GARA MULETA GENERAL HOSPITAL

July 23 to 30 day EBC ACTION PLAN E.C

Section 1: Scope based clinical practice
ACTION TO BE RESPONS
TAKEN IBLE TIME
BODY 23 24 25 26 27 28 29 30
1.1 c1.prepare protocol MD
defining facility level
/scope of practice
C2_C Prepare Scope of “” X
practice for all health
professionals and file it
in there documents.
C5) Prepare MD X
Interdepartmental QI
consultation form and COMMITT
check its usage EE
1.2.c1)Triage done by MD X
at least GP
1.2.C1) Make Sure LIAISON X
Patients Referred From HEAD
Other Facilities Seen AND
By One Step Higher QUALITY
Professional TEAM
C2) Make sure prepare LIAISON X
schedule for referral HEAD
clinic
1.4.C1) Make sure all LIAISON X
consultations are HEAD
carried out by most AND MD
senior clinician

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 C2)check availability of MD X
consultation (print)
form
C3) All electives are OR HEAD, X
done by senior SALTS
physician COORDIN
ATOR

Section 2: Standard based clinical service

ACTIVITY RESPONSI JULY
BLE BODY 23 24 25 26 2 28 29 30
7

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 2.1.C1)check all evidence QI X X
based clinical practice COMMITTE
protocol availed for E
surgical, OPD clinics, ER,
and NICU
C2) prepare round MATRON X X
protocol, nursing
procedures, patient
transportation, bad news
breaking, surgical
scheduling, STG
C3) Train staff on protocols QI X
and their utilization COMMITTE
E,MD
2.2.C1)Prepare training to MD and QI X X
staff on STG COMMITTE
E
C2)Avail STG(printed) on SMT,MD X X
every service area
2.3.C1) conduct regular AUDIT X X X
clinical audit on TEAM
implementation of STG on
focus areas
C2) Design improvement ‘’ ‘’ X
plan on implementation of
STG

Section 3. Evidence Generation and Utilization

JULY
ACTIVITY RESPONSIB 23 24 25 26 27 28 29 30
LE BODY
3.1.C1) Implement full HMIS HEAD X
automation of medical
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records
C2)Regular capacity SMT,QI X
building for staff, with COMMITTEE
prepared manual to make HMIS HEAD
them user friendly
3.2.C1 Establish chart audit SMT, HMIS X
team for completeness of HEAD
cards for OPD and IPD
charts
C2) established system for AUDIT
chart audit TEAM
C3)establish a system to “” x
check completeness of cards
before returning back
3.3 C1) avail adequate SMT,HMIS X
number of data collection HEAD
tools
C2) check proper utilization HMIS HEAD
and completeness of data
and prepare completeness
verification format
C3) Regular PMT meeting “” X X
3.4.Regular LQAS/DQA by “” X
HMIS team and verify by
PMT
3.5. C1) Regular data ““ X X
analysis on focus areas
C2) utilize data for QI QI UNIT X
project based on the finding
from the data
C3)prepare data quality QI
triangulation protocol and COMMITTEE
report
C4)prepare strategic plan ‘’ ‘’

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based on house generated
data
C5)undergo gap oriented ‘’
research

Section 4. System redesign and EHSTG booster

ACTIVITY RESPONSI Five day plan JULY RE

BLE BODY MA
RK
23 24 25 26 27 28 29 30
4.1.Equip triage area with, SMT,TRIAG
prepare ETAT protocol E HEAD
C1)prepare pre triage TRIAGE
protocol and area to HEAD
screen highly infectious
disease
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C2) Avail triage tools, BP SMT,TRIAG
apparatus, stethoscope, E HEAD
pulse oximeter,
glucometer, weight scale
C3) prepare cough SMT ,QI
cornering protocol and COMMITTE
cough clinic E
C4)Equip central triage SMT,TRIAG
based on EHSTG E HEAD
recommendation
4.2) equip OPD with SMT,OPD
chairs, BP apparatus, HEAD
stethoscope, reflex
hammer, weight scale,
glucometer, screen
C1) avail hand washing OPD HEAD
water with soap, CASH AND SMT
audit report regularly
C7) avail adequate OPD OPD HEAD
waiting area
4.3. prepare OPD services “ “
protocol
C2) establish block based OPD HEAD
appointment system AND
LIASON
HEAD
C3) make clinics functional SMT X
during lunch time
4,4.separate pediatric SMT,PED.H X
ward for therapeutic EAD
feeding, ICU, and general,
procedure room, isolation
C2)painting for pediatric HOUSE X
ward KEEPING

