Peer Review Monitoring

VOLTA REGIONAL HEALTH DIRECTORATE
REPORT ON THE FIRST ROUND OF
PEER REVIEW
OF HOSPITALS IN THE VOLTA REGION
DECEMBER, 2011
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SECOND CYCLE PEER REVIEW REPORT,2011
DECLARATION
This report is the result of the Peer Review monitoring by the Regional Clinical Care Division of the Volta Regional Health Directorate, which was actively supported by the Medical Superintendents group. The overriding objective of the exercise is to improve the quality and standards of service delivery for all the twenty one hospitals and the only Polyclinic in the region to become centres of excellence. We the undersigned hereby declare that, the findings and the recommendations made in this report shall be used for the improvement in the quality of healthcare delivery in the Volta Region and not for any other purpose apart from the stated objectives of the Peer Review Process. Any person or group of persons wishing to use any part or whole of this report for any purpose or any other objective should contact the undersigned persons of this declaration.
ROBERT KWAKU ADATSI DEPUTY DIRECTOR CLINICAL CARE VOLTA REGION
DR. KOFI GAFATSI NORMANYO CHAIRMAN, MEDICAL SUPERINTENDENTS GROUP VOLTA DIVISION
MR. SIMON YAO DZOKOTO PEER REVIEW COORDINATOR FOR HOSPITALS, VOLTA REGION
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SECOND CYCLE PEER REVIEW REPORT,2011 ABBREVIATIONS AND ACRONYMS
CCD CHPS GPRS GHS M &E MSG MSG-VD PR QA RDHS RHD VRHD WHO
Clinical Care Division Community-Based Health Planning System Ghana Poverty Reduction Strategy Ghana Health Service Monitoring and Evaluation Medical Superintendents Group Medical Superintendents Group- Volta Division Peer Review Quality Assurance Regional Director of Health Services Regional Health Directorate Volta Regional Health Directorate World Health Organization
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SECOND CYCLE PEER REVIEW REPORT,2011 TABLE OF CONTENT
DECLARATION ............................................................................................................................................... ii ABBREVIATIONS AND ACRONYMS ............................................................................................................... iii TABLE OF CONTENT ..................................................................................................................................... iv MESSAGE FROM HONOURABLE VOLTA REGIONAL MINISTER .................................................................... vi MESSAGE FROM THE REGIONAL DIRECTOR OF HEALTH SERVICES ............................................................ vii EXECUTIVE SUMMARY ............................................................................................................................... viii ACKNOWLEDGEMENT ................................................................................................................................... x CHAPTER ONE-INTRODUCTION..................................................................................................................... 1 1.1 Overview ................................................................................................................................................. 1 1.2 Review of the Check list .......................................................................................................................... 1 1.3 Progress and Limitation in Organization of Peer Review........................................................................ 4 CHAPTER TWO- PERFORMANCE ................................................................................................................... 5 2.2 Performance Change in Thematic Areas................................................................................................. 8 2.3 Comparing the Difference in Means and Standard Deviations of the Thematic Areas of the First and Second Cycle Peer Reviews ............................................................................................................ 9 2.4 Performance Change in the Thematic Areas Based On Ownership...................................................... 12 2.5 PERFORMANCE BASED ON ZONAL LOCATION ...................................................................................... 13 2.6 SECOND CYCLE PEER REVIEW PERFORMANCE AND POST PEER REVIEW PERFORMANCE ................... 15 2.7 OVERALL PERFORMANCE OF HOSPITALS BY OWNERSHIP AND LOCATION.......................................... 19 2.8 PERFORMANCE TARGET SET BY THE REGIONAL DIRECTOR OF HEALTH SERVICE TO ALL MEDICAL SUPERINTENDENTS ............................................................................................................................. 21 2.9 LEAGUE TABLE OF PERFORMANCE OF HOSPITALS ............................................................................... 22 2.10 Improvement or otherwise of facilities .............................................................................................. 23 2.10.1 Description of the problem or stimulant (outliers).................................................................. 23 2.10.1.1 Environment.......................................................................................................................... 23 .................................................................................................................................................................... 24 2.10.1.2 Infection Prevention and Control ................................................................................................. 25 2.10.1.3 Emergency Systems and Services ................................................................................................. 26 2.10.1.4 Quality Assurance Activities.......................................................................................................... 27 2.10.1.5 Clinical Practices............................................................................................................................ 27 2.10.1.6 Clients Care ................................................................................................................................... 27 iv
2.10.1.7 Occupational Health and Safety Issues ......................................................................................... 27 2.10.1.8 Management................................................................................................................................. 28 2.10.2 Regional Directors Mark for Innovation and Organization of the Peer Review ............................. 29 CHAPTER THREE- CONCLUSION & RECOMMENDATION............................................................................. 30 3.1 CONCLUSION ......................................................................................................................................... 30 3.2 RECOMMENDATIONS............................................................................................................................ 30 REFERENCES ................................................................................................................................................ 32 APPENDIX .................................................................................................................................................... 33
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SECOND CYCLE PEER REVIEW REPORT,2011 MESSAGE FROM HONOURABLE VOLTA REGIONAL MINISTER
Health Care delivery demands a concerted effort to ensure that lives are saved. Health is Wealth and therefore an essential component of the better Ghana Agenda. As we get close to the Better Ghana Agenda Part 1, the government has chalked a lot of success by embarking on a number of projects aimed at accelerating improvement in the performance of the health sector with special emphasis on prudent use of resources available to the sector and sustainable improvement in access to quality health care. Human resource which is one of the key ingredients to providing quality Health Care has become a challenge in the Volta Region more especially, in the case of Midwives who are the key people in helping to achieve the MDG 4 & 5. It is in pursuance of this that University of Health and Allied Sciences in the Volta Region and Post Basic Midwifery School in Krachi West District are being established. All these efforts of government are targeted at ensuring sustainable improvement in access to quality health care. However, government again recognizes that the mere presence of physical structure may not necessarily translate to quality health care. In other words, problems of quality health care continue to be a fundamental challenge to access to health care, but have received relatively little attention in the past. It is heartening to realize that the implementation of the Peer Review has improved a lot of aspects of the Health Care delivery in the Hospitals. This was indicated in the results of this report. We at the Regional Coordinating Council will always support programmes like this and project it to put the Region in the limelight. It is in this regard that the Regional Coordinating Council applauded the Peer Review approach of the Regional Health Directorate and the Medical Superintendents Group to standardize and improve quality of Service in the entire Region through cross fertilization of best practices. We will continue to strengthen the process by encouraging all the Municipal/District Assemblies to provide the necessary assistance to the Hospitals to enable them provide quality health care to the good people of Ghana thereby making the better Ghana Agenda a reality. We hope that further broadening of the frontiers would include an Open Day for wider dissemination. The Regional Coordinating Council wishes you an exciting third cycle of the Peer Review.
Hon. Henry Ford Kamel Volta Regional Minister
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MESSAGE FROM THE REGIONAL DIRECTOR OF HEALTH SERVICES We had been through one (2) year of Peer Review and the third cycle already in motion. It is a welcome innovation that is stimulating and energizing all of us. Even as performance target for all facilities was moved from 75% to 80%, am highly delighted that 50% of the facilities have crossed this new target. In my administrative visits to all the Districts, it became clear that the Hospitals have been transformed tremendously. This gives me confidence that the Internally Generated Funds are being used efficiently and effectively. It is behoving on us to improve staff attitude to commensurate the gains made in translating the Hospitals environments. We must find a way to measure staff attitude in the exercise and see it influence outcome of service delivery positively. Due to the improvements seen in the hospitals, I am sure the stakeholders involvement and interest in the process, especially, the Chiefs and District/Municipal Chief Executives will serve as pressure to ensure the sustainability of the process. This will in effect ensure quality of service to our clients. In addition, I am personally happy about the efforts being put in to ensure the quality of the Assessment through the organisation of training on how to properly do the assessment and also to regulating the process through the development of Code of Principles to guide the entire process in the third cycle.
Dr. Joseph Teye Nuertey Volta Regional Director of Health Services
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EXECUTIVE SUMMARY Since 2009 two cycles have been conducted with each hospital peer reviewed in each cycle. Tremendous improvement has been noticed across the facilities at the end of the second cycle. Hospitals which hitherto had no incinerators were able to build multi-purpose incinerators, emergency system were sharpened, most hospitals now have strategic plans and yearly action plans which dovetail into the strategic plan, client satisfaction surveys to elicit the perception of clients on quality of care are now being conducted regularly, infection control practices have been taken to admirable level and hospital environment have been noted to be so pleasing. Several policy issues were introduced into the second cycle PR and performance target increased to 80% instead of 75% during the 1st cycle. Thematic areas covered include; Environment (Both Internal and External), Infection Prevention and Control, Emergency Systems and Services, Quality Assurance, Clinical Practices, Client Care, Occupational Health and Safety issues and Management. All these areas were carved to ensure the implementation of policies of the Ministry of Health in the Volta Region. Results indicated a tremendous improvement over the first cycle PR. Percentage score on Environment improved from 62.6% to 74.5%, IPC from 73.8% to 82%, Emergency Systems and Services from 64.4% to 76.1% and Quality Assurance from 66.8% to 76.4%. Other areas include, Client care which improved from 56.2% to 77.9%, and Management practices from 69.4% to 78.0%. Other areas included in the second cycle were Clinical practices which scored 72.3% Occupational Health and Safety which scored 77.5% and Regional Directors score on innovation and organization of the PR in the facilities which scored 73.3%. Performance during the second cycle was found to be influenced to a large extent by the performance during the first cycle. The ownership of the facilities was found to have no influence on the performance but the location of the facilities according to the Peer Review demarcation had influence on the performance of facilities. Eleven facilities (11) hospitals were able to achieve the target performance of 80% and the other 11 achieved the bracket of 50% - 79.9%. None of the Hospitals scored below 50%. The PR wind blowing in the Volta Region called for a concerted between all the divisions of the Ghana Health Service to improve the Health Status of the Country.
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SECOND CYCLE PEER REVIEW REPORT,2011 ACKNOWLEDGEMENT
The VRHD is very grateful to all people who in diverse ways helped in the Peer Review process in the region. Indeed the enthusiasm and support of Dr. T.S. Letsa cannot be swept under the carpet. He indeed encouraged the process and attended most of the reviews. Our deepest appreciation also goes to all the stakeholders who participated in the second cycle of the Peer Review especially:
District Chief Executives of the District in which the Peer Review is taking place. Presiding Member of the District Assembly Members of Parliament in the District in which the Peer Review is being organized. Chairman of the Social Services Committee of the Assembly The Chairman of the Health Committee of the Assembly (If it exists) Chiefs of the Traditional Area The District Directors of Health Services The Executive Secretary, CHAG The Scheme Manager of NHIS in the District in which Peer Review is being organized.
Finally, we wish to thank the management and staff of all the hospitals in the region who have demonstrated the spirit of commitment and the desire to succeed in all that they do.
Editorial and Technical Task Team Dr Kofi Gafatsi Normanyo Dr Joseph Teye Nuertey Mr Robert K. Adatsi Mr Emmanuel Aforbu Mr Simon Dzokoto Regional Health Directorate Task Team Ms Comfort Agbadja Mr Divine Azameti Ms Priscilla Tawiah Mr Robert Adatsi Mr Simon Dzokoto Regional Health Directorate Task Team Driver Mr Cudjoe Amankwa Medical Superintendents/Medical Officer-In-Charges Dr Kofi Gafatsi Normanyo Chairman, Medical Superintendents Group (Volta Division) Dr K. Asare-Bediaku Aflao Hospital x
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Dr Lawrence Kumi Dr Edwin Danoo Dr. Anthony Ashinyo Dr Felix Tsidi Dr F.E. Abudey Dr Samuel Abudey Dr Hilarius K Abiwu Dr Doe Ocloo Dr Moses Boni Dr Tetteh Augustus Dr Pius Mensah Rev. Sr. Dr Lucy Hometowu Dr Alex Ackon Dr A. Mark Ofori-Adjei Dr William Dwuamena Dr Atsu Seake-Kwawu Dr Bowan Dr Kugbe Mlimor Kudjo Dr George Acquaye Dr Moumoudo Cham
Peki Hospital Hohoe Hospital Nkwanta Hospital Keta Hospital Sogakofe Hospital Jasikan Hospital Krachi West Hospital Adidome Hospital Akatsi Hospital St. Joseph Catholic Hospital Worawora Hospital Margaret Marquart Catholic Hospital Anfoega Catholic Hospital St. Mary Theresa Catholic Hospital, Dodi Papase St. Anthonys Catholic Hospital Ho Polyclinic Battor Catholic Hospital Sacred Heart Hospital,Abor Volta Regional Hospital Comboni Hospital
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CHAPTER ONE-INTRODUCTION
1.1 Overview
Prior to 2009, the Volta Regional Medical Superintendent Group having seen the deplorable state of hospitals infrastructure and the non-adherence to National policies and standards decided to adopt a strategy to bring about change which would lead to improvement in the quality of care across the region. Policy makers across the spectrum and indeed the entire population were concerned about the deteriorating levels of the quality of care in our hospitals. Consequently the Regional Health Directorate introduced Peer Review in July 2009. Since 2009 two cycles have been conducted with each hospital peer reviewed in each cycle. Tremendous improvement has been noticed across the facilities at the end of the first round. Hospitals which hitherto had no incinerators were able to build multi-purpose incinerators, emergency system were sharpened, most hospitals now have strategic plans and yearly action plans which dovetail into the strategic plan, client satisfaction surveys to elicit the perception of clients on quality of care are now being conducted regularly, infection control practices have been taken to admirable level and hospital environment have been noted to be so pleasing. All these achievements notwithstanding, there were challenges with regards to the objectivity of the checklist used for the assessment calling for systems to remove bias.
1.2 Review of the Check list

