April 2012

Improvement Series

African Partnerships for Patient Safety

Patient Safety Situational Analysis

(Short Form)

A series of APPS resources have been co-developed and utilised by the first wave of hospital

partnerships participating in the APPS programme. Although focused on a partnership model,

these resources can be useful to any hospital committed to creating safer health care for

patients. These resources may also be of utility to decision makers involved in planning for

patient safety.

WHO/IER/PSP/2012.5

© World Health Organization 2012 The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. The mention of specific resources does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use.

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Overview

Provides a framework for the rapid collection of information utilizing

predominantly a yes/no approach

Simple enough to allow efficient and effective collection of information on a

range of areas relevant to patient safety in an African hospital

Provides a structured method of undertaking a rapid needs assessment or

gap analysis, and at the same time enables strengths to be identified

Not intended to be a formal research tool, but to assist quick collection of

information which will serve as a baseline and can be easily reviewed and

analysed to aid in the identification of areas needing further assessment

Once areas of interest and/or focus have been identified with this Short Form

the APPS "Patient Safety Situational Analysis Long Form" can be used to

gather detailed information on key patient safety areas

Information gained from the short and long form will be combined to serve as

a robust data foundation for patient safety action planning at the hospital

Who is this for?

Any individual or hospital team that seeks to gain a rapid understanding of the patient

safety situation in their institution.

What is the purpose?

To assist African hospitals in the rapid gathering of information to provide a baseline

patient safety snapshot in a specific hospital.

What is the structure?

The short form has three parts.

The first part addresses key steps in information collection (page 4).

The second part is related to general information on the hospital (page 5).

The third part consists of a series of questions based around 12 key patient

safety action areas (page 6-15).

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Part 1: Information Collection - Key Steps

Identify key individuals within the hospital that have an interest in patient safety

These individuals should cover a range of professions and departments

Identify at least one senior leader who can act as a patient safety champion in

the hospital

Identify an information gathering coordinator responsible for the overall

coordination of information collation

Form a core hospital patient safety team consisting of the key individuals above

Arrange meetings to explain to hospital colleagues why patient safety is being

addressed and to explore current understanding. Share key patient safety

information with this group:

Patient safety burden at the global, regional and national level

Outline of a patient journey highlighting key patient safety issues

The fact that solutions are possible

The 12 patient safety action areas defined by the WHO African Region1

Examples of success in improving hospital patient safety within the hospital or other hospital within the country or in the region

Links between patient safety and improving quality of health care

Reflections on what the above means for the hospital

Secure senior hospital decision maker support on undertaking rapid situational

analysis

Introduce colleagues to the "Patient Safety Situational Analysis Short Form", and

explain how information will be collected and how results will be utilized for action

planning

Decide on a list of key individuals within the hospital that need to be consulted in

order for information to be collected

Ensure that the information gathering coordinator keeps a log of information

sources, and that wherever possible there is cross-checking of information

Utilize existing reports or previous data collection exercises to feed into the findings

of the situational analysis

1 12 Patient Safety Action Areas: 1. Patient Safety and Health Systems; 2. National Patient Safety Policy; 3. Patient

Safety Knowledge and Learning; 4. Raising Patient Safety Awareness; 5. Health care-associated Infections; 6.

Health-care Worker Protection; 7. Health-care Waste Management; 8. Safe Surgical Care; 9. Medication Safety; 10.

Patient Safety Partnerships; 11. Funding for Patient Safety; 12. Surveillance and Research in Patient Safety.

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Part 2: Hospital General Information

Official Hospital Name Name of Information Collection Coordinator

Type of hospital (circle appropriate response)

General Teaching Private

District Tertiary

Number of beds

Annual admissions Population in catchment area

Departments (please circle as appropriate)

Internal Medicine Surgery Intensive care

Emergency Obstetrics Gynaecology

Paediatrics Pharmacy Radiology

Maternity Laboratory Other (list below)

Total number of health- care providers

Total number of administrators or managers

Total number of hospital

staff/ employees

Total number of doctors Total number of trained infection control doctors

Annual number of medical students

Total number of nurses Total number of

trained infection

control nurses

Annual number of nursing

students

Total number of care staff or auxiliary staff

Total number of laboratory staff or scientists

Total number of microbiology scientists or technicians

Total number of pharmacists

Total number of pharmacy technicians

Total number of cleaning staff

Yes No NA

1. Is there a clean supply of running water?

2. Is there a reliable supply of running water?

3. Does the structure of the building protect patients and staff from common weather

events?

