... 12
2.5 PERFORMANCE BASED ON ZONAL LOCATION ...................................................................................... 13
2.6 SECOND CYCLE PEER REVIEW PERFORMANCE AND POST PEER REVIEW PERFORMANCE ................... 15
2.7 OVERALL PERFORMANCE OF HOSPITALS BY OWNERSHIP AND LOCATION.......................................... 19
2.8 PERFORMANCE TARGET SET BY THE REGIONAL DIRECTOR OF HEALTH SERVICE TO ALL MEDICAL
SUPERINTENDENTS ............................................................................................................................. 21
2.9 LEAGUE TABLE OF PERFORMANCE OF HOSPITALS ............................................................................... 22
2.10 Improvement or otherwise of facilities .............................................................................................. 23
2.10.1 Description of the problem or stimulant (outliers).................................................................. 23
2.10.1.1 Environment.......................................................................................................................... 23
.................................................................................................................................................................... 24
2.10.1.2 Infection Prevention and Control ................................................................................................. 25
2.10.1.3 Emergency Systems and Services ................................................................................................. 26
2.10.1.4 Quality Assurance Activities .......................................................................................................... 27
2.10.1.5 Clinical Practices............................................................................................................................ 27
2.10.1.6 Clients Care ................................................................................................................................... 27
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2.10.1.7 Occupational Health and Safety Issues ......................................................................................... 27
2.10.1.8 Management ................................................................................................................................. 28
2.10.2 Regional Directors Mark for Innovation and Organization of the Peer Review ............................. 29
CHAPTER THREE- CONCLUSION & RECOMMENDATION............................................................................. 30
3.1 CONCLUSION ......................................................................................................................................... 30
3.2 RECOMMENDATIONS............................................................................................................................ 30
REFERENCES ................................................................................................................................................ 32
APPENDIX .................................................................................................................................................... 33
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MESSAGE FROM HONOURABLE VOLTA REGIONAL MINISTER
Health Care delivery demands a concerted effort to ensure that lives are saved. Health is Wealth and
therefore an essential component of the better Ghana Agenda. As we get close to the Better Ghana
Agenda Part 1, the government has chalked a lot of success by embarking on a number of projects
aimed at accelerating improvement in the performance of the health sector with special emphasis on
prudent use of resources available to the sector and sustainable improvement in access to quality health
care.
Human resource which is one of the key ingredients to providing quality Health Care has become a
challenge in the Volta Region more especially, in the case of Midwives who are the key people in helping
to achieve the MDG 4 & 5.
It is in pursuance of this that University of Health and Allied Sciences in the Volta Region and Post Basic
Midwifery School in Krachi West District are being established. All these efforts of government are
targeted at ensuring sustainable improvement in access to quality health care.
However, government again recognizes that the mere presence of physical structure may not
necessarily translate to quality health care. In other words, problems of quality health care continue to
be a fundamental challenge to access to health care, but have received relatively little attention in the
past.
It is heartening to realize that the implementation of the Peer Review has improved a lot of aspects of
the Health Care delivery in the Hospitals. This was indicated in the results of this report. We at the
Regional Coordinating Council will always support programmes like this and project it to put the Region
in the limelight.
It is in this regard that the Regional Coordinating Council applauded the Peer Review approach of the
Regional Health Directorate and the Medical Superintendents Group to standardize and improve quality
of Service in the entire Region through cross fertilization of best practices.
We will continue to strengthen the process by encouraging all the Municipal/District Assemblies to
provide the necessary assistance to the Hospitals to enable them provide quality health care to the good
people of Ghana thereby making the better Ghana Agenda a reality.
We hope that further broadening of the frontiers would include an Open Day for wider dissemination.
The Regional Coordinating Council wishes you an exciting third cycle of the Peer Review.
Hon. Henry Ford Kamel
Volta Regional Minister
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MESSAGE FROM THE REGIONAL DIRECTOR OF HEALTH SERVICES
We had been through one (2) year of Peer Review and the third cycle already in motion. It is
a welcome innovation that is stimulating and energizing all of us.
Even as performance target for all facilities was moved from 75% to 80%, am highly
delighted that 50% of the facilities have crossed this new target.
In my administrative visits to all the Districts, it became clear that the Hospitals have been
transformed tremendously. This gives me confidence that the Internally Generated Funds are
being used efficiently and effectively.
It is behoving on us to improve staff attitude to commensurate the gains made in
translating the Hospitals environments. We must find a way to measure staff attitude in the
exercise and see it influence outcome of service delivery positively.
Due to the improvements seen in the hospitals, I am sure the stakeholders involvement
and interest in the process, especially, the Chiefs and District/Municipal Chief Executives will
serve as pressure to ensure the sustainability of the process. This will in effect ensure quality of
service to our clients.
In addition, I am personally happy about the efforts being put in to ensure the quality of the
Assessment through the organisation of training on how to properly do the assessment and
also to regulating the process through the development of Code of Principles to guide the
entire process in the third cycle.
Dr. Joseph Teye Nuertey
Volta Regional Director of Health Services
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EXECUTIVE SUMMARY
Since 2009 two cycles have been conducted with each hospital peer reviewed in each cycle.
Tremendous improvement has been noticed across the facilities at the end of the second cycle.
Hospitals which hitherto had no incinerators were able to build multi-purpose incinerators,
emergency system were sharpened, most hospitals now have strategic plans and yearly action
plans which dovetail into the strategic plan, client satisfaction surveys to elicit the perception
of clients on quality of care are now being conducted regularly, infection control practices have
been taken to admirable level and hospital environment have been noted to be so pleasing.
Several policy issues were introduced into the second cycle PR and performance target
increased to 80% instead of 75% during the 1 st cycle. Thematic areas covered include;
Environment (Both Internal and External), Infection Prevention and Control, Emergency
Systems and Services, Quality Assurance, Clinical Practices, Client Care, Occupational Health
and Safety issues and Management. All these areas were carved to ensure the implementation
of policies of the Ministry of Health in the Volta Region.
Results indicated a tremendous improvement over the first cycle PR. Percentage score on
Environment improved from 62.6% to 74.5%, IPC from 73.8% to 82%, Emergency Systems and
Services from 64.4% to 76.1% and Quality Assurance from 66.8% to 76.4%. Other areas include,
Client care which improved from 56.2% to 77.9%, and Management practices from 69.4% to78.0%. Other areas included in the second cycle were Clinical practices which scored 72.3%
Occupational Health and Safety which scored 77.5% and Regional Directors score on innovation
and organization of the PR in the facilities which scored 73.3%.
Performance during the second cycle was found to be influenced to a large extent by the
performance during the first cycle. The ownership of the facilities was found to have no
influence on the performance but the location of the facilities according to the Peer Review
demarcation had influence on the performance of facilities.
Eleven facilities (11) hospitals were able to achieve the target performance of 80% and theother 11 achieved the bracket of 50% - 79.9%. None of the Hospitals scored below 50%.
The PR wind blowing in the Volta Region called for a concerted between all the divisions of the
Ghana Health Service to improve the Health Status of the Country.
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ACKNOWLEDGEMENT
The VRHD is very grateful to all people who in diverse ways helped in the Peer Review process
in the region.
Indeed the enthusiasm and support of Dr. T.S. Letsa cannot be swept under the carpet. He
indeed encouraged the process and attended most of the reviews.
Our deepest appreciation also goes to all the stakeholders who participated in the second cycle
of the Peer Review especially:
District Chief Executives of the District in which the Peer Review is taking place. Presiding Member of the District Assembly Members of Parliament in the District in which the Peer Review is being organized. Chairman of the Social Services Committee of the Assembly The Chairman of the Health Committee of the Assembly (If it exists) Chiefs of the Traditional Area The District Directors of Health Services The Executive Secretary, CHAG The Scheme Manager of NHIS in the District in which Peer Review is being organized.
Finally, we wish to thank the management and staff of all the hospitals in the region who have
demonstrated the spirit of commitment and the desire to succeed in all that they do.