Feedback during the first cycle strongly indicated that there was the need to review the check list to reflect objectivity of the assessment and include other policy issues which were not added earlier on. The structure of the check list was modified for the second cycle to include the ideal situation, the reason(s) for the ideal situation, and what to do if the ideal situation is not met. For example grass covering at the hospital; when properly done, it is pleasing to the eye, sets the mind of staff and clients at ease, and easily rates the institution as a ready entity to deliver the care necessary. The new policy issues taken on board and their rationale are tabulated below:
Table 1.1 POLICY ISSUES TAKEN ON BOARD.

NO POLICY ISSUE RATIONALE It measures the infection prevention and control measures undertaken by the hospital The entire existence of hospital is to render service through clinical practice. Effectiveness and efficiency of such a practice is paramount. Indicators to measure acute, moderate and chronic cases define such effectiveness. To give focus and organization in the Management of Mass Casualty WHAT THE POLICY ISSUE IS SUPPOSED TO ACHIEVE To reduce infection in the hospitals and To carry out infection control practices A range of indicators looked at how individual facilities fit within the range and indicating the effectiveness and efficiency of managing the case To develop systems and capacity to manage Mass casualty that goes beyond our Emergency rooms. For Example occurrence of earthquakes, landslides, etc.
Proportion of Caesarean Section wound Infection (Select 20 folders randomly)
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Case Fatality Rates, C/S Rates, Fresh Still Rates
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Mass Casualty Incidence management
System for Emergency
Emergency Trays (availability and adequacy) minimum content of emergency tray

Occupational Health and Safety issues e.g. i. Personal Protective Clothing ii. Barrier Nursing iii. Floors (Non-
To ensure there is a system to manage emergency situations To ensure basic equipment and drugs available to enhance management of emergencies.
Safety of staff and patients cannot be compromised under any circumstances and therefore steps must be taken to protect them.
To ensure uniformity in the Management of Emergency in all facilities. To draw attention to what should go into the Emergency Tray To reduce time spent on managing emergencies To stimulate Management to pay attention to protection of staff
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slippery, No excavation) Fire Prevention (Fire Extinguisher & Appropriate use) Annual Screening of Staff(Protocol available, evidence of screening done) 2
Records on Implementation of Management Decisions (Should incl. Decision making date, Decision taken, date of implementation, cost involve)
7 Strategic Plan (SP) (Availability, Staff Knowledge about it) Action Plan (Available in all units, meet standard action plan requirement, Proportion of implementable activities implemented)
Decisions are taken and hardly implemented and even when implemented there are no records to show creating an impression that work is not been done. It is therefore necessary to assess the records of decisions implemented to determine the progress of work. It also helps in report writing. To give focus, direction and motivation to both management and the entire staff. SP involves having broad outlines of local content of activities (including innovations) directed at executing the objectives of MOH/GHS Action plan operationalizes strategic plans and reduces SP to work packages that can easily be managed
To ensure decisions taken are not left hanging. To introduce a culture of reviewing Management decisions
Hospitals think they dont need a Strategic Plan however, hospitals like any other organization needs to have a focus exactly what a strategic Plan is meant to do.
To give uniformity action plans To ensure implementation of activities once they are planned
To guide expenditure decisions
Weekly Cash flow statement (available) To determine financial viability and monitor budget performance. 10
Quarterly Financial Analysis 11 Equipment Replacement Policy Financial Analysis Statement (Half Yearly) Planned Preventive Maintenance Schedule of Equipment and Building (Prop. Implemented) To ensure that broken down equipment are replaced so as not interrupted service delivery Maintenance culture is a big problem in our institutions. Everything has to be done to ensure that equipment and buildings are maintained
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To ensure flow of financial information to management members this hitherto is not the case. Help in Management decision making. To help prevent financial malpractices To ensure flow of financial information to management members this hitherto is not the case. Help in Management decision taking. To help in programme monitoring & evaluation To ensure regular replacement of obsolete equipment and ensure financial analysis is done replacing the Obsolete equipment To inculcate Maintenance culture in our Institutions and ensure that equipment and building do not deteriorate beyond repairs.
1.3 Progress and Limitation in Organization of Peer Review

To promote community participation in health care delivery, invitation was extended to traditional rulers, District Chief Executives, heads of decentralized agencies, NGOs in Health and other key stakeholders. This was done to solicit their support in bridging the gaps identified in health service delivery and strengthen the arm of peer review to ensure sustainability Another feature of the second cycle Peer Review was the introduction of the Regional Directors Score to encourage innovation using local resources and staff participation. A problem solving session which was one of the salient parts of the program during the first cycle died down in the second cycle due to lack of time. Confrontation as to who should participate in the peer review and carry out assessment, number of participants per facility became an issue as was the basis for awarding scores in certain thematic areas.
SECOND CYCLE PEER REVIEW REPORT,2011 CHAPTER TWO- PERFORMANCE
Table 2.1 Performance of the Hospitals by the Thematic Areas of the Checklist
Hosp St. Anthony Sogakofe Dodi Papase Peki Anfoega Abor Keta Ho Mun Battor Adidome Hohoe Ketu South Akatsi VRH MMCH Jasikan Ho Poly Env 92.42 90.91 90.90 89.40 84.85 84.80 78.79 77.30 77.30 77.27 75.76 74.24 74.20 71.21 71.20 71.2 71.20 Hosp Sogakofe Ketu South Akatsi Abor St. Anthony Ho Mun St. Joseph Krachi MMCH Hohoe Peki Adidome Dodi Papase VRH Battor Nkwanta Jasikan IPC 100.0 0 94.44 93.30 93.10 90.28 87.50 87.50 87.50 86.10 83.33 83.30 81.94 80.60 80.56 79.20 79.17 77.80 Hosp Peki Worawora Ho Mun Dodi Papase Ketu South Hohoe St. Anthony MMCH Abor St. Joseph Krachi Sogakofe Jasikan Anfoega Akatsi Keta Nkwanta Emer 100.0 0 100.0 0 94.30 94.30 94.29 94.29 92.86 90.00 85.70 78.57 78.57 75.71 74.30 72.86 68.60 67.14 64.29 Hosp St. Anthony Akatsi Peki Ketu South Sogakofe Keta Ho Mun Worawora Nkwanta Krachi St. Joseph Hohoe Abor Dodi Papase Jasikan Anfoega MMCH QA 97.37 96.50 93.00 92.11 88.60 87.72 80.70 77.60 76.32 74.56 72.81 69.30 68.40 65.80 64.90 64.04 61.40 Hosp Sogakofe Peki Adidome Abor Battor Krachi Anfoega Ho Mun St. Anthony Ketu South Hohoe Nkwanta Keta St. Joseph Dodi Papase VRH Jasikan Clinical Practice 92.86 86.60 82.14 81.30 80.40 79.46 73.21 71.40 70.54 70.54 69.64 69.64 67.86 66.96 66.10 65.18 62.50 Hosp St. Anthony Ho Mun Akatsi St. Joseph Keta Peki Dodi Papase MMCH Anfoega Abor Battor Hohoe Sogakofe Adidome Jasikan Ketu South Krachi Client Care 100.00 100.00 96.70 96.67 93.33 93.30 93.30 93.30 90.00 86.70 86.70 86.67 83.33 80.00 76.70 76.67 63.33 Hosp Peki Abor St. Anthony Worawora Keta Akatsi Sogakofe Ketu South St. Joseph Hohoe Krachi Dodi Papase Ho Municipal Jasikan MMCH VRH Anfoega OH&S 98.50 95.60 94.12 94.12 92.65 89.70 83.82 83.82 82.35 80.88 80.88 79.40 73.50 73.50 70.60 70.59 69.12 Hosp Ho Mun Ketu South St. Joseph Adidome Keta Akatsi Peki Abor Dodi Papase Sogakofe St. Anthony MMCH Worawor a Battor Jasikan VRH Krachi MGT 95.70 94.93 93.91 92.03 92.03 90.60 89.90 89.10 87.00 86.96 85.51 85.50 82.61 72.50 71.70 70.29 64.49

60.61 59.09 59.09 57.58 50.00 Keta Worawora Comboni Ho Poly Anfoega 77.78 76.39 63.89 62.50 56.94 Battor Comboni Ho Poly Adidome VRH 62.90 50.00 50.00 35.71 30.00 Comboni Adidome Battor VRH Ho Poly 58.77 57.02 51.80 48.25 44.70 Comboni Akatsi Worawora MMCH Ho Poly 60.71 60.70 57.14 57.10 42.90 Worawora Ho Poly VRH Comboni Nkwanta 60.00 46.70 36.67 36.67 30.00 Adidome Battor Comboni Ho Poly Nkwanta 67.65 66.20 48.53 41.20 35.29 Hohoe Anfoega Comboni Nkwanta Ho Poly 59.71 48.55 46.38 42.03 41.30
Comboni St. Joseph Worawora Krachi Nkwanta
Table 2.1.Performance of the Hospitals by the Thematic Areas of the Checklist (contn)
Hosp Hohoe Krachi Ketu South Jasikan Abor Akatsi Worawora Adidome Peki Dodi Papase Battor St. Anthony St. Joseph Anfoega MMCH Ho Mun Ho Poly Sogakofe Keta Nkwanta VRH Comboni RDHS Score 100.00 96.67 93.33 88.00 86.70 86.70 83.33 83.33 80.00 80.00 76.70 75.33 73.33 73.33 73.30 66.70 66.70 66.67 60.00 46.67 40.00 26.67 Hosp Peki St. Anthony Sogakofe Ketu South Abor Akatsi Ho Mun Keta Dodi Papase St. Joseph Worawora Hohoe Krachi MMCH Adidome Jasikan Battor Anfoega VRH Nkwanta Comboni Ho Poly 2nd Round Total 94.80 91.80 91.34 90.45 88.40 87.30 87.20 84.63 83.40 82.33 80.20 78.57 77.91 77.90 76.72 75.60 73.90 69.55 62.99 60.45 55.52 53.10 Hosp Peki Ketu South Abor Sogakofe Dodi Papase Ho Mun St. Joseph Jasikan Hohoe Akatsi Comboni MMCH Keta Nkwanta Battor VRH Anfoega St. Anthony Adidome Krachi Worawora Ho Poly 1st Round Total 87.40 79.20 78.90 77.20 75.40 74.60 71.90 70.80 67.30 67.00 65.50 64.60 64.30 62.60 62.30 61.40 57.90 56.40 55.80 51.50 49.70 42.90 Hosp St. Anthony Worawora Krachi Adidome Keta Akatsi Ho Poly MMCH Anfoega Battor Sogakofe Ho Mun Hohoe St. Joseph Ketu South Abor Dodi Papase Peki Jasikan VRH Nkwanta Comboni % Change in Performance 62.77 61.37 51.28 37.49 31.61 30.30 23.78 20.59 20.12 18.62 18.32 16.89 16.74 14.50 14.20 12.04 10.61 8.47 6.78 2.58 -3.44 -15.23
2.2 Performance Change in Thematic Areas H0: There is no difference between the first cycle mean scores and the second cycle mean scores of the various thematic areas H1: There is a difference between first cycle mean scores and second cycle mean scores of the various thematic areas. Table 2.2: Paired Differences in the Performance of Hospitals in the Thematic Areas Mean difference in performa nce 11.89 8.22 11.75 9.62 72.33 21.72 77.49 8.63 73.72 12.72 tvalue Degree of freedom Sig. Value of tTest(=0.05) 0.002 0.004 0.056 0.040 0.000 0.000 0.000 0.026 0.000 0.000
Performance/Th ematic Area
Cycles 2nd Cycle Mean 77.5 83.7 67.3 72.7 70.5 77.0 75.6 79.8 69.1 78.6 1st Cycle Mean 62.04 71.78 66.66 64.9 N/A 56.6 N/A 70.69 N/A 65.46 % Change 24.9 16.6 1 12 N/A 36 N/A 12.9 N/A 20.1
Environment IPC Emergency QA Clinical Practice Client Care OH&S Management RDHS Overall
3.50 3.23 2.02 2.19 32.16 4.21 25.15 2.40 19.15 5.84
21 21 21 21 21 21 21 21 21 21
Since the p-value for the overall performance was less than 0.05, it indicated that there is enough evidence to reject the null hypothesis and accept the alternate hypothesis that there is a difference in the overall performance during the first and second cycles of the Peer Review. In addition, Table 2.2 revealed that the p-value for all thematic areas were less than 0.05 indicating that there is the need to reject the null hypothesis and accept the alternate hypothesis there is a significant difference in the first cycle and second cycle performances in the thematic areas of the Peer Review.
However, with regards to Emergency, the p-value was more than 0.05 indicating that there is enough evidence to accept the null hypothesis that there is no significant difference in the first cycle and second cycle performance in the emergency area of the checklist.
2.3 Comparing the Difference in Means and Standard Deviations of the Thematic Areas of the First and Second Cycle Peer Reviews
Table 2.3 Paired Samples Statistics (n=22)

