SUBMISSION OF ENTRIES FOR AWARD FOR INNOVATION IN PUBLIC SERVICE AS PART OF ACTIVITIES TO COMMEMORATE THE UN/AU PUBLIC SERVICE

DAY, 2012 1.0 BACKGROUND The Ghana Health Service (GHS) is one of the agencies under the Ministry of Health established by Act 525, 1996 of the Parliament of the Republic of Ghana. The Volta Regional Health Directorate being an outpost of the Headquarters of Ghana health Service is mandated to plan and carry out activities and programmes aimed at achieving the core objectives of the Ghana Health services as indicated in Act 525 of 1996, which are stated below. as required by the 1992 constitution. It is responsible for implementation of national policies under the control of the Minister for Health through its governing Council - the Ghana Health Service Council at Regional Level. 1.1 Mandate of the Volta Regional Health Directorate To provide and prudently manage comprehensive and accessible health service with special emphasis on primary health care at district and subdistrict levels in accordance with approved national policies. 1.2 Vision, Directorate Mission and Objectives of Volta Regional Health

The Volta Regional Health Directorate envisioned all Hospitals in the Volta Region are Centres of Excellent. This is believed to be reflected in the following dimensions:

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The Mission of the Volta Regional Health Directorate as adopted from the Ministry of Healths Mission Statement is to contribute to socio-economic development and wealth creation by promoting health and vitality, ensuring access to quality health, population and nutrition services for all people living in Ghana and promoting the development of a local health industry. Source: GHS SP Document/MOH National Health Policy The objects of the Volta Regional Health Service are to: Implement approved national policies for health delivery in the Region. Increase access to good quality health services, and Manage prudently resources available for the provision of the health services. 1.3 Functions or Core Business of Volta Regional Health Directorate For the purposes of achieving its objectives the Volta Regional Health Directorate performs the following functions amongst others: Develop appropriate strategies and set technical guidelines to achieve national/Regional policy goals/objectives Undertake management and administration of the overall health resources within the service in the Region Promote healthy mode of living and good health habits by people Establish effective mechanism for disease surveillance, prevention and control

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Determine charges for health services with the approval of the Minister of Health Provide in-service training and continuing education Perform any other functions relevant to the promotion, protection and restoration of health.

2.0 BACKGROUND ANALYSIS AND RATIONALE FOR INNOVATION (PEER REVIEW) 2.1 Background The Core function of any health care system borders on quality service delivery aimed at saving life, preventing disabilities and ensuring that individuals are able to reproduce themselves with minimum risk. As part of its functions, Ghana Health Service is supposed to adopt and set technical guidelines to achieve policy standards set by the Ministry of Health and performs any other related functions that will ensure sustainable health financing as well as promoting, protecting and restoring of health. 2.2 Rationale for Introducing Peer Review Many Health facilities were facing infrastructure problems countrywide. Apart from Infrastructure gap and deteriorating state what exists is not properly aligned to service delivery. Service lines for water and electricity are commonly difficult. By the 1980s, most hospitals were existing just in name and not surprisingly, described as graveyards because of lack of necessary logistics, medicines and funds to operate. Staff members were demoralized, dispirited and leading to a culture of non-adherence to established standards and policy which on the surface mimics technical incompetency. Desertions had worsened moral; interpersonal relations descended to the lowest. Facility Managers faced with all these virtually raised the levels in despair. The resultant situation- insanitary conditions in hospitals, broken toilets, leaking roofs, broken down equipment, very repugnant customer care, healthcare quality has in its lowest abyss

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Many fact-finding missions were just amazed at the depth of the problem such as: In response, establishment introduced Quality Assurance practices at all levels of the healthcare system. At the level of national headquarters, Quality Assurance Department was established; cadres were sent for training and positioned; policy documents were drafted to guide actions. Regional Quality Assurance teams were established with forays of institutional Quality Assurance teams became the norm and reports were written every year [But as . Put it] Policy documents were gathering dust within the enclaves of the Ministry of Health and Ghana Health Services whilst the deterioration continued at institutional level. The traditional methods of monitoring and supervision were unable to arrest the decaying situation. E.g. from publication to support

