MENU

zcmcmdcms

5. 0  Design and Development Blueprints

5.1 Networking Blueprint

5.1.1   Challenge: Late Referral

Strategic Tag: Networking of Birthing Facilities

Extended Cause Mapping (with operational definition of terms and description of the challenge)

Direct maternal deaths

-          Pregnant patients with imminent death risks

o   Late referrals (from other hospitals, other birthing homes, other RHUs, TBAs)

  Procrastination

         Referring-Facility-Factor

         Referring TBA

         Focal-Facility-Factor 

         Patient-Factor

Late referral means the ill-timed referral and transfer from one birthing facility to another of pregnant patients resulting either in imminent death or “more complicated pregnancy to manage.”

Late referral and transfer is due to procrastination of transfer of pregnant patient from one birthing facility to another.

Procrastination may be due to referring birthing-facility factor; referring TBA=factor; focal-facility-factor; and/or patient factor.

Referring-facility-factors:

                Delay in medical decision-making for transfer by the skilled health attendant or professional in the referring birthing facility

Delay in facilitation of transfer of pregnant patients to focal facility (assuming there is a medical-decision to transfer already and patient has agreed to transfer) – examples: no staff to facilitate transfer; waiting for discharge medical summary; no ambulance; etc.

                Late release of patient because of unsettlement of account

Referring-TBA-factors:

                Delay in health decision-making for transfer by the TBA

Focal-facility-factors:

                Non-conduciveness for referrals

Patient-factors

Mindset of the patient or relatives not to transfer right away for whatever reasons such as distance of the birthing facility to be transferred to and indigency

Definition of Terms

Networking is the partnership and collaboration of institutions and persons on something.  In the context of birthing services, networking can be done among different birthing facilities. 

Birthing facilities are the medical centers, hospitals, birthing homes, and rural health units that have an infrastructure for birthing services.  The medical centers and hospitals can be government or private.  The birthing homes can be government or private. 

Late referrals, in the context of birthing services, means the ill-timed referral and transfer from one birthing facility to another of pregnant patients resulting either in imminent death or “more complicated pregnancy to manage.”   

Focal birthing facility refers to the birthing facility to where other birthing facilities refer pregnant patients.  This is in contrast to the referring birthing facilities which refer pregnant patients to the focal birthing facility.

Description of the Problem

Late referrals from other birthing facilities can lead to a high incidence of pregnant patients with imminent risk of deaths consulting at the focal birthing facility, thereby, increasing the incidence of dead on arrival (DOA) and Emergency Room (ER) deaths.

Late referrals from other birthing facilities can lead to a high incidence of pregnant patients with “more complicated pregnancy to manage” at the focal birthing facility, thereby, increasing the incidence of adverse and sentinel events.

Situational Analysis

What are current statistics on late referrals (not late patient consults) from other birthing facilities that have resulted in maternal deaths? To track, how many dead on arrival (DOA) and ER deaths as a result of late referrals from other birthing facilities (for the past 3 years)?

What are current statistics on late referrals (not late patient consults) from other birthing facilities that have resulted in “more complicated pregnancy to manage? To track, how many adverse and sentinel events as a result of late referrals from other birthing facilities (for the past 3 years)?

What are the causes of the late referrals that have resulted in maternal deaths (for the past 3 years)?

Referring-facility-factors:

                Delay in medical decision-making for transfer by the skilled health attendant or professional in the referring birthing facility

Delay in facilitation of transfer of pregnant patients to focal facility (assuming there is a medical-decision to transfer already and patient has agreed to transfer) – examples: no staff to facilitate transfer; waiting for discharge medical summary; no ambulance; etc.

                Late release of patient because of unsettlement of account

Referring-TBA-factors:

                Delay in health decision-making for transfer by the TBA

Focal-facility-factors:

                Non-conduciveness for referrals

Patient-factors

Mindset of the patient or relatives not to transfer right away for whatever reasons such as distance of the birthing facility to be transferred to and indigency

Assumptions:

Networking with all birthing facilities that can contribute to late referrals to the focal birthing facility will prevent and mitigate pregnant patients dying of imminent deaths at the emergency room.

Networking with all birthing facilities that can contribute to late referrals to the focal birthing facility will prevent and mitigate “more complicated pregnancy to manage” thereby reducing the incidence of adverse and sentinel events.

Networking means partnership and collaboration of all birthing facilities that have the potential of late referrals.

Networking for partnership and collaboration to prevent and mitigate late referrals entails a referral system and a mutual aid system.

A.  Strategic Goals of Focal Birthing Facility:

To develop a networking system of birthing facilities so as to avoid late referrals and transfers that may result in imminent maternal deaths and “more complicated pregnancy to manage.”

Tactical Goals: (Key Results Areas)

         Make the focal birthing facility conducive to be referred pregnant patients to.

         Motivate the referring birthing facilities and referring TBAs to make timely referral and transfer when indicated.

         Communicate and dialogue with referring birthing facility on early referral and transfer.

         Communicate and dialogue with TBAs on early referrals.

         Educate the public on a healthy mindset to avoid late transfer because of unhealthy mindset.

 

Operational Plans for Each of the Tactical Goals (KRAs) 

See Operational plans for each of the tactical goals (KRAs)

 

 

 

 

 

 

 

 

 

 

 

Criteria and Indicators for Performance Excellence of Networking of Birthing Facilities

Criteria and Indicators for Performance Excellence on Networking of Birthing Facilities

Audit Results

Areas for Improvement

There is a Task Force created to handle Networking of Birthing Facilities.

Records

Presence of a Task Force

AUDIT RESULTS:

 

There is a design and development plan for the strategic goal and for operational plans for each of the tactical goals.

Documents and Records

AUDIT RESULTS:

 

There is a deployment, education, and implementation plan and implemented.

Documents and Records

AUDIT RESULTS:

 

There is evaluation, review, and continual improvement plan and implemented.

Documents and Records

AUDIT RESULTS:

 

There is documentation and archiving plan and implemented.

Documents and Records

AUDIT RESULTS:

 

There is management review and independent audit and implemented.

Documents and Records

AUDIT RESULTS:

 

The operational goals and objectives for all the tactical goals have been achieved.

Records:(see Operational goals and objectives for all the tactical goals)

AUDIT RESULTS:

 

 

The tactical goals (the key results areas) have all been achieved.

Records:

Tactical Goals: (Key Results Areas)

         Make the focal birthing facility conducive to be referred pregnant patients to.

         Motivate the referring birthing facilities and referring TBAs to make timely referral and transfer when indicated.

         Communicate and dialogue with referring birthing facility on early referral and transfer.

         Communicate and dialogue with TBAs on early referrals.

         Educate the public on a healthy mindset to avoid late transfer because of unhealthy mindset.

AUDIT RESULTS:

 

 

The strategic goals have been achieved.

Records:

Strategic Goals of Focal Birthing Facility:

To develop a networking system of birthing facilities so as to avoid late referrals and transfers that may result in imminent maternal deaths and “more complicated pregnancy to manage.”

AUDIT RESULTS:

 

 

The birthing facility is conducive to be referred pregnant patients to.

Records:

Conduciveness to be referred to (number of referrals and non- ill-timed referrals)

AUDIT RESULTS:

 

There is a memorandum of agreement on networking renewed every 3 years.

Records:

Memorandum of agreement on networking renewed every 3 years

AUDIT RESULTS:

 

 

There are established guidelines on the referral system.

Records:

Established guidelines on the referral system.

AUDIT RESULTS:

 

There are established practice guidelines on motivating initiatives.

Records:

Established guidelines on the motivating initiatives.

AUDIT RESULTS:

 

There are regular meetings among birthing facilities and TBAs to discuss referral system and motivating initiative concerns.

Records:

Regular meetings among birthing facilities and TBAs to discuss referral system and motivating initiative concerns AUDIT RESULTS

 

No pregnant patient dies of late referral and transfer resulting to imminent risk of death.

Records:

No. of maternal deaths secondary to late referral and transfer resulting to imminent death

 AUDIT RESULTS:

 

No pregnant patient consults with “more complicated pregnancy to manage” because of late referral and transfer.

Records:

No. of pregnant patient consults with “more complicated pregnancy to manage” because of late referral and transfer.  AUDIT RESULTS:

 

  B.  Tactical Goal (KRA): Make the focal birthing facility conducive to be referred pregnant patients to.

Goals: To make the focal birthing facility conducive to be referred pregnant patients to.

Objectives:

To have a reputation of:

1.       No service delay, availability and safety (reception; diagnosis, treatment; discharge procedure; and follow-up and postnatal maternal care services)

2.       No financial constraints in terms of reasonable cost; with PhilHealth accreditation and benefits; with PhilHealth Point-of-Care enrolment; and with availability of other financial and logistical assistance initiatives

3.       Friendly staff

4.       Conducive referral and transfer system

With ZERO complaints by the referring birthing facilities on the abovementioned parameters.  

 

Expected results:

The focal birthing facility is conducive to being referred and transferred pregnant patients to because of non-service delay, availability and safety (reception; diagnosis, treatment; discharge procedure; and follow-up and postnatal maternal care services); non-financial constraints (reasonable cost; with PhilHealth accreditation and benefits; with PhilHealth Point-of-Care enrolment; and with availability of other financial and logistical assistance initiatives); friendly staff; and conducive referral and transfer system.

There is a measurement tool developed and that shows all the items mentioned in the objectives are attained.

Expected impact:                                                 

Control of late referral and transfer that may result to pregnant patients dying of imminent death and “more complicated pregnancy to manage” (Key performance indicator: ZERO)

With ZERO complaints by the referring birthing facilities on the following:

 1.       Service delay, availability and safety (reception; diagnosis, treatment; discharge procedure; and follow-up and postnatal maternal care services)

2.       Financial constraints in terms of unreasonable cost; with no PhilHealth accreditation and benefits; with no PhilHealth Point-of-Care enrolment; and with no other financial and logistical assistance initiatives

3.       Unfriendly staff

4.       Unconducive referral and transfer system

Methods or Interventions:

NO service delay, availability and safety

                Reception – quality and safe – effective and efficient service pathways

Diagnosis – quality and safe clinical and paraclinical diagnosis - effective and efficient service and clinical medical pathways

Treatment – quality and safe – effective and efficient service and clinical medical pathways

Discharge procedure – quality and safe - effective and efficient service and clinical medical pathways

Follow-up and postnatal maternal care services – quality and safe – effective and efficient service and clinical medical pathways

NO financial constraints

Reasonable cost – providing reasonable costing of services; providing value-based health care services

With PhilHealth accreditation and benefits – acquiring and maintaining PhilHealth accreditation; promoting no-balancing billing; granting PhilHealth benefits

With PhilHealth Point-of-Care enrolment – promoting POC enrolment

With availability of other financial and logistical assistance initiatives – sourcing of other financial and logistical initiatives for indigent patient incidents

Friendly staff

                Training of staff to be friendly in rendering all types of services

Conducive referral and transfer system

                Establishment of a conducive referral and transfer system such as facilitating call for referral and transfer; reception of call; and reception of transfer.

Other Methods or Interventions:

There must be a Deployment, Education and Implementation Plan on the conduciveness program.

There must be an Evaluation, Review and Continual Improvement Plan on the conduciveness program.

There must be monitoring of complaints on non-conduciveness to referral and transfer.

There must be a Document and Archiving Plan on the conduciveness program.

There must be Management Review and Independent Audit Plan on the conduciveness program.

Task List / Tracking List (Action Plan):

 

Person-in-Charge

Timelines

Budget

Task Force Creation

     

Design and Development Plan - 

NO service delay, availability and safety

     

Design and Development Plan –

NO financial constraints

     

Design and Development Plan –

Friendly staff

     

Design and Development Plan –

Conducive referral and transfer system

     

Deployment and Education and Implementation 

     

Evaluation, Review and Continual Improvement  

     

Documentation and Archiving

     

Management Review and Independent Audit

     

Criteria and Indicators for Performance Excellence on Conduciveness for Referral and Transfer

Criteria and Indicators for Performance Excellence on Conduciveness for Referral and Transfer

Audit Results

Areas for Improvement

There is a design and development plan.

Documents and Records

AUDIT RESULTS:

 

There is a deployment, education, and implementation plan and implemented.

Documents and Records

AUDIT RESULTS:

 

There is evaluation, review, and continual improvement plan and implemented.

Documents and Records

AUDIT RESULTS:

 

There is documentation and archiving plan and implemented.

Documents and Records

AUDIT RESULTS:

 

There is management review and independent audit and implemented.

Documents and Records

AUDIT RESULTS:

 

The operational goals and objectives have been achieved.

Records:

Goals: To make the focal birthing facility conducive to be referred pregnant patients to.

Objectives:

To have a reputation of:

5.       No service delay, availability and safety (reception; diagnosis, treatment; discharge procedure; and follow-up and postnatal maternal care services)

6.       No financial constraints in terms of reasonable cost; with PhilHealth accreditation and benefits; with PhilHealth Point-of-Care enrolment; and with availability of other financial and logistical assistance initiatives

7.       Friendly staff

8.       Conducive referral and transfer system

 AUDIT RESULTS:

 

There is no late referral and transfer of pregnant patients  because of conduciveness to referral and transfer to the focal birthing facility.

Records:

Conduciveness to be referred to (number of referrals and non- ill-timed referrals)

Customer satisfaction feedback and ratings

AUDIT RESULTS:

 

 

There is no maternal deaths because of conduciveness to refer and transfer to the focal birthing facility.

Records:

No. of maternal deaths secondary to non-conduciveness to referral and transfer (Customer satisfaction feedback and ratings and no. of complaints of non-conduciveness)

 AUDIT RESULTS:

 

 C.  Tactical Goal (KRA): Motivate the referring birthing facilities and referring TBAs to make timely referral and transfer when indicated.

Goals: To motivate the referring birthing facilities and referring Traditional Birth Attendants (TBAs) to make timely referral and transfer when indicated.

Objectives:

1.       To identify the birthing facilities and TBAs that need to be motivated.

2.       To establish and develop initiatives that will motivate the birthing facilities and TBAs to refer to the focal birthing facilities.

3.       To offer the motivating initiatives to the concerned birthing facilities and TBAs.

4.       To enter into a memorandum of agreement on the motivating initiatives with the interested birthing facilities and TBAs.

5.       To deploy and educate concerned staff of focal birthing facility and those of the other birthing facilities and TBAs on the implementation of the memorandum of agreement on motivating initiatives.

6.       To measure the results and impact of the MOA on motivating initiatives.

7.       To evaluate and review the MOA on motivating initiatives.

Expected results: The referring birthing facilities and referring Traditional Birth Attendants (TBAs) are motivated to make timely referral and transfer when indicated as a result of motivating initiatives.

There is a measurement tool developed and that shows all referring birthing facilities and TBAs when they refer to focal birthing facility are motivated.

Expected impact:

Control of late referral and transfer that may result to pregnant patients dying of imminent death and “more complicated pregnancy to manage” (Key performance indicator: ZERO)

As a result of:

All referring birthing facilities when they refer to focal birthing facility are motivated.

All referring Traditional Birth Attendants (TBAs) when they refer to focal birthing facility are motivated.

Methods or Interventions:

Identification of birthing facilities and TBAs that need to be motivated with prioritization

Design and development of motivating initiatives (examples: Tele-referrals, Training Programs, Mutual Aid Programs or Sisterhood Program and Recognition)

Approval of motivating initiatives by governing body or top management

Offer of motivating initiatives to identified birthing facilities and TBAs

Memorandum of Agreement on motivating initiatives with those interested

Deployment and education on MOA on motivating initiatives

Implementation of MOA on motivating initiatives

Evaluation, review and continual improvement of MOA on motivating initiatives

Other Methods or Interventions:

There must be a Deployment, Education and Implementation Plan on the motivation initiatives.

There must be an Evaluation, Review and Continual Improvement Plan on the motivation initiatives.

There must be monitoring of the results and impact on the motivation initiatives.

There must be a Document and Archiving Plan on the motivation initiatives.

There must be Management Review and Independent Audit Plan on the motivation initiatives.

Task List / Tracking List (Action Plan):

 

Person-in-Charge

Timelines

Budget

Task Force creation

     

Identification of birthing facilities to motivate

     

Identification of TBAs to motivate

     

Design and development plans of all motivating initiatives

     

Approval by Governing Body or Top Management

     

Offer of motivating initiatives to interested birthing facilities and TBAs with signing of MOA

     

Deployment and Education of MOA

     

Implementation of MOA

     

Evaluation, Review and Continual Improvement of MOA

     

Documentation and Archiving

     

Management Review and Independent Audit

     

 Criteria and Indicators for Performance Excellence on Motivating Initiatives for Referral and Transfer

Criteria and Indicators for Performance Excellence on Motivating Initiatives for Referral and Transfer

Audit Results

Areas for Improvement

There is a design and development plan.

Documents and Records

AUDIT RESULTS:

 

There is a deployment, education, and implementation plan and implemented.

Documents and Records

AUDIT RESULTS:

 

There is evaluation, review, and continual improvement plan and implemented.

Documents and Records

AUDIT RESULTS:

 

There is documentation and archiving plan and implemented.

Documents and Records

AUDIT RESULTS:

 

There is management review and independent audit and implemented.

Documents and Records

AUDIT RESULTS:

 

The operational goals and objectives have been achieved.

Records:

Goals: To motivate the referring birthing facilities and referring Traditional Birth Attendants (TBAs) to make timely referral and transfer when indicated.

Objectives:

1.       To identify the birthing facilities and TBAs that need to be motivated.

2.       To establish and develop initiatives that will motivate the birthing facilities and TBAs to refer to the focal birthing facilities.

3.       To offer the motivating initiatives to the concerned birthing facilities and TBAs.

4.       To enter into a memorandum of agreement on the motivating initiatives with the interested birthing facilities and TBAs.

5.       To deploy and educate concerned staff of focal birthing facility and those of the other birthing facilities and TBAs on the implementation of the memorandum of agreement on motivating initiatives.

6.       To measure the results and impact of the MOA on motivating initiatives.

7.       To evaluate and review the MOA on motivating initiatives.

AUDIT RESULTS:

 

All the birthing facilities and TBAs that signed the MOA are motivated to refer to the focal birthing facility.

Records:

Number of referrals (adequate and properly timed referrals)

AUDIT RESULTS:

 

There is no maternal death because all the referring birthing facilities and TBAs are motivated to refer and transfer to the focal birthing facility when indicated.

Records:

No. of maternal deaths because of ill-time referrals from birthing facilities and TBAs.

AUDIT RESULTS:

 

D.  Tactical Goal (KRA): Communicate and dialogue with referring birthing facility on early referral and transfer.

Goals: To communicate and dialogue with referring birthing facility on early referral and transfer.

Objectives:

1.       To identify the birthing facilities that need to be communicated and dialogued with for early referral and transfer of pregnant patients when indicated.

