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10.0 Management Reviews and Independent Audit Plans

The policies and procedures outlined in the Management Reviews and Independent Audit Plans shall be followed with adjustments when indicated.

Management Review of Maternal Death Control Management System

1. The purpose of a Management Review is to evaluate the overall performance of the Maternal Death Control Management System and to identify improvement opportunities.

2. The review is carried out by the governing body or top management or the senior management representative.

3. The review is done on a regular basis (every 3 months).

4. There shall be minutes of the Management Reviews.

5. The following are the prescribed minimum agenda of Management Reviews:

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 management review (Evaluation and Identification of Areas for Improvement)

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

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

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

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

10.   Results of independent audits (if done

11.    Results of independent audits (if done)

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:

Vision, Mission & Goals

 

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 Team

     
       

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 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)

Total

DOA / ER Death

Total Inpatient

2010

           

2011

           

2012

           

2013

           

2014

           

2015 (Jan-Mar)

           

2015 (Apr-Jun)

           

2015 (Jul-Aug)

           

2015 (Sep-Dec)

           

2016

           

 Total number of indirect maternal deaths:

Year

DOA

ER Deaths

In-patient (<48 hours)

In-patient (>48 hours)

Total

DOA / ER Death

Total Inpatient

2010

           

2011

           

2012

           

2013

           

2014

           

2015 (Jan-Mar)

           

2015 (Apr-Jun)

           

2015 (Jul-Aug)

           

2015 (Sep-Dec)

           

2016

           

Total number of coincidental maternal deaths:

Year

Coincidental Deaths

2010

 

2011

 

2012

 

2013

 

2014

 

2015 (Jan-Mar)

 

2015 (Apr-Jun)

 

2015 (Jul-Aug)

 

2015 (Sep-Dec)

 

2016

 

Year

Gross Direct Maternal Death Rate

Net Direct Maternal Death Rate

2010

   

2011

   

2012

   

2013

   

2014

   

2015 (Jan-Mar)

   

2015 (Apr-Jun)

   

2015 (Jul-Aug)

   

2015 (Sep-Dec)

   

2016

   

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 (Jan-Mar)

2015

(Apr-Jun)

2015

(Jul-Aug)

2015

(Sep-Dec)

2016

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 (Jan-Mar)

2015

(Apr-Jun)

2015

(Jul-Aug)

2015

(Sep-Dec)

2016

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

                   

Method (poor quality maternal care services)

                   

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

                   

Money (indigency of patients)

                   

Others (place factors)

                   

For each year, for each quarter, 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 (Jan-Mar)

2015 (Apr – Jun)

2015 (Jul – Sep)

2015 (Oct – Dec)

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 Management Review

Areas of Improvement after the Management Review

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

     

 

     

 

     

 Criteria and Indicators for Performance Excellence of Management Review

7. The following are the minimum criteria and indicators to be used for performance excellence of management review:

Criteria and Indicators for Performance Excellence of Management Reviews

Audit Results

Areas for Improvement

A management review is being held regularly at planned intervals (every 3 months).

Minutes

 

The governing body or top management or the senior management representative has always been in attendance.

Minutes

 

Contents of management review 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

 

There is continual improvement on the Maternal Death Control Management System as a result of the management review - showing continual improvement on Maternal Death Statistics and Adverse, Sentinel, and Near-Miss Events

Minutes

 

Independent Audits

Audit is a “systematic, independent and documented process for obtaining audit evidence and evaluating it objectively to determine the extent to which audit criteria are fulfilled". *(ISO 9000:2005)

Persons who conduct an audit are auditors.  Auditors can be internal or external auditors.  Internal auditors are those belonging to the organization for which an audit is going to be made, meaning insiders.  External auditors are those not belonging to the organization for which an audit is going to be made, meaning outsiders. 

Internal and external auditors are expected to conduct “independent” audits.  There is no problem with external auditors as they are coming from outside the organization.  For internal auditors, to be independent, they should not be involved in the program or project they will be auditing.  

Thus, independent audits can be done by internal and external auditors.

Independent Audits of Maternal Death Control Management System

1. There shall be independent audits of the Maternal Death Control Management System at planned intervals.

2. There shall be internal independent audits of the Maternal Death Control Management System at least once a year.

3. There shall be external independent audits of the Maternal Death Control Management System at least once every 3 years.

4. For internal independent audits, internal staff not involved in the Maternal Death Control Management System do the auditing.

