11
Hospital Assesment Hospital Assesment for for
Quality of CareQuality of Care
Country experience : Country experience : INDONESIAINDONESIA
22
OUTLINE
1. BACK GROUND2. HOSPITAL ASSESMENT3. RESULT4. FOLLOW UP AFTER ASSESMENT
33
HEALTH INFRASTRUCTURE
Number of:*-Hospitals (*2011) : 1686 -Community Health Centers : 9133 -Integrated service posts : 266.827- Maternity Huts : 28.558-Village Health Posts : 51.996(*2011)Number of Health Personnel*-General Practitioners : 25.333-Medical Specialists : 8.403-Obstetricians : 1104 -Pediatricians : 1800 -Nurses : 160.074-Midwives : 96.551
Background The sickest children require
hospital care IMCI assumes referral for the
sickest children
~10 (-20%) of children require referral
Child survival interventions depend on good referral system & good care at referral level
To known situation about quality hospital care as a based data
Department of Child and Adolescent Health
and Development
Finding Classification Treatment
Danger signs Severe disease Urgent referral
Cough or difficulty inbreathing
Severe disease Urgent referral
Diarrhoea
Fever
Disease with specifictherapy
Specific medical treatment
Ear problem
Nutritional status/anaemia
Disease without specifictherapy
Symptomatic treatment
Vaccination status Complete/incomplete Vaccinate
Assess and classify
5
Hospital Improvement Process
1 .Country Orientation
2 .Hospital Assessment
3 .Agreement on standards
4 .Definition of interventions & area
5 .Improvement in hospitals
7 .Sharing of Information
6 .Monitoring and Evaluation
PLAN
CHECK
DOACT
5
6
GENERIC ASSESSMENT TOOL
Indonesian assessment tool
ADAPTATION process
2006-2008
IMCIIMCI Minimal Standard of care IDAI
Minimal Standard of care IDAI Standards/guideline,
case management, hospital
accreditation instrument (MOH)
Standards/guideline, case management,
hospital accreditation
instrument (MOH)
6
1. RSU Dr R Sosidoro (B)
2. RSU Dr Soegiri (C)3. RSU Dr Soedomo (C)4. Pkm Baureno
1. RSU Dr R Sosidoro (B)
2. RSU Dr Soegiri (C)3. RSU Dr Soedomo (C)4. Pkm Baureno
1. RSU Raden Mattaher (B)
2. RSU Muara Bungo (C)
3. RSU Bangko (C)
4. PKM. Pemenang
1. RSU Raden Mattaher (B)
2. RSU Muara Bungo (C)
3. RSU Bangko (C)
4. PKM. Pemenang
1.RS Ternate (C )2.RS Tidore (C)3.RS Sanana ( D )4.PKM Galala
1.RS Ternate (C )2.RS Tidore (C)3.RS Sanana ( D )4.PKM Galala
1.RS Prov Sultra (B)2.RS Kota Bau-Bau (C)3.RS Kab. Konawe (C )4.PKM Batauga
1.RS Prov Sultra (B)2.RS Kota Bau-Bau (C)3.RS Kab. Konawe (C )4.PKM Batauga
1. RS. Yohannes(B)2. RS. Kalabahi Alor (D)3. RS. dr. TC Hillers
Maumare (C) 4. PKM Bola Sikka
1. RS. Yohannes(B)2. RS. Kalabahi Alor (D)3. RS. dr. TC Hillers
Maumare (C) 4. PKM Bola Sikka
1.RSDr Doris Sylvanus (B)2.RS Buntok (C)3.RS Muara Teweh (C)4.PKM Kandui
1.RSDr Doris Sylvanus (B)2.RS Buntok (C)3.RS Muara Teweh (C)4.PKM Kandui
04/21/23 7
Methodology: stratified 2 stage random sampling to be geographically representative
.