Thematic Areas of the Peer Review
2 Cycle Environment 1 Cycle Environment 2 Cycle Infection Prevention & Control 1 Cycle Infection Prevention & Control 2 Cycle Emergency Services & Systems 1 Cycle Emergency Services & Systems 2 Cycle Quality Assurance 1 Cycle Quality Assurance 2 Cycle Clinical Practices 1 Cycle Clinical Practices 2 Cycle Client Care practices 1 Cycle Client Care practices 2 Cycle Occupational Health & Safety 1 Cycle Occupational Health & Safety 2 Cycle Management 1 Cycle Management 2 Regional Director of Health Services 1 Regional Director of Health Services 2 Cycle Overall Performance
nd st nd st nd st nd st nd st nd st nd st nd st nd st nd
Mean 74.52 62.63 81.96 73.75 76.14 64.39 76.43 66.81 72.33 0.00 77.89 56.17 77.49 0.00 78.02 69.40 73.72 0.00 78.37
Std. Deviation 11.82 16.30 10.54 14.35 18.61 21.60 13.66 17.36 10.55 0.00 20.75 21.51 14.45 0.00 16.60 15.01 18.05 0.00 11.82
Std. Error Mean 2.52 3.47 2.25 3.06 3.97 4.60 2.91 3.70 2.25 0.00 4.42 4.59 3.08 0.00 3.54 3.20 3.85 0.00 2.52
Skewness -0.30 -0.02 -0.78 -0.36 -1.14 -0.24 -0.25 -0.40 0.52 -. -1.23 0.35 -1.43 -. -0.99 0.07 -1.05 -. -0.78
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st

65.65 10.85 2.31 -0.10
1 Cycle Overall Performance
Table 2.3 above revealed the Mean performance in the various Thematic Areas of the Peer Review. On the whole, the overall standard deviation during the second cycle was lower than the first cycle indicating that every facility was performing to meet the Performance Target. Table 2.4 Paired Samples Test for the Thematic Areas
Paired Samples Test Paired Differences 95% Confidence Interval of the Difference Lower 4.82 2.93 -0.34 0.50 67.65 10.99 71.08 1.15 65.71 8.19 Upper 18.96 13.50 23.84 18.75 77.01 32.45 83.90 16.11 81.72 17.25
Paired Samples Test

Pair 1 Pair 2 Pair 3 Pair 4 Pair 5 Pair 6 Pair 7 Pair 8 Pair 9 Pair 10 Environment 2 - Environment1 IPC2 - IPC1 Emergency2 Emergency1 QA2 - QA1 Clinical Practice2 - Clinical Practice1 Client Care2 Client Care1 OHS2 - OHS1 Management2 Management1 RDHS2 - RDHS1 Overall2 - Overall1
Mean
Std. Deviation 15.94 11.93 27.27 20.58 10.55 24.20 14.45 16.87 18.05 10.22
Std. Error Mean 3.40 2.54 5.81 4.39 2.25 5.16 3.08 3.60 3.85 2.18
df
Sig. (2tailed)
11.89 8.22 11.75 9.62 72.33 21.72 77.49 8.63 73.72 12.72
3.50 3.23 2.02 2.19 32.16 4.21 25.15 2.40 19.15 5.84
21 21 21 21 21 21 21 21 21 21
0.002 0.004 0.056 0.040 0.000 0.000 0.000 0.026 0.000 0.000
Table 2.4 indicated the mean differences in performance during the first and second cycles of the Peer Review in terms of the various thematic areas of the checklist used and the overall performance of the Hospitals. Clinical Practices, Occupational Health and Safety and RHDS areas were introduced in the second cycle; hence their mean performance differences were seen to be higher; thus 72.33, 77.49 and 73.72 respectively. Apart from these three areas, the other thematic areas with high mean differences in performance were the Client Care practices, Environment and Emergency services and systems whilst Infection Prevention and control practices attracted the lowest mean difference in performance.
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Table 2.4 again revealed that there is a significant difference in the overall performance of the Hospitals hence the need to reject the Null Hypothesis that there is no significance difference in overall performance of the Hospitals during the first cycle and the second cycle of the Peer Review hence the need to reject the null hypothesis at p-value of 5% and conclude that there is high probability that the overall mean during the second cycle was influenced by the overall mean during the first cycle of the Peer Review. Similarly, with regards to the various thematic areas, Table 2.4 revealed a significant difference in the performance of the Hospitals hence the need to reject the Null Hypothesis and conclude at significance level of 5% that, there is high probability that means of second cycle performance were influenced by the first cycle performance. However, for Emergency systems and services, there was enough evidence to reject the alternative hypothesis that there is difference in the first cycle and second cycle performance and conclude that there is high probability that the means of the first cycle performance did not influence the second cycle performance. Table 2.5 Correlation between first cycle performance and Second Cycle Performance
Paired Samples Correlations N Pair 1 Pair 2 Pair 3 Pair 4 Environment1 & Environment2 IPC1 & IPC2 Emer1 & Emer2 QA1 & QA2 22 22 22 22 Correlation 0.39 0.58 0.09 0.14 Sig. 0.071 0.005 0.704 0.545
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Client1 & Client2 Mgt1 & Mgt2 Over1 & Over2 22 22 22 0.34 0.43 0.60 0.116 0.044 0.003
Pair 5 Pair 6 Pair 7
With regards to the correlation between the first cycle results and the second cycle results, it was revealed from table 2.5 that there are generally positive correlation between the first cycle performance and the second cycle performances. However, the correlation coefficients revealed weak relationships except between IPC1& IPC2 and the Over1 & Over2 which revealed stronger correlation than in the other thematic areas. This indicated that in most cases, there were improvements in performance of all the hospitals in the thematic areas.
2.4 Performance Change in the Thematic Areas Based On Ownership

H0: There is no difference in performance of CHAG Hospitals and GHS Hospitals. H1: There is difference in the performance of CHAG Hospitals and GHS Hospitals. Table 2.6 GHS & CHAG Hospitals Performance Compared According to Thematic Areas
CHAG Performance Areas Environment IPC Emergency QA Clinical Practice Client Care OH&S Management RDHS Overall 2nd Cycle Mean 77.65 79.7 79.66 75.92 72.7 83.71 77.21 76.61 70.46 76.14 1st Cycle Mean 67.3 72.35 69.44 72.18 N/A 51.50 N/A 68.08 N/A 66.21 % Change 15.38 10.16 14.72 5.18 N/A 62.54 N/A 12.53 N/A 15.00 2nd Cycle Mean 72.72 83.25 74.13 76.73 72.12 74.57 77.64 78.83 75.58 79.67 GHS 1st Cycle Mean 59.96 74.54 61.51 63.74 N/A 58.84 N/A 70.15 N/A 65.32 % Change 21.28 11.69 20.52 20.38 N/A 26.73 N/A 12.37 N/A 21.97
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An analysis of variance to infer whether ownership of the Hospitals affects the performance of the various hospitals revealed that at significance level of 5%, there is enough evidence to reject the null hypothesis that ownership of the hospitals has no influence on the performance of the Hospitals and accept the alternate hypothesis that ownership of the Hospital has influence on the Performance of the Hospital. It is imperative to identify the ownership factors or arrangements that helped in influencing the performance of the facilities so as to infuse the system to ensure continuous quality improvement. Table 2.7 Analysis of Variance Table for 2nd Cycle overall performance and Ownership of Hospitals Tests of Between-Subjects Effects Dependent Variable: Second Cycle Overall Performance Source Model First cycle Overall Performance Ownership of Facility Error Total Type III Sum of Squares 136236.675 1065.061 797.184 1805.946 138042.621 Df 3 1 2 19 22 Mean Square 45412.225 1065.061 398.592 95.050 F 477.773 11.205 4.194 Sig. 0.0000 0.0034 0.0310 Partial Eta Squared 0.9869 0.3710 0.3062
The model above indicated that about 98.7% of the variation in the model can be explained by the model. Also, 37.1% of the variations with regards to first cycle performance and the second cycle can be explained by the above model whilst 30.6% of the variation between ownership and second cycle performance is explainable by the above model. 2.5 PERFORMANCE BASED ON ZONAL LOCATION Table 2.8 Performance by Zonal Location Compared According to Thematic Areas Southern Zone 2nd Cycle 1st Cycle % Mean Mean Change 77.5 62.04 24.9 83.7 71.78 16.6 67.3 66.66 1.0
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Performance Areas Environment IPC Emergency
Northern Zone 2nd Cycle 1st Cycle % Mean Mean Change 70.9 63.33 12.0 79.9 76.93 3.9 84.7 61.67 37.3
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QA 72.7 64.9 12.0 72 69.09 4.2 Clinical Practice 70.5 N/A N/A 68.8 N/A N/A Client Care 77 56.6 36.0 78.3 55.7 40.6 OH&S 75.6 N/A N/A 76.5 N/A N/A Management 79.8 70.69 12.9 72.5 67.84 6.9 RDHS 69.1 N/A N/A 79.5 N/A N/A Overall 78.6 65.46 20.1 78.1 65.87 18.6 H0: There is no difference between the first cycle and second cycle Mean performance scores based on the location of the hospital according to the Peer Review Demarcation H1: There is a difference between the first cycle and second cycle Mean performance scores based on the location of the hospital according to the Peer Review Demarcation Table 2.9 Analysis of Variance Table for overall performance and Location of Hospitals
Tests of Between-Subjects Effects Dependent Variable:Over2 Source Corrected Model Intercept Overall 1st cycle Zonal Location Error Total Corrected Total Type III Sum of Squares 1043.457a 673.126 1015.191 .841 1889.730 138042.621 2933.186 df 2 1 1 1 19 22 21 Mean Square 521.728 673.126 1015.191 .841 99.459 F 5.246 6.768 10.207 .008 Sig. .015 .018 .005 .928 Partial Eta Squared .356 .263 .349 .000
a. R Squared = .356 (Adjusted R Squared = .288)
An analysis of variance to infer whether Location according to the Peer Review demarcation affects the performance of the various hospitals revealed that at significance level of 5%, there is no enough evidence to reject the null hypothesis that the location of the hospitals has no influence on the performance of the Hospitals and reject the alternate hypothesis that location of the Hospital has influence on the Performance of the Hospital.
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2.6 SECOND CYCLE PEER REVIEW PERFORMANCE AND POST PEER REVIEW PERFORMANCE
POST PEER REVIEW AND PEER REVIEW PERFORMANCE COMPARED

