Performance Review Meeting of RDHS-Gampaha 2018-1st and 2nd Quarters
This document provides insights into the performance review meeting of RDHS-Gampaha for the year 2018, focusing on the 1st and 2nd quarters. It includes details about the institution, directors, staff members, and contact information.
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Annexure Annexure 1 1 Performance Review Meeting Performance Review Meeting Performance of the Institution 2018 Performance of the Institution 2018- -1 1st stand 2 quarters quarters and 2nd nd RDHS-Gampaha_________________ Directorate of Healthcare Quality & Safety - Version 6 (Last updated on 30.01.2018)
Quality Management Review 2018- 1st and 2nd quarters Gampaha-RDHS area
Gampaha Gampaha- -RDHS RDHS- -area area DGH-Gampaha DGH-Negombo BH-Wathupitiwala BH-Mirigama BH-Kiribathgoda
Institutional Description Institutional Description- -DGH Head of the Institution Designation Name DGH- -Gampaha Gampaha Contact No Email (Personal) Director/ Medical Superintendent (MS) Dr. Sujeewa Rathnayaka 0710783945 Deputy Director Dr.Priyantha Illepuruma 0718456328 ileperuma2004@gmail.com Staff at QMU Designation Name Permanent / Temporary Contact No Email (Personal) MO-Q Dr.K.P.Udeni Dhammika Permanent 0718194024 uddhammika@gmail.com RHO-Quality A M L S Amarakoon Temporary 0714493543 Official Email address Hospital Email-dghgam@gmail.com QMU Email -qualitydgh@gmail.com Directorate of Healthcare Quality & Safety - Version 6 (Last updated on 30.01.2018) Display Only
Institutional Description Institutional Description- -DGH Head of the Institution Designation Name DGH- -Negambo Negambo Contact No Email (Personal) Director/ Medical Superintendent (MS) Deputy Director Staff at QMU Designatio n Name Permanent/ Temporary Contact No Email (Personal) MO-Q MO Dr. C.Kumara 077 4461503 hmckumara62@gmail.com Temporary DO Official Email address Hospital Email-dghgam@gmail.com QMU Email -quality@gmail.com Display Only Directorate of Healthcare Quality & Safety - Version 6 (Last updated on 30.01.2018)
Institutional Description Institutional Description-BH Head of the Institution Designation Name BH- -Wathupitiwala Wathupitiwala Contact No Email (Personal) Director/ Medical Superintendent (MS) Dr.Priyantah Wejesinghe 0718-013933 priyantha7009@gmail.com Deputy Director Dr.Manoharan 0773516246 manoharnk28@yahoo.com Staff at QMU Designation Name Permanent/ Temporary Contact No Email (Personal) MO-Q Dr.R.M.C.senarathna Permanent 0718-475745 rmchandrani@yahoo.com No-Q Ms.dhamika perera permanent 0716-887112 pereradhamimika@gmail.com Official Email address Hospital Email-msbwwp@yahoo.com QMU Email - Directorate of Healthcare Quality & Safety - Version 6 (Last updated on 30.01.2018) Display Only
Institutional Description Institutional Description- -BH Head of the Institution Designation Name BH- -Mirigama Mirigama Contact No Email (Personal) Director/ Medical Superintendent (MS) Dr. Kelum Amarasinghe 0710362650 Deputy Director Staff at QMU Designation Name Permanent/ Temporary Contact No Email (Personal) MO-Q Dr.chaminda premarathna Temporary Do-Planning Mrs.buwaneka temporary Official Email address Hospital Email- QMU Email - Directorate of Healthcare Quality & Safety - Version 6 (Last updated on 30.01.2018) Display Only