4. Is the electricity supply reliable?

5. Is there a reliable telephone system within the hospital?

6. Is there a reliable access to the internet/emails within the hospital?

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Part 3: Twelve Patient Safety Action Areas

Twelve key areas for patient safety action have been identified by WHO AFRO in a

technical paper presented at the 2008 WHO AFRO Regional Committee Meeting.2

The technical paper was endorsed by each of the 46 countries in the African Region

and is thus used as a starting point. Core questions are defined in each of the twelve

key areas, aiming to collect essential information in each specific area. The twelve

action areas are presented in the table below.

Action Area Short

form

Long

form

1. Patient safety and health services and systems

development

Page 7 Page 8

2. National patient safety policy Page 7 Page 10

3. Knowledge and learning in patient safety Page 8 Page 12

4. Patient safety awareness raising Page 8 Page 14

5. Healthcare-associated infections Page 9 Page 16

6. Health worker protection Page 11 Page 20

7. Health-care waste management Page 12 Page 22

8. Safe surgical care Page 13 Page 24

9. Medication safety Page 14 Page 26

10 Patient safety partnerships Page 14 Page 28

11. Patient safety funding Page 15 Page 30

12. Patient safety surveillance and research Page 15 Page 32

2 Patient Safety in African Health Services: Issues and Solutions, Report of the Regional Director to the 58th WHO

AFRO Regional Committee, September 2008. Yaoundé, Cameroon.

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I Patient Safety and Health Services/Systems

Development

Yes No NA

1. Is there a long term strategic plan for the hospital?

2. Is there an annual hospital plan?

3. Is there an organizational chart that provides details of the hospital leadership, decision making and accountability structure?

4. Was there a detailed inventory of all hospital items completed within the last year?

5. Is there a reliable process for obtaining necessary health-care supplies and materials?

6. Is there a medical record system in use, where each patient encounter is recorded?

7. Are there any hospital programs that promote quality improvement?

II Links with National Policy on Patient Safety

Yes No NA

1. Is there a national committee or board that is responsible for patient safety policy making?

2. Is there a national regulatory agency that monitors implementation of patient safety policies?

3. Is the Hospital Director (or equivalent leader) aware of any present national policies on patient safety issues (examples include hospital hygiene or any other patient safety issue covered in this guide)?

4. Do hospital staff participate in any health policy making forums?

5. Have any guidelines related to patient safety been utilized for hospital policy formation?

6. Are there any national training manuals for patient safety activities?

7. Has the hospital participated in implementation of specific national patient safety policies?

8. Are there any examples of patient safety findings within your hospital influencing national patient safety policy?

9. Are there any mechanisms to discuss coordination of service delivery with other hospitals and health facilities?

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III Knowledge and Learning in Patient Safety

Yes No NA

1. Is there a continuing medical education program within the hospital for doctors?

2. Is there continuing education within the hospital for nurses?

3. Is there a hospital training plan?

4. Is there a system of clinical audit in any department?

5. Is there a system for recording adverse events?

6. Is there a system in place for providing feed back on adverse events and errors?

7. Are specific protocols on patient care utilized in the hospital?

8. Are check lists used for any procedures in the hospital?

9. Is there a multi-disciplinary review of events leading to in-patient mortality?

10. Do links exist between the hospital and any external training institutions?

IV Patient Safety Awareness Raising

Yes No NA

1. Does a Patients' Rights Declaration or Charter exist?

2. In the last year, has the hospital participated in any community focused activities to raise awareness on patient safety?