91.8 100.0 89.4 91.3 90.5 87.3 87.2 88.4 84.6 83.4 82.3 90.0 78.6 80.2 76.7 78.4 77.9 77.9 75.6 74.2 73.9 80.0 69.6 63.0 70.0 60.5 57.6 57.6 54.5 55.5 51.5 51.5 48.5 48.5 60.0 57.6 53.1 44.1 43.9 42.4 50.0 34.8 33.3 33.3 31.8 40.0 30.3 28.8 25.8 25.8 25.8 24.2 30.0 20.0 10.0 0.0 94.8
Overall PPR
Overal PR
Generally, all facilities scored lower during the post peer review monitoring except Hohoe Municipal Hospital. This indicates that most facilities relaxed after the main peer review exercise hence the low performance. Comparing the performance differences, a paired t-test was used as shown in the table 2.10 below. Table 2.10 Comparing Peer Review Performance and Post Peer Review Performances
Paired Samples Statistics (n=22)
Thematic Areas
Pair 1 Pair 2 Environment Post Peer Review Environment Peer Review Infection Prevention & Control Post Peer Review Infection Prevention & Control Peer Review Pair 3 Emergency System Post Peer Review Emergency System Peer Review Pair 4 Quality Assurance Post Peer Review Quality Assurance Peer Review Pair 5 Clinical Practices Post Peer Review Clinical Practices Peer Review
Mean 49.20 74.52 51.82 81.96 36.36 75.20 39.02 72.35 63.64 69.77
Std. Deviation 19.51 11.82 19.83 10.54 34.72 20.25 28.68 15.65 25.01 11.19
Std. Error Mean 4.16 2.52 4.23 2.25 7.40 4.32 6.12 3.34 5.33 2.39
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Client Care Post Peer Review Client Care Peer Review Occupational Health & Safety Post Peer Review Occupational Health & Safety Peer Review 35.60 77.58 24.55 76.00 40.91 76.49 44.15 78.36 26.87 22.09 24.64 17.10 30.75 18.35 16.99 11.82 5.73 4.71 5.25 3.65 6.55 3.91 3.62 2.52
Pair 6 Pair 7
Pair 8 Pair 9
Management Post Peer Review Management Peer Review Overall Post Peer Review Overall Peer Review
The mean performance during the actual Peer Review was 78.36% whilst the post peer review revealed an average performance of 44.15%. Table www also revealed a smaller standard deviation and standard error mean performance between the facilities during the main peer review than during the post peer review. Similar trend was shown in all the thematic areas. As to the correlation between the Post peer review and the main peer review performances, the table qqq below presents the strength of the correlation. Table 2.11 Paired thematic areas Correlations
Paired Samples Correlations
Thematic Areas of Peer Review

Pair 1 Pair 2 Pair 3 Pair 4 Pair 5 Pair 6 Pair 7 Pair 8 Pair 9 Environment Post Peer Review & Environment Peer Review Infection Prevention & Control Post Peer Review & Infection Prevention & Control Peer Review Emergency systems Post Peer Review & Emergency System Peer Review Quality Assurance Post Peer Review & Quality Assurance Peer Review Clinical Practices Post Peer Review & Clinical Practices Peer Review Client Care Post Peer Review & Client Care Peer Review Occupational Health and safety Post Peer Review & Occupational Health and safety Peer Review Management Post Peer Review & Management Peer Review Overall Post Peer Review & Overall Peer Review
N 22 22 22 22 22 22 22 22 22
Correlation 0.356 0.500 0.535 0.114 0.417 0.157 0.324 0.241 0.520
Sig. 0.104 0.018 0.010 0.615 0.054 0.486 0.141 0.280 0.013
Table 2.11 revealed a positive correlation between the Peer Review and Post Peer Review Monitoring. However, the correlation was weak for Environment, Quality Assurance, Client Care, Occupational Health and Safety and Management Issues. Infection Prevention and Control, Clinical Practices, Emergency systems and services and Overall performances indicated stronger correlation. The table also 16
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revealed that apart from Infection Prevention and Control, Emergency Systems and Services and Overall Performance, which indicated that the correlations were statistically significant, the correlations for Environment, Quality Assurance, Client Care, Occupational Health and Safety and Management Issues were not statistically significant. Table 2.12: Paired Samples Test for Peer Review and Post Peer Review Monitoring
Paired Samples Test Paired Differences 95% Confidence Interval of the Difference Lower -33.69 Upper -16.95 T -6.29 df 21
Thematic Areas of the Peer Review

Mean Pair 1 Environment Post Peer Review & Environment Peer Review Infection Prevention & Control Post Peer Review & Infection Prevention & Control Peer Review Emergency systems Post Peer Review & Emergency System Peer Review Quality Assurance Post Peer Review & Quality Assurance Peer Review Clinical Practices Post Peer Review & Clinical Practices Peer Review Client Care Post Peer Review & Client Care Peer Review Occupational Health and safety Post Peer Review & Occupational Health and safety Peer Review Management Post Peer Review & Management Peer Review Overall Post Peer Review & Overall Peer Review -25.32 Std. Deviation 18.87 Std. Error Mean 4.02
Sig. (2tailed) 0.000
Pair 2
-30.14
17.18
3.66
-37.76
-22.52
-8.23
21
0.000
Pair 3
-38.84
29.37
6.26
-51.86
-25.81
-6.20
21
0.000
Pair 4
-33.33
31.07
6.62
-47.11
-19.56
-5.03
21
0.000
Pair 5
-6.13
22.74
4.85
-16.21
3.95
-1.26
21
0.220
Pair 6
-41.97
32.00
6.82
-56.16
-27.79
-6.15
21
0.000
Pair 7
-51.46 -35.58 -34.22
25.02 31.78 14.82
5.33 6.77 3.16
-62.55 -49.67 -40.79
-40.36 -21.49 -27.64
-9.65 -5.25 -10.83
21 21 21
0.000 0.000 0.000
Pair 8
Pair 9
Table 2.12 indicated the mean differences in performance during the main second cycle of the Peer Review and the Post Peer Review Monitoring in terms of the various thematic areas of the checklist used and the overall performance of the Hospitals.
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Table 2.12 again revealed that there is a significant difference in the overall performance of the Hospitals hence the need to reject the Null Hypothesis that there is no significance difference in overall performance of the Hospitals during the Peer Review and Post Peer Review Monitoring hence the need to reject the null hypothesis at p-value of 5% and conclude that there is high probability that the overall mean during the Post Peer Review was influenced by the overall mean during the main second cycle of the Peer Review. Similarly, with regards to the various thematic areas, Table 2.12 revealed a significant difference in the performance of the Hospitals hence the need to reject the Null Hypothesis and conclude at significance level of 5% that, there is high probability that means of Post Peer Review Monitoring were influenced by the performance during the main second cycle performance except with the Clinical Practices where it was realized that, there was enough evidence to reject the alternative hypothesis that there is difference in the Post Peer Review Monitoring and the second cycle performance and conclude that there is high probability that the means of the main second cycle performance did not influence the post Peer Review performance.
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2.7 OVERALL PERFORMANCE OF HOSPITALS BY OWNERSHIP AND LOCATION OVERALL PERFORMANCE OF GHANA HEALTH SERVICE HOSPITALS DURING THE MAIN SECOND CYCLE PEER REVIEW
100.0 90.0 80.0 70.0 60.0 50.0 40.0 30.0 20.0 10.0 0.0 94.8 91.3 90.4 88.0 87.4 87.3 87.2 84.6 80.2 78.6 77.9 76.7 77.2 79.2 75.6 74.6 71.3 70.8 67.3 67 64.3 63.0 61.4 62.253.1 51.5 55.8 49.7 60.4 42.9
2nd Round
1st Round
The mean performance of the Ghana Health Service Hospitals showed an increase from 71.3% during the first cycle Peer Review to 88% in the second cycle indicating an increase of 23.4%.
GHS FACILITIES PPR AND PR PERFORMANCE COMPARED

100.0 80.0 60.0 40.0 20.0 0.0 94.8 91.3 87.3 90.5 89.4 87.2 84.6 80.2 78.7 78.674.2 77.9 76.7 75.6 63.0 60.557.6 57.6 53.1 51.5 51.5 45.4 43.9 33.3 33.3 31.8 30.3 28.8 25.8 25.8
Overall PPR
Overall PR
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The Mean Performance of the GHS Hospitals during the Post Peer Review was 45.4% as against 78.7% during the main Peer Review. This indicates a decrease of 42.3%. OVERALL PERFORMANCE OF CHRISTIAN HEALTH ASSOCIATION OF GHANA (CHAG) HOSPITALS DURING THE MAIN SECOND CYCLE PEER REVIEW
100.0 80.0 60.0 40.0 20.0 0.0 St. Anthony Abor Papase St. Joseph MMCH Battor Anfoega Comboni Mean 91.8 88.4 84.8 82.3 78.9 83.4 77.9 75.4 73.9 71.9 69.6 69.4 65.5 64.6 62.3 57.9 55.5 56.4
2nd Round
1st Round
The CHAG Hospitals on the other hand moved from an average performance of 69.4% during the first cycle to 84.8% during the second cycle indicating 22.2% increase in performance.
However, the Post Peer Review indicated a fall in the Performance as indicated in the graph below:
CHAG FACILITIES PPR AND PR PERFORMANCE COMPARED

100.0 80.0 57.6 60.0 40.0 20.0 0.0 St. Joseph St. Anthony Abor MMCH Dodi Papase Battor Anfoega Comboni Mean 54.5 48.5 48.5 42.4 91.8 82.3 88.4 77.9 83.4 73.9 69.6 55.5 34.8 25.8 24.2 42.0 77.9
Overall PPR
Overall PR
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The Mean Performance during the Post Peer Review was 42.0% as against 77.9% during the main Peer Review. This indicates a decrease of 46.1%. 2.8 PERFORMANCE TARGET SET BY THE REGIONAL DIRECTOR OF HEALTH SERVICE TO ALL MEDICAL SUPERINTENDENTS To ensure that facility heads are held accountable for the performance of their Hospitals, all Medical Superintendents were given a performance target of at least 80% during the second cycle instead of the 75% that was used during the first round of the Peer Review. The dashboard below depicts the performance of the Hospitals in meeting this Performance Target set by the Regional Director of Health Services. The dashboard indicated that during the first round of the Peer Review, only 2 Hospitals were able to score at 80% (the New Performance Target) whilst during the second cycle, 11 (i.e. 50%) Hospitals were able to achieve the Performance Target.
The dashboard also indicated the performance based on the thematic areas of the peer review process.
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2.9 LEAGUE TABLE OF PERFORMANCE OF HOSPITALS The League Table below indicated the extent of the competition among the Hospitals. Table 2.13 League Table of Performance of Hospitals
2nd Round Hospital Peki St. Anthony Sogakofe Ketu South Abor Akatsi Ho Municipal Keta Papase St. Joseph Worawora Hohoe Krachi MMCH Adidome Jasikan Battor Anfoega VRH Nkwanta Comboni Ho Poly 2nd Round 94.8 91.8 91.3 90.4 88.4 87.3 87.2 84.6 83.4 82.3 80.2 78.6 77.9 77.9 76.7 75.6 73.9 69.6 63.0 60.4 55.5 53.1 1st Round 87.4 56.4 77.2 79.2 78.9 67 74.6 64.3 75.4 71.9 49.7 67.3 51.5 64.6 55.8 70.8 62.3 57.9 61.4 62.6 65.6 42.9 % Change 8.5 62.8 18.3 14.2 12.0 30.3 16.9 31.6 10.6 14.5 61.4 16.7 51.3 20.6 37.5 6.8 18.6 20.1 2.6 -3.4 -15.4 23.8 Position 1st 2nd 3rd 4th 5th 6th 7th 8th 9th 10th 11th 12th 13th 14th 15th 16th 17th 18th 19th 20th 21st 22nd 1st Round Position 1st 18th 4th 2nd 3rd 10th 6th 13th 5th 7th 21st 9th 20th 12th 19th 8th 15th 17th 16th 14th 11th 22nd
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2.10 Improvement or otherwise of facilities 2.10.1 Description of the problem or stimulant (outliers)
2.10.1.1 Environment
All Hospitals within the second cycle saw a lot of improvement in their environments; both the Landscaping and the Infrastructure. Significant among the Hospitals were St. Anthonys Hospital, Dzodze, District Hospital, Sogakofe, Krachi West District Hospital, Peki Hospital, Hohoe Hospital etc. Before Second Cycle Peer Review Pictures
Krachi West District Hospital before the Second cycle
Krachi West District Hospital During the 2nd Cycle of the Peer Review
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State of Hohoe Hospital conference Room during 1 Cycle
st
State of External Environment during 1 Cycle
st
Renovated Conference in Hohoe Mun. Hospital during 2 Cycle
nd
State of Environment during 2 cycle
nd
Peki Recreational centre during 1st cycle 24
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Second Cycle Hospital Environment
District Hospital, Sogakofe, During Post Peer Review Monitoring
2.10.1.2 Infection Prevention and Control