2.       To establish and develop guidelines on referral system – when and how to refer.

3.       To communicate and dialogue with the concerned birthing facilities on the guidelines on referral system.

4.       To enter into a memorandum of agreement on the guidelines on referral system with the interested birthing facilities.

5.       To deploy and educate concerned staff of focal birthing facility and those of the other birthing facilities on the implementation of the memorandum of agreement on referral system.

6.       To measure the results and impact of the MOA on referral system.

7.       To evaluate and review the MOA on referral system.


Expected Results:

There is no late referral and transfer of pregnant patients to the focal birthing facility as a result of an established mutually agreed referral system.

There is a measurement tool developed and that shows all referring birthing facilities have timely referral and transfer.


Expected Outcome:

Control of late referral and transfer that may result to pregnant patients dying of imminent death and “more complicated pregnancy to manage” (Key performance indicator: ZERO)

As a result of timely referral from referring birthing facilities.

Methods or Interventions:

Identification of birthing facilities that need to be communicated and dialogued with on early referral and transfer of pregnant patients when indicated

Design and development of referral system – when and how to refer.

                Examples of when to refer:

                                Recognition of high-risk pregnancy – refer right away.

                                Recognition of complicated pregnancy to manage – refer right away.

                Examples of how to refer:

Call – phone, cell phones (voice call, SMS) - (list of persons and contact numbers)

Acceptance – right away

                          Medical abstract

                         Reception – right away

Approval of proposed referral system by governing body or top management

Communication and dialogue with identified birthing facilities on proposed referral system

Memorandum of Agreement on referral system with those interested

Deployment and education on MOA on referral system

Implementation of MOA on referral system

Evaluation, review and continual improvement of MOA on referral system

 Other Methods or Interventions:

There must be a Deployment, Education and Implementation Plan on the referral system.

There must be an Evaluation, Review and Continual Improvement Plan on the referral system.

There must be monitoring of the results and impact on the referral system with the other birthing facilities.

There must be a Document and Archiving Plan on the referral system.

There must be Management Review and Independent Audit Plan on the referral system.

Task List / Tracking List (Action Plan):

 

Person-in-Charge

Timelines

Budget

Task Force Creation

     

Identification of birthing facilities to communicate and dialogue for the referral system

     

Design and development plans of referral system

     

Approval by Governing Body or Top Management

     

Offer of referral system to interested birthing facilities with signing of MOA

     

Deployment and Education of MOA

     

Implementation of MOA

     

Evaluation, Review and Continual Improvement of MOA

     

Documentation and Archiving

     

Management Review and Independent Audit

     

Criteria and Indicators for Performance Excellence on Communication and Dialogue with Birthing Facilities on Referral System

Criteria and Indicators for Performance Excellence on  

Communication and Dialogue with Birthing Facilities on Referral System

Audit Results

Areas for Improvement

There is a design and development plan.

Documents and Records

AUDIT RESULTS:

 

There is a deployment, education, and implementation plan and implemented.

Documents and Records

AUDIT RESULTS:

 

There is evaluation, review, and continual improvement plan and implemented.

Documents and Records

AUDIT RESULTS:

 

There is documentation and archiving plan and implemented.

Documents and Records

AUDIT RESULTS:

 

There is management review and independent audit and implemented.

Documents and Records

AUDIT RESULTS:

 

The operational goals and objectives have been achieved.

Records:

Goals: To communicate and dialogue with referring birthing facility on early referral and transfer.

Objectives:

1.       To identify the birthing facilities that need to be communicated and dialogued with for early referral and transfer of pregnant patients when indicated.

2.       To establish and develop guidelines on referral system – when and how to refer.

3.       To communicate and dialogue with the concerned birthing facilities on the guidelines on referral system.

4.       To enter into a memorandum of agreement on the guidelines on referral system with the interested birthing facilities.

5.       To deploy and educate concerned staff of focal birthing facility and those of the other birthing facilities on the implementation of the memorandum of agreement on referral system.

6.       To measure the results and impact of the MOA on referral system.

7.       To evaluate and review the MOA on referral system.

AUDIT RESULTS:

 

All the birthing facilities and TBAs that signed the MOA have timely referral and transfer to the focal birthing facility.

Records:

Timely referrals frequency

AUDIT RESULTS:

 

There is no maternal deaths because of timely referral and transfer to the focal birthing facilities from other birthing facilities.

Records:

No. of maternal deaths secondary to ill-timed referrals

AUDIT RESULTS:

 

E.  Tactical Goal (KRA): Communicate and dialogue with TBAs on early referrals.

Goals: To communicate and dialogue with TBAs on early referral.

Objectives:

1.       To identify the TBAs who need to be communicated and dialogued with for early referral and transfer of pregnant patients when indicated.

2.       To establish and develop guidelines on referral system – when and how to refer.

3.       To communicate and dialogue with the TBAs on the guidelines on referral system.

4.       To enter into a memorandum of agreement on the guidelines on referral system with the interested TBAs.

5.       To deploy and educate concerned staff of focal birthing facility and the TBAs on the implementation of the memorandum of agreement on referral system.

6.       To measure the results and impact of the MOA on referral system.

7.       To evaluate and review the MOA on referral system.


Expected Results:

There is no late referral and transfer of pregnant patients to the focal birthing facility as a result of an established mutually agreed referral system.

There is a measurement tool developed and that shows all TBAs who signed the MOA have timely referral and transfer.

Expected Outcome:

Control of late referral and transfer that may result to pregnant patients dying of imminent death and “more complicated pregnancy to manage” (Key performance indicator: ZERO)

 As a result of timely referral and transfer from the referring TBAs.

Methods or Interventions:

Identification of TBAs who need to be communicated and dialogued with on early referral and transfer of pregnant patients when indicated

Design and development of referral system – when and how to refer.

                Examples of when to refer:

                                Recognition of high-risk pregnancy – refer right away.

                                Recognition of complicated pregnancy to manage – refer right away.

                Examples of how to refer:

                                Call – phone, cell phones (voice call, SMS) – (list of persons and contact

                               numbers)

                                Acceptance – right away

                                Endorsement

                                Reception – right away

Approval of proposed referral system by governing body or top management

Communication and dialogue with identified TBAs on proposed referral system

Memorandum of Agreement on referral system with those interested

Deployment and education on MOA on referral system

Implementation of MOA on referral system

Evaluation, review and continual improvement of MOA on referral system

Other Methods or Interventions:

There must be a Deployment, Education and Implementation Plan on the referral system.

There must be an Evaluation, Review and Continual Improvement Plan on the referral system.

There must be monitoring of the results and impact on the referral system with the TBAs.

There must be a Document and Archiving Plan on the referral system.

There must be Management Review and Independent Audit Plan on the referral system.

Task List / Tracking List (Action Plan):

 

Person-in-Charge

Timelines

Budget

Task Force creation

     

Identification of TBAs to communicate and dialogue for the referral system

     

Design and development plans of referral system

     

Approval by Governing Body or Top Management

     

Offer of referral system to interested TBAs with signing of MOA

     

Deployment and Education of MOA

     

Implementation of MOA

     

Evaluation, Review and Continual Improvement of MOA

     

Documentation and Archiving

     

Management Review and Independent Audit

     

Criteria and Indicators for Performance Excellence on Communication and Dialogue with TBAs on Referral System

Criteria and Indicators for Performance Excellence on 

Communication and Dialogue with TBAs on Referral System

Audit Results

Areas for Improvement

There is a design and development plan.

Documents and Records

AUDIT RESULTS:

 

There is a deployment, education, and implementation plan and implemented.

Documents and Records

AUDIT RESULTS:

 

There is evaluation, review, and continual improvement plan and implemented.

Documents and Records

AUDIT RESULTS:

 

There is documentation and archiving plan and implemented.

Documents and Records

AUDIT RESULTS:

 

There is management review and independent audit and implemented.

Documents and Records

AUDIT RESULTS:

 

The operational goals and objectives have been achieved.

Records:

Goals: To communicate and dialogue with TBAs on early referral.

Objectives:

1.       To identify the TBAs who need to be communicated and dialogued with for early referral and transfer of pregnant patients when indicated.

2.       To establish and develop guidelines on referral system – when and how to refer.

3.       To communicate and dialogue with the TBAs on the guidelines on referral system.

4.       To enter into a memorandum of agreement on the guidelines on referral system with the interested TBAs.

5.       To deploy and educate concerned staff of focal birthing facility and the TBAs on the implementation of the memorandum of agreement on referral system.

6.       To measure the results and impact of the MOA on referral system.

7.       To evaluate and review the MOA on referral system.

 AUDIT RESULTS:

 

There is no late referral and transfer of pregnant patients because of the referral system with TBAs.

Records:

Frequency of late referrals from TBAs

AUDIT RESULTS:

 

There is no maternal deaths because of timely referral and transfer to the focal birthing facilities from the TBAs.

Records:

No. of maternal deaths secondary to late referrals from TBAs

AUDIT RESULTS:

 


F.  Tactical Goal (KRA): Educate the public on a healthy mindset to avoid late transfer because of unhealthy mindset.

Goals: To educate the public on a healthy mindset to avoid late transfer because of unhealthy mindset.

Objectives:

To educate the public on at least the following that may contribute to late transfer because of unhealthy mindset:

         High-risk pregnancies

         Which birthing facilities to go in case of high-risk pregnancies

         Importance of early transfer if indicated

         Emergency and contingency plans for transfer

 

Intra-facility-based education – targeting pregnant patients and would-be pregnant patients consulting at the facility

To promote a healthy mindset on transfer to focal birthing facility for 100 pregnant and would-be pregnant patients in one year; 150 patients in second year; and 200 patients in the third year. (a survey tool has to be created)

Extra-facility-based education – targeting pregnant patients and would-be pregnant patients in catchment community who have not yet consulted at the facility

To promote a healthy mindset on transfer to focal birthing facility for 100 patients pregnant and would-be pregnant patients in the community in one year; 150 patients in second year; and 200patients in the third year.  (a survey tool has to be created and Rural Health Units and Community Health Teams can be tapped)

Expected results:

The public is educated on high-risk pregnancies; which birthing facilities to go to in case of high-risk pregnancies; importance of early transfer if indicated; and on emergency and contingency plans for transfer.

There is a measurement tool developed and that shows the targets of education on late transfer have been achieved.

Expected impact:                                                 

Control of late referral and transfer that may result to pregnant patients dying of imminent death and “more complicated pregnancy to manage” (Key performance indicator: ZERO)

As a result of timely transfer secondary to patient healthy mindset.

 

Methods or Interventions:

Intra-facility-based educational program – targeting pregnant patients and would-be pregnant patients consulting at the facility

                During prenatal check-ups

                During postnatal check-ups

                During admission to birthing facility

                During Mothers Class / Buntis Class in birthing facility

                During Women Health Forum in birthing facility

 Aided by posters, leaflets and/or videos in strategic areas in the facility              

Extra-facility-based educational program - targeting pregnant patients and would-be pregnant patients in the catchment community who have not yet consulted at the facility

               

                Radio shows

                TV shows

                School program

                Social media

                Websites

                Buntis Congress (in cooperation with other partners)

Other Methods or Interventions:

There shall be a standardized educational tool on promoting a healthy mindset on transfer to other facilities.

See Education of the Public on Pregnancy-Related Issues (Aligned and integrated)

There must be a Deployment, Education and Implementation Plan on the educational program.

There must be an Evaluation, Review and Continual Improvement Plan on the educational program.

There must be monitoring of number of pregnant patients and would-be pregnant patients which has acquired a healthy mindset on transfer.

There must be monitoring of number of pregnant patients who transferred early / late because of healthy / unhealthy mindset.

There must be a Document and Archiving Plan on the educational program.

There must be Management Review and Independent Audit Plan on the educational program.

Task List / Tracking List (Action Plan):

 

Person-in-Charge

Timelines

Budget

Task Force creation

     

Educational Program –Standardized

     

Deployment and Education

     

Implementation

Intra-facility-based educational program

     

Implementation

Intra-facility-based educational program

     

Evaluation, Review and Continual Improvement

     

Documentation and Archiving

     

Management Review and Independent Audit

     

Criteria and Indicators for Performance Excellence on Education for the Public on Transfer to Birthing Facilities

Criteria and Indicators for Performance Excellence on Education for the Public on Transfer to Birthing Facilities

Audit Results

Areas for Improvement

There is a design and development plan.

Documents and Records

AUDIT RESULTS:

 

There is a deployment, education, and implementation plan and implemented.

Documents and Records

AUDIT RESULTS:

 

There is evaluation, review, and continual improvement plan and implemented.

Documents and Records

AUDIT RESULTS:

 

There is documentation and archiving plan and implemented.

Documents and Records

AUDIT RESULTS:

 

There is management review and independent audit and implemented.

Documents and Records

AUDIT RESULTS:

 

The operational goals and objectives have been achieved.

Records:

Goals: To educate the public on a healthy mindset to avoid late transfer because of unhealthy mindset.

Objectives:

To educate the public on at least the following that may contribute to late transfer because of unhealthy mindset:

         High-risk pregnancies

         Which birthing facilities to go in case of high-risk pregnancies

         Importance of early transfer if indicated

         Emergency and contingency plans for transfer

 

Intra-facility-based education – targeting pregnant patients and would-be pregnant patients consulting at the facility

To promote a healthy mindset on transfer to focal birthing facility for 100pregnant and would-be pregnant patients in one year; 150 patients in second year; and 200patients in the third year. (a survey tool has to be created)

Extra-facility-based education – targeting pregnant patients and would-be pregnant patients in catchment community who have not yet consulted at the facility

To promote a healthy mindset on transfer to focal birthing facility for 100patients pregnant and would-be pregnant patients in the community in one year; 150 patients in second year; and 200patients in the third year.  (a survey tool has to be created and Rural Health Units and Community Health Teams can be tapped)

AUDIT RESULTS:

 

There is no late transfer of pregnant patients because of a healthy mindset.

Records:

Frequency of late transfer because of unhealthy mindset

AUDIT RESULTS:

 

There is no maternal deaths resulting from timely transfer because of healthy mindset.

Records:

No. of maternal death secondary to late transfer because of unhealthy mindset

AUDIT RESULTS:

 

5.2   Financial and Logistic Assistance for Indigent Patient Incidents Blueprint

Challenge: Late Consult and Problem in Logistic Secondary to Indigency

Strategic Tag: Financial and Logistic Assistance for Indigent Patient Incidents

Extended Cause Mapping (with operational definition of terms and description of the challenge)

Direct maternal deaths

-          Pregnant patients with and without imminent death risks dying

o   Late consult secondary to indigency

o   Problem in logistic secondary to indigency

Indigency means a situation in which the patient cannot afford to pay for the expenses associated with medical management of the pregnancy.

Definition of Terms: 

Indigent Patient Incidents 

Indigent patient incidents are incidents in which the patients don’t have or don’t have enough money to secure the medicines, supplies, and tests needed for their medical management if these cannot be given for free.

Setting of indigent patient incidents

         hospital’s emergency department

         inpatient services department

         outpatient department

         birthing homes

         rural health unit

         private and government birthing facilities (more common in government)

The “indigent patient incidents” are primarily a result of the presence of indigent patients in the community (Philippines, provinces, cities, municipalities, etc.)

Indigent patients are present in the community because of the inherent presence of citizens who are jobless; not working to earn; struck by unfortunate events in life that drain their financial resources

and reserve, etc.   In short, there will always be a segment of the citizenry in any community in the Philippines which consist of indigent patients.

The “indigent patient incidents” are secondarily a result of increasing costs of healthcare compounded by absence of hospitals which can continuously give out totally free medical services.  

The “indigent patient incidents” are tertiarily a result of a national health insurance system (specifically, PhilHealth) which cannot cover all the medical expenses of every citizen whenever the latter get sick.

There won’t be indigent patient incidents in the community if all individuals and families are economically productive and have a system to adequately meet the demands of current and future medical expenses.  This scenario, however, is extremely difficult, if not possible, to achieve.  

Controlling the costs of healthcare and strengthening the national health insurance system can only mitigate and reduce the number of indigent patient incidents.

There will always be indigent patient incidents in our midst, in hospitals, in birthing homes and rural health units,  whether government or private.

The challenge is not limited to the quantity of free services, medicines, and supplies they can give to indigent patients in their midst.   More importantly, the challenge is on the indigency associated quality and ethical issues.   Specifically, these are, there should be NO delay in treatment because of indigency reason and NO patient is deprived of proper medical/surgical treatment because of indigency reason. 

Value-based Health Care Services

Value-based health care services is providing services in such a way that the cost of the health care management is kept to the lowest minimum possible or most reasonable expense possible while continuing to maintain and improve quality and safe outcomes.  

Value-based health care services emphasizes the importance of

  • accurate clinical diagnosis to avoid unnecessary expenses
  • no unnecessary paraclinical diagnostic procedures
  • no unnecessary treatment procedures
  • no unnecessary drugs and miscellaneous expenses
  • but still maintaining quality and safe outcomes 

Value-based health care services emphasize the use of management options with minimum possible or most reasonable expenses yet maintaining and safe outcomes.   

 

Description of the Problem or Challenge

Indigency resulting to late consult can lead to a high incidence of pregnant patients with imminent risk of deaths consulting dying at the birthing facility.

Indigency resulting to late consult can lead to a high incidence of pregnant patients with “more complicated pregnancy to manage” at the birthing facility, thereby, increasing the incidence of adverse and sentinel events.

Indigency resulting in problems of logistics in management of pregnancy can lead to a high incidence of pregnant patients dying at the birthing facility.

Indigency resulting in problems of logistics in management of pregnancy can lead to a high incidence of pregnant patients with “more complicated pregnancy to manage” at the birthing facility, thereby, increasing the incidence of adverse and sentinel events.

Situational Analysis

How many pregnant patients dies because of indigency?

How many are availing of the No-Balance-Billing of PhilHealth?

How many are availing of the PhilHealth Point-of-Care enrolment?

How many patients who have unsettled account?

Assumptions:

No patients should die of indigency.

There should be NO delay in treatment because of indigency reason.

NO patient is deprived of proper medical/surgical treatment because of indigency reason. 

A.  Strategic Goals of Birthing Facility:

To provide a financial and logistical assistance initiative so that no persons die of indigency; there is no delay in treatment because of indigency; and no patient is deprived of proper medical / surgical treatment because of indigency reason.

B.  Tactical Goals: (Key Result Areas)

         Practice value-based health care services.

         Maximize use of PhilHealth accreditation and benefits for the indigent pregnant patients.

         Develop additional financial and logistical assistance initiatives for indigent pregnant patients.