What were the interventions, activities and progarmmes implemented to achieve these and what is the problem or the gap. However, the Independent Review team of Programme of Work (POW)-2006 found that health centres are not functioning as they should to provide basic intra-partum care. Available health services are of poor quality. There is persistent shortage of basic supplies and equipment. Staff numbers are inadequate and available personnel were de-motivated by poor working conditions. [The Quality Assurance Strategic Plan for the Ghana Health Service 2007-2011] The same document stated the following: Facility infrastructure: Sixty-six (66) percent of facilities reported they had on site water and 39 percent that they had water all year

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round. Only 38 percent have 24 hour electricity supply and 29 percent had no electricity at all. Infection prevention and control: Soap was available in only 70 percent of service delivery areas and only 54 percent of facilities had gloves in all relevant service areas. While 67 percent of facilities had functioning equipment for high-level disinfection or sterilization, only 51 percent had both the equipment and staff who knew the correct processing time. Service availability: A full package of RCH services 21 was available in only 28 percent of facilities. Seventy-two percent of hospitals but only 13 percent of all facilities had all items necessary to provide quality 24-hour service. All hospitals but only 26 percent of clinics had a qualified health care provider Facility management: Only 23 percent of all facilities had a management committee that holds documented meetings at least twice a year; only 14 percent had documented QA activities. Seventy percent of facilities had received external supervision in the 6 months preceding the survey. Forty-nine percent of health workers had received in-service training in the previous 12 months. Underlying constraints in the provision of quality health care are efficiency and financing gaps. These include limited decentralization, inadequate motivation of professional staff, ineffective supervision and monitoring, and weak links between facilities and communities as indicated in the Ghana Poverty Reduction Strategy (GPRS) document.

Corroborating the GPRS document, the Quality Assurance Strategic Plan for the Ghana Health Service 2007-2011 also identified the underlying causes for inefficiencies as non-sustained efforts in quality improvement activities due to irregular and inadequate funding; lack of commitment of
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managers to quality; and an absence of quality maintenance mentality or culture. In spite of so much investment in quality assurance within the Ghana Health Service; quality of health services are still uncoordinated, leading to wasteful duplication - a consequence of all these is inadequate monitoring and supervision of post intervention activities. This document also laments the non-compliance with guidelines on basic patient care, workplace safety and poor staff working environment. 2.2 Historical Nature of Monitoring and Evaluation in Ghana Health Service. The purported aim of Monitoring in the Health sector; essentially is to track and ensure that key elements of the Health Sector performance regarding inputs, activities/processes, and results remains on their projected trajectory. This affords policy/programme implementers to: Determine the extent to which the policies/programmes are meeting desired targets, identify possible inhibitory factors and designed possible interventions to overcome them. ion track and to make any needed corrections accordingly; make informed decisions regarding operations management and service delivery; ensure the most effective and efficient use of resources; and Evaluate the extent to which the programme/project is having or has had the desired impact. The traditional monitoring method usually used in assessing service delivery within the Health Sector involves: 1. The use of structured Checklist to assess specific programme or service areas 2. Hand picking of field staff that sometimes have little or no knowledge in those specific areas or hospital services. 3. After the usual fieldwork, the Field Officers meet with Management Team of the Hospitals and brief them on what they have seen and make few suggestions to address challenges. These suggestions, more often than not, were neither implemented nor tracked.
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So what is the problem? Is the problem due to challenges with the process or the methodology? Is this in consonance with the findings of the GHS 2007-2011 strategic plan? The Ghana Health Service 2007-2011 Strategic Plan identified that there is insufficient monitoring and supervision across all levels of the GHS, contributing to a general lack of commitment and little accountability for performance. Inadequate support and oversight from the national level to the regional and district levels through supervisory visits and performance appraisal also leads to reduced morale and sometimes indiscipline of lowerlevel managers Self-assessment or routine assessment of individual performance within GHS is lacking probably due to non-functional appraisal system with no uniform tools for assessment and if available not well disseminated and shared with all managers. 2.3 The Hospital Strategy document of the Ministry of Health also highlighted the following: Monitoring and Supervision systems with the hospital are weak. (what is the evidence) Hospital managers have not considered monitoring and supervision as crucially important in effective management. Monitoring tools have not been well-developed and disseminated. There seems to be no accountability and responsibility on the part of managers to measure performance of hospitals. Besides, there is a general perception amongst health personnel that monitoring and supervision are bothersome duties which increase their workload. (what are the evidences) The result of the traditional monitoring does not usually bind the Managers of the facilities monitored to take action to correct the problems challenging them. Reports are always written about the performance of the facilities monitored but actions to address the problems to forestall recurrence are usually not taken. (What is the course of this?) 2.4 The Challenge of Closing the Gap. The gap between policy and Implementation to ensure that quality of service is satisfying to all remain a yawning one for years. Closing this gap is a