Institutional Description Institutional Description- -BH Head of the Institution Designation Name BH- -Kiribathgoda Kiribathgoda Contact No Email (Personal) Director/ Medical Superintendent (MS) Dr.Dharshana Pregeeth 071-4463197 Deputy Director Staff at QMU Designation Name Permanent/ Temporary Contact No Email (Personal) MO-Q Dr.K.M.M perera Permanent 077-2096632 kmaheshmperere@yahoo.com Official Email address Hospital Email bhkiribathgoda@yahoo.com QMU Email -bhkiribathgoda@yahoo.com Directorate of Healthcare Quality & Safety - Version 6 (Last updated on 30.01.2018) Display Only
Categories of Staff Categories of Staff- -DGH DGH- -Gampaha Gampaha Approved Carder Number Available Staff Category 1. Total number of Consultants (inclusive of Microbiologists and Surgeons) 2. Surgeons 3. Microbiologists 4. Total number of MO (including MO QMU/MO Public Health/MO Planning/MO Microbiology/ MO OPD) 5. MO QMU 6. MO Public Health 7. MO Planning 8. MO Microbiology 9. MO OPD 10. SGNO 11. Paramedical staff 12. NO(inclusive of Sister In Charge, infection control unit) 13. NO Infection Control Unit 14. Health Assistants Display Only 26 2 1 223 1 1 1 1 30 3 63 428 1 164 Directorate of Healthcare Quality & Safety - Version 6 (Last updated on 30.01.2018)
Categories of Staff Categories of Staff- -BH BH- -Wathupitiwala Wathupitiwala Approved Carder Number Available Staff Category 1. Total number of Consultants (inclusive of Microbiologists and Surgeons) 2. Surgeons 3. Microbiologists 4. Total number of MO (including MO QMU/MO Public Health/MO Planning/MO Microbiology/ MO OPD) 5. MO QMU 6. MO Public Health 7. MO Planning 8. MO Microbiology 9. MO OPD 10. SGNO 11. Paramedical staff 12. NO(inclusive of Sister In Charge, infection control unit) 13. NO Infection Control Unit 14. Health Assistants Display Only 17 2 - 199 1 1 1 1 18 1 46 324 2 149 Directorate of Healthcare Quality & Safety - Version 6 (Last updated on 30.01.2018)
Categories of Staff Categories of Staff- -BH BH- -Mirigama Mirigama Approved Carder Number Available Staff Category 1. Total number of Consultants (inclusive of Microbiologists and Surgeons) 2. Surgeons 3. Microbiologists 4. Total number of MO (including MO QMU/MO Public Health/MO Planning/MO Microbiology/ MO OPD) 5. MO QMU 6. MO Public Health 7. MO Planning 8. MO Microbiology 9. MO OPD 10. SGNO 11. Paramedical staff 12. NO(inclusive of Sister In Charge, infection control unit) 13. NO Infection Control Unit 14. Health Assistants Display Only 06 04 01 0 35 0 0 35 1 1 0 0 1 1 0 0 10 1 5 58 1 7 55 1 1 26 Directorate of Healthcare Quality & Safety - Version 6
Categories of Staff Categories of Staff- -BH BH- -Kiribathgoda Kiribathgoda Approved Carder Number Available Staff Category 1. Total number of Consultants (inclusive of Microbiologists and Surgeons) 2. Surgeons 3. Microbiologists 4. Total number of MO (including MO QMU/MO Public Health/MO Planning/MO Microbiology/ MO OPD) 5. MO QMU 6. MO Public Health 7. MO Planning 8. MO Microbiology 9. MO OPD 10. SGNO 11. Paramedical staff 12. NO(inclusive of Sister In Charge, infection control unit) 13. NO Infection Control Unit 14. Health Assistants Display Only 05 03 00 00 40 00 00 40 01 01 01 00 05 01 15 46 01 00 00 00 03 01 08 31 01 35 01 27 Directorate of Healthcare Quality & Safety - Version 6 (Last updated on 30.01.2018)
Categories of Staff Categories of Staff- -DGH DGH- -Negambo Negambo Approved Carder Number Available Staff Category 1. Total number of Consultants (inclusive of Microbiologists and Surgeons) 2. Surgeons 3. Microbiologists 4. Total number of MO (including MO QMU/MO Public Health/MO Planning/MO Microbiology/ MO OPD) 5. MO QMU 6. MO Public Health 7. MO Planning 8. MO Microbiology 9. MO OPD 10. SGNO 11. Paramedical staff 12. NO(inclusive of Sister In Charge, infection control unit) 13. NO Infection Control Unit 14. Health Assistants Display Only 25 29 02 01 220 02 01 190 01 01 01 02 24 04 69 335 01 01 01 03 26 03 53 358 03 179 02 158 Directorate of Healthcare Quality & Safety - Version 6 (Last updated on 30.01.2018)