1. RSU Dr R Sosidoro (B)
2. RSU Dr Soegiri (C)3. RSU Dr Soedomo (C)4. Pkm Baureno
1. RSU Dr R Sosidoro (B)
2. RSU Dr Soegiri (C)3. RSU Dr Soedomo (C)4. Pkm Baureno
1. RSU Raden Mattaher (B)
2. RSU Muara Bungo (C)
3. RSU Bangko (C)
4. PKM. Pemenang
1. RSU Raden Mattaher (B)
2. RSU Muara Bungo (C)
3. RSU Bangko (C)
4. PKM. Pemenang
1.RS Ternate (C )2.RS Tidore (C)3.RS Sanana ( D )4.PKM Galala
1.RS Ternate (C )2.RS Tidore (C)3.RS Sanana ( D )4.PKM Galala
1.RS Prov Sultra (B)2.RS Kota Bau-Bau (C)3.RS Kab. Konawe (C )4.PKM Batauga
1.RS Prov Sultra (B)2.RS Kota Bau-Bau (C)3.RS Kab. Konawe (C )4.PKM Batauga
1. RS. Yohannes(B)2. RS. Kalabahi Alor (D)3. RS. dr. TC Hillers
Maumare (C) 4. PKM Bola Sikka
1. RS. Yohannes(B)2. RS. Kalabahi Alor (D)3. RS. dr. TC Hillers
Maumare (C) 4. PKM Bola Sikka
1.RSDr Doris Sylvanus (B)2.RS Buntok (C)3.RS Muara Teweh (C)4.PKM Kandui
1.RSDr Doris Sylvanus (B)2.RS Buntok (C)3.RS Muara Teweh (C)4.PKM Kandui
Methods
Assessment teams senior paediatrician, a senior nurse with experience caring for children, surveyor of hospital accreditation committee a doctor working in the ministry of health a health professional from the provincial health office
Visits 2 working days, with observations during the evening
or night. The hospital director was informed in advance and
agreed to the assessment
Based on generic WHO tool Adapted in line of tools of hospital accreditation commission Areas assessed
1. Hospital support functions including drugs, supplies and equipment; laboratory, radiology and hospital information systems
2. Emergency care
3. Children’s ward
4. Case management on the ward
5. Neonatal care
6. Monitoring of patients in the hospital
7. Mother and child friendly services
8. Hospital support
9. Discharge and follow-up
10. Access to hospital
Hospital assessment tool
1010
RESULT OF ASSESSMENTRESULT OF ASSESSMENT
Number of hospital 18 Category class B = 7 Category class C = 9 Category class D = 2
Number of bed 30 – 323 Bed occupancy rate
57% Length of stay is 4 day
Type and number of bed of HospitalBed occupancy in Child
health care
1212
Number of general MD by training received
Trained Number of MD
Basic life support 23
Emergency services 55
ACLS 49
Resuscitation 6
BEONC 15
CEONC 5
ICU/NICU 4
Malnutrition Health Care 6
IMCI 6
EMERGENCY SERVICES IN HOSPITAL
WEAKNESSESWEAKNESSES
STHRENGTHS
STANDARD PARAMETER
Summary of assessment
To be strongly improved
(<60%)
Need to be improved(60-79%) Good
(≥80%)
1.Lay-out and structure
1-4 There are triage system, SOP triage, flow of pediatric patient, referral system.
œ
5.Separated emergency unit
œ
6. Separated of examination and treatment room
œ
7.Easy access to emergency unit
œ
2.Emergency unit staff 1. Skillful triage staff
œ
2.Adequately professional staff
œ
3.Drug and equipments
1.Availability of emergency drug administration
œ
2-3.Availability of essential laboratory test and medical equipments
œ
Separate emergency unit Emergency unit easily accessible Examination and treatment room
separated Adequate numbers of
professional staff Availability of emergency drugs
No triage system for children SOP not complete, especially for
children Majority no wall chart for child
cases Most of staff without training on
child cases No referral policy .
CASE MANAGEMENT IN PEDIATRIC WARD 1. Cough or difficult breathing
Most hospitals (77%) have nebulizer, X-ray, and good supply of O2 .
SOP not complete Incorrect Dx of severe pneumonia and not complying with standard Administration of second line antibiotics (cefotaxim) directly.• Salbutamol only available in 61% RS • Scoring system for child Tb Dx not implemented. Combined anti TB drugs for child not available self-mixing of incorrect dose of anti TB. •Tuberculin test not done. . Non compliance of medical record by pediatrician or physician.
WEAKNESSESWEAKNESSES
STRENGTHS
STANDARD PARAMETER
Summary of assessment
To be strongly
improved(<60%)
Needs to be
improved(60-79%)
Good(≥80%)
1. Diagnosis assessment of severe pneumonia
1. Correct assessment of severe pneumonia
œ
2.Administration appropriate antibiotic, oxygen, management of wheezing, TB medication, usng chest X-ray
1-3. Correct administration of appropriate antibiotics , oxygen , Inhaled bronchodilators
œ
4-5. Correct provision of TB treatment and use of chest x-ray based on clinical indication
œ
CASE MANAGEMENT IN PEDIATRIC WARD 2. DIARRHOEA
STANDARDPARAMETER
Summary of assessment
To be strongly
improved(<60%)
Need to be improved(60-79%)
Good(≥80%)
1. Assessment of dehydration
1.Correct assessment of dehydration
œ
2. Management of rehydration, administration of antibiotics, continued feeding, and Zinc supplementation during diarrhea
Correct rehydration plan is chosen based on the degree of dehydration and monitored
œ
.2. Correct use of antibioticsPolicy that antidiarrhoeal are not given
œ
3. Procedures for continued feeding œ
4.Procedure and policy for Zinc supplementation
œ
• Availability of antibiotics and fluid
SOP not completed. No classification of the severity of dehydration and no plan of continued feeding.
All diarrhoea cases given iv fluid therapy and antibiotics directly. Antidiarrhoeals given frequently
ORS not given Zn not available in most
hospitals (67%). If Zn available, expensive (Zinc-kid Rp. 33.000/10), so not administered routinely especially for poor patients.
