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8.0  Evaluation, Review and Continual Improvement Plans

After the implementation of the Maternal Death Control Management System blueprint, evaluation, review and continual improvement shall be done during monthly meeting of the Maternal Death Control Management System Team.

The policies and procedures outlined in the Evaluation, Review and Continual Improvement Plans shall be followed with adjustments when indicated.

Evaluation, Review and Continual Improvement of Maternal Death Control Management System

1. The purpose of an Evaluation, Review, and Continual Improvement is to keep track of the implementation of the Maternal Death Control Management System and evaluate it on a monthly basis; to review the overall performance of the Maternal Death Control Management System; and to identify improvement opportunities.

2. The Evaluation, Review and Continual Improvement is carried out by the Maternal Death Control Management System Team.

3. The Evaluation, Review and Continual Improvement is done on a regular basis (monthly).

4. There shall be minutes of the Evaluation, Review and Continual Improvement meetings.

5. The following are the prescribed minimum agenda of Evaluation, Review and Continual Improvement meetings:

Agenda:

1.      Goals and objectives of Maternal Death Control Management System (Evaluation and    Identification of Areas for Improvement)

2.       Authorized functions of the Maternal Death Control Management System Team (Evaluation and Identification of Areas for Improvement)

3.       3-year strategic plans of the Maternal Death Control Management System (Evaluation and Identification of Areas for Improvement)

4.       Annual operational plans of the Maternal Death Control Management System (Evaluation and Identification of Areas for Improvement)

5.       Result of action plans for continual improvement derived from last Evaluation, Review and Continual Improvement meeting and last management review (Evaluation and Identification of Areas for Improvement)

6.       Maternal Death Review for the Month and Year to Date (Evaluation and Identification of Areas for Improvement)

7.       Maternal Adverse, Sentinel, Near-Miss Events Review for the Month and Year to Date (Evaluation and Identification of Areas for Improvement)

8.       Statistics on Maternal Care Services for the Month and Year to Date

9.      Customer Feedback (Pregnant Patients) for the Month and Year to Date

10.   Results of independent audits (if done)

11.     Discussion on action plans for areas of improvement after Evaluation, Review and Continual Improvement activities.

12.   Proposed changes in Manual of Operations of Maternal Death Control Management System (if any)

13   Summary of proceedings (Tasks List – Tasks to Do)

The following are the prescribed templates for data and information presentation:

Goals and Objectives

 

Criteria and Indicators

Status(Attained; Maintaining; Not Attained Yet)

Areas for Improvement with Action Plans

Goals

     

Zero maternal deaths 

Zero maternal deaths

   

Quality and safe maternal care services

Zero sentinel events

   
 

Customer satisfaction rating on maternal care services 90% or greater

   

Objectives

     

See Authorized Functions of Maternal Death Control Management System

     
       

Authorized Functions of Maternal Death Control Management System Team

Authorized Functions

Criteria and Indicators

Status(Attained; Maintaining; Not Attained Yet)

Areas for Improvement with Action Plans

To strategize on how to control maternal death.

Presence of a 3-year strategic plan

   

To formulate policies and procedures in controlling maternal death.

Design and development blueprint containing policies and procedures in place

   

To deploy the design and development blueprint in controlling maternal death.

Deployment plan implemented

   

To supervise the implementation of the blueprint in controlling maternal death.

Supervision and tracking of implementation of design and development plan being done as evidenced by monthly evaluation

   

To evaluate and review the implementation outcomes of the blueprint and then formulate a continual improvement action plan.

Monthly evaluation and review of implementation plan being done

   
 

Continual improvement being identified and being implemented

   

To formulate and implement a documentation and an archiving plans.

Documentation plan being implemented

   
 

Archiving plan being implemented

   

To formulate and implement a management review and an independent audit plans.

