KORLE BU TEACHING HOSPITAL – PROGRAMME OF WORK(POW - 2008) Korle Bu Teaching Hospital (KBTH) was established to provide: Tertiary health care for all Ghanaians.

KORLE BU TEACHING HOSPITAL – PROGRAMME OF WORK(POW - 2008)

Korle Bu Teaching Hospital (KBTH) was established to provide:

•Tertiary health care for all Ghanaians.

•Provide facilities to educate and train health professionals,

•Conduct Research and

•Provide specialist Outreach Services to all Ghanaians in other regions and districts.

• Currently KBTH has 17 clinical and diagnostics department and units and has an average daily out-patients attendance of 1,200 with an admission rate of about 150 patients per day. It has 48 functioning wards with 430 doctors and 1050 nurses.

• The hospital faces on daily basis, challenges such as overcrowding and congestion of department and wards by patients. It has inadequate number of staff. In addition there are obsolete medical equipment and deteriorating physical infrastructure.

• These challenges pose a threat to effective and efficient health care delivery at the hospital

POLICY THRUST

• The thrust for 2008 is to ensure that limited recourses are directed towards improving the provision of quality tertiary health care through the upgrading of infrastructure and review of standards of operation at all the clinical departments wards and management levels

PRIORITY ACTIVITIES

•Reorganize services to focus on referral and tertiary services and improve the quality of patient care

•Introduce programmes to promote regenerative health and behaviour change among client.

•Put in place programmes aimed at attracting and retaining the required number of staff to ensure quality of care.

•Expand, modernise and rehabilitate physical structures and facilities, equipment and tools;

POLICY TRUST(ctd.)

• Review financial management systems and improve on internal controls as part of the revenue mobilization efforts.

• Upgrade connectivity and ICT infrastructure to improve information management

• Develop operational research capacity at all levels

EXPECTED RESULTS• Increase by in number of referred cases to

the hospital as a result of high turn over of registered NHIS patients

• Physical structures rehabilitated and modernized

• Financial management practices and internal controls improved

• Staffing levels improved with appropriate staff mix

• New equipment provided to replace obsolete ones

• Operational research and capacity developed for identified service delivery units and departmenst

• ICT applied to identified service areas and Health Information Management system improved

COLLABORATORS• Our collaborators include:- Ministry Of Health, GHS, KATH,TTH,- Medical & Dental Council, UGMS, Pharmacy

Council, Food & Drugs Board CHAG, - Mutual Health Insurance Organization, NHIC,

NGOs, Churches, - Financial institutions(Banks,Insurance

companies,) National Aids Commission- National Sports Council

LOGFRAME FOR PROGRAMME IMPLEMENTATION SECTOR STRATEGIC

OBJECTIVES

PRIORITY

AREAS

ACTIVITIES INDICATORS MEANS OF VERIFICATION

TIME FRAME

START END

Rapidly scale up high impact health, reproduction and nutrition interventions and services, targeting the poor, disadvantaged and vulnerable groups and bridge the gap between interventions that are known to be effective and the current relatively low level of effective population coverage.

1. Improve the (technical) quality of patient care

a) Provide explicit health care protocols/procedure manuals.

b) Pursue daily/weekly clinical auditing.

c) Increase the frequency of the morbidity and mortality review exercise from monthly to fortnightly meetings.

d) Introduce clinical governance/independent auditing by setting up a Professional Standards

•60%of major clinical units prepared treatment protocols

•90% of clinical audit carried out.

•50% of mortality reviews done.

•SOPs developed and 80% of all professionals applying them.

•Copies of treatment protocols displayed in consulting rooms and wards

•Findings entered into sub BMC quarterly reports

•Copies of Mortality Review Reports available on appropriate files.

•Developed SOPs available in simple English language on all clinical notice boards

JAN

JAN

JAN

MARCH

JAN

JUNE

DEC

DEC

DEC

DEC

SECTOR STRATEGIC

OBJS.

