2. Ministry of
Health
OBJECTIVES
1. To establish the quality of services provided in Lacor
Hospital during the period July-Sep 2022.
2. To conduct a data quality assessment for Quarter July-
Sep 2022
3. To identify solutions to improve the provision of
quality services.
3. Ministry of
Health
AREAS OF FOCUS
1. Out patient services.
2. In patient services.
3. Hygiene.
4. Laboratory Services.
5. Pharmaceutical Management.
6. Health Management Information
System
7. Patient Satisfaction
8. Antenatal Services.
9. Deliveries
10. Young Child Visits
11. Immunization
4. Ministry of
Health
1- Out patient services
POSITIVE FINDINGS
• Confidentiality assured.
• Triage done and triage Nurse available.
• Consultation done by skilled staff(CO and MOs)
• Malaria well treated.
• Antibiotics use okay 45%(previous quarter 30%)
against 50% cut off. Adult 33.3% and YCC 56%.
5. Ministry of
Health
1- Out patient services
POSITIVE FINDINGS
• Lab Results in register matches YCC records.
7. Ministry of
Health
2- In patient's ward
POSITIVE FINDINGS
• Regular cleaning observed.
• Access to drinking water available.
• Good ventilation.
• Enough space between beds.
• Good confidentiality( separate wards for male and female).
8. Ministry of
Health
2- In patient's ward
POSITIVE FINDINGS
• ALOS good. 3.4 (3.87 previous quarter) days.
• Placenta pit within and locked.
• Incinerator non functional
• .
13. Ministry of
Health
INPATIENT ISSUES
GAPS
• Expired drugs and tubes in Isolation, ICU, Gyn, X-Ray.
• Drugs in syringes an un-labled- MAT
• Mixed wastes- Almost universal except Trauma,
isolation
• Maggots in waste bin in gyn ward.
• Water and food stuff in fridges-ICU, Dental Unit and
OPD pharmacy
• Broken waste bins- universal
14. Ministry of
Health
3- Hygiene and infection
prevention
POSITIVE FINDINGS
• Toilets available for both staff and patients. Comment-
Visible fecal matter(trauma ward), no soap in patients
toilet.
• Waste pit available for non contaminated wastes. Wastes
are taken by contractor to municipal damping.
15. Ministry of
Health
3- Hygiene and infection
prevention
POSITIVE FINDINGS
• Toilets available for both staff and patients. Comment-
Visible fecal matter(trauma ward), no soap in patients
toilet.
OBSERVATION
• Food remnants in the toilet pan-SURG 1
• Wastes littered at collection points.
16. Ministry of
Health
3- Hygiene and infection
prevention
POSITIVE FINDINGS
• Hand washing facility with soap available.
• Waste bins not in good functional state- foot pedals not
working.
• General cleanliness of the facility not okay. Bushy
compound, littered compound.
17. Ministry of
Health
3- Hygiene and infection
prevention
POSITIVE FINDINGS
Laundry improved and organized.
Temporary storage point behind OPD pharmacy clean and
wastes disposed inside the bin.
Latrine painted and clean.
Security light visitors home in place
Waste bin in solitaries in place and practicing goo SOP for
Covid.
18. Ministry of
Health
3- Hygiene and infection
prevention
GAPS
• Expired fire extinguishers, comboni hse, CHw,
Isolation, Gyn OPD and Medicine ward.
• Incomplete records-Gyn and Medicine ward.
• Plastic bottles and Kavera still in the pretreatment
unit at lagoon.
• Construction around the ash pit not done despite various
reminders.
19. Ministry of
Health
3- Hygiene and infection
prevention
GAPS
• Drainage line filled with wastes-Girls Hostel
• Dirty toilet in school
• Latrine painted with fecal matter.
• Sale of surgical gloves in Hostel
• Pregnancy test strip in girls hostel
• Toilets and birth room in the police quarters- dirty +
cobwebs and compound littered.
• Domestic waste in the facility not picked in time
20. Ministry of
Health
3- Hygiene and infection
prevention
GAPS
• People hired to separate wastes- no protective wears,
lack knowledge(At very high Risk)-Picture
27. Ministry of
Health
4- LABORATORY
POSITIVE FINDINGS
• Lab functional all days of the week including public
holidays.