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frustrating one in spite of various interventions undertaken as stated in the Quality Assurance Strategic Plan for Ghana Health Service 2007-2011 as follows: 1. Establishment of a Quality Assurance Department in the Institutional Care Division of the Ghana Health Service with a substantive head, a deputy and a secretariat. 2. Since mid-2004, the department has targeted support from Quality Health Partners, a project largely dedicated to improving quality of care in GHS and a range of private institutions. It has targeted 30 districts with more than 200 health facilities. 3. Production and cataloguing of numerous policies and operational guidelines and standards on care 4. Production and use of tools for monitoring and supervision. 5. General in-service training to improve competencies of staff 6. In-service training focused on quality assurance and customer care 7. Supervision and monitoring visits focused on quality of care. Visits from national level to regions and from region to other levels were carried out quarterly 8. Annual national quality assurance conferences 9. The QA department has produced annual reports since 2003 10. Regional, district and institutional QA teams have been established 11. Accreditation criteria developed for national health insurance

scheme has used defined standards of quality as criteria and is intended to be used for self-assessment 12. Improvements in infrastructure; drug and equipment supply In spite of the above array of interventions, quality of service delivery in our health institutions remains a far cry from the desirable even though some modest gains have been made. Just how should the challenge be tackled?
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2.5 The Emergence of Peer Review In 2007, the Medical Superintendents Group (MSG), Volta Division, at a conference held in Ho agreed to make Peer Review an Instrument of Monitoring their own service delivery activities. In the conference communiqu, it was suggested that Peer Review be made such an Instrument in the entire health sector at all levels in the country. In the Volta Region, in 2009, Peer Review has assumed exactly the competitive nature as envisioned by the Medical Superintendents GroupVolta Division. The Director General in his 19th January, 2010 letter on the 2010 Direction of Ghana Health Service in the Implementation of the 2010 Programme of Work directed Regional Health Directorates to institutionalize the Peer Review mechanism and District League Performance table and introduce schemes to motivate lower level managers to perform. (Can you please look at the problem statement again? It appears that the problem as indentified is scatted in various document. Can we reorganized it into a paragraph or a page supported by evidence from all these documents) 2.6 Rationale for the Peer Review There was the need to collaborate on improving quality of service delivery in hospitals in the region. Indeed, it was necessary to: Replicate best practices in all hospitals in the region thereby redistributing patient load. Stimulate implementation of policy directives of the Ghana Health Service into facilities by integrating such directives into the checklist Encourage facilities to build own-grown innovative solutions to their problems Get health staff to imbibe the culture of responsibility and accountability for their own actions and inactions.
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 Build functioning teams since health care delivery is teamwork 3.0 THE PEER REVIEW 3.1 What is Peer Review? Peer review is the evaluation of creative work or performance by other people in the same field in order to maintain or enhance the quality of the work or performance in that field1. In our case, it is since as bringing peers together to serve as an organizational Mirror through which reviewed hospitals sees his performance; whether meeting the approved Standards of WHO, National and Regional using an agreed checklist. Through this means, Organizational performance Diagnoses are made and Prescriptions given instantly at the point where the diagnosis is made. At the end of the Diagnosis process, a full discussion or feedback session is usually held on the identified gaps. In so doing, Participants in effect also learn from the process and back at their facilities initiate moves to correct the deficiencies and new ways they found in their sister facilities. 3.0 Detailed Description of Peer Review Process 3.1 Management of the Peer Review Process Peer Review is being managed by the Volta Regional Health Directorate and the Medical Superintendents Group- Volta Division through a Coordinating Department in the Clinical Information Monitoring and Evaluation under Clinical Care Division. All Coordinating activities are done by the Clinical Care Division which is responsible for providing Clinical Governance in the Region. The Coordinating Unit is responsible for the Organization of the Peer Review in each Hospital in collaboration with the various Hospital Managements.

