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SUBMISSION OF ENTRIES FOR AWARD FOR INNOVATION IN PUBLIC
SERVICE AS PART OF ACTIVITIES TO COMMEMORATE THEUN/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 itsgoverning 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 sub-
district levels in accordance with approved national policies.
1.2 Vision, Mission and Objectives of Volta Regional Health
Directorate
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The Mission of the Volta Regional Health Directorate as adopted from theMinistry 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 theRegion
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Determine charges for health services with the approval of theMinister 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 settechnical 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
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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 ofinstitutional 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
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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 correctprocessing 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 hada 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
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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 theGhana 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
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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 lower-
level 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
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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 asfollows:
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 QualityHealth 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
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2.5 The Emergence of Peer ReviewIn 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 Group-
Volta 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 institutionalizethe 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
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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 reviewis the evaluation of creative work or performance by otherpeople in the same field in order to maintain or enhance the quality of the
work or performance in that field
1
.
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
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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 ofReviewers, 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
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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
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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) Presentations by the various groups are then made.c) Discussions of the results are made and the reviewed facility is
allowed to make clarifications on the groups findings.
d) Scores are collated in the various thematic areas on the checklist
e) Strengths and weaknesses of the facility are identified
f) The reviewed facility shares its strategy on the best performingarea.
g) 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) Closing remarks are done by the Regional Director or hisRepresentative and the Chairman MSG.
i) Lunch is served and participants depart thereafter
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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 REVIEW4.1 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 servicedelivery. 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 theappropriate Waste Bins, appropriately colour coded and appropriately lined.
In addition basic Emergency Equipment were acquired and being used
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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 maybe 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 areconveniently 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
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moderate and chronic casesdefine such effectiveness.
1
Mass Casualty Incidencemanagement
To give focus and organizationin the Management of MassCasualty
To develop systems andcapacity to manage Masscasualty that goes beyond ourEmergency rooms. ForExample occurrence ofearthquakes, landslides, etc.
System for Emergency
To ensure there is a system tomanage emergency situations
Emergency Trays(availability andadequacy) -minimumcontent of emergencytray
To ensure basic equipment anddrugs available to enhancemanagement of emergencies.
To ensure uniformity in theManagement of Emergency inall facilities.
To draw attention to whatshould go into the Emergency
TrayTo reduce time spent onmanaging emergencies
Occupational Health and
Safety issues e.g.i. Personal Protective
Clothing
ii. Barrier Nursing
iii. Floors (Non-
slippery, Noexcavation)
iv. Fire Prevention
(FireExtinguisher &
Appropriate
use)
Safety of staff and patients
cannot be compromised underany circumstances andtherefore steps must be takento protect them.
To stimulate Management to
pay attention to protection ofstaff
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(Availability, StaffKnowledge about it)
motivation to bothmanagement and the entire
staff.SP involves having broadoutlines of local content ofactivities (includinginnovations) directed atexecuting the objectives ofMOH/GHS
need a Strategic Planhowever, hospitals like any
other organization needs tohave a focus exactly what astrategic Plan is meant to do.
Action Plan (Availablein all units, meet
standard action planrequirement,Proportion ofimplementableactivitiesimplemented)
Action plan operationalizesstrategic plans and reduces SP
to work packages that caneasily be managed
To give uniformity actionplans
To ensure implementation ofactivities once they areplanned
Weekly Cash flowstatement (available)
To guide expenditure decisions To ensure flow of financialinformation to management
members this hitherto is notthe case.Help in Management decisionmaking.
To help prevent financialmalpractices
Q t l Fi i l
To determine financial viabilityand monitor budget
performance.
To ensure flow of financialinformation to management
members this hitherto is notthe case.Help in Management decisiontaking.T h l i
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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 ORDEPEND 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 serviceimprovement, In some instances creativity of staff being exploited to the
advantage of the facilities etc
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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 basisfor 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 CHALLENGESIn order to mitigate these challenges, the following steps were taken:
a) The Checklist was reviewed to ensure the objectivity of the
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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
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LEAGUE TABLE OF PERFORMANCE OF HOSPITALS
Hospital 2nd Round 1st Round % Change
2nd Round
Position
1st Round
Position
Peki 94.8 87.4 8.5 1st 1st
St. Anthony 91.8 56.4 62.8 2nd 18th
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Krachi 77.9 51.5 51.3 13th 20th
MMCH 77.9 64.6 20.6 14th 12th
Adidome 76.7 55.8 37.5 15th 19th
Jasikan 75.6 70.8 6.8 16th 8th
Battor 73.9 62.3 18.6 17th 15th
Anfoega 69.6 57.9 20.1 18th 17th
VRH 63.0 61.4 2.6 19th 16th
Nkwanta 60.4 62.6 -3.4 20th 14th
Comboni 55.5 65.6 -15.4 21st 11th
Ho Poly 53.1 42.9 23.8 22nd 22nd
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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 PEERREVIEW 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) MULTIPURPOSE INCINERATOR(BEHIND)
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STAKEHOLDER INVOLVEMENT/COLLABORATION IN HOSPITAL ADMINISTRATIONAND MANAGEMENT
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INTERIOR ENVIRONMENT ENCOURAGING STAFF TO PERFORM WITHCHEST 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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DISTRICT HOSPITAL SOGAKOFE IMPROVEMENT IN THE EXTERNAL ENVIRONMENT
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