1. SELF EVALUATION IN KORCA HOSPITAL Dr. Spiro PINE

2. KORÇE HOSPITAL KORÇE HOSPITAL

3. WORK ORGANIZATION DIAGRAMME DIRECTOR doctor Head of cervice Head of wards finance Statistic office Nurse Statistic Nurse- statistics Chief nurse Ward-Chief nurse coordinators

4. CLINICAL EFFECTIVITY CLINICAL EFFECTIVITY 1. Antibiotic prophylaxis - S/caesarea - S/caesarea - Kolecistectomoia - Kolecistectomoia - Hernia - Hernia - Prostata - Prostata - Apendectomia - Apendectomia - Cistocela - Cistocela 2. %- e s/caesarea 3. Maternal deaths intrapartum 4. Perinatal deaths over 22 weeks 5. Return of patients in the emergency Inside 72 hours 6. Deaths in emergency 7. Nursing records - Temperatura - Temperatura - Pulsi - Pulsi - TA - TA

5. CLINICAL EFFECTIVITY DIFFICULTIES  LACK OF UNIFIED PATIENT FILE MODELS  LACK OF COORECT FILE RECORDING  UNREADIBLE RECORD READING  ANTIBIOTICS ARE ALWAYS APPLICABLE AS CONSEQUENCE OF LACK OF DRUGS

6. CLINICAL EFFECTIVITY PROPOSALS  Hospital infections should be considered a performance indicators and should be measured  Introduction of unified patient records with all data recording profiles  Drafting of clinical guidelines.

7. SAFETY Data from:  Patient records  Registry of 24 service doctors  Registry of laboratory data  Nursing records

8. SAFETY DIFFICULTIES  There is no always data collection on patient and personnel's accident

9. SAFETY PROPOSALS:  Blood typing obligatory and recorded  The doctor should fulfill the first page of patient record  All data to be recorded in the nursing record file  Reporting of accidents at work place  Staff safety and protection

10. STAFF ORIENTATION  THERE ARE ONLY ABSENCE AT WORK FROM NURSES AND ADMINISTRATION  BUDGET FOR TRAINING -NUL  TRAINING ONLY SPONSORED BY PHARMACEUTICAL COMPANIES OR NGO-S AND INDIVIDUAL POSSIBILITES

11. STAFF ORIENTATION PROPOSALS  Defined budget earmarked for training  Staff appraisal introduced  Rewarding according to outcomes

12. EFICIENCY DIFFICULTIES  LACK OF ARCHIVE ACCORDING TO THE LAW  LACK OF CLASIFIFCATION OF DISEASES CODES-ICD-9 AND 10

13. EFICIENCY PROPOSALS  DRUG LIST  Diagnosis to be written fully and correctly  Strengthening of information and data collections  Training of statistic personnel

14. Thank you !