• Malaria treated correctly 10/10.
• Parasite demonstration available.
• EQA done with pass. HIV, CD4 and TB
28. Ministry of
Health
5- PHARMACEUTICAL MANAGEMENT
POSITIVE FINDINGS
• All essential medicines and health supplies are Available-
19/20(95% mRDT out of stock for 1 week)
• Stock management- All fine.19/20( Artesunate not balancing
3680 SC, PC 3675)
• Most patients identified prior to drug administration
• Drug name and strengths checked prior to administration.
29. Ministry of
Health
5- PHARMACEUTICAL MANAGEMENT
POSITIVE FINDINGS
• Drug administered same as prescribed on chart.
• Preparation/dilution is correct.
• Rate of administration very first SURG II. Tramadol and
metro infusion in < 1min.
• Route of admin is correct.
30. Ministry of
Health
5- PHARMACEUTICAL MANAGEMENT
GAPS
GAPS/OBSERVATION
• Infection control btn patients during drug
administration. Universal problem.
• Treatment trolley un attended(SURG 2)
• Preparation of drugs in absence of the patient.
• Use of disposable gloves to hang gloves.
31. Ministry of
Health
5- PHARMACEUTICAL MANAGEMENT
POSITIVE FINDINGS GAPS
• Vital observations taken for
all patients in recovery room
and charted.
• In 10/10 patients' information
on indication of drugs was
given. But only 6/10 were
given information on the
general side effects.
Pain grading NOT DONE
done( relapse)
36. Ministry of
Health
6- HEALTH MANAGEMENT INFORMATION
SYSTEM
POSITIVE FINDING GAPS
• Discrepancy was
insignificant 0.169(0.56
previous qtr.)
• Reporting to the National
HMIS system up to date.
• Incomplete documentation.
• Patients not registered.
• Some patients are
registered at discharge.
37. Ministry of
Health 7- PATIENT SATISFACTION
POSITIVE FINDING
• 49/50(98%) (previous qtr. 100%) of patients were
satisfied with the services.
POSITIVE FEEDBACK-NARRATIVES.
• Hospital is clean.
• Lines are followed- first come first served.
• Staff friendly.
• Patients who are badly off-helped faster.
• Treatment on time and daily
38. Ministry of
Health 7- PATIENT SATISFACTION
POSITIVE FINDING
• 50/50(100%) (previous qtr. 90%) of patients were
satisfied with the services.
NEGATIVE FEEDBACK
• Delays
• Wrong names on medical forms
• Patients being chased away-Dental Unit.
• Latrine Dirty
• Work only left for Sr Clare.
39. Ministry of
Health 7- PATIENT SATISFACTION
NEGATIVE FEEDBACK
• SURG 1 • When you patient changes condition and you
alert the staff, they tell you they will come
but need to keep reminding them in order to
come(SURG 2 same but they become
annoyed instead students nurses are the ones
helping us)
• Daktari cogo gi rii kanene wan. X-ray kineno
inge cabit a cel.
40. Ministry of
Health 7- PATIENT SATISFACTION
NEGATIVE FEEDBACK
• TRAUMA • A nurse called XXXX is always on phone
whether when giving treatment or what.
• Some nurses use high tone while
communicating to patients.
41. Ministry of
Health 7- PATIENT SATISFACTION
NEGATIVE FEEDBACK
• OPD • I took long on the line until now(lunch time)
that I am going to the lab from 10am.
• Line in pharmacy is very long. I came early
but dispensing starts at 11aam. Also the y pile
up the med forms before giving us Rx.
42. Ministry of
Health 7- PATIENT SATISFACTION
NEGATIVE FEEDBACK
• Casualty • An attendant of patient- Took 4 days in
casualty without being transferred to ward.
Squeezed space.
43. Ministry of
Health 7- PATIENT SATISFACTION
NEGATIVE FEEDBACK
• Main
Lab
• Tests delay in lab- Thyroid patient- comes on
monthly basis- but test do not come same
day.
44. Ministry of
Health 7- PATIENT SATISFACTION
NEGATIVE FEEDBACK
• ICU • A snr citizen-Investigation take too long by
the time results come back the patients will
have developed complications.
