Assessment of quality of care for children in selected hospitals in ...

Better medicinesfor children in GhanaMinistry of HealthGHANAAssessment of quality of carefor children in selected hospitalsin GhanaDecember 2011

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Assessment of quality of care for children in selected hospitals in GhanaAppendix I: Assessment of the quality of care for children in hospitals ‐‐A generic assessment tool adapted for use in Ghana, June 2010........................................................... 35Introduction ...................................................................................................................................................... 35Overview of the assessment process ............................................................................................................ 361. General hospital information ................................................................................................................. 431.1 Layout of health facility........................................................................................................................................ 442. Hospital support systems ........................................................................................................................ 472.1 Hospital health statistics....................................................................................................................................... 482.2 Essential drugs, equipment and supplies........................................................................................................... 492.3 Laboratory support ............................................................................................................................................... 553. Emergency care.......................................................................................................................................... 573.1 Patient flow ............................................................................................................................................................ 573.2 Staff dealing with emergencies............................................................................................................................ 593.3 Layout and structure of emergency area............................................................................................................ 593.4 Drugs, equipment and supplies........................................................................................................................... 613.5 Case management of emergency conditions...................................................................................................... 614. Children’s ward......................................................................................................................................... 634.1 Staffing and layout ................................................................................................................................................ 634.2 Standards and criteria in the childrenʹs ward.................................................................................................... 645. Case management of common diseases:............................................................................................... 675.1 Cough or difficult breathing ................................................................................................................................ 675.2 Diarrhoea................................................................................................................................................................ 715.3 Fever conditions..................................................................................................................................................... 735.4 Severe malnutrition............................................................................................................................................... 765.5 Children with HIV/AIDS...................................................................................................................................... 796. Supportive care.......................................................................................................................................... 837. Monitoring ................................................................................................................................................. 878. Neonatal care ............................................................................................................................................. 918.1 Nursery staffing and layout ................................................................................................................................. 918.2 Routine neonatal care............................................................................................................................................ 928.3 Nursery facilities.................................................................................................................................................... 948.4 Case management and sick newborn care ......................................................................................................... 969. Paediatric surgery and rehabilitation.................................................................................................... 999.1 Paediatric‐size anaesthesia equipment ............................................................................................................. 10110. Other hospital wards with children .................................................................................................... 10311. Hospital administration......................................................................................................................... 10512. Access to hospital care: Interview with caretakers and health workers ....................................... 107Annex 1: Interviews with caretakers .......................................................................................................... 115Annex 2: Interviews with health workers.................................................................................................. 121Page ii

Assessment of quality of care for children in selected hospitals in GhanaAcronymsAIDSARTARVBMCCFRCSFDHIMSETATGHSHIVICUIMIMCIIMNCIKATHLBWMOHMUACNGNHISNICUOPDRUTFSAMTBUTIWHOAcquired Immunodeficiency SyndromeAntiretroviral TherapyAntiretroviralBetter Medicines for ChildrenCase fatality rateCerebrospinal fluidDistrict Health Information Management SystemEmergency Triage, Assessment and TreatmentGhana Health ServiceHuman Immunodeficiency VirusIntensive Care UnitIntramuscularIntegrated Management of Childhood IllnessIntegrated Management of Neonatal and Childhood IllnessKomfo Anokye Teaching HospitalLow Birth WeightMinistry of HealthMid‐Upper Arm CircumferenceNasogastricNational Health Insurance SchemeNeonatal Intensive Care UnitOutpatient DepartmentReady‐to‐Use Therapeutic FoodSevere Acute MalnutritionTuberculosisUrinary Tract InfectionWorld Health OrganizationPage iii

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Assessment of quality of care for children in selected hospitals in GhanaAcknowledgementsThis study was made possible through funding from the Better Medicines for Childrenproject in Ghana. We wish to thank the steering committee members, especially Mrs MarthaGyansa Lutterodt (Ghana National Drugs Programme) and Mrs Edith Andrews (WHO) fortheir support for this work.We also express our profound gratitude to the following members of the Better Medicinesfor Children Sub‐Committee on Quality of Care for providing technical oversight to theassessment: Dr Cynthia Bannerman, Ag Director Institutional Care Director (ICD), GhanaHealth Service (GHS); Dr Isabella Sagoe‐Moses, National Child Health Coordinator;Professor Jennifer Welbeck, University of Ghana Medical School; and Dr Mary N.A. Brantuo,World Health Organization (WHO).We are grateful to the following individuals who worked tirelessly to adapt the WHOgeneric assessment tools, including: Dr Cynthia Bannerman, Ag Director ICD, GHS; DrIsabella Sagoe‐Moses, National Child Health Coordinator; Professor Jennifer Welbeck,University of Ghana Medical School; Dr Mary N.A. Brantuo, WHO; Dr Emmanuel Addo‐Yobo, Paediatrician, Komfo Anokye Teaching Hospital (KATH); Dr Eric Siffah, Paediatrician,Princess Marie Louise Hospital; Dr Mira Taylor, Paediatrician, Koforiduah RegionalHospital; and Ms Agnes Gbormittah, Deputy Director Nursing, Ridge Hospital.Our Assessment Team visited the facilities to carry out the assessment and put together thereport. Their effort is very much appreciated. Our thanks to: Dr Cynthia Bannerman, AgDirector ICD, GHS; Dr Isabella Sagoe‐Moses, National Child Health Coordinator; Dr EricSiffah, Paediatrician, Princess Marie Louise Hospital; Dr Mary N.A. Brantuo, WHO; DrEmmanuel Dzotsi, Public Health Division, GHS; Dr Nana Yaa Asante, Family HealthDivision, GHS; Dr Kwame Amponsa‐Achiano, Family Health Division, GHS; Dr LarkoOwusu, KATH; Mr Eben Boahene, Greater Accra Regional Health Directorate; Ms EdnaAdzigbli, Institutional Care Division, GHS; Mrs Christiana Akuffo, Institutional CareDivision, GHS; Ms Faustina Asare, Koforidua Regional Hospital; and Mrs Margaret Kyei,Ridge Hospital.Many other people contributed in diverse ways — secretaries, drivers, hospital managementteams, hospital staff, and the staff at the Ghana National Drugs Programme. Our gratitudegoes to these individuals, as well as to the caregivers who patiently responded to ourquestions.Page v

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Assessment of quality of care for children in selected hospitals in GhanaExecutive summaryImproving quality of care is one of the priorities of the Ghanaian health sector and a numberof initiatives have been put in place to achieve this goal, however, progress has been slow.The study, Assessment of quality care for children in selected hospitals in Ghana, was carried outas part of the Better Medicine for Children project in Ghana. Its purpose was to:– assess the quality of paediatric care provided to children less than five years ofage in selected hospitals by comparing aspects of paediatric care provided inthese hospitals with prescribed standards of care;– make recommendations for those facilities that were assessed to improve the gapsidentified that fall within their mandate;– make recommendations to guide national adaptation of guidelines to improve thequality of paediatric care in hospitals.The assessment was carried out in 10 hospitals made up of one specialized children’shospital, two regional hospitals and seven government district hospitals, including one faithbased(mission) hospital.The WHO product, Assessment of the quality of care for children in hospitals: A generic assessmenttool, was adapted by a group of experts using local standards and the WHO Pocket Book ofHospital Care for Children. A team of experienced health workers was trained on the use of thetools. The team then pre‐tested these tools, which were used to collect information from theselected hospitals.The key findings were as follows:– Generally, hospital support systems were adequate (i.e. running water, electricity,backup generator, soap, etc.).– Laboratory support was also good and laboratory results could be obtained inreasonable time (i.e. within two hours), although some hospitals did not carry outcerebrospinal fluid microscopy.– Drugs needed for the management of common childhood illnesses were mostoften available at the pharmacy, but emergency drugs were not readily availableon the wards and in emergency areas.– There was a shortage of professional nurses; in most of the facilities, sick childrenwere cared for by student nurses, health‐care assistants and ward aides who hadinadequate skills and knowledge to do the job.– There were gaps in the case management of common childhood illnesses,especially diarrhoea and malnutrition. Case management protocols andPage vii