Editorial and Technical Task Team
Dr Kofi Gafatsi Normanyo
Dr Joseph Teye NuerteyMr Robert K. Adatsi
Mr Emmanuel Aforbu
Mr Simon Dzokoto
Regional Health Directorate Task Team
Ms Comfort Agbadja
Mr Divine Azameti
Ms Priscilla Tawiah
Mr Robert Adatsi
Mr Simon Dzokoto
Regional Health Directorate Task Team Driver
Mr Cudjoe Amankwa
Medical Superintendents/Medical Officer-In-Charges
Dr Kofi Gafatsi Normanyo Chairman, Medical Superintendents Group (Volta Division)
Dr K. Asare-Bediaku Aflao Hospital
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Dr Lawrence Kumi Peki Hospital
Dr Edwin Danoo Hohoe Hospital
Dr. Anthony Ashinyo Nkwanta Hospital
Dr Felix Tsidi Keta Hospital
Dr F.E. Abudey Sogakofe Hospital
Dr Samuel Abudey Jasikan Hospital
Dr Hilarius K Abiwu Krachi West Hospital
Dr Doe Ocloo Adidome Hospital
Dr Moses Boni Akatsi Hospital
Dr Tetteh Augustus St. Joseph Catholic Hospital
Dr Pius Mensah Worawora Hospital
Rev. Sr. Dr Lucy Hometowu Margaret Marquart Catholic Hospital
Dr Alex Ackon Anfoega Catholic Hospital
Dr A. Mark Ofori-Adjei St. Mary Theresa Catholic Hospital, Dodi PapaseDr William Dwuamena St. Anthonys Catholic Hospital
Dr Atsu Seake-Kwawu Ho Polyclinic
Dr Bowan Battor Catholic Hospital
Dr Kugbe Mlimor Kudjo Sacred Heart Hospital,Abor
Dr George Acquaye Volta Regional Hospital
Dr Moumoudo Cham Comboni Hospital
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CHAPTER ONE-INTRODUCTION
1.1 Overview
Prior to 2009, the Volta Regional Medical Superintendent Group having seen the
deplorable state of hospitals infrastructure and the non-adherence to National policies and
standards decided to adopt a strategy to bring about change which would lead to improvement
in the quality of care across the region. Policy makers across the spectrum and indeed the
entire population were concerned about the deteriorating levels of the quality of care in our
hospitals. Consequently the Regional Health Directorate introduced Peer Review in July 2009.
Since 2009 two cycles have been conducted with each hospital peer reviewed in each cycle.
Tremendous improvement has been noticed across the facilities at the end of the first
round. Hospitals which hitherto had no incinerators were able to build multi-purpose
incinerators, emergency system were sharpened, most hospitals now have strategic plans andyearly action plans which dovetail into the strategic plan, client satisfaction surveys to elicit the
perception of clients on quality of care are now being conducted regularly, infection control
practices have been taken to admirable level and hospital environment have been noted to be
so pleasing.
All these achievements notwithstanding, there were challenges with regards to the
objectivity of the checklist used for the assessment calling for systems to remove bias.
1.2 Review of the Check list
Feedback during the first cycle strongly indicated that there was the need to review thecheck list to reflect objectivity of the assessment and include other policy issues which were not
added earlier on.
The structure of the check list was modified for the second cycle to include the ideal situation,
the reason(s) for the ideal situation, and what to do if the ideal situation is not met. For
example grass covering at the hospital; when properly done, it is pleasing to the eye, sets the
mind of staff and clients at ease, and easily rates the institution as a ready entity to deliver the
care necessary.
The new policy issues taken on board and their rationale are tabulated below:
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Table 1.1 POLICY ISSUES TAKEN ON BOARD.
NO POLICY ISSUE RATIONALE WHAT THE POLICY ISSUE IS
SUPPOSED TO ACHIEVE
1 Proportion of CaesareanSection wound Infection (Select20 folders randomly)
It measures the infection prevention
and control measures undertaken by
the hospital
To reduce infection in the hospitals
and
To carry out infection control
practices
2
Case Fatality Rates, C/S Rates,
Fresh Still Rates
The entire existence of hospital is to
render service through clinical practice.
Effectiveness and efficiency of such a
practice is paramount. Indicators to
measure acute, moderate and chronic
cases define such effectiveness.
A range of indicators looked at how
individual facilities fit within the
range and indicating the
effectiveness and efficiency of
managing the case
3
Mass Casualty Incidence
management
To give focus and organization in the
Management of Mass Casualty
To develop systems and capacity to
manage Mass casualty that goes
beyond our Emergency rooms. For
Example occurrence of earthquakes,
landslides, etc.
4 System for Emergency
To ensure there is a system to manage
emergency situations
5Emergency Trays
(availability and adequacy) -
minimum content of
emergency tray
To ensure basic equipment and drugs
available to enhance management of
emergencies.
To ensure uniformity in the
Management of Emergency in all
facilities.
To draw attention to what should go
into the Emergency Tray
To reduce time spent on managing
emergencies
6
Occupational Health and Safetyissues e.g.
i. PersonalProtective
Clothing
ii. Barrier Nursingiii. Floors (Non-
slippery, No
excavation)
iv. Fire Prevention(Fire
Extinguisher &
Appropriateuse)
v. AnnualScreening of
Staff(Protocol
available,
evidence of
screening done)
Safety of staff and patients cannot becompromised under any circumstances
and therefore steps must be taken to
protect them.
To stimulate Management to payattention to protection of staff
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Records on Implementation of
Management Decisions (Shouldincl. Decision making date,
Decision taken, date of
implementation, cost involve)
Decisions are taken and hardly
implemented and even when
implemented there are no records to
show creating an impression that work
is not been done. It is therefore
necessary to assess the records of
decisions implemented to determine
the progress of work. It also helps in
report writing.
To ensure decisions taken are not left
hanging.
To introduce a culture of reviewing
Management decisions
7
Strategic Plan (SP)
(Availability, Staff
Knowledge about it)
To give focus, direction and motivation
to both management and the entire
staff.
SP involves having broad outlines of
local content of activities (including
innovations) directed at executing the
objectives of MOH/GHS
Hospitals think they dont need a
Strategic Plan however, hospitals like
any other organization needs to have
a focus exactly what a strategic Plan
is meant to do.
8
Action Plan (Available in all
units, meet standard actionplan requirement,
Proportion of
implementable activities
implemented)
Action plan operationalizes strategic
plans and reduces SP to work packagesthat can easily be managed
To give uniformity action plans
To ensure implementation ofactivities once they are planned
9
Weekly Cash flow statement(available)
To guide expenditure decisions To ensure flow of financial
information to management
members this hitherto is not the
case.
Help in Management decision
making.
To help prevent financialmalpractices
10
Quarterly Financial Analysis
To determine financial viability and
monitor budget performance.
To ensure flow of financial
information to management
members this hitherto is not the
case.
Help in Management decision taking.
To help in programme monitoring &
evaluation
11 Equipment Replacement
Policy Financial Analysis
Statement (Half Yearly)
To ensure that broken down
equipment are replaced so as not
interrupted service delivery
To ensure regular replacement of
obsolete equipment and ensure
financial analysis is done replacing
the Obsolete equipment
12 Planned Preventive
Maintenance Schedule of
Equipment and Building
(Prop. Implemented)
Maintenance culture is a big problem in
our institutions. Everything has to be
done to ensure that equipment and
buildings are maintained
To inculcate Maintenance culture in
our Institutions and ensure that
equipment and building do not
deteriorate beyond repairs.
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1.3 Progress and Limitation in Organization of Peer Review
To promote community participation in health care delivery, invitation was extended to
traditional rulers, District Chief Executives, heads of decentralized agencies, NGOs in Health and
other key stakeholders. This was done to solicit their support in bridging the gaps identified in
health service delivery and strengthen the arm of peer review to ensure sustainability
Another feature of the second cycle Peer Review was the introduction of the Regional Directors
Score to encourage innovation using local resources and staff participation.
A problem solving session which was one of the salient parts of the program during the first
cycle died down in the second cycle due to lack of time.
Confrontation as to who should participate in the peer review and carry out assessment,
number of participants per facility became an issue as was the basis for awarding scores in
certain thematic areas.
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CHAPTER TWO- PERFORMANCE
Table 2.1 Performance of the Hospitals by the Thematic Areas of the Checklist
Hosp Env Hosp IPC Hosp Emer Hosp QA Hosp
Clinical
Practice Hosp
Client
Care Hosp OH&S Hosp MGT
St. Anthony 92.42 Sogakofe
100.0
0 Peki
100.0
0 St. Anthony 97.37 Sogakofe 92.86 St. Anthony 100.00 Peki 98.50 Ho Mun 95.70
Sogakofe 90.91 Ketu South 94.44 Worawora
100.0
0 Akatsi 96.50 Peki 86.60 Ho Mun 100.00 Abor 95.60
Ketu
South 94.93Dodi
Papase 90.90 Akatsi 93.30 Ho Mun 94.30 Peki 93.00 Adidome 82.14 Akatsi 96.70 St. Anthony 94.12 St. Joseph 93.91
Peki 89.40 Abor 93.10
Dodi
Papase 94.30 Ketu South 92.11 Abor 81.30 St. Joseph 96.67 Worawora 94.12 Adidome 92.03
Anfoega 84.85
St.
Anthony 90.28 Ketu South 94.29 Sogakofe 88.60 Battor 80.40 Keta 93.33 Keta 92.65 Keta 92.03
Abor 84.80 Ho Mun 87.50 Hohoe 94.29 Keta 87.72 Krachi 79.46 Peki 93.30 Akatsi 89.70 Akatsi 90.60
Keta 78.79 St. Joseph 87.50 St. Anthony 92.86 Ho Mun 80.70 Anfoega 73.21
Dodi
Papase 93.30 Sogakofe 83.82 Peki 89.90
Ho Mun 77.30 Krachi 87.50 MMCH 90.00 Worawora 77.60 Ho Mun 71.40 MMCH 93.30 Ketu South 83.82 Abor 89.10
Battor 77.30 MMCH 86.10 Abor 85.70 Nkwanta 76.32 St. Anthony 70.54 Anfoega 90.00 St. Joseph 82.35
Dodi
Papase 87.00
Adidome 77.27 Hohoe 83.33 St. Joseph 78.57 Krachi 74.56 Ketu South 70.54 Abor 86.70 Hohoe 80.88 Sogakofe 86.96
Hohoe 75.76 Peki 83.30 Krachi 78.57 St. Joseph 72.81 Hohoe 69.64 Battor 86.70 Krachi 80.88
St.
