Peer Review Monitoring

7/29/2019 Peer Review Monitoring

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VOLTA REGIONAL HEALTH

DIRECTORATE

REPORT ON THE FIRST ROUND OF

PEER REVIEWOF HOSPITALS IN THE VOLTA REGION

DECEMBER, 2011


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ii SECOND CYCLE PEER REVIEW REPORT,2011

ii

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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iii SECOND CYCLE PEER REVIEW REPORT,2011

iii

ABBREVIATIONS AND ACRONYMS

CCD Clinical Care Division

CHPS Community-Based Health Planning System

GPRS Ghana Poverty Reduction Strategy

GHS Ghana Health Service

M &E Monitoring and Evaluation

MSG Medical Superintendents Group

MSG-VD Medical Superintendents Group- Volta Division

PR Peer Review

QA Quality Assurance

RDHS Regional Director of Health Services

RHD Regional Health Directorate

VRHD Volta Regional Health Directorate

WHO World Health Organization


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iv SECOND CYCLE PEER REVIEW REPORT,2011

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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


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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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vi SECOND CYCLE PEER REVIEW REPORT,2011

vi

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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viii SECOND CYCLE PEER REVIEW REPORT,2011

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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 1 st 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% to78.0%. 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 theother 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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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 NuerteyMr 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


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Dr Lawrence Kumi Peki Hospital

Dr Edwin Danoo Hohoe Hospital

Dr. Anthony Ashinyo Nkwanta Hospital

Dr Felix Tsidi Keta Hospital

Dr F.E. Abudey Sogakofe Hospital

Dr Samuel Abudey Jasikan Hospital

Dr Hilarius K Abiwu Krachi West Hospital

Dr Doe Ocloo Adidome Hospital

Dr Moses Boni Akatsi Hospital

Dr Tetteh Augustus St. Joseph Catholic Hospital

Dr Pius Mensah Worawora Hospital

Rev. Sr. Dr Lucy Hometowu Margaret Marquart Catholic Hospital

Dr Alex Ackon Anfoega Catholic Hospital

Dr A. Mark Ofori-Adjei St. Mary Theresa Catholic Hospital, Dodi PapaseDr William Dwuamena St. Anthonys Catholic Hospital

Dr Atsu Seake-Kwawu Ho Polyclinic

Dr Bowan Battor Catholic Hospital

Dr Kugbe Mlimor Kudjo Sacred Heart Hospital,Abor

Dr George Acquaye Volta Regional Hospital

Dr Moumoudo Cham Comboni Hospital


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1 SECOND CYCLE PEER REVIEW REPORT,2011

1

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 andyearly 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 thecheck 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:


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Table 1.1 POLICY ISSUES TAKEN ON BOARD.

NO POLICY ISSUE RATIONALE WHAT THE POLICY ISSUE IS

SUPPOSED TO ACHIEVE

1 Proportion of CaesareanSection wound Infection (Select20 folders randomly)

It measures the infection prevention

and control measures undertaken by

the hospital

To reduce infection in the hospitals

and

To carry out infection control

practices

2

Case Fatality Rates, C/S Rates,

Fresh Still Rates

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.

A range of indicators looked at how

individual facilities fit within the

range and indicating the

effectiveness and efficiency of

managing the case

3

Mass Casualty Incidence

management

To give focus and organization in the

Management of Mass Casualty

To develop systems and capacity to

manage Mass casualty that goes

beyond our Emergency rooms. For

Example occurrence of earthquakes,

landslides, etc.

4 System for Emergency

To ensure there is a system to manage

emergency situations

5Emergency Trays

(availability and adequacy) -

minimum content of

emergency tray

To ensure basic equipment and drugs

available to enhance management of

emergencies.

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

6

Occupational Health and Safetyissues e.g.

i. PersonalProtective

Clothing

ii. Barrier Nursingiii. Floors (Non-

slippery, No

excavation)

iv. Fire Prevention(Fire

Extinguisher &

Appropriateuse)

v. AnnualScreening of

Staff(Protocol

available,

evidence of

screening done)

Safety of staff and patients cannot becompromised under any circumstances

and therefore steps must be taken to

protect them.