Management review plan being implemented

   
 

Independent audit plan being implemented

   

3-year strategic plans of the Maternal Death Control Management System 

Strategic Plans – Goals - Objectives

Criteria and Indicators of Accomplishment

Status(Completed; Maintaining; Not Completed Yet; Not Being Implemented Yet)

Areas for Improvement with Action Plans

Networking

     

Strategic objectives (spelled out)

     

Education of the Public

     

Strategic objectives

     

Availability of Skilled Health Professionals

     

Strategic objectives

     

Competency of Skilled Health Professionals

     

Strategic objectives

     

Blood

     

Strategic objectives

     

Medicines

     

Strategic objectives

     

Medical Supplies

     

Strategic objectives

     

Diagnostic Equipment

     

Strategic objectives

     

Treatment Equipment

     

Strategic objectives

     

Indigency Program

     

Strategic objectives

     

OTHERS

     

 Annual operational plans of the Maternal Control Management System (for the year)

Annual Operational Plans (derived from 3-year Strategic Plans – Goals – Objectives)

Criteria and Indicators of Accomplishment

Status(Completed; Maintaining; Not Completed Yet; Not Being Implemented Yet)

Areas for Improvement with Action Plans

Networking

     

Strategic objectives (spelled out)

     

Education of the Public

     

Strategic objectives

     

Availability of Skilled Health Professionals

     

Strategic objectives

     

Competency of Skilled Health Professionals

     

Strategic objectives

     

Blood

     

Strategic objectives

     

Medicines

     

Strategic objectives

     

Medical Supplies

     

Strategic objectives

     

Diagnostic Equipment

     

Strategic objectives

     

Treatment Equipment

     

Strategic objectives

     

Indigency Program

     

Strategic objectives

     

OTHERS

     

Results of action plans for continual improvement derived from last Evaluation, Review and Continual Improvement Meeting

Areas for Continual Improvement (from last Evaluation, Review and Continual Improvement Meeting) – Date: xxxxxx

Action Plans

Criteria and Indicators of Accomplishment

Status

(Completed; Maintaining; Not Completed Yet; Not Being Implemented Yet)

Areas for Improvement with Action Plans

 

     
       
       
       

Results of action plans for continual improvement derived from last management review

Areas for Continual Improvement (from last Management Review) – Date: xxxxxx

Action Plans

Criteria and Indicators of Accomplishment

Status

(Completed; Maintaining; Not Completed Yet; Not Being Implemented Yet)

Areas for Improvement with Action Plans

 

     
       
       
       

 Maternal Death Review

Total number of direct maternal deaths:

Year

DOA

ER Deaths

In-patient (<48 hours)

In-patient (>48 hours)

TotalDOA / ER Death

Total Inpatient

2010

           

2011

           

2012

           

2013

           

2014

           

2015 (Monthly)

           

2016 (Monthly)

           

2017 (Monthly)

           

 Total number of indirect maternal deaths:

Year

DOA

ER Deaths

In-patient (<48 hours)

In-patient (>48 hours)

TotalDOA / ER Death

Total Inpatient

2010

           

2011

           

2012

           

2013

           

2014

           

2015 (Monthly)

           

2016 (Monthly)

           

2017 (Monthly)

           

Total number of coincidental maternal deaths:

Year

Coincidental Deaths

2010

 

2011

 

2012

 

2013

 

2014

 

2015 (Monthly)

 

2016 (Monthly)

 

2017 (Monthly)

 

Year

Gross Direct Maternal Death Rate

Net Direct Maternal Death Rate

2010

   

2011

   

2012

   

2013

   

2014

   

2015 (Monthly)

   

2016 (Monthly)

   

2017 (Monthly)

   

 Formulas and Definition of Terms:

Gross direct maternal death rate (admitted excluding DOA and ER deaths)

= [Total No. of direct maternal deaths for the period / Total No. of maternal (OB) discharges (including deaths) for the period] x 100

Net direct maternal death rate (admitted excluding DOA and ER deaths)

= [Total Direct Deaths– Deaths under 48 hrs. for the period] / [Total No. of Discharges (including deaths) - {deaths under 48 hours for the period}] x 100

 DEAD ON ARRIVAL (DOA)

- are patients brought to the Emergency Room of Hospital, Birthing Home and Rural Health Unit without cardio-pulmonary and brain functions. This will include patients who did not respond to initial resuscitation. 