Assessment of quality of care for children in selected hospitals in Ghana– Facilitative and clinical supervision must be strengthened at all levels to ensurecompliance with standards.– The Ministry of Health (MOH)/GHS should designate best practice hospitals inpaediatric care and use them for study tours and training sites and promoteregular peer reviews.– The health sector is implementing strategies to improve human resource output.Mechanisms for fair distribution must be instituted, as well as adequatecompensation packages.– The Paediatric Society of Ghana must press for the improvement of services forchildren in line with the recommendations in this report and promote localleadership for improvement among its members.– Cost of hospital care is a significant barrier and communities must be encouragedto register all children in the National Health Insurance Scheme (NHIS) as theyare in the exempt category.Page ix

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Assessment of quality of care for children in selected hospitals in Ghana1. Introduction1.1 BackgroundImproving the quality of paediatric care in hospitals is a key challenge in Ghana. Anassessment of the hospital care for children in 2005 showed that the quality of care was notup to the standards recommended by WHO. 1 Although the hospitals had good infrastructuresuch as available water and electricity, case management of common childhood conditionswas below the recommended standard. Emergency care systems were not well established,there were no triaging systems in place, and the emergency units were not well equipped formanaging emergencies. There was a lack of protocols and guidelines for in‐patient care ofcommon childhood conditions (e.g. severe malaria, pneumonia, diarrhoea, malnutrition andHIV/AIDS) resulting in incomplete assessment, treatment and monitoring of cases. Some keyrecommendations were made following the assessment and included the introduction ofemergency systems and provision of guidelines to support case management.As a result of these recommendations, the first training Emergency Triage Assessment andTreatment (ETAT) was conducted in the country in 2007, using WHO guidelines. 2,3 Thetraining included the introduction of the WHO Pocket Book of Hospital Care for Children, 4which provides guidelines on the management of common childhood illnesses. Trainingcommenced in 2007, but limited funding resulted in the involvement of only a few facilities.An opportunity to scale up this initiative on improving the quality of care has now beenprovided by the Better Medicines for Children (BMC) project, which seeks to improve theavailability and access to medicines for children in the country, in line with World HealthAssembly Resolution 60.20 on BMC. 5 One component of the BMC project is to adapt andproduce guidelines for managing childhood illnesses in Ghana.WHO’s framework for quality improvement for hospital care for children 6 outlines the stepsneeded to guide the quality improvement process in countries. This framework describestwo key steps: 1) identifying stakeholders and 2) a situational analysis.This study assessed current paediatric care in hospitals in Ghana against established andaccepted standards of care. The findings will provide the evidence to guide the nationaladaptation of guidelines and standard‐setting process. It is also aimed at improving thequality of paediatric care in hospitals.1.2 Objectives1. Assess the quality of paediatric care provided to children less than five years ofage in hospitals by comparing aspects of paediatric care provided in hospitalswith prescribed standards of care.2. Make recommendations for those facilities that were assessed to improve theidentified gaps that fall within their authority.Page 1

Assessment of quality of care for children in selected hospitals in Ghana3. Make recommendations to guide national adaptation of guidelines to improve thequality of paediatric care in hospitals.1.3 MethodologyStudy populationTen facilities were purposefully selected for assessment. The selection of the facilities tookinto account regional and ecological differences, facility types (i.e. regional, district andspecialist hospitals), and ownership (i.e. public and private/not‐for‐profit/faith‐based)hospitals. The following facilities were assessed:– Northern Region: Tamale Central and Yendi Hospitals– Volta Region: Volta Regional and Adidome Hospitals– Ashanti Region: Bekwai and St Martin’s (Agroyesum) Hospitals– Greater Accra Region: Princess Marie Louise (a children’s hospital) and AdaHospitals– Western Region: Kwesi Mintim and Tarkwa Government HospitalsA team made up of paediatricians, public health physicians and nurses formed the workinggroup with responsibility to oversee the adaptation process. The Institutional Care Divisionof the Ghana Health Service (GHS) led the process with support and collaboration from theFamily Health Division and the Ghana National Drugs Programme. WHO was part of theworking group and provided technical and administrative support to the process.The WHO generic assessment tool was reviewed and adapted to take into account diseaseconditions and the administrative set up within the health system of Ghana. The clinicalmanagement standards were based on the WHO Pocket Book of Hospital Care for Children, 4 aswell as the Standard Treatment Guidelines for Ghana. 8Ten assessors were selected to ensure a doctor–nurse team in each of the facilities to bevisited. The assessors were trained on the use of the adapted tools, followed by pre‐testing intwo hospitals not included in the facilities to be assessed. They worked together in teams andagreed on common criteria for assessing key areas of the facility as good or needingimprovement.Page 2

Assessment of quality of care for children in selected hospitals in GhanaFacility visits were conducted from 7–10 June 2010 by five teams of assessors. Each teamcarried out the assessment of a hospital over a two‐day period. Each assessment was donethrough interviews with hospital managers and other health staff, review of documents andpatient records, observation of patient management procedures, and interviews with staff, aswell as caretakers of children. Information was gathered on:– child morbidity and mortality;– facility supports (i.e. drugs, equipment, supplies and laboratory services);– emergency care;– case management for neonates and children under five years of age;– hospital set‐up to care for children;– monitoring and supportive care;– care‐seeking.This assessment was considered to be a quality improvement exercise; for this reason, ethicalclearance was not obtained. Letters were written to inform the regional and medicalsuperintendents of the selected facilities for the visits, and follow‐up calls were made toensure facility management were aware of the assessment.At the end of the assessment, the assessors debriefed the hospital managers and some keyhospital staff. Each meeting presented the key findings of the assessment, focusing on thestrengths and weaknesses observed and discussing actions to improve the care delivered.2. Key findings2.1 General hospital informationThe facilities visited included one specialized children’s hospital, two regional hospitals andseven district hospitals, one of which was a faith‐based hospital. Two of the facilities werelocated in the northern zone, three in the middle belt, and five in the southern zones of thecountry. Four of the hospitals were in urban areas, while six were located in rural areas.Layout of the facilityThe hospitals did not have separate outpatient departments for children. Similarly there wasno separate emergency area or ward for children in any of the hospitals visited. Theemergency area was part of the general outpatient department (OPD) in most cases. All thehospitals visited had separate admission wards for children, and only four out of 10 hadseparate wards for sick newborns. For the hospitals that had isolation wards, none had aseparate paediatric isolation ward. There was no neonatal intensive care unit (NICU) in anyof the hospitals assessed.In six hospitals, the ward layout was such that children who were very ill were closest to thenurses’ station and therefore could receive more attention. Eight of the 10 hospitals had atPage 3