2018- -1 1st st and 2 and 2nd nd quarters quarters Statistics Statistics 2018 DGH- Negambo Indicator DGH-Gam B.H.Wathu B.H.Meeri B.H.Kiri 864 864 712 600 600 195 195 97 97 Bed Strength 712 90 91 90 91 90 91 90 91 90 91 Number of Days in the Quarter 2463 4 2613 1 191 22 205 45 448 2 508 2 537 3 565 2 Total Number of Admissions in the year 4067 2 4359 6 308 18 316 64 860 1 101 13 843 4 830 8 In-patient Days for the Period 53.0 9 61.7 3 Average Percentage of Bed Occupancy Rate 52 55 57. 57. 96.6 94.1 1.86 1.73 1.97 2.13 1.8 1.7 Average Length of Stay Average Turnover 27.6 30.43 24.41 26.97 55.5 58.2 Paediatric wd Have your Institution establish a process to identify readmissions yes NO NO no Directorate of Healthcare Quality & Safety - Version 6 (Last updated on 30.01.2018) Not Not
2018- -1 1st st and 2 and 2nd nd quarters quarters Statistics Related to OPD Performance Statistics Related to OPD Performance - -2018 Indicator DGH- Negambo DGH-Gam B.H.Wathu B.H.Meeri B.H.Kiri Number of OPD Patients 823 83 732 40 60221 32634 61070 38410 Number of MOs in the OPD 25 19 25 24 24 19 03 03 Number of Patients per Medical Officer in the OPD per Day 37 35.2 120 35.3 2 Directorate of Healthcare Quality & Safety - Version 6 (Last updated on 30.01.2018) 33 40 40 142
Statistics Related to OPD Performance Statistics Related to OPD Performance Average Waiting Time* of a Patient at the OPD Average Waiting Time* of a Patient at the OPD - -2018 2018 Indicator Value (min) DGH- Negambo 15minute s DGH-Gam B.H.Wathu B.H.Meeri B.H.Kiri 2min ND 10 min 5mi nts 5mi nts Average Waiting time for Registration (a) 15 min ND 15minute s 13 min 20m ints 17 Average Waiting time for Consultation (b) 5 min 5 minutes 03 min 10m ints 8 Average time for Consultation (c) 1.5 hr 15minute s 1 hr vary vary Average time for Laboratory Investigations (e) 02 hours 20 min 15-20 minutes 30 min 20m ints 20M INTS Average waiting time for Pharmacy (g) 2 hr 12 min 120 minutes vary vary Average waiting time OPD with Laboratory Investigations (a+b+c+d1+e+d2+f+g+h) 2 hrs & 56 min 42 min 60 minutes vary vary Average waiting time OPD without Laboratory Investigations (a+b+c+f+g+h) 56 min *Waiting Time is defined as the period of time spent by a patient from his/her arrival to the OPD to the moment of leaving the OPD with or without drugs Guide : To fill this table please refer next slide Directorate of Healthcare Quality & Safety - Version 6 (Last updated on 30.01.2018)
Statistics Related to Clinic Performance Statistics Related to Clinic Performance - -2018 2018 Type of Clinic Total number for the Year Waiting Time (min) DGH-Gam DGH Neg BH Wathu BH Miri BH Kiri BH Miri 2726 3569 1822 2377 6635 6607 1355 4 1532 5 1466 8 1371 3 Medicine 2339 2425 149 150 NO NO 5261 5651 3466 3739 General Surgery 1073 1151 435 421 429 586 844 795 1567 1093 Paediatric 2347 2206 102 127 NO NO 1307 1358 2054 2490 Obstetrics 780 1147 182 158 NO NO 1185 1035 1520 1472 Gynecology 1024 2 9915 1006 8 (FM) 1042 7 Any other (Please Mention the Clinic) 55,2 69 73,7 90 Directorate of Healthcare Quality & Safety - Version 6 (Last updated on 30.01.2018) TOTAL
Statistics Related to Clinic Performance Statistics Related to Clinic Performance - -2018 2018 Type of Clinic Total number for the Year BH-kiri. DGH-Gam DGH-Negam. B.H.Wathu B.H.Meeri NA NA NA Orthopedic NA NA NA/s tared Cardiology 3137 3004 NA 737MO) ENT 1945 2226 NA 382(Con. once a month) Skin 3133 336 MO 1200 6335 2737(paed) Psychiatry Available 713 1443(<1yr) Baby clinics Directorate of Healthcare Quality & Safety - Version 6 (Last updated on 30.01.2018) TOTAL