PRIORITY

AREAS

ACTIVITIES INDICATORS MEANS OF VERIFICATION

TIME FRAME

START END

e) Activate work of the Senior and junior Staff Disciplinary Committees to address issues of clinical indiscipline/malpractice and take necessary corrective action

f) Quality Assurance Team to improve the overall quality of patient care.

g) Introduce effective customer complaint handling system to receive and deal with complaints, suggestions, comments from patients, and the general public.

•90% of all reported cases of misdemeanor dealt with.

•60% of set Standards in Q A protocols observed

•80% of all Units have suggestion boxes.

•Information desk available at all Units/ Departments

•Minutes

and quarterly

Reports of the

Committees’

meetings

available

•Quaterly

Reports &

Minutes of the

Q A

Committee

•Complaints Catalogue Book

•Quaterly Reports of Hospital Public Complaints Committee

JAN

MARCH

FEB

DEC

DEC

Ctd. 1

SECTOR STRATEGIC

OBJS.

PRIORITY

AREAS

ACTIVITIES INDICATORS MEANS OF VERIFICATION

TIME FRAME

START END

2. Enhance the quality of staff patient interaction attitudinal and behavioural change/

Client orientation

a) Implement performance monitoring and evaluation systems to assess, periodically, patients’ and other stakeholders’ satisfaction, using surveys and observation.

b) Educate and inform patients and the general public on KBTH’s policies and operating procedures to enable them empathise with and change their attitude and behaviour towards the staff and minimize frustrations resulting from unavoidable delays and other

•A Coordinating Information Desk situated at main Admin. Block.•Appropriate M&E conducted on 60% of identified patients and stakeholders satisfaction indexes.

•Awareness creation conducted for 65% of patients/clientele and some identified opinion leaders of the general

•M&E Quaterly Reports

•Workshop reports

•MARCH

•JAN.

DEC.

DEC.

Ctd. 2

Ctd. 3

SECTOR STRATEGIC

OBJS.

PRIORITY

AREAS

ACTIVITIES INDICATORS MEANS OF VERIFICATION

TIME FRAME

START END

3. Promote research activities in KBTH

inconveniences in service delivery.

a) Set up a Research Department with clearly defined responsibilities, authority and relationshipsb) Identify strategic areas of research opportunities: medical/health

public, on KBTH’s Policies, SOPs and BCC.

• An established and functioning Research & Development (R&D) Unit with an organogram.

•At least one Research and Development Proposal developed per quarter.

• Quaterly Reports.

•Number of R&D Proposals developed.

MARCH

JUNE

JULY.

AUG.

SECTOR STRATEGIC

OBJS.

PRIORITY

AREAS

ACTIVITIES INDICATORS MEANS OF VERIFICATION

TIME FRAME

START END

Strengthen the Health System’s capacity to expand access, manage and sustain high coverage of health services through investment.

4. Improve human resource management so as to attract and retain adequate number of staff/

a) Build human resource management capacity in training and development

b) Develop comprehensive education, training and career development policies for the Hospital.

c) Conduct a comprehensive training needs assessment to identify gaps in staff knowledge, skills, competences, capabilities, attitudes and behaviours

•65% of scheduled Human Resource Management capacity building for top and middle level managers conducted.

•All career development policy documents of the Hospital reviewed and made available to all Units/Depts.

•Training Assessment needs of 70% of all professional groupings done.

•Human Resource development manual and Training reports.

•A reviewed career and development policy document of the Hospital

•Training needs Assessment Reports.

Ctd. 4

SECTOR STRATEGIC

OBJS.

PRIORITY

AREAS

ACTIVITIES INDICATORS MEANS OF VERIFICATION

TIME FRAME

START END

5. Improve information and communication technology infrastructure and systems

d) Improve physical working conditions/environment to enhance job satisfaction and intensify efforts at providing more and better incentives/welfare services.

e) Provide more, reliable and timely opportunities for career development.

a) Commission consultants to develop an integrated information system to enable KBTH to:

•56% of offices wards/clinical areas refurbished.•30% improvement in service conditions/incentives /staff welfare done.

