Third Quarter Internal Supportive Supervision Focus on EBC (4th

EHAQ tool)

June, 2024

G/Guracha
 Assessment Conducted Teams
S.No Name of Assessor Profession Mobile Signature

1 Dr. Tesfaye Taye BSc, MD Team coordinator

2 Dr Ebisa Neguse MD, MPH Secretary

3 Dursa Hussein BSc, MPH Member

4 Demto Kidane BSc, MPH Member

5 Badho Megersa BSc Member

6 Deba Hinsermu BSc, MSc Member

7 Masay Tolcha BSc, MSc Member

Action plan on Identified Gaps

S.N Identified Gaps Action to be taken Responsible Time frame Remark
O
body
1 Scope based practice
1 Implementation of Interdepartmental Develop system to monitor Matron On going
consultation protocol is not implementation of IPD and OPD
monitored interdepartmental protocol coordinator
QU
2 Appropriate HCP isn’t assigned on To assign appropriate HCP on HR+MD 06/10/2016
triage triage (GP)

2 Standard based clinical practice

1 STG protocol in not printed and Avail STG protocol in booklet form QU 15/10/2016
given in booklet form MD
Finance
3 Person -centered care
1 No materials for health education Avail materials for health education SMT Within two weeks
(mass media, leaflets, posters) MD
Literacy focal
person
2 Comprehensive information Provide information Literacy focal Within three
provision is not delivered entirely  Clinical diagnosis person weeks
and consistently  Treatment options MW
 Plan QU
 Follow up
 Lifestyle modifications
3 Discharge planning format is not Attach discharge planning format SMT On going Format not avail
attached for all admitted patient on every admitted patient Liaison
Monitor regularly the practice All staffs
Matron +QO
4 There was no mechanism to assess Avail mechanism to assess patient Literacy unit On going
patient awareness and knowledge awareness and knowledge MD
about their case/disease process Chronic OPD
coordinator
Liaison
5 There were no pain management Avail pain management posters Pain focal person 16/10/2016
posters (‘’Zero tolerance for pain’’)
6 No mechanism to address clients Avail chronic pain and Palliative SMT Next year
with chronic pain and those care clinic pain focal person
requiring palliative care
7 No regular performance report or Conduct audit based on regular Pain focal person Within two weeks
audit involving stakeholders on pain performance report Hospital clinical
control Link to CQI audit team
4. Quality nursing care
1 Poor nursing round in all wards To encourage nurse to perform Matrons Until 10/10/16
hourly and 03 hourly rounds
2 Poor IPC practice, dressing code  To encourage hand washing  Matrons End of 4th quarter
practice among staff  Nurse
 Bed making professional
 Teaching patients and family on  Literacy
IPC personnel
 Implementing national nurse  MD
dressing code  Security team
 Avoiding overcrowding and
suffocations in service areas
2 No skill lab in facility To arrange SMT End of 4th quarter
3 No capacity building for nurses To arrange trainings and/experience SMT End of 4thquarter
sharing
4 Nursing station is not well-equipped TV, Internet, Desktop Facility End of 4th quarter
manager,
Matrons
 5. Evidence generación and utilización
1 No full automation of medical Avail full automation of medical SMT ______
records records HMIS
2 PMT do not conduct analysis and Conduct regular analysis and PMT Starting from next
discussed on data prior to report discussed on data prior to report HMIS month
3 No adequate data collection tools Avail all data collection tools SMT
(register, tally sheet and reporting HMIS
format) e.g no EOPD register
4 Hospital has no gap orientation Conduct research SMT ASAP
research QU
HMIS
6. Surgical service efficiency and safety
1 OR table and productivity is below To establish 07 OR beds, and SMT, OR End 4th quarter
the standard increase productivity director
2 Surgical service daily monitoring Establishing monitoring mechanism OR director, 10/10/16
mechanism is not in place (Performance report review), QID, surgery
performing regular clinical audit department head
and linking to QI project
3 SSI checklist is not being used to Tracing all operated patients with Surgical 10/10/16
trace SSI SSI checklist and registering if department head
identified/diagnosed
7. System redesign and EHSTG Boosters
1 No pre-triage service in the facility To establish the service SMT
2 Triage service is below standard (no To arranging classes and areas OPD director, End of 4th quarter
cough corner and screening area for triage head, MD
infectious diseases, lack of
equipment)
3 OPD clinics not providing services To start providing services during OPD director 10/10/16
 during launch time launch time MD
QU
4 Rehabilitation unit is not stablished To stablished the unit SMT _______
5 No maintenance center (both for To arranging classes with adequate Facility End of 4th quarter
facility management and spaces and spare parts manager,
biomedical) biomedical
engineer head
5 Poor habit of using work order To use routinely biomedical 10/10/16
engineer head
6 HR have no plan for short- and To develop the plan for all HR Mgt End of 4th
long-term training quarter
7 HRIS is not implemented To implement HRIS HR Mgt End of 4nd
quarter
8 Duty rooms is not gender based and To arrange the room by gender and Facility Mgt End of 4th quarter
well equipped make equipped (boiler, TV,
reference books…)
9 Poor senior enrolments To encourage seniors to lead all CEO, MD, QU 10/10/16
activities in the facility including
clinical services, management,
meeting, clinical audit, QI project
and performance report review
8 Efficient use of healthcare resources
1 No clinical outsource Outsource clinical service like Eye SMT Next budget
care, ENT, Pathology, Radiology, GB
dialysis etc Plan unit
2 Clinical outsourcing documents was Update outsourcing documents Finance Within one month
not up to date regularly SMT
Plan unit
3 There was no transparent staff Avail transport staff incentive and HR Next quarter
incentive and recognition system recognition system Finance
4 No benchmarking of staff incentive Avail source documents for staff HR Next quarter
 mechanism incentive guide Finance
Plan unit
9. Improved Emergency, trauma and critical care
1 Emergency triage is not well To avail, purchase and use the unit MD, QU Until 30/10/16
equipped (glucometer, examination only as triage area
bed…) and giving the service as
OPD
2 There is no an acute treatment area Color coded zones depending on Facility mgt Next week
with color coded zones depending the acuity of patient condition
EOPD
on the acuity of patient condition (5/10/2016)
(RED, ORANGE, and coordinator
YELLOW/GREEN ZONES)
3 No isolation room for infectious Avail the service
disease to separate them
10 Improve neonatal intensive care
1 NICU service establishment not NICU service should be level III CED, ORHB Until 4th quarter
based on hospital’s tier level according to your context of 2016

11. Cluster Activities

1 Community forum was not Conduct community forum on GB Next quarter
conducted on quarterly basis quarterly basis SMT
Quality officer
2 The hospital does not conduct Conduct regular mentorship or MD Next quarter
regular mentorship or supervision to supervision to health centers CEO
catchment coordinator health centers Quality officer
3 Hospital do not monitor the Regularly monitor performance of CEO Next quarter
performance of coordinator health health centers MD
centers Quality officer