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 HEAD AND
SMT
C3) Avail national Matron And X
guidelines and job aids SMT
C4) prepare protocol for Matron X
rounds and clinical care
C5) prepare vital sign Matron X
protocol
C6) make sure that growth PED.HEAD X
monitoring is performed
for all U5
C7)prepare pain PAIN X
management protocol and FOCAL
follow its usage PERSON
4.6. prepare place for SMT X
general maintenance
center with adequate
resources(biomedical
workshop) with necessary
tools
C1) conduct regular ‘’ ‘’ X XX X
preventive maintenance for
all facilities and operating
systems(electrical, water,
sanitation, sewerage and
ventilation) and
maintenance and prepare
maintenance schedule
C2) Avail notification SMT X
protocol and work order
system for maintenance
C3) Establish HRIS SMT AND
HR
4.8.prepare HR HR HEAD

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development plan
C1) check plan address HR HEAD X X
skill mix for short term
trainings, long term
trainings based on staff
numbers and budget
allocation and training
schedule
C2) prepare quality QI X
monitoring protocol and COMMITTE
checklist E
C3)Establish pt feedback HMIS HEAD X
and monitoring mechanism AND
HEALTH
LITRACY
HEAD
C4) prepare food and SMT X
beverage service manual
4.10 Avail duty room for SMT X X
half duty team
C1) Avail desktop or TV SMT X
and water boiler
4.11. Avail MEMIS, SMT AND X
medical equipment BIOMEDIC
management information AL HEAD
system
C1) Establish notification BIOMEDIC
and work order system for AL H AND
medical equipment GENERAL
maintenance request SERVICE
C2) have Regular BIOMEDIC
calibration and quality AL H AND
assurance program GENERAL
SERVICE

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C3) Regular inventory of BIOMEDIC
medical equipment and AL H AND
report GENERAL
SERVICE
C4) Avail workshop SMT L
BIOMEDIC
A
4.12. Develop a DTC
mechanism/system for COMMITTE
rational use of medications E AND QI
and stipulates mitigation CMMITEE
strategy for irrational use
of medications
C1) Avail management SMT,METR X
guideline for selected ON AND
prioritized health DTC
conditions and prioritized COMITEE
drug lists (with 2nd and 3rd
line antibiotics, narcotics,
other expensive drugs.
C2) prepare problem PHARMACY
based training on HEAD
pharmacotherapy(when
needed)
C3) Avail a protocol for “”
prescribing, dispensing,
and rational use of
prioritized drugs
C4)monitor rational use of “” X XX X
antibiotics and establish
antibiotics stewardship
team
4.13. Establish clinical SMT AND
audit team with TOR QI

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 COMMITTE
E
C1) regular clinical audit CLINICAL X X
and finding should be AUDIT
presented and linked with TEAM
CQI
4.14. senior led DEP”T X XX X
multidisciplinary round HEADS
that address nursing care,
IPC, client education,
clinical pharmacy and
client satisfaction
C4) prepare senior “”
handover protocol
C5&C6) undergo weekly DEP’T H $ X XX X
senior chart rounds QICOMMIT
addressing clinical EE
evaluation and decision
process, use of appropriate
and justified workup,
rational use of drugs,
nursing care

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 Section 5. Efficient utilization of healthcare resources
ACTIVITY RESPON TIME
SIBLE
BODY 23 24 25 26 27 28 29 30
5.1. outsource clinical SMT
services
5.2 implement different ‘’ ‘’
staff incentive and
recognition mechanism
after preparing guide
5.3 Assess sources of ““ X X
inefficiency in procurement,
HR for health and supply
chain
5.4 Harmonization of ‘’ “ X
planning, budgeting and
budget execution processes,
including producing and
disseminating the required
financial and audit reports