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The Process The following are the Processes we have gone through to implement this innovation: 1 Developed an Assessment tool or checklist for the assessment 2 Developed a Code of Principles to guide the behaviour of Reviewers, Reviewee, Reviewed Facility, Referees, and Reviewing Facilities. 3 Prepared a Schedule for all the Hospitals. You can ballot for the Period the Hospital should be reviewed or prepare the date for each Hospital. 4 Hospitals Identified Accredited Reviewers with a Minimum Qualification determined by the Regional Health Directorate 5 Train all the Accredited Reviewers to understand how to administer the Checklist or the Assessment tool. 6 Regularly invite the Hospitals to the Peer Review. 3.1. Methodology of the Peer Review Process 2.1 Distribution of Peer Review Schedule and Checklist To enable facilities adequately prepare for the Peer Review in their facility, the Peer Review Schedule and the Checklist were distributed by the Regional Health Directorate ahead of time. This was to afford them know the areas they will be assessed on and also to enable them to identify the areas they need to work on before they are Peer reviewed. 2.2 Follow-up on readiness of the facility to be reviewed

A follow up telephone call to remind facilities of the Peer Review dates is made by the Regional Health Directorate a week preceding the event. A

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Facebook Group has also been created to inform all hospitals about the Hospitals that will be reviewed. 2.3 Pre-monitoring Session on the day of PR

The Pre Monitoring activities include: Assembling of Heads of Departments/Units of the Institution being Peer reviewed and Participants from other sister facilities. Discussion of the Checklist and other procedures/methods (Observation, Interview, Records review etc.) to be adopted during the Monitoring Session so as to ensure that all participants are conversant with the Checklist and the Procedures. Grouping of participants and assigning different areas on the Checklist to them to monitor. 2.4 Monitoring Session During the Actual Monitoring and Supportive Supervision Session: i. Peers visit all Units/Departments of the Hospital to observe, interview, review records and ask staff to demonstrate some procedures before scoring the Hospital per the checklist. The reviewers usually take notes on the things they see for discussion. ii. Peers also interact with staff to properly understand processes used in the Best Practices identified so as to replicate it at their own facilities. iii. iv. v. Where Peers realized that a particular process falls below the recommended standard, they facilitate or advise staff on duty. When the reviewers finish the rounds, they discuss their findings among themselves before the scoring on the checklist. The checklist.
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Regional

Team

also

goes

round

to

find

out

if the

teams/groups were having any problems with regards to the

2.5 The Post Monitoring Session The Post monitoring session activities include: a) A staff durbar organized for all the members of staff for each Hospital visited. At least all Units/Wards/Department of the Hospital were represented during the dissemination. b) c) d) e) f) g) area. The Peers and the host then agree on a specific poor performing area and carry out a problem solving session to assist the reviewed facility overcome the specific problem. h) i) Closing remarks are done by the Regional Director or his Lunch is served and participants depart thereafter. Representative and the Chairman MSG. A scoring sheet has also been developed which is filled in duplicate. A copy is given to the Head of the Hospital or his representative. At the end of each cycle a League Table is prepared on the performance of each Hospital. Presentations by the various groups are then made. Discussions of the results are made and the reviewed facility is Scores are collated in the various thematic areas on the checklist Strengths and weaknesses of the facility are identified The reviewed facility shares its strategy on the best performing

allowed to make clarifications on the groups findings.

Post Peer Review Monitoring In order sustain the gains made during the Peer Review, the Post Peer Review Monitoring was also introduced. The date for the Post Peer Review in each Hospital is not communicated to the Hospitals. The Post Peer Review date is solely determined by the Peer Review Coordinator who selects other experienced Nurses and other professionals to use an abridged version of
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the main Peer Review Checklist. This period is also used to assess whether efforts were initiated to correct issues raised during the main Peer Review.

Tools for the Process Budget 4. ACCOMPLISHMENTS OF THE PEER REVIEW 4.1 Intermediate Results 4.1.1 Availability of Service Inputs Every hospital is expected to acquire some basic inputs for quality Service Delivery. In the era where most facilities were neglected and occasionally monitored for these inputs, it was difficult getting these inputs for service delivery. This attitude demoralizes the Staff to perform to meet the required standards. On the day of Peer Review when these items are assessed, Management of the Hospitals make frantic efforts to acquire these basic inputs which will be used regularly. Hitherto, it was difficult seeing appropriate Waste Bins in the Hospitals, but now every Hospital has the appropriate Waste Bins, appropriately colour coded and appropriately lined. In addition basic Emergency Equipment were acquired and being used. In summary, the Peer Review ensured the availability of at least the following items and Plans for replacement of major equipment: Emergency Medicines and Equipment Appropriate Waste Bins and Liners Basic Consumables and Non-consumables