“ER” DEATH 

 - refers to death of patients who arrived at the Emergency Room of Hospital, Birthing Home or Rural Health Unit with no detectable vital signs (BP, HR, RR ) but revived by initial resuscitative measures, but eventually died, regardless of the time of stay.  (derived from DOH Manual of Standards and Guidelines on the Management of the Hospital Emergency)

 Underlying Causes of Direct Maternal Death

Underlying causes of death(direct maternal death)

2010

2011

2012

2013

2014

2015 (Monthly)

2016

(Monthly)

2017

(Monthly)

Abortive outcome

               

Hypertensive disorders

               

Obstetric hemorrhage

               

Pregnancy-related infection

               

Unanticipated complications of management (severe adverse effects and other unanticipated complications of medical and surgical care) 

               

Others

               

 

Contributory Causes of Direct Maternal Death

Contributory causes of death

(direct maternal death)

2010

2011

2012

2013

2014

2015 (Monthly)

2016

(Monthly)

2017

(Monthly)

Man (non-availability of skilled health attendants / professionals)

               

Method (poor quality maternal care services)

               

Machine (lack of proper infrastructure, equipment, blood, drugs, etc.)

               

Money(indigency of patients)

               

Others (place factors)

               

For each year, for each month, in each box, based on your experience, preferably based on data (if available), place 0 to 3, with 0 = did not contribute to direct maternal death; 1 = sometimes; 2 = often times; 3 = most of the times.

 Maternal Adverse, Sentinel, Near-Miss Events Review for the Quarter and Year to Date

 

2015 (Monthly)

2016 (Monthly)

2017 (Monthly)

Maternal Adverse Events (Non-Sentinel Events)

 

   

Enumerate

     
       

Maternal Sentinel Events

     

Deaths

     

Coma

     
       

Maternal Near-miss events

     

Describe

     

Statistics on Maternal Care Services

Total number of in-facility deliveries

Total number of vaginal deliveries

Total number of live-birth vaginal deliveries (normal)

Total number of Caesarian-section deliveries

Total number of live-birth C-section deliveries (Caesarians)

Total number of other deliveries

Total number of antenatal care visits

Total number of postnatal care visits

Customer Feedback (Pregnant Patients)

Customer Satisfaction Rating
Customer Expression of Delights
Customer Expression of Dissatisfaction

 

Results of independent audits (if done)

Audit Criteria(set of policies, procedures, or requirements)

Audit Evidence

Suggested Areas for Improvement

 

 

 

 

 

 

 

 

 

Discussion on action plans for areas of improvement after the Evaluation, Review and Continual Improvement Activities

Areas of Improvement after Evaluation, Review and Continual Improvement Activities

Action Plans

Person-in-charge

Timeline

Budget

         
         
         
         

 Proposed changes in Manual of Operations of Maternal Death Control Management System (if any)

Proposed changes in Manual of Operations of Maternal Death Control Management System

Action

(Approved; Disapproved; Hold)

Original items

Proposed changes

 
     
     

Summary of proceedings (Tasks List – Tasks to Do)

Tasks List

Person-in-charge

Timeline

Budget (if any)

Tasks Done

     
       
       
       

Tasks to Do

     

 

     

 

     

 

     

7. A summary of the outcome of the Evaluation, Review and Continual Improvement Meeting is presented in the Management Review at regular intervals (every 3 months).

8. The following are the minimum criteria and indicators to be used for performance excellence of Evaluation, Review and Continual Improvement Meeting:

Criteria and Indicators for Performance Excellence of Evaluation, Review and Continual Improvement Meeting

Audit Results

Areas for Improvement

An Evaluation, Review and Continual Improvement Meeting is being held regularly at planned intervals (every month).

Minutes

 

The Chairperson or his designated representative has always been in attendance.

Minutes

 

Contents of Evaluation, Review and Continual Improvement Meeting are adequate (based on prescribed contents).

Minutes

 

Areas for continual improvement are being identified.

Minutes

 

Action plans are clearly formulated for every areas of continual improvement.

Minutes

 

Summary of Evaluation, Review and Continual Improvement Meetings is presented to the Management Review once every 3 months.

Minutes

 

There is continual improvement on the Maternal Death Control Management System as a result of the Evaluation, Review and Continual Improvement Meeting – particularly on Maternal Death Statistics and Adverse, Sentinel, and Near-Miss Events

Minutes