Statistics Related to Clinic Performance Statistics Related to Clinic Performance- -2018 2018 Type of Clinic Total number for the Quarter Waiting Time (min) DGH-GamDGH- DGH- Gam DGH- N NegamboB.H.Wathu B.H.Meer B.H.Kiri B.H.W B.H.Meeri B.H.Kiri NA/(in gyn.cli nic) ND ND NA NA NA NA/(in gyn.clini 386 Family planing ND ND Recently started( MO) ND ND NA 36572 24435( visitin g con.) Eye 12600 (incl.min or sx) ND ND ND NA NA NA NA OMF ND ND NA NA NA NA NA NA Child obesity ND ND NA NA NA NA NA NA Anesthesia 45min ND NA 1246 NA NA NA Diabetic clinic ND ND NA NA/pla n to start NA NA NA NA Nutrition Directorate of Healthcare Quality & Safety - Version 6 (Last updated on 30.01.2018)
Statistics Related to Surgical Performance Statistics Related to Surgical Performance - -2018 2018 DGH G DGH N BH W Indicator Major Surgeries 1) Number of Major Surgeries Performed 202 252 594 486 2) Number of Checklists* attached 200 250 409 273 3) Number of Checklists* completed 200 250 00 212 Minor Surgeries 1) Number of Minor Surgeries Performed 1897 2568 1843 1996 2) Number of checklists* attached 1000 1000 00 00 3) Number of Checklists* completed 1000 1000 Directoratee Quality & Safety - Version 6 (Last updated on 30.01.2018) Post-Surgical Infection Rate (Except LSCS) * Checklist issued from HQS based on WHO Surgical Safety Checklist
Statistics Related to Obstetric Performance Statistics Related to Obstetric Performance - -2018 2018 DGH G DGH N BH W BH M BH K Indicator Total Number of Deliveries 856 883 979 02 846 1017 1067 01 NA Total Number of Normal Vaginal Deliveries (Including Instrumental Deliveries) 488 477 551 587 573 680 02 01 NA Total Number of Caesarean Sections (LSCS) 433 364 332 37.5 9% Not Calc ulat ed 430 42.2 8% Not Calc ulat ed 340 34.72 % 335 31.3 % N/A NA Caesarean Section (LSCS) Rate 0.5 0.43 N/A NA Post-Partum Infection Rate N/A NA Number of Maternal Deaths Nil Nil N/A NA Neonatal Mortality Rate (NMR) 3.08 5.64 NA Directorate of Healthcare Quality & Safety - Version 6 (Last updated on 30.01.2018)
Post LSCS -Surgical Site Infection Rate-2018 DGH-G DGH-N BH-W BH-M BH-K Indicator 0.2 9% 0.5 9% ND Post Caesarean Surgical Site Infection Rate(TOTAL) 0.46 % 0.27 % NA NA Post Caesarean Surgical Site Infection Rate(Elective) NA ND ND NA Post Caesarean Surgical Site Infection Rate (Emergency) NA ND ND NA Directorate of Healthcare Quality & Safety - Version 6 (Last updated on 30.01.2018)
Statistics Related to Infection Control Statistics Related to Infection Control - -2017 2017 Hand Hygiene Compliance(HHC) Rate According to Staff Category Unit Medical Officers Nursing Officers Minor Staff DGH N DGH G BH K NA BH W DGH G DGH N BH W BH M BH K DGH G DGH N BH M BH K BH W BH M Ref. 61% Ref. Ref. 85% NA 15% ICU ND ND NA ND 89% 92% NA 51% PBU ND ND NA ND NA 99% ND 98 % ND 90% Medical Ward ND ND ND ND NA ND NA Surgical Ward ND ND NA ND LR- 82% 92% LR 67% Other ND Guide : To be done by the Ward Liaison Nurse Infection Control/ NO Infection Control Unit Mention the unit and Healthcare Professional category where the audit carried out Total HHC for the unit= Total Correct Moments x 100% Total Observed Moments Directorate of Healthcare Quality & S6 (Last updated on 30.01.2018) Refer the Guideline Hand Hygiene Compliance Introduction of Hand Hygiene Tools
