ACTION PLAN OF IPD SERVICE IMPROVEMENT
1. Fulfilling the IPD SOP
Gaps Identified
IPD management structures lack some elements
1. no IPD director assigned
2. organogram is not prepared
3. JD is not clearly described to all case teams
4. 2016 performance is not reviewed
5. 2017 annual plan is not cascaded
6. Nursing and MW service mx not well-functioning
7. HDA not well stablished
fixed time for case team discussion
8. Regular performance evaluation is not established
Inpatient staff regularly follow and implement the hospital's admission and discharge proto
No admission discharge protocols
no visitors management
The Hospital provides standard inpatient services meeting relevant regulatory standards
sub standard patient care
sub standard patient food service
All inpatient records contain completed medical record formats
incomplete patient chart
The hospital conducts MDT round twice daily and chart audit by the senior for newly admitt
irregular MDR protocol based rounding
The inpatient department is staffed with adequate personnel appropriately trained and eq
no comprehensive assignment
The department has guidelines for verbal and written communication on patient care inclu
no communication guideline
Established procedures exist for inter-professional and inter-departmental consultations an
2. IPD FACILITIES, INFRASTRUCTURES, EQUIPMENTS, AND SUPPLIES
ROOM RESSHUFFLE& LABELING,
MEDICAL EQUIPMENTS
IPD ME requirements
SUPPLIES
standard requirements as per guidelines
HUMAN RESOURCES
imbalanced assignment
inadequate capacity building
inadequate on-job training
accountability problems
non-performance based assesment
dress code
absence and proper duty discharging
lack of close supportive supervision
work place health
key activities for imrovement
Assign IPD Director with JD
prepare organogram
provide clear JD to, ped,med,surgical,NICU,&maternity wards case team
Conduct 2016 performance evaluation
cascaded annual plan to the case team level and individual levels
availing and orienting nursing care standards, protocols for main nursing procedures
Establishing case team HDa with regular meeting, self-assessment, minutes& action plan
establishing IPD PMT and regular evaluation and feed back mechanisms
1. adapt national admission & discharge protocol &orient staff
2. posting admission process flow chart and orient staff
3. determine a care giver that accompanies an IPD as only 1 person,
4. assign a security guard on IPD enterance
5.close the IPD gate leads to the administration building
6. decide the visitors time @4:00 in the morning
7. prepare care giver badge
8. orient staffs to adhere to the protocols
1. On arrival, a nurse receives and orients the patient and care givers.
2.Receiving nurses should assess all patients/clients' conditions on arrival in the ward and make the patient feel welcome, com
3. For critically ill patients, the nurse informs the physician for immediate assessment.
4. All patients should be assessed by a doctor within 2 hours of arrival and a history and physical examination completed.
5. This assessment guides immediate management.
6. The nursing process needs to be completed within 8 hours (before the next shift)
7. stable patients - physicians daily, nurses 4 hourly; critically ill - physicians twice daily or more, nurses more frequently
8. Contacts are documented using physician progress notes and nursing/midwifery progress sheets
9. other nursing and midwifery care as per nursing and MW standards and EBC change packages
10. establishing MDT committee that monitors food service as per guideline
the following patient encounter tools(at least 19 types)
admission card, hx&PE ,progress note, consultation form,consent form, physician order sheet, lab order and report form,
routine observation form, medication administration sheet, fluid balance chart, discharge summary,post mortem req& report,
radiology order and report form, pharmacy care plan, nursing process forms(nursing admission assmt, nursing problem list, nu
the following data summary tools
tally sheet, registers, log book,
the following periodic aggregate reporting tool
monthly, quarterly, PHEM, disease report forms enough at least for 3 months
implementation of MDTR Protocol
y standards
comprehensive assignment of all types of required staff with their name and contact and schedule posted clearly
sciplines
prepare guideline and orient staff
y of care
avail and orient staff on consultation protocol
HDU is the room near nursing station
surgical and medical wards are merged but separated for male and female(medical-surgical ward male room, MS room Female
TB isolation shall be for both > 5 years children and adults but separate for sex
measles & pertusis isolation becomes the duty room beside tetanus isolation
tetanus dark room
procedure room shall be separated into 3 areas for medical,surgical and pediatric wards with their own couch, shelves and cab
IPD duty Room shall be only two (female, male)
GYN nurse station shall be IPD office
SC store shall be the central store for all IPD or for pedi&med
GYN store becomes store for gyn and surgical/or cleaners store
1 Gyn duty room shall be cleaners room
KMC shall take the former NICU female duty room with curtains, 2 bed and other bedside equipments
OB duty room shall be one, if female staff comes, they will join NICU female room
maternal corner shall be separated into waiting area and NICU maternal room
study shall be conducted how minor room becomes 2nd stage?