5. For internal independent audits, the processes used for obtaining audit evidence and evaluating it objectively to determine the extent to which audit criteria are fulfilled, are at least 1) documentation inspection; 2) interview for needed data both from the Maternal Death Control Management System Team itself and from outside the Team, especially, recipients of maternal care services; and 3) observation on how the System and the Team are functioning based on the authorized functions and vision-mission-goals of the Maternal Death Control Management System.

6. For internal independent audits, a tracer methodology will also be used. See Tracer Methodology for Maternal Death Control Management System.

7. For internal independent audits, checklists on audit criteria and indicators for performance excellence shall be used.  See checklists on audit criteria and indicators for performance excellence on Maternal Death Control Management System.

8. For external independent audits, the processes used for obtaining audit evidence and evaluating it objectively to determine the extent to which audit criteria are fulfilled, will be dependent on the policies and procedures of the external auditors. 

9. The results of the independent audits, both internal and external audits, shall be presented in a management review.

10. The following are the minimum criteria and indicators for performance excellence of independent audits:

Criteria and Indicators for Performance Excellence of Independent Audits

Criteria and Indicators for Performance Excellence of Independent Audits

Audit Results

Areas for Improvement

Internal independent audits are being conducted at planned intervals (at least once a year)

Audit Records

 

External independent audits are being conducted at planned intervals (at least once every 3 years)

Audit Records

 

For internal independent audits, internal staff not involved in the Maternal Death Control Management System do the auditing.

Audit Records

 

For internal independent audits, a tracer methodology is being used.

Audit Records

 

For internal independent audits, prescribed checklists of criteria and indicators for performance excellence are being used.

Audit Records

 

Results of independent audits are presented in management reviews.

Minutes of Management Reviews

 

 Notes on Tracer Methodology:

Tracer Methodology

Tracer methodology is systems approach to auditing.

It traces a number of patients through the organization’s entire health care process   As cases are examined, the surveyor may identify performance issues in one or more steps of the process or in the interfaces between processes.

The objectives of the tracer methodology consist of the following: 1) Follow course of care and services provided to the patients; 2) Assess relationships among disciplines and important functions; 3) Evaluate performance of processes relevant to the individual disciplines.

A tracer methodology takes about 90 minutes but may reach 3 hours.

Tracer Methodology in Maternal Death Control Management System

Patient and how patient is being treated (from start to end)

Possible areas for tracer methodology: 

Current emergency department patient

Discharged emergency department patient

Current inpatient

Discharged inpatient

Emergency department management of a pregnant patient

Inpatient management of a pregnant patient

Processes used in tracer methodology

Use of clinical pathways

Tracing of course of maternal care services provided to patients with assessment of performance of individual disciplines and assessment of interfacing of different disciplines

 
Tools used in tracer methodology

Chart inspection

Interview

Observation

Checklists of Criteria and Indicators of Performance Excellence in Different Phases of the Management System

Criteria and Indicators for Performance Excellence of System or Program Management

Criteria and Indicators for Performance Excellence of System or Program Management

Audit Results

Areas for Improvement

There is a documented manifestation of commitment of support of governing body or top management on the Maternal Death Control Management System renewed every three (3) years.

Record:

Manifestation of Commitment and Support by governing body or top management and renewed every 3 years

AUDIT RESULTS:

 

There is an appointment of a senior management team by the governing body or top management to oversee and supervise the Maternal Death Control Management Team.

Records:

Appointment of Senior Management Representative with job description

AUDIT RESULTS:

 

There is an official creation of the Maternal Death Control Management Team inclusive of a designated chairperson and members and job descriptions.

Records:

·         Creation of Maternal Death Control Management System

·         Appointment of Chair with job description

·         Appointment of members with job descriptions

AUDIT RESULTS:

 

There is formal acceptance of appointment, roles, responsibilities and authority of the Chairperson and members of the Maternal Death Control Management System Team.

Records:

Conforme signatures of Chair and members of the Maternal Death Control Management System Team

AUDIT RESULTS:

 

There is a Manual of Operations of the Maternal Death Control Management System in print and digital media which is reviewed every 3 years.

Documents and Records:

Manual of Operations of the Maternal Death Control Management System and reviewed every 3 years

In print and digital media

AUDIT RESULTS:

 

The Manual of Operations contain at least the following: 1) Goals and Objectives, Key Result Areas and Key Performance Indicators;

2) Cause Mapping; 3) Design and Development Blueprint; 4) Deployment, Education and Implementation Plan; 5) Evaluation, Review and Continual Improvement Plan; 6) Documentation and Archiving Plan; and 7) Management Review and Independent Audit Plan.