Assessment of quality of care for children in selected hospitals in Ghanaleast one qualified nurse per shift and this was complemented with auxiliary staff; e.g. wardassistants, health‐care assistants and student nurses. Two facilities kept sick children on thefemale ward during peak seasons, and neonates in the maternity ward as their neonatal unitswere not well equipped. One facility – a newly established district hospital referred all sickneonates to the next referral level – the regional hospital. In four of the hospitals, all childrenwith surgical conditions were referred to other hospitals either because there were notheatres or no expertise to take care of them. In hospitals where paediatric surgeries wereconducted, children were either admitted to the general paediatric ward or to the adultsurgical ward.In one hospital, there was no doctor assigned to the paediatric ward; doctors had to be calledon an ad hoc basis to attend to children which poses a challenge to under‐five and paediatriccare. Assessors in one urban hospital observed that the shift system was especially weak asdoctors do not wait to hand over before leaving their shift. Most hospital OPDs close at 17:00,after which children with emergencies were admitted straight to the wards.2.2 Hospital infrastructure systemsTable1: Availability of hospital infrastructureNumber of facilitiesOPD/EmergencyWardsElectricity continuously available 8 7Backup power supply in the event of apower cut9 8Running water (pipe-borne)10 10Soap and/or disinfectant available 10 9A sharps disposal box available6 8Functioning refrigerator available for drugs 3 8Functioning refrigerator available forvaccinesInformation desk or complaints/ suggestionbox 9 1CommentsDeep wells or bore-holes wherethe national water system wasunavailable.Some of the boxes wereimprovised.Vaccines usually kept at theReproductive and Child HealthUnit of the District HealthAdministration.The nurses’ station served thepurpose of information desk onthe ward.Page 4

Assessment of quality of care for children in selected hospitals in GhanaGenerally, the support system was good.However, hospitals face power supplyinterruptions from the national grid, whichaffect the running of the emergencyarea/OPD and wards. Most of the hospitalsassessed have a backup power supply.With the exception of one hospital, most ofthe backup power was from generators.Generators were usually turned off afterabout 22:00.Veronica Bucket available in facilities that may nothave a consistent supply of running tap waterRunning water was available in the children’s ward and the emergency/OPD in all hospitals.For some hospitals, where the national water system was unavailable, water is piped in fromdeep wells or bore‐holes. Soap and disinfectants were available in the emergency areas orOPD and the children’s ward in most hospitals. There was a functioning refrigerator fordrugs in the children’s ward in most of the hospitals, but this was not common in theemergency area or OPD. These refrigerators were used to store medicines, as well as waterand food for staff in some of the hospitals.Refrigerators for vaccine storage were normally found in the Public Health unit in most ofthe hospitals and not on the children’s wards or in emergency areas or OPDs. Informationdesks were available in the emergency area or OPD, while the nurses’ station served thepurpose of information desk on the children’s ward in most of the hospitals.Hospital health statisticsThe 2009 data available from six facilities show that the total annual outpatient attendance ofchildren less than five years of age ranged from 3437 to 16748 children, for an average dailyattendance ranging from 9 to 45 in the respective facilities. Age‐specific case fatality rate(CFR) was between 1% and 2% for all age groups in under‐fives. The hospitals’ annual healthstatistics were based on the District Health Information Management System (DHIMS). TheDHIMS was not disaggregated to track children’s emergencies and neonates, as indicated inthe standards used.The top five causes of admissions and deaths in children were similar in all the hospitals andincluded malaria, anaemia, acute respiratory infections/pneumonia, diarrhoeal diseases andsepticaemia. In hospitals where surgeries were conducted, the top five most commonPage 5

Assessment of quality of care for children in selected hospitals in Ghanasurgeries included incision and drainage, hernia repair, hydrocoelectomy, excision of lumps,and repair of lacerations. Circumcision was commonly performed in the hospitals but notdocumented, thus records were not available in most cases. Additional surgeries carried outwere reduction and immobilisation of fractures in one regional hospital, and skingrafting/reconstructive surgery in a district hospital within a buruli ulcer endemic area.Essential drugs, equipment and suppliesThe full complement of essential drugs, equipment and supplies needed for paediatric carewere not available in all the facilities as shown in the table below. In some facilities, drugswere available at the pharmacy but were not found at the emergency area or ward. Alsosome programme drugs, such as anti‐tuberculous drugs, were managed at the DistrictHealth Directorate. Essential equipment and supplies, such as oxygen, nebulizers andglucometers, were not available in some children’s units.The hospital laboratories provided 24 hour support services in all the facilities visited,however some tests, such as cerebrospinal fluid (CSF) microscopy, blood grouping andcross‐matching, were not available in some of the facilities. If a differential diagnosis ofmeningitis was made, there was usually no way of confirming it due to the absence of a CSFmicroscopy test. In the case of one hospital, a private firm provides laboratory services.In most facilities, other emergency laboratory tests, such as haemoglobin, blood film, andgrouping and cross matching, were provided not only during regular business hours, butalso at night, at weekends and during holidays. Most of the laboratory tests were able to bedone within two hours and for inpatients, the results were obtained within 24 hours.Table 2: Availability of drugs, equipment, supplies and laboratory supportNumber of facilities out of 10 found to be:Care assessed Good In need of someimprovementCommentsAvailability of essential drugs 4 6Availability of paediatric equipment 2 8 Infant-sized equipment notavailable in some facilities.Adequate equipment is available inthe emergency area and on theward2 8Essential laboratory tests availableand timely2.3 Emergency care servicesPatient flow4 6 Testing for CSF not available inall facilities.There was no separate outpatient department for children in any of the health facilities andchildren joined adults in the same queue for their hospital cards in all the facilities. Therewere designated health professionals to see sick children at the OPD in three facilities. Twohad paediatricians, while in the other a staff member trained in integrated management ofchildren’s illnesses (IMCI) solely sees children less than five years of age. All sick children atthese three facilities, including emergencies and severely ill children, were received at thesame place in the OPD.Page 6

Assessment of quality of care for children in selected hospitals in GhanaNone of the facilities had the requisite layout, protocols, medications and staff capacity toprovide emergency services according to the standards, as shown in Table 3.Table 3: Management of emergenciesNumber of facilities out of 10 found to be:GoodNeeds to beimprovedLayout and physical structure of the1 9emergency departmentAdequate staffing 0 10CommentsAvailability of essential drugs 5 5Availability of essential laboratory6 4supportAvailability of essential equipment 2 8Practice and case management ofemergency conditions3 7A triaging system was in place in only one hospital where the health‐care assistant is trainedin Emergency Triage and Assessment and Treatment (ETAT). Health workers in otherhospitals identified seriously ill children using a range of systems from a nurse going roundlooking for seriously ill children to announcements through a public address system callingfor mothers with seriously ill children to report at the nurses’ station. In the absence ofproper triaging, seriously ill and emergency patients were missed and had to wait in thequeue to be seen. The exception was those with obvious emergencies, like seizures.Qualified health professionals were always available but most of them have not been trainedin ETAT and therefore do not have adequate skills to manage emergencies. Protocols, or jobaids to guide the management of emergencies, were not available in most of the facilities.The few that were displayed need to be updated and also contained very scanty information.Commonly displayed on walls were memos and notices that were very old, having outlivedtheir usefulness and no longer relevant to the care of sick children. Three facilities had somestaff trained in ETAT, as well as charts and protocols displayed on the walls in the children’sward.Page 7