1. Chlorine is now being used in all the hospitals in the Region as requested by the IPC Policy of the Ministry of Health. However, the flow of accurate information concerning the chlorine between the suppliers, Procurement Officers, Stores, and the User Units of the Hospitals. Still more needs to be done in this regard. 2. Hand washing, a major way of controlling microbes is still a problem in few of the Hospitals. The Table 2.14 below depict the average score of the cadres of workers assessed during the Peer review. Table 2.14 Mean Performance of Cadres of workers on Hand washing Medical Laboratory Pharmacy Hand washing Orderlies Nurses Officer/Assistant Staff Staff Mean (Expected Score is 4) 2.93 3.24 3.40 2.90 2.69
3. Facilities without Proper Incinerators were also able to build ultra-modern Multi-Purpose Incinerators to take of the solid wastes.
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New Multipurpose Incinerator-St. Anthonys Hosp
Burning Pit Constructed in Worawora Hosp.
New Washing Machine installed in Adidome Hosp.
2.10.1.3 Emergency Systems and Services

One of the major challenges faced by the facilities concerning Emergency Systems and Services was the non-availability of Largactil for Management of Emergency Mental conditions. Also, there was no standard protocol for Mass Casualty Incident Management in the entire Region. There is therefore the need to collate all the protocols developed by the various facilities, meet over the protocols to develop a standard protocol for Mass Casualty Incident Management in the Region.
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Some facilities also realizing the need for proper Emergency Services were able to start construction or completed a new Emergency Units. Ketu South Hospital was able to construct a New Emergency Unit and procured a Patients Monitor for the Unit.
Briefing of Staff by Incident Commander
Emergency Preparedness in a Hospital
2.10.1.4 Quality Assurance Activities

Few challenges concerning the current referral system were exposed such as feedback to the referring facility. It also exposed the quality of the referrals being done in our facilities across the region. Another significant thing the revealed with regards to quality Assurance was the fact that Maternal Death Audits were organized at least in all the Hospitals in which there were these deaths.
2.10.1.5 Clinical Practices

One major outlier concerning Clinical practices is the issue of documentation. Most Caesarean section wound conditions were not properly document both by the Medical Officers and the Nurses. Issues concerning high Ceasarean Section rate came up strongly in some facilities. This issue also revealed a lot of concerns about the referral system in the Region.
2.10.1.6 Clients Care

To a very large extent, awareness was created to ensure complaints Management systems are strengthened in all Hospitals. Client Satisfaction Surveys are also being conducted by most hospitals regularly, at least twice in a year.
2.10.1.7 Occupational Health and Safety Issues

Occupational Health and Safety issues incorporated into the check list indeed expose the gaps in the system. At least barrier nursing and wearing of Personal Protective clothing was enforced to some extent. The use of Colour coded bins and liners were enforced to ensure segregation of waste. Fire Extinguishers were also procured and serviced by most of the Hospitals.
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Laundry Staff on the way to collect dirty Linen
Waste Segregation point in VRH
2.10.1.8 Management
Attempts were made by some facilities to develop Strategic Plans to give them a strategic direction since this was a requirement of the Checklist. Even though, some of the documents submitted did not include the ingredients of a strategic Plan, it is an attempt in the right direction. To some extent facilities were also entreated to implement their action plans hitherto, action plans were usually prepared but not shared amongst staff and not even implemented. Efforts were also made by the various Hospitals to analyse the state of their equipment and prepare Equipment replacement financial analysis. Planned preventive maintenance was also emphasized as a result of the Peer Review. Furthermore, the process is encouraging other Members of management to demand weekly cash flow and Quarterly Financial Analysis from the Accountants. This to a large extent is helping to ensure information flow on the finance of the Hospital at least among Management members.
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2.10.2 Regional Directors Mark for Innovation and Organization of the Peer Review
As part of excitement, the Regional Directors Score was introduced to encourage facilities to innovate using the local resources available to them. In addition, this was expected to stimulate the facilities to judiciously use their resources especially the Internally Generated Fund (IGF) was introduced. This element resulted in a lot of the facilities committing their resources into things such as: Renovation of apartment used for training to a proper conference room standard in Hohoe Municipal Hospital. Conversion of Recreational centre to a conference room by Peki Government Hospital Building of Emergency Unit and Procurement of Patients Monitor to improve Emergency Management in Ketu South District Hospital Staff accommodation initiated and an Orange orchard also started in Sogakofe Hospital. Collaboration with MPs to provide Street Light at Nkwanta South District Hospital Collaboration with MP to provide Blood Bank Fridge in Mary Theresas Catholic Hospital. Renovation of Krachi West District Hospital Building of a New Pharmacy Block at St. Joseph Catholic Hospital, Nkwanta Completion of a New Maternity Unit at the Margret Marquart Catholic Hospital
New Pharmacy Block @ St. Joseph Cath. Hosp 29
New Maternity Block @ MMCH
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CHAPTER THREE- CONCLUSION & RECOMMENDATION
3.1 CONCLUSION
The second cycle of the Peer review revealed that 1. Performance of the Hospitals improved tremendously. Fifty (50) per cent of the Hospitals were able to meet the Regional Directors performance target 2. All the thematic areas on the Checklist indicated great improvement over the first cycle performance. 3. Team approach to work has been strengthened through the Peer Review since everybody in the facilities understands that they will be jointly accountable to the good or bad performance during the Peer Review. This has even catch-up with the Community members as the Chiefs and community members were found helping the Hospitals during Communal Labour. 4. Most Policy documents lying on shelves not implemented were implemented to a large extent through the Peer Review. Policies such as Infection Prevention and Control, Waste Management, Occupational Health and Safety, etc. 5. Internally Generated Funds were being used judiciously as most facilities ensured the availability of basic equipment and drugs for service delivery.
3.2 RECOMMENDATIONS
1. Evaluation of the Peer Review In every programme Implementation, one success factor is the periodic/process evaluation of the programme to: 1. identify internal and external impediments/success factors of the programme. 2. To identify factors that needs further attention. 3. Re-strategizing. As part of the plan of the Peer Review Coordinating team, it was agreed that since this is the second cycle of the Implementation of the Peer Review, an Evaluation be done to inform on the key implementation challenges, Key lessons learnt and sustainability factors of the programme. The evaluation also intended to look at Clients perspective, Staff perspective and Influence of Management skills of the Hospital Managers and Managements perspective of the outcomes of the programme. It also intends to look at how Human Resource situations are influencing the implementation of the programme. It was also expected that this Evaluation will inform on the necessary steps to take in order to improve the process and the expected outcomes.
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The evaluation was not done due to reasons beyond the Peer Review Secretariat. 2. How to Continue with the Peer Review In other to ensure that the current momentum is sustained, there was the need to incorporate activities that may continue to entice Management of the Hospitals to always attend the Peer Review hence the need to refine the checklist and add other activities. It is also recommended that the Headquarters takes up the process, develop a national Checklist for all the Health Centres, Hospitals (Regional and District/Municipal), District Health Directorates, Regional Health Directorates and all Divisions. This will help to compare performance at all levels of service delivery and improve all the indicators. 3. Modification of the Process and the Checklist and what it should contain Due to challenges encountered with regards to conduct of some reviewers, there was the need to streamline the behaviours of participants. This resulted in the development of Code of Principle to guide the entire process. The Code of Principles will be used during the third cycle of the Peer Review.
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REFERENCES
1. The Quality Assurance Strategic Plan for the Ghana Health Service 2007-2011 2. Peer Review of Hospitals in the Volta Region, December 2010
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SECOND CYCLE PEER REVIEW REPORT,2011 APPENDICES
Appendix A: Checklist used in 2011 Peer Review

VOLTA REGIONAL HEALTH DIRECTORATE CHECKLIST AND NOTES/GUIDELINES ON SCORING AT PEER REVIEW SESSIONS (NOVEMBER, 2010- OCTOBER, 2011)
PREAMBLE: Documentation is a huge problem in Ghana and for that matter the Health Sector; this problem must be addressed. The guideline therefore takes this into consideration in many respects. ENVIRONMENT (EXTERNAL AND INTERNAL) ITEM RATIONALE HOW TO SCORE EXPECTED SCORE IDEAL(EXPECTED) SITUATION EXISTING OR ON THE GROUND SITUATION
NO
OVERALL SCORE (after deduction)
1. 1.a
EXTERNAL ENVIRONMENT Grass Covering
Therapy involves many facets including the impact of the environment on staff and patients satisfaction When properly done, it is pleasing to the eye, sets the mind of staff and clients at ease, easily rates the institution as a ready entity to deliver the care necessary Flowers by themselves give a lot of healing - availability of the grass -Grass should be Green, not mixed with weeds (other grasses, area well boxed by kerbs, grass cut (mowed) very low, no bare area, -If no grass cover score overall 0 -If Grass not green deduct 0.5 -If Grass mixed with weeds deduct 0.5 -If grass not boxed by kerbs deduct 0.5 - If grass bushy deduct 0.5 -If bare areas available deduct 0.5 3
1.b
Flowers (Availability, Arrangements, Spread)
-Availability of the flowers -Variety of flowers -Spread of the flowers (all over the landscape) -Arrangement of the flowers (planted to follow a pattern) - Caring of the flowers (Properly taken care of) 33
If flowers not available give overall score 0 -Same Variety of flowers deduct 0.5 -Not well Spread (all over the landscape) or localized deduct 0.5 -No pattern (planted haphazardly) deduct 0.5 - Not properly kept deduct 0.5
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1.c
Trees and Hedges
Trees give shade and serve as a wind break and oxygen source for the environment. Hedges check erosion and beautify the environment
1.2a
INTERNAL ENVIRONMENT Staff Toilet
-Non-availability give overall score of 0 4 -If trees do not provide shade deduct 0.5 -Trees not well spread all over the facility deduct 0.5 -No pattern in planted trees (planted haphazardly) deduct 0.5 -Leaves droppings left under the trees deduct 0.5 -Hedges not trimmed deduct 1.0 -Trimmed Hedges not providing a pattern deduct 0.5 A sanitized internal Environment gives staff and the clients the needed confidence and easy mobility and safety To provide speed and comfort in attending to natures call in a hygienic manner -Available in all Units -Clean (No water on floor, no pieces of paper on floor, no stains on WC & Walls,) -Functional WC (Flushable) -Unbroken Pot and Cistern) -Toilet Rolls available -Odourless (sweet smelling fragrance) -Waste Paper bin (not to be used for anal droppings -Available in all Wards & OPD -Clean (No water on floor, no pieces of paper on floor, no stains on WC & Walls,) -Functional WC (Flushable) -Unbroken Pot and Cistern) -Toilet Rolls available -Odourless (sweet smelling 34 -Not available in all unit deduct 0.5 -Not Clean deduct 0.5 -Not Functional WC (Flushable) deduct 0.5 -Broken Pot and Cistern) deduct 0.5 -Toilet Rolls not available 0.5 -Odour Present deduct 0.5 -Odour ( No sweet smelling fragrance) deduct 0.5 -Waste Paper bin (contains anal droppings) deduct 0.5 -Not available in all units deduct 0.5 -Not Clean deduct 0.5 -Not Functional WC (Flushable) deduct 0.5 -Broken Pot and Cistern) deduct 0.5 -Toilet Rolls not available 0.5 -Odour present. No sweet smelling fragrance) deduct 0.5 -Waste Paper bin (contains anal droppings) 4
-Availability of trees & Hedges -Trees provide shade -Spread of the trees and Hedges (all over the landscape) -Arrangement of the trees & Hedges (planted to follow a pattern) - Hedges trimmed to provide pattern
1.2c
Client Toilet
To provide speed and comfort in attending to natures call
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fragrance) -Waste Paper bin (not to be used for anal droppings -Non-leaking roof and ceiling -No cracks in the Walls -No cracks or breaks in the floor -Walls painted -Non-peeling paints and washable -Walls not damp with fungal growth -Ceilings intact and painted with one colour -Nature of the floor (Not slippery) -Floor should not have dirt -Floor should not be stained -Floor must be sparkling - No cobwebs on the ceilings and walls -No stains on the ceilings and Walls -Well arranged furniture(to create space and prevent injury) -Cleanable working table top -Steady tables and chairs (Nails not popping up etc) -Stuffed Chairs should not have torn leathers -Adequate windows or ACs to allow free flow of air) -Working area should be bright -Available in every office -Pedal operated -Pedals are functioning 35 deduct 0.5
1.2d State of Infrastructure
To provide safety for staff & clients and aesthetic beauty
-Leaking roof and ceiling deduct 0.5 -Cracks in the Walls deduct 0.5 -Cracks or breaks in the floor deduct 0.5 -Non-painted Walls deduct 0.5 -Peeling paints deduct 0.5 -Walls damp with fungal growth deduct 0.5 -Ceilings not intact and painted with more than one colour deduct 0.5 - Nature of the floor (Slippery) deduct 0.5
1.2e
Working Areas
Should not pose danger to both clients and staff
1.2f
Waste Bins in Offices
To prevent littering of the Environment
-Dirt on Floor deduct 0.5 -Stains on Floor deduct 0.5 -Floor not sparkling deduct 0.5 - Cobwebs on the ceilings and walls deduct 0.5 -Stains on the ceilings and Walls deduct 0.5 -Furniture not well arranged deduct 0.5 -Non-Cleanable working table top deduct 0.5 -Non-Steady tables and chairs (Nails popping up etc) deduct 0.5 -Stuffed Chairs having torn leathers deduct 0.5 -Inadequate windows or No ACs to allow free flow of air) deduct 0.5 -Working area not bright enough deduct 0.5 -If not Available in some offices deduct 0.5 -Not Pedal operated deduct 0.5 -Pedals not functioning deduct 0.5
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-Should have a black liner in -No black liner in the waste bins deduct 0.5 -Not Available in every Service Area deduct 0.5 -Proper Colour coding not adhered to deduct 0.5 -Waste segregation practices not taking place deduct 0.5 -Bins are not pedal operated deduct 0.5 -Pedals are not functioning deduct 0.5 -Inappropriate liners for waste segregation deduct 0.5 3
1.2g
Waste Bins in Clients -Service Areas
To prevent littering of the Environment and to prevent danger posed by microorganisms and chemicals
-Available in every Service Area -Proper Colour coding adhered to -Waste segregation practices taking place -Bins are pedal operated -Pedals are functioning -Appropriate liners for waste segregation
INFECTION PREVENTION AND CONTROL