Section 6. Improve quality of Nursing Care

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ACTIVITY RESPONSI TIME
BLE BODY 30
23 24 25 26 27 28 29
6.1. C1. Prepare MATRON
nursing care
protocol and check
its adherence
C2) prepare nursing MATRON
procedure protocol
for IV line securing,
NGT insertion,
catheterization and
do regular KAP
assessment
6.2 undergo regular IPD X
nursing care audit HEAD $
and link identified DIRECTOR
gaps with QI project
C1) Establish IPD HEAD X
nursing care round
and audit( assessing
nursing process,
patient monitoring,
pain management,
medication
administration and
client education)
team with TOR
C3) Regular SMT , QI X X X X
performance report COMMITTE
review every month E
involving key
stakeholders(with
minute)
C4) Data driven QI QI X
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project on identified COMMITTE
gaps E
6.3 c1) prepare daily ““
nursing round
protocol ( 1hr vs 3
hr)
C2) prepare shift DEPARTME
handover protocol NT HEAD
and form
C3) prepare nursing SMT $ HR
code of conduct
including dress
code, cleanness, IPC
practices
C4) prepare daily QI X X
round package and COMMITTE
emergency table E$ IPD
preparedness HEADE
protocol
6.4 C1) prepare ICU QI X X
nursing care COMMITTE
package/protocol E$ IPD
that includes V/S HEADE
and fluid balance
monitoring
requirements,
eternal nutrition, GI
prophylaxis, DVT
prophylaxis, and
medication
administration
6.5 Establish skill QI X
lab COMMITTE
E$ IPD
HEADE$
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 OPD HEAD
C2) prepare skill QI X
gap assessment COMMITTE
checklist and E$ IPD
conduct regular HEADE$
capacity building OPD HEAD
C3) prepare QI X
capacity building COMMITTE
protocol E$ IPD
HEADE$
OPD HEAD
6.6 standardize SMT , X
nursing stations 1
desk top, TV, health
education material
and different
protocol
aforementioned
6.7 c1. prepare QI X
patient orientation COMMITTE
protocol and make E
sure it is registered
on patients chart
C2. Involve pt in DEPARTME X X
care plan, NT HEAD
intervention,
expected discharge
planning, estimated
cost, and expected
outcome

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 Section 7. Surgical service efficiency and safety

ACTIVITY RESPON TIME

SIBLE
BODY 23 24 25 26 27 28 29 30
C1) prepare 4 OR tables SMT
C2) conduct 3 surgeries per table OR
TEAM
AND OR
DIRECT
ORE
C3) make sure first case incision OR
is made before 8am and prepare HEAD
OR schedule and make
turnaround time 20 min
C5) two shift implementation OR
TEAM
C6) prepare schedule notification OR
format HEAD
C7) QI project on improving OR “ “
efficiency
C8) prepare elective surgical OR
service plan HEAD
7.2 establish multidisciplinary SMT
preadmission evaluation clinic
C1) prepare pre admission OR
protocol, prepare preoperative HEAD QI
format, make sure all Ix is done a TEAM
day before surgery, check
consent form signed a day before
surgery
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C2) prepare standardized OR
preoperative evaluation workup HEAD QI
protocol TEAM
C3) regular QI project on OR
cancellation based on data HEAD QI
obtained from regular TEAM
performance monitoring
C4) conduct multidisciplinary SMT,QI
perioperative conference COMMIT
TEE,OR
STAFF
7.4 c1) prepare preoperative and QI X
postoperative hospital stay COMMIT
protocol and monitor regularly TEE
7.5 c1) Assign OR director SMT X
C2) prepare briefing and OR X
debriefing protocol HEAD
7.7 have regular performance SALTS X
report review every 2 wks with COMITE
SaLTS committee and other E
stakeholders
C2) data driven QI projects QI X
based on identified gaps COMMIT
TEE
7.8 c1) Prepare SSC audit X
protocol and have regular audit CLINICA
for completeness of SSC and L AUDIT
regular report TEAM
C2) Regular direct observation of OR X
OR for adherence to the SC HEAD
7.9. Prepare SSI register at STM X
major OR and c\S room
C2) prepare SSI protocol SALTs X
TEAM

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C3) establish a system for post ‘’ X
discharge SSI tracking

