DEPARTMENT OF HEALTH MOMBASA COUNTY HEALTH QUALITY MANAGEMENT POLICY 2022 – 2027 Foreword The Mombasa County Department of Health Services (DOHs) is committed to providing the highest attainable standards of healthcare to all, in line with the Kenya Constitution, 2010 and Vision 2030. The Quality Management Policy for Mombasa County is the first of its kind in Kenya. This policy offers a paradigm shift for the Mombasa health system to improve the quality of Health services in all public and private healthcare facilities while ensuring these services are client-centered, safe, efficient and effective. This policy was developed through a consultative process involving multiple stakeholders in health sector including national ministry of health, county department of health, development and implementing partners (faith-based, non-governmental organization, private sector, and civil society). I wish to acknowledge the leadership of the Chief Officer of Medical services, Dr. Khadija Shikely, and Director of Medical services, Dr. Shem Patta, in steering this process. The goal of this Policy is to provide a structured process by which healthcare services are delivered in a safe, effective, efficient, client-centered, timely and equitable manner to the residents of Mombasa County and beyond. It is my sincere hope that, under the devolved system of Government, all the actors in health sector in Mombasa will rally around this policy direction. This will ensure that the county progressively moves towards the realization of the right to highest attainable quality of healthcare services and steers the County towards the desired health goals. County Executive Committee Member of Health Services Dr. Godfrey Nato Acknowledgement The county department of health through the Quality and Health Standards unit would like to acknowledge the financial and technical contribution of the County Health Management Team (CHMT), Sub County Health Management Teams (SCHMTs), development and implementing partners involved in the development of this Policy. Special thanks go to the County Executive Committee Member (CECM) for Health, Dr. Godfrey Nato; County Chief Officer for Public Health (CCO-PH), Pauline Oginga; County Director Medical Services (CD-MS), Dr. Shem Patta; County Director Public Health (CD-PH) Dr. Salma Swaleh; Head of Quality and Health Standards Dr. Neema Ali; Head of Division of Policy, Planning, Health Information and M&E, Sarah Kayanda; Head of Division of Clinical Services Esha Yahya; Head of Division of Health Products & Technology, Dr. Mohamed Hanif Jin; County Head of research, Dr. Ahmed Adam, Director of Quality Assurance and Outreaches Coast General Teaching and Referral Hospital Dr. Everlyne Sumbi; for their excellent support through the entire policy-making process. The Unit would also like to specifically acknowledge Ministry of Health division of Quality and Health Standard, Marie Stopes Kenya (MSK), DSW, KANCO, KAIZEN Institute, BOMU Hospital, Kenya Red Cross, AMREF(DESIP), PSK, USAID Stawisha Pwani, AIDS Healthcare Foundation (AHF), AMURT, Pharmaccess, ICRH, MINDCRAFT, Mombasa Cement and Aga khan Hospital - Mombasa. In particular, the technical contributions of Mr. Victor Mainga of Marie Stopes Kenya, Mr. Erik Sang of Kaizen Institute, Mr. Gregory Onyango of KANCO, Mr. George Gititu of USAID Stawisha Pwani and Mr. Mohammed Rajab of Kenya Red Cross. Chief Officer of Medical Services Dr. Khadija Shikely TABLE OF CONTENTS Acronyms..............................................................................................................................................i Definition Of Terms.............................................................................................................................iii 1.CHAPTER I: INTRODUCTION..................................................................................................................................1 1.1 Background...................................................................................................................................2 1.2 The Policy Development Process..................................................................................................4 2.CHAPTER II: SITUATION ANALYSIS......................................................................................................................5 2.1 Health Leadership.........................................................................................................................6 2.2 Health Financing...........................................................................................................................8 2.3 Infrastructure................................................................................................................................9 2.4Human Resource for Health........................................................................................................10 2.5Health Service Delivery...............................................................................................................13 2.6 Health Products and Technologies.............................................................................................14 2.7 Health Information System.......................................................................................................16 2.8 Research and Development......................................................................................................18 3.CHAPTER III: POLICY GOAL, GUIDING PRINCIPLES, OBJECTIVES AND STRATEGIES............................................20 3.1 Policy Goal.................................................................................................................................21 3.2 Guiding Principles.......................................................................................................................21 3.3 Policy Objectives.........................................................................................................................24 TABLE OF CONTENTS 4.CHAPTER IV: IMPLEMENTATION FRAMEWORK....................................................................................................26 1.1 Institutional Framework.............................................................................................................27 4.2 Institutional Arrangements.......................................................................................................30 4.3 Implementation Plan..................................................................................................................31 4.4 Legal Frameworks......................................................................................................................31 4.2 Financial Framework.................................................................................................................33 5.CHAPTER V: MONITORING AND EVALUATION.....................................................................................................34 5.1 Monitoring and Evaluation Framework......................................................................................35 Policy Objectives..............................................................................................................................36 REFERENCES....................................................................................................................................44 CONTRIBUTORS TO POLICY DEVELOPMENT...................................................................................45 PARTNERS.......................................................................................................................................46 i LIST OF ACRONYMS AMR Antimicrobial Resistance AMS Antimicrobial Stewardship CCOH County Chief Officer of Health CDH County Director of Health CECM County Executive Committee Member CEO Chief Executive Officer CGTRH Coast General Teaching and Referral Hospital CHA Community Health Assistant CHVs Community Health Volunteers CME Continuous Medical Education CO Chief Officer CSO Civil Society Organizations COK Constitution of Kenya DQA Data Quality Assessment EHR Electronic Health Records e-KQMH Electronic Kenya Quality Model for Health EMR Electronic Medical Records ERC Ethics Research Committee FBOs Faith Based Organizations FIF Facility Improvement Fund GRM Grievances Redress Management HCW Healthcare Workers HIMS Health Information Management System HIS Health Information System HPT Health Product and Technology HPTU Health Product and Technology Units HRH Human Resource for Health HRIO Health Record Information Officer IPC Infection Prevention & Control ISO International Organization of Standardization KEMRI Kenya Medical Research Institute KENAS Kenya Accreditation Services ii LIST OF ACRONYMS KHIS Kenya Health Information System KHPOA Kenya Health Professions Oversight Authority KIPPRA Kenya Institute for Public Policy Research and Analysis KMTC Kenya Medical Training College KNH Kenyatta National Hospital KQMH Kenya Quality Model for Health M&E Monitoring and Evaluation MERC Mombasa Ethics Review Committee MES Managed Equipment Services MOH Ministry of Health MOU Memorandum of Understanding MPDSR Maternal and Perinatal Death Surveillance and