Documents:

Manual of Operations with at least the following contents:

1) Goals and Objectives, Key Result Areas and Key Performance Indicators;

2) Cause Mapping;

3) Design and Development Blueprint;

4) Deployment, Education and Implementation Plan;

5) Evaluation, Review and Continual Improvement Plan;

6) Documentation and Archiving Plan; and

7) Management Review and Independent Audit Plan.

AUDIT RESULTS:

 

The authorized functions of the Maternal Death Control Management System / Team are spelled out and being used to guide actions and evaluation.

Documents and Records:

Presence of authorized functions of the Maternal Death Control Management System / Team and being used to guide actions and evaluation

(see agenda of meetings of MCDMS Team)

AUDIT RESULTS:

 

The goals and objectives of the Maternal Death Control Management System / Team are spelled out and used to guide actions and evaluation.

Documents and Records:

Presence of goals and objectives of the Maternal Death Control Management System / Team and being used to guide actions and evaluation

(see agenda of meetings of MCDMS Team)

AUDIT RESULTS:

 

The key result areas of the Maternal Death Control Management System /Team are spelled out and used to guide actions and evaluation.

Documents and Records:

Presence of key result areas of the Maternal Death Control Management System / Team and being used to guide actions and evaluation (see agenda of meetings of MCDMS Team)

AUDIT RESULTS:

 

The key performance indicators of the Maternal Death Control Management System / Team are spelled out and used to guide actions and evaluation.

Documents and Records:

Presence of key performance indicators of the Maternal Death Control Management System / Team and being used to guide actions and evaluation (see agenda of meetings of MCDMS Team)

AUDIT RESULTS:

 

There are meetings of the Maternal Death Control Management Team held regularly at least once a month to plan, deploy, implement, evaluate and document.

Records:

Minutes

Meetings every month

Purposes: plan, deploy, implement, evaluate and document activities

AUDIT RESULTS:

 

The contents of the meeting (agenda) are adequate (based on prescribed contents).

Records:

Minutes (Agenda based on prescribed contents)

AUDIT RESULTS:

 

Design and Development Blueprint (Manual of Operations)

Deployment, Education, and Implementation

Criteria and Indicators for Performance Excellence of Deployment, Education, and Implementation Plan

Audit Results

Areas for Improvement

There is a structured and comprehensive deployment plan of the Maternal Death Control Management System with identification of concerned stakeholders; methods; timeline; and people in charge.

   

There is a communication on deployment of the Maternal Death Control Management System to all concerned stakeholders.

   

There is an orientation on the Maternal Death Control Management System to all concerned stakeholders prior to its implementation.

   

There is an education and training of all concerned staff on the Maternal Death Control Management System prior to its implementation.

   

There is an implementation plan of the Maternal Death Control Management System.

   

Evaluation, Review and Continual Improvement

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

 

 

Documentation and Archiving

Criteria and Indicators for Performance Excellence of Documentation and Archiving

Audit Results

Areas for Improvement

There is adequate documentation of formal activities of the Maternal Death Control Management System.

-     Minutes of monthly meetings of the Maternal Control Management System Team

-     Minutes of Management Reviews

-     Reports of Independent Audits

   

There is control of documents (legibility; currency; easy retrieval; safekeeping; security; and confidentiality).

   

There is control of records (legibility; currency; easy retrieval; safekeeping; security; and confidentiality)

   

There is digitalization of documents and records

   

The retention period for patient medical records is being followed.

   

The retention period for hard copies of documents and records is being followed.

   

The retention period for digital copies of documents and records is being followed.

   

  Management Reviews

Criteria and Indicators for Performance Excellence of Management Reviews

Audit Results

Areas for Improvement

A management review is being held regularly at planned intervals (every 3 months).

Minutes

 

The governing body or top management or the senior management representative has always been in attendance.

Minutes

 

Contents of management review 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

 

There is continual improvement on the Maternal Death Control Management System as a result of the management review -showing continual improvement on Maternal Death Statistics and Adverse, Sentinel, and Near-Miss Events

Minutes

 

Independent Audits

Criteria and Indicators for Performance Excellence of Independent Audits

Audit Results

Areas for Improvement

Internal independent audits are being conducted at planned intervals (at least once a year)

Audit Records

 

External independent audits are being conducted at planned intervals (at least once every 3 years)

Audit Records

 

For internal independent audits, internal staff not involved in the Maternal Death Control Management System do the auditing.

Audit Records

 

For internal independent audits, a tracer methodology is being used.

Audit Records

 

For internal independent audits, prescribed checklists of criteria and indicators for performance excellence are being used.

Audit Records

 

Results of independent audits are presented in management reviews.

Minutes of Management Reviews