DILCHORA REFERRAL HOSPITAL
EHAQ 4TH CYCLE ACTION PLAN
Evidence Based Care (EBC)
Prepared By: - Dr. Yosef A.
May 2021
Dire Dawa
Table of Contents
Contents
Table of content...........................................................................................................................................2
Introduction.................................................................................................................................................3
Objective.....................................................................................................................................................4
Action plan..................................................................................................................................................7
Introduction
Federal Ministry of health has been implemented stepwise national programs, initiatives & various
strategic plans successfully based on the goal outlined HSDP and the current HSTP which has been
transforming the country’s health care service system at all levels.
FMOH has developed and implemented Ethiopian Hospital Alliance for Quality (EHAQ] initiatives
throughout the country for the purpose of improving the quality of health care provisions at hospital level
through the fourth cycle evidence based care [EBC] initiatives with focus area of improved quality of
patient outcome in neonatal, emergency, surgical and selected NCDs.
EHIAQ was designed to create a network of hospitals that are committed to helping one another
& improve services. As a result of this, Dilchora hospital has been a lead hospital in Dire Dawa and
incorporates 2 hospital & 9 health centers in the Dilchora hospital cluster.
To our hospitals provide standardize and a continuum quality of health care service for their
community it is important to do baseline assessment of DilChora hospital & develop action plane
on identified gaps. Baseline assessment was done by EHAQ 4TH cycle technical team.
This document aims to show major gaps identified in EHAQ 4 th cycle EBC audit tool assessment
and the actions planned over one years for successful implementation of EHAQ 4th cycle EBC
program.
Objective
General objective
To conduct Evidence Based care & its implementation for improving the quality of
DilChora hospital as per the standards developed nationally.
Specific objectives
To promote and support the implementation of scope-based practice.
To strengthen continuous Quality improvement and culture of learning.
To Improve People-Cantered Care.
To improve patient outcome in neonatal, emergency, surgical and selected NCDs.
To build the capacity of health workers.
To provide onsite technical feedbacks for service providers and hospital management
team.
To identify possible barriers and come up with feasible recommendations.
To build the capacity of implementing EBC initiatives.
To ensure the availability of all materials needed for EBC.
DILCHORA REFERRAL HOSPITAL EHAQ 4TH CYCLE
ACTION PLANE FROM MAY, 2022 – JUNE, 2023
S.N Identified gaps Proposed solution Measurement Responsible Time Estimated
body frame budget
SECTION I :- Mechanisms to Avail High Quality Evidence
1 Related to scope based clinical practice
Hospital doesn’t have Prepare protocol/ guideline Number of Medical Director
protocol defining facility prepared
1.1 level/specific scope of protocols Quality Team
practice SMT
Interdepartmental Interdepartmental Number of Medical Director
consultations are NOT done consultations are requested prepared
1.2 by highest available scope by at least senior residents protocols Focus service area
[Senior] & No or GP & above clinicians. senior
Interdepartmental
Consultation Protocol
2 Standard Based Clinical Service Audit tool
Protocols/policy/procedures Avail listed protocols at Level of clinical Focus service area
are NOT developed for EOPD, NICU, OR, NCD service based on coordinators
2.1 Rounds, Selected nursing OPD listed protocol
procedures, Patient Quality Team
transportation, Bad news
breaking, Surgical
scheduling, Standard
treatment guideline
2.2 No STG orientation training Prepare STG orientation Number of CEO
for the staff training training
Quality Team
No STG & Clinical protocols Conduct STG clinical audit STG & Focus service area
implementation regular improvement coordinators
2.3 clinical audit and Prepare STG Improvement plan
Improvement plans plan implementation
Section II. Evidence Generation and Utilization
1 Evidence generation and utilization
1.2 No system to check Adopt procedure to check MRU OPD case manager,
completeness of medical medical records performance OPD coordinator &
records before returning back completeness MRU coordinator
to MRU.