Operational Plans for Each of the Tactical Goals (KRAs) 

See Operational plans for each of the tactical goals (KRAs)

 Criteria and Indicators for Performance Excellence of Financial and Logistical Assistance for Indigent Patients

Criteria and Indicators for Performance Excellence on Financial and Logistical Assistance for Indigent Patients

Audit Results

Areas for Improvement

There is a Task Force created to handle the Financial and Logistical Assistance for Indigent Patients

Records

Presence of a Task Force

AUDIT RESULTS:

 

There is a design and development plan for the strategic goal and for operational plans for each of the tactical goals.

Documents and Records

AUDIT RESULTS:

 

There is a deployment, education, and implementation plan and implemented.

Documents and Records

AUDIT RESULTS:

 

There is evaluation, review, and continual improvement plan and implemented.

Documents and Records

AUDIT RESULTS:

 

There is documentation and archiving plan and implemented.

Documents and Records

AUDIT RESULTS:

 

There is management review and independent audit and implemented.

Documents and Records

AUDIT RESULTS:

 

The operational goals and objectives for all the tactical goals have been achieved.

Records:

(see Operational goals and objectives for all the tactical goals)

AUDIT RESULTS:

 

 

The tactical goals (the key results areas) have all been achieved.

Records:

Tactical Goals: (Key Result Areas)

         Practice value-based health care services.

         Maximize use of PhilHealth accreditation and benefits for the indigent pregnant patients.

         Develop additional financial and logistical assistance initiatives for indigent pregnant patients.

AUDIT RESULTS:

 

The strategic goals have been achieved.

Records:

Strategic Goal:

To provide a financial and logistical assistance initiative so that no persons die of indigency; there is no delay in treatment because of indigency; and no patient is deprived of proper medical / surgical treatment because of indigency reason.

AUDIT RESULTS:

 

There are established practice guidelines on value-based health care services.

Records:

Presence of practice guidelines on value-based health care services

AUDIT RESULTS:

 

There is maximal utilization of the PhilHealth accreditation and benefits.

Records:

Presence of maximal utilization of the PhilHealth accreditation and benefits.

AUDIT RESULTS:

 

There are additional financial and logistical assistance initiatives aside from PhilHealth.

Records:

Presence of financial and logistical assistance initiatives aside from PhilHealth

AUDIT RESULTS:

 

There is NO delay in treatment because of indigency reason.

Records:

No. of patients with delay in treatment because of indigency

AUDIT RESULTS:

 

NO patient is deprived of proper medical/surgical treatment because of indigency reason. 

Records:

No. of patients deprived of proper medical/surgical treatment because of indigency

AUDIT RESULTS:

 

No pregnant patient dies because of indigency.

Records:

No. of maternal deaths secondary to indigency

AUDIT RESULTS:

 

C.   Tactical Goal (KRA): Practice value-based health care services.

Goals: To practice value-based health care services.

Value-based health care services is providing services in such a way that the cost of the health care management is kept to the lowest minimum possible or most reasonable expense possible while continuing to maintain and improve quality and safe outcomes.   

Objectives:

1.       To develop practice guidelines on value-based health care services on pregnant patients.

2.       To deploy and educate concerned staff on the practice guidelines on value-based health care services.

3.       To implement the practice guidelines on value-based health care services.

4.       To measure the results and impact of the practice guidelines on value-based health care services.

5.       To evaluate and review the practice guidelines on value-based health care services.

Expected Results:

As a result of the practice guidelines on value-based health care service, the maternal care services are provided in such a way that the cost of the management is kept to the lowest minimum possible or most reasonable expense possible while continuing to maintain and improve quality and safe outcome.

There is a measurement tool developed and that shows good health care outcomes with pesos spent or expended.   

Expected Outcomes:

         No patient dies of indigency.

         There should be NO delay in treatment because of indigency reason.

         NO patient is deprived of proper medical/surgical treatment because of indigency reason. 

 Methods or Interventions:

Development of practice guidelines on value-based health care services for pregnant patients

Deployment and education on practice guidelines on value-based health care services

Implementation of practice guidelines on value-based health care services

Evaluation, review and continual improvement of practice guidelines on value-based health care services

Other Methods or Interventions:

There must be a Deployment, Education and Implementation Plan on the practice guidelines on value-based health care services.

There must be an Evaluation, Review and Continual Improvement Plan on the practice guidelines on value-based health care services.

There must be monitoring of the results and impact of the practice guidelines on value-based health care services.

There must be a Document and Archiving Plan on the practice guidelines on value-based health care services.

There must be Management Review and Independent Audit Plan on the practice guidelines on value-based health care services.

Task List / Tracking List (Action Plan):

 

Person-in-Charge

Timelines

Budget

Task Force creation

     

Development of practice guidelines on value-based health care services

     

Deployment and Education 

     

Implementation   

     

Evaluation, Review and Continual Improvement  

     

Documentation and Archiving

     

Management Review and Independent Audit

     

 Criteria and Indicators for Performance Excellence on Practice of Value-based Health Care Services

Criteria and Indicators for Performance Excellence on Practice of Value-based Health Care Services

Audit Results

Areas for Improvement

There is a design and development plan.

Documents and Records

AUDIT RESULTS:

 

There is a deployment, education, and implementation plan and implemented.

Documents and Records

AUDIT RESULTS:

 

There is evaluation, review, and continual improvement plan and implemented.

Documents and Records

AUDIT RESULTS:

 

There is documentation and archiving plan and implemented.

Documents and Records

AUDIT RESULTS:

 

There is management review and independent audit and implemented.

Documents and Records

AUDIT RESULTS:

 

The operational goals and objectives have been achieved.

Records:

Goals: To practice value-based health care services.

Objectives:

1.       To develop practice guidelines on value-based health care services on pregnant patients.

2.       To deploy and educate concerned staff on the practice guidelines on value-based health care services.

3.       To implement the practice guidelines on value-based health care services.

4.       To measure the results and impact of the practice guidelines on value-based health care services.

5.       To evaluate and review the practice guidelines on value-based health care services.

AUDIT RESULTS:

 

The practice of value-based health care services brings down the cost of medical care of pregnant patients yet maintaining quality and safe outcomes.

Records:

Practice of value-based health care services

AUDIT RESULTS:

 

There is NO delay in treatment because of indigency reason.

Records:

No. of patients with delay in treatment because of indigency

AUDIT RESULTS:

 

NO patient is deprived of proper medical/surgical treatment because of indigency reason.

Records:

No. of patients deprived of proper medical/surgical treatment because of indigency

AUDIT RESULTS:

 

No patient dies of indigency.

Records:

No. of maternal deaths secondary to indigency

AUDIT RESULTS:

 

 

D.  Tactical Goal (KRA): Maximize use of PhilHealth accreditation and benefits for the indigent pregnant patients.

Goals: To maximize the use of PhilHealth accreditation and benefits for the indigent pregnant patients.

Objectives:

1.       To get and maintain accreditation with PhilHealth.

2.       To promote No-Balance-Billing for Philhealth members especially indigent pregnant patients.

3.       To provide PhilHealth Point-of-Care enrolment to all indigent pregnant patients.

Expected Results:

                PhilHealth accreditation obtained and maintained

                No-Balance-Billing for indigent patients who are PhilHealth members

                PhilHealth Point-of-Care enrolment for all indigent pregnant patients

Expected Outcomes:

         No patient dies of indigency.

         There should be NO delay in treatment because of indigency reason.

         NO patient is deprived of proper medical/surgical treatment because of indigency reason. 

Methods or Interventions:

Get and maintain PhilHealth Accreditation.

Promote No-Balance-Billing for for Philhealth members especially indigent pregnant patients.

Provide PhilHealth Point-of-Care enrolment to all indigent pregnant patients

Other Methods or Interventions:

There must be a Deployment, Education and Implementation Plan on the PhilHealth initiative.

There must be an Evaluation, Review and Continual Improvement Plan on the PhilHealth initiative.

There must be monitoring of the results and impact of the PhilHealth initiative. 

There must be a Document and Archiving Plan on the PhilHealth initiative. 

There must be Management Review and Independent Audit Plan on the PhilHealth initiative.

 

 

Task List / Tracking List (Action Plan):

   

Person-in-Charge

Timelines

Budget

Task Force creation

       

PhilHealth accreditation

       

No-Balance-Billing

       

Point-of-Care enrolment

       

Deployment and Education 

       

Implementation   

       

Evaluation, Review and Continual Improvement  

       

Documentation and Archiving

       

Management Review and Independent Audit

       

Criteria and Indicators for Performance Excellence on PhilHealth Initiative

Criteria and Indicators for Performance Excellence on PhilHealth Initiative

Audit Results

Areas for Improvement

There is a design and development plan.

Documents and Records

AUDIT RESULTS:

 

There is a deployment, education, and implementation plan and implemented.

Documents and Records

AUDIT RESULTS:

 

There is evaluation, review, and continual improvement plan and implemented.

Documents and Records

AUDIT RESULTS:

 

There is documentation and archiving plan and implemented.

Documents and Records

AUDIT RESULTS:

 

There is management review and independent audit and implemented.

Documents and Records

AUDIT RESULTS:

 

The operational goals and objectives have been achieved.

Records:

Goals: To maximize the use of PhilHealth accreditation and benefits for the indigent pregnant patients.

Objectives:

1.       To get and maintain accreditation with PhilHealth.

2.       To promote No-Balance-Billing for Philhealth members especially indigent pregnant patients.

3.       To provide PhilHealth Point-of-Care enrolment to all indigent pregnant patients.

AUDIT RESULTS:

 

There is accreditation with PhilHealth.

Records:

Accredited with PhilHealth

AUDIT RESULTS:

 

No-Balance-Billing is maximally used for indigent pregnant patients with PhilHealth benefit.

Records:

Maximal utilization of NO-Balance-Billing

AUDIT RESULTS:

 

PhilHealth Point-of-Care enrolment is given to all indigent pregnant patients.

Records:

 PhilHealth Point-of-Care enrolment is given to all indigent pregnant patients.

AUDIT RESULTS:

 

There is NO delay in treatment because of indigency reason.

Records:

No. of patients with delay in treatment because of indigency

AUDIT RESULTS:

 

NO patient is deprived of proper medical/surgical treatment because of indigency reason.

Records:

No. of patients deprived of proper medical/surgical treatment because of indigency

AUDIT RESULTS:

 

No patient dies of indigency.

Records:

No. of maternal deaths secondary to indigency

AUDIT RESULTS:

 

E.  Tactical Goal (KRA): Develop additional financial and logistical assistance initiatives for indigent pregnant patients.

Goals: To develop additional financial and logistical assistance initiatives for indigent pregnant patients.

Objectives:

Financial Assistance Initiative

1.       To calculate an annual financial assistance budget for pregnant indigent patient incidents.

2.       To look for other sources of financial assistance for pregnant indigent patient incidents.  

Logistical Assistance Initiative

1.       To calculate an annual logistical assistance budget for pregnant indigent patient incidents.

2.       To look for sources of logistical assistance for pregnant indigent patient incidents.

a.       Blood

b.      Medicines

c.       Medical supplies

d.      Diagnostic equipment

e.      Treatment equipment

Expected Results:

Additional financial and logistical initiatives for indigent pregnant patients always enough to cover for the projected annual requirements

Expected Outcomes:

         No patient dies of indigency.

         There should be NO delay in treatment because of indigency reason.

         NO patient is deprived of proper medical/surgical treatment because of indigency reason. 

Methods or Interventions:

Calculation of an annual financial assistance budget for pregnant indigent patient incidents

Calculation of an annual logistical assistance budget for pregnant indigent patient incidents

Development of a financial assistance initiative

Development of a logistical assistance initiative

Approval from governing body or top management

Deployment and education on financial and logistical assistance initiative.

Implementation of financial and logistical assistance initiative

Evaluation, review and continual improvement of financial and logistical assistance initiative

Other Methods or Interventions:

There must be a Deployment, Education and Implementation Plan on the financial and logistical assistance initiative.

There must be an Evaluation, Review and Continual Improvement Plan on the financial and logistical assistance initiative.

There must be monitoring of the results and impact of the financial and logistical assistance initiative.

There must be a Document and Archiving Plan on the financial and logistical assistance initiative.

There must be Management Review and Independent Audit Plan on the financial and logistical assistance initiative.

Task List / Tracking List (Action Plan):

 

Person-in-Charge

Timelines

Budget

Task Force creation

     

Design and development of a financial assistance initiative

     

Design and development of a logistical assistance initiative

     

Approval by governing body or top management

     

Deployment and Education 

     

Implementation   

     

Evaluation, Review and Continual Improvement  

     

Documentation and Archiving

     

Management Review and Independent Audit

     

Criteria and Indicators for Performance Excellence on Other Financial and Logistical Assistance Initiatives

Criteria and Indicators for Performance Excellence on Other Financial and Logistical Assistance Initiatives

Audit Results

Areas for Improvement

There is a design and development plan.

Documents and Records

AUDIT RESULTS:

 

There is a deployment, education, and implementation plan and implemented.

Documents and Records

AUDIT RESULTS:

 

There is evaluation, review, and continual improvement plan and implemented.

Documents and Records

AUDIT RESULTS:

 

There is documentation and archiving plan and implemented.

Documents and Records

AUDIT RESULTS:

 

There is management review and independent audit and implemented.

Documents and Records

AUDIT RESULTS:

 

The operational goals and objectives have been achieved.

Records:

Goals: To develop additional financial and logistical assistance initiatives for indigent pregnant patients.

Objectives:

Financial Assistance Initiative

         To calculate an annual financial assistance budget for pregnant indigent patient incidents.

         To look for other sources of financial assistance for pregnant indigent patient incidents.

Logistical Assistance Initiative

         To calculate an annual logistical assistance budget for pregnant indigent patient incidents.

         To look for sources of logistical assistance for pregnant indigent patient incidents.

         Blood

         Medicines

         Medical

             supplies

         Diagnostic

           equipment

         Treatment equipment

AUDIT RESULTS:

 

There are other financial assistance initiative.

Records:

Presence of other financial assistance initiative

AUDIT RESULTS:

 

There are other logistical assistance initiative.

Records:

Presence of other logistical assistance initiative

AUDIT RESULTS:

 

There is enough other financial assistance to cover the needs of the indigent pregnant patients.

Records:

Enough other financial assistance to cover the needs of the indigent pregnant patients AUDIT RESULTS:

 

There is enough logistical assistance to cover the needs of the indigent pregnant patients.

Records:

Enough other logistical assistance to cover the needs of the indigent pregnant patients AUDIT RESULTS:

 

There is NO delay in treatment because of indigency reason.

Records:

No. of patients with delay in treatment because of indigency

AUDIT RESULTS:

 

NO patient is deprived of proper medical/surgical treatment because of indigency reason.

Records:

No. of patients deprived of proper medical/surgical treatment because of indigency

AUDIT RESULTS:

 

No patient dies of indigency.

Records:

No. of maternal deaths secondary to indigency

AUDIT RESULTS:

 

  5.3   Education of the Public on Pregnancy-related Issues Blueprint

5.3.1  Challenge: Mindset

Strategic Tag: Education of the Public on Pregnancy-related Issues

Extended Cause Mapping (with operational definition of terms and description of the challenge)

Cause mapping of unhealthy mindsets

Mindset is the established set of attitudes held by someone. It is a particular way of thinking.  It is a person’s attitude or set of opinions about something.  (Merriam-Webster)

Mindset of a person on pregnancy-related issues:

Healthy mindset – that which will promote and maintain health of a pregnant woman from conventional medicine point of view

Unhealthy mindset – that which will not promote and maintain health of a pregnant woman from conventional medicine point of view

Aspects of mindset that will affect outcome of pregnancy:

Pregnancy issues

Maternal care

Place of maternal care

Financial aspect of maternal care

Unhealthy mindset

Pregnancy issues

                Cannot be pregnant

                No risk in pregnancy

Maternal care

                No need for prenatal check-up

                No need for postnatal check-up

Place of maternal care

                At home

Financial aspect of maternal care

                Expensive to go to a birthing facility

Healthy mindset

Pregnancy issues

                Planned pregnancy

                Recognition of high-risk pregnancy

Maternal care

                Need for prenatal check-up

                Ned for postnatal check-up

Place of maternal care

                Birthing facility

Financial aspect of maternal care

                Not expensive to go to a birthing facility

Causes of Unhealthy Mindset

Lack of knowledge

Tradition (on unhealthy mindset)

Influenced by peers and elders (with unhealthy mindset)

Long distance from birthing facility

Indigency (financial issues)

Description of the Challenge or the Problem:

Unhealthy mindset can result to a high incidence of pregnant patients with imminent risk of deaths consulting dying at the birthing facility.

Unhealthy mindset can result to late consult thereby leading to a high incidence of pregnant patients with “more complicated pregnancy to manage” at the birthing facility, therefore increasing the incidence of adverse and sentinel events.

Situational Analysis

What is the current situation on mindset of pregnant patients that can lead to maternal deaths?

On pregnancy issues

On  maternal care

On place of maternal care

On financial aspect of maternal care

Reasons for unhealthy mindset:

Lack of knowledge

Tradition (on unhealthy mindset)

Influenced by peers and elders (with unhealthy mindset)

Long distance from birthing facility

Indigency (financial issues)

Assumptions:

Unhealthy mindset of the public can lead to maternal deaths.

A.   Strategic Goals of Birthing Facility:

B.   Goals:

To control maternal deaths resulting from unhealthy mindset through education of the public on pregnancy-related issues.

To prevent “more complicated pregnancy to manage” resulting from unhealthy mindset through education of the public on pregnancy-related issues.

Education – to change unhealthy mindsets and to maintain healthy mindsets

(In addition): Provision of logistic assistance when needed

so that:

No pregnant patient will die because of late consult resulting to imminent risk of death.

No pregnant patient will die because of reasons of distance from birthing facility.

No pregnant patient will die because of indigency reasons.

No pregnant patient will die because of unhealthy mindset.

No pregnant patient will consult with “more complicated pregnancy to manage” because of unhealthy mindset.

 C.  Tactical Goals (Key Result Areas):

Convert all unhealthy mindsets to healthy mindsets through education with logistical assistance particularly on distance of birthing facility and indigency.

Intra-facility- and extra-facility-based tactics (with focus on intra-facility-based tactics for the birthing facilities)

Intra-facility-based tactics – targeting pregnant patients and would-be pregnant patients consulting at the facility

Extra-facility-based tactics – targeting pregnant patients and would-be pregnant patients in catchment community who have not yet consulted at the facility

D.  Operational Plans on Tactical Goals (KRA):  

Goals: To convert lack of knowledge to adequate knowledge of healthy mindset on pregnancy issues.

                What is pregnancy? What are the signs of pregnancy?

                Why planned pregnancy?

 What are unwanted pregnancies? (Teenage pregnancies, elderly pregnancies, other high-risk pregnancies)

                What are signs of high-risk pregnancy?

                What to do when pregnant?
                                Importance of prenatal check-ups

                                Importance of postnatal check-ups

             Where to go for management of pregnancies / high-risk pregnancies?

