Monitoring and Reporting
Monitoring and Reporting
Monitoring and Reporting
Section 2 Introduction
Section 3 Operational Standards
Section 4 Implementation Guidance
Section 5 Implementation Monitoring
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Learning Objectives
At the end of this presentation participants will be
able to understand;
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Introduction
Hospital management and Governing Boards are
responsible to monitor their hospital performance.
Monitoring has a number of objectives including:
◦ To ensure that activities are proceeding as planned and on
schedule
◦ To maximize the quality, effectiveness and efficiency of
services
◦ To ensure financial viability of the hospital, and
◦ To ensure that the hospital is attaining of national targets.
4
Operational Standards
1. The hospital has an HMIS Monitoring Team (or
equivalent) which collaborates with the CG&QIU in
reviewing the HMIS indicators and takes action to
address any areas of concern.
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Operational Standards (cont’d)
4. The correspondence between data reported on
HMIS forms and data recorded in registers and
patient / client records, as measured by Data
Quality Assurance (DQA) and Lot Quality
Assurance Sample (LQAS) is ≥85%.
5. In collaboration with the Governing Board through
the CEO, the Clinical Governance and Quality
Improvement Unit have established performance
indicators for the hospital that are described in
hospital performance reports presented by the
CEO to the Governing Board as a minimum every
quarter.
6. . 6
Operational Standards (cont’d)
6. Indicators included in the hospital performance
monitoring system are a combination of
national/regional indicators and other local
indicators as determined by the Governing Board.
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Implementation Guidance
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Health Management Information System
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Health Management Information System …
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HMIS data aggregation and reporting
Latest date report
Frequency of
Health Facility Reporting level should be Comment
reporting
submitted
Monthly, Quarterly
Health facility WoHOs 26th of the month
& Annual
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Data quality assurance tools
and
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Data quality assurance tools
Lot quality assurance sampling (LQAS) is a
methodology that originated in manufacturing as a
low-cost way to assess and assure quality.
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Data quality assurance tools
LQAS Table: Decisions Rules for Sample Sizes of 12 and Coverage Targets/Average of 20-95%
Sample
Size Less
than 20% 25% 30% 35% 40% 45% 50% 55% 60% 65% 70% 75% 80% 85% 90% 95%
20%
N/A
12 1 1 2 2 3 4 5 5 6 7 7 8 8 9 10 11
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Role of the Governing Board to monitor hospital
performance
Governing Board should review and monitor the selected set
of HMIS Indicators assure that the hospital is performing to a
high standard and quality services.
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Balanced Scorecard
The BSC is recommended by the FMOH as a management and
measurement tool for all levels of the health sector
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Balanced Scorecard…
Governing Boards should determine selected
indicators within each of the four key areas
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Implementation monitoring
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Assessment Tool for Operational Standards
Yes No
1 An HMIS Monitoring Team (or equivalent) has been
established.
2 Self assessments of hospital performance are
conducted.
3 Monthly, quarterly and annual HMIS reports are
submitted to relevant bodies.
4 Lot Quality Assurance Samples have been done.
5 Lot Quality Assurance Samples show a result ≥80%.
6 The CEO and Governing Board have defined
performance indicators (that are a combination of
national, regional and other local indicators) in a
Balanced Scorecard
7 Performance indicators in a Balanced Scorecard (BSC)
have been reported to the Governing Board.
8 BSC orientations have been provided to staff. 20
END
Thank You
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