CIPE on Evaluation - NDCMS - Certificate of Mastery

Criteria and Indicators for Performance Excellence on Evaluation, Review and Continual Improvement Plan

(For Certificate of Mastery – Minimum Pass Level per CIPE category =75%)

Prescribed contents of Evaluation, Review and Continual Improvement Meetings

The following are the prescribed minimum agenda of Evaluation, Review and Continual Improvement Meetings (those tasks that have been completed for the year may not be discussed or taken up anymore in subsequent monthly meetings):

Agenda

• 1. Call to order

  2. Approval of agenda (see agenda)

     1. Evaluation, Review and Continual Improvement

     2. Prevention and Mitigation - Action Plans and CIPE

     3. Other Agenda (Pls. specify)

  3. Review and approval of minutes of last meeting

  4. Business arising from last meeting (use Task List – Tasks Done / Tasks to Do)

  5. Agenda (presentation, discussion and deliberation)

  6. Other matters

  7. Summary of Proceedings (Tasks List – Tasks Done / Tasks to Do)

  8. Adjournment

Agenda on Evaluation, Review and Continual Improvement:

1. Goals and objectives (authorized functions) of Neonatal Death Control Management System (Evaluation and Identification of Areas for Improvement)

2. Three-year and annual strategic plans of the Neonatal Death Control Management System (Evaluation and Identification of Areas for Improvement) [See Preventive and Mitigation and Action Plans and CIPE]

3. Neonatal Death Review for the Month and Year to Date (Evaluation and Identification of Areas for Improvement)

4. Neonatal Death Audit (Sentinel, Adverse, and Near-Miss Events Review) for the Month and Year to Date (Evaluation and Identification of Areas for Improvement)

5. Statistics on Neonatal Care Services for the Month and Year to Date

6. Customer Feedback (Pregnant Patients) for the Month and Year to Date

7. Results of independent audits (if done)

8. Proposed changes in Manual of Operations of Neonatal Death Control Management System (if any)

Agenda on Prevention and Mitigation - Action Plans and CIPE

• CIPE on System or Program Management

• CIPE on Deployment, Training and Implementation Plan

• CIPE on Evaluation, Review and Continual Improvement Plan

• CIPE on Documentation and Archiving

• CIPE on Management Review and Independent Audit

• Prevention and Mitigation – Action Plans and CIPE – Late Referral

• Prevention and Mitigation – Action Plans and CIPE – Late Consult

• Prevention and Mitigation – Action Plans and CIPE – Indigency Issues

• Prevention and Mitigation – Action Plans and CIPE – Non-availability of Skilled Health Professionals

• Prevention and Mitigation – Action Plans and CIPE – Inadequate Competency of Health Professionals

• Prevention and Mitigation – Action Plans and CIPE – Lack and Unsafe Blood

• Prevention and Mitigation – Action Plans and CIPE – Lack and Unsafe Medicine

• Prevention and Mitigation – Action Plans and CIPE – Lack and Unsafe Supply

• Prevention and Mitigation – Action Plans and CIPE – Lack and Unsafe Diagnostic Equipment

• Prevention and Mitigation – Action Plans and CIPE – Lack and Unsafe Treatment Equipment

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