What are the myths in pregnancy?

What are the unhealthy mindsets in pregnancy issue?

                What are the birthing facilities in the community?

                What is the cost of pregnancy management? What is the usefulness of PhilHealth?

Objectives:

Intra-facility-based tactics – targeting pregnant patients and would-be pregnant patients consulting at the facility

To convert lack of knowledge to adequate knowledge of healthy mindset on pregnancy issue for 100 pregnant and would-be pregnant patients in one year; 150 patients in second year; and 200patients in the third year. (a survey tool has to be created)

To provide logistical assistance to all patients with issues of distance to birthing facility.

To provide logistical assistance to all patients with indigency issues.

Extra-facility-based tactics – targeting pregnant patients and would-be pregnant patients in catchment community who have not yet consulted at the facility

To convert lack of knowledge to adequate knowledge of healthy mindset on pregnancy issues for 100 patients pregnant and would-be pregnant patients in the community in one

year; 150patients in second year; and 200 patients in the third year.  (a survey tool has to be created and Rural Health Units and Community Health Teams can be tapped)

Expected Results:

See Objectives


Expected Outcomes:

Education – to change unhealthy mindsets and to maintain healthy mindsets

(In addition): Provision of logistic assistance when needed

so that:

No pregnant patient will die because of late consult resulting to imminent risk of death.

No pregnant patient will die because of reasons of distance from birthing facility.

No pregnant patient will die because of indigency reasons.

No pregnant patient will die because of unhealthy mindset.

No pregnant patient will consult with “more complicated pregnancy to manage” because of unhealthy mindset.

Methods or Interventions:

Intra-facility-based educational program – targeting pregnant patients and would-be pregnant patients consulting at the facility

  • During prenatal check-ups
  • During postnatal check-ups
  • During admission to birthing facility
  • During Mothers Class / Buntis Class in birthing facility
  • During Women Health Forum in birthing facility

                Aided by posters, leaflets and/or videos in strategic areas in the facility

Extra-facility-based educational program - targeting pregnant patients and would-be pregnant patients in the catchment community who have not yet consulted at the facility

             

  • Radio shows
  • TV shows
  • School program
  • Social media
  • Websites
  • Buntis Congress (in cooperation with other partners)

Other Methods or Interventions:

There shall be a standardized educational tool on converting lack of knowledge to adequate knowledge of healthy mindset on pregnancy issues.

There shall be a procedure on providing logistic support to all patients with issues of distance to birthing facility.

There shall be a procedure on providing logistic support to all patients with indigency issues.

There must be a Deployment, Education and Implementation Plan on the education of the public on pregnancy-related issues.

There must be an Evaluation, Review and Continual Improvement Plan on the education of the public on pregnancy-related issues.

There must be monitoring of number of pregnant patients and would-be pregnant patients converted from lack of knowledge to adequate knowledge of healthy mindset in pregnancy issues.

 There must be a Document and Archiving Plan on the practice guidelines on education of the public on pregnancy-related issues.

There must be Management Review and Independent Audit Plan on the education of the public on pregnancy-related issues.

Task List / Tracking List (Action Plan):

 

Person-in-Charge

Timelines

Budget

Task Force creation

     

Design and Development Plan 

     

Design and Development of Educational Materials

     

Deployment and Education 

     

Implementation   

     

Evaluation, Review and Continual Improvement  

     

Documentation and Archiving

     

Management Review and Independent Audit

     

 Criteria and Indicators for Performance Excellence on Education of the Public on Pregnancy-related Issues (or on Converting Lack of Knowledge to Adequate Knowledge of Healthy Mindset in Pregnancy Issues).

Criteria and Indicators for Performance Excellence on Education of the Public on Pregnancy-related Issues

Audit Results

Areas for Improvement

There is a Task Force created to handle the Education of the Public Initiative.

Records

Presence of a Task Force

AUDIT RESULTS:

 

There is a design and development plan.

Documents and Records

AUDIT RESULTS:

 

There is a deployment, education, and implementation plan.

Documents and Records

AUDIT RESULTS:

 

There is evaluation, review, and continual improvement plan.

Documents and Records

AUDIT RESULTS:

 

There is documentation and archiving plan.

Documents and Records

AUDIT RESULTS:

 

There is management review and independent audit.

Documents and Records

AUDIT RESULTS:

 

The operational goals and objectives for all the tactical goals have been achieved.

Records:

(see Operational goals and objectives for all the tactical goals)

AUDIT RESULTS:

 

 

The tactical goals (the key results areas) have all been achieved.

Records:

Tactical Goals (Key Result Areas):

Convert all unhealthy mindsets to healthy mindsets through education with logistical assistance particularly on distance of birthing facility and indigency.

Intra-facility- and extra-facility-based tactics (with focus on intra-facility-based tactics for the birthing facilities)

         Intra-facility-based tactics – targeting pregnant patients and would-be pregnant patients consulting at the facility

         Extra-facility-based tactics – targeting pregnant patients and would-be pregnant patients in catchment community who have not yet consulted at the facility

AUDIT RESULTS:

 

 

The strategic goals have been achieved.

Records:

Strategic Goals of Birthing Facility:

         To control maternal deaths resulting from unhealthy mindset through education of the public on pregnancy-related issues.

         To prevent “more complicated pregnancy to manage” resulting from unhealthy mindset through education of the public on pregnancy-related issues.

AUDIT RESULTS:

 

Lack of knowledge is converted to adequate knowledge of healthy mindset on pregnancy issues in the facility based on projected targets.

Records:

Percentage of conversion

AUDIT RESULTS:

 

Logistical assistance are provided to all patients with issues of distance to birthing facility (100%)

Records:

Logistical assistance provided with issues of distance to birthing facility

AUDIT RESULTS:

 

Logistical assistance are provided to all patients with indigency issues (100%)

Records:

All indigent patients given logistical assistance

AUDIT RESULTS:

 

Lack of knowledge is converted to adequate knowledge of healthy mindset on pregnancy issues in the community based on projected targets.

Records:

Percentage of conversion

AUDIT RESULTS:

 

No pregnant patient dies because of late consult resulting to imminent risk of death.

Records:

No. of maternal deaths secondary to late consult resulting in imminent risk of death

AUDIT RESULTS:

 

 

No pregnant patient dies because of reasons of distance from birthing facility.

Records:

No. of maternal deaths secondary to distance from birthing facility

AUDIT RESULTS:

 

No pregnant patient dies because of indigency reasons.

Records:

No. of maternal deaths secondary to indigency reasons

AUDIT RESULTS:

 

No pregnant patient dies because of unhealthy mindset.

Records:

No. of maternal deaths secondary to unhealthy mindset

AUDIT RESULTS:

 

No pregnant patient consult with more complicated pregnancy to manage because of unhealthy mindset.

Records:

No. of “more complicated pregnancy to manage” secondary to unhealthy mindset

AUDIT RESULTS:

 

 5.4  Availability of Skilled Health Professionals Blueprint

5.4.1  Challenge: Lack of Skilled Health Professionals

Strategic Tag: Availability of Skilled Health Professionals

Extended Cause Mapping (with operational definition of terms and description of the challenge)

Lack of skilled health professionals

                Skilled health professionals

  • Obstetricians
  • MDs (MHOs) with obstetrical competency
  • Nurses with obstetrical competency
  • Midwifes with obstetrical competency
  • Others support skilled health professionals (anesthesiologists, internists, pathologists, radiologists, etc.)

Lack in term of:

                Required number for services in the birthing facility 24/7 availability

Lack in terms of required number for services in the birthing facility

  • Nobody is applying
  • A few are applying
  • No or few skilled health professionals residing in the community
  • Work environment in the birthing facility is not conducive for job application and /or retention.

24/7 availability

Assuming the required number of skilled health professionals for services in the birthing facility is already adequate

                No system for 24/7 coverage by individual skilled health professionals

                No system for 24/7 coverage by a maternal care service team

                System of 24/7 coverage not fully implemented

Description of the Challenge or Problem:

Lack of skilled health professionals in the birthing facility can lead to maternal deaths.

Situational Analysis:

Required number of skilled health professionals for service in birthing facility (including support staff)

  • Obstetricians
  • MDs (MHOs) with obstetrical competency
  • Nurses with obstetrical competency
  • Midwives with obstetrical competency
  • Anesthesiologists
  • Internists
  • Pathologists
  • Radiologists

Status

Is there a 24/7 coverage of maternal care services of skilled health professionals by specialty?

Is there a 24/7 coverage of maternal care services by a maternal care service team?

Is the 24/7 coverage system being implemented all the time?

Assumptions:

Lack of skilled health professionals in the birthing facility can lead to maternal deaths.

A.  Strategic Goals:

To ensure that there is adequate number of skilled health professionals for management of pregnant patients.

To ensure that there is 24/7 coverage of the maternal care services.

so as to avoid maternal deaths secondary to unavailability of skilled health professionals.

B.  Tactical Goals (Key Result Areas):

 1.       Ensure adequacy of number of skilled health professionals based on computed requirements.

2.       Ensure provision of a system of 24/7 coverage of the maternal care service.

Operational Plans based on Tactical Goals (KRAs)

See Operational Plans based on Tactical Goas (KRAs)

Criteria and Indicators for Performance Excellence of Availability of Skilled Health Professionals

Criteria and Indicators for Performance Excellence on Availability of Skilled Health Professionals

Audit Results

Areas for Improvement

There is a Task Force created to handle the Availability of Skilled Health Professionals.

Records

Presence of a Task Force

AUDIT RESULTS:

 

There is a design and development plan for the strategic goal and for operational plans for each of the tactical goals.

Documents and Records

AUDIT RESULTS:

 

There is a deployment, education, and implementation plan and implemented.

Documents and Records

AUDIT RESULTS:

 

There is evaluation, review, and continual improvement plan and implemented.

Documents and Records

AUDIT RESULTS:

 

There is documentation and archiving plan and implemented.

Documents and Records

AUDIT RESULTS:

 

There is management review and independent audit and implemented.

Documents and Records

AUDIT RESULTS:

 

The operational goals and objectives for all the tactical goals have been achieved.

Records:

(see Operational goals and objectives for all the tactical goals)

AUDIT RESULTS:

 

The tactical goals (the key results areas) have all been achieved.

Records:

1.       Ensure adequacy of number of skilled health professionals based on computed requirements.

2.       Ensure provision of a system of 24/7 coverage of the maternal care service.

AUDIT RESULTS:

 

The strategic goals have been achieved.

Records:

Strategic Goals:

         To ensure that there is adequate number of skilled health professionals for management of pregnant patients.

         To ensure that there is 24/7 coverage of the maternal care services.

so as to avoid maternal deaths secondary to unavailability of skilled health professionals.

AUDIT RESULTS:

 

There is adequate number of skilled health professionals.

Records:

Adequate number

AUDIT RESULTS:

 

There is 24/7 coverage of maternal care service.

Records:

Adequate coverage of maternal care service

AUDIT RESULTS:

 

There is no maternal death secondary to unavailability of skilled health professionals.

Records:

No. of maternal deaths secondary to unavailability of skilled health professionals

AUDIT RESULTS:

 

C.  Tactical Goal (KRA): Ensure adequacy of number of skilled health professionals based on computed requirements.

Goal: To ensure adequacy of number of skilled health professionals for service of pregnant patients based on computed requirements.

Objectives:

         Compute requirements.

         Recruit skilled health professionals.

         Make work environment conducive for job application and retention.

         Deploy and educate.

         Evaluate, review and continual improvement.

         Document and archiving

         Management review and independent audit

Expected Results:

                Adequate number of skilled health professionals needed for service of pregnant patients.

Expected Outcomes:

                No maternal deaths secondary to non-availability of skilled health professionals.

Methods or Interventions:

Compute

Recruit

Make work environment conducive for job application and retention (attractive salary scale, career satisfaction, professional and friendly relationship, etc.)

Other Methods or Interventions:

There must be a Deployment, Education and Implementation Plan on ensuring adequate number of skilled health professionals.

There must be an Evaluation, Review and Continual Improvement Plan on ensuring adequate number of skilled health professionals.

There must be monitoring of the results and impact of the plan on ensuring adequate number of skilled health professionals.

There must be a Document and Archiving Plan on ensuring adequate number of skilled health professionals.

There must be Management Review and Independent Audit Plan on ensuring adequate number of skilled health professionals.

Task List / Tracking List (Action Plan):

 

Person-in-Charge

Timelines

Budget

Task Force creation

     

Computation of required number of skilled health professionals

     

Recruitment of skilled health professionals

     

Design and development plan for making work environment conducive for job application and retention

     

Deployment and Education 

     

Implementation   

     

Evaluation, Review and Continual Improvement  

     

Documentation and Archiving

     

Management Review and Independent Audit

     

 Criteria and Indicators for Performance Excellence of Adequate Number of Skilled Health Professionals

Criteria and Indicators for Performance Excellence on Adequate Number of Skilled Health Professionals

Audit Results

Areas for Improvement

There is a design and development plan.

Documents and Records
AUDIT RESULTS:

 

There is a deployment, education, and implementation plan and implemented.

Documents and Records
AUDIT RESULTS:

 

There is evaluation, review, and continual improvement plan and implemented.

Documents and Records
AUDIT RESULTS:

 

There is documentation and archiving plan and implemented.

Documents and Records
AUDIT RESULTS:

 

There is management review and independent audit and implemented.

Documents and Records
AUDIT RESULTS:

 

The operational goals and objectives have been achieved.

Records:

Goal: To ensure adequacy of number of skilled health professionals for service of pregnant patients based on computed requirements.

Objectives:

         Compute requirements.

         Recruit skilled health professionals.

         Make work environment conducive for job application and retention.

         Deploy and educate.

         Evaluate, review and continual improvement.

         Document and archiving

         Management review and independent audit

AUDIT RESULTS:

 

There is adequate number of skilled health professionals based on computed requirements.

Records:

Presence of adequate number based on computed requirements

AUDIT RESULTS:

 

 

Work environment is conducive for job application and retention.

Records:

Presence of work environment conducive to job application and retention

AUDIT RESULTS:

 

 

There is no maternal death secondary to unavailability of skilled health professionals.

Records:

No. of maternal deaths secondary to non-availability of skilled health professionals

AUDIT RESULTS:

 

D.  Tactical Goal (KRA): Ensure provision of a system of 24/7 coverage of the maternal care service.

Goal: To ensure provision of a system of 24/7 coverage of maternal care service.

Objectives:

Develop a system of 24/7 coverage of the maternal care service by specialty and maternal care service team.

Expected Results:

A system of 24/7 coverage of the maternal care service by specialty and maternal care service team.

Expected Outcomes:

No maternal deaths secondary to non-availability of skilled health professionals.

Methods or Interventions:

Develop a system of 24/7 coverage of the maternal care service by specialty and maternal care service team.

Implement.

Track.

Other Methods or Interventions:

There must be a Deployment, Education and Implementation Plan on ensuring 24/7 coverage of maternal care service.

There must be an Evaluation, Review and Continual Improvement Plan on ensuring 24/7 coverage of maternal care service.

There must be monitoring of the results and impact of the plan on ensuring 24/7 coverage of maternal care service.

There must be a Document and Archiving Plan on ensuring 24/7 coverage of maternal care service.

There must be Management Review and Independent Audit Plan on ensuring 24/7 coverage of maternal care service.

Task List / Tracking List:

 

Person-in-Charge

Timelines

Budget

Task Force creation

     

Development of a system of 24/7 coverage of maternal care services

     

Deployment and Education 

     

Implementation   

     

Evaluation, Review and Continual Improvement  

     

Documentation and Archiving

     

Management Review and Independent Audit

     

Criteria and Indicators for Performance Excellence on 24/7 Coverage of Maternal Care Service

Criteria and Indicators for Performance Excellence on 24/7 Coverage of Maternal Care Service

Audit Results

Areas for Improvement

There is a design and development plan.

Documents and Records
AUDIT RESULTS:

 

There is a deployment, education, and implementation plan and implemented.

Documents and Records
AUDIT RESULTS:

 

There is evaluation, review, and continual improvement plan and implemented.

Documents and Records
AUDIT RESULTS:

 

There is documentation and archiving plan and implemented.

Documents and Records
AUDIT RESULTS:

 

There is management review and independent audit and implemented.

Documents and Records
AUDIT RESULTS:

 

The operational goals and objectives have been achieved.

Records:

Goal: To ensure provision of a system of 24/7 coverage of maternal care service.

Objectives:

Develop a system of 24/7 coverage of the maternal care service by specialty and maternal care service team.

AUDIT RESULTS:

 

There is 24/7 coverage of maternal care service by specialty and fully implemented.

Records:

Presence of 24/7 coverage of maternal care service by specialty and fully implemented.

AUDIT RESULTS:

 

 

 There is 24/7 coverage by maternal care service team and fully implemented.

Records:

Presence of 24/7 coverage by maternal care service team and fully implemented.

AUDIT RESULTS:

 

 

There is no maternal death secondary to unavailability of skilled health professionals.

Records:

No. of maternal deaths secondary to non-availability of skilled health professionals

AUDIT RESULTS:

 

 5.5   Competency of Health Professionals Blueprint

5.5.1  Challenge: Lack of Competency of Health Professionals

Strategic Tag: Competency of Health Professionals

Extended Cause Mapping (with operational definition of terms and description of the challenge)

System or Program Managers are those in charge of the Maternal Death Control Management System.

Patient Managers are those in charge of managing pregnant patients, either medical or non-medical.

System or Program Managers

Lack of knowledge and skills in system or program management

Lack of commitment to accomplish things; to be educated; and to persevere in the face of continuing challenges

                People involved:

         Hospital Director

         Senior Management Representative

         A representative from the Obstetric-Gynecology Department as head of the Team

         A representative from the Anesthesiology Department

         A representative from the Internal Medicine Department

         A representative from the Nursing Service in the Emergency Department

         A representative from the Nursing Service in the Labor - Delivery Room or   

            Department

         A representative from the Nursing Service in the OB Ward or Floor

         A representative from the Laboratory / Blood Bank Department

         A representative from the Pharmacy Department

         A representative from the Supply Department

         A representative from the Medical Records Department

         A representative from the IT Department

         A representative from the Finance / PhilHealth Department

         A representative from the Social Service Department

Patient Managers

                Lack of higher levels of knowledge and skills in pregnant patient management

                Lack of knowledge and skills in multi – or transdisciplinary pregnant patient management

Lack of commitment to accomplish things; to be educated; and to persevere in the face of continuing challenges

People involved: Staff from

         Obstetric-Gynecology Department  

         Anesthesiology Department

         Internal Medicine Department

         Nursing Service in the Emergency Department

         Nursing Service in the Labor - Delivery Room or Department

         Nursing Service in the OB Ward or Floor

         Laboratory / Blood Bank Department

         Pharmacy Department

         Supply Department

         Medical Records Department

         IT Department

         Finance / PhilHealth Department

         Social Service Department

Description of the Challenge or Problem:

Lack of competency of system or program managers and patient managers can lead to maternal deaths.

