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
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Criteria and Indicators |
Status(Attained; Maintaining; Not Attained Yet) |
Areas for Improvement with Action Plans |
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Goals |
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Zero maternal deaths |
Zero maternal deaths |
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Quality and safe maternal care services |
Zero sentinel events |
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Customer satisfaction rating on maternal care services 90% or greater |
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Objectives |
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See Authorized Functions of Maternal Death Control Management System |
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Authorized Functions of Maternal Death Control Management System Team
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Authorized Functions |
Criteria and Indicators |
Status(Attained; Maintaining; Not Attained Yet) |
Areas for Improvement with Action Plans |
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To strategize on how to control maternal death. |
Presence of a 3-year strategic plan |
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To formulate policies and procedures in controlling maternal death. |
Design and development blueprint containing policies and procedures in place |
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To deploy the design and development blueprint in controlling maternal death. |
Deployment plan implemented |
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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 |
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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 |
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Continual improvement being identified and being implemented |
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To formulate and implement a documentation and an archiving plans. |
Documentation plan being implemented |
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Archiving plan being implemented |
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To formulate and implement a management review and an independent audit plans. |
Management review plan being implemented |
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Independent audit plan being implemented |
3-year strategic plans of the Maternal Death Control Management System
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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 |
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Networking |
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Strategic objectives (spelled out) |
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Education of the Public |
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Strategic objectives |
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Availability of Skilled Health Professionals |
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Strategic objectives |
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Competency of Skilled Health Professionals |
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Strategic objectives |
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Blood |
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Strategic objectives |
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Medicines |
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Strategic objectives |
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Medical Supplies |
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Strategic objectives |
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Diagnostic Equipment |
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Strategic objectives |
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Treatment Equipment |
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Strategic objectives |
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Indigency Program |
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Strategic objectives |
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OTHERS |
Annual operational plans of the Maternal Control Management System (for the year)
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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 |
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Networking |
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Strategic objectives (spelled out) |
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Education of the Public |
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Strategic objectives |
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Availability of Skilled Health Professionals |
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Strategic objectives |
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Competency of Skilled Health Professionals |
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Strategic objectives |
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Blood |
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Strategic objectives |
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Medicines |
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Strategic objectives |
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Medical Supplies |
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Strategic objectives |
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Diagnostic Equipment |
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Strategic objectives |
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Treatment Equipment |
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Strategic objectives |
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Indigency Program |
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Strategic objectives |
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OTHERS |
Results of action plans for continual improvement derived from last Evaluation, Review and Continual Improvement Meeting
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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 |
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Results of action plans for continual improvement derived from last management review
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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 |
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Maternal Death Review
Total number of direct maternal deaths:
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Year |
DOA |
ER Deaths |
In-patient (<48 hours) |
In-patient (>48 hours) |
TotalDOA / ER Death |
Total Inpatient |
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2010 |
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2011 |
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2012 |
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2013 |
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2014 |
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2015 (Monthly) |
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2016 (Monthly) |
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2017 (Monthly) |
Total number of indirect maternal deaths:
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Year |
DOA |
ER Deaths |
In-patient (<48 hours) |
In-patient (>48 hours) |
TotalDOA / ER Death |
Total Inpatient |
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2010 |
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2011 |
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2012 |
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2013 |
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2014 |
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2015 (Monthly) |
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2016 (Monthly) |
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2017 (Monthly) |
Total number of coincidental maternal deaths:
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Year |
Coincidental Deaths |
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2010 |
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2011 |
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2012 |
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2013 |
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2014 |
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2015 (Monthly) |
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2016 (Monthly) |
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2017 (Monthly) |
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Year |
Gross Direct Maternal Death Rate |
Net Direct Maternal Death Rate |
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2010 |
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2011 |
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2012 |
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2013 |
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2014 |
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2015 (Monthly) |
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2016 (Monthly) |
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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
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Underlying causes of death(direct maternal death) |
2010 |
2011 |
2012 |
2013 |
2014 |
2015 (Monthly) |
2016 (Monthly) |
2017 (Monthly) |
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Abortive outcome |
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Hypertensive disorders |
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Obstetric hemorrhage |
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Pregnancy-related infection |
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Unanticipated complications of management (severe adverse effects and other unanticipated complications of medical and surgical care) |
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Others |
Contributory Causes of Direct Maternal Death
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Contributory causes of death (direct maternal death) |
2010 |
2011 |
2012 |
2013 |
2014 |
2015 (Monthly) |
2016 (Monthly) |
2017 (Monthly) |
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Man (non-availability of skilled health attendants / professionals) |
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Method (poor quality maternal care services) |
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Machine (lack of proper infrastructure, equipment, blood, drugs, etc.) |
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Money(indigency of patients) |
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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
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2015 (Monthly) |
2016 (Monthly) |
2017 (Monthly) |
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Maternal Adverse Events (Non-Sentinel Events) |
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Enumerate |
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Maternal Sentinel Events |
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Deaths |
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Coma |
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Maternal Near-miss events |
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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)
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Audit Criteria(set of policies, procedures, or requirements) |
Audit Evidence |
Suggested Areas for Improvement |
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Discussion on action plans for areas of improvement after the Evaluation, Review and Continual Improvement Activities
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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)
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Proposed changes in Manual of Operations of Maternal Death Control Management System |
Action (Approved; Disapproved; Hold) |
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Original items |
Proposed changes |
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Summary of proceedings (Tasks List – Tasks to Do)
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Tasks List |
Person-in-charge |
Timeline |
Budget (if any) |
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Tasks Done |
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Tasks to Do |
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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:
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Criteria and Indicators for Performance Excellence of Evaluation, Review and Continual Improvement Meeting |
Audit Results |
Areas for Improvement |
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An Evaluation, Review and Continual Improvement Meeting is being held regularly at planned intervals (every month). |
Minutes |
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The Chairperson or his designated representative has always been in attendance. |
Minutes |
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Contents of Evaluation, Review and Continual Improvement Meeting are adequate (based on prescribed contents). |
Minutes |
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Areas for continual improvement are being identified. |
Minutes |
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Action plans are clearly formulated for every areas of continual improvement. |
Minutes |
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Summary of Evaluation, Review and Continual Improvement Meetings is presented to the Management Review once every 3 months. |
Minutes |
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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 |