NO ITEM RATIONALE HOW TO SCORE IDEAL(EXPECTED) SITUATION EXISTING OR ON THE GROUND SITUATION EXPECTED SCORE OVERALL SCORE (after deduction)
II
II .1 II.1a
INFECTION PREVENTION AND CONTROL Decontamination Procedure

Use of Chlorine based Disinfectant (Chlorine disintegrates rapidly, Should not be left overnight)!
i. ii.
To prevent danger of infection posed to clients and staff. To reduce longer stay of clients through infection
To remove microorganisms likely to be transmitted. To remove microorganisms likely to be transmitted. -Stock strength of Chlorine communicated to all user Units -Prepared chlorine solution well labelled for strength and date -3 people describe appropriate use of chlorine with regards to time for disinfection, type of material and appropriate concentration for use in the different scenarios 36 -Stock strength of chlorine not known by user units deduct 0.5 -Stores not giving accurate info about stock strength deduct 0.5 -Prepared chlorine solution not labelled deduct 0.5 -Inability of an interviewee to appropriately answer in terms of (time {duration}, type of material and 3
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appropriate concentration) deduct 0.5 each -Not Available in all user units/points of preparation deduct 1 -Not Bold enough to fill an A-3 Paper and well laminated deduct 1 -Not Conspicuously displayed deduct 1
II.1b Written Protocol for Preparation of appropriate Chlorine solution (Available at all user units, conspicuously displayed) HAND WASHING II.2
PRACTICES
A new member of staff will not have difficulty in preparing the chlorine solution
-Available in all user units/points of preparation. -Bold enough to fill an A-3 Paper and well laminated -Conspicuously displayed
To decontaminate the hand in order to prevent cross infection Social hand washing (routine hand washing) is for every health worker so as not to transfer micro organism from one place to the other and from one person to the other Inputs for hand washing: -Soap (liquid or Carbolic Cake soap, if cake then soap dish) -Running Water -One-per-wash hand towel in a dispenser -Towel in dispenser easily reached but not soiled with hand water -Inter digital space rub -Avoid contaminating with tap after hand wash -Avoid soiling distal forearm after hand wash For each category of staff mentioned if: -Soap not appropriate deduct 0.5 -Soap dish or dispenser not appropriate deduct 0.5 -No running water deduct 0.5 -Multiple-use hand towel deduct 0.5 -No towel dispenser and easily soiled with hand water, deduct 0.5 -Wrong inter digital space rub deduct 0.5 -Contamination of tap after hand wash deduct 0.5 -Soiled distal forearm after hand wash deduct 0.5 12 (4 per person)
II.2a
Randomly select any 3 of the following Category of staff to perform social hand washing and score them (Take into consideration availability of all necessary inputs for the hand washing before allotting marks.) i. Orderly ii. Nurse iii. Medical Officer and Medical Assistant iv. Laboratory Personnel v. Pharmacy Staff
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To remove source of infection and prevent wrongful deposition of rubbish in and around client areas as an eyesore To prevent infection -Availability of Multipurpose 9 Incinerator (MI)for sharps, General Waste, Tissue Waste -Multipurpose Incinerator Functional -Multipurpose Incinerators used for the purpose. If Multipurpose Incinerator not available there must be Placenta -If No incinerator deduct 3 3 Pit, Burning pit and Incinerator for -If no Burning pit deduct 3 3 sharp -If no Placenta pit deduct 3 3 To have liquid waste properly disposed to avoid the danger it will pose to both staff and clients To have liquid waste properly disposed to avoid the danger it will pose to both staff and clients
-Available
II.3 II.3a
WASTE DISPOSAL
Dry/Solid Waste Disposal
II.3b Wet/Liquid Waste Disposal Soak-Away (available to collect soiled water from maternity & Theatre, Functional) II.3c Drains condition (not broken down, free of rubbish and weeds, no static collections of water II.3d Septic Tanks condition (Functional, easily accessible by truck, not weedy)
-Well sealed -No water collected around it
-Not available score overall score of 0 -Not well sealed deduct 0.5 - Water collected around it deduct 0.5
To have liquid waste properly disposed to avoid the danger it will pose to both staff and clients To have liquid waste properly disposed to avoid the danger it will pose to both staff and clients
Drains condition -not broken down, - free of rubbish and weeds, -no static collections of water -Not silted -No fungal growth -Available -Well sealed -No water collected around it -Easily accessible -Surrounding not weedy
Drains condition: -Broken down deduct 0.5 -Contains rubbish and weeds deduct 0.5 -Static collection of water deduct 0.5 -Drains Silted deduct 0.5 -Fungal growth deduct 0.5 -Septic tank not available overall score of 0 -Not well sealed deduct 0.5 -Water collected around septic tank deduct 0.5 -Not easily accessible deduct 0.5
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-Surrounding weedy deduct 0.5
EMERGENCY SERVICES AND SYSTEMS