4.1.2 Monitoring of Client Satisfaction As part of the Process, all Hospitals were required to monitor the satisfaction of the Clients by conducting at least biannual Client Satisfaction Survey. In addition, Hospitals have created Complaints Desks to enable both Clients

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and Staff to officially lodge their complaints. Managements were also tasked to regularly deal with these complaints. 4.1.3 Readiness for Mass Casualty Incidence Management As part of the process of improving Emergency and Mass Casualty Incidence Management, systems has been created in the Region to put the Region in readiness for Managing Mass Casualty situations where the resources may be inadequate in one facility. In addition, basic equipment and Medicine needed for providing Emergency Services were ensured in all the Hospitals in the Volta Region. 4.1.4 Infection Prevention and Control In order to ensure patients are not infected in the Hospital, all Hospitals are conveniently using Chlorine Based Disinfectant. In addition, the process ensured the availability of the appropriate Soap, Stand-by Water systems etc. to ensure that at least social hand washing is being done. In addition knowledge of staff on barrier nursing has been enforced. 4.2. IMMEDIATE RESULT In terms of immediate results, the table below depicts how the Health Delivery system in the Region was influenced especially with regards to the implementation of policy guidelines in the MOH/GHS
NO POLICY ISSUE
Proportion of Caesarean Section wound Infection (Select 20 folders randomly) Case Fatality Rates, C/S Rates, Fresh Still Rates

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,

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

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moderate and chronic cases define such effectiveness. To give focus and organization in the Management of Mass Casualty
Mass Casualty Incidence management System for Emergency

To develop systems and capacity to manage Mass casualty that goes beyond our Emergency rooms. For Example occurrence of earthquakes, landslides, etc. 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

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

Occupational Health and Safety issues e.g. i. Personal Protective Clothing ii. Barrier Nursing

To ensure there is a system to manage emergency situations To ensure basic equipment and drugs available to enhance management of emergencies.

iii. Floors (Nonslippery, No excavation) iv. Fire Prevention (Fire Extinguisher & Appropriate use) v. Annual Screening of Staff(Protocol available, evidence of screening done)

Safety of staff and patients cannot be compromised under any circumstances and therefore steps must be taken to protect them.

Records on Implementation of Management Decisions (Should incl. Decision making date, Decision taken, date of implementation, cost involve)

Strategic Plan (SP) 16 | P a g e

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

To ensure decisions taken are not left hanging. To introduce a culture of reviewing Management decisions

Hospitals think they dont

(Availability, Staff Knowledge about it) Action Plan (Available in all units, meet standard action plan requirement, Proportion of implementable activities implemented)

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

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.

VIII. 6b

Quarterly Financial Analysis Equipment Replacement Policy Financial Analysis Statement (Half Yearly) Planned Preventive Maintenance Schedule of Equipment and Building (Prop. Implemented)

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 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

Major GHS/MOH Policies were implemented through the use of the Peer Review IPC and Occupational Health & Safety

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 Referral Policy Waste Management Maternal Health Audit Customer Care Policy/Guideline High Staff Motivation to assist Management of the Hospitals. Basic Service delivery Inputs are available to staff to deliver quality Service

4.3 EXTENT TO WHICH INNOVATION HAS BEEN MAINSTREAMED OR DEPEND ON LOCAL RESOURCES The implementation of the Peer Review ensured that Revenue generated is plough back into the service delivery judiciously. More equipment to were being purchased to ensure quality of Service Delivery to clients e.g. Patient Monitors, Emergency Units constructed and well equipped for service improvement, In some instances creativity of staff being exploited to the advantage of the facilities etc. 4.4 EXTENT TO WHICH THE PEER REVIEW HAS BEEN REPLICATED AND/OR HAVE THE POTENTIAL FOR REPLICATION ELSEWHERE In terms of replication, Peer Review could be replicated in every MDAs. It is a very simple mechanism that pushes all the staff; both management and staff to get things they may not ordinarily do, done. It helps in implementing all policies that are not being implemented to be implemented. In addition it helps in exposing the Policy deficiencies. Currently, the Volta Region is assisting Focus Health Region to replicate this programme in Western Region and Greater Accra Region.

