five year rolling strategic plan 2015 - 2020 - …kcmc.ac.tz/downloads/kcmc strategic plan...

1

Kilimanjaro Christian Medical Centre

FIVE YEAR ROLLING

STRATEGIC PLAN

2015 - 2020

2

FOREWORD

In the year 2013, Kilimanjaro Christian Medical Centre embarked in preparing Strategic Plan.

KCMC Management in this regard is grateful to the Board of Governors, Board of Trustees. the

Consultant and the entire KCMC staff for their constructive and fruitful contributions.

We pray to Almighty God, to continue giving KCMC staff good health, courage and love so that

they continue to serve with humility and dignity for the benefit of patients, students and visitors

who come to KCMC.

Prof. R. M. Olomi

ACTING: EXECUTIVE DIRECTOR, KCMC AND

EXECUTIVE SECRETARY, GSF

3

TABLE OF CONTENTS

CHAPTER ONE ..................................................................................................................................... 4

1.0 Introduction ................................................................................................................................... 5

1.1 Background Information ............................................................................................................... 5

1.2 Strategic Planning Process ............................................................................................................ 7

CHAPTER TWO .................................................................................................................................... 7

2.0 The Vision, Mission, Values and Functions of the Hospital ............................................................ 8

2.1 The Vision ..................................................................................................................................... 8

2.2 The Mission .................................................................................................................................. 8

2.3 Values ........................................................................................................................................... 8

2.4 The Functions ................................................................................................................................ 9

CHAPTER THREE .............................................................................................................................. 10

3.0 Environmental Scanning ................................................................................................................ 10

3.1 General environment ...................................................................................................................... 10

3.2 Global Environment ....................................................................................................................... 10

3.3 National environment ..................................................................................................................... 10

3.4 Institutional level Environment ...................................................................................................... 11

CHAPTER FOUR ................................................................................................................................ 15

4.0 Strengths, Weaknesses, Opportunities and Threats (SWOTs) analysis ......................................... 15

4.1 SWOTS Clinical Services .............................................................................................................. 15

4.2 SWOTs Leadership and management ......................................................................................... 16

4.3 SWOTs Human Resources.......................................................................................................... 17

4.4 SWOTs Financial Resource and sustainability ........................................................................... 18

4.5 SWOTS Infrastructure development ........................................................................................... 19

4.6 SWOTs Hospital equipment and Supplies .................................................................................. 20

4.7 SWOTs Health Management Information System ..................................................................... 21

CHAPTER FIVE .................................................................................................................................. 22

5.0 Strategic Objectives .................................................................................................................... 22

CHAPTER SIX .................................................................................................................................... 31

6.0 Operating plan and Budget ......................................................................................................... 31

6.1 Introduction ................................................................................................................................. 31

6.2 Budget Plan ................................................................................................................................ 31

4

6.3 Budget summary ......................................................................................................................... 31

6.4 Financing sources ........................................................................................................................ 37

ABBREVIATIONS

1. EDR – Executive Director

2. CCFCC – Child Centred Family Care Clinic

3. CPS – Clinical Pastoral Services

4. TATCOT – Tanzania Training Centre for Orthopaedic Technologists

5. CPEP – Continue Paediatric Education Pragramme

6. ENT – Ear, Nose and Throat (Otorhinolaryngology) Department

7. ICU – Intensive Care Unit

8. OPD – Out Patient Department

9. SOP – Standard Operating Procedures

10. CBM – Christoffel Blinden Mission

11. EGPAF – Elizabeth Glasier Paediatric AIDS Foundation

12. GSF – Good Samaritan Foundation

13. KCMU Co – Kilimanjaro Christian Medical University College

5

CHAPTER ONE

1.0 Introduction

1.1 Background Information Soon after Independence of Tanganyika from British rule, the Government called on the

protestant Churches in the Country to establish a referral and teaching hospital in the Northern

zone of the country. Under the leadership of the Right Reverend Stefano R. Moshi, Bishop of the

Evangelical Lutheran Church in Tanganyika, Good Samaritan Foundation (GSF) was established

as a corporate body and registered in Tanganyika in 1961, with Bishop Stefano Moshi as its first

Chairman.

GSF planned for the construction of the Kilimanjaro Christian Medical Centre (KCMC) and

raised large funds from overseas partners to build and equip the hospital.

Therefore, the idea to build Kilimanjaro Christian Medical Centre (KCMC) was born 1961, with

capital funds assured from Luther Hjalpen of Sweden , Central Agency and Bread for the World

of Germany, coupled with an anonymous Christian donation of USD $209,000.00 from Texas,

USA. Site work began in April 1965. The cornerstone for the hospital was laid by the first

President of Tanzania, Julius K. Nyerere, on 8th June 1965.

The project was an integral and essential part of the Tanzania Government's 5-Year Medical

Plan. The Government agreed to contribute annually towards its basic operating costs. In the

overall plan of 1965 there was provision for development, at a later stage of full Medical School.

Kilimanjaro Christian Medical Centre is one among the four Zonal Consultant hospitals in

Tanzania. It was formally established in 1971 as a Zonal Referral Consultant hospital owned by

the Evangelical Lutheran Church of Tanzania (ELCT) under the Good Samaritan Foundation

(GSF). The aim was to create an independent legal body which nevertheless is to be permanently

linked to the ELCT and Christian Council of Tanganyika. The immediate purpose of the

foundation was to be a body capable of establishing the Kilimanjaro Christian Medical Centre.

The referral hospital was established in order to serve the northern, eastern and central zone of

Tanzania. Its record in Medical Services, Research, and Education has significant influence in

East Africa and beyond.

In 2011, KCMC continued to carry out its services to people according to the mission statement,

“To render God’s healing services to set mankind free from the bondage of sickness, suffering

and sin”, “To reflect Christ’s character of love, mercy, compassion and faithfulness in the course

of fulfilling the call to care and heal the sick” and “To share God’s grace and love through the

power of the Holy Spirit in the course of treating and caring for the sick”. Since 1971 the

Hospital has continued to grow, serving the northern, eastern and central zones of Tanzania as a

world-class centre for patient care, teaching and research with leading clinical specialty areas and

an internationally renowned research institute. KCMC has ability to create a culture of

excellence and care and therefore this has made KCMC as an institution where patients want to

6

come for care and staff and trainees want to work. We remain inspired by the dedication of our

founders and we are committed to their vision of providing excellent care, now and in the future.

7

1.2 Strategic Planning Process

Through a participatory process the hospital developed the 2015-2020 Five Year Rolling

Strategic Plan. The development of the Strategic Plan started from the Hospital constituent

key units, which included all stakeholders with participation of the Hospital management

under the leadership of the Executive Director, setting the agenda for brainstorming. Key

result areas were identified and discussed.

This was a done through a series of Strategic Planning workshops.

8

CHAPTER TWO

2.0 The Vision, Mission, Values and Functions of the Hospital

2.1 The Vision

A referral hospital excelling in quality service, training and research

2.2 The Mission

To provide accessible, affordable and high quality health care services

2.3 Values

In order to realize the vision and its mission, KCMC shall be guided by the following values:

Excellence

Excellence and Innovation in Clinical Care, Teaching and Research

Pursue excellence in everything we do with continuous improvements in quality, service and

cost-effectiveness.

Patient-Centred Care

Prioritize safety, quality and the patient experience in everything we do.

KCMC will always regard the patient as the centre of its activities and maintain a patient -

centered hospital environment.

Teamwork

Embrace a collaborative and interdisciplinary approach to clinical care, teaching and research.

Collaboration

Establish internal and external partnerships to integrate and coordinate patient services

effectively.

Respect and Diversity

Value and respect the differences of the patients and families who seek our care as well as those

who provide that care.

Leadership

Promote the development and growth of leaders throughout the organization and continue to

allow our leading programs to export our knowledge nationally and internationally.

Accountability and Transparency

In making decisions and implementation of all activities, KCMC management will observe

openness, team-work, participation, liableness and answerability.

9

Moral Standard and Integrity

In all its undertakings, the KCMC community will uphold and observe accuracy, professional

ethics, honesty, corporate social responsibility and human respect.

Partnerships

KCMC will work very closely with its stakeholders who include staff, students, Government

institutions, NGOs, Civil Society groups, service providers, development partners and other health care

providing institutions, both within and outside the country

Equity

KCMC is an equity observing institution. Thus all sections of the society, especially the

disadvantaged groups and individuals, will be given opportunity to education, training,

recruitment, promotion, decision-making and treatment.

Innovation

In performing the activities related to its core functions, KCMC will attempt to be creative, up to

date and novel

2.4 The Functions The functions and activities of the hospital are guided by the following components of the Mission

1. To provide the public high quality of health care services

2. To provide to the public super-specialized health care services

3. To serve as a centre of excellence for certain specific diseases that can be utilized by local

stakeholders for the development, optimization or implementation of medical interventions and

health policies.