Assessment of quality of care for children in selected hospitals in GhanaProtocol for treatment ofhypoglycaemia displayed onthe wardThere was a system forreceiving referrals fromlower levels of care,however referral noteswere found to beincomplete and hadinadequate information tohelp with the managementof sick children at thereceiving facility.Staff dealing with emergenciesIn all of the facilities, the various categories of health workers who take care of children withemergency needs were inadequate in number. As a result, health‐care assistants or wardassistants received and managed children with emergencies in most facilities due to thelimited number of qualified health professionals.Layout and infrastructure of the emergency areaDistance from the consulting rooms to the emergency management area in most of thefacilities was ranged from seconds to a few minutes’ walk (in one case, a maximum 3minutes), and were within the same building. With the exception of one, most facilities didnot have emergency rooms and had either improvised an area in the OPD or on the ward forthis purpose. In most cases, these areas were not well equipped to take care of sick childrenin emergency situations.Medicines, equipment, and suppliesEssential medicines and supplies were inadequate and not immediately available for use;some basic equipment was not in good working order. None of the facilities have all themedicines or equipment required to provide appropriate care for children in an emergencyarea.Page 8

Assessment of quality of care for children in selected hospitals in Ghanalodging facilities for caretakers were not in existence, and toilets and bathrooms for sickchildren and their carertakers were inadequate and in poor condition. However, the wardswere fairly clean and dangerous items were kept out of the reach of children.Paediatric ward staffingThere was a shortage of all categories of health workers in all the hospitals visited. In somefacilities, children’s wards were being managed by student nurses or health or wardassistants. However, there was always a doctor or medical assistant on call.2.5 Case management of common conditionsCough or difficult breathingAs shown in Table 4, health workers correctly assessed and diagnosed pneumonia andrecognized severity of illness in three out of the 10 facilities. In the other facilities, althoughcorrect diagnosis was made, there was no classification of the severity of the pneumonia.The signs required for diagnosing and classifying pneumonia, such as respiratory rate, chestin‐drawing and subcostal recession, were not documented. This was important indetermining the level of care for the sick child, as well as in reviewing the patient toascertain if there had been an improvement or deterioration in their condition.Once the diagnosis of pneumonia was made, administration of antibiotics was consideredappropriate in all facilities. Broad spectrum antibiotics, such as ampicillin, gentamycin orceftriazone, were given. Patients with pneumonia were regularly reviewed in eight out ofthe 10 facilities and other diagnoses were considered.Table 4: Management of cough or difficult breathingStandards of care assessedPerformance of hospitals(Number of hospitals out of 10)GoodNeeds to beimprovedCough/difficult breathingSeverity of pneumonia is correctly assessed and diagnosed 3 7Appropriate antibiotics are administered for pneumonia10 0Oxygen is correctly administered when necessary 8 2Correct use of chest x-ray 5 5Appropriate diagnosis and management of tuberculosis 6 4Inhaled bronchodilators are given appropriately, when indicated 7 3Patient monitoring appropriately performed and charted 2 8Supportive care provided appropriate for condition 3 7In most facilities, oxygen was administered correctly to all children who needed it usingnasal prongs or nasal catheters. However, in some cases, nasal prongs were reused. Somehealth staff used a much higher rate of oxygen flow compared to the recommendedstandard of 1‐2 litres per minute.Page 10

Assessment of quality of care for children in selected hospitals in GhanaThe use of chest X‐rays in the diagnosis and management of pneumonia was good in fivefacilities. In the others, chest X‐rays were not requested for young infants with pneumonia,and in one facility chest X‐ray equipment was not available.Asthma was considered as a differential diagnosis of wheezing illness and children in needof bronchodilators were correctly identified or diagnosed. However, the management wasinadequate as inhaled bronchodilators (including nebulizers) were available in only half ofthe facilities assessed. Follow up of children with asthma varied. It was best in one hospitalthat had an asthma clinic.Anti‐tuberculous treatment was given according to national guidelines in six facilities. Inone hospital, cases with tuberculosis (TB) were referred to the regional hospital formanagement as the unit was not yet set up. In other hospitals, TB was not considered as adifferential diagnosis in unresolved pneumonia or malnutrition as recommended by thestandards.Diarrhoeal conditionsTable 5: Management of diarrhoeal conditionsStandards of care assessedPerformance of hospitals(Number of hospitals out of 10)GoodNeeds to beimprovedDiarrhoeaDehydration is correctly assessed 5 5Rehydration plan is appropriate to severity of dehydration, andrehydration appropriately monitored 4 6Appropriate antibiotics only given when necessary 7 3Appropriate (continued) feeding given during diarrhoea2 8From the review of patient case notes, it was observed that the signs for assessingdehydration were not documented, and dehydration was not correctly classified in half ofthe facilities. An adequate rehydration plan for managing diarrhoea was observed in lessthan half of all facilities. Some hospitals indicated the plan being used, whereas others gaveno indication. Children were put on intravenous fluids — 1/5 normal saline in dextrose,ringers lactate, normal saline or oral rehydration therapy — however, they were notmonitored appropriately.There were no input–output charts for the children with diarrhoea. Antibiotics wereinappropriately used in the management of diarrhoea in three out of the 10 hospitals. Cotrimoxazole,amoxicillin, or metronidazole were given in cases of diarrhoea when no signsof dysentery were present. In accordance with set standards, proper anti‐diarrhoea drugswere not administered in any of the hospitals. Feeding of children with diarrhoea wasappropriate in only one facility. In the other facilities, there was no supervision ordocumentation of feeding by hospital staff, hence caregivers fed children using their owndiscretion. This has implications for the quality of care as traditionally food was withheldfrom children with diarrhoea. Related to this area of weakness was the inadequatePage 11