Response NACOSTI National Commission for Science Technology and innovation NGO Non-Governmental Organizations NHIF National Hospital Insurance Fund OJT On Job Training OSHA Occupational Safety & Health Administration PPP Public Private Partnership PVERS Pharmacovigilance Electronic Reporting System QA Quality Assurance QHKA Quality Healthcare Kenya Awards QI Quality Improvement QIC Quality Improvement Committee QIT Quality Improvement Teams QM Quality Management SLAMTA Strengthening Laboratory Management Toward Accreditation SDGs Sustainable Development Goals SOPs Standard Operating Procedures SWOT Strengths, Weaknesses, Opportunities and Threats TOR Terms of Reference TQM Total Quality Management TUM Technical University of Mombasa TWG Technical Working Group UHC Universal Healthcare UON University of Nairobi WHO World Health Organizations WIT Work Improvement Team iii DEFINITION OF TERMS Access The ability to obtain healthcare services such as prevention, diagnosis, treatment, and management of diseases, illness, disorders, and other health-impacting conditions Care plan A written personalized care plan, which, under the single assessment process, details a patient’s integrated health and social care needs. Client A person (internal/external) giving or receiving health care services. Governance The system by which an organization is controlled and operated and the mechanisms by which the system and its people are held accountable. Leadership The ability of an individual or a group of individuals to influence and guide followers or other members of an organization. Patient A patient is any recipient of healthcare services that are performed by healthcare professionals. The patient is most often ill or injured and in need of treatment. Policy A policy is an explicit statement of intent that outlines the agreed course of action. Quality Assurance A means of establishing standards (for example, clinical protocols and guidelines, programs and administrative standard operating procedures) and consistently using them as a basis of quality performance assessment. Results obtained from quality assurance evaluation and monitoring lead to the quality improvement process. Quality Control The regulatory process through which actual performance is measured, compared with set standards and difference acted upon. iv Quality Healthcare Quality healthcare can be defined in many ways but there is a growing acknowledgement that quality health services across the world should be: • Effective: Providing health care services based on scientific knowledge and evidence- based guidelines. • Safe: Delivering health care services that minimize risks and harm to medical service users, including avoiding preventable injuries and reducing medical errors. • People-centered: Providing care that takes into account the preferences ,needs, values and aspirations of individual medical service users and the culture of their community. • Timely: Reducing delays in providing and receiving health care services and reducing waiting times. • Equitable: providing health care services that do not vary in quality on account of age, sex, gender, race, ethnicity, geographical location, religion, socio-economic status, linguistic or political affiliation. • Integrated: providing health care that is coordinated across all levels and providers and makes available a full range of health care services throughout the life course. • Efficient: Delivering health care services through maximum resource utilization to avoid wastage. Quality Improvement A systematic approach that continuously monitors, assesses, and improves the standards of quality health care provision Quality Management A set of coordinated activities and infrastructure within an organization, designed to support the activities that address quality of health care services through quality planning, quality control, quality improvement and quality assurance. Quality Planning A set of activities designed to establish the objectives and requirements for quality management and the application of quality system elements Universal Health Coverage Accessibility of quality health care services by all people, when and where they need them without financial constraint. 1 1. CHAPTER I: INTRODUCTION 2 1.1. Background Kenya’s Constitution enshrines the right to quality healthcare by providing that “every person has the right to the highest attainable standard of health”. Since 2014, the country’s health sector agenda has been guided by the Kenya Health Policy (2014 – 2030) which states its goal as ‘attaining the highest possible standard of health in a manner responsive to the needs of the population’. This goal would be achieved through supporting provision of equitable, affordable and quality health and related services at the highest attainable standards to all Kenyans. Vision 2030, Kenya’s flagship long-term national development agenda details priority reforms crucial to maintaining a healthy workforce. It advocates for the restructuring of the health sector’s leadership and governance mechanisms; improving procurement and availability of essential medicines and medical supplies; modernizing health information systems; accelerating health facility infrastructure development to improve access; human resources for health development; developing equitable financing mechanisms as well as the establishment of social health insurance. Kenya Health Policy aims to contribute to the attainment of Vision 2030 by providing high-quality healthcare services to maintain a healthy population able to deliver the development agenda 1.1.1 A Quality Management Policy for the Health System of Mombasa County The 2010 Constitution devolved the responsibility of coordinating and managing the delivery of primary health care services – including promotion of primary health care, public health and sanitation, disease surveillance and response to counties. Since the advent of devolution, massive progress has been witnessed in Mombasa County’s health sector. One of the goals of the County Government of Mombasa is to improve access to quality health services at all levels of care in the County. Prior to the establishment of the Quality and Health Standards Unit in the Department of Health in 2017, most initiatives, to improve the quality of care in the County’s health sector were undertaken as isolated projects or as part of packages of reform in public health and primary care. This entailed efforts to maintain and improve standards of healthcare and to control costs by encouraging competition, improving public accountability and restoring public confidence in the face of emerging evidence of health system failures. Target 3.8 of the Sustainable Development Goal (SDG) 3, to ensure healthy lives and promote well-being for all at all ages, highlights the importance of quality essential healthcare services. The World Health Organization’s (WHO) Framework for Action on advancing Universal Health Coverage (UHC) highlights the need to strengthen governance and accountability as one of the five strategic focus areas. The development of a policy with clearly articulated strategies for enhancing the quality of health service delivery is a crucial entry-point activity that will aid the development of processes and structures for quality. As such, the health department can best utilize the resources available and continuously seek to improve health outcomes while also reducing waste and redundancy. 3 Ministry of Health (MoH) provides an oversight role in regulating and assessing standards of quality of healthcare services. The MoH has developed the Kenya Quality Model for Health (KQMH) that provides a conceptual framework and national quality improvement tool for an integrated approach to improved quality of healthcare provision in Kenya. The standards described in KQMH apply to all healthcare facilities of public, private and faith-based organizations. KQMH guides self-assessment, peer assessment of network of facilities and assessment by external assessors such as health insurance institutions, county departments of health, Ministry of Health, regulators and certification bodies in healthcare at all levels in line with the services provided. Improving the quality of healthcare remains a long-term and ongoing priority for the county’s health system. Mombasa County needs to strengthen its efforts to ensure residents can access the highest attainable standards of quality of healthcare when needed in an equitable manner and at affordable prices. This policy provides an overarching framework for the reorientation of a quality healthcare approach that is consistent with other health policies and strategic plans. The Quality Management (QM) Policy is anchored on the Kenya Health Policy 2014-2030 and the Kenya Quality Model for Health. The purpose of the QM Policy is to provide an overarching framework for integrating and coordinating Quality Assurance (QA) and Quality Improvement (QI) initiatives across the health system. This will contribute to addressing the gaps in quality of healthcare, thereby contributing towards the achievement of Universal Health Coverage (UHC). The Health and Quality Standards Unit will act as a secretariat to facilitate the coordination of this QM Policy. This policy document is intended to guide all stakeholders including the County Department of Health, county hospitals, Sub-County hospitals, Healthcare centers, Dispensaries and community units, private healthcare facilities and faith-based institutions. With the advent of the decentralization of oversight powers from the MoH to the County, the QM Policy outlines the strategies the County will undertake to ensure the provision of quality healthcare services to all. 1.1.2 Vision and Mission for the Quality and Health Standards Unit Vision A model County of excellence in quality healthcare service in the region and beyond. MISSION: To provide effective leadership, focused on developing an organizational culture of quality and patient safety, regulation and improved institutional capacity towards client-centered sustainable quality health systems. 4 1.2. The Policy Development Process The Mombasa County Health Quality Management Policy 2022-2027 was developed through intensive planning, informed by evidence-based and extensive consultative process with various stakeholders. These stakeholders included the Ministry of Health, Division of quality and Standards, development and implementing partners, experts in quality management and Mombasa County Department of Health leadership, faith-based sector, private sector, and civil society organizations. Stakeholder planning meetings were held weekly during the planning phase to identify the issues to be addressed by the proposed policy and mobilize funds for its formulation. Thematic areas were chosen based on the six WHO building blocks of the health system. Development of draft zero was over a 5-day workshop with the relevant actors. The draft underwent consolidation over a 2-day workshop. This was followed by a series of stakeholder engagement meetings and validation by the CHMT. The final draft was submitted to the county leadership for final review and approval. 5 2. CHAPTER II: SITUATION ANALYSIS 6 This chapter elaborates the Quality Health System Strengths, Opportunities, Weaknesses and Threats (SWOT) in Mombasa County. The purpose of this SWOT analysis is to highlight any un-usual pattern, identify institutional gaps, build on the strengths, and seize opportunities to address gaps while minimizing the associated risks. The end-term review of the First Mombasa County Health Strategic and Investment Plan (CHSIP 2014-2018) highlighted gaps in the quality of healthcare services in the County. This was brought about by inadequate health infrastructure, equipment, shortage of qualified and motivated staff, inadequate supply and distribution of health products, low quality of health information. In addition, limited capacity healthcare workers to handle the county’s health system challenges affected the quality of health care services. 2.1 Health Leadership Leadership, governance, and oversight are central to ensuring commitment, accountability and transparency of quality management processes. High levels of commitment are needed to provide visionary leadership for the development and nurturing of a culture of quality of healthcare provision. The County leadership and governance team is responsible for ensuring that the Department of Health is adequately guided, led, managed, and governed for effective and efficient delivery of quality healthcare services. Leaders create unity; maintain a team environment in which staff can become fully involved in achieving the organization’s objectives; demonstrate commitment and help to overcome workers’ natural resistance to change and to convince staff that quality is important and crucial. Good Leadership provides guidance and motivation to improve quality of healthcare. Quality Management is achieved through leadership commitment in its Quality Policy statement. Table 1: SWOT Analysis for Leadership Strengths Existence of a County Leadership and reporting structure for quality and health care starndards Goodwill and commitment from department leadership Linkage with other units like Pharmacy and Poisons Board for joint inspection of the Health Care facilities both private and public Community strategies that provide a channel for feedback to the community Adoption of the Joint health inspection checklist tool from KHPOA Existence of TWG for the QI /MPDSR Scheduled facility support supervision on QI Recognition of good performance through awards across all levels Subscription of facilities to accreditation bodies- Safecare, KENAS (SLAMTA) Existence of patients’ rights charter Facility QIT and WITs meetings Existence of joint inspection units 7 Weaknesses Inadequate human resource for QI Weak reporting systems Competing tasks for QI focal persons. Most facilities do not have the patients’ rights charter displayed Inconsistent supervision Inadequate transport to enable timely support supervision Not all facilities have the required SOPs and Guidelines Inadequate capacity of QI personnel Opportunities The 2010 constitution provides a legal framework with the bill of rights that gives all people a right to the highest attainable quality of health care The 2017 Health Act provides a legislation for a unified health system with regulations for health care services providers and health products Commitment by the political and department leadership Quality improvement is enshrined in the constitution Goodwill from supporting partners Existence of KQMH & e-KQMH guidelines Support from MOH through KQMH and e-KQMH capacity building Availability of CHVs to provide data for gaps identification and a channel for feedback Threats Lack of culture of safety among the workforce Resistance to change Political uncertainties Change in leadership 8 2.2 Health Financing Health systems continue to experience resource constraints and low revenue collection due to free healthcare services. While hospitals and clinics are responsible for providing care to populations, they can still generate revenue without compromising access and quality. Effective payment systems should allow the health systems to focus less on payment and more on delivering the best care. Financing systems need to be designed to provide people with access to prevention, promotion, treatment, and rehabilitation services as well as cushion the user from financial hardship. Table 2: SWOT Analysis for Health Financing Strengths The department gets the largest share of the County’s budget allocation Existence of a budget line for QI activities Additional mobilization of resources for QI from partners Trained HCWs on QI Retention of FIF for facility improvement Capitation form NHIF Linda Mama program Weaknesses Poor access to allocated funds to cater for the QI budget needs Poor cash flow Delayed payments from NHIF Rejected claims from Linda Mama Opportunities Training opportunities from the National Government on PBB Goodwill from partners Enactment of a Facility Improvement Fund regulation to enable retention of FIF Accreditation of facilities by NHIF for capitation 9 Threats High levels of poverty leading to waiver of services provided High percentage of the finances are channeled towards a high wage bill The treasury equitable allocation share does not favor Mombasa County with the budget reduced to 1 billion Low health insurance coverage – NHIF 2.3 Infrastructure Vision 2030 states, “revitalization of health infrastructure will facilitate provision of efficient, equitable, affordable and high-quality healthcare’’, thereby improving the health status of individuals, families, and communities. Health infrastructure is a key pillar in health service delivery and is one of the eight policy orientations in the Kenya Health Policy 2014-2030. The overall goal is to provide a network of functional, efficient and sustainable health infrastructure for effective healthcare service delivery to all people. Health infrastructure is regarded as the foundation for planning, delivering, evaluating, and bringing about improvements in public health. Table 3: SWOT Analysis for Infrastructure Strengths Implementation of Infrastructure Norms & Standards (2017) Use of medical equipment from National Government through Managed Equipment Services Project (MES) Accessibility of accredited health facilities within a 5 Km radius Strong collaboration with partners Availability of all-weather roads Availability of specialized equipment Weaknesses Some facilities do not have piped water and rely on bowsers Inadequate referral systems Some facilities do not meet the minimum infrastructure norms and standards Mushrooming of unlicensed facilities 10 Opportunities Facilities have adequate space for expansion Support from partners Threats Lack of title deeds for most of the facilities Insecurity Boundary disputes of some health care facilities 2.4 Human Resource for Health A well performing health workforce is one that works in ways that are responsive, fair and efficient to achieve the best health outcomes possible. This implies that, there should be available resources, adequate staff (enough skills mix) that are equitably distributed, competent, responsive, and productive. (WHO, 2007) The availability of skilled human resources for health (HRH) is crucial to improving the quality of healthcare. In a bid to improve the availability of skilled HRH, the Mombasa County Department of Health established its Health and Quality Standards Unit in 2017. By then, the governance structures were only available at the county level. Quality Improvement Systems should be set up at all levels of healthcare provision; private care providers, hospitals, other institutions and at all interfaces between them. Over the years, through county and partner support, the Quality Management structure has grown and spread its branches to sub-county and facility level. The facilities have also established Work Improvement Teams (WIT) and Quality Improvement Teams (QIT) to implement improvement at facility level. Capacity building has been ongoing over the years and approximately 300 healthcare workers have been trained on QI and the KQMH. To improve staff motivation and aid in the recognition and rewarding of high achievers, the DoHS has participated in the National Quality Healthcare Awards (QHKA) since 2020 emerging victorious over three years under different categories: 2020 - Miritini received the Excellence in Innovation of the year award. 2021 - Mombasa County recieved the award of County with the best-managed health care system and a Leadership award. 2022 - Four finalists for the Award of Excellence in Innovation of the year. Port-reitz sub-county hospital received the award. 2022 - Beyond Zero Awards had 13 finalists/ winners from Mombasa County. 11 Figure 1 Table 4: SWOT Analysis for HRH Strengths Availability of a strong QI structure Availability of trained personnel Availability of supportive leadership Supportive partners in implementation e.g., QI Committed personnel Availability of specialized HR Availability of mentorship/coaching programs Availability of scholarships to the less privileged (Afya Elimu) 12 Weaknesses Inadequate trained staff Demotivated workforce Negative workforce culture Unconducive working environment Contractual /casual terms of employments Opportunities Committed partners Availability of opportunities for abstracts/research Benchmarking from private and other governmental facilities Availability of medical training institutions Existence of professional unions to defend workers’ interests High interest on career development among HRH Threats Brain drain Combative professional unions HRH preference for greener pastures High attrition of staff Aging staff 13 2.5 Health Service Delivery Good health services are those which deliver effective, safe, quality, personal and non-personal health interventions to those that need them, when and where needed with minimum waste of resources. Quality of healthcare is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge (WHO, 2007). Delivering quality health services is a global imperative for universal health coverage. It describes the essential role of quality in the delivery of healthcare services. As nations commit to achieving universal health coverage by 2030, there is a growing acknowledgement that optimal healthcare cannot be delivered by simply ensuring coexistence of infrastructure, medical supplies, and healthcare providers. Cognizance to that, Mombasa County seeks to improve delivery of quality health services through providing effective, safe, people-centered care that is timely, equitable, integrated and efficient. Table 5: SWOT Analysis for Health Service Delivery Strengths Existing national guidelines/policies in health care service provision Good infrastructure (current technology and machine) Buy-in of the leadership Availability of skilled personnel Availability of affordable, accessible and acceptable services e.g., In reaches, outreaches, NHIF accredited services Availability of GRM Weaknesses Lack of community awareness of all available services Over-reliance on donor funding Fragmentation of services Untimely responses to emergencies and disasters Inadequate communication channels Weak reporting mechanism on medical errors Inconsistent client exit interviews and client satisfactory surveys 14 Opportunities Supportive partners Emerging technologies Availability and close proximity to learning institution Threats Economic slowdown Political instability 2.6 Health Products and Technologies For the success of any service provision in the healthcare setting at any level, the availability, accessibility, quality and affordability of Health Products and Technologies (HPT) are critical. To ensure availability, supply chain planning (Forecasting and Quantification) at all levels is required. Adequate forecasting and quantification of health products and technologies informs the budgeting processes done at the County and National levels. Contributors to quality HPTs include and not limited to adequate funding allocations to health commodities; sound and ethical procurement procedures; reliable suppliers; acceptable lead times; economies of scale; robust logistical systems for ordering and distribution; good storage practices; healthcare worker capacity both numerical and skills; post marketing surveillance and laboratory testing for quality control to assure quality before use. 15 Table 6: SWOT Analysis for Health Products and Technologies Strengths Existence of Mombasa County Formulary List Operational HPTU Existing institution responsible for setting standards Commitment and leadership from the County to ensure HPTs QA Well-established proficiency testing system for Laboratories Mini-Lab – several pharmacists have been trained on the use of the Mini Lab and a complete mini lab is available at CGTRH Support for Commodity Management Trainings Available support for stores (Air conditioners, shelves, pallets) Guidelines, SOPs, and Job Aids available for Commodity Management Weaknesses Underfunding Dependence on donors for funding on HPTS Irregular commodity DQAs Weak reporting for poor quality HPTs by HCWs and subsequent response Inadequate pharmaceutical personnel at all facilities. Inadequate storage space for HPTUs at some facilities Opportunities Inter-County Collaboration Cordial relationship between the County and Professional bodies (Pharmaceutical Society of Kenya and Kenya Pharmaceutical Association) and other Private-public partnerships 16 Threats 25% of HPTs in the market are counterfeits (WHO) Parallel importers Unqualified practitioners (Quacks) Political interests in procurement processes Lack of ring-fencing of funds allocated by the County government for HPTUs Bureaucratic procurement processes 2.7 Health Information System HMIS is a data collection system specifically designed to support planning, management and decision-making in healthcare facilities and organizations. The role of the Health Information System (HIS) in the health system is not just routine collection of health service data and dutiful conveyance of the same to higher levels of the healthcare system, but to facilitate evidence-based decision-making at all levels, especially at the point of collection. The underlying rationale for a HIS’s efforts is improvement in the health status of the population within a health system. Information collection, analysis, and presentation should be organized in such a way that the neediest groups and individuals are identified. Sound health statistics are essential for health decision-making at all levels of health systems. At the county level, most data generated from health facilities have improved in terms of quality though a shortage of health records and information officers is still a major concern, especially across all public facilities, and also inadequate reporting tools. There is a need to strengthen facility health information systems through integrated electronic medical records system (EMR/EHR) and employment of HRIO at primary level health facilities. Table 7: SWOT Analysis for Health Information System Strengths Availability of HIS policy 2014-2030 guiding on information handling Existing Data protection act 2019 Availability of a DQA protocol Availability of technology –KHIS Indicator Manual available Improved reporting rate Skilled personnel in county and sub-counties Costed HIMS activities 17 Weaknesses Inadequate data demand and information use at facility level Inconsistent quarterly DQA on service delivery Staff shortage at the facility –HROs Inadequate HIMS Tools Inadequate partner support Inadequate facility storage capacity Lack of access to budgeted funds Poor quality of patients’ clinical documentation Lack of disability integrated HIS tools Lack of health digital platform (Integrated EMR) Opportunities Goodwill of the National Government to Review QI – using KQMH. Different QI models being implemented across levels of – KQMH and Safe Care Programs dashboards- KHIS Performance based awards Capacity building of Health care workers in data demand and information use and QI QI desk reviews/PPP Documentation of best practices Threats Digital security where data can be hacked Emerging and re-emerging diseases Crisis situations 18 2.8 Research and Development Health services research examines how people get access to healthcare, how much it costs and what happens to patients because of this care. The main goals of health services research are to identify the most effective ways to organize, manage, finance, and deliver high-quality care; reduce medical errors and improve patient safety. The County Government of Mombasa has put efforts to enhance the generation and utilization of research by establishing the Mombasa Ethics Research Committee (MERC). The MERC aims to improve quality standards in health research by: 1. Unveiling quality gaps in research. 2. Strengthening the link between research, policy and implementation. 3. Ensuring proper ethical conduct and integrity of research The MERC works closely with National Commission for Science, Technology, and Innovation (NACOSTI), the Kenya Institute of Public Policy Research and Analysis (KIPPRA), the Kenya Medical Research Institute (KEMRI), KNH-UoN Ethics and Research Committee, CGTRH ERC (Ethics and Research Committee) and other research and learning institutions to strengthen ethical conduct of research and enhance evidence-informed policy making. Table 8: SWOT Analysis for Research and Development Strengths Available County data on DHIS2 Existing Mombasa County Ethics Review Committee (MERC) Research prioritization with the formulation of a research department/Goodwill of county leadership Existence of some guidelines/SOPs/TORs for MERC Skilled health worker with an interest in research Weaknesses Lack of adequate budget allocation for research Weak utilization of research to inform policy and programming Lack of individual-level data to inform research gaps Institutionalization of research evidence by research institutions/lack of dissemination of data 19 Opportunities Collaborative research with different stakeholders including research institutions and universities (TUM, KMTC, UON) Accreditation of MERC Publishing QI research in peer-reviewed journals. Capacity building of MERC and health workers on research Inter-county collaborations Threats Dependence on donors Expectation for remuneration for staff whenever QA&QI is mentioned Lack of a streamlined research approval process from the county Competing tasks/priorities Unethical research practices 20 3. CHAPTER III: POLICY GOAL, GUIDING PRINCIPLES, OBJECTIVES AND STRATEGIES 21 3.1. Policy Goal The goal of this QM Policy is to provide a structured process by which health care services are delivered in a safe, effective, efficient, patient-centered, timely and equitable manner to the residents of Mombasa and beyond 3.2. Guiding Principles This policy embraces the principles of equity, people-centeredness, efficiency, social solidarity and a multi-sectoral approach that aims at putting in place efficient health service delivery systems, adequate health facilities and human resources, responsive information systems, good leadership and governance and enabling legislation. The nine principles of quality improvement Quality are outlined below: Figure 2: Nine principles of quality improvement Quality for Mombasa County 3.2.1. Client Focused Approach The first quality management principle begins with the client. Having a client focus approach ensures that the client receives the benefit of a product or service being offered. Without clients, the health care system will serve no purpose of its existence. Clients are willing to invest their money on a quality products and services and thus the need to continuously improve quality of health care services and medical products. Understanding client wants and needs provides a better chance of identifying the right materials, people, and processes to meet and exceed their expectations. 22 3.2.2. Total Employee Commitment Productivity increases when there is total commitment of all employees. Employees need to be sensitized on the county health care vision, mission, goals, and objectives in order to put their effort to attaining them. All employees must be sufficiently trained and given the proper resources to complete tasks in order to be committed to reaching goals on time. Clear understanding of the vision, goals and objectives of quality healthcare will support smooth implementation as health care workers execute their roles and responsibilities. The Heath care system should focus on motivating the healthcare workers to harness total commitment for maximum involvement and productivity 3.2.3. Process Approach The process approach is a method of thinking applied to understand and plan the sequence and interactions of processes in the system. Setting and adhering to processes is critical in quality management in ensuring that proper steps are taken in a timely and consistent manner to enhance productivity and performance. Processes ensure that the proper steps are taken at the right time to ensure consistency and speed up production. This approach aims to iron out any inefficiencies, making it easier for health system to work on continual improvement. The processes should be clearly defined and communicated to all relevant parties for proper implementation, monitoring, and evaluation. The county will continue to identify key processes, establish standards, and ensure documentation of the process for proper progress measurement and evaluation. The county will focus on integrating, aligning, and linking processes and institutional functions effectively to achieve the desired goals and objectives. 3.2.4. Integrated system A system is a set of different components that work together to produce a desired result. Health is a system achieved through different departments. These departmental functions should be interconnected with horizontal processes that should be the focus of Total Quality Management. When departments work in isolations, the desired health outcome will never be achieved. In an integrated system, everybody in every department should have a thorough understanding of policies, standards, objectives, and processes. An integrated health system helps to achieve continuous quality improvement. An integrated system will connect improvement elements in an attempt to continually improve and exceed the expectations of clients, employees and stakeholders. 23 3.2.5. Strategic and systematic approach The International Organization for Standardization (ISO) describes this principle as “Identifying, understanding and managing interrelated processes as a system contributes to the organization’s effectiveness and efficiency in achieving its objectives.” Multiple processes within a development or production cycle are managed as a system of processes in an effort to increase efficiency and productivity. System approach foster identification, understanding and management of a system of interrelated processes for any goals that will improve the health care efficiency. 3.2.6. Continual Quality Improvement This is the continuous assessment of health system, processes, and services to identify gaps and their root c a u s e s w i t h t h e a i m o f p r o v i d i n g c o u n t e r measures and corrective actions. The health system should incorporate a risk mitigation approach for developing preventive measures to avoid future occurrences. Continuous Improvement efforts to seek incremental improvement processes, tools, products, services over time. The county advocate for the use of PDSA (Plan, Do, Study, Act) cycle as continuous improvement model. 3.2.7. Evidence-based Decision Making This is a decision-making approach that relies on extensive analysis of gathered data to achieve reliable and reproducible outcomes. It enables departmental leaders on all levels within the health system to identify challenges based on facts and address their root causes. Evidence informed decision making involve assessing risks and collecting relevant information before taking a step. Informed decision focuses on the risks and benefits involved in the decision-making process. The culture of evidence-based practice will ensure quality decisions that will improve due to use of trustworthy evidence 24 3.2.8. Communications The plans, strategies, policies, standards and methods should be clearly communicated to all stakeholders in the health system to enable a unified approach in the implementation of the Quality Management Plan. Effective and appropriate communication channels should be adopted for seamless and timely transfer and exchange of information across all levels. A good communication plan will help to mitigate risk of failure. 3.2.9. Leadership Effective leadership is essential for providing guidance and creating unity in the objectives and direction of the organization. Leaders should maintain a team environment to ensure total staff involvement and demonstrated commitment in achieving organizational objectives. They should adopt a tactical approach of educating staff on the importance of quality practices as an integral part of success which will also help in overcoming worker’s resistance to change. 3.3. Policy Objectives The overall objective of this Policy is to provide an overarching framework for Quality Improvement in health care approach that is consistent with other health policies and strategic plans. This will be achieved through four policy objectives as follows:- 3.3.1. Policy Objective 1: Provide effective, efficient and equitable healthcare services to all Policy Statements: To achieve efficiency and effectiveness in delivery of equitable health care services, the policy sets the following strategic priorities: i. Improve efficient use and equitable availability of health system resources, healthcare workers, health products and technologies at all levels of care. ii. Increase uptake of UHC as a progressive mechanism to ensure holistic care for all. iii. Provide a holistic approach that is respectful and responsive to individual patient preferences, needs and values. The adopted approach will ensure patients’ values guide all clinical decisions. iv. Capacity building for healthcare workers to ensure healthcare services accessed by the clients meet the set standards for delivering desired health outcome. v. Enhance public private partnerships (PPP) at all levels of healthcare service delivery, linkages, and referrals for improved health outcomes. vi. Ensure availability of the required policies, guidelines, and SOPs at all levels of healthcare services 25 3.3.2. Policy Objective 2: Provide leadership, governance and oversight of Quality Management in healthcare while incorporating inputs from all stakeholders Policy Statements: Strong leadership, governance and oversight plays a pivotal role in ensuring functionality of quality management structures. To achieve optimal leadership and governance, the following strategic priorities are established: i. Regularly review and update the health policy and strategy to improve existing guidelines, mechanisms, protocols, and procedures governing health service delivery. ii. Strengthen quality management mechanism in all health care facilities in alignment with national system for the monitoring and improvement of health service delivery. iii. Establish, provide, and enforce implementation of relevant clinical and operating standards and protocols applied at all levels within the health sector. iv. Facilitate an integrated supportive supervision approach at all levels with an aim of improving the quality of care using standardized supervision tools, procedures, and protocols. v. Strengthen the county quality management technical working group to reflect high leadership commitment, constituted of relevant stakeholders to provide leadership, oversight and accountability for QA &QI initiatives in health. 3.3.3. Policy Objective 3: Inculcate the culture of quality and safety at all levels of health care Policy statements: For sustainability of quality management strategies, there is need to ensure a culture of quality within all the levels of healthcare. To achieve this, the strategic priorities below are adopted: i. Reduce communication errors while providing healthcare services. ii. Improve surgical safety. iii. Improve patient safety by reducing medical errors in health care provision. iv. Ensure a safe environment within the premises. 3.3.4. Policy Objective 4: Provide timely client-oriented health care services to deliver better health outcomes Policy Statements: This policy objective seeks to ensure optimal health outcomes through provision of client-centered and timely healthcare services. This will be achieved through the following strategic priorities: i. Improve on health system values and inclusivity. ii. Support healthcare workers to offer client-centred services. iii. Monitor and improve on service turnaround times. iv. Ensure positive and empowering client experiences. 26 4. CHAPTER IV: IMPLEMANTATION FRAMEWORK 27 This chapter provides coordination and administrative mechanisms for policy implementation which highlights any institutional, legal, and regulatory reforms that must be undertaken for the successful implementation of the policy. 4.1. Institutional Framework 4.1.1. The Department of Health The QM Policy will be implemented using established government structures at each level of the health system 4.1.2. The Health and Quality Standards Unit The Health and Quality Standards Unit in the Department of Health shall oversee and provide day-to-day coordination and secretariat functions for smooth implementation of the QM Policy. It will be responsible for coordinating QI initiatives that will include strengthening QM structures, harmonizing QM frameworks and coordinating various QI approaches and initiatives across the health sector. Functions i. Design quality improvement projects and replicate best practices to improve health provision in the county. ii. Oversee capacity building and mentorship programs for facility officers to ensure uniform understanding of quality approaches, models and methods. iii. Devising methods and tools for obtaining feedback from stakeholders to identify performance gaps and devise appropriate interventions. iv. Develop and harmonize clinical auditing tools; v. Roll out incentives to enhance the motivation of the health workforce. vi. Assessing the impact of quality improvement initiatives. vii. Serve as a consolidated source of information on progress in quality initiatives to allow stakeholders to learn and build QM expertise. viii. Monitoring all technical aspects of healthcare service delivery. ix. Coordinating operational research in Quality of Care. x. Strengthening the use of data for decision making and assessing the effectiveness and quality of data collection and planning systems. xi. Fast tracking the implementation of the County Health QM Policy. 28 4.1.3. The County Quality Improvement Technical Working Group (TWG) The County Quality Improvement Technical Working Group shall be the highest-level multi-sectoral steering committee responsible for providing oversight in technical implementation of the QM Policy at county level. It shall consist of the county QI committees, Sub-County QI focal persons and the QI experts from stakeholders. The CCOH shall be the chair while the head of Quality and health standards shall be the secretary. The TWG will be meeting Quarterly to discuss on the quality agenda for the county. 4.1.4. The County Quality Improvement Committee The County Quality Improvement Committee shall be the highest level of QI committee responsible for providing oversight in the implementation of the QM Policy for the various programs at county level. The membership shall be drawn from the County Health Management Teams. The county QI committee will be meeting quarterly to discuss performance and opportunities for quality improvement in the different program areas. 4.1.5. Sub-County Quality Improvement Committee The County Quality Improvement Committee shall be the highest level of QI committee responsible for providing oversight in the implementation of the QM Policy for the various programs at county level. The membership shall be drawn from the County Health Management Teams. The county QI committee will be meeting quarterly to discuss performance and opportunities for quality improvement in the different program areas. 4.1.6. Level 5 Facilities At the level 5 level, there shall be a designated Quality Improvement Team (QIT) headed by a Quality Improvement (QI) director. The QIT will oversee and coordinate QM approaches across the hospital and report to the Hospital Chief Executive Officer (CEO). The QI Director will chair the QIT, which will consist of heads from each hospital department. Heads of Departments shall lead QM interventions in their respective departments through Work Improvement Teams (WITs). Each department with more than three staff must form a Work Improvement Team (WIT). Departments with less than three staff will be merged with closely related department to form a WIT. The head of each WIT will report to the QI Director QI reports and a copy sent to sub county QI focal person and County QI and Standard coordinator. The QIT will be meeting monthly to discuss performance of QI projects / initiatives while the WITS will meet weekly to initiate or monitor progress of QI projects / Small Test of Change. 29 4.1.7. Level 4 Facilities At level 4 facility, there shall be a designated Quality Improvement team headed by a Medical superintendent or designate Facility Quality Improvement Focal Persons (QIFPs). The Quality focal person will oversee and coordinate QM approaches across the hospital and report to the Sub-County Quality Improvement Committee through sub county QI focal person. The Quality Improvement Focal Person in each facility will chair the Quality Improvement Team, which will consist of Heads / representatives of each department. Each department with more than three staff will form a Work Improvement Team (WIT). All QI activities implemented by each WIT shall be reported to the Quality Improvement Focal Persons (QIFPs) and a copy sent to sub county QI Focal Person who will aggregate and submit a sub county QI report to County QI and Standard Coordinator. The QIT will be meeting monthly to discuss performance of QI projects / initiatives while the WITs will meet weekly to initiate or monitor progress of QI projects / Small Test of Change. 4.1.8. Level 2 and 3 Facilities At each level 2 and level 3 facility, there shall be a designated Facility Quality Improvement Team and facility Quality Improvement Focal Person (QIFP). The Facility Quality Improvement Team will oversee and coordinate QM approaches across the facility and report to the Sub-County Quality Improvement Committee through the sub county Quality Improvement Focal Person. Some of the level two and three with high number of staff will form Work Improvement Teams (WITs) for each department that has more than three staff. For health centers and dispensaries with less than 12 staff will only form one WIT. Facility QI focal person shall consolidate the WIT QI reports and submit to the sub county QI Focal Person. The QIT will be meeting monthly to discuss performance of QI projects / initiatives while the WITs will meet weekly to initiate or monitor progress of QI projects / Small Test of Change. 4.1.9. Stakeholder Roles The policy implementation process will adopt a multi-sectoral approach involving different stakeholders, consumers (individuals, Households, communities), non-state actors (CSOs, FBOs/NGOs, private sector, and development and implementing partners), and state actors (government ministries and agencies) at the county level. 30 4.2. Institutional Arrangements 31 4.3 Implementation Plan This QM Policy is complimented by an Implementation Plan which will guide the implementation of all listed policy strategies. The Plan includes core activities to be taken on by partners and stakeholders in addition to the Department of Health in order to achieve the aforementioned policy goal, objectives and priority areas. The Implementation Plan will be integrated in the county Integrated Development Plan (CIDP), County Health Sector Strategic and Investment Plan (CHSSIP) and Annual Work Plan (AWP). To improve coordination and efficiency, all partners in the health sector shall develop and implement quality initiatives based on the priorities in this policy and the Implementation Plan. Additionally, to improve alignment, partner implementation initiatives shall be endorsed by county or sub county QI structures prior to commencement of its implementation. 4.4 Legal Framework For the implementation of this policy, the following institutional and legal reform focus areas should be highlighted AREA OF FOCUS HIGHLIGHTS Regulation • Strengthening the regulatory oversight by the Department of Health services, County Assembly, County Attorney and the public and other health sector stakeholders at all levels through a defined platform. • There is an existing joint health inspection team. • Healthcare workers’ regulatory bodies regulate professional conduct of medical practitioners by prescribing standards and codes of ethics. 32 AREA OF FOCUS HIGHLIGHTS Access • Expansion of the network of health care facilities to provide services to its clients in all levels of care in both public and private sectors. Quality • An Independent certification body should be set up to accredit Healthcare Assurance facilities which should comprise of all regulatory bodies. • Development of coordinated structures for referrals at the county and sub-counties levels, through support for the formation of technical Referral working groups, referral units and/or identification of focal persons for System referrals. • Improved monitoring of referral services, especially building referral linkages. Service Integration • Providing care that ensures availability of a full range of services at all levels. 33 4.5 Financial Framework National Government Treasury(including all health-related conditional grants) County Government equitable share of revenue & local revenues County Department of Health Partners/Donors County Directorate of Quality & Starndards NHIF/Linda Mama/FIF Facility (Level 1-4) Level 5 Referral Hospital 34 5. CHAPTER V: MONITORING AND EVALUATION 35 Monitoring and evaluation in quality management is a systematic establishment of indicators, data collection and analysis with periodic reviews to identify suitable action plans for improved performance of ongoing processes. Monitoring and evaluation of processes and outcomes of the policy implementation is critical to the success of the strategies herein enshrined. The quality management M&E Framework will guide the quality management monitoring and evaluation systems. The M&E framework will provide: Details of the measurable and reportable indicators at each stage of implementation. Standardized M&E tools across all levels of service delivery; and The frequency and modalities of data collection and reporting. The Department of Quality and Health Standard Unit shall review the data collection and monitoring tools to assess their adequacy for the policy implementation based on emerging needs. Aggregated data collected from at all levels shall be interpreted, discussed and used to inform performance, areas of collaborative learning and policy planning. Onsite feedback, review meetings and technical working groups will provide routine forums for discussion and dissemination of information to key stakeholders. The Quality Management M&E framework will be anchored into the Mombasa County Department of Health M&E Framework. 5.1 Monitoring and Evaluation framework The Monitoring and evaluation framework will assess to what extent the QI policy has met its objectives and evaluate the effectiveness and efficiency of the policy. The framework will align with the quality assurance and quality improvement policy implementation plan. There shall be monitoring and evaluation at all levels of service delivery. 36 PPoolliiccyy O Obbjejcetcivteiv 1e: P1r:o Pvirdoev eidffee cetffivee,c etffiiveci,e entffi acnide enqtu aitnadb leeq hueiatlathbclea rhe esearlvtihcceas rteo aslel rvices to all StrSatteragtice gPirci oPrriitoyr ity ActivitAyc tivity INDINICDAITCOART OR DADTAAT ASO SUORUCREC E Conduct support Number of Support supervision supervision supervision done report Conduct quarterly Number of Data Data Quality Quality Reports To improve the efficient use, Assessment (DQA) Assessment done and equitable availability of Conduct facility health system resources, inventory Number of MOH 647 reports health service providers, management to facilities with stock KHIS report health products and ensure nil stock out on out electronic health at all levels health care products of care. Conduct head count Number of staff staff establishment of all health care returns delivered reports workers Conduct health Number of health facilities inspection facilities inspected reports Conduct community Number of dialogues sessions on dialogues sessions Reports UHC conducted on UHC Conduct barazas Number of barazas Reports sessions on UHC done on UHC To encourage increased Conduct radio uptake of UHC as Number of radio report and sessions to increase progressive mechanism to sessions done recordings uptake of UHC ensure holistic care for all. Number of KQMH checklist Conduct annual facilities meeting facility quality 60% compliance assessment based on KQMH Assessment report assessment checklist Number of To provide a holistic Avail bilingual service facilities displaying report approach that is respectful, charter to all facilities bi lingual service responsive to individual charters client preferences, needs Number of patients’ and values Avail patient rights rights charters report charters to all facilities displayed Conduct Number of HCWs Enhance capacity of trainings/sensitization healthcare providers to to health care workers trained/ sensitized Training/ on standards and sensitization reports ensure services accessed by on standards and guidelines the clients meet the guidelines acceptable standards to Conduct CMEs to deliver desired health health care workers on Number of CMEs Participant list outcome. standards and conducted Reports guidelines Enhance Public private Number of partnership, linkages and Conduct stakeholders stakeholders Inventory directory mapping referrals at all levels of mapped 37 Conduct Number of HCWs Enhance capacity of trainings/sensitization to health care workers trained/ sensitized Training/ healthcare providers to on standards and sensitization reports ensure services accessed by on standards and guidelines the clients meet the guidelines acceptable standards to Conduct CMEs to deliver desired health health care workers on Number of CMEs Participant list outcome. standards and conducted Reports guidelines Enhance Public private Number of partnership, linkages and Conduct stakeholders stakeholders Inventory directory mapping referrals at all levels of mapped 38 Provide leadership 2: Governance and oversight of Quality Management in healthcare PwPoholiilclieyc yOin bcOjoercbptjieovcerta 1itv:i enP gro 2ivn:id peuP etrffso efvcriotdimvee ,a elelffil ascdtiaeenkrsteh ahinpod,l deeqgurositvaebrlnea hnecaelt hacanrde seorvviecressi gtoh ta ll of Quality Management in healthcare while incorporating inputs from all stakeholders Strategic Priority Activity INDICATOR DATA SOURCE SSttrraatteeggiicc PPrriioorriittyies ActivAityct ivity IndicINatDoIrCsA TOR DAatTaA S SoOuUrcReC E Review, update and disseminate the QI Existence of a Revised QI policy every 5 years revised and policy document Regularly review and with involvement of updated QI Policy update the health key stakeholders policy and strategy to Update quality improve existing management guidelines, guidelines, mechanisms, mechanisms, protocols and protocols and Existence of a Revised QI procedures governing revised and procedures in Policy document health service delivery response to changes updated QI Policy in the National / County health policy and strategy No. of healthcare Conduct capacity workers provided Training Strengthen quality improvement of all with continuous registration management healthcare workers medical Education forms mechanism in all on QI health facilities in Ensure availability and No. of Facilities alignment with utilization of SOPs with SOPs Supervision national system for and guidelines at displayed and in report the monitoring and facility level use improving of health service delivery Initiate QI projects in No. of QI projects QIT / WITs low performing areas initiated reports/ Minutes Establish relevant Number of relevant clinical and clinical and operational standards operational QI Unit report Enhance for quality standards implementation of management established relevant clinical and operating standards No of clinical and and protocols at all Disseminate operational levels standards /protocols standards / QI unit reports across all levels protocols disseminated 39 Support Facilitate an No of quarterly Conduct quarterly supervision integrated supportive support supervision support book, visitors supervision approach supervisions done book using standardized supervision tools, Review and update procedures and supervision tools to No of supervision tools revised and QI Unit reports protocols. cater for emerging needs updated 40 Policy Objective 3: To Inculcate the culture of quality and safety at all levels of healthcare Policy Objective 3: To Inculcate the culture of quality and safety at all levels of healthcare SSttrraattegiic Priority AActcivtiitvyity INDIICnAdTicOaRtor DDAaTtaA SSoOuUrcReC E Incidents/accident Incidents/accident To standardize and reporting system guide reporting system operationalize the in place. guide incidence/accident % of reporting system Incidents/accident accident/incidences reporting register reported on time To develop a Standard standard reporting Incidences/accidents Incidents/accident tool for reporting tools reporting register accident/incident available and in use reporting Train HCWs on % of HWCs trained on Training / CMEs incident/accident incident/accident participants list reporting reporting No of HCWs sensitized To Improve on on hazard communication Participant To sensitize HCW on identification, of medical errors registration form while providing hazard identification, mitigation and healthcare mitigation and reporting services reporting No of incidents Incidence and / accidents reported accident registers monthly Availability of SOPs on Strengthen handing handing over and SOP over and exchange exchange of patient of patient information information No of HCW sensitized Participant list on Handing over SOP Encourage No. of awareness openness, sessions on openness accountability and in the CME register appreciation of the Incident reports lessons learnt from Number of recurring the error incidences incidences reported reporting. Disseminate No. of facilities with updated surgical updated surgical safety Report safety SoPs SoPs To Improve on Surgical safety Monitor compliance % of surgical Surgical safety to aseptic procedures applying assessment reports techniques in the aseptic techniques as and checklist surgical procedures. per the guideline 41 Monitor post- No. of post-surgical surgical Reports complications complications reported Monitor post- surgical No. of post-surgical Reports complications reported complications T o institutionalize safe care in all health % of health care facilitates workers Training Data base sensitization of sensitized on HCWs on guidelines guidelines No of service delivery To avail guidelines to Guidelines and points with standards HCWs at service and guidelines for use/ standard at service delivery points delivery points reference To avail the infection prevention and % Presence of IPC IPC guidelines and guidelines in the health standards at service control guidelines in all health institutions facilities delivery point No of IPC assessments IPC assessment Improving done reports patient safety by Minutes for IPC To institutionalize reducing medical No of functional IPC meetings, IPC practices in all errors in committees in place Appointment letters, health institutions healthcare TOR’s No of HCWs trained on Participant list IPC Training report Provide Guidelines % of compliance for on prescribing based use of essential drug Assessment reports on Kenya essential list drug list To ensure the Support supervision existence and No of service delivery reports utilization of SOPs at points with SOPs all the service Dissemination list / delivery points. Inventory 42 Policy Objective 4: Provide timely client-oriented healthcare services to deliver better health outcomes Strategic Priority Activity INDICATOR DATA SOURCE % Healthcare providers trained Training reports on client centred care. Conduct HCW Client surveys, trainings on client- Client satisfaction index Client exit centered care interviews Support Staff satisfaction index Staff survey healthcare KHIS, Hospital workers to offer Average length of hospital stay records client-centred services. Number of compliments/Complains GRM register Seek and address received. feedback from GRM register clients Proportion of client feedback addressed. Complaints minutes, reports Community No. of community health KHIS sensitizations on health seeking sensitization held on health seeking behavior behavior MoH 515 Conduct quarterly facility support No. of quarterly support Supervision supervision conducted reports supervisions Improve on Ensure KQMH health system compliance with Proportion of facilities assessment values and complying with national norms national norms report inclusivity and standards guide. and standards iHRIS Ensure facilities Number of facilities with a QI have QI Focal QI reports Focal person person Develop and Performance disseminate Performance appraisal SoPs performance developed and disseminated appraisals reports appraisal SOPs 43 Conduct regular Number of community Community community Ensure positive dialogues conducted dialogue reports dialogue sessions and Improve client empowering Defaulter client retention rates in % decrease in defaulters in key register key clinics (HIV, clinics (HIV, TB, ANC, experiences TB, ANC, Immunization) MOH registers Immunization) Monitor and Conduct quarterly No. of facilities conducting improve service analysis of client quarterly analysis of client Analysis Report turnaround waiting time at times. facility level waiting time 44 References Dept. 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(2017, November). Leadership. Retrieved from TechTarget: https://www.techtarget.com/ searchcio/definition/leadership United Nations. (2015). UNDP. Retrieved from Sustainable development Goals: https://www.undp.org/ sustainable-development-goals University of Missouri. (2020). Health Care Access. Retrieved from MU School of Medicine: https:// medicine.missouri.edu/centers-institutes-labs/health-ethics/faq/health-care-access#:~:text=Health %20care%20access%20is%20the,must%20be%20affordable%20and%20convenient. Wikipedia. (2020). Patient. Retrieved from Wikipedia: https://en.wikipedia.org/wiki/Patient#:~:text= A%20patient%20is%20any%20recipient,or%20other%20health%20care%20provider. World Health Organization. (2018). Handbook for National Policy and Strategy. Geneva: World Health Organization. World Health Organiztion. (2016). Framework for action on advancing universal health coverage (UHC). WHO. Care plan. (n.d.) 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Rockville, MD: Agency for Healthcare Research and Quality; 2008 Chapter 44, Tools and strategies for quality improvement and patient safety 45 Contributors to Policy Development MOMBASA DEPARTMENT OF HEALTH STAFF SN NAME TITLE 1 Dr. Khadija Shikely Chief Officer Medical Services 2 Dr. Shem Patta Director Medical Services 3 John Kuti Director Administration 4 Esha Yahya Head Clinical Services 5 Dr. Mohamed Hanif Head Health Products and Technology 6 Sarah Kayanda Head Policy and Planning 7 Dr. Neema Ali County Head Quality & Standards 8 Emily Mwaringa County Chief Nursing Officer 9 Zeituni Ahmed County AIDs and STIs Control Coordinator 10 Austin Odaba County School health coordinator 11 Dr. Ahmed Adam County Head of Research 12 Mwanakarama Ahmed County Reproductive health Coordinator 13 Florence Wachira County IPC Coordinator 14 Dr. Everlyne Sumbi Director Quality & Health Standards CGTRH 15 Miriam Mumbua Quality Assurance officer CGTRH 16 Nasibo Sarbo Sub County QI Coordinator- Kisauni/Nyali 17 Khadija Luvuno Sub County QI Coordinator- Likoni 18 Yusra Awadh Sub County QI Coordinator- Changamwe/Jomvu 19 Dr. Karima Dawood Sub County QI Coordinator- Mvita 46 PARTNERS SN NAME ORGANIZATION 20 Dr. Christine Kerubo Aga Khan Mombasa 21 Shadrack Muthoka AHF 22 Elizabeth Akinyi AMREF 23 Fredrick Maweu AMURT 24 Dr. Mariam Said Bomu Hospital 25 Judy Mboku DSW 26 Dr. Patricia Owira ICRH 27 Erick Sang Kaizen institute 28 Japheth Mulwa Kaizen institute 29 Jared Okuku Kaizen institute 30 Gregory Onyango KANCO 31 Victor Mainga Marie Stopes Kenya 33 Sylvester Kimeu PSK 34 Mohamed Rajab Kenya Red Cross 35 George Gititu USAID STAWISHA PWANI DEPARTMENT OF HEALTH. Department of Health Services, Msanifu Kombo Street. P.O Box 90441 - 80100 | www.mombasa.go.ke