4. To conduct clinical research 5. To train different levels of health cadres

10

CHAPTER THREE

3.0 Environmental Scanning

3.1 General environment The environmental scanning for KCMC includes both external and internal environment. It covers health,

political, social, economic and technological developments and their challenges. In this chapter a number

of pertinent issues at different levels (Global, National and institutional) have been described. As a result

KCMC has an obligation to respond to the resulting dynamics, opportunities and challenges.

3.2 Global Environment Worldwide socio-cultural-economic relations have been intensified by globalization resulting into impact

on health development. Tanzania is faced with a challenge of integration in the competitive areas of

health care delivery on one hand, and international knowledge in scientific and technological

developments on the other hand. KCMC has a responsibility to contributing to the national development

in these areas.

Health delivery The Millennium Development Goals (MDGs) and related global initiatives have refocused global

attention on the challenges facing the world and Africa in particular. For instance the World Health

Organization (WHO) asserts that in order to achieve the MDGs a minimum density of 2.5 health workers

per 1,000 people is required. In Tanzania there is a severe shortage of health workers especially in the

high skilled cadre and the density is estimated to be 1.5. Therefore KCMC as one of the zonal referral and

teaching hospitals in the country has a responsibility to contribute to the national efforts in the attainment

of the health related MDGS.

3.3 National environment

3.3.1 National Economy The country’s economic performance is still poor and a good proportion of the Government budget is

dependent on donor support. As a result Government revenue that could be made available to the health

sector is insufficient compared to the actual demand. This requires new approaches of funding the health

sector. Under these circumstances KCMC community needs to acquire and develop entrepreneurship

skills so as to be able to mobilize resources to cover the budget deficit and meet its recurrent and capital

development budget

3.3.2 The national Health Policy The Tanzania Health Policy has adopted Primary Health care (PHC) as an approach to health

improvement in the country. This policy puts an emphasis on equity in health service, which is responsive

to the needs of the community, especially those who are most at risk. It is geared to address the MDGs

within the National Strategy for Growth and Poverty Reduction (NSGPR) and Vision 2025 which aim at

11

providing access to quality reproductive services, reduction in infant and maternal mortality, raise life

expectancy and reduction of malaria related morbidity and mortality.

NSGPR has identified key obstacles in the provision and access to health care services, which include

shortage of skilled health care providers and poor quality of care, accountability and governance. KCMC

intends to play a positive role in addressing these issues.

KCMC will endeavor to address the problem of poverty reduction impediments by offering high quality

service to the population and by increasing the number and diversity of highly trained health care

providers and managers of health care systems. KCMC will also continue to give high priority to research

activities that aim at improving care and reducing the burden of most prevalent diseases in Tanzania.

3.3.3 Political Environment The orientation of political environment in the country is towards effective and greater democratization

and pluralism. The Government agenda of ensuring good governance is applied in all institutions. KCMC,

though a faith based institution has an obligation to practice good governance just as it is done in the

public institutions.

3.4 Institutional level Environment

3.4.1 Institutional Governance

Based on the organizational structure of KCMC, the institution is headed by the Executive

Director who is answerable to the Good Samaritan Foundation (GSF) Board of Trustees. The

Executive Director serves also as the Executive Secretary of GSF. Under the Executive Director

are Directors of different units and under them are Heads of Departments.

13

3.4.2 Human resource Development and Management

Human resource is an important element for institutional development. The Directorate of

Human Resources is concerned with supervising and coordinating departmental heads of general

administration and personnel in Managerial matters. It also implements Personnel Development

Plan as well as recommending and advising management on training policy and available

training opportunities.

3.4.3 Financial Resources and Management

The source of funding of the hospital is mainly from the Government, Cost sharing, GSF and

donations.

KCMC has an established financial management structure. The Finance Directorate is

comprising of five departments namely Revenue, Salaries, Expenditure, Projects and Final

Accounts.

3.4.4 Training

Training is one of the core functions of KCMC. The hospital currently is hosting 16 Allied

Health Schools which are owned by the MoHSW. These Schools offer different

disciplines/specialties in both certificate and diploma levels. The KCMU Co uses KCMC as a

teaching hospital.

3.4.5 Research Development and Management

Research is one of the core functions of KCMC. Through the Kilimanjaro Clinical Research

Institute (KCRI) KCMC has managed to harmonize health services, health training and health

research. This unique practice of harmonizing patients’ care, training of health professionals and

conducting health research without jeopardizing patients’ health and well-being is well

structured through the establishment of well-defined functions of the KCMC hospital, the

University Medical College (KCMU – College).

3.4.6 Links and Networking

KCMC has always had links with various partners both locally and internationally.

Through these links it has been able to fulfill its mission.

3.4.7 Infrastructure Development and other Support facilities

The hospital started functioning in 1971 However, it has continued to expand for example

establishment of the Orthopaedic Rehabilitation Unit, Dermatology and Burns Unit, Child

14

Centred Family Care Clinic and Emergency Medicine. The other planned expansion areas

include establishment of the Orthopaedic Centre for Excellence and Cancer Unit.

3.4.8 Public Relations

In order to remain competitive KCMC has to device novel ways of conducting its business.

Through the Unit of Public Relations the hospital has continued to maintain its good relationship

with all key stakeholders/parties i.e. government, political leaders, donors, other hospitals and

the surrounding communities.

3.4.9 Gender issues

In order to address issues pertaining gender, the hospital has created a gender desk with a

coordinator and a counselor. Gender policy and guidelines for antisexual harassment and

discrimination are still in process of preparation. Nevertheless, the hospital needs to expand the

gender activities.

15

CHAPTER FOUR

4.0 Strengths, Weaknesses, Opportunities and Threats (SWOTs) analysis

4.1 SWOTs Clinical Services

4.1.1 Strengths 1. Unique Clinical Departments and Services (Dermatology, CCFCC, Orthopaedics,

Research laboratory, Endoscopy Services CT-Scan, Mammography)

2. Unique Clinical Services (Paediatric Urology, Clinical Pastoral services (CPS), Birth

registry, TATCOT

3. Training of Specialists

4. Networking with other hospitals e.g. Flying Doctors Services, CPEP

5. Community Ophthalmology

6. Indigenous Specialists who know the local conditions well

7. Existing Post Graduate Seminars twice a year

8. Existing of clinical conferences every Wednesday

9. Nurses continuous education weekly and annual conference

16

4.1.2 Weaknesses 1. Shortage of Staff (ENT, Anaesthesia, Radiology, Dermatology. And Nurses in all

Departments,)

2. Inadequate space in the patient wards e.g. Surgical, Clinics Casualty, Diabetic and

offices (Mainly a cross cutting issue )

3. Inadequate supplies

4. Shortage of specialists and super speciality e.g. –Cardiologist, Neurologists,

Haematologist, Pathologists, Endocrinologists, Nephrologists, Oncologists, ICU nurses

5. Poor Patient flow

6. Lack of 24 hours OPD Services

7. Shortage of Equipments e.g. Autoclaves, Ventilators, MRI,

8. Lack of SOPs and Protocols

9. Misallocation of staff e.g. Pathology

10. Lack of Disaster Emergency preparedness e.g. assembly hall

11. Ineffective Laboratory support services

12. Poor system of accessibility of staff for emergency on call rooms, transport, residence

house

13. 0vercrowding of students

14. Poor Referral System

15. Lack of effective Retention Program for staff

16. Shortage of Funds

17. Standards not validated

4.1.3 Opportunities 1. Well established services known inside and outside the country

2. Support from the Ministry

3. Existing collaborations e.g. Duke, CBM, EGPAF

4. Ongoing resource services support from ministry

5. International collaboration

4.1.4 Threats 1. Inadequate government funds

2. Donors dependency

3. Exodus of staff e.g. laboratory technicians, Nurses,

4. Inability to keep pace with modern equipment e.g. CBC

4. Unprepared for internal competition e.g. East African Community

4.2 SWOTs Leadership and management

4.2.1 Strengths 1. Existence of well structured organogram of leadership

(EDR, Directors, Heads of Departments)

2. Unification of directorates of College, Research and Clinical entities under the overall

leadership of EDR

3. Existence of top governing bodies i.e Board of Governors and Board of trustees

17

4. Good relationship between KCMC and government through Ministry of Health and

Social Welfare

5. Existence of hospital managerial committee

(Hospital Management Team/Committee)