Situational Analysis:

Current assessment:

 

Assessment of Competency (Current)

System or Program Managers

 

Lack of knowledge and skills in system or program management

 

Lack of commitment to accomplish things; to be educated; and to persevere in the face of continuing challenges

 
   

Patient Managers

 

Lack of higher levels knowledge and skills in pregnant patient management

 

Lack of knowledge and skills in multi – or transdisciplinary patient management

 

Lack of commitment to accomplish things; to be educated; and to persevere in the face of continuing challenges

 

Assess the competency using the following key: 3 – total lack; 2 – moderate lack; 1 – slight lack; 0 – no lack.

Assumptions:

Lack of competency of system or program managers and patient managers can lead to maternal deaths. 

A.  Strategic Goals:

To ensure presence of adequate competency of system or program managers so that there will effective control of maternal deaths and there will be quality and safe maternal care services.

To ensure presence of adequate competency of patient managers so that there will effective control of maternal deaths and there will be quality and safe maternal care services. 

B.  Tactical Goals (Key Result Areas):

1.       To establish and develop an educational program for the system or program managers on maternal death control management system.

2.       To establish and develop an educational program for the patient managers on higher levels of knowledge and skills in pregnant patient management.

3.       To establish and develop an educational program for the patient managers on knowledge and skills in multi – or transdisciplinary pregnant patient management

Operational Plans based on Tactical Goals (KRAs)

See Operational Plans based on Tactical Goas (KRAs)

Criteria and Indicators for Performance Excellence of Competency of Health Professionals

Criteria and Indicators for Performance Excellence on Competency of Health Professionals

Audit Results

Areas for Improvement

There is a Task Force created to handle the educational program for system or program managers.

Records

Presence of a Task Force

AUDIT RESULTS:

 

There is a Task Force created to handle the educational program for patient managers.

Records

Presence of a Task Force

AUDIT RESULTS:

 

There is a design and development plan for the strategic goals and for operational plans for each of the tactical goals.

Documents and Records

AUDIT RESULTS:

 

There is a deployment, education, and implementation plan and implemented.

Documents and Records

AUDIT RESULTS:

 

There is evaluation, review, and continual improvement plan and implemented.

Documents and Records

AUDIT RESULTS:

 

There is documentation and archiving plan and implemented.

Documents and Records

AUDIT RESULTS:

 

There is management review and independent audit and implemented.

Documents and Records

AUDIT RESULTS:

 

The operational goals and objectives for all the tactical goals have been achieved.

Records:

(see Operational goals and objectives for all the tactical goals)

AUDIT RESULTS:

 

The tactical goals (the key results areas) have all been achieved.

Records:

Tactical Goals (Key Result Areas):

1.       To establish and develop an educational program for the system or program managers on maternal death control management system.

2.       To establish and develop an educational program for the patient managers on higher levels of knowledge and skills in pregnant patient management.

3.       To establish and develop an educational program for the patient managers on knowledge and skills in multi – or transdisciplinary pregnant patient management

AUDIT RESULTS:

 

The strategic goals have been achieved.

Records:

Strategic Goals:

         To ensure presence of adequate competency of system or program managers so that there will effective control of maternal deaths and there will be quality and safe maternal care services.

         To ensure presence of adequate competency of patient managers so that there will effective control of maternal deaths and there will be quality and safe maternal care services.

AUDIT RESULTS:

 

All system or program managers have competency in maternal death control management system.

Records:

All have required competency

AUDIT RESULTS:

 

All patient managers have higher levels of knowledge and skills in management of pregnant patients.

Records:

All have acquired higher levels of knowledge and skills in management of pregnant patients

AUDIT RESULTS:

 

All patient managers have competency in multi- or transdisciplinary management of pregnant patients.

Records:

All have required competency

AUDIT RESULTS:

 

There is no maternal death because of presence of competent system or program managers.

Records:

No. of maternal deaths secondary to presence of incompetent system or program managers

AUDIT RESULTS:

 

There is no maternal death because of presence of competent patient managers.

Records:

No. of maternal deaths secondary to presence of incompetent patient managers

AUDIT RESULTS:

 

C.  Tactical Goal (KRA): To establish and develop an educational program for the system or program managers on maternal death control management system.

Goal: To establish and develop an educational program for the system or program managers on maternal death control management system.

Objectives:

1.       To design an educational program for the system or program managers on maternal death control management system.

2.       To deploy and educate trainers on the educational program.

3.       To implement the educational program.

4.       To evaluate, review, and continually improve the program.

Expected Results:

                Competent system or program managers on maternal death control management system.

 Expected Outcomes:

                No maternal deaths secondary to incompetent system or program managers.

Methods or Interventions:

1.        To design an educational program for the system or program managers on maternal death control management system.

2.       To deploy and educate trainers on the educational program.

3.       To implement the educational program.

4.       To evaluate, review, and continually improve the program.

 Other Methods or Interventions:

There must be a Deployment, Education and Implementation Plan on the educational program.

There must be an Evaluation, Review and Continual Improvement Plan on the educational program.

There must be monitoring of the results and impact of the educational program.

There must be a Document and Archiving Plan on the educational program.

There must be Management Review and Independent Audit Plan on the educational program.

 Task List / Tracking List (Action Plan):

 

Person-in-Charge

Timelines

Budget

Task Force creation

     

Design of the educational program

     

Deployment and Education 

     

Implementation   

     

Evaluation, Review and Continual Improvement  

     

Documentation and Archiving

     

Management Review and Independent Audit

     

 Criteria and Indicators for Performance Excellence of Educational Program for System or Program Managers

Criteria and Indicators for Performance Excellence on Educational Program for System or Program Managers

Audit Results

Areas for Improvement

There is a design and development plan.

Documents and Records
AUDIT RESULTS:

 

There is a deployment, education, and implementation plan and implemented.

Documents and Records
AUDIT RESULTS:

 

There is evaluation, review, and continual improvement plan and implemented.

Documents and Records
AUDIT RESULTS:

 

There is documentation and archiving plan and implemented.

Documents and Records
AUDIT RESULTS:

 

There is management review and independent audit and implemented.

Documents and Records
AUDIT RESULTS:

 

The operational goals and objectives have been achieved.

Records:

Goal: To establish and develop an educational program for the system or program managers on maternal death control management system.

Objectives:

1.       To design an educational program for the system or program managers on maternal death control management system.

2.       To deploy and educate trainers on the educational program.

3.       To implement the educational program.

4.       To evaluate, review, and continually improve the program.

AUDIT RESULTS:

 

All system or program managers have competency in maternal death control management system.

Records:

All have required competency

AUDIT RESULTS:

 

There is no maternal death secondary to incompetent system or program managers.

Records:

No. of maternal deaths secondary to presence of incompetent system or program managers

AUDIT RESULTS:

 

 

D.  Tactical Goal (KRA): To establish and develop an educational program for the patient managers on higher levels of knowledge and skills in pregnant patient management.

Goal: To establish and develop an educational program for the patient managers on higher levels of knowledge and skills in pregnant patient management.

Objectives:

1.        To design an educational program.

2.       To deploy and educate trainers on the educational program.

3.       To implement the educational program.

4.       To evaluate, review, and continually improve the program.

Expected Results:

Competent patient managers on management of pregnant patients (higher levels of knowledge and skills)

Expected Outcomes:

No maternal deaths secondary to incompetent patient managers.

Methods or Interventions:

1.       To design an educational program.

2.       To deploy and educate trainers on the educational program.

3.       To implement the educational program.

4.       To evaluate, review, and continually improve the program.

Other Methods or Interventions:

 There must be a Deployment, Education and Implementation Plan on the educational program.

There must be an Evaluation, Review and Continual Improvement Plan on the educational program.

There must be monitoring of the results and impact of the educational program.

There must be a Document and Archiving Plan on the educational program.

There must be Management Review and Independent Audit Plan on the educational program.

 Task List / Tracking List (Action Plan):

 

Person-in-Charge

Timelines

Budget

Task Force creation

     

Design of the educational program

     

Deployment and Education 

     

Implementation   

     

Evaluation, Review and Continual Improvement  

     

Documentation and Archiving

     

Management Review and Independent Audit

     

 Criteria and Indicators for Performance Excellence on Educational Program for Patient Managers (Higher Levels of Knowledge and Skills)

Criteria and Indicators for Performance Excellence on Educational Program for Patient Managers for Higher Levels of Knowledge and Skills

Audit Results

Areas for Improvement

There is a design and development plan.

Documents and Records
AUDIT RESULTS:

 

There is a deployment, education, and implementation plan and implemented.

Documents and Records
AUDIT RESULTS:

 

There is evaluation, review, and continual improvement plan and implemented.

Documents and Records
AUDIT RESULTS:

 

There is documentation and archiving plan and implemented.

Documents and Records
AUDIT RESULTS:

 

There is management review and independent audit and implemented.

Documents and Records
AUDIT RESULTS:

 

The operational goals and objectives have been achieved.

Records:

Goal: To establish and develop an educational program for the patient managers on higher levels of knowledge and skills in pregnant patient management.

Objectives:

1.        To design an educational program.

2.       To deploy and educate trainers on the educational program.

3.       To implement the educational program.

4.       To evaluate, review, and continually improve the program.

AUDIT RESULTS:

 

All patient managers have higher levels of knowledge and skills in management of pregnant patients.

Records:

All have acquired higher levels of knowledge and skills in management of pregnant patients

AUDIT RESULTS:

 

There is no maternal death secondary to incompetent patient managers.

Records:

No. of maternal deaths secondary to presence of incompetent patient managers

AUDIT RESULTS:

 

 E.  Tactical Goal (KRA): To establish and develop an educational program for the patient managers on knowledge and skills in multi – or transdisciplinary pregnant patient management

Goal: To establish and develop an educational program for the patient managers on knowledge and skills in multi – or transdisciplinary pregnant patient management

Objectives:

1.        To design an educational program.

2.       To deploy and educate trainers on the educational program.

3.       To implement the educational program.

4.       To evaluate, review, and continually improve the program.

Expected Results:

Competent patient managers on management of pregnant patients (multi- or transdisciplinary)

Expected Outcomes:

No maternal deaths secondary to incompetent patient managers.

Methods or Interventions:

1.       To design an educational program.

2.       To deploy and educate trainers on the educational program.

3.       To implement the educational program.

4.       To evaluate, review, and continually improve the program.

Other Methods or Interventions:

 There must be a Deployment, Education and Implementation Plan on the educational program.

There must be an Evaluation, Review and Continual Improvement Plan on the educational program.

There must be monitoring of the results and impact of the educational program.

There must be a Document and Archiving Plan on the educational program.

There must be Management Review and Independent Audit Plan on the educational program.

Task List / Tracking List (Action Plan):

 

Person-in-Charge

Timelines

Budget

Task Force creation

     

Design of the educational program

     

Deployment and Education 

     

Implementation   

     

Evaluation, Review and Continual Improvement  

     

Documentation and Archiving

     

Management Review and Independent Audit

     

Criteria and Indicators for Performance Excellence on Educational Program for Patient Managers (Multi- or Transdisciplinary)

Criteria and Indicators for Performance Excellence on Educational Program for Patient Managers for Multi- or Transdisciplinary Management  of Pregnant Patients

Audit Results

Areas for Improvement

There is a design and development plan.

Documents and Records
AUDIT RESULTS:

 

There is a deployment, education, and implementation plan and implemented.

Documents and Records
AUDIT RESULTS:

 

There is evaluation, review, and continual improvement plan and implemented.

Documents and Records
AUDIT RESULTS:

 

There is documentation and archiving plan and implemented.

Documents and Records
AUDIT RESULTS:

 

There is management review and independent audit and implemented.

Documents and Records
AUDIT RESULTS:

 

The operational goals and objectives have been achieved.

Records:

Goal: To establish and develop an educational program for the patient managers on knowledge and skills in multi – or transdisciplinary pregnant patient management

Objectives:

1.       To design an educational program.

2.       To deploy and educate trainers on the educational program.

3.       To implement the educational program.

4.       To evaluate, review, and continually improve the program.

AUDIT RESULTS:

 

All patient managers have competency in multi- or transdisciplinary management of pregnant patients.

Records:

All have required competency

AUDIT RESULTS:

 

There is no maternal death secondary to incompetent patient managers.

Records:

No. of maternal deaths secondary to presence of incompetent patient managers

AUDIT RESULTS:

 

 5.6 Available and Safe Blood Blueprint

5.6.1.  Challenge: Lack and Unsafe Blood

Strategic Tag: Available and Safe Blood

Extended Cause Mapping (with operational definition of terms and description of the challenge)

First issue:

Blood is not available when needed for pregnant patients thereby causing maternal deaths.

Blood is not available and not readily available because there is no reserve of blood in the birthing facilities (such as there is no blood bank).

Blood is not available and not readily available because there are no or enough blood donors or there is wastage of blood

(overuse and spoilage; no effective system of efficient use).

There is not enough blood donors because of lack of effective system of blood donor recruitment.

Second Issue:

There is unsafe administration of blood and blood products causing maternal deaths.

There is no effective precautionary or safety measures in the administration of blood and blood products.

Description of the Challenge or Problem:

Lack of blood can lead to maternal deaths.

Unsafe use of blood can lead to maternal deaths. 

Situational Analysis:

How many pregnant patients have died for reason of non-availability of blood?

How many pregnant patients have died because of unsafe use of blood?

Is there a projected number of requirements of blood each month, each quarter, each year?  Is the projected number met with actual

number of reserved blood?

What is the incidence of irrational use of blood transfusion?

What is the incidence of spoilage of blood?

What is the incidence of adverse events related to blood use for pregnant patients?

  Assumptions:

Lack of blood can lead to maternal deaths.

Unsafe use of blood can lead to maternal deaths.

A.  Strategic Goals:

To ensure presence of adequate blood reserve for use in pregnant patients when needed so that no patients die because of lack of blood.

To ensure safety in blood transfusion in pregnant patients.

B.  Tactical Goals (Key Result Areas):

1.       To establish and develop a blood banking system in the birthing facility.

2.       To establish and develop a blood donor recruitment program.

3.       To develop and implement practice guidelines in the rational use of blood.

4.       To develop and implement practice guidelines in the safe use of blood.

Operational Plans based on Tactical Goals (KRAs)

See Operational Plans based on Tactical Goas (KRAs)

Criteria and Indicators for Performance Excellence of Available and Safe Blood

Criteria and Indicators for Performance Excellence on Available and Safe Blood

Audit Results

Areas for Improvement

There is a Task Force created to handle the available and safe blood initiative.

Records

Presence of a Task Force

AUDIT RESULTS:

 

There is a design and development plan for the strategic goals and for operational plans for each of the tactical goals.

Documents and Records

AUDIT RESULTS:

 

There is a deployment, education, and implementation plan and implemented.

Documents and Records

AUDIT RESULTS:

 

There is evaluation, review, and continual improvement plan and implemented.

Documents and Records

AUDIT RESULTS:

 

There is documentation and archiving plan and implemented.

Documents and Records

AUDIT RESULTS:

 

There is management review and independent audit and implemented.

Documents and Records

AUDIT RESULTS:

 

The operational goals and objectives for all the tactical goals have been achieved.

Records:

(see Operational goals and objectives for all the tactical goals)

AUDIT RESULTS:

 

The tactical goals (the key results areas) have all been achieved.

Records:

Tactical Goals (Key Result Areas):

1.       To establish and develop a blood banking system in the birthing facility.

2.       To establish and develop a blood donor recruitment program.

3.       To develop and implement practice guidelines in the rational use of blood.

4.       To develop and implement practice guidelines in the safe use of blood.

AUDIT RESULTS:

 

The strategic goals have been achieved.

Records:

Strategic Goals:

         To ensure presence of adequate blood reserve for use in pregnant patients when needed so that no patients die because of lack of blood.

         To ensure safety in blood transfusion in pregnant patients.

AUDIT RESULTS:

 

There is available blood reserve all the time.

Records:

Ever presence availability

AUDIT RESULTS:

 

 

There is a contingency plan whenever there is no available blood.

Records:

Presence of contingency plan

AUDIT RESULTS:

 

There are practice guidelines on the rational use of blood.

Records:

Presence of practice guidelines on rational use of essential medicines.

AUDIT RESULTS:

 

There are practice guidelines on safe use of blood.

Records:

Presence of practice guidelines on safe use of essential medicines.

AUDIT RESULTS:

 

There is no maternal death because of unavailability of blood.

Records:

No. of maternal deaths secondary to unavailability of blood

AUDIT RESULTS:

 

There is no maternal death because of unsafe blood transfusion.

Records:

No. of maternal deaths secondary to unsafe use of blood

AUDIT RESULTS:

 

 

C.  Tactical Goal (KRA): To establish and develop a blood banking system in the birthing  facility.

Goal: To establish and develop a blood banking system in the birthing facilities.

Objectives:

1.       To design a blood banking system in the birthing facility.

2.       To project the blood requirements of pregnant patients each month, each quarter, each year.

3.       To deploy and educate the blood banking system.

4.       To implement the blood banking system.

5.       To evaluate, review, and continually improve the blood banking system.

Expected Results:

An effective blood banking system that will ensure availability of blood in the birthing facility when needed which will include efficient use of blood and no spoilage of blood.

 Expected Outcomes:

No maternal deaths secondary to unavailability of blood.

Methods or Interventions:

1.       To design a blood banking system in the birthing facility.

2.       To project the blood requirements of pregnant patients each month, each quarter, each year.

3.       To deploy and educate the blood banking system.

4.       To implement the blood banking system.

5.       To evaluate, review, and continually improve the blood banking system.

Other Methods or Interventions:

There must be a Deployment, Education and Implementation Plan on the blood banking system.

There must be an Evaluation, Review and Continual Improvement Plan on the blood banking system.

There must be monitoring of the results and impact of the blood banking system.

There must be a Document and Archiving Plan on the blood banking system.

There must be Management Review and Independent Audit Plan on the blood banking system.

 Task List / Tracking List (Action Plan):

 

Person-in-Charge

Timelines

Budget

Task Force creation

     

Design of the blood banking system

     

Deployment and Education 

     

Implementation   

     

Evaluation, Review and Continual Improvement  

     

Documentation and Archiving

     

Management Review and Independent Audit

     

 Criteria and Indicators for Performance Excellence on Blood Banking System

Criteria and Indicators for Performance Excellence on Blood Banking System

Audit Results

Areas for Improvement

There is a design and development plan.

Documents and Records

AUDIT RESULTS:

 

There is a deployment, education, and implementation plan and implemented.

Documents and Records

AUDIT RESULTS:

 

There is evaluation, review, and continual improvement plan and implemented.

Documents and Records

AUDIT RESULTS:

 

There is documentation and archiving plan and implemented.