IPD shall have 1 nurse station with all requirements fullfilled (standard requires 1 station per 35 beds)
duty room cleanliness, security, bed and other items shall be considered and corrections shall be made.
hand washing basin per room with soap and either flowing water/bucket water
at least 1 functional for patients and one for staff
rooms, stores and cabinets security shall be rensured with high-quality locks
Inpatient ward soiled utility room with shelves and leak proof containers with leads shall be available
HDU Shall have two wall mounted multiparameter pt monitors
4 Beds with removable headboard and adjustable position
10 cylinders shall be committed to HDU and 4 of them are ready each time
suction machine, weelchair, intubation set, LP set, enema set,
Electrocardiogram
emergency resuscitation equipment
Adequate lighting for bedside procedures
24-huors monitoring and the provision of oxygen, Nasal cannula, non-re breather masks, Bag valve mask,
Oxygen with its flow meter
High-flow nasal cannula, Nebulizer, Insert tons of airway equipment here such as direct laryngoscopes, Glide Scopes, bougies,
Equipment to support hemodynamically unstable patients, including infusion pumps, blood warmer, pressure bags,
Sterile gowns and sterile drapes Central venous catheters, external pacemaker device
Chest tubes / pigtail catheters, chest drainage systems
Thoracentesis kit, Paracentesis kit, Hypo/hyperthermia blankets
Glucometer, urine dipstic, minor set,
Foley catheters, Insert tons of wound care supplies, Weight Scales
PROCEDURE ROOM SHALL HAVE THE FF EQUIPMENT
procedure bed/couch, deep sink, handwashing basin, dressing trolley, worktable with laminated top, shelves and cabinets/loc
OTHER NECESSARY EQUIPMENTS
One chair and bedside cabinet per bed, iv stand per each bed, medication capboard, side cabinet, feeding table, stretcher, refr
examination light, vital signs set, instrument and medication trolleys, folding screens,
safety box, dust bins as per IPC standard (sharp-safety box, infectious-yellow, general-black, red-chemical waste)
urinals and bed pans if available or otherwise care giver should bring a bowl for urine and feces, instrument sterilizer
linens, blankets, bed sheets
new skill mix, protocol-based assignment
Unit of measurement
number
number
number
numbers
no. of meeting with minutes and action plan on identified gaps
number
Quantity Responsible body
1 MD
1 MD&Finance
5 MD
all IPD team
IPD Director&heads
1 nursing standard & 10 major procedures protocols matron, IPD case teams
>48times each case team
12 times
schedule
29/10/2016
30/10/2016
30/10/2016
11/02/2016
upto 5/11/2015
8-13/11/2015
every week from the last week of 1st MON. of 2017 EFY
ACTION PLAN OF IPD SERVICE IMPROVEMENT
1. Fulfilling the IPD SOP
Gaps Identified
IPD management structures lack some elements
1. no IPD director assigned
2. organogram is not prepared
3. JD is not clearly described to all case teams
4. 2016 performance is not reviewed
5. 2017 annual plan is not cascaded
6. Nursing and MW service mx not well-functioning
7. HDA not well stablished
fixed time for case team discussion
8. Regular performance evaluation is not established
Inpatient staff regularly follow and implement the hospital's admission and discharge proto
No admission discharge protocols
no visitors management
The Hospital provides standard inpatient services meeting relevant regulatory standards
sub standard patient care
sub standard patient food service
All inpatient records contain completed medical record formats
incomplete patient chart
The hospital conducts MDT round twice daily and chart audit by the senior for newly admitt
irregular MDR protocol based rounding
The inpatient department is staffed with adequate personnel appropriately trained and eq
no comprehensive assignment
The department has guidelines for verbal and written communication on patient care inclu
no communication guideline
Established procedures exist for inter-professional and inter-departmental consultations an
2. IPD FACILITIES, INFRASTRUCTURES, EQUIPMENTS, AND SUPPLIES
ROOM RESSHUFFLE& LABELING,
MEDICAL EQUIPMENTS
IPD ME requirements
SUPPLIES
standard requirements as per guidelines
HUMAN RESOURCES
imbalanced assignment
inadequate capacity building
inadequate on-job training
accountability problems
non-performance based assesment
dress code
absence and proper duty discharging
lack of close supportive supervision
work place health
ent care per regulatory standards
within and between disciplines
ers to ensure continuity of care
key activities for imrovement
Assign IPD Director with JD
prepare organogram
provide clear JD to, ped,med,surgical,NICU,&maternity wards case team
Conduct 2016 performance evaluation
cascaded annual plan to the case team level and individual levels
availing and orienting nursing care standards, protocols for main nursing procedures
Establishing case team HDa with regular meeting, self-assessment, minutes& action plan
establishing IPD PMT and regular evaluation and feed back mechanisms
1. adapt national admission & discharge protocol &orient staff
2. posting admission process flow chart and orient staff
3. determine a care giver that accompanies an IPD as only 1 person,
4. assign a security guard on IPD enterance
5.close the IPD gate leads to the administration building
6. decide the visitors time @4:00 in the morning
7. prepare care giver badge
8. orient staffs to adhere to the protocols
1. On arrival, a nurse receives and orients the patient and care givers.
2.Receiving nurses should assess all patients/clients' conditions on arrival in the ward and make the patient feel welcome, com
3. For critically ill patients, the nurse informs the physician for immediate assessment.
4. All patients should be assessed by a doctor within 2 hours of arrival and a history and physical examination completed.