1.3 No facility specific data The facility should have a Institutional QI HMIS & QIU
analysis & data driven specific data analysis at project
least on quarterly basis Focus service area
decision making
coordinator
1.4 No Regular staff capacity Prepare standardized Staff BSC result Quality Team
building & No capacity manual Medical Director
building Plan for staff training
Develop capacity building
Plan
1.5 No data quality triangulation The data quality Number of HMIS & QIU
between units triangulation should be reports on data together with
scheduled between units triangulation concerned
managers
Prepare protocol for
triangulation of selected
data
1.6 No gap oriented research at Develop mechanism Number of CED,CCO , QIU &
the hospital to encourage encourage evidence research report Case team
evidence generation. generation managers
Allocate budget for research
2 System redesign and EHSTG Boosters Audit tool
2.1 No Pre-triage set up screen Start pre-triage screening Number of CEO
for highly infectious cases and isolation services patient who
screened & Medical Director
and isolate
isolate
2.2 No Cough corner and cough Open cough clinic Number of Medical director
clinic cough clinic OPD coordinator
Develop protocol for opened
patient channeling to the
cough clinic
2.3 OPD clinics No Well- Develop OPDs premises Availability of CEO
ventilated and ensures protocols Medical director
privacy Prepare airborne and droplet OPD coordinator
precaution protocols coordinator
Avail privacy keeping
equipment
2.4 OPD NOT Well equipped - at Avail listed medical Presence of Medical director
least BP apparatus, equipment listed of the OPD coordinator
stethoscope, reflex hammer medical Coordinator
weighing scale and equipments
glucometer available at the
OPDs
2.5 Absent Hand Construct functional hand Performance of Medical director
washing/hygiene facility in washing basins with water, CASH audit OPD coordinator
OPD soap & 70% of ABHR reports on hand Coordinator
solution hygiene
Environmental and
sanitation focal
2.6 Absent protocols for OPD Prepare OPD Services Performance of Medical director
start time, service and Protocol client OPD coordinator
academic activities to be satisfaction Coordinator
conducted in parallel, lunch OPD services
time service initiation time
2.7 No physiotherapy service Establish physiotherapy Number of Medical director
service patient who visit Physiotherapy
Prepare protocols for physiotherapy focal
physiotherapy service clinic
2.7 Inadequate preventive Scheduling preventative Performance of Biomedical staff
maintenance for all facilities maintenance for major Biomedical unit Electrical worker
and operating systems (e.g., equipments Environmental
electrical, water, sanitation, Prepare Preventive focal
sewerage and ventilation) maintenance protocol
2.8 Inadequate human resource Prepare & scheduling Performance Human resource
development plan evaluation performance review plan review
decrement/report
2.9 Profession based duty rooms Make duty room gender Staff satisfaction CEO
& not well equipped based Nurse director
Avail 3 water boiler, TV & Cass team
desktop computer with Coordinator
connection to internet or
reference books loaded on
computer.
2.10 MEM inadequate calibration Register MEM Biomedical staff
and quality assurance
programs for prioritized
medical equipment
2.11 No Problem-based training Prepare training on Pharmacy
on pharmacotherapy pharmacotherapy coordinator
2.12 No established system Prepare protocol on rational Prescription Medical director
monitor appropriate and use of drug audit Pharmacy
rational use of the selected Audit Antibiotics performance coordinator
and prioritized drugs. Stewardship Performance
2.13 Clinical audit aren’t linked Develop Clinical audit Number of Quality Team
with CQI. improvement plan clinical audit
findings linked Clinical audit team
with QI
2.14 New admissions NOT audited Develop protocol - Medical director
and co-signed by day and Focus service area
duty time assigned senior coordinators
physicians
2.15 Duty senior physician Develop handover protocol Senior physician Medical director
shouldn’t make handover BSC Focus service area
from day time senior performance coordinators
physician
2.16 No weekly senior chart round Do chart review weekly Number of chart Quality Team
practice and identified gaps Evaluate status of QI linked review
aren’t linked with CQI to Chart review finding Medical director
2.17 Quality improvement Identify role of senior Number of QI Quality Team
projects not led by senior physicians in QI project project lead by
physicians seniors Medical director
Section III. Efficient use of healthcare resources
1 Efficient utilization of healthcare resources
1.1 No Outsourced Non-clinical
Services
1.2 No Benchmarking of staff
incentive mechanisms are
undertaken
Section IV. Focus Service Areas
1 Quality Nursing Care
1.1 NO Regular nursing care Avail Nursing Audit Monthly ICU coordinator
audit, performance report Protocol performance Medical Director
review & Data driven QI Prepare nursing round Nurse head
projects on identified gaps protocol
Link QI project to identified
gap
Do Monthly performance
1.2 No ICU nursing care package Prepare ICU nursing care ICU mortality Nurse head
protocol rate Focus service area
coordinator
1.3 NO capacity building for Established skill Lab Capacity Medical Director
nursing staff Prepare schedule for the building Laboratory head
utilization of the skill lab Performance Focus service area
Prepare skill lab register coordinator
DO skill gap assessment CEO
Prepare capacity building
plan
1.4 Nurse staffs poor Do Review Meeting Capacity Nurse head