Documents and Records

AUDIT RESULTS:

 

There is management review and independent audit and implemented.

Documents and Records

AUDIT RESULTS:

 

The operational goals and objectives have been achieved.

Records:

Goal: To establish and develop a blood banking system in the birthing facilities.

Objectives:

1.       To design a blood banking system in the birthing facility.

2.       To project the blood requirements of pregnant patients each month, each quarter, each year.

3.       To deploy and educate the blood banking system.

4.       To implement the blood banking system.

5.       To evaluate, review, and continually improve the blood banking system.

AUDIT RESULTS:

 

There is a projection of the blood requirements of pregnant patients each month, each quarter, each year.

Records:

Presence of projection

AUDIT RESULTS

 

There is always a blood reserve for pregnant patients.

Records:

Ever presence availability

AUDIT RESULTS:

 

There is no wastage of blood (no spoilage and with efficient use of blood).

Records:

No wastage of blood

AUDIT RESULTS:

 

There is no maternal death secondary to non-availability of blood.

Records:

No. of maternal deaths secondary to non-availability of blood

AUDIT RESULTS:

 

  D.  Tactical Goal (KRA): To establish and develop a blood donor recruitment program.

Goal: To establish and develop a blood donor recruitment program.

Objectives:

1.       To project the blood requirements of pregnant patients each month, each quarter, each year.

2.       To design a blood donor recruitment program.

3.       To deploy and educate trainers on the blood donor recruitment program.

4.       To implement the blood donor recruitment program.

5.       To evaluate, review, and continually improve the blood donor recruitment program.

Expected Results:

Effective blood donor recruitment program – there is always enough reserve of blood for use of pregnant patients when needed.

Expected Outcomes:

No maternal deaths secondary to non-availability of blood.

 Methods or Interventions:

1.       To project the blood requirements of pregnant patients each month, each quarter, each year.

2.       To design a blood donor recruitment program.

3.       To deploy and educate trainers on the blood donor recruitment program.

4.       To implement the blood donor recruitment program.

5.       To evaluate, review, and continually improve the blood donor recruitment program.

Other Methods or Interventions:

There must be a Deployment, Education and Implementation Plan on the blood donor recruitment program.

There must be an Evaluation, Review and Continual Improvement Plan on the blood donor recruitment program.

There must be monitoring of the results and impact of blood donor recruitment program.

There must be a Document and Archiving Plan on the blood donor recruitment program.

There must be Management Review and Independent Audit Plan on the blood donor recruitment program.

Task List / Tracking List (Action Plan):

 

Person-in-Charge

Timelines

Budget

Task Force creation

     

Design of the blood donor recruitment program

     

Deployment and Education 

     

Implementation   

     

Evaluation, Review and Continual Improvement  

     

Documentation and Archiving

     

Management Review and Independent Audit

     

Criteria and Indicators for Performance Excellence on Blood Donor Recruitment Program

Criteria and Indicators for Performance Excellence on Blood Donor Recruitment Program

Audit Results

Areas for Improvement

There is a design and development plan.

Documents and Records

AUDIT RESULTS:

 

There is a deployment, education, and implementation plan and implemented.

Documents and Records

AUDIT RESULTS:

 

There is evaluation, review, and continual improvement plan and implemented.

Documents and Records

AUDIT RESULTS:

 

There is documentation and archiving plan and implemented.

Documents and Records

AUDIT RESULTS:

 

There is management review and independent audit and implemented.

Documents and Records

AUDIT RESULTS:

 

The operational goals and objectives have been achieved.

Records:

Goal: To establish and develop a blood donor recruitment program.

Objectives:

6.       To project the blood requirements of pregnant patients each month, each quarter, each year.

7.       To design a blood donor recruitment program.

8.       To deploy and educate trainers on the blood donor recruitment program.

9.       To implement the blood donor recruitment program.

10.   To evaluate, review, and continually improve the blood donor recruitment program.

AUDIT RESULTS:

 

There is a projection of the blood requirements of pregnant patients each month, each quarter, each year.

Records:

Presence of projection

AUDIT RESULTS:

 

There is an effective blood donor recruitment program.

Records:

Ever presence availability of blood

AUDIT RESULTS:

 

There is no maternal death secondary to non-availability of blood.

Records:

No. of maternal deaths secondary to non-availability of blood

AUDIT RESULTS:

 

 

 E.  Tactical Goal (KRA): To develop and implement practice guidelines in the rational use of blood.

Goal: To develop and implement practice guidelines in the rational use of blood.

Objectives:

1.       To develop practice guidelines in the rational use of blood.

2.       To deploy and educate the practice guidelines in the rational use of blood.

3.       To implement the practice guidelines in the rational use of blood.

4.       To evaluate, review, and continually improve the practice guidelines in the rational use of blood.

Expected Results:

There is rational use of blood.

Expected Outcomes:

No maternal deaths secondary to unavailability of blood due to irrational use of blood.

Methods or Interventions:

1.       To develop practice guidelines in the rational use of blood.

2.       To deploy and educate the practice guidelines in the rational use of blood.

3.       To implement the practice guidelines in the rational use of blood.

4.       To evaluate, review, and continually improve the practice guidelines in the rational use of blood. 

Other Methods or Interventions:

There must be a Deployment, Education and Implementation Plan on the practice guidelines in the rational use of blood.

There must be an Evaluation, Review and Continual Improvement Plan on the practice guidelines in the rational use of blood.

There must be monitoring of the results and impact of the practice guidelines in the rational use of blood.

There must be a Document and Archiving Plan on the practice guidelines in the rational use of blood.

There must be Management Review and Independent Audit Plan on the practice guidelines in the rational use of blood.

Task List / Tracking List (Action Plan):

 

Person-in-Charge

Timelines

Budget

Task Force creation

     

Development of the practice guidelines in the rational use of blood

     

Deployment and Education 

     

Implementation   

     

Evaluation, Review and Continual Improvement  

     

Documentation and Archiving

     

Management Review and Independent Audit

     

 Criteria and Indicators for Performance Excellence of Practice Guidelines in the Rational Use of Blood

Criteria and Indicators for Performance Excellence on Practice Guidelines in the Rational Use of Blood

Audit Results

Areas for Improvement

There is a design and development plan.

Documents and Records

AUDIT RESULTS:

 

There is a deployment, education, and implementation plan and implemented.

Documents and Records

AUDIT RESULTS:

 

There is evaluation, review, and continual improvement plan and implemented.

Documents and Records

AUDIT RESULTS:

 

There is documentation and archiving plan and implemented.

Documents and Records

AUDIT RESULTS:

 

There is management review and independent audit and implemented.

Documents and Records

AUDIT RESULTS:

 

The operational goals and objectives have been achieved.

Records:

 Goal: To develop and implement practice guidelines in the rational use of blood.

Objectives:

5.       To develop practice guidelines in the rational use of blood.

6.       To deploy and educate the practice guidelines in the rational use of blood.

7.       To implement the practice guidelines in the rational use of blood.

8.       To evaluate, review, and continually improve the practice guidelines in the rational use of blood.

AUDIT RESULTS:

 

There is rational use of blood.

Records:

No irrational use of blood

AUDIT RESULTS:

 

There is no maternal death secondary due to irrational use of blood.

Records:

No. of maternal deaths secondary to irrational use of blood

AUDIT RESULTS:

 

 F.  Tactical Goal (KRA): To develop and implement practice guidelines in the safe use of blood.

 

Goal: To develop and implement practice guidelines in the safe use of blood.

Objectives:

1.       To develop practice guidelines in the safe use of blood.

2.       To deploy and educate the practice guidelines in the safe use of blood.

3.       To implement the practice guidelines in the safe use of blood.

4.       To evaluate, review, and continually improve the practice guidelines in the safe use of blood.

Expected Results:

There is safe use of blood.

Expected Outcomes:

No maternal deaths secondary to unsafe use of blood.

Methods or Interventions:

1.       To develop practice guidelines in the safe use of blood.

2.       To deploy and educate the practice guidelines in the safe use of blood.

3.       To implement the practice guidelines in the safe use of blood.

4.       To evaluate, review, and continually improve the practice guidelines in the safe use of blood.

 Other Methods or Interventions:

There must be a Deployment, Education and Implementation Plan on the practice guidelines in the safe use of blood.

There must be an Evaluation, Review and Continual Improvement Plan on the practice guidelines in the safe use of blood.

There must be monitoring of the results and impact of the practice guidelines in the safe use of blood.

There must be a Document and Archiving Plan on the practice guidelines in the safe use of blood.

There must be Management Review and Independent Audit Plan on the practice guidelines in the safe use of blood stem.

 Task List / Tracking List (Action Plan):

 

Person-in-Charge

Timelines

Budget

Task Force creation

     

Development of the practice guidelines in the safe use of blood

     

Deployment and Education 

     

Implementation   

     

Evaluation, Review and Continual Improvement  

     

Documentation and Archiving

     

Management Review and Independent Audit

     

 

Criteria and Indicators for Performance Excellence of Practice Guidelines in the Safe Use of Blood

Criteria and Indicators for Performance Excellence on Practice Guidelines in the Safe Use of Blood

Audit Results

Areas for Improvement

There is a design and development plan.

Documents and Records

AUDIT RESULTS:

 

There is a deployment, education, and implementation plan and implemented.

Documents and Records

AUDIT RESULTS:

 

There is evaluation, review, and continual improvement plan and implemented.

Documents and Records

AUDIT RESULTS:

 

There is documentation and archiving plan and implemented.

Documents and Records

AUDIT RESULTS:

 

There is management review and independent audit and implemented.

Documents and Records

AUDIT RESULTS:

 

The operational goals and objectives have been achieved.

Records:

Goal: To develop and implement practice guidelines in the safe use of blood.

Objectives:

5.       To develop practice guidelines in the safe use of blood.

6.       To deploy and educate the practice guidelines in the safe use of blood.

7.       To implement the practice guidelines in the safe use of blood.

8.       To evaluate, review, and continually improve the practice guidelines in the safe use of blood.

AUDIT RESULTS:

 

There is safe use of blood.

Records:

No. of adverse and sentinel events secondary to use of blood

AUDIT RESULTS:

 

There is no maternal death secondary to unsafe use of blood.

Records:

No. of maternal deaths secondary to unsafe use of blood

AUDIT RESULTS:

 

 

  

5.7 Available and Safe Essential Medicines  Blueprint

Challenge: Lack and Unsafe Essential Medicines

Strategic Tag: Available and Safe Essential Medicines

Extended Cause Mapping (with operational definition of terms and description of the challenge)

First issue:

Essential medicines are not available when needed for pregnant patients thereby causing maternal deaths.

Essential medicines are not available and not readily available because there is no reserve of essential medicines in the birthing facilities.

Essential medicines are not available and not readily available because there is no fund for them or there is wastage of essential medicines (overuse and spoilage; no effective system of efficient use).

Second Issue:

There is unsafe administration of essential medicines causing maternal deaths.

There is effective precautionary or safety measures in the administration of essential medicines.

 

Description of the Challenge or Problem:

Lack of essential medicines can lead to maternal deaths.

Unsafe use of essential medicines can lead to maternal deaths.

 

Situational Analysis:

How many pregnant patients have died for reason of non-availability of essential medicines?

How many pregnant patients have died because of unsafe use of essential medicines?

Is there a projected number of requirements of essential medicines each month, each quarter, each year? 

Is the projected number met with actual number of reserved blood?

What is the incidence of irrational use of essential medicines?

What is the incidence of spoilage of essential medicines?

What is the incidence of adverse events related to essential medicines use for pregnant patients?

Assumptions:

Lack of essential medicines can lead to maternal deaths.

Unsafe use of essential medicines can lead to maternal deaths.

A.  Strategic Goals:

To ensure presence of adequate essential medicines reserve for use in pregnant patients when needed

so that no patients die because of lack of essential medicines.

To ensure safety in essential medicines use in pregnant patients.

B.  Tactical Goals (Key Result Areas):

1.       To establish and develop an inventory system of essential medicines in the birthing facility.

2.       To develop and implement practice guidelines in the rational and safe use of essential medicines.

Operational Plans based on Tactical Goals (KRAs)

See Operational Plans based on Tactical Goals (KRAs)

Criteria and Indicators for Performance Excellence of Available and Safe Essential Medicines

Criteria and Indicators for Performance Excellence on Available and Safe Essential Medicines

Audit Results

Areas for Improvement

There is a Task Force created to handle the available and safe essential medicines initiative.

Records

Presence of a Task Force

AUDIT RESULTS:

 

There is a design and development plan for the strategic goals and for operational plans for each of the tactical goals.

Documents and Records

AUDIT RESULTS:

 

There is a deployment, education, and implementation plan and implemented.

Documents and Records

AUDIT RESULTS:

 

There is evaluation, review, and continual improvement plan and implemented.

Documents and Records

AUDIT RESULTS:

 

There is documentation and archiving plan and implemented.

Documents and Records

AUDIT RESULTS:

 

There is management review and independent audit and implemented.

Documents and Records

AUDIT RESULTS:

 

The operational goals and objectives for all the tactical goals have been achieved.

Records:

(see Operational goals and objectives for all the tactical goals)

AUDIT RESULTS:

 

The tactical goals (the key results areas) have all been achieved.

Records:

1.       To establish and develop an inventory system of essential medicines in the birthing facility.

2.       To develop and implement practice guidelines in the rational and safe use of essential medicines.

AUDIT RESULTS:

 

The strategic goals have been achieved.

Records:

Strategic Goals:

         To ensure presence of adequate essential medicines reserve for use in pregnant patients when needed so that no patients die because of lack of essential medicines.

         To ensure safety in essential medicines use in pregnant patients.

AUDIT RESULTS:

 

There is available essential medicines all the time.

Records:

Ever presence availability

AUDIT RESULTS:

 

There is a contingency plan whenever there is no available special diagnostic equipment.

Records:

Presence of contingency plan

AUDIT RESULTS:

 

There are practice guidelines on the rational and safe use of essential medicines.

Records:

Presence of practice guidelines on rational and safe use of essential medicines.

AUDIT RESULTS:

 

There is no maternal death because of unavailability of essential medicines.

Records:

No. of maternal deaths secondary to unavailability of essential medicines

AUDIT RESULTS:

 

There is no maternal death because of unsafe use of essential medicines.

Records:

No. of maternal deaths secondary to unsafe use of essential medicines

AUDIT RESULTS:

 

  C.  Tactical Goal (KRA): To establish and develop an inventory system of essential medicines in the birthing facility.

Goal: To establish and develop an inventory system of essential medicines in the birthing facilities.

Objectives:

1.       To design an inventory system of essential medicines in the birthing facility.

2.       To project the essential medicines requirements of pregnant patients each month, each quarter, each year.

3.       To deploy and educate the inventory system of essential medicines.

4.       To implement the inventory system of essential medicines.

5.       To evaluate, review, and continually improve the inventory system of essential medicines.

Expected Results:

An effective inventory system of essential medicines that will ensure availability of essential medicines in the birthing facility when needed which will include efficient use and no spoilage of medicines.

 Expected Outcomes:

No maternal deaths secondary to unavailability of essential medicines.

Methods or Interventions:

1.       To design an inventory system of essential medicines in the birthing facility.

2.       To project the essential medicines requirements of pregnant patients each month, each quarter, each year.

3.       To deploy and educate the inventory system of essential medicines.

4.       To implement the inventory system of essential medicines.

5.       To evaluate, review, and continually improve the inventory system of essential medicines.

 Other Methods or Interventions:

There must be a Deployment, Education and Implementation Plan on the inventory system of essential medicines.

There must be an Evaluation, Review and Continual Improvement Plan on the inventory system of essential medicines.

There must be monitoring of the results and impact of the inventory system of essential medicines.

There must be a Document and Archiving Plan on the inventory system of essential medicines.

There must be Management Review and Independent Audit Plan on the inventory system of essential medicines.

 Task List / Tracking List (Action Plan):

 

Person-in-Charge

Timelines

Budget

Task Force creation

     

Design of the inventory system of essential medicines

     

Deployment and Education 

     

Implementation   

     

Evaluation, Review and Continual Improvement  

     

Documentation and Archiving

     

Management Review and Independent Audit

     

Criteria and Indicators for Performance Excellence on Inventory System of Essential Medicines

Criteria and Indicators for Performance Excellence on Inventory System of Essential Medicines

Audit Results

Areas for Improvement

There is a design and development plan.

Documents and Records
AUDIT RESULTS:

 

There is a deployment, education, and implementation plan and implemented.

Documents and Records
AUDIT RESULTS:

 

There is evaluation, review, and continual improvement plan and implemented.

Documents and Records
AUDIT RESULTS:

 

There is documentation and archiving plan and implemented.

Documents and Records
AUDIT RESULTS:

 

There is management review and independent audit and implemented.

Documents and Records
AUDIT RESULTS:

 

The operational goals and objectives have been achieved.

Records:

Goal: To establish and develop an inventory system of essential medicines in the birthing facilities.

Objectives:

1.       To design an inventory system of essential medicines in the birthing facility.

2.       To project the essential medicines requirements of pregnant patients each month, each quarter, each year.

3.       To deploy and educate the inventory system of essential medicines.

4.       To implement the inventory system of essential medicines.

5.       To evaluate, review, and continually improve the inventory system of essential medicines.

AUDIT RESULTS:

 

There is a projection of the essential medicine requirements of pregnant patients each month, each quarter, each year.

Records:

Presence of projection
AUDIT RESULTS:

 

There is always essential medicines reserve for pregnant patients.

Records:

Presence of reserve 
AUDIT RESULTS:

 

There is no wastage of essential medicines (no spoilage and with efficient use of medicines).

Records:

No wastage

AUDIT RESULTS:

 

There is no maternal death secondary to non-availability of essential medicines.

Records:

No. of maternal deaths secondary to non-availability of essential medicines
AUDIT RESULTS:

 

 

 D.  Tactical Goal (KRA): To develop and implement practice guidelines in the rational and safe use of essential medicines.

Goal: To develop and implement practice guidelines in the rational and safe use of essential medicines.

Objectives:

1.       To develop practice guidelines in the rational and safe use of essential medicines.

2.       To deploy and educate the practice guidelines in the rational and safe use of essential medicines.

3.       To implement the practice guidelines in the rational and safe use of essential medicines.

4.       To evaluate, review, and continually improve the practice guidelines in the rational and safe use of essential medicines.

Expected Results:

There is rational and safe use of essential medicines.

Expected Outcomes:

No maternal deaths secondary to irrational and unsafe use of essential medicines.

 

Methods or Interventions:

1.       To develop practice guidelines in the rational and safe use of essential medicines.

2.       To deploy and educate the practice guidelines in the rational and safe use of essential medicines.

3.       To implement the practice guidelines in the rational and safe use of essential medicines.

4.       To evaluate, review, and continually improve the practice guidelines in the rational and safe use of essential medicines.