3. Are there any mechanisms within the hospital to inform patients of their rights (e.g. leaflets, posters, etc)?

4. Are there any mechanisms in place to sensitize hospital staff on the importance of patient safety issues?

5. Is there a system in place (forms and protocols) for obtaining patient’s consent before procedures?

6. Is there a system in place for patients to report patient safety issues to the hospital?

7. Are there any mechanisms in place for patients and health-care professionals to share ideas and concerns related to patient safety?

8. Does the hospital have any links with civil society and the community that can be utilized for raising awareness on patient safety?

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V Healthcare-Associated Infections

Yes No NA

1. Structures and mechanisms for infection prevention and control (IPC) leadership in the hospital

a Is there a person responsible for leading/coordinating IPC activities?

b Is there a functioning multidisciplinary IPC team/ committee?

c Are the responsibilities of the team/committee clearly defined?

d Are the strategies and goals of IPC defined?

e Is the IPC team represented on relevant hospital wide bodies/committees?

2. Human Resources

a Is there a full time doctor/nurse designated to carry out hospital IPC

activities?

b Are job descriptions for each individual clearly documented?

c Is there a clear chain of command for IPC activities?

3. Do written hospital policies or guidelines exist for the following:

a Hand hygiene

b Disinfection and sterilization

c General infection prevention and control

d Aseptic practices related to patient care

e Safe injection practices

f Sharp disposal

g Triaging patients with high risk of rapid infectious disease transmission

h Equipment/instrument reuse

i Antibiotic use

4. Is there a method in place to assess compliance to infection control guidelines and provide feed back to health-care workers?

5. Is there a system in place for conducting health worker training on health care-associated infections?

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Yes No NA

6. Are there reminders (e.g. posters) on hand hygiene and other issues related to infection prevention and control (IPC) in patient care areas?

7. Microbiology laboratory facilities

a. Is there a microbiology service on-site at the facility?

b. Is there a regular program to assess and promote standard

microbiology quality practices?

8. Capacity for surveillance related to infection prevention & control

a. Is there routine notification of infectious diseases to the national

surveillance system?

b. Is there any research based surveillance of infections?

c. Are health care-associated infection surveillance data available,

for any time period?

9. Structures for supporting IPC activity

a. Is there adequate reliable supply of soap throughout the hospital?

b. Is there an adequate reliable supply of single use paper towels

throughout the hospital?

c. Is there an adequate reliable supply of alcohol based handrub

throughout the hospital?

d. Is there a centralized sterile supply department for the hospital?

e. Is adequate equipment available to perform sterilization of

equipment?

f. Are quality control (QC) measures in place for equipment?

g. Do the quality control tests fail?

h. Is there a protocol for changing, handling, and reusing bed linen?

10. Related to anti-microbial resistance (AMR):

a. Are there antibacterial medicine use policies and guidelines?

b. Are there policies for surgical prophylaxis?

c. Are there records of antibiotics dispensed?

d. Is AMR data available for any bacterium during the last year?

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VI. Health Worker Protection

Yes No NA

1. Is there a national policy on health worker protection?

2. Is there a hospital policy or guidance document on health worker protection?

3. Are necessary articles for personal protection (clean gloves, aprons/gowns, masks, goggles) adequately available for health worker use?

4. Is there a system in place to register and follow up accidents and injuries among health workers (e.g. needle/sharp injuries)?

5. Is there a protocol for post exposure prophylaxis for health workers in place?

6. Are all health workers immunized against Hepatitis B?

7. Is there a system in place to track excessive employee work hours?

8. Is there adequate access to emergency treatment for health workers?

9. Are universal precautions followed in all departments at all times?

10. Is there a protocol in use to notify health workers when extra precautions are indicated?

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VII. Health-Care Waste Management

Yes No NA

1. Is there a national policy on health-care waste management?

2. Is there a high-level hospital policy or guidance document on health-care waste management?

3. Are protocols for health-care waste management used in the hospital?

4. Are there adequate supplies/materials to collect all waste types (sharps; biohazard; infectious; toxic; chemical; radiation) at all generation points?