Assessment of quality of care for children in selected hospitals in Ghanamonitoring and supportive care provided to children being treated for diarrhoea. This wasattributed to the limited numbers of nursing staff available to care for the patients on theward.FeverThe assessment of fever considering differential diagnosis for other possible conditions wasappropriate in three facilities (see Table 6). Some gaps observed in the other facilitiesincluded inadequate assessment and investigation to exclude other infections of the ear,throat and urinary tract.Table 6: Management of feverStandards of care assessedPerformance of hospitals(Number of hospitals out of 10)GoodNeeds to beimprovedFeverDifferential diagnosis of fever considered and appropriate investigationsundertaken 3 7Correct diagnosis and management of meningitis 4 6Severe complicated malaria correctly managed 6 4Measles correctly managed 7 3Other febrile conditions correctly managed 7 3The diagnosis and management of meningitis was adequate in four facilities. In facilitieswhere cerebrospinal meningitis was commonly seen during outbreaks, there was a systemin place to perform lumbar punctures to confirm diagnosis. In other facilities, lumbarpunctures were infrequently done due to limited expertise or the inability of the laboratoryto conduct microbiological tests. Despite these limitations, once meningitis was suspected,adequate antibiotic treatment was started without delay in all but one facility. The preferredtreatment for meningitis in that facility was cefuroxime (a second‐generation cephalosporin),which is not the drug of choice for meningitis. The recommended drug for meningitis wasceftriaxone (a third‐generation cephalosporin) which was available in that facilityThe complications of meningitis, such as hypoglycaemia and convulsions, were wellmanagedin five hospitals. In the other hospitals, random blood sugar testing was not donefor patients who were not on the National Health Insurance Scheme because of cost. Alsosome facilities gave dextrose intravenously, but did not pass nasogastric tubes for continuedfeeding. Monitoring of patients with meningitis was found to be inadequate as the state ofconsciousness, respiratory rate and pupil size were not charted.Diagnosis of malaria was confirmed in all facilities by microscopy or rapid diagnostictesting. The signs and symptoms required for making a diagnosis of severe malaria were notdocumented in a number of facilities. Intramuscular quinine was given in most facilities forsevere malaria. One facility was found to be giving intravenous quinine, which needs veryclose monitoring and was not available in this particular hospital. Another facility gavePage 12

Assessment of quality of care for children in selected hospitals in Ghanaintramuscular (IM) artemether to all suspected malaria cases irrespective of the severity. Inone instance, a child was observed receiving both IM artemether and quinine.MalnutritionThere were gaps in the assessment and diagnosis of children with malnutrition in most ofthe hospitals (see Table 7). Although the weight of children was measured, this was not usedto plot the weight for age; as a result, children with various severities of malnutrition werelikely to be missed. In cases diagnosed as severe malnutrition, laboratory examinations wereinadequate to determine underlying or concurrent infections and the history was notdetailed enough to establish the social circumstances of the child. Only three facilitiesinvestigated associated conditions with severe malnutrition, such as tuberculosis and HIVinfections. More than half of the hospitals managed infections appropriately by giving broadspectrum antibiotics. Also Vitamin A and other vitamin supplementation were given toaddress micronutrient deficiencies.Table 7: Management of malnutritionStandards of care assessedPerformance of hospitals(Number of hospitals out of 10)Good Needs to beimprovedMalnutritionNutritional status assessed by weight for age/Mid-upper arm1 9circumference (MUAC), including differential diagnosis for severemalnutritionManagement of infection 6 4Management of electrolyte imbalance and micronutrients 1 9Correct management of dehydration 4 6Hypoglycaemia and hypothermia checked and managed in children with2 8severe malnutritionCorrect feeding of severely malnourished children 1 9Correct management of associated conditions 3 7Rehydration Solution for Malnutrition (Resomal) and low sodium content solution formanaging dehydration in malnourished children were not available in most facilities.Potassium supplements were considered in only two facilities. In one of these, potassiumrichfoods, such as bananas, were incorporated into the meal plan. In the other facility,special preparations for malnutrition which contain potassium (F75 and F100) wereavailable.The actions taken to prevent and manage hypoglycaemia and hypothermia were inadequatein more than half of the facilities visited. In a few facilities, caretakers were asked to clotheand cover their children to prevent hypothermia. In other facilities, no instructions weregiven. There were no systems in place to ensure frequent feeding of severely malnourishedchildren both during the day and night. There were feeding charts in a few instances;however, caretakers were not given guidance on how often to feed their children. Bloodglucose levels were not checked for those without health insurance on account of the cost.For other children, this was not monitored during the night in some facilities.Page 13

Assessment of quality of care for children in selected hospitals in GhanaSeverely malnourished children were correctly fed in two of the facilities visited.Commercially prepared or ready‐to‐use therapeutic foods (RUTF) and regimens, such asF75, F100, and “Plumpy’nut”, were not available in several of the facilities. In two facilities,F75 was prepared by the hospitals using milk, sugar, vegetable oil and cereal flour asrecommended in the recipe. In another facility where “Plumpy’nut” was available, it wasnot used in accordance with the standards established for managing children with severemalnutrition. Frequent feeding during the day and night was observed in only two facilities.Generally, the feeding was left to the caretaker with no guidance on frequency. There wasno documentation in most facilities to indicate the daily intake and weight gain ofmalnourished children, which is critical for monitoring a child’s progress.Most facilities observed correct treatment of associated conditions of malnutrition. Otherclinicians, such as the eye nurse, were involved in the management of various conditionsassociated with malnutrition. There were no protocols in place for managing malnutrition inmost facilities and this was compounded by the lack of dieticians to provide guidance inmost hospitals on feeding malnourished children.Also, children with severe anaemia received blood transfusions. Sensory stimulation forchildren with severe malnutrition, through the provision of toys for play, was good in onlytwo facilities.HIV/AIDSTable 8: Management of children with HIV/AIDSStandards of care assessedPerformance of hospitals(Number of hospitals out of 10)GoodNeeds to beimprovedChildren with HIVHIV tests used correctly and when indicated 10 0Professional counselling services are in place with confidentiality ensured 9 1Antiretroviral (ARV) treatment follows national guidelines 8 2Nutritional advice provided 7 3Immunizations and co-trimoxazole-prophylaxis administered correctly 10 0Opportunistic infections correctly diagnosed/treated 8 2Patients are referred for home-based care and palliative care focuses onsymptom control 4 6The management of HIV/AIDS was found to be either good or in little need of improvementin nine of the facilities visited. There were protocols for managing patients, in the form ofcharts, booklets and patient folders, which provided detailed guidance for the health staffmanaging the cases. The main area of weakness was supportive care and follow up oninfected children.Page 14

Assessment of quality of care for children in selected hospitals in GhanaA few hospitals did not have any links for referring patients to home‐based care groups.Health workers observed that some of the patients lost interest in these groups after a shortperiod of engagement. It was also observed that in cases where a child’s parents had died,the caregivers were more reluctant to attend follow up.2.6 Supportive careStandards of care assessedSupportive careTable 9: Provision of supportive carePerformance of hospitals(Number of hospitals out of 10)Good Needs to beimprovedNutritional needs are met, according to age and ability to feed 0 10Breastfeeding is promoted 7 3Intravenous fluids given only when indicated; appropriate choice of0 10fluids, and monitoring of rateDrug treatment according to diagnosis; polypharmacy is avoided 6 4Blood transfusion only when indicated; blood is screened, rate monitored 4 6Health workers did not pay particular attention to the nutritional needs of children admittedwith HIV/AIDS. Full nutritional needs, according to age, were mostly not met, particularlyfor infants aged six to 12 months. In some facilities, children were fed up to three times aday, but there was no supervision to ensure these foods were in appropriate forms or wereconsumed by the children. Also no consideration was given to ensure that calorierequirements were met. Breastfeeding infants was encouraged by health workers; howevermothers were not supervised or assisted to breastfeed.Inappropriate drug treatment and polypharmacy were found in fewer than half of thehospitals visited. Some examples include the use of antibiotics for treating diarrhoea with noindication of dysentery and the use of antihistamines to stop vomiting in children.2.7 MonitoringOnly one facility properly assessed the nutritional status of children admitted to its facility(see Table 10). Although the children were weighed in some facilities, there was noassessment of their weight for age; as a result, cases of malnutrition were likely to be missed.A typical case was observed in which a one‐year old child, who had been to the facilityseveral times throughout the year, was never recorded as malnourished until beingdiagnosed with severe malnutrition.Page 15