•65% of the identifiable professional groupings benefit from varied relevant training programmes.

•85% of all functions, both Clinical and non Clinical driven by ICT Systems.

•Quarterly/Annual Hospital Reports

•Human Resource development manual

•ICT Unit quarterly reports.

Ctd. 5

SECTOR STRATEGIC

OBJS.

PRIORITY

AREAS

ACTIVITIES INDICATORS MEANS OF VERIFICATION

TIME FRAME

START END

-provide an integrated automated system for Clinical Departments- enhance the automated processes in the Finance Department- build individual personnel database and use the data to provide relevant reports for management information and action.- computerize vehicle management function

b) Train Staff on ICT.

Ctd. 6

SECTOR STRATEGIC

OBJS.

PRIORITY

AREAS

ACTIVITIES INDICATORS MEANS OF VERIFICATION

TIME FRAME

START END

6. Expand, modernise and rehabilitate physical structures/facilities, equipment and tools

a) Carry out facilities and equipment survey throughout the Hospital and determine facility and equipment requirements for effective (tertiary) care

b) Plan, implement and monitor effective repair and maintenance system/periodic maintenance for structures and equipment

c) Renovate and refurbish existing physical structures:

•90% of all facilities and equipment in the Hospital inspected.

•92% of all activities in the Plan Preventive maintenance (PPM) plan adhered to.

•62% of all physical structures in poor state of repair refurbished.

•Activity Survey Report from the Technical team.

•Quarterly PPM Reports.

•Hospital Annual or Semi-annual Reports.

Ctd. 7

SECTOR STRATEGIC

OBJS.

PRIORITY

AREAS

ACTIVITIES INDICATORS MEANS OF VERIFICATION

TIME FRAME

START END

–Medical Block (on – going)- Maternity Block- Child Health Children’s Block- Surgical (wards, etc)- Staff residential accommodation- Medical Records Department

d) Replace obsolete and worn-out equipment and operating facilities.

-e) Refurbish or repair major equipment in the Hospital:- Thirteen (13) elevators- Servicing of two (2) Gas Plants- Medical Gas piping for all the wards

•85% of all obsolete equipment replaced.

•65% of all major equipment refurbished/

repaired.

•Quarterly PPM Reports.

•Quarterly PPM Reports.

Ctd. 8

SECTOR STRATEGIC

OBJS.

PRIORITY

AREAS

ACTIVITIES INDICATORS MEANS OF VERIFICATION

TIME FRAME

START END

Promote good governance, partnerships and sustainable financing

7. Improve corporate governance and management systems

8. Enhance financial management and internal controls

a) Improve the internal communication system through more frequent (interactive) meeting:

b) Increase the decision – making authority of Sub–BMCs.

a) Carry out a comprehensive review of the Hospital’s accounting, financial management and internal control systems.

•80% of all planned interactive meetings held

•Policy decision on this made and all Sub BMCs allowed to implement at least 90% of their own decisions taken.

•All Accounting, financial Mgt. and internal control systems reviewed.

•Workshop/durbars/meetings minutes or reports.

•Minutes of Sub BMC core mgt Committee Meetings/Sub BMC Action plans.

•Reviewed documents of all accounting and Auditing procedures.

MARCH

JAN.

MARCH

DEC.

DEC.

JUNE

Ctd. 9

SECTOR STRATEGIC

OBJS.

PRIORITY

AREAS

ACTIVITIES INDICATORS MEANS OF VERIFICATION

TIME FRAME

START END

b) Review the entire purchasing, procurement and supply management systems.

c) Conduct Training programmes for Core Members of Sub-BMCs on KBTH 5-Y-S-Plan.

•All the Hospital procurement and supply mgt systems reviewed.

•80% of all scheduled training programmes on KBTH 5-Y-S- Plan conducted.

•Reviewed procurement document.

•Workshop Report.

MARCH

MARCH

JUNE

JUNE

Ctd. 10

THANK YOU