Section 8. Improved Neonatal Intensive Care

ACTIVITY RESPONSI TIME
BLE BODY
23 24 25 26 27 28 29 30
8.1.C1.check level of service NICU
for infrastructure, HR, HEAD
Medical equipment(review
protocol for NICU service)
C2. Make sure the service ‘’ ‘’
being given align with the
scope level
C3. Train all staffs ““
C4. Avail all the needed SMT X
rooms
C5.check all equipment are NICU X
functional HEAD
8.2c1. Avail all neonatal NICU X
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guidelines, protocol HEAD
C2. Check for adherence of QI X
protocols COMMITT
EE, NICU
HEAD
C3. Under go performance NICU
review meeting (Q3mo) HEAD
8.3. c1.Perform clinical audit NICU X
on NICU services( at least 2 HEAD
audits)
C2. Perform QI projects (at QI X
least 1) and document it COMMTIT
EE
8.4 c1. Establish family NICU
counseling corner HEAD
C2. Involve parents in NICU X X
decision making STAFF

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 Section 9: Improve Emergency, Trauma, and Critical
Care
ACTIVITY RESPONSIBL TIME
E BODY
23 24 25 26 27 28 29 30
C1. Conduct regular EMERGENCY X
assessment based on the HEAD AND
national emergency COORDINATO
leveling document R
checklist
C2. Conduct regular ““
capacity building based
on gap assessment done
regularly
C2.1 prepare capacity ““
building plan
C3. Upgrade ER ““ X x
department to meet
standards
C4.expand the use of “ “ x x
BEC toolkits in facilities
9.2 c1. level ICUs based ““ x x
on the national ICU

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leveling document
C1.1 conduct regular Emergency X X
assessment head
C2.prepare upgrade plan SMT X
and upgrade ICU
standards
C2.1 avail equipment and SMT,DEP”T X X X
regularly check their HEAD
functionality
C3.prepare ICU Emergency X
protocols on admission, head and
treatment, and discharge Coordinator
and check their
adherence
9.3 c1.prepare protocol ‘’ ‘’ X
and guideline for
referral, triage, burn,
poisoning, trauma ED
ICU services
C2. Regularly check ““ X X
adherence of protocols
and guidelines
9.4 c1. Implement WHO “‘ X X
trauma registry
C2. Avail revised ICU, HMIS And X X
ER, Liaison, referral, and Emergency
ambulance service head
registers
9.5 c1.conduct regular Emergency X X
clinical audits and head
undergo QI project for
EICC

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 Section 10. Person centered Care
ACTIVITY RESPONSIBLE July
BODY
10.3 comprehensive information HL HEAD
provision based on patient 23 24 25 26 27 28 29 30
preference
Check the register of Literacy HL
10.4 avail a protocol for QI
discharge planning COMMITTE
E
C2. Create and standardize ‘’ ‘’ X
discharge plan format for
selected diseases based on
hospital morbidity and
mortality
C3. Check the Attachment of LH X
discharge plan on every
patients admitted
C4. Monitor regularly HL And IPD X
implementation of discharge Head
planning
10.5 c1. Design mechanism to HL And IPD X
assess the awareness and Head
knowledge audit
C2.bi weekly performance HL And IPD X X
report and improvement plan Head
C3. Data driven QI projects QI
based on identified gaps COMMITTE
E
10.6 establish pain clinic or SMT X
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integrate to the existing all the
service delivery points
C2. Prepare pain Mgt protocol QI X
COMMITTE
E
C3. Avail pain assessed in PAIN FOCAL X
regularly as 5th v/s ,tally sheets PERSON
and reporting formats
C4. Check pain is managed ‘’ ‘’ X
according to the protocol
C5. Advocate zero pain ““
tolerance for pain through
posters and other methods
C6. Address clients with “ ‘’ X
chronic pain and those
requiring palliative care
C7. Assign pain focal person SMT
10.7 regular audit for adequacy PAIN FOCAL X
of pain control and PERSON
performance report weekly
C2. Data driven QI project PAIN FOCAL
based on identified gaps PERSON $
QI
COMMITTE
E
10.8.establish or strengthen a Social service X
social service unit focal
C2. Avail social service QI X
guideline/ protocol COMMITTE
E $ LIASN H
C3. Conduct regular audit for CLINICAL X
social service and prepare AUDIT
improvement plan TEAM

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