5. Are methods in place for final waste disposal for each of the following:

Infectious waste

Plastic waste

Sharps waste

Food waste

Domestic waste

6. Are there facilities for appropriate temporary storage of waste?

7. Are procedures regularly used for pest eradication?

8. Is there an environmental cleaning protocol (frequency, areas/items to be cleaned, products used for different situations, etc) that is communicated to cleaning & supervisory staff?

9. Are any single use items (catheters, gloves, syringes) reused?

10. Does the hospital provide any instructions for disposing 'patient produced waste' (needles, soiled wound dressings, outdated medications) at home?

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VIII Safe Surgical Care

1. How many surgical procedures are performed in the hospital each year?

2. What percentage of surgical procedures conducted in the hospital are:

Emergency cases1

Elective cases2

3. How many surgeons are in the hospital (include doctors and other licensed surgical providers)?

4. How many anesthesia providers are in the hospital (include doctors, nurses, and other licensed anesthesia providers)?

5. How many nurses work in the operating theatres?

6. How many operating rooms does the hospital have?

7. How many of the hospital operating rooms have functioning pulse oximeters available at all times?

Yes No NA

8. Is there a mechanism to record hospital deaths following surgery?

9. Is there a mechanism to record complications resulting from surgery?

10. Is anyone at the hospital aware of the WHO Safe Surgical Checklist?

1Emergency cases are procedures that must be completed within 24 hours of

hospital admission in order to save life, limb, or functional capacity

2Elective surgery is a planned, non-emergency surgical procedure

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IX Medication Safety

Yes No NA

1. Are there any policy documents on medication safety (national policy, sub-national policy, hospital policy)?

2. Is there a functioning hospital Drug and Therapeutics Committee or equivalent?

3. Is there a member of staff specifically responsible for medication safety?

4. Is the drug procurement process effective?

5. Is there a hospital medicine formulary?

6. Is there a reporting system for adverse drug reactions and medication errors?

7. Are pharmacists’ advice documented in the patient record?

8. Are there mechanisms for educating health-care workers and patients on medication safety within the hospital?

9. Do pharmacists and pharmacy technicians participate in regular (at least annual) training updates?

X Patient Safety Partnerships

Yes No NA

1. Has the hospital involved patients and community members in health service delivery planning, and patient safety improvement (perhaps through a community advisory board or other such body)?

2. Are there methods to encourage the involvement of patients/family members in improving patient safety through feedback (suggestion box, surveys, interviews, focus groups, open house, community fairs)?

3. Has there been any study or survey on the way information is handled between clinicians and patient /family members?

4. Is there a member of staff responsible for managing patient complaints?

5. Does the hospital have a committee to plan and develop partnerships between patients, family members, health professional and policy makers?

6. Does the hospital have regular meetings with key local community/civil society players to exchange ideas and concerns?

7. Does the hospital participate with local government policy makers in shaping delivery of hospital services?

8. Does the hospital have any outreach programmes working in the community?

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XI. Patient Safety Funding

Yes No NA

1. Does the hospital have a clear financial management mechanism?

2. Does the hospital have a planned annual budget?

3. In the last financial year, did the hospital meet the planned expenditure in its annual budget?

4. Is there a dedicated budget allocated to patient safety activities?

5. Does the hospital require a direct financial contribution from the patient (or patient representative) for hospital care?

6. Are hospital employees paid by the government?

7. Does the hospital receive supplies from the government?

8. Is the hospital involved with any public-private partnerships?

9. Are there any plans to receive significant additional funds over the next two years that could be dedicated to Patient Safety activities?

XII Patient Safety Surveillance and Research

Yes No NA

1. Is there a national health research strategy?

2. Is there a hospital research strategy?

3. Are there any links between the hospital and academic centers either within the country or internationally that conduct research?

4. Has there been any research conducted in the hospital on measuring the problems associated with patient safety?

5. Has there been any research conducted in the hospital on understanding the causes of patient safety problems?

6. Has there been any research conducted in the hospital on generating solutions for patient safety problems?

7. Has there been any research conducted in the hospital on translating patient safety solutions into practice?

8. Has there been any research conducted in the hospital on evaluating the effectiveness of patient safety solutions?

9. Is there a hospital surveillance system that connects to any national surveillance system?