involvement in MDT Establish Attendance building Focus service area
meeting, round, audit, and verification mechanism Performance coordinator
research Include it in Capacity
building protocol
1.5 Patient preference not Avail patient orientation Client All Hospital staff
included in decision making protocol satisfaction Esp. physician
Document patient
orientation in their chart
2 Surgical service efficiency and safety
2.1 NO monitoring mechanism & Do regular performance Elective surgery OR Director
gaps NOT linked with QI Monitoring performance Surgical ward
project in the OR Develop QI Project on Cancellation rate senior physician
identifying gaps to Medical director
improving OR efficiency
2.2 NO patient preparation room Construct patient Client CEO
in the OR preparation room in the or satisfaction Medical director
OR Director
2.3 NO Standardize preoperative Avail pre-operative workup OR performance Medical director
evaluations and work-ups Protocol rate OR Director
Develop perioperative Client Nurse Head
checklist satisfaction Surgical ward
nurse head &
senior physician
2.4 NO monitoring mechanism of Develop QI Project on Cancellation rate Medical director
OR performance & linked reducing cancellation OR performance OR Director
with quality improvement Do regular performance rate Nurse Head
monitoring
project Client Surgical ward
satisfaction nurse head &
senior physician
2.5 NO multidciplinary Prepare schedule for Surgical ward
perioperative conference a perioperative Conference nurse head &
day before surgery Develop patient preparation senior physician
plan for each of surgical Surgical ward staff
patient
2.6 No protocol for Preoperative Prepare Preoperative and Medical director
and postoperative hospital postoperative hospital stay OR Director
stay protocol Surgical ward
senior physician
2.7 No monitoring & Conduct hospital stay Surgical ward
accountability mechanism for monitoring mechanism nurse head &
hospital stay List actions linked to senior physician
monitoring findings Surgical ward staff
2.8 Poor surgical governance and Officially Assign OR Surgical ward
management structure director nurse head &
Develop department senior physician
specific team Surgical ward staff
Do daily team briefing and
debriefing at the beginning
and end of the OR day
Prepare briefing and
debriefing protocol
Document feedbacks and
action plans
Prepare day care surgery
protocol
2.8 Poor SaLTS committee Conduct Regular[bi- SaLTS Surgical ward
performance weekly] performance nurse head &
performance report review senior physician
Link identified gaps to QI Surgical ward staff
Project
Prepare SSC[Surgical
Safety Checklist] Audit
protocol
2.9 Poor WHO SSI checklist, Avail availability of SSI SSI rate Surgical ward
wound assessment and Protocol nurse head &
documentation on charts for senior physician
every patient Surgical ward staff
3 Improve neonatal intensive care
3.1 Inadequate regular Make all room to be NICU head nurse
performance review meetings functional Quality Team
& all available room intended Perform Quality NICU staff
to service provision improvement projects for
NICU care services
4 Improved Emergency, trauma and critical care
4.1 Emergency service NOT Perform assessment EOPD director
given based on the national according to the national Medical director
standard. standard
Conduct gap assessment
Prepare Regular capacity
building & plane for
improvement
Expand WHO BEC toolkit
Perform Continuous QI for
EICC services
4.2 Substandard critical care Conducts regular ICU head
service assessment based on the EOPD head
national ICU leveling Medical director
document checklist ICU & EOPD
Prepare plans of upgrading staffs
ICUs
Make all equipment
available and functional in
ICU
4.2 No protocols and guidelines Avail standard Protocols Medical director
for Evidence based service and guidelines for referral, ICU head
triage, burn, poisoning, EOPD head
trauma ED ICU services Medical director
Monitor using of guidelines ICU & EOPD
and protocols in Clinical staffs
practice
4.2 No standardized registries Avail WHO trauma registry HMIS
Avail revised ICU, Quality team
Emergency, Liaison referral Medical director
and ambulance service
registers
Section IV:- Patient Preferences and Value
1 Person- centered care
1.1 Poor documentation of health Register patients full Client Health literacy unit
literacy unit register name ,address, DX, satisfaction Medical director
information provided,
contact number at least
1.2 Absent Audio visual Health Avail Audio visual Client Health literacy unit
education material education material satisfaction Finance Officer
1.3 No Comprehensive Information provision Client Health literacy unit
Information provision should address clinical satisfaction
diagnosis, treatment options
and plan, subsequent follow
up scheme and parameters,
expected life style
modifications
Create mechanism to
address patient and family
concern
1.4 Improper patient patient Prepare protocol for Client Health literacy unit
discharge planning discharge planning satisfaction
1.5 No Client awareness and Avail of mechanism to Client Health literacy unit
knowledge audit assess awareness and satisfaction
knowledge of the client on
their specific case
Perform Bi weekly
performance report review
Link identified gaps to QI
projects
1.6 No pain clinic Palliative care Establish pain clinic Client CEO
clinic Establish Palliative care satisfaction Medical director
clinic
Perform Bi weekly
performance report review
Link identified gaps to QI
projects
1.7 No social service unit Establish social service unit CEO
Do social services audit Medical director
Social service unit