6. Availability of several (27) operational committees

7. Availability of legitimate health workers, academic staff, and students’ welfare

committees

8. Existence of internal hospital policies e.g patient/client charter

9. Availability of job description of various cadres.

10. Availability of statutory laws and regulations for KCMC employees

11. Availability of job description of various cadres.

12. Existence of ALMANAC

4.2.2 Weaknesses 1. Lack of Planning Unit

2. Lack of Quality Assurance unit

3. Overlapping of functions in certain committees

4. Lack of other important Staff welfare Policies: e.g

Anti- sexual harassment, Gender policy, retirement policy, staff establishment policy

5. Lack of job description for doctors

6. Lack of induction/orientation course for newly employed staff

7. Reception of unskilled foreign staff

8. Reception of unwanted/worn out materials

9. Reception of unregistered/unrecognized foreign groups from their country of origin.

4.2.3 Opportunities 1. Representation of Ministry of Health and Social Welfare (MoHSW) in the Board of

Governors and Board of Trustees

2. Integration of Hospital with external faith based institutions.

4. Government support through remittance of funds (salaries), provision of drugs and

placement of health staff

5. Financial, human and material support from foreign collaborators/partners

4.2.4 Threats 1. Overdependence on MoHSW and donors’ support

2. Human right advocacy institutions

3. Certification by MoHSW regulatory bodies

4. Collaborators/partners dependence

5. Unemployment of indigenous staff

4.3 SWOTs Human Resources

4.3.1 Strengths 1. Existence of specialized health professionals

2. Existence of training institutions

3. Having local employees who are familiar with the working environment

18

4. Existence of a programme for recognition and rewarding employees at all levels for good

performance

5. Involvement of employees in various decision-making organs

6. Reliable source of staff salaries

7. Existence of super specialities (Urology, ENT)

8. Existence of unique specialties (TATCOT)

4.3.2 Weaknesses 1. Overdependence on staff from the Government through the Ministry of Health and Social

Welfare

2. Big proportion of aged staff

3. Non existence of succession plan

4.3.3 Opportunities 1. Availability of training institutions within the hospital.

2. Combination of patient care, training and research activities under one roof.

3. Training avenues.

4. Availability of enough land for expansion

5. Good – will by Government and other stakeholders

8. Society demand for specialized services in health.

12. Existence of International Collaboration programmes.

13. Big catchment area to offer referral services

4.3.4 Threats 1. Change of policy.

2. Donor/Government dependency

3. Society demand for specialized services in health.

4. Brain drain due to inadequate staff remuneration and retirement benefits

5. Upgrading of regional hospitals to become referral hospitals.

6. Establishment of private hospitals offering health services.

7. HIV/AIDS pandemic

4.4 SWOTs Financial Resource and sustainability

4.4.1 Strengths 1. Cost sharing as source of revenue

2. Government funding

3. Collaboration with Insurance companies (e.g. National Health Insurance)

4. Existence of some viable GSF projects

5. Existence of three pillars, patient care, training and research attracts more research

funding

6. Existence of research projects which remit to KCMC overhead funds

7. Funds from specialized and unique services

8. Introduction of accounting package WEBERP and Care2x

9. Existence of land which can be used as collateral for sourcing of investment funds

19

4.4.2 Weaknesses

1. Terms and conditions for insurance services not favorable to KCMC

2. Reliance on government funding

3. GFS projects operate on service oriented rather than commercial bases.

4. Uncompleted research registry

5. Specialized and unique services not fully utilized on commercial bases eg fast track

services.

6. Weak internal audit in terms of resources (staffing and qualified personnel)

7. Weak internal control systems (reconciliation, documentation, authorization, timely

preparation of books of accounts, revenue controls)

8. The current accounting system not able to capture all finance related data. It is manually

done

9. Failure to utilize current ICT development

10. Inadequate budget. Control mechanisms (Budgeted expenditure. Vs actual)

11. Non adherence to procurement plan

12. Failure to optimize and utilize land, including investment appraisal mechanism.

13. Low level cost containment awareness.

4.4.3 Opportunities

1. Provision of grants from government

3. Ready market for projects if operated on commercial basis

4. Reputation of KCMC to major funders such as EDTCP, EU

5. Existence of donor funded projects.

7. Existence of financial institutions to extend loans for investment

8. Exemption from tax being faith based institution, assist our cash flow.

4.4.4 Threats

1. Change in government policy/MoU

2. Disparity between requested budget vs approved budget (approximately 30%)

3. Untimely remittance of funds

4.5 SWOTS Infrastructure development

4.5.1 Strengths 1. Availability of adequate land with title deed

2. Availability of Structured hospital buildings.

- Wards

-Service laboraties

-Hostels.

-Residential houses.

-Offices.

-Lecture/ Seminar halls

3. Availability of adequate water supply

4. Possibility of sharing infrastructure

20

5. Availability of dedicated electric supply and backup system

6. Availability of ramp and elevators

7. Availability of functioning internal communication system

8. Availability of central sewage system.

4.5.2 Weaknesses 1. Land is not physically protected/fencing

2. Inadequate space;

-Wards.

-Emergency department.

-Offices.

-Stores.

-Car parking.

-Laboratory rooms.

3. Buildings have not been renovated for a long time

4. Reliance on a single source of water

5. Lack of infrastructure development plan and implementation

6. Unstable power supply -Standby generator does not cover the whole hospital

4.5.3 Opportunities 1. Government and donor support

2. Suitable geographical location

4.5.4 Threats

1. Over dependence and change of interest of donors /Government

2. Unstable national economy

4.6 SWOTs Hospital equipment and Supplies

4.6.1 Strengths 1. Availability of hospital formulary list

2. Availability of annual procurement Plan

3. The zonal medical store is within the catchment area

4. Existence and use of tendering system

5. Availability of hospital equipment donations

6. Support from Ministry of Health and Social Welfare

7. Availability of ICT equipment

8. Availability of orthopaedic workshop

9. Existence of local production of intravenous fluids and additives e.g spinal anaesthesia

and local anaesthetics

10. Existence of local production of extemporaneous preparations. e.g dermatological and

oral solutions for paediatric

11. Existence of categorized storage space

12. Existence of proper system of documentation

13. Availability of oxygen and Nitrogen Plants

21

4.6.2 Weaknesses

1. Irrational prescribing

2. Poor disposal of expired medicines, medical supplies and equipment

3. Lack of Hospital equipments planned preventive maintenance

5. Poor specification of equipments and supplies

6. Donation guideline not used

7. Inadequate equipments and supplies

8. Inconsistence allocation of funds for purchase of equipments and supplies

9. Inadequate ICT facilities

10. Low production rate of wheelchair and Prosthetic materials

11. The machine for local production of intravenous fluids and additives is very old

12. Unavailability of ingredients for Local production of extemporaneous preparations. e.g

dermatological and oral solutions for paediatric.

13. Dead stock generation eg. Vaccines, laboratory reagents and some equipment

14. Lack of reliable transport system

15. Loss/poor feedback on drugs, equipments and supplies.

4.6.3 Opportunities 1. Guaranteed support of funding from ministry of Health and Social welfare

2. Collaboration with various collaborators

3. High profile of KCMC as an Institution

4. Availability of funds from cost sharing, NHIF and Donors

5. Sharing of resources with other hospitals e.g. Sterilization of equipment

4.6.4 Threats 1. Lack of sustainable funding

2. Fluctuation of foreign currency

3. Over dependency on government funding

4. Change of Government policy

4.7 SWOTs Health Management Information System

4.7.1 Strengths 1. Existence of professionally designed filing system (6 digit coding system)

2. Functioning patient file location system

3. Existence of the only medical records training school in the country

4. Presence of physical space

5. Presence of trained indigenous personnel

6. Existence of medical archives

7. Possibility of access to patient data for research

8. Regular production of reports on regular basis

9. Data entry and analysis mechanisms in place

10. Dissemination mechanism in place

13. Existence of a solid and continuous patient folder reference mechanism

22

4.7.2 Weaknesses 1. Manual filling system which is labor intensive and needs a large physical space

2. Patient filling system is manual thus difficult to retrieve

3. Medical records training school is small with small intakes. It offers certificate training

only

-Outdated curriculum

-Being the only school in Tanzania, minimizes comparative competence

4. Space for medical records is small

5. Small number of Tanzanian students on training the rest being foreign

6. Inadequate archive management system

7. For medical records real time statistical analyses is not done

8. No emergency reporting mechanism

9. Absence of standardized data entry and analysis strategy

10. Unclear dissemination system

-data utilization not properly planned

11. Unguaranteed patient confidentiality

4.7.3 Threats 1. Rapid change in ICT technology

2. Similar Web based, distance learning programs by other institutions

3. Current archive is vulnerable to fire, rainfall etc

CHAPTER FIVE

5.0 Strategic Objectives The strategic objectives have been developed based on the environmental scanning and the

SWOT analysis which reflect the current status of the Hospital and the factors that would

positively or negatively influence its development.