45. Ministry of
Health 7- PATIENT SATISFACTION
NEGATIVE FEEDBACK
• CHW • Daktair` lok I leb munu ki dong wan bene
walok ki leb acoli- Double aged
• For us we are the ones who are problematic.
46. Ministry of
Health 7- PATIENT SATISFACTION
NEGATIVE FEEDBACK
• X_RAY • Long lines but we understand that patients
are many but few staff.
• I got scan, was told there was no problem,
given some treatment for 5 days but no
improvement. Came back and was sent for
rescan- Dr CP confirmed that there was
problem- Is it not true that many patients are
being mis-diagnozied.
47. Ministry of
Health 7- PATIENT SATISFACTION
NEGATIVE FEEDBACK
• OPD-
Lab
• The services have become expensive(only 3
tests at 45,000/=)
48. Ministry of
Health 7- PATIENT SATISFACTION
NEGATIVE FEEDBACK
• SURG 2 • File picked since yesterday, not got treatment
for two days. When I ask they say they are
looking for it.
49. Ministry of
Health 7- PATIENT SATISFACTION
NEGATIVE FEEDBACK
• PRIVATE • U/S room in private not working. When
they come to the general are, people are
many and sometimes bounced
50. Ministry of
Health 7- PATIENT SATISFACTION
NEGATIVE FEEDBACK
• Gang
welo
• Latrine is dark at night- no light. Mito I pim
buu apima.
• Some patients are too weak to be here. They
should be in the ward. Abdominal distention
51. Ministry of
Health
8- ANC
POSITIVE FINDINGS
• All mothers who attended ANC for the first time were
tested for HIV and results recorded in the register and
given(100%).
• 4/5 mothers who tested +ve for HIV were initiated on
HAART(100%).
52. Ministry of
Health
9- DELIVERIES-MAT
POSITIVE FINDINGS
• Delivery room clean and comfortable.
• (6/6) initiated breast feeding within 1 hr. of delivery).
• Basic Emoc- All medicines available and not expired.
• Post C- section infection(3/193- 1.6%)
53. Ministry of
Health
9- DELIVERIES-MAT
POSITIVE FINDINGS
• 7/10 C/S within 1 hour. 3 cases
-Time for decision making not documented
- exceed 1 hour(by 20 mins)
- decision time not clear
( Instances of 2 time documentation for decision-)
• Post C- section infection(3/193- 1.6%)
54. Ministry of
Health
9- DELIVERIES-MAT
FINDINGS
• 1/6 mothers received postnatal observations appropriately
done at least 7 times. For the 5
-Bp taken 3 times in a row, but different times
documented- testimony from mothers.
• Partographs correctly filled (9/10). ( time variation on
time btn sending to labor suite and starting partograph)
55. Ministry of
Health
10- YOUNG CHILD VISITS
POSITIVE FINDINGS
• Children with Pneumonia 9/10 correctly treated(1st line
ABCs, amoxicillin and given Vit A. But 1 child-
Azythromycin.
• Weight taken and plotted properly(8/10). CHC not
available and 2nd case plotted but not joined.
• All children with fever , Malaria was excluded-
10/10=100%.
• Children with diarrhea receive ORS and Znso4(20/20).
Acronym- GLIS
56. Ministry of
Health
11- IMMUNIZATION
POSITIVE FINDINGS
• Cold chain maintained with back up energy in place and
temp monitored twice a day.( temp +6oc).
• BCG, DPT, Hep/Hip on schedule (10/10).
• 10/10(100%) weighed and plotted on the growth
monitoring chart.
57. Ministry of
Health
GENERAL OBSERVATIONS
• The tool seems to have reached a point of satiety and
Hospital has achieved the basic minimum.
Overall pediatrics continues to sustain
improvements
58. Ministry of
Health
OBSERVATIONS
• Waste segregation still remain a challenge.
• Records/ Data management need to be prioritized.
• Dissatisfaction mainly linked to deficient communication
• Medicine and Gyn wards need focus.
• Technical department still have many areas that require their
attention.
59. Ministry of
Health
RECOMMENDATIONS
• May be need to improve the assessment tool more on towards
processes of service provision.
• Provide training and PPEs for team supporting waste separation
at the waste disposal site.
• Key support focus on medicine ward
• Technical team make follow up of findings