Statistics Related to Infection Control Statistics Related to Infection Control - -2018 Hospital Acquired Infection Rate Hospital Acquired Infection Rate- -2018 2018 2018 DGB G DGH N BH W BH M BH K Indicator 1.95 1.89 Staphylococcus aureus Bacteraemia Rate per 10,000 patient days 1/10000( 1st) ND ND 1.29 1.26 MRSA Bacteraemia Rate per 10,000 patient days 0 ND ND 0 - Hospital onset MRSA Bacteraemia Rate per 10,000 patient days ND ND 66% 66% Proportion of MRSA: Staphylococcus aureus in blood cultures(expressed as percentage) 0 Refer next slide for calculations Directorate of Healthcare Quality & Safety - Version 6 (Last updated on 30.01.2018)
Mechanisms to Monitor Antibiotic Resistance Do you follow any Guideline to monitor Antibiotic Resistance in your institution? YES/NO Does your institution has a permanent Consultant Microbiologist ? YES/NO If not, Does your institution has a cover-up from a Consultant Microbiologist? YES/NO Results of Surveillance Mechanisms carried out to identify the pattern of Antibiotic Resistance Surveillance Mechanism details Pattern of antibiotic resistance Enable /facilitate rational use of antibiotics Directorate of Healthcare Quality & Safety - Version 6 (Last updated on 30.01.2018)
DGB G DGH N BH W BH M BH K Indicator Guideline to monitor Antibiotic Resistance No NO NO No NO permanent Consultant Microbiologist Yes NO NO NO Yes Yes cover-up from a Consultant Microbiologist? YES/NO Refer next slide for calculations Directorate of Healthcare Quality & Safety - Version 6 (Last updated on 30.01.2018)
Statistics Related to Adverse Events Statistics Related to Adverse Events - -2018 2018 Category of Adverse Event*** Total number of reported Events DGH-G DGH-N BH-W BH-M BH-K Fall/ Safety issues 22 32 15 08 06 Treatment/ Diagnosis issues ND NA NA NA NA Drugs/ IV / Blood issues 26 NA NA 02 NA Surgery/ Anaesthesia issues ND NA NA NA NA Laboratory reports ND NA NA NA NA Labour /Delivery issues ND NA NA NA NA Miscellaneous issues ND NA 01 NA NA Other(suicidal attempt) 03 NA NA NA NA Guide : Please breakdown Adverse Events under above categories. Refer the Guideline for Adverse Event/Incident Reporting and Adverse Event/Incident Reporting Form (Health 1259) ***An Adverse Event is defined as an injury related to medical management in contrast to complications of disease. Medical management includes all aspects of care, including diagnosis & treatment, failure to diagnose or treat, and the systems and equipment used to deliver care. Adverse event may be preventable or non- preventable (WHO 2005). (Last updated on 30.01.2018) Directorate of Healthcare Quality & Safety - Version 6
Progress of Quality Management Units Progress of Quality Management Units - -2018 2018 DGH G Yes DGH N Yes BH W BH M BH K Area of Concern Availability of a Focal Point for Healthcare Quality and Safety Programme Yes Yes Yes Availability of a Steering Committee for QMU Yes Yes Yes Yes Yes Number of Steering Committee Meetings conducted in your Institution during the Quarter 0 02 01 02 01 Work Improvement Team (WIT) No of Wards and Units 20 56 26 12 14 No of Established WITs 20 11 20 10 10 No of WITs functioning 0? 01 13 06 07 Criteria to be fulfill for a functioning WIT To meet monthly Number of participation should be >50% of total number in the ward Eg; Total no. of staff in the ward=20, Number of staff participated for the WIT meeting=15 Participation as a percentage= 15/20 x 100% = 75% Minutes should be recorded At least one matter should be discussed and implemented per month Directorate of Healthcare Quality & Safety - Version 6 (Last updated on 30.01.2018)