WEAKNESSES
STRENGTHS
CASE MANAGEMENT IN PEDIATRIC WARD 3. FEVER
STANDARDPARAMETER
Summary of assessment
To be strongly
improved(<60%)
Need to be
improved(60-79%)
Good (≥80%)
1.Assesment and differential diagnosis
1. Appropriate assessment undertaken for all children with febrile conditions and have a differential diagnosis for possible and likely conditions considered.
œ
2. Diagnosis an management of fever
1-2.Correct diagnosis of Dengue viral infection and management of DHF with or without shock and monitored.
œ
3-4.Correct diagnosis and management of severe malaria (with complication and appropriate antimalarial treatment are given
œ
5-6. Correct diagnosis and management of meningitis and appropriate treatment.. œ
SOP not completeNo consideration of DD• No record of the severity of
DHF, excessive fluid therapy, not monitored, haematocrit test not done as routine lab test.
• Thick blood smear not done as routine test
• New guideline of malaria therapy not yet implemented and Artesunate & Amodiaquin not available in most hospitals
LP not done as routine test for patients suspected of meningitis
STRENGTH
WEAKNESS
Availability of essential laboratory tests
CASE MANAGEMENT IN PEDIATRIC WARD 3. MALNUTRITION
STANDARDPARAMETER
Summary of assessment
To be strongly improved
(<60%)
Need to be improved(60-79%)
Good(≥80%)
1. Nutritional status is assessed to all patients
1.Assesed nutritional status to all inpatient œ
2. Management 1. Correct
assessment of hypoglycemia and hypothermia to children with severe malnutrition
œ
2.Correct administration of antibiotics and micronutrients
œ
3. Correct feeding to malnourish children and feeding formula is available œ
There were 6 physicians trained in malnutrition
No SOP /not complete SOP. Nutritional status is not assessed by height but only by weight. Scale for height not available.
Management of severe malnutrition is not compliant with guidelines.
STANDARDPARAMETER
Summary of assessment
To be strongly improved
(<60%)
Need to be improved(60-79%)
Good(≥80%)
1. Nutritional status is assessed to all patients
1.Assesed nutritional status to all inpatient
œ
2. Management 1. Correct assessment of hypoglycemia and hypothermia to children with severe malnutrition
œ
2.Correct administration of antibiotics and micronutrients
œ
3. Correct feeding to malnourish children and feeding formula is available œ
STRENGTH
WEAKNESS
CASE MANAGEMENT IN PEDIATRIC WARD 3. HIV/AIDS
STANDARDPARAMETER
Summary of assessment
To be strongly improve
d(<60%)
Need to be
improved(60-79%)
Good(≥80%)
1.Assesment and counseling for HIV suspected children
1. Correct assessment and counseling to HIV suspected children
œ
2. Corect nursing care for health condition related to HIV infected children œ
Physicians and nurses are available to participate in HIV training
Guidelines or SOP were not in place for counselling, the diagnosis and staging of paediatric HIV
No HIV trained staff HIV infected children cases
are rarely diagnosed
STRENGTH
WEAKNESS
NEONATAL CARE3. CASE MANAGEMENT OF SICK NEWBORN
STANDARD PARAMETER
Summary of assessment
To be strongly
improved(<60%)
Need to be
improved(60-79%)
Good(≥80%)
1.Diagnosis sepsis in neonates
1. Correct diagnosis of neonatal sepsis
2. Management
2. Management procedure of neonatal sepsis is in place
2. Specific feeding are give frequently to sick young infants and those with low birth weight.
3. Procedures are in place to check the bilirubin level and to manage jaundice
no SOP/SOP not yet complete administration of 2nd line antibiotics directly no breastfeeding promotion assessment of jaundice based on clinical sign. No SOP to collect blood specimen for infantExchange transfusion not available
no SOP/SOP not yet complete administration of 2nd line antibiotics directly no breastfeeding promotion assessment of jaundice based on clinical sign. No SOP to collect blood specimen for infantExchange transfusion not available
NICU available in 3 class B hospitals and 1 C class hospitals, trained physicians:4 on intensive care (PICU/ NICU), 4 on basic neonatal obstetrical emergency services BEONC, and 15 on CEONCPhototherapy available in most hospitals
WEAKNESS
STRENGTH
Percentage of standard achievement of 10 services in hospitals by provinces
1. Supporting services
2. Emergency services
3. Children’s ward
4. Case management in the pediatrics ward
5. Neonatal care6. Patient
monitoring7. Mother and
child friendly services
8. Hospital support
9. Discharge and follow-up
10. Access to the hospital
Follow up after Assesment
Collaboration MOH,Pediatrician and WHO
Dissemination of pocket book: 2009 25000 copies 2011 25000 copies evaluation of reach, Training CD introducedHospital assessment tool is being revised Improved skills for health personal by routine training Adaptation standard operating procedures Promote quality of health services for community
2323
THANK YOUFOR YOUR ATTENTION
Thank you
24
TERIMA KASIH