PAWE HOSPITAL CLUASTER

REVIEW MEETING report

April 2013
debretabor
Out line
 Back ground
Hospital profile
Employees in the hospital
Services in the hospital
 Gaps identified for pt satisfaction
 Root cause analysis
 Action taken for implementation

 Achievements
 Best practices
Hospital profile
 Catchment population
male 204119
female 198483
female 15-49 yrs 47834
pregnant women 1770
children >1 yrs 13,688
children >5 yrs 65,222
Total popn 402,602
Employees in the hospital 215
Total
others 3
supportive staff 108
X-RAY technicians 3
anesthetist 3
EHW 2
pharmacy all type 8
laboratory all type 11
Midwives all type 10
Diploma nurse 44
BSC nurses 6
HO 4
MD 6
Services provided
Clinical service
Laboratory services
Pharmacy services
Diagnostic services & non clinical services
Ten top out pt visits
others
dispepsia 5%
5%
URTI
5%

TF
6% malaria
37%
UTI
6%

pnemonia
6%

D/Musculo
skeletal AFI
7% 15%
helimenthasise
8%
Ten top causes of admission
70
61.2%
60

50

40

30

20
12.2%
10 6.5% 4.9% 3.1% 2.9% 2.9% 2.8% 2.15 1.4%
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Ten top causes of in pt mortality
22.2%
25
20 16.6% 16.6%
15 11.1%
10 5.6% 5.6% 5.6% 5.6% 5.6% 5.6%
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Gaps identified for pt satisfaction
Poor referral linkage
Absence of specialists
Poor medical record mgt
Negligence of staffs
Shortage of medical equipments
Hydroelectric power fluctuation
Condensed card room
 rY

people
Process/policy
Poor communication absence of referral protocol

Clinical & administration negligence of health worker late implementation of BPR

Poor nursing care absence of BSC

poor health service

delivery system

absence of back up light absence of blood bank

condensed card

room & central

triage
Shortage of reagents
lack of community
Equipments /resource environments
awareness
Actions taken
Orientation of staff on EHRIG
Strengthen medical record mgt
Implementation of nursing care standard
Strengthen health education program
Availing medical equipments &regents
Establishing liaison&referal service
Procurement of back up generator –on process
 constructing of central triage & card room
Quarterly evaluation of EHRIG &kpI reports
Achievements
Nursing care standard

2004 4th Q

83% 2005 1stQ

67% 2005 2ndQ

33%

Series1
Pt satisfaction

9.5 1st Q 2ndQ

9

3rdQ
8

Series1
Best practice
Central medication control
The way forward
Starting implementation of BSC& HDA
Strengthen laboratory service for accreditation
Strengthen liaison & referral service
Starting use of medication cardex
Tanks