Progress of Quality Management Units Progress of Quality Management Units -2018 2018 DGH G DGH N BH W BH M BH K Area of Concern Patient Satisfaction Surveys 1) Number of Patient Satisfaction Surveys Conducted in the Quarter (at least two Patient Satisfaction Surveys should be conducted per year) 01 ND OPD 00 01(OPD) Ref. 2) Key findings and actions taken for key findings Employee Satisfaction Surveys ` 1) Number of Employee Satisfaction Surveys Conducted in the quarter (at least one Employee Satisfaction Survey should be conducted per year) 01 ND ND 01 01 2) Key findings and actions taken for key findings In-service Training Programmes Number of In-service Training Programmes Conducted (At least 4 in-service training programme/year (01 per quarter): Related to Quality and Safety in Healthcare should be conducted for Healthcare staff) 01 04 05 02 03 Stress Mx Introducti on to Quality and safety 5S WITS 5 S TQM Kaizen Directorate of Healthcare Quality & Safety - Version 6 (Last updated on 30.01.2018)
Statistics Related to Clinical Audits Statistics Related to Clinical Audits - -2018 2018 Total number for the Year DGH N HH DGH G BH W BH M BH K Indicator HH ND ND HH Number of Clinical audits* conducted. Mention the Top 05 Clinical Audits (Topics in brief) conducted in year 2017 Perinatal death audit 1 Hand hygiene audit 2 Dengue death audit 3 Maternal death audit 4 5 Guide : At least one audit per quarter Please mention -what type of audit carried out *Clinical audit is a quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the implementation of change. Directorate of Healthcare Quality & Safety - Version 6 (Last updated on 30.01.2018)
Statistics Related to Death Reviews Statistics Related to Death Reviews 2017 2017 Indicator Indicator Total Total number for the Quarter number for the Quarter DGH DGH- -G G DGH DGH- -N N BH BH- -W W BH BH- -M M BH BH- -K K 07 Deaths per year Death Reviews 00 01 00 NA 1) Maternal Death Reviews 07 06 00 NA 2) Perinatal Death Reviews 00 00 00 NA 3) Dengue Death Reviews 00 00 00 NA 4) Any Other (Please mention the name of Death Review 34 07 00 TOTAL Directorate of Healthcare Quality & Safety - Version 6 (Last updated on 30.01.2018)
Progress of Selected Standards and Indicators in accordance with the Circular No: 02 Progress of Selected Standards and Indicators in accordance with the Circular No: 02- - 122/2013 122/2013 Please fill in the excel form attached Please fill in the excel form attached Indicator Comment Please use the softcopy of the excel sheet provided True findings -Circular M&E All 20 indicators will be assessed. 1. Provision of Safe Water 2. Notification of communicable diseases 3. Sanitation (General) 4. Sanitation (Specific) 5. Maternal Care 6. Examination of in-patients by a House Officer / Senior House Officer 7. Efficiency of sterilization of instruments 8. Diet Services 9. Nursing care 10. Disaster preparedness 11. Patient safety 12. Patients waiting time in OPD 13. Monitoring quality improvement programme (Quality of Care) 14. Community participation in Hospital management 15. In-service training 16. Intensive Care 17. Neonatal Care 18. Operating Theatre Services 19. Responsiveness to specialized groups 20. Standardized visuals Directorate of Healthcare Quality & Safety - Version 6 (Last updated on 30.01.2018)
Quality Programme Dash Board Quality Programme Dash Board Plan for year 2018 Plan for year 2018 (HSDP indicators) (HSDP indicators) DGH G DGH N BH W BH M BH K Topic 1. Training of Staff 2 Functioning of WITS 3 Conducting Customer Satisfaction Survey 100% Completed 50% Completed 25% Completed Started Not Started Guide : Please refer next slide for explanation Directorate of Healthcare Quality & Safety - Version 6 (Last updated on 30.01.2018)