The seven key result areas which have been considered are:

1. Clinical services

2. Leadership and management

3. Human Resources

4. Financial resources and sustainability

5. Infrastructure development

6. Hospital equipment and supplies

7. Health management information system

Strategic Objective No 1: Improved Quality of Clinical services

The competitive environment with which the Hospital operates demands quality performance in its core

function of patient care. In order to ensure quality delivery of services the hospital needs to improve its

specialist patient care. This strategic objective is geared towards achieving this goal.

23

Targets

1. Hospital social welfare services provided to all needy patients by June 2015

2. A continuous quality improvement program strengthened by June 2015

3. Compliance with national standards and guidelines improved by June 2015

4. An acceptable level of staff competences in providing quality services achieved by June

2016

5. Emergency preparedness ensured by December 2015

6. Rational prescribing of drugs ensured by July 2015

7. Timely availability of supplies ensured by July 2015

Strategies 1. Develop Hospital policy and guidelines for social welfare services

2. Adopt and implement the 5s-CQI-TQM in each clinical department

3. Update the hospital formulary annually and regularly and provide prescribers with information on

drugs available

4. Institute regular clinical audit

5. Put in place disaster preparedness plans

6. Conduct disaster preparedness exercises regularly

7. Train staff in disaster management

8. Run short courses for prescribing of drugs for doctors

9. Ensure the implementation of annual procurement plan

10. Strengthen procurement process

Performance indicators 1. Proportion of hospital days due to waiting for social services (repatriation, exemptions)

2. Proportion of referred upcountry patients exempted from paying fees

2. Proportion of staff trained in 5s-CQI-TQM in each department

3. Number of functioning Quality improvement teams in the hospital

4. Proportions of clinical departments attaining step 5 (sustain/self discipline)

5. Client/Patient satisfaction rates

6. 95% of prescriptions are appropriate

7. Proportion of meetings of Hospital Therapeutics Committee

8. List of drugs not available issued fortnightly

9. Client/patient satisfaction rates

10. Hospital mortality rates/case fatality rates reduced by 20%.

11. Average duration of hospital stay less than 8 days on average

12. Proportion of unnecessary and rejected requests for laboratory investigations reduced by 50%

13. Re-attendances as a proportion of all full consultancy episodes

24

14. Proportion of patient files with proper specialist documentation

15. Proportion of admissions seen by a specialist before discharge

16. Outpatient consultations of at least 6 new cases and at least 10 follow-up per specialist clinic

17. Referrals from wards as % of all outpatient visits

18. Laboratory tests per outpatient visits

19. Proportion of discharge forms fully and accurately completed in Jeeva System

20. Proportion of patients who receive medication on time

21. Patient re-operation rates

22. % of elective surgeries without postoperative infections and complications

23. Number of trained staff

Strategic Objective No 2: Enhanced Institutional Governance and

Management

KCMC has a well structured organogramme of leadership with relevant committees. There exist

also top governing bodies (Board of Governors and Board of Trustees). However, certain

important units and policies are lacking. These would greatly enhance the governance and

management of the hospital. This objective is designed to facilitate improvement in governance

and management.

Targets

1. Directorate of planning and Development Established by June 2015

2. Institutional management team trained on leadership and management skills by July 2015

3. External links unit established by June 2015

4. Institutional policies developed by December 2015

5. Board of Governors, Board of Trustees, Institutional Committees Strengthened

6. MoU between and GSF reviewed and updated

7. Number of HMI system personnel increased by 50% by December 2015

8. All of HMI system personnel on electronic HMI system trained by June 2015

9. HMI system physical infrastructure refurbished by June 2015

10. Electronic HMI system established by August 2015

11. Number of students in school of medical records increased by 100% by September 2015

12. Diploma course in Medical Records introduced by September 2015

Strategies

1. Prepare a write up of Establishment of Directorate of planning and development

2. Locate space for the directorate of Planning and Development

3. Employ staff for the Directorate of Planning and Development

4. Develop anti sexual harassment policy

5. Develop gender policy

25

6. Develop recruitment , retention and retirement policy

7. Develop staff establishment policy

8. Provide office for the links unit

9. Recruit links office staff

10. Develop data base for external links

11. Review tenure, roles and responsibilities, composition of staff

12. Increase number of personnel through employment of new graduates from the school of medical

records

13. Conduct training on advanced ICT utilization

14. Organize on-job training on use of electronic HMI system e.g. care 2X

15. Restructure and refurbish the current physical infrastructure to support both manual and

electronic HMI systems

16. Develop SOPs for HMI system (data entry, analysis, reporting and dissemination)

17. Establish quality assurance and control system

18. Acquire ICT facilities

19. Install appropriate HMI system software

20. Acquire modern learning aids (audio-visual systems, computers etc)

21. Advertise the school made widely

22. Develop curriculum for diploma programme in medical Records

23. Negotiate for the programme to be registered under the KCMC University College

Performance indicators 1. Directorate of planning and Development

2. Head personnel of the Directorate of Planning and Development

3. Anti sexual harassment Policy

4. Gender Policy

5. Staff establishment policy

6. Data base

7. Regular meetings

Strategic Objective No 3: Enhanced Human Resources Management

The hospital human resource consists of mostly staff seconded from the Government. The government

will second only staff requested by the hospital. Once staff is seconded to the hospital, it is its

responsibility to see to it that the staff are enabled to work properly and well motivated. Currently the

necessary tools to that end are lacking. Therefore KCMC needs to put in place the necessary mechanisms

for that. This strategic objective is designed to enhance recruitment, retention and motivation of staff at

the hospital.

Targets

1. Human resource development plan developed by December 2015

26

2. Job descriptions for all staff operationalized by December 2015

3. Performance management System established by January 2016

4. Staff retention improved by June 2015

5. Number of various specialists increased by June 2015

6. Human Resources policies operationalized by December 2015

7. Effective Human resource Information Health system developed by December 2016

8. An acceptable level of staff compliance with national guidelines and standards achieved

by June 2017

Strategies

1. Do Situational analysis of the existing staff

2. Apply job description

3. Review the current staff scheme of service and promotion guidelines

4. Operationalize the reviewed staff promotion guidelines

5. Improve the existing general working environment

6. Develop an attractive loan/credit scheme for staff

7. Involve staff in decision –making process

8. Improve the existing employees’ induction/ orientation process.

9. Review and update the existing Staff and training regulations.

10. Recruit various specialists to increase their number from 60 to 120

11. Train various specialists for deficient specialties

12. Establish recreational facilities for staff

13. Maintain an updated database of all staff

Performance indicators

1. Human resource needs identified

2. Recruitment plan prepared

3. Staff training and development plan in place

4. Job description

5. Linkage between staff annual review and staff promotion

6. Number of specialists

7. Worker’s participation in decision making

Strategic Objective No 4: Enhanced financial capability, efficiency and

sustainability

KCMC although a faith-based institution, largely depends on Government and Good Samaritan

Foundation (GSF) funding to carry out its core functions. However, these sources of funding are

also constrained. KCMC therefore needs to develop mechanisms that will ensure that the funds

27

are utilized in an efficient and sustainable way. The strategic objective is designed to ensure

rational utilization of available funds at the centre.

Targets

1. Internal audit department strengthened by Jan 2016

2. Accounting software (WebERP) operationalized fully by Dec 2016

3. Internally generated income improved by June 2015

4. Accounting and procurement manuals established by January 2017

5. Internal control systems improved by Dec 2016

6. Government funding level increased to 40% from current level (30%) by May 2016

7. Revenue unit strengthened by November 2016

8. Expenditure unit strengthened by November 2016

9. Budget unit established by November 2015

10. Procurement unit strengthened by November 2016

11. Inventory unit established by December 2016

Strategies

1. Recruit more professional and competent internal audit staff at least one Senior Internal Auditor

and three Assistant Senior internal Auditors

2. Provide capacity building (continuing education) to Auditors

3. Establish Audit Committee

4. Develop internal Audit Manuals

5. Purchase audit software and ICT equipment

6. Provide office space for internal audit unit

7. Encourage staff to use WebERP

8. Conduct cost benefit analysis for internally income generating projects

9. Draft accounting and procurement manuals

10. Review the current internal control systems

11. Negotiate with government to increase funding level

12. Head of the unit appointed

10. Qualified receiving and paying cashiers employed

11. Strong room built

12. Cash office grilled

13. Clearly defined authorization mechanism established

14. Provide office space for Budgeting unit

15. Recruit staff ( Management accountant)

15. Head of the inventory unit employed

16. Qualified staff employed for inventory unit

28

Performance indicators 1. Efficiency of audit unit

2. Audit committee

3. Internal Audit manuals

4. Amount of internally generated funds

5. Funding from Government

6. Funding from GSF

7. Expenditure

8. Budgeting

9. Procurement

10. Inventory of hospital property

Strategic Objective No 5: Developed and maintained Hospital infrastructure

Most of the infrastructure at the hospital dates back to 1971 when it was established. Since then some

buildings have been added and sporadic rehabilitation of some of the buildings has been done. However,

systematic care of the infrastructure has been lacking. This strategic objective therefore is designed to

ensure that proper units and systems are in place to oversee proper care of the hospital infrastructure.

Targets

1. Estate Department improved by July 2016

2. Existing Infrastructure rehabilitated by July 2018

3. Water supply system improved by December 2017

4. Power supply improved by June 2017

5. Maintenance systems strengthened by July 2016

6. Communication and information systems improved by December 2015

7. Administration block constructed by June 2019

8. Clinical wards expanded by December 2019

9. Hospital feeder roads improved by 2019

Strategies

1. Separate instrument repair laboratory from Estates Department

2. Repair all hospital buildings

3. Paint all hospital buildings

4. Put in place second source of water supply

5. Seek from TANESCO exemption from power rationing

6. Put in place mechanisms of reduction of power consumption

7. Rehabilitate internal telephone communication system

8. Prepare architectural drawings for the new administrative block

9. Solicit funds for Administrative block construction

29

10. Prepare architectural drawings for the new clinical wards

11. Solicit funds for clinical wards construction

12. Rehabilitate all the hospital feeder roads


1. Well organized and efficient estates department

2. Condition of hospital buildings

3. Condition of hospital feeder roads

4. Availability of water supply

5. Availability of electrical power supply

6. Telephone internal communication system

7. Administration block

8. New clinical wards

Strategic Objective No 6: Ensured availability of Hospital equipment

KCMC is currently equipped with a mixture of equipment some being new while others are old. There is

no system of ensuring that there is adequate and updated equipment. This strategic objective is designed

to ensure adequacy of equipment at KCMC hospital.

Targets

1. Central workshop strengthened by July 2016

2. Planned Preventive Maintenance (PPM) for hospital equipment developed by July 2015

3. All old machines replaced with new ones by July 2019

4. Production of locally manufactured equipment and supplies increased by July 2019

Strategies

1. Procure equipment for the central workshop

2. Solicit funds for renovation of central workshop to carter for hospital equipment

maintenance

3. Employ and train technical staff

4. Prepare a write up for Planned Preventive Maintenance (PPM) for hospital equipment

5. Establish replacement policy of old machines/equipment

6. Acquire new and modern equipment

7. Optimize production skills for local products

8. Set production targets

9. Strengthen the local production of infusions


1. New equipment

30

2. Renovated central workshop

3. Locally produced infusions

Strategic Objective No 7: Enhanced Response among staff towards HIV and

AIDS Prevention, Treatment and care

HIV and AIDS is a global health problem which has affected all sectors of service delivery. KCMC as

one of the health care delivery institutions has the responsibility to put in place mechanisms for

prevention and control of the pandemic at the work place.

Targets

1. HIV and AIDS control activities strengthened at KCMC by July 2015

2. HIV and AID research and consultancy strengthened by July 2015

Strategies

1. Strengthen the KCMC Technical AIDS subcommittee

2. Operationalize the KCMC HIV and AIDS Policy

3. Support the existing HIV and AIDS prevention and control activities

4. Support and participate in the National intervention for voluntary counseling and

testing

5. Establish KCMC HIV and AIDS situation at KCMC

6. Support research and consultancy on HIV and AIDS


1. Technical AIDS subcommittee

2. Research and consultancy on AIDS

3. Situation analysis

4. Voluntary counseling and testing

5. Prevention and control

31

CHAPTER SIX

6.0 Operating plan and Budget

6.1 Introduction This strategic plan is based on the KCMC vision and mission. In order to achieve this, KCMC has

developed novel approaches in the implementation of its core functions. The strategic plan has taken into

account that service delivery to the public has to be improved in a sustainable way.

6.2 Budget Plan This budget focuses on the recurrent costs, capital and research development.

The operational plan and estimated budget has been prepared with the following assumptions:

1. The rate of inflation will remain constant and therefore for the whole period of the five-year plan

prices will remain reasonably stable

2. Availability of continued Government support and development partners

6.3 Budget summary The table below summarizes the targets of the main strategic objectives and the estimated budget for

implementation

Figures (x1000)

Strategic Objective No 1: Improved Quality of Clinical

services

2015/16 2016/17 2017/18 2018/19 2019/20

Target 1 Hospital social welfare services provided to all

needy patients by June 2015

50,000 0 0 0 0

32

Target 2 A continuous quality improvement program

strengthened by June 2015

20,000 0 0 0 0

Target 3 Compliance with national standards and

guidelines improved by June 2015

0 0 0 0 0

Target 4 Acceptable level of staff competences in providing

quality services achieved by June 2015 20,000 0 0 0 0

Target 5 Emergency preparedness ensured by December

2016

0 0 0 0 0

Target 6 Rational prescribing of drugs ensured by July 2016

0 0 0 0 0

Target 7 Timely availability of supplies ensured by July

2015

0 0 0 0 0

SUBTOTAL 90,000 0 0 0 0

Strategic Objective No. 2: Enhanced Institutional

Governance and Management

2015/16 2016/17 2017/18 2018/19 2019/20

Target No. 1 Directorate of planning and Development

Established by July 2015

20,000 0 0 0 0

Target No. 2 Institutional management team trained on

leadership and management skills by July 2015

20,000 0 0 0 0

Target No. 3 External links unit established by June 2015

0 0 0 0 0

Target No. 4 Institutional policies developed by December

2015

20,000 0 0 0 0

33

Target No.5 Board of Governors, Board of Trustees,

Institutional Committees Strengthened by June 2015

0 0 0 0 0

Target No. 6 MoU between KCMC and GSF reviewed and

updated by June 2015

0 0 0 0

Target No.7 Number of HMI system personnel increased by

50% by December 2015

20,000 0 0 0 0

Target No.8 All of HMI system personnel trained by June

2015

20,000 0 0 0 0

Target No.9 HMI system physical structure refurbished by

June 2015

20,000 0 0 0 0

Target No. 10 Electronic HMI system established by

August 2015

20,000 0 0 0 0

Target No. 11 Number of students in school of medical

records increased by 100% by September 2015

0 0 0 0 0

Target No. 12 Diploma course in Medical Records

introduced by 2015 0 0 0 0 0

SUBTOTAL

140,000 0 0 0 0

Strategic Objective No 3: Enhanced Human Resources

Management

2015/16 2016/17 2017/18 2018/19 2019/20

Target No.1 Human resource development plan developed

by December 2015

20,000 0 0 0 0

Target No.2: Job descriptions for all staff operationalized

by December 2015 0 0 0 0 0

34

Target No.3: Performance management System established

by January 2016

5,000 0 0 0

Target No.4: Staff retention improved by June 2015

0 0 0 0 0

Target No.5: Number of various specialists increased by

June 2015

50,000 0 0 0 0

Target No.6: Human Resources policies operationalized

by December 2015

0 0 0 0 0

Target No.7: Effective Human resource Information Health

system developed by December 2016

20,000 0 0 0 0

Target No.8: An acceptable level of staff compliance with

national guidelines and standards achieved by June 2017

5,000 5,000 0 0 0

SUBTOTAL 100,000 5,000 0 0 0

Strategic Objective No 4:Enhanced financial capability,

efficiency and sustainability

2015/16 2016/17 2017/18 2018/19 2019/20

Target No.1: Internal audit department strengthened by

Jan 2016

5,000 0 0 0 0

Target No.2: Accounting software (WebERP)

operationalized fully by December 2016

0 0 0 0 0

Target No. 3: Internally generated income improved by

December 2016 0 0 0 0 0

35

Target No.4: Accounting and procurement manuals

established by January 2017

5,000 0 0 0 0

Target No. 5 Internal control systems improved by

December 2016 0 0 0 0 0

Target No. 6 Government funding level increased to 40%

from current level (30%) by May 2015

0 0 0 0 0

Target No.7: Revenue unit strengthened by December 2016

5,000 0 0 0 0

Target No 8: Expenditure unit strengthened by November

2016

0 0 0 0

Target No.9: Budget unit established by November 2015

5,000 0 0 0 0

Target No10: Procurement unit strengthened by November

2016

5,000 0 0 0 0

Target No.11: Inventory unit established by December 2016

5,000 0 0 0 0

SUBTOTAL 30,000 0 0 0 0

Strategic Objective No 5: Developed and maintained

Hospital infrastructure

2015/16 2016/17 2017/18 2018/19 2019/20

Target No.1: Estate Department improved by July 2016 30,000 20,000 0 0 0

Target No.2: Existing Infrastructure rehabilitated by July

2018

500,000 300,000 200,000 100,000 0

Target No.3: Water supply system improved by December

2017 50,000 30,000 20,000 0 0

36

Target No.4: Power supply improved by June 2017

30,000 20,000 20,000 0 0

Target No.5: Maintenance systems strengthened by July

2016

20,000 20,000 0 0 0

Target No.6: Communication and information systems

improved by December 2015

50,000 0 0 0 0

Target No.7: Administration block constructed by June

2019

300,000 200,000 100,000 100,000 50,000

Target No.8: Clinical wards expanded by December 2019

300,000 50,000 20,000 20,000 20,000

Target No. 9: Hospital feeder roads improved by 2019

100,000 50,000 20,000 20,000 20,000

SUBTOTAL 1,360,000 690,000 380,000 240,000 90,000

Strategic Objective No 6:Ensured availability of

Hospital equipment

2015/16 2016/17 2017/18 2018/19 2019/20

Target No.1: Central workshop strengthened by July 2016

30,000 30,000 0 0 0

Target No.2: Planned Preventive Maintenance (PPM) for

hospital equipment developed by July 2015

30,000 0 0 0 0

Target No.3: All old machines replaced with new ones by

July 2019

500,000 0 0 0 0

Target No. 4: Production of locally manufactured

equipment and supplies increased by July 2019 20,000 0 0 0 0

SUBTOTAL 580,000 30,000 0 0 0

37

Strategic Objective No 7:Enhanced Response among

staff towards HIV and AIDS Prevention, Treatment and

care

2015/16 2016/17 2017/18 2018/19 2019/20

Target No.1: HIV and AIDS control activities strengthened

at KCMC by July 2015

5,000 0 0 0 0

Target No.2: HIV and AID research and consultancy

strengthened by July 2015

5,000 0 0 0 0

SUBTOTAL 10,000 0 0 0 0

GRAND TOTAL 2,310,000 725,000 380,000 240,000 90,000

GRAND TOTAL BUDGET FOR FIVE YEARS 3,745,000,000

6.4 Financing sources KCMC will depend on the Good Samaritan Foundation, Government, donor support and internally

generated funds to finance the Five year Rolling Strategic Plan

38

CHAPTER SEVEN

7.0 Implementation Framework, Monitoring and Evaluation

7.1 Introduction

Monitoring and Evaluation of the KCMC Five-Year Rolling and Strategic Plan is designed to

ensure effective and efficient implementation of the plan and sustainability of the intended

impacts. It is presented as a review mechanism to monitor the progress and appraise outcomes

compared to the original objectives, targets and expected results.

7.2 Implementation

The KCMC Management is responsible for the implementation of the Five-Year Rolling and

Strategic Plan. In order to increase efficiency and effectiveness, the Directorate of Planning shall

coordinate all the activities related to the implementation of the plan. The implementation shall

be realized through annual plans and budgets, where departments and Units will prepare their

plans and budgets in line with the KCMC-wide strategic plan.

The Directorate of Planning, on the basis of the individual Departments and Units Plans will

prepare a KCMC – level annual work plan (operational plan) to guide the implementation of the

Five-Year Rolling and Strategic Plan. This will show all the activities to be implemented by

KCMC and its units.

Each key officer responsible for the implementation of a specific activity will be expected to

observe the anticipated targets together with the time frame and resources required.

7.3 Monitoring

A monitoring and evaluation system is required to measure and evaluate the level of

implementation, performance, achievement and impact of the strategic plan.

Monitoring of the implementation will be the overall responsibility of the KCMC Management

through the Directorate of Planning.

39

KCMC shall organize bi-annual meetings to discuss the progress in implementing the KCMC-

wide and units’ plans.

The progress reports will be used to update and roll forward the Strategic Plan every year.

The following table is the format to be used for reporting the progress implementation of the

strategic plan

Table 1. Progress implementation report of the Five-Year Rolling and Strategic Plan.

Strategic

Objectives

Targets Strategies Planned

activities

Achievements Planned

Remedial

Action

Performed

activities

Targets

achieved

Reasons

for

deviation

7.4 Evaluation

Evaluation will focus of comparison between planned targets and actual performance. The

evaluation of KCMC strategic plan will have the following objectives:

i) Assessing the reasons for success or failure of specific aspects of the strategic plan

ii) Assessing whether the Strategic Plan is achieving its objectives

iii) Finding out whether the effects of the strategic Plan are contributing to a better

fulfillment of the Mission and Vision of KCMC

40

iv) Assessing the adequacy of resources being mobilized for implementation of the plan

v) Determining whether available resources are being utilized efficiently

vi) Determining whether the process of strategic planning and implementation is facing

any problems that need attention

Strategic Objective No. 1: Improved Quality of Clinical services

Targets Strategies Planned Activities Performance indicators

Number of various

specialists

increased by June

2018

Recruit various

specialists to increase

their number from 60

to 120

Request for recruitment

permission from GSF

Advertise required

positions

Request for secondment

form Government

Number of specialists

Train various

specialists for deficient

specialties

Seek for funds

Identify suitable

Undergraduate candidates

Identify suitable

registrars in various

departments

Quality social

welfare services

provided to all

patients by June

2015

Establish social

welfare department

Develop proposal for

establishment of social

welfare department

Identify office space

Equip the office

Employ/deploy staff

Proportion of hospital

days due to waiting for

social services

(repatriation, exemptions,

etc)

1. Develop standard

operating

procedures

Appoint committee

Process SOPs through

participatory organs

Operationarize the SOPs

Proportion of referred

upcountry patients

served with meals

41



An acceptable

level of staff

competences in

providing quality

services achieved

by June 2017

Establish continuing

education office

Develop proposal for

establishment of the

office

Employ/deploy staff

Establish continuous

professional development

programs

Proposal in place and

office established

Required staff recruited

Professional development

programmes established

Staff to be compelled

to attend at least one

continued medical

education course per

year

Introduce attendance of

at least one continued

medical education course

per year as criteria for

promotion

Staff attend continued

medical education as one

of the promotion

criterion

Train staff in customer

care

Identify staff to be trained

in customer care

Solicit for funds

Identify

consultant/training

institution

Send them for training

Proportion of staff trained

in customer care

A continuous

quality

improvement

program

established by

June 2015

Establish service

targets for all

departments

Draw up a Standard

Operating Procedures

(SOPs) for service

delivery

Projections of services to

be provided available for

each department

Develop and

implement standards

of care for all major

causes of attendance

and admission

Implement the agreed

SOPs

Proportions of

patients/clients attended

according to set standards

Proportions of

patients/clients not

attended the same day

(includes postponed

clinics)

Copies of

Guidelines/protocols

present at places of work

Update the hospital

formulary annually

95% of prescriptions are

appropriate

42



and regularly provide

prescribers with

information on drugs

available

Proportion of meetings of

Hospital Therapeutics

Committee held as

planned

List of drugs not

available issued

fortnightly

Institute clinical audit Client/Patient satisfaction

rates.

Proportions of hospital

information accurately

entered (completeness of

data records and entry)

Hospital mortality

rates/case fatality rates

reduced by 20%.

Average duration of

hospital stay less than 8

days.

Proportion of rejected

requests for laboratory

investigations reduced by

50%

Proportion of all basic

investigations results

received within 24 hrs of

admission.

Proportion of inter-

departmental

consultations attended

within 24 hours of

request

Proportion of days with

bed occupancy of less

than 100%

% of patient charts

completed as required

Average time from

admission to clerking by

admitting doctor

Proportion of days

without ward rounds

43



Proportion of planned

mortality/morbidity

meetings attended by all

staff

Proportions of patients

examined in side rooms (

privacy observed during

patient examination)

Average number of

outpatients per doctor

Proportion of patients for

major surgery with pre-

operative evaluation by

an anaesthetist

Proportion of emergency

patients attended by a

medical officer within 15

minutes of arrival.

Proportions of patients

seen by a specialist

within 12 hours of

admission.

Waiting time for

appointment to outpatient

clinics and physiotherapy

less than 2 weeks.

Re-attendances as a

proportion of all full

consultancy episode

Re-admission as a

proportion of all

admissions.

Proportion of patient files

with proper specialist

documentation

Proportion of admissions

seen by a specialist

before discharge

An outpatient

consultations of at least 6

new cases and at least 10

follow-up per specialist

clinic

44



Referrals from wards as

% of all outpatient visits

Laboratory tests per

outpatient visits

X-rays per outpatient

visits

Laboratory tests per

admission

Proportion of appropriate

X-rays requested among

admitted patients

Number of major

operations per doctor per

month

Number of caesarian

section operations per

doctor per month

Number of minor

operations per doctor per

month

% of major ward rounds

attended by all

consultants for the ward.

Proportion of

prescriptions in generic

drug names

Proportion of all

caesarian sections are

elective

Proportion of surgeries as

private among all

surgeries

Proportion of discharge

forms fully and

accurately completed in

Jeeva System

Proportion of patients

transferred into another

department following

wrong admissions.


discharged within a day

of admission

45



Proportion of seriously ill

patients sent to the wards

before appropriate

resuscitation


HIV/AIDS tested among

all patients


with proper nursing

documentation

Proportion of charts

appropriately filled


who received appropriate

medications on time


with nursing plans

Copies of guidelines/

protocols present and

followed

Caesarian sections as %

of all deliveries

% of babies with AGPAR

Score equal or less than 6

% Fresh stillbirth among

all deliveries

Fresh stillbirth rates

reduced by 50%

Patient re-operation rates.

Average time from

notifying theatre to start

of operation


operated within 2 hours

from notifying theatre

and starting the

operation.

% of elective surgeries

without post-operative

infections

% of elective surgeries

without any

complications

46




waiting for less than 4

weeks for elective

surgery following the

decision to operate.

Average hospital stay

before operation


who stay for less than 48

hours before operation

Average hospital stay

after operation


who stay less than 4 days

post operatively

Postoperative sepsis rates

in elective surgery


operations not done (or

done) within three hours

of admission


results communicated

within 1hr of submission

of specimen

Proportion of all results

of basic investigations

available within 24 hrs of

specimens being taken.

Proportion of results of

cultures available within

the minimum standard

period of 72 hrs.

Proportion of biopsy

results available within 7

working days of the

biopsy.

Proportion of all

requested tests available.

Proportion of all

laboratory tests under a

quality assurance scheme.

47



Waiting time for

dispensing drugs less

than 15 minutes

Proportion of blood

products requests

fulfilled within 24 hours


requests for blood

fulfilled within 45

minutes of request

Waiting time at radiology

less than 30 minutes

Proportion of radiology

results reported within 24

hours

Proportion of days

without an efficient

communication system.


with temporary files


available at the beginning

of a clinic

% of laboratory test

results available at the

next visit

Number of major

incidents simulations

performed

Disaster

preparedness

ensured by

December 2015

Put in place disaster

preparedness plans

Employ

consultant/identify a team

to develop disaster

preparedness plans

Plans available

Conduct disaster

preparedness exercises

regularly

Create a committee that

will be carrying out

disaster preparedness

regularly

Regular reports available

48



Train staff in disaster

management


in disaster management

Solicit for funds

Identify

consultant/training

institution

Number of trained staff

Scope of tertiary

services provided

increased by

December 2015

Recruit and/or train

required staff

Develop manning levels

of the hospital


Recruit new staff

Number of new

specialists services

established

Procure required

equipment

Carry out needs

assessment of the

required equipment

Initiate tendering process

Procure equipment

Essential equipment

available for the new

services

Procure required space

and/or buildings

Identify Suitable

building/Areas

Space availability

Easy availability

of key clinical

staff on call

ensured by

December 2012

Provide mobile phones

to key staff

Identify staff to be

provided with mobile

phones

Procure and issue mobile

phones to the identified

staff

Proportion of key staff

with mobile phones

Build houses within or

near the hospital to

accommodate staff for

emergency services

Identify area for staff

construction

Solicit for funds to

construct staff houses

Identify consultant and

contractor

Proportion of key staff

accommodated within 5

km of the hospital

49

Strategic Objective No. 2: Enhanced Institutional Governance and Management


KCMC planning

unit established by

December 2014

Provide office space

for the planning unit

Solicit for Funds,

Renovate the acquired

office space

Procure office furniture

Availability of space

Recruit planning office

staff

Seek recruitment permit

Carry out recruitment

process

Availability of planning

officer and other staff

Institutional

quality assurance

unit established by

December 2015


for the quality

assurance unit

Solicit for Funds,

Renovate the acquired

office space


Availability of space

Recruit Quality

Assurance office staff

Seek recruitment permit

Carry out recruitment

process

Availability of quality

assurance staff

3. Institutional

policies

established by

April 2015

Develop staff welfare

policy

Solicit for funds

Identify consultant/team

to develop staff welfare

policy

Availability Staff

Welfare Policy made

available

Develop anti sexual

harassment policy

Solicit for funds


to develop anti sexual

harassment policy

Availability antisexual

harassment

Policy made available

Develop gender policy

Solicit for funds


to develop gender policy

Availability of Gender

Policy made

Develop recruitment ,

retention and

retirement policy

Identify a team to

develop recruitment ,

retention and retirement

policy

Availability of

recruitment , retention

and retirement policy

50

Strategic Objective No. 2: Enhanced Institutional Governance and Management


Develop institutional

staff

establishment/manning

levels

Solicit for funds


to develop institutional

staff

establishment/manning

levels

Availability of

institutional staff

requirement

Institutional

management

team trained on

leadership and

management skills

by July 2015

Hold training

workshop

Identify sources and

solicit for funds

Required funds acquired

by December 2010

Identify facilitators and

conduct the training

Facilitators identified and

training programme

developed by October

2010

Job descriptions

for all staff

operationalized by

December 2015

Head of each unit to

ensure each staff has

job description

Develop job description

for each staff

Availability of Job

Description of each staff

Job description

External links unit

established by

December 2016

Provide office for the

links unit

Allocate and renovate

office for external links


Office space made

available

Recruit links office

staff

Advertise the identified

positions

Recruit suitable staff

Staff recruited

Develop data base for

external links

Develop database for

archiving links

information

Links data base

established and updated

Strategic Objective No. 3: Enhanced Human resources Management


51



Staff Recruitment

and development

master plan

developed and

operationalized by

December 2015

Do Situational analysis

of existing staff to

establish recruitment

needs.

Carry out needs

assessment using

available tools

Needs assessment carried

out by July 2014

Establish staff

recruitment needs.

Analyze data to establish

the needs

Recruitment and staff

development

requirements established

by July 2015

Establish staff training

and development

master plan.

Draw up and implement

the master plan

Staff recruitment and

development master plan

in place and

operationalized by July

2015

Shortage of staff

addressed staff by

2016.

Make use of the

permission given to the

institution to fill in

Specific approved

positions.

Advertise all positions

which have permission

Staff recruited by June

2015

Use contractual

employment as a

mechanism for

handling current

critical staff shortages.

Solicit funds to finance

salaries for contractual

employee

Availability of fund

Required staff requited

Introduce tenure of

employment for staff.

Put in place an

effective human

resource succession

plan

Develop staff succession

master plan

Succession master plan

made available

3. Staff promotion

guidelines

reviewed and

operationalized by

December 2015

Review the current

staff scheme of service

and promotion

guidelines

Review of scheme of

service and guidelines

for promotion

Revised scheme of

service and guidelines for

promotion in place by

December 2014

Operationalize the

reviewed staff

promotion guidelines.

Disseminate the

guidelines to stakeholders

and implement

Guidelines and

implemented by March

2015

52



Produce guidelines for

promotion and scheme of

service

Guidelines for promotion

and scheme of service

operationalised by July

2015

Improved staff

retention by

December, 2015

Improve the existing

general working

environment.

Improve incentive

packages for staff.

Improve and

implement institutional

retirement benefits.

Provide office space for

all staff

Provide an attractive

loan/credit scheme for

staff

Involve staff in decision

making process.

Improve the existing

employees’ induction/

orientation process.

Review and update the

existing Staff and training

regulations.

Timely promotion and

salary increase to eligible

staff.

Introduce attractive

retirement benefits.

Reduced Staff turnover

Remuneration and other

staff incentives improved

% Increase in retirement

benefits

Staff welfare

policy

operationalized by

December 2017

Institute an effective

housing policy that

encourages staff to

own their own houses

Recruit

consultant/appoint a

committee to develop

effective staff housing

committee

Availability of Housing

policy

Establish effective and

efficient transport

system for staff.

Carry out needs

assessment for

requirements of motor

vehicles

Needs assessment carried

out and at least 80% of

the required vehicles

procured by July 2016

Establish recreational

facilities for staff.

Recruit sufficient and

appropriate personnel

Required personnel

recruited by July 2016

53



Effective Human

Resource

Information

Health system

developed by

December 2017.

Procure and Install

integrated software for

human resource and

health information

systems.

Identify suitable software

Procure and install IT

equipment

Provide training for ICT

staff and identified users.

Establish databases to

provide staff’s

particulars.