Other Methods or Interventions:

There must be a Deployment, Education and Implementation Plan on the practice guidelines in the rational and safe use of essential medicines.

There must be an Evaluation, Review and Continual Improvement Plan on the practice guidelines in the rational and safe use of essential medicines.

There must be monitoring of the results and impact of the practice guidelines in the rational and safe use of essential medicines.

There must be a Document and Archiving Plan on the practice guidelines in the rational and safe use of essential medicines.

There must be Management Review and Independent Audit Plan on the practice guidelines in the rational and safe use of essential medicines. 

Task List / Tracking List (Action Plan):

 

Person-in-Charge

Timelines

Budget

Task Force creation

     

Development of the practice guidelines in the rational and safe use of essential medicines

     

Deployment and Education 

     

Implementation   

     

Evaluation, Review and Continual Improvement  

     

Documentation and Archiving

     

Management Review and Independent Audit

     

 Criteria and Indicators for Performance Excellence of Practice Guidelines in the Rational and

 Safe Use of Essential Medicines

Criteria and Indicators for Performance Excellence on Practice Guidelines in the Rational and Safe Use of Essential Medicines

Audit Results

Areas for Improvement

There is a design and development plan.

Documents and Records

AUDIT RESULTS:

 

There is a deployment, education, and implementation plan and implemented.

Documents and Records

AUDIT RESULTS:

 

There is evaluation, review, and continual improvement plan and implemented.

Documents and Records

AUDIT RESULTS:

 

There is documentation and archiving plan and implemented.

Documents and Records

AUDIT RESULTS:

 

There is management review and independent audit and implemented.

Documents and Records

AUDIT RESULTS:

 

The operational goals and objectives have been achieved.

Records:

Goal: To develop and implement practice guidelines in the rational and safe use of essential medicines.

Objectives:

1. To develop practice guidelines in the rational and safe use of essential medicines.

2. To deploy and educate the practice guidelines in the rational and safe use of essential medicines.

3. To implement the practice guidelines in the rational and safe use of essential medicines.

4. To evaluate, review, and continually improve the practice guidelines in the rational and safe use of essential medicines.

AUDIT RESULTS:

 

There is rational and safe use of essential medicines.

Records:

No. of adverse and sentinel events secondary to irrational and unsafe use of essential medicines

AUDIT RESULTS:

 

There is no maternal death secondary to irrational and unsafe use of medicines.

Records:

No. of maternal deaths secondary to irrational and unsafe use of essential medicine

AUDIT RESULTS

 

  

5.8   Lack and Unsafe Essential Medical Supplies  Blueprint

5.8.1 Challenge: Lack and Unsafe Essential Medical Supplies

Strategic Tag: Available and Safe Essential Medical Supplies

Extended Cause Mapping (with operational definition of terms and description of the challenge)

First issue:

Essential medical supplies are not available when needed for pregnant patients thereby causing maternal deaths.

Essential medical supplies are not available and not readily available because there is no reserve of essential medical supplies in the birthing facilities.

Essential medical supplies are not available and not readily available because there is no fund for them or there is wastage of essential medical supplies (overuse and spoilage; no effective system of efficient use). 

Second Issue:

There is unsafe administration of essential medical supplies causing maternal deaths.

There is no effective precautionary or safety measures in the administration of essential medical supplies. 

Description of the Challenge or Problem:

Lack of essential medical supplies can lead to maternal deaths.

Unsafe use of essential medical supplies can lead to maternal deaths.

Situational Analysis:

How many pregnant patients have died for reason of non-availability of essential medical supplies?

How many pregnant patients have died because of unsafe use of essential medical supplies?

Is there a projected number of requirements of essential medical supplies each month, each quarter,

each year?  Is the projected number met with actual number of reserved essential medical supplies?

What is the incidence of irrational use of essential medical supplies?

What is the incidence of spoilage of essential medical supplies?

What is the incidence of adverse events related to essential medical supplies use for pregnant patients?

Assumptions:

Lack of essential medical supplies can lead to maternal deaths.

Unsafe use of essential medical supplies can lead to maternal deaths.

A.  Strategic Goals:

To ensure presence of adequate essential medical supplies reserve for use in pregnant patients

when needed so that no patients die because of lack of essential medical supplies.

To ensure safety in essential medical supplies use in pregnant patients.

 B.  Tactical Goals (Key Result Areas):

1.       To establish and develop an inventory system of essential medical supplies in the birthing facility.

2.       To develop and implement practice guidelines in the rational and safe use of essential medical supplies.

Operational Plans based on Tactical Goals (KRAs)

See Operational Plans based on Tactical Goas (KRAs)

Criteria and Indicators for Performance Excellence of Available and Safe Essential Medical

Supplies

Criteria and Indicators for Performance Excellence on Available and Safe Essential Medical Supplies

Audit Results

Areas for Improvement

There is a Task Force created to handle the available and safe essential medical supplies initiative.

Records

Presence of a Task Force

AUDIT RESULTS:

 

There is a design and development plan for the strategic goals and for operational plans for each of the tactical goals.

Documents and Records

AUDIT RESULTS:

 

There is a deployment, education, and implementation plan and implemented.

Documents and Records

AUDIT RESULTS:

 

There is evaluation, review, and continual improvement plan and implemented.

Documents and Records

AUDIT RESULTS:

 

There is documentation and archiving plan and implemented.

Documents and Records

AUDIT RESULTS:

 

There is management review and independent audit and implemented.

Documents and Records

AUDIT RESULTS:

 

The operational goals and objectives for all the tactical goals have been achieved.

Records:

(see Operational goals and objectives for all the tactical goals)

AUDIT RESULTS:

 

The tactical goals (the key results areas) have all been achieved.

Records:

Tactical Goals (Key Result Areas):

1.       To establish and develop an inventory system of essential medical supplies in the birthing facility.

2.       To develop and implement practice guidelines in the rational and safe use of essential medical supplies.

AUDIT RESULTS:

 

The strategic goals have been achieved.

Records:

Strategic Goals:

         To ensure presence of adequate essential medical supplies reserve for use in pregnant patients when needed so that no patients die because of lack of essential medical supplies.

         To ensure safety in essential medical supplies use in pregnant patients.

AUDIT RESULTS:

 

There is available essential medical supplies all the time.

Records:

Ever presence availability

AUDIT RESULTS:

 

There is a contingency plan whenever there is no available medical supplies.

Records:

Presence of contingency plan

AUDIT RESULTS:

 

There are practice guidelines on the rational and safe use of essential medical supplies.

Records:

Presence of practice guidelines on rational and safe use of essential medical supplies.

AUDIT RESULTS:

 

There is no maternal death because of unavailability of essential medical supplies.

Records:

No. of maternal deaths secondary to unavailability of essential medical supplies.

AUDIT RESULTS:

 

There is no maternal death because of unsafe use of essential medical supplies.

Records:

No. of maternal deaths secondary to unsafe use of essential medical supplies.

AUDIT RESULTS:

 

 C.  Tactical Goal (KRA): To establish and develop an inventory system of essential medical supplies in the birthing facility.

Goal: To establish and develop an inventory system of essential medical supplies in the birthing facilities.

Objectives:

1.       To design an inventory system of essential medical supplies in the birthing facility.

2.       To project the essential medical supplies requirements of pregnant patients each month, each quarter, each year.

3.       To deploy and educate the inventory system of essential medical supplies.

4.       To implement the inventory system of essential medical supplies.

5.       To evaluate, review, and continually improve the inventory system of essential medical supplies.

Expected Results:

An effective inventory system of essential medical supplies that will ensure availability of essential medical supplies in the birthing facility when needed which will include efficient use and nospoilage of medical supplies.

 Expected Outcomes:

No maternal deaths secondary to unavailability of essential medical supplies.

Methods or Interventions:

1.        To design an inventory system of essential medical supplies in the birthing facility.

2.       To project the essential medical supplies requirements of pregnant patients each month, each quarter, each year.

3.       To deploy and educate the inventory system of essential medical supplies.

4.       To implement the inventory system of essential medical supplies.

5.       To evaluate, review, and continually improve the inventory system of essential medical supplies.

 Other Methods or Interventions:

There must be a Deployment, Education and Implementation Plan on the inventory system ofessential medical supplies.

There must be an Evaluation, Review and Continual Improvement Plan on the inventory system of essential medical supplies.

There must be monitoring of the results and impact of the inventory system of essential medical supplies.

There must be a Document and Archiving Plan on the inventory system of essential medical supplies.

There must be Management Review and Independent Audit Plan on the inventory system of essential medical supplies.

Task List / Tracking List (Action Plan):

 

Person-in-Charge

Timelines

Budget

Task Force creation

     

Design of the inventory system of essential medical supplies

     

Deployment and Education 

     

Implementation   

     

Evaluation, Review and Continual Improvement  

     

Documentation and Archiving

     

Management Review and Independent Audit

     

 

 

 

Criteria and Indicators for Performance Excellence on Inventory System of Essential

Medical Supplies

Criteria and Indicators for Performance Excellence on Inventory System of Essential Medical Supplies

Audit Results

Areas for Improvement

There is a design and development plan.

Documents and Records
AUDIT RESULTS:

 

There is a deployment, education, and implementation plan and implemented.

Documents and Records
AUDIT RESULTS:

 

There is evaluation, review, and continual improvement plan and implemented.

Documents and Records
AUDIT RESULTS:

 

There is documentation and archiving plan and implemented.

Documents and Records
AUDIT RESULTS:

 

There is management review and independent audit and implemented.

Documents and Records
AUDIT RESULTS:

 

The operational goals and objectives have been achieved.

Records:

Goal: To establish and develop an inventory system of essential medical supplies in the birthing facilities.

Objectives:

1.       To design an inventory system of essential medical supplies in the birthing facility.

2.       To project the essential medical supplies requirements of pregnant patients each month, each quarter, each year.

3.       To deploy and educate the inventory system of essential medical supplies.

4.       To implement the inventory system of essential medical supplies.

5.       To evaluate, review, and continually improve the inventory system of essential medical supplies.

AUDIT RESULTS:

 

There is a projection of the essential medicine requirements of pregnant patients each month, each quarter, each year.

Records:

Presence of projection
AUDIT RESULTS:

 

There is always essential medical supplies reserve for pregnant patients.

Records:

Presence of reserve 
AUDIT RESULTS:

 

There is no wastage of essential medical supplies (no spoilage and with efficient use of medical supplies).

Records:

No wastage

AUDIT RESULTS:

 

There is no maternal death secondary to non-availability of essential medical supplies.

Records:

No. of maternal deaths secondary to non-availability of essential medical supplies
AUDIT RESULTS:

 

 D.  Tactical Goal (KRA): To develop and implement practice guidelines in the rational and safe use of essential medical supplies.

Goal: To develop and implement practice guidelines in the rational and safe use of essential medical supplies.

Objectives:

1.       To develop practice guidelines in the rational and safe use of essential medical supplies.

2.       To deploy and educate the practice guidelines in the rational and safe use of essential medical supplies.

3.       To implement the practice guidelines in the rational and safe use of essential medical supplies.

4.       To evaluate, review, and continually improve the practice guidelines in the rational and safe use of essential medical supplies.

Expected Results:

There is rational and safe use of essential medical supplies.

Expected Outcomes:

No maternal deaths secondary to irrational and unsafe use of essential medical supplies.

Methods or Interventions:

1.       To develop practice guidelines in the rational and safe use of essential medical supplies.

2.       To deploy and educate the practice guidelines in the rational and safe use of essential medical supplies.

3.       To implement the practice guidelines in the rational and safe use of essential medical supplies.

4.       To evaluate, review, and continually improve the practice guidelines in the rational and safe use of essential medical supplies.

Other Methods or Interventions:

There must be a Deployment, Education and Implementation Plan on the practice guidelines in the rational and safe use of essential medical supplies.

There must be an Evaluation, Review and Continual Improvement Plan on the practice guidelines in the rational and safe use of essential medical supplies.

There must be monitoring of the results and impact of the practice guidelines in the rational and safe use of essential medical supplies.

There must be a Document and Archiving Plan on the practice guidelines in the rational and safe use of essential medical supplies.

There must be Management Review and Independent Audit Plan on the practice guidelines in the rational and safe use of essential medical supplies.

Task List / Tracking List (Action Plan):

 

Person-in-Charge

Timelines

Budget

Task Force creation

     

Development of the practice guidelines in the rational and safe use of essential medical supplies

     

Deployment and Education 

     

Implementation   

     

Evaluation, Review and Continual Improvement  

     

Documentation and Archiving

     

Management Review and Independent Audit

     

 Criteria and Indicators for Performance Excellence of Practice Guidelines in the Rational and Safe Use of Essential Medical Supplies

Criteria and Indicators for Performance Excellence on Practice Guidelines in the Rational and Safe Use of Essential Medical Supplies

Audit Results

Areas for Improvement

There is a design and development plan.

Documents and Records

AUDIT RESULTS:

 

There is a deployment, education, and implementation plan and implemented.

Documents and Records

AUDIT RESULTS:

 

There is evaluation, review, and continual improvement plan and implemented.

Documents and Records

AUDIT RESULTS:

 

There is documentation and archiving plan and implemented.

Documents and Records

AUDIT RESULTS:

 

There is management review and independent audit and implemented.

Documents and Records

AUDIT RESULTS:

 

The operational goals and objectives have been achieved.

Records:

Goal: To develop and implement practice guidelines in the rational and safe use of essential medical supplies.

Objectives:

1.       To develop practice guidelines in the rational and safe use of essential medical supplies.

2.       To deploy and educate the practice guidelines in the rational and safe use of essential medical supplies.

3.       To implement the practice guidelines in the rational and safe use of essential medical supplies.

4.       To evaluate, review, and continually improve the practice guidelines in the rational and safe use of essential medical supplies.

AUDIT RESULTS:

 

There is rational and safe use of essential medical supplies.

Records:

No. of adverse and sentinel events secondary to irrational and unsafe use of essential medical supplies

AUDIT RESULTS:

 

There is no maternal death secondary to irrational and unsafe use of medical supplies.

Records:

No. of maternal deaths secondary to irrational and unsafe use of medical supplies

AUDIT RESULTS:

 

 

  

5.9  Available and Safe Essential Medical Supplies Blueprint

Challenge: Lack and Unsafe Essential Medical Supplies

Strategic Tag: Available and Safe Essential Medical Supplies

Extended Cause Mapping (with operational definition of terms and description of the challenge)

First issue:

Essential medical supplies are not available when needed for pregnant patients thereby causing maternal deaths.

Essential medical supplies are not available and not readily available because there is no reserve of essential medical supplies in the birthing facilities.

Essential medical supplies are not available and not readily available because there is no fund for them or there is wastage of essential medical supplies (overuse and spoilage; no effective system of efficient use).

 Second Issue:

There is unsafe administration of essential medical supplies causing maternal deaths.

There is no effective precautionary or safety measures in the administration of essential medical supplies.

 Description of the Challenge or Problem:

Lack of essential medical supplies can lead to maternal deaths.

Unsafe use of essential medical supplies can lead to maternal deaths.

 Situational Analysis:

How many pregnant patients have died for reason of non-availability of essential medical supplies?

How many pregnant patients have died because of unsafe use of essential medical supplies?

Is there a projected number of requirements of essential medical supplies each month, each quarter, each year?  Is the projected number met with actual number of reserved essential medical supplies?

What is the incidence of irrational use of essential medical supplies?

What is the incidence of spoilage of essential medical supplies?

What is the incidence of adverse events related to essential medical supplies use for pregnant patients?

  Assumptions:

Lack of essential medical supplies can lead to maternal deaths.

Unsafe use of essential medical supplies can lead to maternal deaths.

 A.  Strategic Goals:

To ensure presence of adequate essential medical supplies reserve for use in pregnant patients when needed so that no patients die because of lack of essential medical supplies.

To ensure safety in essential medical supplies use in pregnant patients.

 B.  Tactical Goals (Key Result Areas):

1.       To establish and develop an inventory system of essential medical supplies in the birthing facility.

2.       To develop and implement practice guidelines in the rational and safe use of essential medical supplies.

Operational Plans based on Tactical Goals (KRAs)

See Operational Plans based on Tactical Goas (KRAs)

Criteria and Indicators for Performance Excellence of Available and Safe Essential Medical Supplies

Criteria and Indicators for Performance Excellence on Available and Safe Essential Medical Supplies

Audit Results

Areas for Improvement

There is a Task Force created to handle the available and safe essential medical supplies initiative.

Records

Presence of a Task Force

AUDIT RESULTS:

 

There is a design and development plan for the strategic goals and for operational plans for each of the tactical goals.

Documents and Records

AUDIT RESULTS:

 

There is a deployment, education, and implementation plan and implemented.

Documents and Records

AUDIT RESULTS:

 

There is evaluation, review, and continual improvement plan and implemented.

Documents and Records

AUDIT RESULTS:

 

There is documentation and archiving plan and implemented.

Documents and Records

AUDIT RESULTS:

 

There is management review and independent audit and implemented.

Documents and Records

AUDIT RESULTS:

 

The operational goals and objectives for all the tactical goals have been achieved.

Records:

(see Operational goals and objectives for all the tactical goals)

AUDIT RESULTS:

 

The tactical goals (the key results areas) have all been achieved.

Records:

Tactical Goals (Key Result Areas):

1.       To establish and develop an inventory system of essential medical supplies in the birthing facility.

2.       To develop and implement practice guidelines in the rational and safe use of essential medical supplies.

AUDIT RESULTS:

 

The strategic goals have been achieved.

Records:

Strategic Goals:

         To ensure presence of adequate essential medical supplies reserve for use in pregnant patients when needed so that no patients die because of lack of essential medical supplies.

         To ensure safety in essential medical supplies use in pregnant patients.

AUDIT RESULTS:

 

There is available essential medical supplies all the time.

Records:

Ever presence availability

AUDIT RESULTS:

 

There is a contingency plan whenever there is no available medical supplies.

Records:

Presence of contingency plan

AUDIT RESULTS:

 

There are practice guidelines on the rational and safe use of essential medical supplies.

Records:

Presence of practice guidelines on rational and safe use of essential medical supplies.

AUDIT RESULTS:

 

There is no maternal death because of unavailability of essential medical supplies.

Records:

No. of maternal deaths secondary to unavailability of essential medical supplies.

AUDIT RESULTS:

 

There is no maternal death because of unsafe use of essential medical supplies.

Records:

No. of maternal deaths secondary to unsafe use of essential medical supplies.

AUDIT RESULTS:

 

 C.  Tactical Goal (KRA): To establish and develop an inventory system of essential medical supplies in the birthing facility.

Goal: To establish and develop an inventory system of essential medical supplies in the birthing facilities.

Objectives:

1.       To design an inventory system of essential medical supplies in the birthing facility.

2.       To project the essential medical supplies requirements of pregnant patients each month, each quarter, each year.