Statistics related to Clinical Indicators Statistics related to Clinical Indicators - -2018 2018- - 1. Clinical Indicators of Medicine Indicator Commenced YES/NO Value for the Year Issues during implementation DGH G DGH N BH W BH M BH K 1. Percentage of patients given a fibrinolytic in <30 minutes of arrival in ST Elevation Myocardial Infarction(STEMI) or ND ND ND Yes/ recently 3/118 2.54% undergoing primary Percutaneous Coronary Intervention(PCI) in <90 minutes of arrival to hospital NA NA NA NA NA Directorate of Healthcare Quality & Safety - Version 6 (Last updated on 30.01.2018)
Cont..Clinical Indicators of Medicine-BH-Wathupitiwala Indicator Value for the Year Issues during implementation DGH G DGH N BH W BH M BH K 2. Percentage of patients with diabetes who are attending to Medical clinics, having FBS measured at least once in two months controlled to target FBS < 126mg/dl ND ND 60% ND/ Started recentl y ND HbA1C measured at least once in 6 months and controlled to target HbA1C < 7 Not started ND/Sta rted recentl y ND ND ND 3. Percentage of patients with BP controlled to target < 140/90mmHg in the patients with cardiovascular risks. 99/100 99% ND ND ND/sta rted recentl y ND Directorate of Healthcare Quality & Safety - Version 6 (Last updated on 30.01.2018)
Cont.Clinical Indicators of Medicine Indicator Commenced YES/NO Value for the Year Issues during implementation DGH G DGH N BH W BH M BH K 4.Percentage of errors in administration of prescribed medication to the right patient at any stage of medication process (i.e., prescribing, transcribing, dispensing, administration and monitoring) ND ND ND ND 5. Percentage of patients with a physician diagnosis of asthma who receive out-patient/ETU/PCU nebulisations ND ND/Sta rted ND ND Directorate of Healthcare Quality & Safety - Version 6 (Last updated on 30.01.2018)
Statistics related to Clinical Indicators Statistics related to Clinical Indicators - -2018 2018 2. Clinical Indicators of Surgery Indicator Commenced YES/NO Value for the Quarter Issues during implementation DGH G DGH N BH W BH M BH K 1. Rate of Postponement of Elective Surgery Yes ND ND 7.44% (4th) ND NA 2. Waiting time duration in indexed operations. Divided into cancer and non- cancer ND ND NA NA NA Cancer NA NA NA Non Cancer Directorate of Healthcare Quality & Safety - Version 6 (Last updated on 30.01.2018)
Cont.Clinical Indicators of Surgery Indicator Commenced YES/NO Value for the Quarter Issues during implementation DGH G DGH N BH W BH M BH K 3. Percentage of Surgical facilities using the Surgical Safety Checklist Yes ND Yes(Ra te not calcula ted) NA NA 4.Rate of Surgical Site Sepsis ND/sta rted ND ND NA NA 5. Average hospital stay after an index operation( ex: Appendicitis, inguinal hernia, amputation for diabetic gangrene) Appendicitis ND/sta rted ND ND NA NA Inguinal hernia ND/sta rted ND ND NA NA Amputation for diabetic gangrene ND/sta rted (Last updated on 30.01.2018)ND ND ND NA NA Directorate of Healthcare Quality & Safety - Version 6
Statistics related to Clinical Indicators Statistics related to Clinical Indicators - -2018 2018- - 3. Clinical Indicators of Paediatrics Indicator Value for the Quarter Issues during implementation DGH G DGH N BH W BH M BH K 1. Hypothermia on admission to Neonatal Unit when transferring from one institution to another (Outside born baby) or from the maternity unit to the neonatal unit in the same hospital (In born baby). ND ND 02 2. Re-admission to the ward with wheezing who had bronchiolitis under one year of age. ND ND ND Directorate of Healthcare Quality & Safety - Version 6 (Last updated on 30.01.2018)