Anthony 85.51
Ketu South 74.24 Adidome 81.94 Sogakofe 75.71 Hohoe 69.30 Nkwanta 69.64 Hohoe 86.67
Dodi
Papase 79.40 MMCH 85.50
Akatsi 74.20
Dodi
Papase 80.60 Jasikan 74.30 Abor 68.40 Keta 67.86 Sogakofe 83.33
Ho
Municipal 73.50
Worawor
a 82.61
VRH 71.21 VRH 80.56 Anfoega 72.86
Dodi
Papase 65.80 St. Joseph 66.96 Adidome 80.00 Jasikan 73.50 Battor 72.50
MMCH 71.20 Battor 79.20 Akatsi 68.60 Jasikan 64.90
Dodi
Papase 66.10 Jasikan 76.70 MMCH 70.60 Jasikan 71.70
Jasikan 71.2 Nkwanta 79.17 Keta 67.14 Anfoega 64.04 VRH 65.18 Ketu South 76.67 VRH 70.59 VRH 70.29
Ho Poly 71.20 Jasikan 77.80 Nkwanta 64.29 MMCH 61.40 Jasikan 62.50 Krachi 63.33 Anfoega 69.12 Krachi 64.49
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Comboni 60.61 Keta 77.78 Battor 62.90 Comboni 58.77 Comboni 60.71 Worawora 60.00 Adidome 67.65 Hohoe 59.71
St. Joseph 59.09 Worawora 76.39 Comboni 50.00 Adidome 57.02 Akatsi 60.70 Ho Poly 46.70 Battor 66.20 Anfoega 48.55
Worawora 59.09 Comboni 63.89 Ho Poly 50.00 Battor 51.80 Worawora 57.14 VRH 36.67 Comboni 48.53 Comboni 46.38
Krachi 57.58 Ho Poly 62.50 Adidome 35.71 VRH 48.25 MMCH 57.10 Comboni 36.67 Ho Poly 41.20 Nkwanta 42.03
Nkwanta 50.00 Anfoega 56.94 VRH 30.00 Ho Poly 44.70 Ho Poly 42.90 Nkwanta 30.00 Nkwanta 35.29 Ho Poly 41.30
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Table 2.1.Performance of the Hospitals by the Thematic Areas of the Checklist (contn)
Hosp RDHS Score Hosp 2nd Round Total Hosp 1st Round Total Hosp
% Change in
Performance
Hohoe 100.00 Peki 94.80 Peki 87.40 St. Anthony 62.77
Krachi 96.67 St. Anthony 91.80 Ketu South 79.20 Worawora 61.37
Ketu South 93.33 Sogakofe 91.34 Abor 78.90 Krachi 51.28
Jasikan 88.00 Ketu South 90.45 Sogakofe 77.20 Adidome 37.49
Abor 86.70 Abor 88.40 Dodi Papase 75.40 Keta 31.61
Akatsi 86.70 Akatsi 87.30 Ho Mun 74.60 Akatsi 30.30
Worawora 83.33 Ho Mun 87.20 St. Joseph 71.90 Ho Poly 23.78
Adidome 83.33 Keta 84.63 Jasikan 70.80 MMCH 20.59
Peki 80.00 Dodi Papase 83.40 Hohoe 67.30 Anfoega 20.12
Dodi Papase 80.00 St. Joseph 82.33 Akatsi 67.00 Battor 18.62
Battor 76.70 Worawora 80.20 Comboni 65.50 Sogakofe 18.32
St. Anthony 75.33 Hohoe 78.57 MMCH 64.60 Ho Mun 16.89
St. Joseph 73.33 Krachi 77.91 Keta 64.30 Hohoe 16.74
Anfoega 73.33 MMCH 77.90 Nkwanta 62.60 St. Joseph 14.50
MMCH 73.30 Adidome 76.72 Battor 62.30 Ketu South 14.20
Ho Mun 66.70 Jasikan 75.60 VRH 61.40 Abor 12.04
Ho Poly 66.70 Battor 73.90 Anfoega 57.90 Dodi Papase 10.61
Sogakofe 66.67 Anfoega 69.55 St. Anthony 56.40 Peki 8.47
Keta 60.00 VRH 62.99 Adidome 55.80 Jasikan 6.78
Nkwanta 46.67 Nkwanta 60.45 Krachi 51.50 VRH 2.58
VRH 40.00 Comboni 55.52 Worawora 49.70 Nkwanta -3.44
Comboni 26.67 Ho Poly 53.10 Ho Poly 42.90 Comboni -15.23
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2.2 Performance Change in Thematic Areas
H0: There is no difference between the first cycle mean scores and the second cycle mean scores of the
various thematic areas
H1: There is a difference between first cycle mean scores and second cycle mean scores of the variousthematic areas.
Table 2.2: Paired Differences in the Performance of Hospitals in the Thematic Areas
Performance/Th
ematic Area
Cycles
%
Change
Mean
difference
in
performa
nce
t-
value
Degree
of
freedom
Sig. Value of t-
Test(=0.05)
2nd Cycle
Mean
1st Cycle
Mean
Environment 77.5 62.04 24.9 11.89 3.50 21 0.002
IPC 83.7 71.78 16.6 8.22 3.23 21 0.004
Emergency 67.3 66.66 1 11.75 2.02 21 0.056
QA 72.7 64.9 12 9.62 2.19 21 0.040
Clinical Practice 70.5 N/A N/A 72.33 32.16 21 0.000
Client Care 77.0 56.6 36 21.72 4.21 21 0.000
OH&S 75.6 N/A N/A 77.49 25.15 21 0.000
Management 79.8 70.69 12.9 8.63 2.40 21 0.026
RDHS 69.1 N/A N/A 73.72 19.15 21 0.000
Overall 78.6 65.46 20.1 12.72 5.84 21 0.000
Since the p-value for the overall performance was less than 0.05, it indicated that there is
enough evidence to reject the null hypothesis and accept the alternate hypothesis that there is
a difference in the overall performance during the first and second cycles of the Peer Review.
In addition, Table 2.2 revealed that the p-value for all thematic areas were less than 0.05
indicating that there is the need to reject the null hypothesis and accept the alternate
hypothesis there is a significant difference in the first cycle and second cycle performances in
the thematic areas of the Peer Review.
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However, with regards to Emergency, the p-value was more than 0.05 indicating that there is
enough evidence to accept the null hypothesis that there is no significant difference in the first
cycle and second cycle performance in the emergency area of the checklist.
2.3 Comparing the Difference in Means and Standard Deviations of the Thematic Areas of the First and
Second Cycle Peer Reviews
Table 2.3 Paired Samples Statistics (n=22)
Thematic Areas of the Peer ReviewMean
Std.
Deviation
Std. Error
Mean
Skewness
2nd
Cycle Environment 74.52 11.82 2.52 -0.30
1
st
Cycle Environment 62.63 16.30 3.47 -0.02
2nd
Cycle Infection Prevention & Control 81.96 10.54 2.25 -0.78
1st
Cycle Infection Prevention & Control 73.75 14.35 3.06 -0.36
2nd
Cycle Emergency Services & Systems 76.14 18.61 3.97 -1.14
1st
Cycle Emergency Services & Systems 64.39 21.60 4.60 -0.24
2nd
Cycle Quality Assurance 76.43 13.66 2.91 -0.25
1st
Cycle Quality Assurance 66.81 17.36 3.70 -0.40
2n
Cycle Clinical Practices 72.33 10.55 2.25 0.52
1st
Cycle Clinical Practices 0.00 0.00 0.00 -.
2nd
Cycle Client Care practices 77.89 20.75 4.42 -1.23
1st
Cycle Client Care practices 56.17 21.51 4.59 0.35
2nd
Cycle Occupational Health & Safety 77.49 14.45 3.08 -1.43
1st
Cycle Occupational Health & Safety 0.00 0.00 0.00 -.
2nd
Cycle Management 78.02 16.60 3.54 -0.99
1st
Cycle Management 69.40 15.01 3.20 0.07
2n
Regional Director of Health Services 73.72 18.05 3.85 -1.05
1st
Regional Director of Health Services 0.00 0.00 0.00 -.
2n
Cycle Overall Performance 78.37 11.82 2.52 -0.78
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1st
Cycle Overall Performance 65.65 10.85 2.31 -0.10
Table 2.3 above revealed the Mean performance in the various Thematic Areas of the Peer
Review. On the whole, the overall standard deviation during the second cycle was lower than
the first cycle indicating that every facility was performing to meet the Performance Target.
Table 2.4 Paired Samples Test for the Thematic Areas
Paired Samples Test
Paired Samples Test
Paired Differences
t dfSig. (2-
tailed)MeanStd.
Deviation
Std.
Error
Mean
95% Confidence
Interval of the
Difference
Lower Upper
Pair 1 Environment 2 - Environment1 11.89 15.94 3.40 4.82 18.96 3.50 21 0.002
Pair 2 IPC2 - IPC1 8.22 11.93 2.54 2.93 13.50 3.23 21 0.004
Pair 3 Emergency2 Emergency1 11.75 27.27 5.81 -0.34 23.84 2.02 21 0.056
Pair 4 QA2 - QA1 9.62 20.58 4.39 0.50 18.75 2.19 21 0.040
Pair 5 Clinical Practice2 - Clinical Practice1 72.33 10.55 2.25 67.65 77.01 32.16 21 0.000
Pair 6 Client Care2 Client Care1 21.72 24.20 5.16 10.99 32.45 4.21 21 0.000
Pair 7 OHS2 - OHS1 77.49 14.45 3.08 71.08 83.90 25.15 21 0.000
Pair 8 Management2 Management1 8.63 16.87 3.60 1.15 16.11 2.40 21 0.026
Pair 9 RDHS2 - RDHS1 73.72 18.05 3.85 65.71 81.72 19.15 21 0.000
Pair 10 Overall2 - Overall1 12.72 10.22 2.18 8.19 17.25 5.84 21 0.000
Table 2.4 indicated the mean differences in performance during the first and second cycles of
the Peer Review in terms of the various thematic areas of the checklist used and the overall
performance of the Hospitals. Clinical Practices, Occupational Health and Safety and RHDS
areas were introduced in the second cycle; hence their mean performance differences were
seen to be higher; thus 72.33, 77.49 and 73.72 respectively.
Apart from these three areas, the other thematic areas with high mean differences in
performance were the Client Care practices, Environment and Emergency services and systems
whilst Infection Prevention and control practices attracted the lowest mean difference in
performance.
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Table 2.4 again revealed that there is a significant difference in the overall performance of the
Hospitals hence the need to reject the Null Hypothesis that there is no significance difference in
overall performance of the Hospitals during the first cycle and the second cycle of the Peer
Review hence the need to reject the null hypothesis at p-value of 5% and conclude that there is
high probability that the overall mean during the second cycle was influenced by the overall
mean during the first cycle of the Peer Review.
Similarly, with regards to the various thematic areas, Table 2.4 revealed a significant difference
in the performance of the Hospitals hence the need to reject the Null Hypothesis and conclude
at significance level of 5% that, there is high probability that means of second cycle
performance were influenced by the first cycle performance. However, for Emergency systems
and services, there was enough evidence to reject the alternative hypothesis that there is
difference in the first cycle and second cycle performance and conclude that there is high
probability that the means of the first cycle performance did not influence the second cycle
performance.
Table 2.5 Correlation between first cycle performance and Second Cycle Performance
Paired Samples Correlations
N Correlation Sig.
Pair 1 Environment1 & Environment2 22 0.39 0.071
Pair 2 IPC1 & IPC2 22 0.58 0.005
Pair 3 Emer1 & Emer2 22 0.09 0.704
Pair 4 QA1 & QA2 22 0.14 0.545
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Pair 5 Client1 & Client2 22 0.34 0.116
Pair 6 Mgt1 & Mgt2 22 0.43 0.044
Pair 7 Over1 & Over2 22 0.60 0.003
With regards to the correlation between the first cycle results and the second cycle results, it
was revealed from table 2.5 that there are generally positive correlation between the first cycle
performance and the second cycle performances. However, the correlation coefficients
revealed weak relationships except between IPC1& IPC2 and the Over1 & Over2 which revealed
stronger correlation than in the other thematic areas.
This indicated that in most cases, there were improvements in performance of all the hospitals
in the thematic areas.
2.4 Performance Change in the Thematic Areas Based On Ownership
H0: There is no difference in performance of CHAG Hospitals and GHS Hospitals.
H1: There is difference in the performance of CHAG Hospitals and GHS Hospitals.
Table 2.6 GHS & CHAG Hospitals Performance Compared According to Thematic Areas
Performance
Areas
CHAG GHS
2nd Cycle
Mean
1st Cycle
Mean
%
Change
2nd Cycle
Mean
1st Cycle
Mean
%
Change
Environment 77.65 67.3 15.38 72.72 59.96 21.28
IPC 79.7 72.35 10.16 83.25 74.54 11.69
Emergency 79.66 69.44 14.72 74.13 61.51 20.52
QA 75.92 72.18 5.18 76.73 63.74 20.38
Clinical Practice 72.7 N/A N/A 72.12 N/A N/A
Client Care 83.71 51.50 62.54 74.57 58.84 26.73
OH&S 77.21 N/A N/A 77.64 N/A N/A
Management 76.61 68.08 12.53 78.83 70.15 12.37
RDHS 70.46 N/A N/A 75.58 N/A N/A
Overall 76.14 66.21 15.00 79.67 65.32 21.97
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An analysis of variance to infer whether ownership of the Hospitals affects the performance of
the various hospitals revealed that at significance level of 5%, there is enough evidence to
reject the null hypothesis that ownership of the hospitals has no influence on the performance
of the Hospitals and accept the alternate hypothesis that ownership of the Hospital has
influence on the Performance of the Hospital.
It is imperative to identify the ownership factors or arrangements that helped in influencing the
performance of the facilities so as to infuse the system to ensure continuous quality
improvement.
Table 2.7 Analysis of Variance Table for 2nd
Cycle overall performance and Ownership of
Hospitals
Tests of Between-Subjects EffectsDependent Variable: Second Cycle Overall Performance
Source
Type III Sum of
Squares Df
Mean
Square F Sig.
Partial Eta
Squared
Model 136236.675 3 45412.225 477.773 0.0000 0.9869
First cycle Overall
Performance1065.061 1 1065.061 11.205 0.0034 0.3710
Ownership of Facility 797.184 2 398.592 4.194 0.0310 0.3062
Error 1805.946 19 95.050
Total 138042.621 22
The model above indicated that about 98.7% of the variation in the model can be explained by
the model. Also, 37.1% of the variations with regards to first cycle performance and the second
cycle can be explained by the above model whilst 30.6% of the variation between ownership
and second cycle performance is explainable by the above model.
2.5 PERFORMANCE BASED ON ZONAL LOCATION
Table 2.8 Performance by Zonal Location Compared According to Thematic Areas
Performance Areas
Southern Zone Northern Zone
2nd Cycle
Mean
1st Cycle
Mean
%
Change
2nd Cycle
Mean
1st Cycle
Mean
%
Change
Environment 77.5 62.04 24.9 70.9 63.33 12.0
IPC 83.7 71.78 16.6 79.9 76.93 3.9
Emergency 67.3 66.66 1.0 84.7 61.67 37.3
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QA 72.7 64.9 12.0 72 69.09 4.2
Clinical Practice 70.5 N/A N/A 68.8 N/A N/A
Client Care 77 56.6 36.0 78.3 55.7 40.6
OH&S 75.6 N/A N/A 76.5 N/A N/A
Management 79.8 70.69 12.9 72.5 67.84 6.9
RDHS 69.1 N/A N/A 79.5 N/A N/A
Overall 78.6 65.46 20.1 78.1 65.87 18.6
H0: There is no difference between the first cycle and second cycle Mean performance scores
based on the location of the hospital according to the Peer Review Demarcation
H1: There is a difference between the first cycle and second cycle Mean performance scores
based on the location of the hospital according to the Peer Review Demarcation
Table 2.9 Analysis of Variance Table for overall performance and Location of Hospitals
Tests of Between-Subjects Effects
Dependent Variable:Over2
Source Type III Sum
of Squares df Mean Square F Sig.
Partial Eta
Squared
Corrected
Model
1043.457a 2 521.728 5.246 .015 .356
Intercept 673.126 1 673.126 6.768 .018 .263
Overall 1st
cycle 1015.191 1 1015.191 10.207 .005 .349
Zonal Location .841 1 .841 .008 .928 .000
Error 1889.730 19 99.459Total 138042.621 22
Corrected Total 2933.186 21
a. R Squared = .356 (Adjusted R Squared = .288)
An analysis of variance to infer whether Location according to the Peer Review demarcation
affects the performance of the various hospitals revealed that at significance level of 5%, there
is no enough evidence to reject the null hypothesis that the location of the hospitals has no
influence on the performance of the Hospitals and reject the alternate hypothesis that locationof the Hospital has influence on the Performance of the Hospital.
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2.6 SECOND CYCLE PEER REVIEW PERFORMANCE AND POST PEER REVIEW PERFORMANCE
Generally, all facilities scored lower during the post peer review monitoring except Hohoe Municipal
Hospital. This indicates that most facilities relaxed after the main peer review exercise hence the low
performance. Comparing the performance differences, a paired t-test was used as shown in the table2.10 below.
Table 2.10 Comparing Peer Review Performance and Post Peer Review Performances
Paired Samples Statistics (n=22)
Thematic Areas Mean Std. Deviation Std. Error Mean
Pair 1 Environment Post Peer Review 49.20 19.51 4.16
Environment Peer Review 74.52 11.82 2.52
Pair 2 Infection Prevention & Control Post Peer Review 51.82 19.83 4.23
Infection Prevention & Control Peer Review 81.96 10.54 2.25
Pair 3 Emergency System Post Peer Review 36.36 34.72 7.40
Emergency System Peer Review 75.20 20.25 4.32
Pair 4 Quality Assurance Post Peer Review 39.02 28.68 6.12
Quality Assurance Peer Review 72.35 15.65 3.34
Pair 5 Clinical Practices Post Peer Review 63.64 25.01 5.33
Clinical Practices Peer Review 69.77 11.19 2.39
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90.0
100.0 89.4
74.2
57.6 57.6 54.5 51.5 51.5 48.5 48.543.9 42.4
34.8 33.3 33.3 31.8 30.3 28.8 25.8 25.8 24.2
57.6
25.8
44.1
78.6
91.3
82.387.3
91.8
63.0
87.2 88.4
77.9 77.983.4
73.9
90.5
75.6
84.680.2
76.7
60.5
69.6
55.5
94.8
53.1
78.4
POST PEER REVIEW AND PEER REVIEW PERFORMANCE COMPARED
Overall PPR Overal PR
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Pair 6 Client Care Post Peer Review 35.60 26.87 5.73
Client Care Peer Review 77.58 22.09 4.71
Pair 7 Occupational Health & Safety Post Peer Review 24.55 24.64 5.25
Occupational Health & Safety Peer Review 76.00 17.10 3.65
Pair 8 Management Post Peer Review 40.91 30.75 6.55
Management Peer Review 76.49 18.35 3.91
Pair 9 Overall Post Peer Review 44.15 16.99 3.62
Overall Peer Review 78.36 11.82 2.52
The mean performance during the actual Peer Review was 78.36% whilst the post peer review revealed
an average performance of 44.15%. Table www also revealed a smaller standard deviation and standard
error mean performance between the facilities during the main peer review than during the post peer
review. Similar trend was shown in all the thematic areas.
As to the correlation between the Post peer review and the main peer review performances, the table
qqq below presents the strength of the correlation.
Table 2.11 Paired thematic areas Correlations
Paired Samples Correlations
Thematic Areas of Peer Review N Correlation Sig.
Pair 1 Environment Post Peer Review & Environment Peer Review 22 0.356 0.104
Pair 2 Infection Prevention & Control Post Peer Review & Infection
Prevention & Control Peer Review
22 0.500 0.018
Pair 3 Emergency systems Post Peer Review & Emergency System
Peer Review
22 0.535 0.010
Pair 4 Quality Assurance Post Peer Review & Quality Assurance Peer
Review
22 0.114 0.615
Pair 5 Clinical Practices Post Peer Review & Clinical Practices Peer
Review
22 0.417 0.054
Pair 6 Client Care Post Peer Review & Client Care Peer Review 22 0.157 0.486
Pair 7 Occupational Health and safety Post Peer Review &
Occupational Health and safety Peer Review
22 0.324 0.141
Pair 8 Management Post Peer Review & Management Peer Review 22 0.241 0.280
Pair 9 Overall Post Peer Review & Overall Peer Review 22 0.520 0.013
Table 2.11 revealed a positive correlation between the Peer Review and Post Peer Review Monitoring.
However, the correlation was weak for Environment, Quality Assurance, Client Care, Occupational
Health and Safety and Management Issues. Infection Prevention and Control, Clinical Practices,
Emergency systems and services and Overall performances indicated stronger correlation. The table also
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revealed that apart from Infection Prevention and Control, Emergency Systems and Services and Overall
Performance, which indicated that the correlations were statistically significant, the correlations for
Environment, Quality Assurance, Client Care, Occupational Health and Safety and Management Issues
were not statistically significant.
Table 2.12: Paired Samples Test for Peer Review and Post Peer Review Monitoring
Paired Samples Test
Thematic Areas of the Peer
Review
Paired Differences
T df
Sig. (2-
tailed)Mean
Std.
Deviation
Std. Error
Mean
95% Confidence
Interval of the
Difference
Lower Upper
Pair 1 Environment Post Peer
Review & Environment
Peer Review
-25.32 18.87 4.02 -33.69 -16.95 -6.29 21 0.000
Pair 2 Infection Prevention &
Control Post Peer Review
& Infection Prevention &
Control Peer Review
-30.14 17.18 3.66 -37.76 -22.52 -8.23 21 0.000
Pair 3 Emergency systems Post
Peer Review &
Emergency System Peer
Review
-38.84 29.37 6.26 -51.86 -25.81 -6.20 21 0.000
Pair 4 Quality Assurance Post
Peer Review & Quality
Assurance Peer Review
-33.33 31.07 6.62 -47.11 -19.56 -5.03 21 0.000
Pair 5 Clinical Practices Post
Peer Review & Clinical
Practices Peer Review-6.13 22.74 4.85 -16.21 3.95 -1.26 21
0.220
Pair 6 Client Care Post Peer
Review & Client Care
Peer Review-41.97 32.00 6.82 -56.16 -27.79 -6.15 21
0.000
Pair 7 Occupational Health and
safety Post Peer Review
& Occupational Health
and safety Peer Review-51.46 25.02 5.33 -62.55 -40.36 -9.65 21 0.000
Pair 8 Management Post Peer
Review & Management
Peer Review
-35.58 31.78 6.77 -49.67 -21.49 -5.25 21 0.000
Pair 9 Overall Post Peer Review
& Overall Peer Review-34.22 14.82 3.16 -40.79 -27.64 -10.83 21 0.000
Table 2.12 indicated the mean differences in performance during the main second cycle of the
Peer Review and the Post Peer Review Monitoring in terms of the various thematic areas of the
checklist used and the overall performance of the Hospitals.
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Table 2.12 again revealed that there is a significant difference in the overall performance of the
Hospitals hence the need to reject the Null Hypothesis that there is no significance difference in
overall performance of the Hospitals during the Peer Review and Post Peer Review Monitoring
hence the need to reject the null hypothesis at p-value of 5% and conclude that there is high
probability that the overall mean during the Post Peer Review was influenced by the overall
mean during the main second cycle of the Peer Review.
Similarly, with regards to the various thematic areas, Table 2.12 revealed a significant
difference in the performance of the Hospitals hence the need to reject the Null Hypothesis and
conclude at significance level of 5% that, there is high probability that means of Post Peer
Review Monitoring were influenced by the performance during the main second cycle
performance except with the Clinical Practices where it was realized that, there was enough
evidence to reject the alternative hypothesis that there is difference in the Post Peer Review
Monitoring and the second cycle performance and conclude that there is high probability that
the means of the main second cycle performance did not influence the post Peer Review
performance.
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2.7 OVERALL PERFORMANCE OF HOSPITALS BY OWNERSHIP AND LOCATION
OVERALL PERFORMANCE OF GHANA HEALTH SERVICE HOSPITALS DURING THE MAIN SECOND CYCLE
PEER REVIEW
The mean performance of the Ghana Health Service Hospitals showed an increase from 71.3%
during the first cycle Peer Review to 88% in the second cycle indicating an increase of 23.4%.
0.0
10.020.0
30.0
40.0
50.060.0
70.0
80.0
90.0
100.094.8 91.3 90.4 87.3 87.2 84.6
80.2 78.6 77.9 76.7 75.6
63.0
60.453.1
88.087.4
77.2 79.2
6774.6
64.3
49.7
67.3
51.555.8
70.8
61.4 62.2
42.9
71.3
2nd Round 1st Round
0.0
20.0
40.0
60.0
80.0
100.0 89.4
74.2
57.651.5 51.5
43.933.3 33.3 31.8 30.3 28.8 25.8
57.6
25.8
45.4
78.691.3 87.3
63.0
87.277.9
90.5
75.684.6 80.2 76.7
60.5
94.8
53.1
78.7
GHS FACILITIES PPR AND PR PERFORMANCE
COMPARED
Overall PPR Overall PR
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The Mean Performance of the GHS Hospitals during the Post Peer Review was 45.4% as against 78.7%
during the main Peer Review. This indicates a decrease of 42.3%.
OVERALL PERFORMANCE OF CHRISTIAN HEALTH ASSOCIATION OF GHANA (CHAG) HOSPITALS DURING
THE MAIN SECOND CYCLE PEER REVIEW
The CHAG Hospitals on the other hand moved from an average performance of 69.4% during
the first cycle to 84.8% during the second cycle indicating 22.2% increase in performance.
However, the Post Peer Review indicated a fall in the Performance as indicated in the graph below:
0.0
20.0
40.0
60.0
80.0
100.0
St.
Anthony
Abor Papase St.
Joseph
MMCH Battor Anfoega Comboni Mean
91.8 88.483.4 82.3
77.973.9
69.6
55.5
84.8
56.4
78.9 75.4 71.964.6 62.3
57.965.5 69.4
2nd Round 1st Round
0.0
20.0
40.0
60.0
80.0
100.0
St.
Joseph
St.
Anthony
Abor MMCH Dodi
Papase
Battor Anfoega Comboni Mean
57.6 54.548.5 48.5
42.434.8
25.8 24.2
42.0
82.3
91.8 88.4
77.983.4
73.969.6
55.5
77.9
CHAG FACILITIES PPR AND PR PERFORMANCECOMPARED
Overall PPR Overall PR
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The Mean Performance during the Post Peer Review was 42.0% as against 77.9% during the main Peer
Review. This indicates a decrease of 46.1%.
2.8 PERFORMANCE TARGET SET BY THE REGIONAL DIRECTOR OF HEALTH SERVICE TO ALL MEDICAL
SUPERINTENDENTS
To ensure that facility heads are held accountable for the performance of their Hospitals, all Medical
Superintendents were given a performance target of at least 80% during the second cycle instead of the
75% that was used during the first round of the Peer Review.
The dashboard below depicts the performance of the Hospitals in meeting this Performance Target set
by the Regional Director of Health Services.
The dashboard indicated that during the first round of the Peer Review, only 2 Hospitals were able to
score at 80% (the New Performance Target) whilst during the second cycle, 11 (i.e. 50%) Hospitals were
able to achieve the Performance Target.
The dashboard also indicated the performance based on the thematic areas of the peer review
process.
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2.9 LEAGUE TABLE OF PERFORMANCE OF HOSPITALS
The League Table below indicated the extent of the competition among the Hospitals.
Table 2.13 League Table of Performance of Hospitals
Hospital 2nd Round 1st Round % Change2nd Round
Position1st RoundPosition
Peki 94.8 87.4 8.5 1st 1st
St. Anthony 91.8 56.4 62.8 2nd
18th
Sogakofe 91.3 77.2 18.3 3rd
4th
Ketu South 90.4 79.2 14.2 4th 2nd
Abor 88.4 78.9 12.0 5th
3rd
Akatsi 87.3 67 30.3 6th
10th
Ho Municipal 87.2 74.6 16.9 7th 6th
Keta 84.6 64.3 31.6 8th
13th
Papase 83.4 75.4 10.6 9th 5th
St. Joseph 82.3 71.9 14.5 10th
7th
Worawora 80.2 49.7 61.4 11th
21st
Hohoe 78.6 67.3 16.7 12th 9th
Krachi 77.9 51.5 51.3 13th
20th
MMCH 77.9 64.6 20.6 14th 12th
Adidome 76.7 55.8 37.5 15th
19th
Jasikan 75.6 70.8 6.8 16th
8th
Battor 73.9 62.3 18.6 17th
15th
Anfoega 69.6 57.9 20.1 18th 17th
VRH 63.0 61.4 2.6 19th
16th
Nkwanta 60.4 62.6 -3.4 20th
14th
Comboni 55.5 65.6 -15.4 21st
11th
Ho Poly 53.1 42.9 23.8 22nd
22nd
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2.10 Improvement or otherwise of facilities
2.10.1 Description of the problem or stimulant (outliers)
2.10.1.1 Environment
All Hospitals within the second cycle saw a lot of improvement in their environments; both the
Landscaping and the Infrastructure. Significant among the Hospitals were St. Anthonys Hospital,
Dzodze, District Hospital, Sogakofe, Krachi West District Hospital, Peki Hospital, Hohoe Hospital etc.
Before Second Cycle Peer Review Pictures
Krachi West District Hospital before the Second cycle
Krachi West District Hospital During the 2nd
Cycle of the Peer Review
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State of Hohoe Hospital conference Room during 1st
Cycle State of External Environment during 1st
Cycle
Renovated Conference in Hohoe Mun. Hospital during 2nd
Cycle State of Environment during 2nd
cycle
Peki Recreational centre during 1st
cycle
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Second Cycle Hospital Environment
District Hospital, Sogakofe, During Post Peer Review Monitoring
2.10.1.2 Infection Prevention and Control
1. Chlorine is now being used in all the hospitals in the Region as requested by the IPC Policy of theMinistry of Health. However, the flow of accurate information concerning the chlorine between
the suppliers, Procurement Officers, Stores, and the User Units of the Hospitals. Still more needs
to be done in this regard.
2. Hand washing, a major way of controlling microbes is still a problem in few of the Hospitals. TheTable 2.14 below depict the average score of the cadres of workers assessed during the Peer
review.
Table 2.14 Mean Performance of Cadres of workers on Hand washing
Hand washing Orderlies Nurses
Medical
Officer/Assistant
Laboratory
Staff
Pharmacy
Staff
Mean (Expected
Score is 4) 2.93 3.24 3.40 2.90 2.69
3. Facilities without Proper Incinerators were also able to build ultra-modern Multi-PurposeIncinerators to take of the solid wastes.
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New Multipurpose Incinerator-St. Anthonys Hosp Burning Pit Constructed in Worawora Hosp.
New Washing Machine installed in Adidome Hosp.
2.10.1.3 Emergency Systems and Services
One of the major challenges faced by the facilities concerning Emergency Systems and Services was the
non-availability of Largactil for Management of Emergency Mental conditions.
Also, there was no standard protocol for Mass Casualty Incident Management in the entire Region.
There is therefore the need to collate all the protocols developed by the various facilities, meet over the
protocols to develop a standard protocol for Mass Casualty Incident Management in the Region.
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Some facilities also realizing the need for proper Emergency Services were able to start construction or
completed a new Emergency Units. Ketu South Hospital was able to construct a New Emergency Unit
and procured a Patients Monitor for the Unit.
Briefing of Staff by Incident Commander Emergency Preparedness in a Hospital
2.10.1.4 Quality Assurance Activities
Few challenges concerning the current referral system were exposed such as feedback to the referring
facility. It also exposed the quality of the referrals being done in our facilities across the region.
Another significant thing the revealed with regards to quality Assurance was the fact that Maternal
Death Audits were organized at least in all the Hospitals in which there were these deaths.
2.10.1.5 Clinical PracticesOne major outlier concerning Clinical practices is the issue of documentation. Most Caesarean section
wound conditions were not properly document both by the Medical Officers and the Nurses. Issues
concerning high Ceasarean Section rate came up strongly in some facilities. This issue also revealed a lot
of concerns about the referral system in the Region.
2.10.1.6 Clients Care
To a very large extent, awareness was created to ensure complaints Management systems are
strengthened in all Hospitals. Client Satisfaction Surveys are also being conducted by most hospitals
regularly, at least twice in a year.
2.10.1.7 Occupational Health and Safety Issues
Occupational Health and Safety issues incorporated into the check list indeed expose the gaps in the
system. At least barrier nursing and wearing of Personal Protective clothing was enforced to some
extent. The use of Colour coded bins and liners were enforced to ensure segregation of waste. Fire
Extinguishers were also procured and serviced by most of the Hospitals.
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Laundry Staff on the way to collect dirty Linen Waste Segregation point in VRH
2.10.1.8 Management
Attempts were made by some facilities to develop Strategic Plans to give them a strategic direction since
this was a requirement of the Checklist. Even though, some of the documents submitted did not include
the ingredients of a strategic Plan, it is an attempt in the right direction. To some extent facilities were
also entreated to implement their action plans hitherto, action plans were usually prepared but not
shared amongst staff and not even implemented.
Efforts were also made by the various Hospitals to analyse the state of their equipment and prepare
Equipment replacement financial analysis. Planned preventive maintenance was also emphasized as a
result of the Peer Review.
Furthermore, the process is encouraging other Members of management to demand weekly cash flow
and Quarterly Financial Analysis from the Accountants. This to a large extent is helping to ensure
information flow on the finance of the Hospital at least among Management members.
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2.10.2 Regional Directors Mark for Innovation and Organization of the Peer
Review
As part of excitement, the Regional Directors Score was introduced to encourage facilities to
innovate using the local resources available to them. In addition, this was expected to stimulate
the facilities to judiciously use their resources especially the Internally Generated Fund (IGF)
was introduced.
This element resulted in a lot of the facilities committing their resources into things such as:
Renovation of apartment used for training to a proper conference room standard inHohoe Municipal Hospital.
Conversion of Recreational centre to a conference room by Peki Government Hospital Building of Emergency Unit and Procurement of Patients Monitor to improve
Emergency Management in Ketu South District Hospital
Staff accommodation initiated and an Orange orchard also started in Sogakofe Hospital. Collaboration with MPs to provide Street Light at Nkwanta South District Hospital Collaboration with MP to provide Blood Bank Fridge in Mary Theresas Catholic Hospital. Renovation of Krachi West District Hospital Building of a New Pharmacy Block at St. Joseph Catholic Hospital, Nkwanta Completion of a New Maternity Unit at the Margret Marquart Catholic Hospital
New Pharmacy Block @ St. Joseph Cath. Hosp New Maternity Block @ MMCH
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CHAPTER THREE- CONCLUSION & RECOMMENDATION
3.1 CONCLUSION
The second cycle of the Peer review revealed that
1. Performance of the Hospitals improved tremendously. Fifty (50) per cent of the Hospitals wereable to meet the Regional Directors performance target
2. All the thematic areas on the Checklist indicated great improvement over the first cycleperformance.
3. Team approach to work has been strengthened through the Peer Review since everybody in thefacilities understands that they will be jointly accountable to the good or bad performance
during the Peer Review. This has even catch-up with the Community members as the Chiefs and
community members were found helping the Hospitals during Communal Labour.
4. Most Policy documents lying on shelves not implemented were implemented to a large extentthrough the Peer Review. Policies such as Infection Prevention and Control, Waste
Management, Occupational Health and Safety, etc.
5. Internally Generated Funds were being used judiciously as most facilities ensured the availabilityof basic equipment and drugs for service delivery.
3.2 RECOMMENDATIONS
1. Evaluation of the Peer ReviewIn every programme Implementation, one success factor is the periodic/process evaluation of the
programme to:
1. identify internal and external impediments/success factors of the programme.2. To identify factors that needs further attention.3. Re-strategizing.
As part of the plan of the Peer Review Coordinating team, it was agreed that since this is the second
cycle of the Implementation of the Peer Review, an Evaluation be done to inform on the key
implementation challenges, Key lessons learnt and sustainability factors of the programme.
The evaluation also intended to look at Clients perspective, Staff perspective and Influence of
Management skills of the Hospital Managers and Managements perspective of the outcomes of the
programme. It also intends to look at how Human Resource situations are influencing the
implementation of the programme.
It was also expected that this Evaluation will inform on the necessary steps to take in order to improve
the process and the expected outcomes.
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The evaluation was not done due to reasons beyond the Peer Review Secretariat.
2. How to Continue with the Peer ReviewIn other to ensure that the current momentum is sustained, there was the need to incorporateactivities that may continue to entice Management of the Hospitals to always attend the Peer
Review hence the need to refine the checklist and add other activities.
It is also recommended that the Headquarters takes up the process, develop a national
Checklist for all the Health Centres, Hospitals (Regional and District/Municipal), District Health
Directorates, Regional Health Directorates and all Divisions. This will help to compare
performance at all levels of service delivery and improve all the indicators.
3. Modification of the Process and the Checklist and what it should containDue to challenges encountered with regards to conduct of some reviewers, there was the need
to streamline the behaviours of participants. This resulted in the development of Code of
Principle to guide the entire process. The Code of Principles will be used during the third cycle
of the Peer Review.
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REFERENCES
1. The Quality Assurance Strategic Plan for the Ghana Health Service 2007-20112. Peer Review of Hospitals in the Volta Region, December 2010
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APPENDICES
Appendix A: Checklist used in 2011 Peer Review
VOLTA REGIONAL HEALTH DIRECTORATE
CHECKLIST AND NOTES/GUIDELINES ON SCORING AT PEER REVIEW SESSIONS (NOVEMBER, 2010- OCTOBER, 2011)
PREAMBLE:
Documentation is a huge problem in Ghana and for that matter the Health Sector; this problem must be addressed. The guideline thereforetakes this into consideration in many respects.
ENVIRONMENT (EXTERNAL AND INTERNAL)
NO ITEM RATIONALE HOW TO SCORE EXPECTED
SCORE
OVE
SCO
(afte
dedu
IDEAL(EXPECTED) SITUATION EXISTING OR ON THE GROUND SITUATION
1. EXTERNAL
ENVIRONMENT
Therapy involves many facets including the impact of the environment on staff and patients satisfaction
1.a Grass Covering When properly done, it
is pleasing to the eye,
sets the mind of staff
and clients at ease,
easily rates the
institution as a readyentity to deliver the
care necessary
- availability of the grass
-Grass should be Green, not mixed
with weeds (other grasses, area
well boxed by kerbs, grass cut
(mowed) very low, no bare area,
-If no grass cover score overall 0
-If Grass not green deduct 0.5
-If Grass mixed with weeds deduct 0.5
-If grass not boxed by kerbs deduct 0.5
- If grass bushy deduct 0.5
-If bare areas available deduct 0.5
3
1.b Flowers (Availability,Arrangements,
Spread)
Flowers by themselves
give a lot of healing
-Availability of the flowers
-Variety of flowers
-Spread of the flowers (all over the
landscape)
-Arrangement of the flowers
(planted to follow a pattern)
- Caring of the flowers (Properly
taken care of)
If flowers not available give overall score 0
-Same Variety of flowers deduct 0.5
-Not well Spread (all over the landscape) or
localized deduct 0.5
-No pattern (planted haphazardly) deduct
0.5
- Not properly kept deduct 0.5
3
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1.c Trees and Hedges Trees give shade and
serve as a wind break
and oxygen source for
the environment.
Hedges check erosion
and beautify the
environment
-Availability of trees & Hedges
-Trees provide shade
-Spread of the trees and Hedges
(all over the landscape)
-Arrangement of the trees &
Hedges (planted to follow a
pattern)
- Hedges trimmed to provide
pattern
-Non-availability give overall score of 0
-If trees do not provide shade deduct 0.5
-Trees not well spread all over the facility
deduct 0.5
-No pattern in planted trees (planted
haphazardly) deduct 0.5
-Leaves droppings left under the trees
deduct 0.5
-Hedges not trimmed deduct 1.0
-Trimmed Hedges not providing a pattern
deduct 0.5
4
INTERNAL
ENVIRONMENT
A sanitized internal Environment gives staff and the clients the needed confidence and easy mobility and safety
1.2a Staff Toilet To provide speed and
comfort in attending to
natures call in a
hygienic manner
-Available in all Units
-Clean (No water on floor, no
pieces of paper on floor, no stains
on WC & Walls,)
-Functional WC (Flushable)
-Unbroken Pot and Cistern)
-Toilet Rolls available
-Odourless (sweet smelling
fragrance)-Waste Paper bin (not to be used
for anal droppings
-Not available in all unit deduct 0.5
-Not Clean deduct 0.5
-Not Functional WC (Flushable) deduct 0.5
-Broken Pot and Cistern) deduct 0.5
-Toilet Rolls not available 0.5
-Odour Present deduct 0.5
-Odour ( No sweet smelling fragrance)
deduct 0.5
-Waste Paper bin (contains anal droppings)deduct 0.5
4
1.2c Client Toilet To provide speed and
comfort in attending to
natures call
-Available in all Wards & OPD
-Clean (No water on floor, no
pieces of paper on floor, no stains
on WC & Walls,)
-Functional WC (Flushable)
-Unbroken Pot and Cistern)
-Toilet Rolls available
-Odourless (sweet smelling
-Not available in all units deduct 0.5
-Not Clean deduct 0.5
-Not Functional WC (Flushable) deduct 0.5
-Broken Pot and Cistern) deduct 0.5
-Toilet Rolls not available 0.5
-Odour present. No sweet smelling
fragrance) deduct 0.5
-Waste Paper bin (contains anal droppings)
4
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fragrance)
-Waste Paper bin (not to be used
for anal droppings
deduct 0.5
1.2d State of
Infrastructure
To provide safety for
staff & clients and
aesthetic beauty
-Non-leaking roof and ceiling
-No cracks in the Walls
-No cracks or breaks in the floor
-Walls painted
-Non-peeling paints and washable
-Walls not damp with fungal
growth
-Ceilings intact and painted with
one colour
-Nature of the floor (Not slippery)
-Leaking roof and ceiling deduct 0.5
-Cracks in the Walls deduct 0.5
-Cracks or breaks in the floor deduct 0.5
-Non-painted Walls deduct 0.5
-Peeling paints deduct 0.5
-Walls damp with fungal growth deduct 0.5
-Ceilings not intact and painted with more
than one colour deduct 0.5
- Nature of the floor (Slippery) deduct 0.5
4
1.2e Working Areas Should not pose danger
to both clients and staff
-Floor should not have dirt
-Floor should not be stained
-Floor must be sparkling
- No cobwebs on the ceilings and
walls
-No stains on the ceilings and Walls
-Well arranged furniture(to create
space and prevent injury)
-Cleanable working table top-Steady tables and chairs (Nails not
popping up etc)
-Stuffed Chairs should not have
torn leathers
-Adequate windows or ACs to
allow free flow of air)
-Working area should be bright
-Dirt on Floor deduct 0.5
-Stains on Floor deduct 0.5
-Floor not sparkling deduct 0.5
- Cobwebs on the ceilings and walls deduct
0.5
-Stains on the ceilings and Walls deduct 0.5
-Furniture not well arranged deduct 0.5
-Non-Cleanable working table top deduct
0.5-Non-Steady tables and chairs (Nails
popping up etc) deduct 0.5
-Stuffed Chairs having torn leathers deduct
0.5
-Inadequate windows or No ACs to allow
free flow of air) deduct 0.5
-Working area not bright enough deduct 0.5
6
1.2f Waste Bins in
Offices
To prevent littering of
the Environment
-Available in every office
-Pedal operated
-Pedals are functioning
-If not Available in some offices deduct 0.5
-Not Pedal operated deduct 0.5
-Pedals not functioning deduct 0.5
2
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-Should have a black liner in -No black liner in the waste bins deduct 0.5
1.2g Waste Bins in
Clients -Service
Areas
To prevent littering of
the Environment and to
prevent danger posed
by microorganisms and
chemicals
-Available in every Service Area
-Proper Colour coding adhered to
-Waste segregation practices
taking place
-Bins are pedal operated
-Pedals are functioning
-Appropriate liners for waste
segregation
-Not Available in every Service Area deduct
0.5
-Proper Colour coding not adhered to
deduct 0.5
-Waste segregation practices not taking
place deduct 0.5
-Bins are not pedal operated deduct 0.5
-Pedals are not functioning deduct 0.5
-Inappropriate liners for waste segregation
deduct 0.5
3
INFECTION PREVENTION AND CONTROLNO ITEM RATIONALE HOW TO SCORE EXPECTED
SCORE
OVERA
SCORE
(after
deduc
IDEAL(EXPECTED) SITUATION EXISTING OR ON THE GROUND SITUATION
I INFECTION
PREVENTION AND
CONTROL
i. To prevent danger of infection posed to clients and staff.ii. To reduce longer stay of clients through infection
I .1 DecontaminationProcedure To remove microorganisms likely to be transmitted.