Assessment of quality of care for children in selected hospitals in GhanaTable 10: Monitoring progress of admitted childrenStandards of care assessedMonitoringPerformance of hospitals(Number of hospitals out of 10)Good Needs to beimprovedNutritional status is assessed in all admitted children 1 9Each child’s progress is individually monitored, and charts are used 2 8The most ill children receive the highest attention 4 6All admitted children are appropriately reassessed by a nurse 5 5All admitted children are appropriately reassessed by a doctor 7 3Monitoring of patients’ progress was not done in most of the facilities. A monitoring planwas available in only two facilities to assess the severity of a patient’s condition at the timeof their admission. Standard monitoring charts were available for tracking temperature,pulse, respiratory rates and treatments given, but weight, blood pressure and feeding ofchildren were not routinely monitored. It was also observed that vital signs were notchecked correctly. In other facilities, only temperature was routinely checked and othersigns, such as pulse and respiratory rate, were not monitored, even in children with allforms of pneumonia. Inadequate staffing was given as the reason for not monitoringpatients correctly. In addition, some of the health workers lacked adequate knowledge andskills to identify complications and assess the severity of illness. In one facility, the onlyqualified nurse on the children’s ward was on duty from the morning until 15:00, sosupervision was not adequate in the afternoons, at night, at weekends or at holidays.The doses and times for administering medications were properly documented in more thanhalf of the facilities. The main gap observed in most facilities was the inadequate monitoringof administered intravenous fluids. There were no input and output charts, and there wereno intravenous infusion (giving) sets to regulate the amount of fluid a child received(dorsiflow infusion sets, or infusion sets with calibrated burettes). The exception was in thespecialized children’s hospital, where monitoring of malnourished children was found to begood. In this facility, oxygen saturation was also checked in children with respiratorydistress.In eight facilities, patients who were admitted were seen by a doctor at least once a day. Intwo facilities, the number of doctors and nurses assigned to the children’s ward wasinadequate. As a result, children were reviewed once or twice a week by a doctor.Follow up of children after discharge was not routinely done in any of the visited facilities.In one facility, a staff member indicated that provisions were made for follow up, butcaretakers and patients usually did not return. A discharge note explaining the child’scondition was not always provided due to heavy workload and inadequate staffing.Page 16

Assessment of quality of care for children in selected hospitals in Ghana2.8 Neonatal careNursery staffing and layoutThere was generally a shortage of staff designated for neonatal care in all of the facilities.However, staff were available on call during the weekends and at night to attend todeliveries. Only three facilities had nurseries for sick newborns, two of which had limitedcapacity for all the cases seen. The absence of nurseries was due mainly to inadequate space.At one of the regional hospitals, the nursery was not in operation due to staffing shortages.Sick neonates born outside the hospital or those older than two weeks were admitted to thechildren’s ward. In other facilities, all sick newborns were admitted to the children’s ward orthe maternity ward. These wards were not well equipped with appropriate equipment vitalfor managing neonates.Routine neonatal careTable 11 shows a breakdown of facilities that adhered to various standards of routineneonatal care. Nine facilities out of the 10 visited conducted deliveries.Table 11: Routine care for newbornsStandards of care assessedPerformance of hospitals(Number of hospitals out of 10)Good Needs to beimprovedRoutine neonatal care assessed in nine facilities conducting deliveriesResuscitation procedures are correctly performed 5 4Early and exclusive breastfeeding is promoted, skin contact is ensured 9 1Clean delivery and newborn care is practiced 8 1Thermal protection is practiced 7 3Eye and Vitamin K prophylaxis and immunizations are given 3 7Five of the facilities had written guidelines for neonatal resuscitation based on WHOrecommendations, as well as resuscitation equipment, such as functioning, self‐inflatingbags with newborn and premature size masks. It was observed that where guidelines wereavailable, they were not always followed. Facilities that applied the guidelines had staff whohad been trained in their use.Early and exclusive breastfeeding and skin contact was initiated immediately within the firsthalf‐hour post‐delivery in all nine facilities where deliveries took place. Infant formula wasnot promoted by staff or distributed to mothers.Clean delivery were conducted using sterile instruments and proper hand hygiene, i.e. birthattendants washed their hands before and after each delivery, wore gloves and usedsterilized instruments.Good thermal care for neonates was practiced in seven out of nine hospitals that conductdeliveries. The newborns were kept in a warm room, wrapped with dry cloth, and given totheir mothers for breastfeeding. Bathing was done six hours post‐delivery. ProblemsPage 17

Assessment of quality of care for children in selected hospitals in Ghanaidentified in the two facilities that needed improvement were early bathing of neonates (i.e.within 30 minutes of delivery), and inadequate monitoring of body temperature.Eye prophylaxis, Vitamin K (ketamine), and immunizations (BCG for TB and OPV0 forpolio) were given according to national guidelines in only three facilities. In one facility, itwas explained that the evidence for giving Vitamin K was not clear to them, and noproblems had been observed among neonates who had not received it. Because of this lackof clarity, the doctor in charge questioned the need for administering Vitamin K to normalneonates with no bleeding disorder.Nursery facilitiesOnly nine of the 10 facilities visited admitted sick newborns.Table 12: Services for sick newbornsStandards of care assessedNursery facilities admitting newbornsPerformance of hospitals(Number of hospitals out of 9) 1GoodNeeds to beimprovedThere is a separate room for sick newborn babies and their mothers 0 9There are hygienic services for the mothers of newborns 5 4Clean ward; accident prevention and disposal of sharps is in place 6 3Closest attention for the most seriously ill newborn is ensured 4 5In all of the facilities, the nurseries for sick newborns needed improvement. In one of thefacilities, (a district hospital) all sick newborns were referred to the next referral level – theregional hospital in that locality. In the other facilities, most of the neonates were kept witholder children or in the maternity ward. The few facilities that had separate nurseries werenot well equipped for the care of neonates. The facilities where mothers and their babiescould be in the same room were not adequate. At least half of the facilities had suitablehygienic services for mothers, and clean wards with good disposal of waste. Less than halfof the wards were organized such that seriously ill infants were closest to the nursingstation.Case management and sick newborn careNeonatal sepsis was diagnosed based mainly on clinical signs and symptoms; appropriateinvestigations like blood culture, urine microscopy and lumbar puncture were notperformed in most facilities. The treatment of neonatal sepsis was good in more than halfthe hospitals assessed (see Table 13). Appropriate antibiotics were given according to weightand 4‐hourly temperature charts were used to monitor the response to treatment.1Out of 10 facilities, only nine admit newborns. Data reflect this number.Page 18