NO ITEM RATIONALE OVERALL SCORE (after deduction) Hospitals receive individual (single) cases and large number of cases needing emergency services. It is ideal that systems are built to take care of both category of cases To ensure there is a -Emergency duty roster found in all Duty roster for any team category not 5 system to manage Units covering all the categories in available deduct 0.5 emergency situations the team *doctors, *lab Technicians, * anaesthetists, *pharmacy, with telephone numbers of all the Team members with the Telephonist -Clearly defined line of who calls the team -where emergency cases are to be -No clearly defined line of who calls the sent outlined team deduct 0.5 -flow of what happens to the -No outline of where emergency cases are emergency case after received in a to be sent 0.5 flow diagram outlined -No flow diagram outlining what happens to emergency cases deduct 0.5 To ensure basic -Emergency Trays Emergency Tray not available in 20 equipment and drugs (availability and adequacy) all expected units, give overall available to enhance -emergency tray in all score of zero management of wards, triage and a -emergency tray not in an emergencies. designated emergency expected unit or ward, triage and room a designated emergency room deduct 1.0 each -minimum content of -minimum content of emergency tray EXISTING OR ON THE GROUND SITUATION 39 HOW TO SCORE IDEAL(EXPECTED) SITUATION EXPECTED SCORE
III III.1
EMERGENCY SERVICES System for Emergency
III.2
Emergency Trays (availability and adequacy)
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emergency tray The lack of one of each item in childrens and maternity ward deduct 0.5 *AMBU bag at least 1 Adult and 1 Pediatric unit *One-way masks small, medium, large; *Sphygmomanometer, age appropriate, ex. pediatric, adult, extra-large *Stethoscope *Flashlight and extra batteries * Oxygen tank with mask (serviced yearly and checked monthly) * Syringes and needles of various sizes * Alcohol swabs or sponges * Gloves,
*Bag Valve Mask (AMBU bag) at least 1 Adult and 1 Pediatric unit. *One-way masks small, medium, large; *Sphygmomanometer, age appropriate, ex. pediatric, adult, extra-large *Stethoscope *Flashlight and extra batteries * Oxygen tank with mask (serviced yearly and checked monthly) * Syringes and needles of various sizes * Alcohol swabs or sponges * Gloves, * Aqueous epinephrine (1:1000; 1mL ampoules, *Diazepam ampoules at least 4, *Largactil ampoules at least 5, *Promethazine 20mg/mL vials (a minimum of 4) *Hydrocortizone 100mg ampoules (at least 2) *Atropine sulfate ampoules 0.6 mg/mL (optional) 40
* Aqueous epinephrine (1:1000; 1mL ampoules, *Diazepam ampoules at least 4, *Largactil ampoules at least 5, *Promethazine 20mg/mL vials (a minimum of 4) *Hydrocortizone 100mg ampoules (at least 2) *Atropine sulfate ampoules 0.6 mg/mL (optional) * Poison Control phone number GHANA,
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* Poison Control phone number GHANA, NATIONAL Poison Center Emergency Phone: 0302-243552, 0302-238626, 0302-244773, 0243-646758 National Ambulance No. Of The Catchment Area * Emergency equipment, supplies and medications inventory list with log of monthly reviews/inventory * Emergency protocols signed by a local physician *A copy of the Emergency Equipment, Supplies, and Medications list is to be placed on the crash cart, emergency tray or off-site emergency kits with a copy of the current signed protocols Protocol on Mass Casualty available in all units NATIONAL Poison Center Emergency Phone: 0302-243552, 0302-238626, 0302-244773, 0243-646758 National Ambulance No. Of The Catchment Area * Emergency equipment, supplies and medications inventory list with log of monthly reviews/inventory * Emergency protocols signed by a local physician *A copy of the Emergency Equipment, Supplies, and Medications list is to be placed on the crash cart, emergency tray or off-site emergency kits with a copy of the current signed protocols
III.3a
Protocol for Mass Casualty Management
III.3b Simulation Exercise for Mass Casualty Management (at least once a year)
To give focus and organization in the Management of Mass Casualty To keep staff alert and to review procedures and processes of managing Mass Casualties RATIONALE
No protocol available give overall score 0
Simulation exercise for Mass Casualty Management conducted once a year Report available
No evidence of simulation exercise conducted give overall score of 0
QUALITY ASSURANCE
NO ITEM HOW TO SCORE IDEAL(EXPECTED) SITUATION 41 EXISTING OR ON THE GROUND SITUATION EXPECTED SCORE OVERALL SCORE
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(after deduction)
IV. QUALITY ASSURANCE
To improve on care given to clients To guide the QATs focus -Availability of action plan for the year -Properly filed in QA designated file -Action plan must have *Activity list *Start Date *Finish date *Person/Team Responsible for specific actions *Cost element (Budget for the activities) *Remarks column -Reports/Evidence of implementation of activities -Remark column indicating status of activities whose dates has lapsed -If not Available overall score is 0 -No QA designated file deduct 0.5 -Action Plan not properly filed in QA designated file deduct 0.5 -Action plan not having *Activity list deduct 0.5 *Start Date deduct 0.5 *Finish date deduct 0.5 *Person/Team Responsible for specific actions deduct 0.5 *Cost element (Budget for the activities) deduct 0.5 *Remarks column deduct 0.5 No evidence of implementation of activities score overall 0 -Remark column not indicating status of activities whose date has elapsed deduct 0.5 -% scored on activities undertaken multiplied by 3 gives the score 4
IV.1a
Quality Assurance Action Plan available IV.1b To be sure the action is being implemented
Proportion of Activities in Action Plan Executed IV.2a Maternal Mortality (Report Forms filled? audits conducted? Report To improve on maternal care given
-100% of activities whose time has elapsed undertaken
All Report Forms filled and properly filed: -Notification Form, -Form 1A, 42
The following Report Forms (all may be in the same file) properly not filled (deduct 0.5) and not properly filed (deduct 0.5) for each:
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- Form 1B, -Audit Form -Notification Form -Form 1A - Form 1B, -Audit Form - Audits not conducted deduct 2 -Report not Submitted to RHD, deduct 0.5 - Recommendation not implemented deduct 1 -List of the Maternal deaths not available deduct 0.5 *If No Maternal Death Scores Not applicable -List of deaths not available deduct 1 -Minutes of conference not available deduct 1 -Recommendations not implemented deduct 1
Submitted to RHD, Recommendation)
- Audits conducted -Report Submitted to RHD, - Evidence of Recommendation implemented -List of Maternal deaths Available
IV.2b Evidence of other Mortality Conferences (Minutes, evidence of implementation of recommendations) IV.2c Evidence of Clinical Meetings (Reports Available, Attendance List) IV.3a
To improve on care given
-List of deaths available -Minutes of conference available, -evidence of implementation of recommendations
To improve on care given
-Reports Available, -Attendance List
-Reports not Available deduct 1.5, -No Attendance List deduct 1.5
To reduce undue delay in case management with other institutions
-Available at all units, -staff knowledge of guidelines
Referral Guidelines (Available at all units, staff knowledge of guidelines) IV.3b Referral Forms (Available, proper
To ensure uniformity of referrals forms
-Available, - proper utilization- inspect 5 filled 43
Interview 3 Nurses/Doctors selected at random to find out their knowledge about: - the levels of referrals deduct 0.5 for each person -Procedure for referrals (Form filling, Telephone calls, staff accompanying patient etc) deduct 0.5 for each person -Not Available, overall score 0 - Improper utilization of the form (inspect
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forms for cases referred 5 filled forms for cases referred) deduct 1for each -Not Available at all referring units/wards, overall score 0 -Not utilized in these units deduct 1 for each unit -No Composite Register with the Matron deduct 2 -If no evidence of feedback for each of 5 cases referred deduct 1 5
utilization- inspect filled forms for cases referred) IV.3c Referral Registers (Available at all referring units/wards, utilized) IV.3d Evidence of feedback to referring facility within 1 month of referral IV.4a Case Management Protocols Available at all treatment units (at least Malaria, Diarrhoea, Convulsion) IV.4b Case Management Protocols for Maternal cases available (Eclampsia, PPH) IV.4c Use of Partograph in Maternity/Labour Ward (Evidence of Use) IV.4d Is Cold Chain Maintained for To ensure uniformity of referrals and provide information
-Available at least 3 referring units/wards, -utilized in these 3 units -Composite Register (Referred in & Out) with the Matron Evidence of feedback to referring facility within 1 month of referral
To ensure uniformity of referrals
A new member of staff will not have difficulty in treatment of Malaria, Diarrhoea, Convulsion etc
-Available in all user units/points. -Bold enough to fill an A-3 Paper and well laminated -Conspicuously displayed
-Not Available in all user units/points deduct 1 -Not Bold enough to fill an A-3 Paper and well laminated deduct 1 -Not Conspicuously displayed deduct 1
A new member of staff will not have difficulty in treatment of Eclampsia, PPH
-Available in all user units/points. -Bold enough to fill an A-3 Paper and well laminated -Conspicuously displayed
-Not Available in all user units/points deduct 1 -Not Bold enough to fill an A-3 Paper and well laminated deduct 1 -Not Conspicuously displayed deduct 1
A guide to monitoring of clinical skills for good maternal health
Partograph is used on all labour cases that needs it
Select 5 normal delivery cases and find 5 out -if partograph is not used appropriately deduct 1 for each
-No Temp chart available (Laboratory, Pharmacy & Maternity) deduct 1for each 6
-Temp chart available -Thermometer for Fridge available 44
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-No Thermometer for Fridge available (Laboratory, Pharmacy & Maternity) deduct 1 for each
ASV,ARV, ATS, Oxytocin, Ergometrine
CLINICAL PRACTICES
CLINICAL PRACTICES
V.1a
Proportion of Caesarean Section wound Infection (Select 20 folders randomly)
V.1b
Fresh Still birth rates in the previous year Monthly monitoring of the ff. Outcome Indicators
The entire existence of hospital is to render service through clinical practice. Effectiveness and efficiency of such a practice is paramount. Indicators to measure acute, moderate and chronic cases define such effectiveness. All C/S wounds not infected It measures the Each caesarean section wound infected 20 infection prevention deduct 1 and control measures undertaken by the hospital Baseline Information on Fresh Still When Fresh Still Birth Rate is: 3 Birth Rate in VR is 3.2% 0-3.98 overall score is 3 3.99-4.75 deduct 1.5 4.76 or more give overall score of 0
V.2 V.2a
Baseline CFR for Malaria in VR is 4.35% i. Malaria Case fatality Rate
When CFR (in %) for Malaria is: 0-5.06 overall score is 3 5.07-5.78 deduct 1.5 5.79 or more give overall score of 0
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When CFR (in %) for Diabetes Mellitus is: 0-24.81 overall score is 3 24.82-33.98 deduct 1.5 33.99 or more give overall score of 0 3
V.2b
Baseline CFR for Diabetes Mellitus in VR is 15.65% ii. Diabetes Mellitus Case Fatality Rate
V.2c
iii. Caesarean Section Rate Baseline information on Caesarean Section Rate in VR is 15.78% Baseline information on Institutional Maternal Mortality Rate in VR is 5.32% iv. Institutional Maternal Mortality Rate Monitoring of Rational Use of Medicine
V.2d
When Caesarean Section Rate (in %) is: 0-17.58 overall score is 3 17.59-19.38 deduct 1.5 19.39 or more give overall score of 0 When Institutional Maternal Mortality Rate
(in %)
0-6.70 overall score is 3 6.71-8.09 deduct 1.5 8.10 or more give overall score of 0
V.3 V.3a
Percentage Prescriptions with written Diagnosis V.3b Average number of Drugs per Prescription V.3c Percentage of Drugs prescribed by Generic Name
Expected Percentage Prescriptions with written Diagnosis is 100%
Average number of Drugs per Prescription is 3
Percentage of Drugs prescribed by Generic Name 90% 46
When Expected Prescription with diagnosis is 95-100% overall score 3 69-94 deduct 1.5 Less or equal to 68 award 0 When average number of drugs per prescription is: Less or Equal to 3 award 3 3-5 deduct 1.5 more than 5 award 0 When Expected Percentage of Drugs prescribed generic name is 89-100% overall score 3 62-88 deduct 1.5 Less or equal to 62 award 0
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When Expected Percentage of Drugs prescribed are from EML is 89-100% overall score 3 62-88 deduct 1.5 Less or equal to 62 award 0 When Expected Prescription with Antibiotic is 0-30% overall score 3 31-58.5 deduct 1.5 More than 58.6 award 0 When Expected Prescription with Antibiotic is 0-10% overall score 3 11-19.5 deduct 1.5 More than 19.6 award 0 When Expected Prescription with Review date is 95-100% overall score 3 69-94 deduct 1.5 Less or equal to 68 award 0 3
V.3d Percentage of Drugs in Essential Medicine List V.3e Percentage of Prescriptions with Antibiotic V.3f Percentage of Prescriptions with Injection V.3g Percentage of Prescriptions with Review Date
Percentage of Prescriptions of Drugs in EML 100%
Percentage of Prescriptions with Antibiotic 30%
Percentage of Prescriptions with Injection 10%
Percentage of Prescriptions with Review Date 100%
CLIENT CARE
CLIENT CARE
VI.1a
Client satisfaction surveys (# conducted in past year, records available, major issues identified)
Hospitals exist for client care. This is to improve on Service delivery To accurately judge -2 Surveys conducted every year -Each report score 1 clients expectation -Hard copies of Reports available -Hard copies not available deduct 0.5 for about the service being -Recommendation listed for each delivered implementation -List of recommendations not available -Report or recommendation deduct 0.5 for each report. disseminated (Evidence e.g. -No dissemination deduct 0.5 47
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minutes, etc)
VI.1b
To ensure expectation of clients identified are addressed
Client satisfaction surveys (strategies to address major issues, evidence of implementation)
-Availability of action plan for the year -Properly filed in QA dedicated file -Action plan must have *Activity list *Start Date *Finish date *Person/Team Responsible for specific actions *Cost element (Budget for the activities) *Remarks column -Info Desk Available -Functional * Permanent staff to manage the unit *Documentation available *Evidence of being reviewed by a senior officer -Evidence of report to Management and -properly filed in a designated file.
-If not Available overall score is 0 -If not properly filed in QA dedicated file deduct 0.5 -If Action plan does not have *Activity list *Start Date *Finish date *Person/Team Responsible for specific actions *Cost element (Budget for the activities) *Remarks column Deduct 0.5 for each item above
VI.2a
Information Desk (Available, functional, weekly report from Information Desk to Management) VI.2b Complaints Management System VI.2c
To ensure clients have access to information easily and also to ensure that they dont get confused
Information Desk not available 4 functional *No permanent staff to manage deduct 0.5 *No Documentation available deduct 0.5 *No evidence of being reviewed by a senior officer deduct 0.5 *No report to management deduct 0.5 *Not properly filed in a designated file deduct 0.5 There will always be conflicts in an organization. Aggrieved parties (Staff or clients) will complain to Managers and avenues to register complains must be available To document all complains and ensure they are addressed
-Register Available
i. Complaints
Register (available, evidence of action taken on complaints)
-Existence of Designated Complaints File -Evidence of action taken should be on Complaints file
-Complaints register not available give overall score 0 -No designated complaints file deduct 0.5 -No evidence of action taken, deduct 0.5
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OCCUPATIONAL HEALTH AND SAFETY ISSUES