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5.0 CHALLENGES ENCOUNTERED The following were the Challenges encountered in implementing the Peer Review: 1. The initial Checklist used during the first cycle had some subjectivity in it. 2. Some outlier behaviours were identified in some facilities 3. Sustainability of gains made during the day of the Peer Review was a challenge 4. 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 5. 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. 6.0 MEASURES ADOPTED TO MITIGATE CHALLENGES a) The Checklist was reviewed to ensure the objectivity of the assessment. Also the structure of the Checklist was modified to include the ideal situation, the reasons for the ideal situation and what to do if the ideal situation is not met by the facility being reviewed b) 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

In order to mitigate these challenges, the following steps were taken:

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c) 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. d) A code of principle was also developed to guide the behavior of the Participants (Reviewed Facilities and Reviewing facilities) and the referees (Regional Health Directorate) e) Training was done for those selected by the various Hospitals as their accredited reviewers to ensure uniformity of the assessment at the various zones the Region was divided into.

APPENDIX A OVERALL PERFORMANCE OF GHANA HEALTH SERVICE HOSPITALS

OVERALL PERFORMANCE OF GHANA HEALTH SERVICE HOSPITALS

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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 21 | P a g e 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 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 % 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 Position 1st 2nd 3rd 4th 5th 6th 7th 8th 9th 10th 11th 12th 1st Round Position 1st 18th 4th 2nd 3rd 10th 6th 13th 5th 7th 21st 9th

Krachi MMCH Adidome Jasikan Battor Anfoega VRH Nkwanta Comboni Ho Poly

77.9 77.9 76.7 75.6 73.9 69.6 63.0 60.4 55.5 53.1

51.5 64.6 55.8 70.8 62.3 57.9 61.4 62.6 65.6 42.9

51.3 20.6 37.5 6.8 18.6 20.1 2.6 -3.4 -15.4 23.8

13th 14th 15th 16th 17th 18th 19th 20th 21st 22nd

20th 12th 19th 8th 15th 17th 16th 14th 11th 22nd

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APPENDIX B- PICTURE GALLERY OF ACHIEVEMENTS OF THE PEER REVIEW

SERENE AND THERAPEUTIC ENVIRONMENT EXPERIENCE IN HOSPITALS

ENSURING SERENE AND THERAPEUTIC ENVIRONMENTS IN THE HOSPITALS

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IMPROVING THE EXISTING INFRASTRUCTURE THROUGH PEER REVIEW INFRASTRUCTURE OF KRACHI HOSPITAL BEFORE THE PEER REVIEW

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IMPROVING THE EXISTING INFRASTRUCTURE THROUGH PEER REVIEW AT KRACHI

HOSPITAL

POLICY ON SEGREGATION OF WASTE BEING ENFORCED THROUGH PR

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WASTE MANAGEMENT PROCESS IN HO MUNICIPAL HOSPITAL

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WASTE SEGREGATION SHADE (IN FRONT) (BEHIND)

MULTIPURPOSE INCINERATOR

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STAKEHOLDER INVOLVEMENT/COLLABORATION IN HOSPITAL ADMINISTRATION AND MANAGEMENT

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INTERIOR ENVIRONMENT ENCOURAGING STAFF TO PERFORM WITH CHEST OUT AT HOHOE HOSPITAL

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HOSPITAL ENVIRONMENT IN ST. ANTHONYS HOSPITAL, DZODZE

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ENSURING THE COMFORT OF CLIENTS IN OUR HOSPITALS

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WARDS IN KRACHI WEST DISTRICT HOSPITAL BEFORE PEER REVIEW AND AFTER THE PEER REVIEW

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CLIENTS BATHROOM IN MARGRET MARQUART HOSPITAL BEFORE AND AFTER PEER REVIEW

NEW MATERNITY BLOCK CONSTRUCTED AT MARGRET MARQUART HOSPITAL TO HELP ACHIEVE THE MDG 4 &5

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NEW PHARMACY BLOCK COMMISSIONED FOR ST. JOSEPH CATHOLIC HOSPITAL, NKWANTA

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NEW MATERNITY OF MARGRET MARQUART CATHOLIC HOSPITAL

PEKI HOSPITAL RECREATIONAL CENTRE CHANGED TO CONFERENCE ROOM

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DISTRICT HOSPITAL SOGAKOFE IMPROVEMENT IN THE EXTERNAL ENVIRONMENT

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