Assessment of quality of care for children in selected hospitals in GhanaStandards of care assessedSick newbornsTable 13: Management of neonatal conditionsPerformance of hospitals(Number of hospitals out of 9)Good Needs to beimprovedNeonatal sepsis is appropriately diagnosed 2 7Neonatal sepsis is appropriately treated 6 3Specific feeding needs of sick young infants and those with low birth3 6weight are metJaundice is adequately recognized and managed 3 6Mothers were encouraged to breastfeed, but there were no feeding charts to monitor intake,particularly by low birth weight neonates. There were no dosiflow or infusion (giving) setswith calibrated burettes to adequately monitor intravenous fluids and prevent fluidoverload. Kangaroo mother care was practiced in very few hospitals. Only two hospitalswere set up for exchange transfusion and phototherapy, although all the laboratories couldmeasure serum bilirubin levels. In one facility, jaundiced neonates were put in the earlymorning sun.2.9 Paediatric surgerical care and rehabilitationThe standards of paediatric surgical care and rehabilitation are shown in the box below.Standards of paediatric surgical care and rehabilitation– Pre‐operative care was child‐friendly and fasting was kept to a minimum.– Intra‐operative routine procedures prevent hypothermia and hypoglycaemia.– Post‐operative care ensures safe recovery, including monitoring, pain relief andearly feeding.– The surgical ward was child friendly, provided food for children andopportunities for play.– Paediatric size anaesthesia equipment was available (see Table below).– Basic rehabilitation equipment was available.Four facilities did not have surgical theatres and thus referred all surgical cases to betterequippedhospitals. Only one facility had written standard procedures (i.e. a surgical preoperativechecklist) in place to prepare a child for surgery. None of the facilities had writtenguidelines for the safe use of local anaesthetics. In most cases, the surgeon’s notes on theprocedures that were performed were scanty.Post‐operative monitoring was infrequent due to staff shortages and inadequateinfrastructure. Oxygen and suction equipment were readily available in most cases, butthere were no guidelines on post‐operative pain management. After surgery, children wereallowed to eat only after the doctor had seen the patient and given the go ahead. In all cases,Page 19

Assessment of quality of care for children in selected hospitals in Ghanamedical and surgical cases were kept in the same room. Some facilities had a few toys forchildren to play with. Physiotherapy and rehabilitation facilities were available in only onefacility. Staff complained that items like toys and crutches were often lost after children weredischarged. Paediatric blood pressure cuffs were only used in one facility where thephysiotherapy unit was privately owned and a patient could be seen for GHC 5.00 a day.2.10 Other hospital wards with childrenOnly two of the facilities admitted children in wards or units other than the children’s ward.Children at these hospitals were either kept in the female ward during peak seasons or inthe maternity ward, since the neonatal units were not well equipped. Very sick neonateswere referred to other hospitals.Staffing was inadequate in all the wards. Midwives on the maternity ward also attended tosick neonates in addition to their mothers, thus compromising the level of monitoring for theneonate and the mother. Supplies and equipment, such as oxygen, were also inadequate andlimited in quantity.2.11 Hospital administrationAvailability of adequate and updated treatment guidelinesRecent paediatric textbooks were found in two of the facilities. In the other facilities, a mix ofcurrent and out‐dated textbooks were found. Standard Treatment Guidelines were common,but there were no complementary wall charts or protocols. Wall charts and protocols onnewborn resuscitation, in particular, were also not seen in most of the facilities. The mostcommonly seen charts were for managing fever, convulsions, and hypoglycaemia. Othersincluded information for managing sickle cell crisis, cerebral malaria, asthma, severeanaemia and diarrhoea.Performance of auditsAudits were organized in various forms in the facilities. A few facilities held audits once amonth, while others held them when “time allow[ed]”. Clinical meetings were not a regularfeature in most of the facilities. In a few facilities, the conduct of mortality audits wasregular, but there was no clarity on the follow‐up actions to address problems identified.Not all the required staff categories participated in the audit meetings.Transport for referralEight of the facilities assessed had ambulances, most of which were in poor condition. Somefacilities relied on the National Ambulance Service, but this was sometimes unreliable. Firstlevelfacilities lacked ambulances.2.12 Access to hospital careReferral by first level or primary health careReferral notes written by first‐level workers did not have IMCI classifications. In somedistricts, medical assistants in surrounding subdistricts had been trained in IMCI, but thePage 20

Assessment of quality of care for children in selected hospitals in Ghanaclassifications were not being used. In addition, not all patients who were given referred hadnotes. In some of the cases, patients’ referral notes were not completely filled out (e.g. prereferraltreatments or signs and symptoms of illness were not provided).Transportation to hospitalsGeographically, most of the hospitals were accessible to their patients. For those living inisland communities, hospitals were not situated in favourable areas as clients/patients had torely on boats for transportation. Referrals were sometimes delayed due to a lack of transportoptions. A majority of those who were interviewed came to hospitals by commercialtransport, such as taxis or minibuses. Only a few travelled in private vehicles. In all cases,availability and cost of transportation, especially in chartered taxis in the case ofemergencies, was very expensive, often costing as much as GHC 30.00 within the Accrametropolitan area.Care-seeking by parentsMost caretakers who were interviewed were able to recognize the signs and symptoms thatrequire a visit to a hospital. However, despite this recognition, there were significant delaysdue to a number of factors, including: ignorance, cultural beliefs, lack of money,transportation difficulties, and so forth. Some caretakers said they visited chemical orpharmacy shops first before going to a hospital. For others, the hospital was their firstchoice. Caretakers of non‐insured children delayed reporting to a hospital because of costimplications; in some cases, seeking care from a prayer camp or traditional healer was acheaper alternative.Cultural beliefs posed a barrier to care‐seeking. One caretaker said “I strongly believe intraditional medicine but only when the child is more than a year old, by which time thechild’s intestines would be mature. I brought my child here because he is not yet one‐yearold”.In another situation, a child who had convulsions was carried upside down and given to amale to send to a herbalist. Another child with fever was given herbal nasal drops and anenema. This child did not get better and only then was brought to a hospital. In the case ofcaretakers and patients from island communities, care seeking was hindered by thegeographical location of health facilities.Economic barriers to hospital careThe majority of clients or patients who visit some hospitals are not insured. Hospital feespose a major barrier to hospital care for these clients. Some caretakers said they borrowedmoney for the care of a child, while others said they brought the child to the hospital withthe hope that they would be allowed to pay the facility in instalments. Hospital fees werenot officially communicated to caretakers. A few of those who were interviewed said theywere told the fees only on request. In one facility, only fees for mortuary services weredisplayed. One caretaker said a nurse collected GHC 8.00 from her one night, explaining thefee was to pay for medication that had been administered through the child’s IV line.Page 21

Assessment of quality of care for children in selected hospitals in GhanaThe management at one facility said that to help offset the economic burden on caretakers,prescribers often tried to stay within the limits of the insurance benefits package. Somehospitals employed social workers to make arrangements with non‐insured clients for thepayment of hospital fees by instalments. In most cases, hospitals made a loss because thecaretakers failed to pay for services received.Traditional medicineSome of the caretakers who were interviewed first visited traditional medicine practitionersprior to reporting to hospital thus causing delays in treatment. The managers of one facilityreported, “The people are generally superstitious, so they prefer herbalists. Interestingly, most ofthose who patronize [their] services are insured, but they prefer to use herbal preparations alongsideorthodox medicine”.The experiences of caretakers in the outpatients’ department (OPD)Positives• Staff‐patient relationships were good.• The reception given at the OPD was warm.• Prompt attention was given to children and, in emergency situations, treatment wasgiven before payment was demanded or before the folder was retrieved regardless ofinsurance status.• Staff took their time to explain procedures to caretakers and generally exercisedpatience in their interactions. Caretakers were reassured of their child’s survival.• In some cases, the waiting time was pleasantly short and, in cases where the childhad high temperature, they were sponged down prior to seeing the prescriber.Page 22