To stimulate Management to payattention to protection of staff


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Records on Implementation of

Management Decisions (Shouldincl. Decision making date,

Decision taken, date of

implementation, cost involve)

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 ensure decisions taken are not left

hanging.

To introduce a culture of reviewing

Management decisions

7

Strategic Plan (SP)

(Availability, Staff

Knowledge about it)

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

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.

8

Action Plan (Available in all

units, meet standard actionplan requirement,

Proportion of

implementable activities

implemented)

Action plan operationalizes strategic

plans and reduces SP to work packagesthat can easily be managed

To give uniformity action plans

To ensure implementation ofactivities once they are planned

9

Weekly Cash flow statement(available)

To guide expenditure decisions To ensure flow of financial

information to management

members this hitherto is not the

case.

Help in Management decision

making.

To help prevent financialmalpractices

10

Quarterly Financial Analysis

To determine financial viability and

monitor budget performance.

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

11 Equipment Replacement

Policy Financial Analysis

Statement (Half Yearly)

To ensure that broken down

equipment are replaced so as not

interrupted service delivery

To ensure regular replacement of

obsolete equipment and ensure

financial analysis is done replacing

the Obsolete equipment

12 Planned Preventive

Maintenance Schedule of

Equipment and Building

(Prop. Implemented)

Maintenance culture is a big problem in

our institutions. Everything has to be

done to ensure that equipment and

buildings are maintained

To inculcate Maintenance culture in

our Institutions and ensure that

equipment and building do not

deteriorate beyond repairs.


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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.


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CHAPTER TWO- PERFORMANCE

Table 2.1 Performance of the Hospitals by the Thematic Areas of the Checklist

Hosp Env Hosp IPC Hosp Emer Hosp QA Hosp

Clinical

Practice Hosp

Client

Care Hosp OH&S Hosp MGT

St. Anthony 92.42 Sogakofe

100.0

0 Peki

100.0

0 St. Anthony 97.37 Sogakofe 92.86 St. Anthony 100.00 Peki 98.50 Ho Mun 95.70

Sogakofe 90.91 Ketu South 94.44 Worawora

100.0

0 Akatsi 96.50 Peki 86.60 Ho Mun 100.00 Abor 95.60

Ketu

South 94.93Dodi

Papase 90.90 Akatsi 93.30 Ho Mun 94.30 Peki 93.00 Adidome 82.14 Akatsi 96.70 St. Anthony 94.12 St. Joseph 93.91

Peki 89.40 Abor 93.10

Dodi

Papase 94.30 Ketu South 92.11 Abor 81.30 St. Joseph 96.67 Worawora 94.12 Adidome 92.03

Anfoega 84.85

St.

Anthony 90.28 Ketu South 94.29 Sogakofe 88.60 Battor 80.40 Keta 93.33 Keta 92.65 Keta 92.03

Abor 84.80 Ho Mun 87.50 Hohoe 94.29 Keta 87.72 Krachi 79.46 Peki 93.30 Akatsi 89.70 Akatsi 90.60

Keta 78.79 St. Joseph 87.50 St. Anthony 92.86 Ho Mun 80.70 Anfoega 73.21

Dodi

Papase 93.30 Sogakofe 83.82 Peki 89.90

Ho Mun 77.30 Krachi 87.50 MMCH 90.00 Worawora 77.60 Ho Mun 71.40 MMCH 93.30 Ketu South 83.82 Abor 89.10

Battor 77.30 MMCH 86.10 Abor 85.70 Nkwanta 76.32 St. Anthony 70.54 Anfoega 90.00 St. Joseph 82.35

Dodi

Papase 87.00

Adidome 77.27 Hohoe 83.33 St. Joseph 78.57 Krachi 74.56 Ketu South 70.54 Abor 86.70 Hohoe 80.88 Sogakofe 86.96

Hohoe 75.76 Peki 83.30 Krachi 78.57 St. Joseph 72.81 Hohoe 69.64 Battor 86.70 Krachi 80.88

St.

Anthony 85.51

Ketu South 74.24 Adidome 81.94 Sogakofe 75.71 Hohoe 69.30 Nkwanta 69.64 Hohoe 86.67

Dodi

Papase 79.40 MMCH 85.50

Akatsi 74.20

Dodi

Papase 80.60 Jasikan 74.30 Abor 68.40 Keta 67.86 Sogakofe 83.33

Ho

Municipal 73.50

Worawor

a 82.61

VRH 71.21 VRH 80.56 Anfoega 72.86

Dodi

Papase 65.80 St. Joseph 66.96 Adidome 80.00 Jasikan 73.50 Battor 72.50

MMCH 71.20 Battor 79.20 Akatsi 68.60 Jasikan 64.90

Dodi

Papase 66.10 Jasikan 76.70 MMCH 70.60 Jasikan 71.70

Jasikan 71.2 Nkwanta 79.17 Keta 67.14 Anfoega 64.04 VRH 65.18 Ketu South 76.67 VRH 70.59 VRH 70.29

Ho Poly 71.20 Jasikan 77.80 Nkwanta 64.29 MMCH 61.40 Jasikan 62.50 Krachi 63.33 Anfoega 69.12 Krachi 64.49


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Comboni 60.61 Keta 77.78 Battor 62.90 Comboni 58.77 Comboni 60.71 Worawora 60.00 Adidome 67.65 Hohoe 59.71

St. Joseph 59.09 Worawora 76.39 Comboni 50.00 Adidome 57.02 Akatsi 60.70 Ho Poly 46.70 Battor 66.20 Anfoega 48.55

Worawora 59.09 Comboni 63.89 Ho Poly 50.00 Battor 51.80 Worawora 57.14 VRH 36.67 Comboni 48.53 Comboni 46.38

Krachi 57.58 Ho Poly 62.50 Adidome 35.71 VRH 48.25 MMCH 57.10 Comboni 36.67 Ho Poly 41.20 Nkwanta 42.03

Nkwanta 50.00 Anfoega 56.94 VRH 30.00 Ho Poly 44.70 Ho Poly 42.90 Nkwanta 30.00 Nkwanta 35.29 Ho Poly 41.30


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Table 2.1.Performance of the Hospitals by the Thematic Areas of the Checklist (contn)

Hosp RDHS Score Hosp 2nd Round Total Hosp 1st Round Total Hosp

% Change in

Performance

Hohoe 100.00 Peki 94.80 Peki 87.40 St. Anthony 62.77

Krachi 96.67 St. Anthony 91.80 Ketu South 79.20 Worawora 61.37

Ketu South 93.33 Sogakofe 91.34 Abor 78.90 Krachi 51.28

Jasikan 88.00 Ketu South 90.45 Sogakofe 77.20 Adidome 37.49

Abor 86.70 Abor 88.40 Dodi Papase 75.40 Keta 31.61

Akatsi 86.70 Akatsi 87.30 Ho Mun 74.60 Akatsi 30.30

Worawora 83.33 Ho Mun 87.20 St. Joseph 71.90 Ho Poly 23.78

Adidome 83.33 Keta 84.63 Jasikan 70.80 MMCH 20.59

Peki 80.00 Dodi Papase 83.40 Hohoe 67.30 Anfoega 20.12

Dodi Papase 80.00 St. Joseph 82.33 Akatsi 67.00 Battor 18.62

Battor 76.70 Worawora 80.20 Comboni 65.50 Sogakofe 18.32

St. Anthony 75.33 Hohoe 78.57 MMCH 64.60 Ho Mun 16.89

St. Joseph 73.33 Krachi 77.91 Keta 64.30 Hohoe 16.74

Anfoega 73.33 MMCH 77.90 Nkwanta 62.60 St. Joseph 14.50

MMCH 73.30 Adidome 76.72 Battor 62.30 Ketu South 14.20

Ho Mun 66.70 Jasikan 75.60 VRH 61.40 Abor 12.04

Ho Poly 66.70 Battor 73.90 Anfoega 57.90 Dodi Papase 10.61

Sogakofe 66.67 Anfoega 69.55 St. Anthony 56.40 Peki 8.47

Keta 60.00 VRH 62.99 Adidome 55.80 Jasikan 6.78

Nkwanta 46.67 Nkwanta 60.45 Krachi 51.50 VRH 2.58

VRH 40.00 Comboni 55.52 Worawora 49.70 Nkwanta -3.44

Comboni 26.67 Ho Poly 53.10 Ho Poly 42.90 Comboni -15.23


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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 variousthematic areas.

Table 2.2: Paired Differences in the Performance of Hospitals in the Thematic Areas

Performance/Th

ematic Area

Cycles

%

Change

Mean

difference

in

performa

nce

t-

value

Degree

of

freedom

Sig. Value of t-

Test(=0.05)

2nd Cycle

Mean

1st Cycle

Mean

Environment 77.5 62.04 24.9 11.89 3.50 21 0.002

IPC 83.7 71.78 16.6 8.22 3.23 21 0.004

Emergency 67.3 66.66 1 11.75 2.02 21 0.056

QA 72.7 64.9 12 9.62 2.19 21 0.040

Clinical Practice 70.5 N/A N/A 72.33 32.16 21 0.000

Client Care 77.0 56.6 36 21.72 4.21 21 0.000

OH&S 75.6 N/A N/A 77.49 25.15 21 0.000

Management 79.8 70.69 12.9 8.63 2.40 21 0.026

RDHS 69.1 N/A N/A 73.72 19.15 21 0.000

Overall 78.6 65.46 20.1 12.72 5.84 21 0.000

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.


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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 ReviewMean

Std.

Deviation

Std. Error

Mean

Skewness

2nd

Cycle Environment 74.52 11.82 2.52 -0.30

1

st

Cycle Environment 62.63 16.30 3.47 -0.02

2nd

Cycle Infection Prevention & Control 81.96 10.54 2.25 -0.78

1st

Cycle Infection Prevention & Control 73.75 14.35 3.06 -0.36

2nd

Cycle Emergency Services & Systems 76.14 18.61 3.97 -1.14

1st

Cycle Emergency Services & Systems 64.39 21.60 4.60 -0.24

2nd

Cycle Quality Assurance 76.43 13.66 2.91 -0.25

1st

Cycle Quality Assurance 66.81 17.36 3.70 -0.40

2n

Cycle Clinical Practices 72.33 10.55 2.25 0.52

1st

Cycle Clinical Practices 0.00 0.00 0.00 -.

2nd

Cycle Client Care practices 77.89 20.75 4.42 -1.23

1st

Cycle Client Care practices 56.17 21.51 4.59 0.35

2nd

Cycle Occupational Health & Safety 77.49 14.45 3.08 -1.43

1st

Cycle Occupational Health & Safety 0.00 0.00 0.00 -.

2nd

Cycle Management 78.02 16.60 3.54 -0.99

1st

Cycle Management 69.40 15.01 3.20 0.07

2n

Regional Director of Health Services 73.72 18.05 3.85 -1.05

1st

Regional Director of Health Services 0.00 0.00 0.00 -.

2n

Cycle Overall Performance 78.37 11.82 2.52 -0.78


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1st

Cycle Overall Performance 65.65 10.85 2.31 -0.10

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 Samples Test

Paired Differences

t dfSig. (2-

tailed)MeanStd.

Deviation

Std.

Error

Mean

95% Confidence

Interval of the

Difference

Lower Upper

Pair 1 Environment 2 - Environment1 11.89 15.94 3.40 4.82 18.96 3.50 21 0.002

Pair 2 IPC2 - IPC1 8.22 11.93 2.54 2.93 13.50 3.23 21 0.004

Pair 3 Emergency2 Emergency1 11.75 27.27 5.81 -0.34 23.84 2.02 21 0.056

Pair 4 QA2 - QA1 9.62 20.58 4.39 0.50 18.75 2.19 21 0.040

Pair 5 Clinical Practice2 - Clinical Practice1 72.33 10.55 2.25 67.65 77.01 32.16 21 0.000

Pair 6 Client Care2 Client Care1 21.72 24.20 5.16 10.99 32.45 4.21 21 0.000

Pair 7 OHS2 - OHS1 77.49 14.45 3.08 71.08 83.90 25.15 21 0.000

Pair 8 Management2 Management1 8.63 16.87 3.60 1.15 16.11 2.40 21 0.026

Pair 9 RDHS2 - RDHS1 73.72 18.05 3.85 65.71 81.72 19.15 21 0.000

Pair 10 Overall2 - Overall1 12.72 10.22 2.18 8.19 17.25 5.84 21 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 Correlation Sig.

Pair 1 Environment1 & Environment2 22 0.39 0.071

Pair 2 IPC1 & IPC2 22 0.58 0.005

Pair 3 Emer1 & Emer2 22 0.09 0.704

Pair 4 QA1 & QA2 22 0.14 0.545


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Pair 5 Client1 & Client2 22 0.34 0.116

Pair 6 Mgt1 & Mgt2 22 0.43 0.044

Pair 7 Over1 & Over2 22 0.60 0.003

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

Performance

Areas

CHAG GHS

2nd Cycle

Mean

1st Cycle

Mean

%

Change

2nd Cycle

Mean

1st Cycle

Mean

%

Change

Environment 77.65 67.3 15.38 72.72 59.96 21.28

IPC 79.7 72.35 10.16 83.25 74.54 11.69

Emergency 79.66 69.44 14.72 74.13 61.51 20.52

QA 75.92 72.18 5.18 76.73 63.74 20.38

Clinical Practice 72.7 N/A N/A 72.12 N/A N/A

Client Care 83.71 51.50 62.54 74.57 58.84 26.73

OH&S 77.21 N/A N/A 77.64 N/A N/A

Management 76.61 68.08 12.53 78.83 70.15 12.37

RDHS 70.46 N/A N/A 75.58 N/A N/A

Overall 76.14 66.21 15.00 79.67 65.32 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 EffectsDependent Variable: Second Cycle Overall Performance

Source

Type III Sum of

Squares Df

Mean

Square F Sig.

Partial Eta

Squared

Model 136236.675 3 45412.225 477.773 0.0000 0.9869

First cycle Overall

Performance1065.061 1 1065.061 11.205 0.0034 0.3710

Ownership of Facility 797.184 2 398.592 4.194 0.0310 0.3062

Error 1805.946 19 95.050

Total 138042.621 22

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

Performance Areas

Southern Zone Northern Zone

2nd Cycle

Mean

1st Cycle

Mean

%

Change

2nd Cycle

Mean

1st Cycle

Mean

%

Change

Environment 77.5 62.04 24.9 70.9 63.33 12.0

IPC 83.7 71.78 16.6 79.9 76.93 3.9

Emergency 67.3 66.66 1.0 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 Type III Sum

of Squares df Mean Square F Sig.

Partial Eta

Squared

Corrected

Model

1043.457a 2 521.728 5.246 .015 .356

Intercept 673.126 1 673.126 6.768 .018 .263

Overall 1st

cycle 1015.191 1 1015.191 10.207 .005 .349

Zonal Location .841 1 .841 .008 .928 .000

Error 1889.730 19 99.459Total 138042.621 22

Corrected Total 2933.186 21

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 locationof 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

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 table2.10 below.

Table 2.10 Comparing Peer Review Performance and Post Peer Review Performances

Paired Samples Statistics (n=22)

Thematic Areas Mean Std. Deviation Std. Error Mean

Pair 1 Environment Post Peer Review 49.20 19.51 4.16

Environment Peer Review 74.52 11.82 2.52

Pair 2 Infection Prevention & Control Post Peer Review 51.82 19.83 4.23

Infection Prevention & Control Peer Review 81.96 10.54 2.25

Pair 3 Emergency System Post Peer Review 36.36 34.72 7.40

Emergency System Peer Review 75.20 20.25 4.32

Pair 4 Quality Assurance Post Peer Review 39.02 28.68 6.12

Quality Assurance Peer Review 72.35 15.65 3.34

Pair 5 Clinical Practices Post Peer Review 63.64 25.01 5.33

Clinical Practices Peer Review 69.77 11.19 2.39

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

100.0 89.4

74.2

57.6 57.6 54.5 51.5 51.5 48.5 48.543.9 42.4

34.8 33.3 33.3 31.8 30.3 28.8 25.8 25.8 24.2

57.6

25.8

44.1

78.6

91.3

82.387.3

91.8

63.0

87.2 88.4

77.9 77.983.4

73.9

90.5

75.6

84.680.2

76.7

60.5

69.6

55.5

94.8

53.1

78.4

POST PEER REVIEW AND PEER REVIEW PERFORMANCE COMPARED

Overall PPR Overal PR


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Pair 6 Client Care Post Peer Review 35.60 26.87 5.73

Client Care Peer Review 77.58 22.09 4.71

Pair 7 Occupational Health & Safety Post Peer Review 24.55 24.64 5.25

Occupational Health & Safety Peer Review 76.00 17.10 3.65

Pair 8 Management Post Peer Review 40.91 30.75 6.55

Management Peer Review 76.49 18.35 3.91

Pair 9 Overall Post Peer Review 44.15 16.99 3.62

Overall Peer Review 78.36 11.82 2.52

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 N Correlation Sig.

Pair 1 Environment Post Peer Review & Environment Peer Review 22 0.356 0.104

Pair 2 Infection Prevention & Control Post Peer Review & Infection

Prevention & Control Peer Review

22 0.500 0.018

Pair 3 Emergency systems Post Peer Review & Emergency System

Peer Review

22 0.535 0.010

Pair 4 Quality Assurance Post Peer Review & Quality Assurance Peer

Review

22 0.114 0.615

Pair 5 Clinical Practices Post Peer Review & Clinical Practices Peer

Review

22 0.417 0.054

Pair 6 Client Care Post Peer Review & Client Care Peer Review 22 0.157 0.486

Pair 7 Occupational Health and safety Post Peer Review &

Occupational Health and safety Peer Review

22 0.324 0.141

Pair 8 Management Post Peer Review & Management Peer Review 22 0.241 0.280

Pair 9 Overall Post Peer Review & Overall Peer Review 22 0.520 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


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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

Thematic Areas of the Peer

Review

Paired Differences

T df

Sig. (2-

tailed)Mean

Std.

Deviation

Std. Error

Mean

95% Confidence

Interval of the

Difference

Lower Upper

Pair 1 Environment Post Peer

Review & Environment

Peer Review

-25.32 18.87 4.02 -33.69 -16.95 -6.29 21 0.000

Pair 2 Infection Prevention &

Control Post Peer Review

& Infection Prevention &

Control Peer Review

-30.14 17.18 3.66 -37.76 -22.52 -8.23 21 0.000

Pair 3 Emergency systems Post

Peer Review &

Emergency System Peer

Review

-38.84 29.37 6.26 -51.86 -25.81 -6.20 21 0.000

Pair 4 Quality Assurance Post

Peer Review & Quality

Assurance Peer Review

-33.33 31.07 6.62 -47.11 -19.56 -5.03 21 0.000

Pair 5 Clinical Practices Post

Peer Review & Clinical

Practices Peer Review-6.13 22.74 4.85 -16.21 3.95 -1.26 21

0.220

Pair 6 Client Care Post Peer

Review & Client Care

Peer Review-41.97 32.00 6.82 -56.16 -27.79 -6.15 21

0.000

Pair 7 Occupational Health and

safety Post Peer Review

& Occupational Health

and safety Peer Review-51.46 25.02 5.33 -62.55 -40.36 -9.65 21 0.000

Pair 8 Management Post Peer

Review & Management

Peer Review

-35.58 31.78 6.77 -49.67 -21.49 -5.25 21 0.000

Pair 9 Overall Post Peer Review

& Overall Peer Review-34.22 14.82 3.16 -40.79 -27.64 -10.83 21 0.000

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

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%.

0.0

10.020.0

30.0

40.0

50.060.0

70.0

80.0

90.0

100.094.8 91.3 90.4 87.3 87.2 84.6

80.2 78.6 77.9 76.7 75.6

63.0

60.453.1

88.087.4

77.2 79.2

6774.6

64.3

49.7

67.3

51.555.8

70.8

61.4 62.2

42.9

71.3

2nd Round 1st Round

0.0

20.0

40.0

60.0

80.0

100.0 89.4

74.2

57.651.5 51.5

43.933.3 33.3 31.8 30.3 28.8 25.8

57.6

25.8

45.4

78.691.3 87.3

63.0

87.277.9

90.5

75.684.6 80.2 76.7

60.5

94.8

53.1

78.7

GHS FACILITIES PPR AND PR PERFORMANCE

COMPARED

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

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:

0.0

20.0

40.0

60.0

80.0

100.0

St.

Anthony

Abor Papase St.

Joseph

MMCH Battor Anfoega Comboni Mean

91.8 88.483.4 82.3

77.973.9

69.6

55.5

84.8

56.4

78.9 75.4 71.964.6 62.3

57.965.5 69.4

2nd Round 1st Round

0.0

20.0

40.0

60.0

80.0

100.0

St.

Joseph

St.

Anthony

Abor MMCH Dodi

Papase

Battor Anfoega Comboni Mean

57.6 54.548.5 48.5

42.434.8

25.8 24.2

42.0

82.3

91.8 88.4

77.983.4

73.969.6

55.5

77.9

CHAG FACILITIES PPR AND PR PERFORMANCECOMPARED

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

Hospital 2nd Round 1st Round % Change2nd Round

Position1st RoundPosition

Peki 94.8 87.4 8.5 1st 1st

St. Anthony 91.8 56.4 62.8 2nd

18th

Sogakofe 91.3 77.2 18.3 3rd

4th

Ketu South 90.4 79.2 14.2 4th 2nd

Abor 88.4 78.9 12.0 5th

3rd

Akatsi 87.3 67 30.3 6th

10th

Ho Municipal 87.2 74.6 16.9 7th 6th

Keta 84.6 64.3 31.6 8th

13th

Papase 83.4 75.4 10.6 9th 5th

St. Joseph 82.3 71.9 14.5 10th

7th

Worawora 80.2 49.7 61.4 11th

21st

Hohoe 78.6 67.3 16.7 12th 9th

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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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 1st

Cycle State of External Environment during 1st

Cycle

Renovated Conference in Hohoe Mun. Hospital during 2nd

Cycle State of Environment during 2nd

cycle

Peki Recreational centre during 1st

cycle


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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 theMinistry 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. TheTable 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

Hand washing Orderlies Nurses

Medical

Officer/Assistant

Laboratory

Staff

Pharmacy

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-PurposeIncinerators 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 PracticesOne 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 inHohoe 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 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 wereable to meet the Regional Directors performance target

2. All the thematic areas on the Checklist indicated great improvement over the first cycleperformance.

3. Team approach to work has been strengthened through the Peer Review since everybody in thefacilities 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 extentthrough 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 availabilityof basic equipment and drugs for service delivery.

3.2 RECOMMENDATIONS

1. Evaluation of the Peer ReviewIn 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 ReviewIn other to ensure that the current momentum is sustained, there was the need to incorporateactivities 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 containDue 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 2007-20112. Peer Review of Hospitals in the Volta Region, December 2010


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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 thereforetakes this into consideration in many respects.

ENVIRONMENT (EXTERNAL AND INTERNAL)

NO ITEM RATIONALE HOW TO SCORE EXPECTED

SCORE

OVE

SCO

(afte

dedu

IDEAL(EXPECTED) SITUATION EXISTING OR ON THE GROUND SITUATION

1. EXTERNAL

ENVIRONMENT

Therapy involves many facets including the impact of the environment on staff and patients satisfaction

1.a Grass Covering When properly done, it

is pleasing to the eye,

sets the mind of staff

and clients at ease,

easily rates the

institution as a readyentity to deliver the

care necessary

- 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)

Flowers by themselves

give a lot of healing

-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)

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

3


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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

-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

-Non-availability give overall score of 0

-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

4

INTERNAL

ENVIRONMENT

A sanitized internal Environment gives staff and the clients the needed confidence and easy mobility and safety

1.2a Staff Toilet 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

-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

4

1.2c Client Toilet To provide speed and

comfort in attending to

natures call

-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

-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


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fragrance)

-Waste Paper bin (not to be used

for anal droppings

deduct 0.5

1.2d State of

Infrastructure

To provide safety for

staff & clients and

aesthetic beauty

-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)

-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

4

1.2e Working Areas Should not pose danger

to both clients and staff

-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

-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

6

1.2f Waste Bins in

Offices

To prevent littering of

the Environment

-Available in every office

-Pedal operated

-Pedals are functioning

-If not Available in some offices deduct 0.5

-Not Pedal operated deduct 0.5

-Pedals not functioning deduct 0.5

2


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-Should have a black liner in -No black liner in the waste bins deduct 0.5

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

-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

INFECTION PREVENTION AND CONTROLNO ITEM RATIONALE HOW TO SCORE EXPECTED

SCORE

OVERA

SCORE

(after

deduc


I INFECTION

PREVENTION AND

CONTROL

i. To prevent danger of infection posed to clients and staff.ii. To reduce longer stay of clients through infection

I .1 DecontaminationProcedure To remove microorganisms likely to be transmitted.

I.1a Use of Chlorinebased Disinfectant

(Chlorine

disintegrates rapidly,

Should not be left

overnight)!

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

-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

I.1b Written Protocol

for Preparation of

appropriate

Chlorine solution

(Available at all

user units,

conspicuously

displayed)

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

-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

3

I.2 HAND WASHINGPRACTICES

To decontaminate the hand in order to prevent cross infection

I.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 handwashing before

allotting marks.)

i. Orderly

ii. Nurse

iii. Medical Officer

and Medical

Assistant

iv. Laboratory

Personnel

v. Pharmacy Staff

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)


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I.3 WASTE DISPOSAL To remove source of infection and prevent wrongful deposition of rubbish in and around client areas as an eyesore

I.3a Dry/Solid Waste

Disposal

To prevent infection -Availability of Multipurpose

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

Pit, Burning pit and Incinerator for

sharp

-If No incinerator deduct 3

-If no Burning pit deduct 3

-If no Placenta pit deduct 3

9

3

3

3

I.3b Wet/Liquid Waste

Disposal

To have liquid waste properly disposed to avoid the danger it will pose to both staff and clients

Soak-Away

(available to

collect soiled

water from

maternity &

Theatre,

Functional)

To have liquid waste

properly disposed to

avoid the danger it will

pose to both staff and

clients

-Available

-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

3

I.3c Drains condition

(not broken down,free of rubbish and

weeds, no static

collections of

water


properly disposed toavoid the danger it will


clients

Drains condition -not broken

down, - free of rubbish and weeds,-no static collections of water

-Not silted

-No fungal growth

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

3

I.3d Septic Tanks

condition

(Functional, easily

accessible by

truck, not weedy)


properly disposed to

avoid the danger it will


clients

-Available

-Well sealed

-No water collected around it

-Easily accessible

-Surrounding not weedy

-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

3


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-Surrounding weedy deduct 0.5

EMERGENCY SERVICES AND SYSTEMS

NO ITEM RATIONALE HOW TO SCORE EXPECTED

SCORE

OVER

SCOR

(afte

dedu


II EMERGENCY

SERVICES

Hospitals receive individual (single) cases and large number of cases needing emergency services. It is ideal that systems are built t

take care of both category of casesII.1 System for

Emergency

To ensure there is a

system to manage

emergency situations

-Emergency duty roster found in all

Units covering all the categories in

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

sent outlined

-flow of what happens to the

emergency case after received in a

flow diagram outlined

Duty roster for any team category not

available deduct 0.5

-No clearly defined line of who calls the

team deduct 0.5

-No outline of where emergency cases are

to be sent 0.5

-No flow diagram outlining what happens

to emergency cases deduct 0.5

5

II.2 Emergency Trays

(availability and

adequacy)

To ensure basic

equipment and drugs

available to enhance

management of

emergencies.

-Emergency Trays

(availability and adequacy)

-emergency tray in all

wards, triage and a

designated emergency

room

-minimum content of

Emergency Tray not available in

all expected units, give overall

score of zero

-emergency tray not in an

expected unit or ward, triage and

a designated emergency room

deduct 1.0 each

-minimum content of emergency tray

20


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emergency tray

*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)

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

*Flashli

Peer Review Monitoring

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