Minutes - ZDSMC - 15mar25 - ZFF

PROVINCIAL LEADERSHIP AND GOVERNANCE PROGRAM

HOSPITAL COACHING SESSION (1^st)

Zamboanga Del Sur Medical Center

By: Dr. Reynaldo Joson (Consultant)

March 25, 2015

Notes/Agreements/Inputs

· The session started around 9:30 in the morning with 18 attendees from Zamboanga Del Sur Medical Center (COH, Chief of Clinics, and Department Heads) – you may refer to the attached Attendance sheet for list of mentees.

· Maternal deaths in the hospital was accounted using the three (3) year records (2012 – 17 deaths; 2013 – 14 deaths; 2014 – 10 deaths), usual causes of deaths were also highlighted (blood loss, Sepsis, eclampsia).

· When the mentees were asked by Dr. Joson what attributes to the reduction, all in unison responded to the following factors: good referral system, blood availability, better access to hospital facilities and improved management of care of patient.

· Dr. Joson emphasizes that when analyzing current statistics both negative and positive causes should be identified. While it is good to see positive causes of its reduction, it is also equality important to highlight negative causes why mothers dying in the hospital like low quality patient care, staffs negative attitude in handling patients, stock outs of medicines, among others. This will bring a more logical way of analyzing health system in the hospital.

· Dr. Blancia pointed out that complaints from RHUs relative to how the patient was managed by her staff have reached her end already and she called for a meeting with all the staff. Accordingly, any complaints directly involved her nurses, doctors, even office staff will be called by the Grievance Committee and appropriate sanction if proven guilty will be administer by the management.

· In line with the coaching scheme in the 6 months frame, Dr. Joson created a program for ZDSMC which now be called as MATERNAL DEATH CONTROL MANAGEMENT SYSTEM. It’s all focus to reducing maternal deaths in the hospital and improving accountability among mentees.

· The main Objective of MDCMS will be “Zero Maternal Death in 2016”

· The people that will be involved in the system are also the identified. The COH will issue a Memo creating the Maternal Death Control Management System with the following compositions;

· OB Gyne

· Anesthesiologist

· ER/Pedia

· Chief of Clinic

· Nurse: OR Head Nurse & Nurse Supervisor

· Head of the Medical Social Services

· Pharmacy (Officer of the Day)

· Management Information System

· Supply

· Hospital Administrator

· Internal Medicine

· Accounting

· The core group will have the following major functions to follow;

§ Develop/ formulate policies, protocols on achieving the group’s objective that is Zero Maternal Deaths in 2016

§ Develop strategy/plan/ comprehensive plan

§ Evaluate the implementation

§ Keep track of the implementation

· Individual roles/functions were also identified and will be included in the department memo that the COH will be issuing within the month.

· The Maternal Death Control Management System will be a sub-set committee of the Hospital Management Committee. A monthly meeting will also be done by the core group.

· Listed in the table below are some of the agreed functions of individual members of Maternal Death Control Management System, viz;

· Dr. Joson told Dr. Blancia that all policies implemented in the hospital should all be supported with Memo. Like in the case of a functioning Nurse Coordinator in the Assigned Floor, this should be supported with Memo specifying that Nurse Coordinator has say in his/her assigned floor --- that even doctors should abide to it.

· Dr. Joson utilized the data of ZDSMC in projecting the minimum level of blood requirement in the hospital based on medical cases re: OB gyne, Surgery, Internal Medicine, and Pedia. It was noted during the analysis of the data, that 72% of the OB cases per month in the hospital need blood; around 20% of the Surgery cases per month also require blood.

· Upon analysis of the team, the hospital will need at a minimum 300 bags/units per month to cover up the blood requirement of all departments in the hospital.

· If this projection is accurate, the available blood at the Philippine Red Cross is not even enough to cover-up the entire Province. At an average, PRC is able to collect blood at an average of 400 bags/units per month and PRC is servicing not just only ZDSMC but including Margosatubig Regional Hospital, and more than ten (10) private hospitals in the Province.

· ZDSMC is encouraged to do their-own mass blood drive to fill in the gap.

· As an input by Dr. Joson, he encouraged Dr. Blancia to create a BLOOD UTILIZATION COMMITTEE in the hospital apart from the existing BLOOD TRANSFUSION COMMITTEE. The BUC will be in-charge for ensuring that hospital blood requirements per month are determined and that blood products are properly utilized.

· Dr. Joson also made some improvements in some of the major indicators in the hospital assessment template after we presented which area at the hospital needs improvement, thus;

The notes in red are some of the indicators that he will be looking into the hospital to be more specific.

· The next coaching schedule of Dr. Joson with ZDSMC will be on April 22, 2015.

· Minutes of the meeting will be provided by Maam Regina Quipot of ZDSMC, since, she was the one assigned by the team during the coaching session.

Prepared by:

Charlou E. Peligro

Associate

ZamPen