5. This assessment guides immediate management.
6. The nursing process needs to be completed within 8 hours (before the next shift)
7. stable patients - physicians daily, nurses 4 hourly; critically ill - physicians twice daily or more, nurses more frequently
8. Contacts are documented using physician progress notes and nursing/midwifery progress sheets
9. other nursing and midwifery care as per nursing and MW standards and EBC change packages
10. establishing MDT committee that monitors food service as per guideline
the following patient encounter tools(at least 19 types)
admission card, hx&PE ,progress note, consultation form,consent form, physician order sheet, lab order and report form,
routine observation form, medication administration sheet, fluid balance chart, discharge summary,post mortem req& report,
radiology order and report form, pharmacy care plan, nursing process forms(nursing admission assmt, nursing problem list, nu
the following data summary tools
tally sheet, registers, log book,
the following periodic aggregate reporting tool
monthly, quarterly, PHEM, disease report forms enough at least for 3 months
implementation of MDTR Protocol
comprehensive assignment of all types of required staff with their name and contact and schedule posted clearly
prepare guideline and orient staff
avail and orient staff on consultation protocol
HDU is the room near nursing station
surgical and medical wards are merged but separated for male and female(medical-surgical ward male room, MS room Female
TB isolation shall be for both > 5 years children and adults but separate for sex
measles & pertusis isolation becomes the duty room beside tetanus isolation
tetanus dark room
procedure room shall be separated into 3 areas for medical,surgical and pediatric wards with their own couch, shelves and cab
IPD duty Room shall be only two (female, male)
GYN nurse station shall be IPD office
SC store shall be the central store for all IPD or for pedi&med
GYN store becomes store for gyn and surgical/or cleaners store
1 Gyn duty room shall be cleaners room
KMC shall take the former NICU female duty room with curtains, 2 bed and other bedside equipments
OB duty room shall be one, if female staff comes, they will join NICU female room
maternal corner shall be separated into waiting area and NICU maternal room
study shall be conducted how minor room becomes 2nd stage?
IPD shall have 1 nurse station with all requirements fullfilled (standard requires 1 station per 35 beds)
duty room cleanliness, security, bed and other items shall be considered and corrections shall be made.
hand washing basin per room with soap and either flowing water/bucket water
at least 1 functional for patients and one for staff
rooms, stores and cabinets security shall be rensured with high-quality locks
Inpatient ward soiled utility room with shelves and leak proof containers with leads shall be available
HDU Shall have two wall mounted multiparameter pt monitors
4 Beds with removable headboard and adjustable position
10 cylinders shall be committed to HDU and 4 of them are ready each time
suction machine, weelchair, intubation set, LP set, enema set,
Electrocardiogram
emergency resuscitation equipment
Adequate lighting for bedside procedures
24-huors monitoring and the provision of oxygen, Nasal cannula, non-re breather masks, Bag valve mask,
Oxygen with its flow meter
High-flow nasal cannula, Nebulizer, Insert tons of airway equipment here such as direct laryngoscopes, Glide Scopes, bougies,
Equipment to support hemodynamically unstable patients, including infusion pumps, blood warmer, pressure bags,
Sterile gowns and sterile drapes Central venous catheters, external pacemaker device
Chest tubes / pigtail catheters, chest drainage systems
Thoracentesis kit, Paracentesis kit, Hypo/hyperthermia blankets
Glucometer, urine dipstic, minor set,
Foley catheters, Insert tons of wound care supplies, Weight Scales
PROCEDURE ROOM SHALL HAVE THE FF EQUIPMENT
procedure bed/couch, deep sink, handwashing basin, dressing trolley, worktable with laminated top, shelves and cabinets/loc
OTHER NECESSARY EQUIPMENTS
One chair and bedside cabinet per bed, iv stand per each bed, medication capboard, side cabinet, feeding table, stretcher, refr
examination light, vital signs set, instrument and medication trolleys, folding screens,
safety box, dust bins as per IPC standard (sharp-safety box, infectious-yellow, general-black, red-chemical waste)
urinals and bed pans if available or otherwise care giver should bring a bowl for urine and feces, instrument sterilizer
linens, blankets, bed sheets
new skill mix, protocol-based assignment