3.       To deploy and educate the inventory system of essential medical supplies.

4.       To implement the inventory system of essential medical supplies.

5.       To evaluate, review, and continually improve the inventory system of essential medical supplies.

Expected Results:

An effective inventory system of essential medical supplies that will ensure availability of essential medical supplies in the birthing facility when needed which will include efficient use and no spoilage of medical supplies.

 Expected Outcomes:

No maternal deaths secondary to unavailability of essential medical supplies.

Methods or Interventions:

1.        To design an inventory system of essential medical supplies in the birthing facility.

2.       To project the essential medical supplies requirements of pregnant patients each month, each quarter, each year.

3.       To deploy and educate the inventory system of essential medical supplies.

4.       To implement the inventory system of essential medical supplies.

5.       To evaluate, review, and continually improve the inventory system of essential medical supplies.

Other Methods or Interventions:

There must be a Deployment, Education and Implementation Plan on the inventory system of essential medical supplies.

There must be an Evaluation, Review and Continual Improvement Plan on the inventory system of essential medical supplies.

There must be monitoring of the results and impact of the inventory system of essential medical supplies.

There must be a Document and Archiving Plan on the inventory system of essential medical supplies.

There must be Management Review and Independent Audit Plan on the inventory system of essential medical supplies.

Task List / Tracking List (Action Plan):

 

Person-in-Charge

Timelines

Budget

Task Force creation

     

Design of the inventory system of essential medical supplies

     

Deployment and Education 

     

Implementation   

     

Evaluation, Review and Continual Improvement  

     

Documentation and Archiving

     

Management Review and Independent Audit

     

Criteria and Indicators for Performance Excellence on Inventory System of Essential Medical Supplies

Criteria and Indicators for Performance Excellence on Inventory System of Essential Medical Supplies

Audit Results

Areas for Improvement

There is a design and development plan.

Documents and Records
AUDIT RESULTS:

 

There is a deployment, education, and implementation plan and implemented.

Documents and Records
AUDIT RESULTS:

 

There is evaluation, review, and continual improvement plan and implemented.

Documents and Records
AUDIT RESULTS:

 

There is documentation and archiving plan and implemented.

Documents and Records
AUDIT RESULTS:

 

There is management review and independent audit and implemented.

Documents and Records
AUDIT RESULTS:

 

The operational goals and objectives have been achieved.

Records:

Goal: To establish and develop an inventory system of essential medical supplies in the birthing facilities.

Objectives:

1.       To design an inventory system of essential medical supplies in the birthing facility.

2.       To project the essential medical supplies requirements of pregnant patients each month, each quarter, each year.

3.       To deploy and educate the inventory system of essential medical supplies.

4.       To implement the inventory system of essential medical supplies.

5.       To evaluate, review, and continually improve the inventory system of essential medical supplies.

AUDIT RESULTS:

 

There is a projection of the essential medicine requirements of pregnant patients each month, each quarter, each year.

Records:

Presence of projection
AUDIT RESULTS:

 

There is always essential medical supplies reserve for pregnant patients.

Records:

Presence of reserve 
AUDIT RESULTS:

 

There is no wastage of essential medical supplies (no spoilage and with efficient use of medical supplies).

Records:

No wastage

AUDIT RESULTS:

 

There is no maternal death secondary to non-availability of essential medical supplies.

Records:

No. of maternal deaths secondary to non-availability of essential medical supplies
AUDIT RESULTS:

 

 D.  Tactical Goal (KRA): To develop and implement practice guidelines in the rational and safe use of essential medical supplies.

Goal: To develop and implement practice guidelines in the rational and safe use of essential medical supplies.

Objectives:

1.       To develop practice guidelines in the rational and safe use of essential medical supplies.

2.       To deploy and educate the practice guidelines in the rational and safe use of essential medical supplies.

3.       To implement the practice guidelines in the rational and safe use of essential medical supplies.

4.       To evaluate, review, and continually improve the practice guidelines in the rational and safe use of essential medical supplies.

Expected Results:

There is rational and safe use of essential medical supplies.

Expected Outcomes:

No maternal deaths secondary to irrational and unsafe use of essential medical supplies.

Methods or Interventions:

1.       To develop practice guidelines in the rational and safe use of essential medical supplies.

2.       To deploy and educate the practice guidelines in the rational and safe use of essential medical supplies.

3.       To implement the practice guidelines in the rational and safe use of essential medical supplies.

4.       To evaluate, review, and continually improve the practice guidelines in the rational and safe use of essential medical supplies.

Other Methods or Interventions:

There must be a Deployment, Education and Implementation Plan on the practice guidelines in the rational and safe use of essential medical supplies.

There must be an Evaluation, Review and Continual Improvement Plan on the practice guidelines in the rational and safe use of essential medical supplies.

There must be monitoring of the results and impact of the practice guidelines in the rational and safe use of essential medical supplies.

There must be a Document and Archiving Plan on the practice guidelines in the rational and safe use of essential medical supplies.

There must be Management Review and Independent Audit Plan on the practice guidelines in the rational and safe use of essential medical supplies.

Task List / Tracking List (Action Plan):

 

Person-in-Charge

Timelines

Budget

Task Force creation

     

Development of the practice guidelines in the rational and safe use of essential medical supplies

     

Deployment and Education 

     

Implementation   

     

Evaluation, Review and Continual Improvement  

     

Documentation and Archiving

     

Management Review and Independent Audit

     

 Criteria and Indicators for Performance Excellence of Practice Guidelines in the Rational and Safe Use of Essential Medical Supplies

Criteria and Indicators for Performance Excellence on Practice Guidelines in the Rational and Safe Use of Essential Medical Supplies

Audit Results

Areas for Improvement

There is a design and development plan.

Documents and Records

AUDIT RESULTS:

 

There is a deployment, education, and implementation plan and implemented.

Documents and Records

AUDIT RESULTS:

 

There is evaluation, review, and continual improvement plan and implemented.

Documents and Records

AUDIT RESULTS:

 

There is documentation and archiving plan and implemented.

Documents and Records

AUDIT RESULTS:

 

There is management review and independent audit and implemented.

Documents and Records

AUDIT RESULTS:

 

The operational goals and objectives have been achieved.

Records:

Goal: To develop and implement practice guidelines in the rational and safe use of essential medical supplies.

Objectives:

1.       To develop practice guidelines in the rational and safe use of essential medical supplies.

2.       To deploy and educate the practice guidelines in the rational and safe use of essential medical supplies.

3.       To implement the practice guidelines in the rational and safe use of essential medical supplies.

4.       To evaluate, review, and continually improve the practice guidelines in the rational and safe use of essential medical supplies.

AUDIT RESULTS:

 

There is rational and safe use of essential medical supplies.

Records:

No. of adverse and sentinel events secondary to irrational and unsafe use of essential medical supplies

AUDIT RESULTS:

 

There is no maternal death secondary to irrational and unsafe use of medical supplies.

Records:

No. of maternal deaths secondary to irrational and unsafe use of medical supplies

AUDIT RESULTS:

 

 

  5.10  Available and Safe Essential Treatment Equipment Blueprint

Challenge: Lack and Unsafe Essential Treatment Equipment

Strategic Tag: Available and Safe Essential Treatment Equipment

Extended Cause Mapping (with operational definition of terms and description of the challenge)

First issue:

Essential treatment equipment are not available when needed for pregnant patients thereby

causing maternal deaths.

Second Issue:

There is unsafe use of essential treatment equipment causing maternal deaths.

Description of the Challenge or Problem:

Lack of essential treatment equipment can lead to maternal deaths.

Unsafe use of essential treatment equipment can lead to maternal deaths.

 Situational Analysis:

How many pregnant patients have died for reason of non-availability of essential treatment equipment?

How many pregnant patients have died because of unsafe use of essential treatment equipment?

Is there a projected number of requirements of essential treatment equipment each month, each quarter, each year?  Is the projected number met with essential treatment equipment?

What is the incidence of irrational use of essential treatment equipment?

What is the incidence of adverse and sentinel events related to unsafe essential treatment equipment use for pregnant patients?

Is there calibration and preventive maintenance of essential treatment equipment?

Is there corrective management of defective essential treatment equipment?

 Assumptions:

Lack of essential treatment equipment can lead to maternal deaths.

Unsafe use of essential treatment equipment can lead to maternal deaths.

 A.  Strategic Goals:

To ensure presence of adequate essential treatment equipment for use in pregnant patients

when needed so that no patients die because of lack of essential treatment equipment.

To ensure safety in essential treatment equipment use in pregnant patients.

 B.  Tactical Goals (Key Result Areas):

1.       To establish and develop an inventory system of essential treatment equipment in the  birthing facility.

2.       To develop and implement practice guidelines in the rational and safe use of essential treatment equipment.

C.  Operational Plans based on Tactical Goals (KRAs)

See Operational Plans based on Tactical Goals (KRAs)

Criteria and Indicators for Performance Excellence of Available and Safe Essential

Treatment Equipment

Criteria and Indicators for Performance Excellence on Available and Safe Essential Treatment Equipment

Audit Results

Areas for Improvement

There is a Task Force created to handle the available and safe essential treatment equipment initiative.

Records:

Presence of a Task Force

AUDIT RESULTS:

 

There is a design and development plan for the strategic goals and for operational plans for each of the tactical goals.

Documents and Records

AUDIT RESULTS:

 

There is a deployment, education, and implementation plan and implemented.

Documents and Records

AUDIT RESULTS:

 

There is evaluation, review, and continual improvement plan and implemented.

Documents and Records

AUDIT RESULTS:

 

There is documentation and archiving plan and implemented.

Documents and Records

AUDIT RESULTS:

 

There is management review and independent audit and implemented.

Documents and Records

AUDIT RESULTS:

 

The operational goals and objectives for all the tactical goals have been achieved.

Records:

(see Operational goals and objectives for all the tactical goals)

AUDIT RESULTS:

 

The tactical goals (the key results areas) have all been achieved.

Records:

Tactical Goals (Key Result Areas):

1. To establish and develop an inventory system of essential treatment equipment in the birthing facility.

2. To develop and implement practice guidelines in the rational and safe use of essential treatment equipment.

AUDIT RESULTS:

 

The strategic goals have been achieved.

Records:

Strategic Goals:

1.       To ensure presence of adequate essential treatment equipment for use in pregnant patients when needed so that no patients die because of lack of essential treatment equipment.

2.       To ensure safety in essential treatment equipment use in pregnant patients.

AUDIT RESULTS:

 

There is available essential treatment equipment all the time.

Records:

Ever presence availability

AUDIT RESULTS:

 

There is a contingency plan whenever there is no available special treatment equipment.

Records:

Presence of contingency plan

AUDIT RESULTS:

 

There are practice guidelines on the rational and safe use of essential treatment equipment.

Records:

Presence of practice guidelines on rational and safe use of essential treatment equipment.

AUDIT RESULTS:

 

There is no maternal death because of unavailability of essential treatment equipment.

Records:

No. of maternal deaths secondary to unavailability of essential treatment equipment.

AUDIT RESULTS:

 

There is no maternal death because of unsafe use of essential treatment equipment.

Records:

No. of maternal deaths secondary to unsafe use of essential treatment equipment.

AUDIT RESULTS:

 

 

  D.  Tactical Goal (KRA): To establish and develop an inventory system of essential treatment equipment in the birthing facility.

Goal: To establish and develop an inventory system of essential treatment equipment in the birthing facilities.

Objectives:

1.       To design an inventory system of essential treatment equipment in the birthing facility.

2.       To project the essential treatment equipment requirements of pregnant patients each month, each quarter, each year.

3.       To have regular calibration and preventive maintenance of essential treatment equipment.

4.       To deploy and educate the inventory system of essential treatment equipment.

5.       To implement the inventory system of essential treatment equipment.

6.       To evaluate, review, and continually improve the inventory system of essential treatment equipment.

Expected Results:

An effective inventory system of essential medical supplies that will ensure availability of essential medical supplies in the birthing facility when needed which will include efficient use and no spoilage of medical supplies.

 Expected Outcomes:

No maternal deaths secondary to unavailability of essential medical supplies.

Methods or Interventions:

1.       To design an inventory system of essential treatment equipment in the birthing facility.

2.       To project the essential treatment equipment requirements of pregnant patients each month, each quarter, each year.

3.       To have regular calibration and preventive maintenance of essential treatment equipment.

4.       To deploy and educate the inventory system of essential treatment equipment.

5.       To implement the inventory system of essential treatment equipment.

6.       To evaluate, review, and continually improve the inventory system of essential treatment equipment.

Other Methods or Interventions:

There must be a Deployment, Education and Implementation Plan on the inventory system of essential treatment equipment.

There must be an Evaluation, Review and Continual Improvement Plan on the inventory system of essential treatment equipment.

There must be monitoring of the results and impact of the inventory system of essential treatment equipment.

There must be a Document and Archiving Plan on the inventory system of essential treatment equipment.

There must be Management Review and Independent Audit Plan on the inventory system of essential treatment equipment.

 Task List / Tracking List (Action Plan):

 

Person-in-Charge

Timelines

Budget

Task Force creation

     

Design of the inventory system of essential treatment equipment

     

Deployment and Education 

     

Implementation   

     

Evaluation, Review and Continual Improvement  

     

Documentation and Archiving

     

Management Review and Independent Audit

     

 Criteria and Indicators for Performance Excellence on Inventory System of Essential

Treatment Equipment

Criteria and Indicators for Performance Excellence on Inventory System of Essential Treatment Equipment

Audit Results

Areas for Improvement

There is a design and development plan.

Documents and Records
AUDIT RESULTS:

 

There is a deployment, education, and implementation plan and implemented.

Documents and Records
AUDIT RESULTS:

 

There is evaluation, review, and continual improvement plan and implemented.

Documents and Records
AUDIT RESULTS:

 

There is documentation and archiving plan and implemented.

Documents and Records
AUDIT RESULTS:

 

There is management review and independent audit and implemented.

Documents and Records
AUDIT RESULTS:

 

The operational goals and objectives have been achieved.

Records: Goal: To establish and develop an inventory system of essential treatment equipment in the birthing facilities.

Objectives:

1. To design an inventory system of essential treatment equipment in the birthing facility.

2. To project the essential treatment equipment requirements of pregnant patients each month, each quarter, each year.

3. To have regular calibration and preventive maintenance of essential treatment equipment.

4. To deploy and educate the inventory system of essential treatment equipment.

5. To implement the inventory system of essential treatment equipment.

6. To evaluate, review, and continually improve the inventory system of essential treatment equipment.
AUDIT RESULTS:

 

There is a projection of the essential treatment equipment requirements of pregnant patients each month, each quarter, each year.

Records:

Presence of projection
AUDIT RESULTS:

 

There is always essential treatment equipment reserve for pregnant patients.

Records:

Presence of reserve 
AUDIT RESULTS:

 

There is regular calibration and preventive maintenance of essential treatment equipment.

Records:

Regular calibration

Regular preventive maintenance
AUDIT RESULTS:

 

There is no maternal death secondary to non-availability of essential treatment equipment.

Records:

No. of maternal deaths secondary to non-availability of essential treatment equipment
AUDIT RESULTS:

 

 E.  Tactical Goal (KRA): To develop and implement practice guidelines in the rational and safe use of essential treatment equipment.

Goal: To develop and implement practice guidelines in the rational and safe use of essential treatment equipment.

Objectives:

1.       To develop practice guidelines in the rational and safe use of essential treatment equipment.

2.       To deploy and educate the practice guidelines in the rational and safe use of essential treatment equipment.

3.       To implement the practice guidelines in the rational and safe use of essential treatment equipment.

4.       To evaluate, review, and continually improve the practice guidelines in the rational and safe use of essential treatment equipment.

Expected Results:

There is rational and safe use of essential treatment equipment.

Expected Outcomes:

No maternal deaths secondary to irrational and unsafe use of essential treatment equipment.

Methods or Interventions:

1.        To develop practice guidelines in the rational and safe use of essential treatment equipment.

2.       To deploy and educate the practice guidelines in the rational and safe use of essential treatment equipment.

3.       To implement the practice guidelines in the rational and safe use of essential treatment equipment.

4.       To evaluate, review, and continually improve the practice guidelines in the rational and safe use of essential treatment equipment.

 Other Methods or Interventions:

There must be a Deployment, Education and Implementation Plan on the practice guidelines inthe rational and safe use of essential treatment equipment.

There must be an Evaluation, Review and Continual Improvement Plan on the practice guidelinesin the rational and safe use of essential treatment equipment.

There must be monitoring of the results and impact of the practice guidelines in the rational and safe use of essential treatment equipment.

There must be a Document and Archiving Plan on the practice guidelines in the rational and safeuse of essential treatment equipment.

There must be Management Review and Independent Audit Plan on the practice guidelines inthe rational and safe use of essential treatment equipment.

 Task List / Tracking List (Action Plan):

 

Person-in-Charge

Timelines

Budget

Task Force creation

     

Development of the practice guidelines in the rational and safe use of essential treatment equipment

     

Deployment and Education 

     

Implementation   

     

Evaluation, Review and Continual Improvement  

     

Documentation and Archiving

     

Management Review and Independent Audit

     

 Criteria and Indicators for Performance Excellence of Practice Guidelines in the Rational and Safe Use of Essential Treatment Equipment

Criteria and Indicators for Performance Excellence on Practice Guidelines in the Rational and Safe Use of Essential Treatment Equipment

Audit Results

Areas for Improvement

There is a design and development plan.

Documents and Records

AUDIT RESULTS:

 

There is a deployment, education, and implementation plan and implemented.

Documents and Records

AUDIT RESULTS:

 

There is evaluation, review, and continual improvement plan and implemented.

Documents and Records

AUDIT RESULTS:

 

There is documentation and archiving plan and implemented.

Documents and Records

AUDIT RESULTS:

 

There is management review and independent audit and implemented.

Documents and Records

AUDIT RESULTS:

 

The operational goals and objectives have been achieved.

Records:

Goal: To develop and implement practice guidelines in the rational and safe use of essential treatment equipment.

Objectives:

1. To develop practice guidelines in the rational and safe use of essential treatment equipment.

2. To deploy and educate the practice guidelines in the rational and safe use of essential treatment equipment.

3. To implement the practice guidelines in the rational and safe use of essential treatment equipment.

4. To evaluate, review, and continually improve the practice guidelines in the rational and safe use of essential treatment equipment.

AUDIT RESULTS:

 

There is rational and safe use of essential treatment equipment.

Records:

No. of adverse and sentinel events secondary to irrational and unsafe use of essential treatment equipment

AUDIT RESULTS:

 

There is no maternal death secondary to irrational and unsafe use of treatment equipment.

Records:

No. of maternal deaths secondary to irrational and unsafe use of treatment equipment

AUDIT RESULTS: