April 2012
Improvement Series
African Partnerships for Patient Safety Patient Safety Situational Analysis
(Long Form)
A series of APPS resources have been co-developed and utilised by the first wave of hospital partnerships participating in the APPS programme. Although focused on a partnership model, these resources can be useful to any hospital committed to creating safer health care for patients. These resources may also be of utility to decision makers involved in planning for patient safety.
WHO/IER/PSP/2012.4
© World Health Organization 2012
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The mention of specific resources does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned.
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However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use.
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Overview
Once areas of interest and/or focus have been identified with the "Patient Safety Situational Analysis Short Form" this "Long Form" can be used to gather detailed information on key patient safety areas
Simple enough to allow efficient and effective collection of information on a range of areas relevant to patient safety in an African hospital
Provides a structured method of undertaking a needs assessment or gap analysis, and at the same time enables strengths to be identified
Not intended to be a formal research tool, but to facilitate collection of detailed information which will serve as a baseline and can be easily reviewed and analysed
Information gained from the short and long form can be combined to serve as a robust data foundation for patient safety action planning at the hospital
Who is this for?
Any individual or hospital team that seeks to gain an understanding of the patient safety situation in their institution.
What is the purpose?
To assist hospitals in the gathering of detailed information to provide a patient safety snapshot, building on the findings from the rapid utilization of the "Patient Safety Situational Analysis Short Form".
What is the structure?
The long form has three parts.
The first part addresses key steps in information collection (page 4).
The second part is related to general information on the hospital (page 5-6).
The third part consists of a series of questions based around 12 key patient safety action areas (page 7-33).
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Part 1: Information Collection - Key Steps
Identify key individuals within the hospital with an interest in patient safety
These individuals should cover a range of professions and departments
Identify at least one senior leader who can act as a patient safety champion in the hospital
Identify an information gathering coordinator responsible for the overall coordination of information collation
Form a core hospital patient safety team consisting of the key individuals above
There may already be a team comprised of these individuals whose purpose is quality and/or infection prevention
Where possible make use of existing teams/groups/meetings to minimize the time burden on clinical teams
Arrange core team meetings to share findings from the rapid patient safety situational analysis conducted using the "Short form"
Secure senior hospital decision maker support on undertaking a detailed patient safety situational analysis
Introduce colleagues to the "Patient Safety Situational Analysis Long Form", and explain how information will be collected and how results will be utilized for action planning
Decide on a list of key individuals within the hospital that need to be consulted in order for information to be collected
Ensure that the information gathering coordinator keeps a log of information sources, and that wherever possible there is cross-checking of information
Utilize existing reports or previous data collection exercises to feed into the findings of the situational analysis
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Official Hospital Name Name of Information Collection Coordinator
Type of hospital (circle
appropriate response) General Teaching Private
District Tertiary
Number
of beds Annual admissions Population in catchment
area Departments (please circle as
appropriate) Internal Medicine Surgery Intensive care
Emergency Obstetrics Gynaecology
Paediatrics Pharmacy Radiology
Maternity Laboratory Other (list below)
Total number of health-
care providers Total number of
managers or administrators
Total number of hospital staff/ employees
Total number of doctors Total number of trained infection control doctors
Annual number of medical students
Total number of nurses Total number of trained infection control nurses
Annual number of nursing students
Total number of care staff
or auxiliary staff Total number of
laboratory staff or scientists
Total number of
microbiology scientists or technicians
Total number of
pharmacists Total number of
pharmacy technicians Total number of cleaning staff
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Hospital General Information (continued)
Yes No NA
1. Is there a clean supply of running water? If no, provide further details, particularly the source of the problem and ways this is being addressed.
2. Is there a reliable supply of running water? If no, provide further details on the source of the problem and practical options available.
3. Does the structure of the building protect patients and staff from common weather events? If no, provide details below.
4. Is the electricity supply reliable? If no, describe the frequency of problems and practical options available.
5. Is there a reliable telephone system within the hospital? If no, provide details below.
6. Is there a reliable access to the internet/emails within the hospital? If no, provide details below.
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Twelve key areas for patient safety action have been identified by the WHO African Regional Office (AFRO) in a technical paper presented at the 2008 WHO AFRO Regional Committee Meeting.1 The technical paper was endorsed by each of the 46 countries in the African Region and is thus used as a starting point. Core questions are defined in each of the twelve key areas, aiming to collect essential information in each specific area. The twelve action areas are presented in the table below.
1.
Patient safety and health services & systems development
Pages 8-92.
National patient safety policy
Pages 10-113.
Knowledge and learning in patient safety
Pages 12-13 4.Patient safety awareness raising
Pages 14-15 5.Healthcare-associated infections
Pages 16-196.
Health worker protection
Pages 20-217.
Health-care waste management
Pages 22-238.
Safe surgical care
Pages 24-259.
Medication safety
Pages 26-2710
Patient safety partnerships
Pages 28-2911.
Patient safety funding
Pages 30-3112.
Patient safety surveillance and research
Pages 32-33
1 Patient Safety in African Health Services: Issues and Solutions, Report of the Regional
Director to the 58th WHO AFRO Regional Committee, September 2008. Yaoundé, Cameroon.
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I. Patient Safety and Health Services/Systems Development
Yes No NA 1. Is there a long term strategic plan for the hospital? If yes, provide further
information below - how was it developed; when will it be renewed; who is responsible; does it include patient safety improvement?
2. Is there an annual hospital plan? If yes, provide further information below - how was it developed; when will it be renewed; who is responsible; does it include patient safety improvement?.
3. Is there a hospital organizational chart? If yes, obtain a copy.
4. Was there a detailed inventory of all hospital items completed in the last year?
If no, state the year in which the last inventory was conducted below.
5. Is there a reliable procurement process for obtaining necessary health-care supplies and materials? If no, provide details of the key problems in relation to procurement below.
6. Is each patient encounter recorded in a medical record? Describe how the patient records system is organized and highlight any key challenges below.
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7. Are computers used for managing patient information? If yes, provide details below.
8. Are there currently any hospital programs that promote quality improvement?
If yes, provide details below and describe the impact of the program.
9. Has there been any attempt to assess organizational culture? If yes provide details of the assessment below and whether it was perceived as useful by staff.
10. Is there a hospital supervision system? If yes, describe below.
Provide any important information relevant to this section that has not been mentioned above.
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II. National Policy on Patient Safety
Yes No NA 1. Is there a national committee or board that is responsible for patient safety or
quality improvement policy making? If yes, provide details below.
2. Is there a national regulatory agency that monitors implementation of patient safety policies? If yes, provide details below.
3. Is the Hospital Director (or equivalent leader) aware of any national policies on patient safety issues (examples include hospital hygiene or any other patient safety issue covered in this guide)? If yes, provide details below.
4. Do hospital staff participate in any health policy making forums outside the hospital (national, sub-national, local)? If yes, provide details below.
5. Have any guidelines related to patient safety been utilized for hospital policy formation? If yes, provide details below.
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6. Has the hospital participated in implementation of specific national patient safety policies? If yes, provide details below and collect available documentation.
7. Are there any examples of patient safety findings within your hospital influencing national patient safety policy? If yes, provide details below and collect any available documentation.
8. Are there any mechanisms in place to discuss coordination of service delivery with other hospitals and health facilities? If yes, provide details below (including how often these meeting occur and whether these are hosted by the government).
Provide any important information relevant to this section that has not been mentioned above.
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III Knowledge and Learning in Patient Safety
Yes No NA 1. Is there a continuing medical education program within the hospital for
doctors? If yes, provide details below, including whether attendance is mandatory and documented.
2. Is there continuing education within the hospital for nurses? If yes, provide details below, including whether attendance is mandatory and documented.
3. Is there a hospital training plan? If yes, provide details below, including who is responsible and budget details.
4. Is there a system of clinical audit in any department? If yes, describe below.
5. Is there a system for recording adverse events (an adverse event can be defined as any injury caused by medical care)? If yes, provide details below, including how findings are reviewed.
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6. Is there a system for providing feed back on adverse events and errors?
If yes, provide details (including who the information is fed back to; how the information is fed back; and whether any protocols are in place).
7. Are specific protocols on patient care utilized in the hospital? If yes, provide details of how these are used below.
8. Are checklists used for any procedures in the hospital? If yes, provide details.
9. Is there a multi-disciplinary review of events leading to in-patient mortality?
If yes, provide details of the system (frequency, information use, etc)..
10. Do links exist between the hospital and any external training institutions?
If yes, provide details below.
Provide any important information relevant to this section that has not been mentioned above.
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IV Patient Safety Awareness Raising
Yes No NA 1. Does a Patients' Rights Declaration or Charter exist? If yes, provide details.
2. In the last year, has the hospital participated in any community focused activities to raise awareness on patient safety? If yes, provide details below.
3. Are there any mechanisms within the hospital to inform patients of their rights (e.g. leaflets, posters)? If yes, provide details below
4. Are there any mechanisms in place to sensitize hospital staff on the importance of patient safety issues? If yes, provide details below.
5. Are there any mechanisms in place to sensitize health professionals on the necessity and means through which patients and the community can be engaged on patient safety issues? If yes, provide details below.
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6. Is there a system in place (forms and protocols) for obtaining patient’s consent before procedures? If yes, provide details below.
7. Are there any mechanisms in place for informing patients and families about patient safety? If yes, provide details below.
8. Is there a mechanism in place for patients to report patient safety issues to the hospital? If yes, provide details (including whether there are any specific forms and who is responsible for collecting and collating the information).
9. Are there any mechanisms in place for patients and health-care professionals to share ideas and concerns related to patient safety? If yes, provide details (including the nature of exchange and how this is documented and followed up).
10. Does the hospital have any links with civil society and the community that can be utilized for raising awareness on patient safety? If yes, provide details.
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V Healthcare-Associated Infections
This section is more detailed than others, as health care-associated infections is the common platform of work for each hospital working with African Partnerships for Patient Safety (APPS).
Yes No NA 1. Structures and mechanisms for infection prevention and control (IPC)
leadership in the hospital
a Is there a person leading/coordinating IPC activity? If yes, provide name and designation in the space below:
b Is there a multidisciplinary IPC team/ committee? If yes, provide details of the composition below (and include whether this is based on hospital based thinking, national regulation or international guidelines)
c Are the responsibilities of the team/committee clearly defined?
d Are the strategies and goals of IPC defined?
e Is the IPC team represented on relevant hospital wide bodies/committees?
2. Human resources availability
a Is there a full time doctor/nurse designated for hospital IPC activities?
b Are job descriptions for each individual in the IPC team clearly documented?
c Is there a clear chain of command within the IPC team? Provide details.
d Are there individuals involved full time in IPC activities?
e Does the IPC team have infection control training? If yes, provide details
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3. Do written hospital policies or guidelines exist for the following:
a Hand hygiene
b Disinfection and sterilization
c General infection prevention and control d Isolation policies
e Aseptic practices related to patient care f Safe injection practices
g Sharp disposal h Outbreak management
i Triaging patients with high risk of rapid infectious disease transmission
j Equipment/instrument reuse k Antibiotic use
l Standard precautions m Respiratory infections
4. Is there a method in place to assess compliance to guidelines and provide feed back to health-care workers? If yes, provide details below (include any
mechanisms to collect data on compliance and any improvements recorded).
5. Is there a system in place for conducting health worker training on health care-associated infections? If yes, provide details below (include how regular, who is trained, key documentation used, and how this is updated).
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Yes No NA 6. Are there reminders (e.g. posters) on hand hygiene and other issues related to
infection prevention and control (IPC) in patient care areas? If yes, provide details below
7. Microbiology laboratory facilities
a. Is there a microbiology service on-site at the facility?
b. If yes, is there capacity for:
microscopy ? aerobic culture?
anaerobic culture?
susceptibility testing?
c. Is quality assurance practiced in the microbiology laboratory on a regular basis?
d. Does the service face any constraints which prevent it functioning effectively? If yes: provide details in the space below:
8. Capacity for surveillance related to infection prevention and control (IPC) a. Is there routine notification of infectious diseases to the national surveillance system?
If yes, is feedback received from the national surveillance system?
b. Is there any research based surveillance of infections?
c. Are health care-associated infection surveillance data available, for any time period?
d. Has the surveillance team been trained in the revised International Health Regulation (2005)?
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9. Supply structures for supporting IPC activity
a. Is there adequate reliable supply of soap throughout the hospital? If no, provide further details of key problems.
b. Is there an adequate reliable supply of single use paper towels throughout the hospital? If no, provide further details of key problems.
c. Is there an adequate reliable supply of alcohol based handrub throughout the hospital? If no, provide further details of key problems.
d. Is there a centralized sterile supply department for the hospital?
If yes, is there one person responsible for this department?
If yes, is the department located in a separated/limited access area?
If yes, is there an autoclave with adequate capacity for requirements?
e. Are quality control (QC) measures in place for equipment?
f. Do quality control (QC) tests routinely fail?
g. Is there a written protocol for changing, handling, and reusing bed linen?
10. Related to mechanisms for the containment of anti-microbial resistance:
a. Are there antibacterial medicine use policies and guidelines?
b. Are there policies for surgical prophylaxis?
c. Are there records of antibiotics dispensed?
d. Is AMR data available for any bacterium during the last year?
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VI. Health Worker Protection
Yes No NA 1. Is there a national policy on health worker protection?
2. Is there a high-level hospital policy or guidance document on health worker protection? If yes, provide details including how employees are informed of the hospital guidance.
3. Are necessary personal protection articles (clean gloves, aprons/gowns, masks, goggles) available for health worker use?
If yes, are the following actually used in practice?
clean gloves aprons/gowns Masks Goggles
Provide details of any specific constraints to their use below.
4. Is there a system in place to register and follow up accidents and injuries among health workers (e.g. needle/sharp injuries)?
5. Is there a protocol for post exposure prophylaxis for health workers in place?
6. Are all health workers (including trainees) immunized against Hepatitis B?
7. Is there a system in place to track excessive employee work hours? If yes, describe how “excessive work hours” are quantified and acted upon
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8. Is there adequate access to emergency treatment for health workers while working? If yes, provide details of how treatment is delivered below..
9. Are universal precautions followed in all departments at all times? If yes, provide details of the system below.
10. Is there a protocol in use to notify health workers when extra precautions are indicated? If yes, provide details below.
Provide any important information relevant to this section that has not been mentioned above.
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VII. Health-Care Waste Management
Yes No NA 1. Is there a national policy on health-care waste management?
2. Is there a high-level hospital policy or guidance document on health- care waste management? If yes, provide details below (include whether this document is based on WHO guidelines)
3. Are protocols for health-care waste management used in the hospital?
4. Are there adequate supplies/materials to collect all waste types (sharps; biohazard; infectious; toxic; chemical; radiation) at all generation points?
5. Are methods in place for final waste disposal for each of the following:
Infectious waste. If yes, describe in space below.
Plastic waste. If yes, describe in space below.
Sharps waste. If yes, describe in space below.
Food waste. If yes, describe in space below.
Domestic waste. If yes, describe in space below.
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6. Are there facilities for appropriate temporary storage of waste?
7. Are procedures regular used for pest eradication? If yes, provide details below.
8. Is there an environmental cleaning protocol (frequency, areas/items to be cleaned, products used for different situations, etc) that is communicated to cleaning & supervisory staff?
9. Are any single use items (catheters, gloves, syringes) reused?
10. Does the hospital provide any instructions for disposing 'patient produced waste' (needles, soiled wound dressings, outdated medications) at home?
Provide any further important information relevant to this section that has not been mentioned above.
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VIII Safe Surgical Care
Answer the first seven questions using numerical data.
Questions 8-10 are yes/no questions, followed by instructions to provide further details.
1. How many surgical procedures are performed in the hospital each year?
2. What percentage of the surgical procedures conducted in the hospital are:
Emergency cases1
Elective cases2
3. How many surgeons are in the hospital (include doctors and other licensed surgical providers)?
4. How many anesthesia providers are in the hospital (include doctors, nurses, and other licensed anesthesia providers)?
5. How many nurses work in the operating theatres?
6. How many operating rooms does the hospital have?
7. How many of the hospital operating rooms have functioning pulse oximeters available at all times?
1Emergency cases are procedures that must be completed within 24 hours of hospital admission in order to save life, limb, or functional capacity
2Elective surgery is a planned, non-emergency surgical procedure
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8. Is there a mechanism to record hospital deaths following surgery?
If yes, provide details below including how this data is used. .
9. Is there a mechanism to record complications resulting from surgery? If yes, provide details below including how this data is used.
.
10. Is anyone at the hospital aware of the WHO Safe Surgical Checklist? If yes, provide details below.
Provide any further important information relevant to this section that has not been mentioned above.
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IX Medication Safety
Yes No NA 1. Are there key policy documents on medication safety (national
policy, sub-national policy, hospital policy? If yes, provide details.
2. Is there a functioning hospital Drug and Therapeutics Committee or equivalent? If yes, provide details of composition and responsibilities (include whether this is based on international or national guidelines).
3. Is there a member of staff (or group) specifically responsible for medication safety? If yes, provide details below (include specific training and whether the role is well known to all hospital staff).
4. Is the drug procurement process effective? Provide details of the process below (include information on record keeping, quality assurance, storage, and drug promotion issues).
5. Is there a hospital medicine formulary? If yes, provide details of whether and how this is linked to a national list of essential medicines.
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6. Does the hospital pharmacist have a role other than dispensing medications? If yes, provide details (include responsibility for educating prescribers, ensuring steady supplies, information resources, and any other relevant areas).
7. Is there a clear process between prescribing & administering a medicine for an inpatient? If yes, provide details (include all steps between prescribing and patient finally receiving medication).
8. Is there a reporting system for adverse drug reactions and medication errors? If yes, describe the system below and include whether it is linked to a national or regional reporting system.
9. Are pharmacists’ advise documented in the patient record? If yes, describe whether this is routinely examined to improve the quality and safety of medication use by prescribers.
10. Are there mechanisms for education on medication safety within the hospital? If yes, provide details below (include details of pharmacists/pharmacy technicians training, health-care worker training and any education focused on patients).
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X Patient Safety Partnerships
(patients, family, health workers & policy makers)
Yes No NA 1. Has the hospital involved patients and community members in priority
setting, policy development, health service delivery planning, and patient safety improvement (perhaps through a community advisory board or other such body)? If yes, provide details below.
2. Are there mechanisms in use to facilitate the involvement of
patients/family members in improving patient safety through feedback?
If yes, provide details below (include any use of suggestion boxes, surveys, interviews, focus groups, open house, community fairs).
3. Has there been any study or survey on the way information is handled between clinicians and patient /family members? If yes, provide details of findings below.
4. Is there a member of staff responsible for managing patient complaints?
5. Does the hospital have a committee to plan and develop partnerships between patients, family members, health professional and policy makers? If yes, provide details below.
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6. Does the hospital have regular meetings with key local
community/civil society players to interface and exchange concerns?
If yes, provide details below.
7. Does the hospital participate with local government policy makers in shaping delivery of hospital services? If yes, provide details below.
8. Does the hospital have any outreach programmes working in the community? If yes, provide details of the spectrum of outreach programmes (and include any subject specific work e.g. hand hygiene, antenatal care, HIV, immunization, etc).
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XI. Patient Safety Funding
Yes No NA 1. Does all the funding for the hospital come from the government?
If no, provide details of any other funding source (include
international, private and community sources, as well as any funding received in relation to education and research).
2. Does the hospital have a clear financial management mechanism?
3. Does the hospital have a planned annual budget?
4. In the last financial year, did the hospital meet the planned expenditure in its annual budget?
5. Is there a dedicated budget allocated to patient safety activities? If yes, provide details below.
6. Does the hospital require a direct financial contribution from the patient (or patient representative) for hospital care? If yes, provide details of the expected financial contributions below.
7. Are hospital employees paid by the government?
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8. Does the hospital receive supplies from the government (medications, hygiene supplies, equipment, etc)?
9. Is the hospital involved with any public-private partnerships? If yes, provide details below.
10. Are there any plans to receive significant additional funds over the next two years that could be dedicated to Patient Safety activities? If yes, provide details below.
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XII Patient Safety Surveillance and Research
Yes No NA 1. Is there a national health research strategy? If yes, provide details
below.
2. Is there a hospital research strategy? If yes, provide details below.
3. Are there any links between the hospital and academic centers? If yes, provide details below (include whether these centres are within the country or are international).
4. Has there been any research conducted in the hospital on measuring the problems associated with patient safety? If yes, provide brief details below (include titles of available documents).
5. Has there been any research conducted in the hospital on
understanding the causes of patient safety problems? If yes, provide brief details below (include titles of available documents).
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6. Has there been any research conducted in the hospital on generating solutions for patient safety problems? If yes, provide brief details below (include titles of available documents).
7. Has there been any research conducted in the hospital on translating patient safety solutions into practice? If yes, provide brief details below (include titles of available documents).
8. Has there been any research conducted in the hospital on evaluating the effectiveness of patient safety solutions? If yes, provide brief details below (include titles of available documents).
9. Are there subject areas considered research priorities for the hospital?
If yes, provide a list below (including any patient safety issues).
10. Is there a hospital surveillance system? If yes, describe the system and how it connects with the national system.