Cont..Clinical Indicators of Paediatrics Indicator Commenced YES/NO Value for the Year Issues during implementation DGH G DGH N BH W BH M BH K 3. Readmission rate within 14 days following discharge from a Paediatric ward. NA ND ND 4. Hypoglycemia on Admission to the Neonatal Unit when transferring from one institution to another (Outside born baby) or from the maternity unit to the neonatal unit in the same hospital (In born baby) Yes ND 12 5. Case fatality rate in Dengue Hemorrhagic Fever 0.16 (3rd) 0% (4th) NA 0.23% Directorate of Healthcare Quality & Safety - Version 6 (Last updated on 30.01.2018)
Statistics related to Clinical Indicators Statistics related to Clinical Indicators - -2017 2017 4. Clinical Indicators of Obstetrics & Gynaecology Indicator Commenced YES/NO Value for the Year Issues during implementation DGH G DGH N BH W BH M BH K 1. Labour Induction Rate No ND ND ND ND NA 2. Episiotomy rate No ND ND ND ND NA 3. Caesarian section rate ND NA Yes 44.3% 29.73% NA 4. Proper use of Partogram ND ND Yes 100% No proper use NA 5. Average waiting time for routine major Gynaecological surgery Yes ND ND ND ND NA Directorate of Healthcare Quality & Safety - Version 6 (Last updated on 30.01.2018)
As the focal point..RDHS Felicitation of winners in 2016- productivity award Review QM activities six monthly Capacity building of QM focal points at the district-Sharing best practices Way forward .. Coordinate with hospitals to implement all clinical indicators Supervisory visit to the institutions Workshop to prepare 2019 QM action plan Year end review Directorate of Healthcare Quality & Safety - Version 6 (Last updated on 30.01.2018)
No. Objective Strategy Activity Responsible person Time line Budget Process Indicator 01. To streamline the quality management activities in the health institutions in Gampaha district Preparing action plans for each health institutions for 2019(both hospitals & MOH offices) Workshop on preparing action plans for, Mo-QM September 2018 HSDP % of hospitals & MOH offices prepared action plans before 2019 January 1.focal points at hospitals (focal point) at RDHS 2.designated officer at MOHs 02. To monitor the quality management activities in Gampaha district 1.Review activities at district level Review meetings at RDHS office Mo-QM(focal point April & September HSDP % of hospitals & MOH offices participated i)Preparing a supervisory tool Mo-QM(focal point Two hospital for a month 2.Supervisory visit to the institutions by using a supervisory tool % of hospitals & MOH offices supervised ii) Visit the hospitals by a team consist of focal point RDHS,CCP and one independent Mo(QM) from a hospital Do supervision incorporated into the MOH supervision ii.Visit the MOH offices 03. To improve customer satisfaction and quality of care given to patients at health institutions at the district Capacity building Workshops at institutional level 1.DGH Negambo&Gampaha 2.B.H wathupitiwala&meerigama 3.Divisional hospital Divulapitiya,Kiribathgoda,Dompe, Minuwangoda Mo-focal point at RDHS &relevant focal point at the institutions From June to September HSDP % of institutions completed work shop Directorate of Healthcare Quality & Safety - Version 6 (Last updated on 30.01.2018)
Thank You Directorate of Healthcare Quality & Safety - Version 6 (Last updated on 30.01.2018)