I.1a Use of Chlorinebased Disinfectant
(Chlorine
disintegrates rapidly,
Should not be left
overnight)!
To remove
microorganisms likely to
be transmitted.
-Stock strength of Chlorine
communicated to all user Units
-Prepared chlorine solution well
labelled for strength and date
-3 people describe appropriate use
of chlorine with regards to time for
disinfection, type of material and
appropriate concentration for use
in the different scenarios
-Stock strength of chlorine not known by
user units deduct 0.5
-Stores not giving accurate info about
stock strength deduct 0.5
-Prepared chlorine solution not labelled
deduct 0.5
-Inability of an interviewee to
appropriately answer in terms of (time
{duration}, type of material and
3
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appropriate concentration) deduct 0.5
each
I.1b Written Protocol
for Preparation of
appropriate
Chlorine solution
(Available at all
user units,
conspicuously
displayed)
A new member of staff
will not have difficulty in
preparing the chlorine
solution
-Available in all user units/points of
preparation.
-Bold enough to fill an A-3 Paper
and well laminated
-Conspicuously displayed
-Not Available in all user units/points of
preparation deduct 1
-Not Bold enough to fill an A-3 Paper and
well laminated deduct 1
-Not Conspicuously displayed deduct 1
3
I.2 HAND WASHINGPRACTICES
To decontaminate the hand in order to prevent cross infection
I.2a Randomly select
any 3 of the
following Category
of staff to perform
social hand
washing and score
them (Take into
consideration
availability of all
necessary inputs
for the handwashing before
allotting marks.)
i. Orderly
ii. Nurse
iii. Medical Officer
and Medical
Assistant
iv. Laboratory
Personnel
v. Pharmacy Staff
Social hand washing
(routine hand washing)
is for every health
worker so as not to
transfer micro organism
from one place to the
other and from one
person to the other
Inputs for hand washing:
-Soap (liquid or Carbolic Cake soap,
if cake then soap dish)
-Running Water
-One-per-wash hand towel in a
dispenser
-Towel in dispenser easily reached
but not soiled with hand water
-Inter digital space rub
-Avoid contaminating with tap
after hand wash-Avoid soiling distal forearm after
hand wash
For each category of staff mentioned if:
-Soap not appropriate deduct 0.5
-Soap dish or dispenser not appropriate
deduct 0.5
-No running water deduct 0.5
-Multiple-use hand towel deduct 0.5
-No towel dispenser and easily soiled with
hand water, deduct 0.5
-Wrong inter digital space rub deduct 0.5
-Contamination of tap after hand wash
deduct 0.5-Soiled distal forearm after hand wash
deduct 0.5
12 (4 per
person)
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I.3 WASTE DISPOSAL To remove source of infection and prevent wrongful deposition of rubbish in and around client areas as an eyesore
I.3a Dry/Solid Waste
Disposal
To prevent infection -Availability of Multipurpose
Incinerator (MI)for sharps, General
Waste, Tissue Waste
-Multipurpose Incinerator
Functional
-Multipurpose Incinerators used
for the purpose.
If Multipurpose Incinerator not
available there must be Placenta
Pit, Burning pit and Incinerator for
sharp
-If No incinerator deduct 3
-If no Burning pit deduct 3
-If no Placenta pit deduct 3
9
3
3
3
I.3b Wet/Liquid Waste
Disposal
To have liquid waste properly disposed to avoid the danger it will pose to both staff and clients
Soak-Away
(available to
collect soiled
water from
maternity &
Theatre,
Functional)
To have liquid waste
properly disposed to
avoid the danger it will
pose to both staff and
clients
-Available
-Well sealed
-No water collected around it
-Not available score overall score of 0
-Not well sealed deduct 0.5
- Water collected around it deduct 0.5
3
I.3c Drains condition
(not broken down,free of rubbish and
weeds, no static
collections of
water
To have liquid waste
properly disposed toavoid the danger it will
pose to both staff and
clients
Drains condition -not broken
down, - free of rubbish and weeds,-no static collections of water
-Not silted
-No fungal growth
Drains condition:
-Broken down deduct 0.5-Contains rubbish and weeds deduct 0.5
-Static collection of water deduct 0.5
-Drains Silted deduct 0.5
-Fungal growth deduct 0.5
3
I.3d Septic Tanks
condition
(Functional, easily
accessible by
truck, not weedy)
To have liquid waste
properly disposed to
avoid the danger it will
pose to both staff and
clients
-Available
-Well sealed
-No water collected around it
-Easily accessible
-Surrounding not weedy
-Septic tank not available overall score of
0
-Not well sealed deduct 0.5
-Water collected around septic tank
deduct 0.5
-Not easily accessible deduct 0.5
3
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-Surrounding weedy deduct 0.5
EMERGENCY SERVICES AND SYSTEMS
NO ITEM RATIONALE HOW TO SCORE EXPECTED
SCORE
OVER
SCOR
(afte
dedu
IDEAL(EXPECTED) SITUATION EXISTING OR ON THE GROUND SITUATION
II EMERGENCY
SERVICES
Hospitals receive individual (single) cases and large number of cases needing emergency services. It is ideal that systems are built t
take care of both category of casesII.1 System for
Emergency
To ensure there is a
system to manage
emergency situations
-Emergency duty roster found in all
Units covering all the categories in
the team *doctors,
*lab Technicians,
* anaesthetists,
*pharmacy, with telephone
numbers of all the Team members
with the Telephonist
-Clearly defined line of who calls
the team
-where emergency cases are to be
sent outlined
-flow of what happens to the
emergency case after received in a
flow diagram outlined
Duty roster for any team category not
available deduct 0.5
-No clearly defined line of who calls the
team deduct 0.5
-No outline of where emergency cases are
to be sent 0.5
-No flow diagram outlining what happens
to emergency cases deduct 0.5
5
II.2 Emergency Trays
(availability and
adequacy)
To ensure basic
equipment and drugs
available to enhance
management of
emergencies.
-Emergency Trays
(availability and adequacy)
-emergency tray in all
wards, triage and a
designated emergency
room
-minimum content of
Emergency Tray not available in
all expected units, give overall
score of zero
-emergency tray not in an
expected unit or ward, triage and
a designated emergency room
deduct 1.0 each
-minimum content of emergency tray
20
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emergency tray
*Bag Valve Mask (AMBU
bag) at least 1 Adult and
1 Pediatric unit.
*One-way masks small,
medium, large;
*Sphygmomanometer, age
appropriate, ex. pediatric,
adult, extra-large
*Stethoscope
*Flashlight and extra
batteries
* Oxygen tank with mask
(serviced yearly and
checked monthly)
* Syringes and needles of
various sizes
* Alcohol swabs or
sponges
* Gloves,* Aqueous epinephrine (1:1000;
1mL ampoules, *Diazepam
ampoules at least 4,
*Largactil ampoules at least 5,
*Promethazine 20mg/mL vials (a
minimum of 4)
*Hydrocortizone 100mg ampoules
(at least 2)
*Atropine sulfate ampoules 0.6
mg/mL (optional)
The lack of one of each item in
childrens and maternity ward
deduct 0.5
*AMBU bag at least 1 Adult and
1 Pediatric unit
*One-way masks small,
medium, large;
*Sphygmomanometer, age
appropriate, ex. pediatric, adult,
extra-large
*Stethoscope
*Flashli