1. SELF EVALUATION IN SARANDA HOSPITAL. Tirane 3 Mars 2008 Dr.Dhimitraq Dhame.

2. CLINCAL EFFECTIVITY CLINCAL EFFECTIVITY Indicator Nr. 1. AB/PROFILAXIX DURING SURGICAL INTERVENTIONS Evaluation: possible to be emasured Evaluation: possible to be emasured Tools and methods: in random samples with 30 patient record files. Tools and methods: in random samples with 30 patient record files. Recommendations: Patient record files withdrown from hospital archive Recommendations: Patient record files withdrown from hospital archive

3. CLINCAL EFFECTIVITY Indicator Nr. 2. % of S / cesarea Evaluation: lightly possible to be measured Evaluation: lightly possible to be measured Tools and methods: according to records 4 / Sh. Tools and methods: according to records 4 / Sh. Recommendations: to be fulfilled by statistical section. Recommendations: to be fulfilled by statistical section.

4. CLINCAL EFFECTIVITY Indicator Nr. 3. Maternal death intra-partum and Perinatal death. Evaluation : lightly possible to be measured Evaluation : lightly possible to be measured Tools and methods: Yearly evidence, statistical data that statistical section sends to MOH Tools and methods: Yearly evidence, statistical data that statistical section sends to MOH Recommendations: data to be correctly fulfilled and sent Recommendations: data to be correctly fulfilled and sent

5. CLINCAL EFFECTIVITY Indicator Nr. 4. % of patient returned back to hospital after 72 hours. Evaluation : difficult to be measured. Evaluation : difficult to be measured. Reccomendations: the item to be included in the recorded format. Reccomendations: the item to be included in the recorded format.

6. CLINCAL EFFECTIVITY Indicator Nr.5. Death in emergency wards. Evaluation: easy to be measured Evaluation: easy to be measured Tools and methods: death regisitry at emergency wards Tools and methods: death regisitry at emergency wards

7. CLINCAL EFFECTIVITY Indicator Nr.6. Fulfilling the nursing patient record (temperature,pule, TA) Evaluation: not light to be measured Evaluation: not light to be measured Tools and methods: nursing records Tools and methods: nursing records

8. SAFETY SAFETY Indicator nr. 1. Undesired blood reations. Evaluation: difficult to be measued in average Evaluation: difficult to be measued in average Tools and methods: cases registred from the blood bank or the wards. Tools and methods: cases registred from the blood bank or the wards. Recommendations: Special registry fro recording blood reactions and its derivativs Recommendations: Special registry fro recording blood reactions and its derivativs

9. SAFETY Indicator Nr. 2. Alergic reactions from drugs Evaluation possibility: difficult to be measured, there is no written evidence Evaluation possibility: difficult to be measured, there is no written evidence Tools and methods: patient file & registry Tools and methods: patient file & registry Recommendations: patient files to be redrafted with all details Recommendations: patient files to be redrafted with all details

10. SAFETY Indicator Nr. 3. Medical errors Evaluation possibility: difficult to be measued. Evaluation possibility: difficult to be measued. Rekomandime: reporting should be a culture Rekomandime: reporting should be a culture

11. SAFETY Indicator nr 4. Medical accidents Possibility of evaluation: easy to be measured Possibility of evaluation: easy to be measured Tools and methods: E vidence in service and case analysis. Tools and methods: E vidence in service and case analysis. Recommendations: reporting system to be established Recommendations: reporting system to be established

12. SAFETY Indicator Nr.5. Patient accidents in hospitals. Possibility of evaluation: ??? Possibility of evaluation: ??? Tools and methods: ??? Tools and methods: ??? Recommendations: ??? Recommendations: ???

13. SAFETY Indicator Nr.6. Staff accidents Possibility of evaluation: easy to be measured Possibility of evaluation: easy to be measured Tools and methods: E vidence in service and case analysis. Tools and methods: E vidence in service and case analysis. Recommendations: cases to be reported Recommendations: cases to be reported

14. SAFETY Indicator Nr. 7. Deaths from disaeses with low mortality Mundesia e vleresimit: easy to be measured Mundesia e vleresimit: easy to be measured Tools and methods: calculated according to registry nr 2./ Annual recording registry. Tools and methods: calculated according to registry nr 2./ Annual recording registry.

15. STAFF ORIENTATION Indicator Nr. 1. Staff absence days 1, 1 – 3, 4 – 41 days Possibility of mesaurments : easy Possibility of mesaurments : easy Tools and methods: human resources registry Tools and methods: human resources registry

16. STAFF ORIENTATION Indicator Nr. 2. Training for nurses and doctors Measurment possibility: not easy Measurment possibility: not easy Recommendations: CPD registry and portofolio Recommendations: CPD registry and portofolio-

17. STAFF ORIENTATION Indicator Nr. 3. Satisfaction on the second incomes Mundesia e vleresimit: easy to be measured Tools and methods: staff questionnaire Mundesia e vleresimit: easy to be measured Tools and methods: staff questionnaire-

18. EFICIENCY EFICIENCY Indicator nr. 1. % of total costs that goes to patient care in the hospital Evaluation possibility: difficult to be measured. Evaluation possibility: difficult to be measured. Recommendations: to be included in the finace registry.

19. EFICIENCY EFICIENCY Indicator Nr. 2. Average day stay :diabetes, chronic pulmonary diseases, apendicits, MI. Possibility for evaluation: easy to be measured Possibility for evaluation: easy to be measured Ttols and methods: MOH register format 2 / Sh Ttols and methods: MOH register format 2 / Sh

20. EFICIENCY Indicator Nr. 3. Bed utilization : (OBG, Pathology, Surgery, Paediatrics). Evaluation possibility: easy to be measured Evaluation possibility: easy to be measured Tools and methods: MOH registry format 1 / Sh Tools and methods: MOH registry format 1 / Sh

21. Recommendations a ) Quality commitee : head of service, head nurse, head of statistics b ) data collection and distribution to be regulated by by laws. c ) Indicators to be collected and evaluated inside 15.03. of each subsequent year

22. Thans you ! Sarande 26.02.2008 FALEMINDERIT