NO ITEM RATIONALE OVERALL SCORE (after deduction) Safety of staff and patients cannot be compromised under any circumstances and therefore steps must be taken to protect them. EXISTING OR ON THE GROUND SITUATION To prevent cross infection and injury Available, appropriate use of gloves, masks, boots, aprons, goggles) Ask 1 staff each from 3 different units applicable to demonstrate the use of -How to wear gloves -How to wear masks - How to wear boots -How to wear aprons -How to wear goggles Ask 1 staff each from 3 different units applicable to demonstrate the use of -Unable to wear gloves properly deduct 0.5 - Unable to wear masks properly deduct 0.5 - Unable to wear boots properly deduct 0.5 - Unable to wear aprons properly deduct 0.5 - Unable to wear goggles properly deduct 0.5 Non availability deduct 0.5 Inappropriate use deduct 0.5 Select 3 nurses at random and ask details about barrier nursing. If staff display no knowledge about barrier nursing score 0 4 HOW TO SCORE IDEAL(EXPECTED) SITUATION EXPECTED SCORE
VII VII.1a
OCCUPATIONAL HEALTH AND SAFETY ISSUES
Personal Protective Clothing (Available, appropriate use of gloves, masks, boots, aprons, goggles) VII.1b Personal Protective Clothing for Highly Infective
We have all forgotten barrier nursing to the detriment of already
-Assess staff knowledge on barrier
15
nursing for the 5 elements (5 steps to make barrier technique whole): 49
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compromised staff. Staff exposed to the dangers of highly infective conditions must be protected at all cost. * Doctors, Nurses & other technicians attending to the patient wear gowns, masks gloves and goggles *Number of visitors are restricted *Disposable materials are burned after use *Reusable materials are sterilized before use *all surfaces cleaned with a sanitizing solution Select 3 nurses at random and ask details about barrier nursing. -Available (WHO approved, No improvised) -Evidence of use Black for General Waste Yellow for Infection Brown for hazardous Appropriate linings Corresponding Bigger Bins each Deduct 1.0 for each step missed
Conditions e.g. Dengue Fever, Lassa Fever, H1N1 etc (knowledge of use)
VII.2a Sharp Disposal Box (available and evidence of use) VII.2b
-Not available score 0 -overflowing deduct 0.5 -Folded wrongly deduct 0.5 -When black is not used for General Waste deduct 0.5 -When yellow is not used for Infectious waste deduct 0.5 -When brown is not used for hazardous waste deduct 0.5 -Inappropriate corresponding bigger bins deduct 0.5 -Inappropriate linings deduct 0.5 -Slippery floor deduct 0.5 -Breaks on floor deduct 0.5
Segregation of Waste (Appropriate use of colour coded bins & Linings VII.3 Floors (Nonslippery, No excavation) Fire Prevention (Fire Extinguisher 3 wards selected at random and examined that floors; -Non-slippery, -No breaks on the floor Select 3 units and look out for availability of Fire Extinguishers 50
VII.4
-Score overall 0 if no Fire Extinguishers are not available
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-3 Staff in those units Appropriately use)
Protocol available for screening of Staff annually All staff screened annually
& Appropriate use) VII.5 Annual Screening of Staff(Protocol available, evidence of screening done)
-Deduct 0.5 for each if not able to appropriately use the fire extinguisher Score overall if no annual screening of staff (evidence that screen done is report on the screening) Deduct 0.5 if No protocol exist on Annual screening of staff
MANAGEMENT
NO ITEM OVERALL SCORE (after deduction) Management is the engine room for any endeavour and for that matter Hospital practice. Issues that are related to management therefore cannot be taken out of any review. Decisions are taken and -Availability of Register/Ledger to -Ledger not available deduct 2 4 record the implementation of hardly implemented - If decisions have been implemented as management decision. and even when deemed from other sources, just give 1 implemented there are - Ledger should include Decision -No decision making date deduct 0.5 making date, Decision taken, date of no records to show -Decision taken not clear deduct 0.5 implementation, cost involve creating an impression -Decision implementation date not clear that work is not been deduct 0.5 done. It is therefore -Cost involved not stated deduct 0.5 necessary to assess the records of decisions implemented to determine the progress of work. It also helps in report writing. To give focus, direction -SP is available - If available award 2 marks but 9 and motivation to both -Review plan available Not available award overall score management and the -Monitoring report of progress of 0 EXISTING OR ON THE GROUND SITUATION 51 RATIONALE HOW TO SCORE IDEAL(EXPECTED) SITUATION EXPECTED SCORE
VIII
MANAGEMENT
VIII.1
Records on Implementation of Management Decisions (Should incl. Decision making date, Decision taken, date of implementation, cost involve)
VIII.2 a
Strategic Plan (SP) (Availability, Staff Knowledge about
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entire staff. SP involves having broad outlines of local content of activities (including innovations) directed at executing the objectives of MOH/GHS Action plan operationalizes strategic plans and reduces SP to work packages that can easily be managed implementation of the SP Staff knowledge (interview 5 members of staff about awareness of the strategic plan and about the vision of the SP) No Review plan deduct 1 No Monitoring deduct 1 No Awareness by each staff interviewed deduct 0.5 No awareness of the Vision by each staff deduct 0.5
it)
VIII.2 b
VIII.3 a
Action Plan (Available in all units, meet standard action plan requirement, Proportion of implementable activities implemented) Ward Meetings (Frequency, minutes available, verify implementation of decisions taken) Staff Durbars (Frequency, minutes available)
-Available in all units -Meet standard action plan requirement Action plan must have *Activity list *Start Date *Finish date *Person/Team Responsible for specific actions *Cost element (Budget for the activities) *Remarks column -Implementation of the action plan -Once a month (The measure of being held is the availability of minutes) - At least 3 decisions executable by staff of the Ward implemented
-Once a quarter month (The measure
-Not available at all give overall score 0 -Not available in all units deduct 0.5 -Does not meet Standard action plan requirement i.e. if the following are not on the plan deduct 0.5 for each *Activity list *Start Date *Finish date *Person/Team Responsible for specific actions *Cost element (Budget for the activities) *Remarks column -% scored on activities undertaken multiplied by 3 gives the score -Each month not held deduct 0.5
VIII.3 b
Ward meeting exert team work practices for resolution of problems related to patients care and resource management Provide platform for info sharing, conflict prevention and promoting unity among
-Each of the 3 decisions unsubstantiated as being implemented deduct 1 -Each quarter not held deduct 1 -Less than 50% of entire staff attendance during the Peer Review year of the institution deduct 1 4
of being held is the availability of minutes) -At least 50% of staff must attend 52
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staff each quarter during the PR year -Training assessment done -Training plan available -At least 2 Facility based organized In-service training (basis of IST conducted is the availability of Report covering it) -No Training Need Assessment done deduct 1 -Training plan following the standard deduct 0.5 for each *Programme Area, *Course Title, *Objective, *Activity, *Expected Output, *Date, *Target Group, *No. Of Participants, *Duration, *Venue, * Funding, *Resp. Person, *Health Learning Materials Req. -2 Facility based organized training deduct 2 for each if not conducted -Designated file not available deduct 1 -No Records in file deduct 1 -Core management members (Med. Supt, Administrator, Matron, Pharmacist & Accountant) not having copies deduct 1 -Designated file not available deduct 1 -No Records in file deduct 1 -Core management members (Med. Supt, Administrator, Matron, Pharmacist & Accountant) not having copies deduct 1 -List of equipment needs not available deduct 1 12
VIII.4
Health Care Delivery is dynamic and therefore sharpening the skills and updating knowledge necessary for service delivery is very important
In-Service Training conducted (records available, TNA done) VIII.5 a Weekly Cash flow statement (available) VIII.5 b Quarterly Financial Analysis Equipment Replacement To determine financial viability and monitor budget performance. To guide expenditure decisions Every Cash flow statement is filed in a designated file and made available to core management
Every Quarterly Financial Analysis filed in a designated file and made available to core management
VIII.6 a
To ensure that broken down equipment are
-Equipment needs assessed (include those broken down and 53
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replaced so as not interrupted service delivery need to replaced) -List of equipment to be procured available (for a year) -Financial analysis statement on the above list -PPM Schedule available (include list of equipment & building, Current status (functional/nonfunctional/obsolete), date of procurement, date last serviced, next service date, location of equipment, Lifespan of the equipment) -Actions taken to dispose obsolete equipment -Prop. Of implemented -List of equipment to be procured based on prioritization not available deduct 1 -Financial analysis statement on the list not available deduct 1
Policy Financial Analysis Statement (Half Yearly)
VIII.6 b
Maintenance culture is a big problem in our institutions. Everything has to be done to ensure that equipment and buildings are maintained Planned Preventive Maintenance Schedule of Equipment and Building (Prop. Implemented)
PPM Schedule available. If it does not include *Current status(functional/nonfunctional, obsolete) *date of procurement, *date last serviced, *next service date, *location of equipment, *Lifespan of the equipment deduct 0.5 for each -No action taken to dispose obsolete equipment deduct 1 -% scored on activities undertaken multiplied by 5 gives the score
REGIONAL DIRECTORS MARK (TO BE AWARDED BY REGIONAL DIRECTOR/REPRESENTATIVES)

IX.1
To encourage creativity and local initiative
Mark for Innovation
Any Institution should be able to solve local problems using appropriate local technology. This innovation should be outstanding (as seen by the Regional Health Directorate)
5 for any particular innovation. This must be a bonus for the facility must not be
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part of the denominator but the numerator *Staff not on time 10 for any *Ushering poor particular *Arrangement of the conference area innovation. poor This must be *Participation of the General staff a bonus for (questioning, seeking clarification) the facility *Inability to ensure the other stakeholders must not be are present part of the denominator but the numerator
IX.2
*Timeliness *Ushering *Arrangement of the conference area *Participation of the General staff (questioning, seeking clarification)
Mark for Organization of the Peer Review
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CORE VALUES
Client Centred Service Staff Centred Service Professionalism Teamwork Innovation/Excellence Discipline Integrity
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Peer Review Monitoring

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Peer Review Monitoring

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VOLTA REGIONAL HEALTH DIRECTORATE

REPORT ON THE FIRST ROUND OF

SECOND CYCLE PEER REVIEW REPORT,2011

ROBERT KWAKU ADATSI DEPUTY DIRECTOR CLINICAL CARE VOLTA REGION

SECOND CYCLE PEER REVIEW REPORT,2011 ABBREVIATIONS AND ACRONYMS

SECOND CYCLE PEER REVIEW REPORT,2011 TABLE OF CONTENT

SECOND CYCLE PEER REVIEW REPORT,2011

Hon. Henry Ford Kamel Volta Regional Minister

SECOND CYCLE PEER REVIEW REPORT,2011

Dr. Joseph Teye Nuertey Volta Regional Director of Health Services

SECOND CYCLE PEER REVIEW REPORT,2011

SECOND CYCLE PEER REVIEW REPORT,2011

SECOND CYCLE PEER REVIEW REPORT,2011 ACKNOWLEDGEMENT

SECOND CYCLE PEER REVIEW REPORT,2011

SECOND CYCLE PEER REVIEW REPORT,2011

1.2 Review of the Check list

SECOND CYCLE PEER REVIEW REPORT,2011

Table 1.1 POLICY ISSUES TAKEN ON BOARD.

Proportion of Caesarean Section wound Infection (Select 20 folders randomly)

System for Emergency

Emergency Trays (availability and adequacy) minimum content of emergency tray

SECOND CYCLE PEER REVIEW REPORT,2011

To guide expenditure decisions

SECOND CYCLE PEER REVIEW REPORT,2011

1.3 Progress and Limitation in Organization of Peer Review

SECOND CYCLE PEER REVIEW REPORT,2011 CHAPTER TWO- PERFORMANCE

SECOND CYCLE PEER REVIEW REPORT,2011

Comboni St. Joseph Worawora Krachi Nkwanta

SECOND CYCLE PEER REVIEW REPORT,2011

SECOND CYCLE PEER REVIEW REPORT,2011

Performance/Th ematic Area

SECOND CYCLE PEER REVIEW REPORT,2011

Table 2.3 Paired Samples Statistics (n=22)

SECOND CYCLE PEER REVIEW REPORT,2011

1 Cycle Overall Performance

Paired Samples Test

SECOND CYCLE PEER REVIEW REPORT,2011

SECOND CYCLE PEER REVIEW REPORT,2011

Pair 5 Pair 6 Pair 7

2.4 Performance Change in the Thematic Areas Based On Ownership

SECOND CYCLE PEER REVIEW REPORT,2011

Performance Areas Environment IPC Emergency

SECOND CYCLE PEER REVIEW REPORT,2011

a. R Squared = .356 (Adjusted R Squared = .288)

SECOND CYCLE PEER REVIEW REPORT,2011

POST PEER REVIEW AND PEER REVIEW PERFORMANCE COMPARED

SECOND CYCLE PEER REVIEW REPORT,2011

Thematic Areas of Peer Review

SECOND CYCLE PEER REVIEW REPORT,2011

Thematic Areas of the Peer Review

Sig. (2tailed) 0.000

-51.46 -35.58 -34.22

25.02 31.78 14.82

5.33 6.77 3.16

-62.55 -49.67 -40.79

-40.36 -21.49 -27.64

-9.65 -5.25 -10.83

0.000 0.000 0.000

SECOND CYCLE PEER REVIEW REPORT,2011

SECOND CYCLE PEER REVIEW REPORT,2011

GHS FACILITIES PPR AND PR PERFORMANCE COMPARED

SECOND CYCLE PEER REVIEW REPORT,2011

CHAG FACILITIES PPR AND PR PERFORMANCE COMPARED

SECOND CYCLE PEER REVIEW REPORT,2011