Ensure maintenance

schedules for the

equipment

Integrated software for

software for human

resource and health

information systems in

place

Strategic Objective No. 4: Enhanced financial capability, efficiency and sustainability


Internal audit

department

strengthened by

Jan 2018

Recruit more

professional and

competent internal

audit staff

Carry out needs

assessment

Recruit competent and

required number of

auditors

Competent and required

number of auditors

employed

Purchase audit

software and ICT

equipments

Identify Audit software ,

ICT equipment and

initiate tendering

processes

Required audit software,

ICT equipment Procured


for internal audit

Secure and allocate office

to internal audit unit

Internal audit office made

available

Accounting

software

(WebERP)

operationalized

fully by Dec 2015

Encourage staff to use

Web ERP

Train staff on Web ERP

software

All staff are conversant

with Web ERP software

Budgeting unit

established by

Dec. 2016


for Budgeting unit

Secure and allocate office

to budgeting unit

Internal audit office made

available

2. Recruit staff for

budget unit

Seek recruitment

permission from relevant

organ

Required staff employed

54

Strategic Objective No. 4: Enhanced financial capability, efficiency and sustainability


Internally

generated income

improved by June

2016

Conduct cost benefit

analysis for internally

income generating

projects.

Develop procedures for

cost containment

Procedures in place and

in use by July 2015

Sensitize KCMC

community to exercise

cost containment

measures

Cost contained by at least

20% by July 2015

Hire consultant/expert

for new

investments/Investment

plan

Identify

experts/consultants

Develop Investment

business plan for the next

five years

Consultant procured and

investment business plan

in place

Institutional

Financial

Regulation

Developed by Nov

2015

Hire consultant/expert

for development of

KCMC Financial

regulations

Identify

experts/consultants

Develop Investment

business plan for the next

five years

KCMC financial

regulation in place

Internal control

systems improved

by Dec 2015

.Strengthen the internal

control system

Review the current

internal control systems

Existence of better

control system

Government and

other good

Samaritan funding

level increased to

40% from current

level (30%) by

May 2018

Negotiate with

government and other

donors to increase

funding level

Draw up a fundable

proposal

Proposal developed and

submitted to relevant

funding agencies

55

Strategic Objective No. 5: Developed and maintained Hospital infrastructure


Directorate of

Planning and

Development

Established by

2016

Prepare a write up of

Establishment of

Directorate of planning

and development

Identify a team of experts

to develop a write up

Write up in place

Establish Directorate of

Planning and

Development

Directorate of planning

and Development

Established

Locate space for the

Directorate of

Planning and

Development

Renovate and procure

furniture for the

directorate

Office allocated

Employ staff for the

Directorate of

Planning and

Development

Advertise and recruit

staff for the Directorate

Staff recruited

Estate Department

Improved by 201

Streamline function of

estate department

Separate instrument

repair laboratory from

Estates Department

Laboratory repair

instrument are not kept in

the estate department

Existing

Infrastructure

rehabilitated by

July 2014

Repair all hospital

buildings

Solicit for funds Availability of funds

Identify contractor

through tendering system

Contractor identified

Paint all hospital

buildings

Solicit for funds Availability of funds

Identify contractor



Repair all hospital

feeder roads

Solicit for funds

Availability of funds

Identify contractor



Water supply

system improved

by December 2015

Put in place second

source of

Water supply

Drill water bore halls Availability of water

from bore halls

Power supply

improved by July

2014

Seek from TANESCO

exemption from power

rationing

Send a request and make

follow up with

TANESCO

No Power rationing

Put in place

mechanisms of

reduction of power

consumption

Sensitize KCMC staff to

switch off power when is

not in use

Mater separation

Electricity bill reduced

Communication

improved by July

2015

Rehabilitate internal

telephone

communication system

Solicit for funds Better performance of

internal telephone

communication system Initiate procurement of

contractor

56

Strategic Objective No. 5: Developed and maintained Hospital infrastructure


Rehabilitate the telephone

system

Administrative

block constructed

by 2015

Prepare architectural

drawings for the new

administrative block

Solicit funds for

Administrative block

construction

Funding status

established by July 2014

Procure consultant Architectural drawings

for the new

administrative block in

place

Prepare Architectural

drawings

Procure contractor and

initiate construction

Administrative block

constructed by 2015

Clinical wards

expanded by 2016



clinical wards

Solicit funds for Clinical

wards construction

Funding status



for the new Clinical

wards in place July 2015 Prepare Architectural

drawings



New clinical wards

constructed by 2016

Strategic Objective No. 6: Ensured availability of Hospital equipment and supplies


Central workshop

established by July

2018



central workshop

Solicit funds for Central

workshop construction

Funding status



for the new Central

workshop in place July

2015

Prepare Architectural

drawings

Availability of

architectural drawings

July 2015



New Central workshop

constructed by 2018

57



Employ and train

technical staff for the

new central workshop

Recruit required and

competent staff

Staff in employed by

June 2017

Conduct training needs

assessment

Report on training needs

assessment in place June

2017

Identify facilitator and

conduct training

Facilitator identified and

training conducted June

2017

Planned

Preventive

Maintenance

(PPM) for hospital

equipment

developed by July

2015.

Prepare a write up for

Planned Preventive

Maintenance (PPM)

for hospital equipment

Identify

consultant/experts

Preventive and

Maintenance programe in

place and full operational

June 2015 Develop KCMC

Preventive and

Maintenance programme

All old machines

replaced with new

ones by July 2016.

Establish replacement

policy of old

machines/equipment

Draw up KCMC disposal

and replacement policy

Availability of disposal

and replacement policy

by June 2015

Dispose obsolete

equipment

All obsolete equipment

disposed September 2015

Acquire modern

equipment

Solicit for fund Modern equipment

acquired by June 2016 Procure modern and

required equipment

Production of local

manufactured

equipment

increased by July

2015.

Optimize production

skills for local

products.

Identify and train staff Local manufactured

equipment increased by

30% by July 2015.

Set production targets establish production

target

Rational

prescribing of

drugs ensured by

July 2015.

Run short courses for

prescribing of drugs

for doctors

Develop training needs

assessment and identify

staff to be trained

Better prescription of

drugs July 2015

Indentify facilitators and

train staff

Timely availability

of supplies

ensured by July

2016

Ensure the

implementation of

annual procurement

plan

Solicit for funds Planned Goods and

services procured as

planned July 2015 Timely preparation of

annual procurement plan

Strengthen

procurement process.

Recruit requirement

number of staff

Timely acquisition of

goods and services July

58



Improve system of

procurement process

2015

Strategic Objective No. 7: Improved Health Management Information system


Number of HMI

system personnel

increased by 50%

by December 2015

Increase number of

personnel through

employment of new

graduates from the

school of medical

records

Develop staff

establishment

Recruit required number

of HMI staff

Number of employed

HMI personnel by

December 2015

All of HMI system

personnel on

electronic HMI

system trained by

February 2016

Conduct training on

advanced ICT

utilization

Solicit for funds


conduct training

Staff trained in advanced

ICT utilization by

January 2016

Organize on-job

training on use of

electronic HMI system

e.g. care2X

Solicit for funds


conduct training

Staff trained in electronic

HMI February 2016

HMI system

physical

infrastructure

refurbished by

June 2015

Restructure and

refurbish the current

physical infrastructure

to support both

manual and electronic

HMI systems

Identify consultant to

develop architectural

design

Rehabilitate the identifies

facility to suit the

requirement

physical infrastructure

refurbished to support

both manual and

electronic HMI systems

June 2015

Electronic HMI

system established

by August 2016

Develop SOPs for

HMI system (data

entry, analysis,

reporting and

dissemination)

Identify a team of expert

to develop SOPs

Submit to the relevant

organs for approval

SOPs developed and in

use by June 2016

Establish quality

assurance and control

system

Establish directorate of

quality control

Develop KCMC quality

control policy

Directorate of quality

control established

Quality control document

made available

59

Strategic Objective No. 7: Improved Health Management Information system


Acquire ICT facilities

Solicit for funds

Procure required ICT

equipment

ICT equipment procured

Establish reliable

back-up system

Procure servers and

heavy duty UPS

Availability of savers and

UPS

Number of

students in school

of medical records

increased by 100%

by September

2018

Request from

Government to

increase by two-fold

the current enrollment

of students

Prepare a proposal and

submit to Government

that justify two fold

increase of students

Permission granted by

June 2015

Recruit new teaching

staff

Seek recruitment

permission

Advertise the position

and recruit required

number of staff

Number of staff recruited

June 2015

Acquire modern

learning aids (audio-

visual systems,

computers etc)

Solicit for funds

Procure required quantity

of learning aids

Availability of Learning

Aids June 2015

Advertisements of the

school made widely

Develop marketing tools

Upload course provided

in the website

Increase number of

registered students June

2015

Diploma course in

Medical Records

introduced by

September 2015

Develop curriculum

for diploma program in

medical records

Identify a team of expert

to develop curriculum for

diploma program in

medical records

Submit to the relevant

organs for approval

Curriculum for diploma

program in medical

records

developed and

operationarised by June

2016

five year rolling strategic plan 2015 - 2020 - …kcmc.ac.tz/downloads/kcmc strategic plan...

Documents