The baseline score of 33 in November 2020 highlighted the need for concerted effort and significant resource investment to achieve the goal of international accreditation. Many structural and process gaps were identified – a lot of work was needed to gain compliance.
The Executive Director, with support from the quality assurance office, appointed “service element” leaders, usually heads of departments, to drive quality processes in their respective units. They were trained to understand and implement the standards. Several sessions of staff training were undertaken to demystify areas of quality improvement, resuscitation, infection prevention and control as well as risk management.
The Quality Assurance office coordinated the development of all key documents through hospital committees, especially the Quality Assurance and the Clinical Quality Improvement committees. These documents included policies, manuals, guidelines, standard operating procedures, forms, logs, and templates – both clinical and non-clinical. Staff are continuously trained to use and implement what is written in the documents so that they do not gather dust on a shelf.
An internal audit team was established to support the ongoing self-evaluation cycle. This same team was appointed to mentor and coach staff in poorly performing services.
Following the self-evaluation, the teams were tasked with conducting gap analyses and action planning guided by the Quality Assurance office. This enabled staff to identify specific requirements for resource planning.
Several re-engineering initiatives were undertaken, including the centralisation of autoclaving by merging units into a single central sterile supply department (CSSD), restructuring the Emergency and Surgical Outpatient departments and upgrading the Paediatric ward into a fully-fledged inpatient unit.
Significant facility and equipment improvements were made, notably the renovation of operating theatres and the establishment of a state-of-the-art Organ Transplant Theatre (Dr. Rita Moser Transplant Center).
The COHSASA High Command’ chose to partner with professionals from an accredited facility to conduct an external audit to validate the competency of Lubaga’s internal quality auditors. COHSASA provided virtual support and valuable guidance through remote evaluations by their quality advisors.
To keep staff engaged and motivated, management introduced a Quality Champion recognition initiative, displaying portraits of top-performing units after each self-evaluation period.
