Project Title: - Decreasing Neonatal Sepsis Prevalence From 47.

1% to 25%
among admitted Neonates at Kuyu General Hospital from May 01,2024 to
August 01,2024 G.C

March, 2024

G/Guracha, Ethiopia

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Contents

Contents
Contents ........................................................................................................................................................ 1
MISSION ...................................................................................................................................................... 3
VISSION ....................................................................................................................................................... 3
List of problem.............................................................................................................................................. 4
Problem identification and prioritization ...................................................................................................... 4
Problem Statement ........................................................................................................................................ 4
Aim statement ............................................................................................................................................... 4
Root Cause Analysis (Fish Bone) ................................................................................................................. 5
The List of proposed interventions (change ideas) ....................................................................................... 7
Intervention Matrix ....................................................................................................................................... 7
Measures/ Indicators ..................................................................................................................................... 8
PDSA Cycle .................................................................................................................................................. 9
Outcome measurement data collection plan ............................................................................................... 10
Process measurement data collection plan .................................................................................................. 11

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Back Ground
Kuyu general hospital is located in the North Shoa Zone, Oromia region 156 km away from A.A
city and 42 km from Fiche town to the North. It was established 2002 E.C as primary hospital and
developed to the general hospital in 2009 E.C. Now the hospital Is giving health service for more
than 648446 peoples. The hospital has 71 beds, and the average length of stay is 4.57 days 82%
bed occupancy rate. After it was upgraded to Kuyu General Hospital, it is serving as a referral
center for catchment area population and currently serves over 648462 people. It also serves as a
teaching institution for the students who come from Salale university and other private universities
and colleges. There are different service points like OPD (Outpatient department), IPD (In patient
department), Oby/gyn, Neonatal intensive care unit (NICU), ICU, EOPD, Operation room (OR),
pharmacy, laboratory department, radiology, and different clinics. The hospital has one surgeons
and gynecologists and obstetrician, one IESOs, ten general practitioners, three master degree
holder in MPH, one adult health nurse specialists, seventy-two nurses of different categories,
thirteen laboratory, two biomedical technicians, fifteen midwives, three anesthetists, and twelve
pharmacists.

MISSION
❖ To reduce morbidity, mortality, and disability, promotes health and wellbeing of its
catchment population through providing and regulating a comprehensive package of
promotive, preventive, curative and rehabilitative health services of the highest possible
quality in an equitable manner

VISSION
❖ To see healthy, productive, and prosperous population in our catchments area

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List of problem
1. High prevalence of neonatal sepsis
2. Low National STG Adherence
3. Completeness of IPD Medical Record
4. Low Bed Occupancy Rate
5. High NICU Referral rate

Problem identification and prioritization

Table 1: Problem identification and prioritization

S/N Problem List Criteria for Rank Total Rank

Score
Importance Effectiveness Feasibility

1 High neonatal sepsis 5 5 5 15 1

2 Low National STG 5 3 2 10 3

Adherence

3 Completeness of IPD 5 3 4 12 2
Medical Record

4 Low Bed Occupancy Rate 4 3 2 9 4

5 High NICU Referral rate 4 2 3 9 5

Problem Statement
In Kuyu General Hospital the finding indicated that the prevalence of neonatal sepsis among
admitted neonates is high. Based on Kuyu General Hospital HMIS data extraction and registration
book report of third Quarter of 2016 EFY, prevalence of neonatal sepsis among admitted neonates
at Kuyu General Hospital was 47.1%, which increases neonatal morbidity and mortality.

Aim statement
We Kuyu General Hospital NICU QI team aimed to reduce sepsis admission from 47.1% to 25%
from April 20/2024 to October 30/2024.
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Root Cause Analysis (Fish Bone)

Figure 1: Root Cause Analysis (Fish Bone) diagram for QI project drafted to reduce neonatal
sepsis from 47.1% to 25% from April 20/2024 to October 30/2024.

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Figure 2: Driver diagram

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The List of proposed interventions (change ideas)
a) Make restricted area (label the area by color)
b) Increase awareness Mothers ANC follow up.
c) Train staff on protocol adherence, IPC practice.
d) Prepare adequate NICU room as standard.
e) Monitor NICU service regularly
f) Train ICU Nurses on infection prevention.

Intervention Matrix
Table 2: Focus matrix table show that implementing activity according to their prioritization
2024.

Importance

Lowest (1) 2 3 4 5 most

Hardest (1) b

3 f
Feasibility

4 c

5 e d

5(Easiest) a

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Measures/ Indicators

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 PDSA Cycle

P of PDSA

No. What Process Where(service Who When (timetable )

(Change Measure area) (responsible
ideas) body)
Start date End date

1 Create % of Triage waiting MD,QU 15/8/2016 30/9/2016

awareness awareness area
for session
mothers

2 Train staff % trained Hospital/training ➢ CEO,HRM 15/08/2016 30/9/2016

staff centers

3 Restricted % of zone Hospital Facility mgt 8/08/2016 15/8/2016

the area prepared

4 Regular % Hospital QU,MD 15/05/2016 30/8/2016

monitoring monitoring
NICU session
service done

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Outcome measurement data collection plan

AIM Data source Data collection Time Responsible

(Where) method (how) for DC
(When)

DHIS, Register Monthly report monthly QU

To reduce sepsis admission from 47.1%
to 25% from April 20/2024 to October

review
30/2024

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 Process measurement data collection plan
Process/Change Data source Data Time Responsible
idea (Where) collection Person
(When)
method
(how)

Create observation Counting From 15/8/2016- MD,QU

awareness on available 30/10/2016 (two
ANC follow up sessions times per week)
for attendants

Train staff Observation Review From 15/8/16 to CEO,MD,HRM,QU

of training 30/8/2016( two
registration attendance session)

Prepare Observation Observing Starting from CEO ,Finance

adequate NICU available 15/8/2016
room rooms

Regular Observation Audit Starting from QU

monitoring on of NICU report 1/9/2016
NICU service monthly

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Do

✓ Test your change ideas one at a time

✓ Use Run chart to monitor your QI project over time.
o Carry out plan
o Document observations
o Collect data

NICU Admission and sepsis case before Qi project

Study

➢ Describe the measured results and how they compared to the predictions and baseline.

✓ What happened?

✓ W ’ ?

✓ Summarize what was learned

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