Assessment of quality of care for children in selected hospitals in GhanaNegatives• Some OPD bathrooms were an eyesore; the toilets were dirty and smelly.• Caretakers were victims of insults by some staff at the OPD.• One OPD was congested and had long waiting periods. There also was no separatequeue for children.• Caretakers experienced delays, because they had to join long queues to photocopyhealth insurance documents requested by the hospitals’ records staff.• Some patients who reported to hospital before 6:00 were neglected by night nursesand made to wait until the arrival of the morning staff.• Some patients had to wait to be admitted, because no beds were available.• One caretaker mentioned that, although her child had a high temperature, none ofthe nurses at the OPD showed any concern.Staff viewsHealth workers mentioned a number of factors necessary for improving the quality of childcare. Some of the views expressed included:– Inadequate staffing, resulting in shortages that affected staff of all grades,especially paediatricians, paediatric surgeons, general practitioners, nurses andmidwives.– Buildings need to be renovated.– Most OPDs were shared by both children and adults, with prolonged waitingtimes for children.– Some wards were found in a state of disrepair. Caretakers and sick children wereoften inundated by rain due to the absence of windows or louvre blades.– The children’s wards were found to be particularly small and both surgical andmedical cases were housed together.– The wards were stuffy with some faulty fans seen hanging over sick children.– Well‐equipped and well‐staffed nurseries are needed in most facilities.– In terms of equipment, oxygen was mentioned as facing regular shortage. Somechildren’s units lacked refrigerators for storing essential drugs.– Some beds needed side rails and screens, and bed sheets and blankets wereinadequate.– Stand‐by/back‐up generators were unable to supply power to some children’swards during outages.Page 23

Assessment of quality of care for children in selected hospitals in Ghana– Brush and vegetation overgrowth surrounded some facilities, sheltering snakesand scorpions that were a threat to staff and patients.– Most toilets and bathrooms needed urgent attention.Staff’s perceptions on the common causes of death among children include malaria,pneumonia, diarrhoea, neonatal sepsis and malnutrition. Delay in seeking care wasmentioned as the leading cause resulting in deaths. This was followed by lack of staffproviding appropriate and adequate care and monitoring. Some staff believed they had therequisite skills to care for children, but they also mentioned emergency care and paediatricprocedures/protocols as areas where they wished to be trainedReasons for staff dissatisfaction• Inadequate staffing, resulting in work overload• Delay in promotions• Lack of motivation (e.g. transport for staff, drinking water)• Lack of equipment• Lack of refresher courses• Failure on the part of supervisors to recognize the work of their staff• Inadequate infrastructure• Lack of funds for those in need• Non‐involvement in decision‐making• Inadequate communication of policies, etc.3. Discussion3.1 Children are not adultsGenerally, there were separate wards for children, which was commendable. However,children who had undergone surgery were kept on adult wards. In some emergency unitsand at the OPD, children and adults were not separated. Treating children as adults andkeeping them in the same queue has implications for prompt management of emergenciesspecific to children and generally have the tendency of quickly deteriorating into moresevere situations. As a result of improper prioritization within the facility, caretakers oftenfailed to understand the situation and, therefore, failed to complain when severely illchildren were not given priority. In one of the hospitals, a practitioner trained in IMCI wasgiven the sole responsibility for attending to children at the OPD.Page 24

Assessment of quality of care for children in selected hospitals in GhanaMost of the assessed facilities kept both healthy and sick newborns on their maternity units.This practice has to be reviewed in order to prevent cross‐infections and to allow adequatemonitoring of sick newborns.Location of the Nurses’ StationThe nurses’ station is a fulcrum of activity on an inpatient ward. Practically every functionof the hospital intersects at this point, involving simultaneous clinical and administrativework processes. Standards for the location of nurses’ stations were met in most facilities. Insome facilities, however, the station was located outside the ward, preventing directoversight and delays in response to emergency situations. This type of set‐up arises whenward sizes are too small to accommodate a proper nurses’ station.3.2 StaffingAn acute shortage of professional staff was observed in most health facilities. This canseriously compromise quality of care in many ways; e.g. treatments may not be given ontime and time schedule and dosage for administration may not be followed. There may alsobe poor monitoring and documentation of progress of patients, etc. Time spent in providingcare for individual patients may be inadequate. Student nurses or health assistants whocomplement staff are unlikely to have the requisite knowledge and skills and may becarrying out functions far beyond their competencies.3.3 Support systemsHospital support systems (i.e. water, electricity, etc.) were found to be adequate in mostfacilities. Hospital refrigerators for storage of medicines were also used to store water andfood for staff. This practice is dangerous as food may be contaminated and frequent openingof the refrigerators minimizes optimal temperatures for safe storage of medicines.Hospitals were not child friendly; emotional support and play facilities were lacking in allbut one hospital. Toilets and bathroom facilities were poor and lodging facilities forcaretakers were non‐existent. Because of the lack of lodging or proper nutritionprogrammes, caretakers were often forced to sleep on the floors and to obtain food forthemselves and their children.On the children’s wards, both cots and adult‐sized beds were available. Some have no siderails, which presents the potential danger of patients falling out their beds.Page 25

Assessment of quality of care for children in selected hospitals in Ghana3.4 Hospital dataThe standards for hospital data for children were not met. There was no disaggregation forneonates. This could be traced to the DHIMS, which has made no provision for collection ofsuch data. Data on emergency services were also not readily available. The top five causes ofadmissions and death were similar and include malaria, anaemia, acute respiratoryinfections/pneumonia, diarrhoeal diseases and septicaemia. This picture mirrors whatpertains to the country as a whole. In hospitals where surgeries were performed, the top fivemost common surgeries include incision and drainage, hernia repair, hydrocoelectomy,excision of lumps and repair of lacerations. This may not reflect the whole picture, however,as circumcisions, which was often carried out by midwives, were not documented.3.5 Drugs, equipment and suppliesEssential drugs and supplies were available in the pharmacies of most facilities, however onthe wards and in emergency areas it was a different story. The lack of medicines inemergency units may be attributable to the difficulty in accounting for their use under theNational Health Insurance Scheme (NHIS). As a result, patients with emergency conditionswere required to have their prescriptions filled at the pharmacy in the hospital, leading todelays in initial treatment and managing emergencies.Basic equipment was also inadequate and often not available, including:– Intravenous (giving) sets with paediatric chambers.– Spacers with masks for administration of inhaled salbultamol.– Suction machines.– Weighing scales.– Self‐inflating bags for respiratory support.– Oxygen.– Nasogastric tubes (especially size 12).Laboratory support was good and results were often available within a reasonable timeframe ranging from 30 minutes to 2 hours. The quality of laboratory tests, however, was notassessed in this study. In all the hospitals assessed, microscopy for cerebrospinal fluid wasnot done, thus the management of meningitis was based strictly on clinical diagnosis.3.6 Emergency careImproving emergency care is a priority in the Ghanaian health sector’s Programme of Work,yet inadequate attention has been paid to this area. As a result, emergency care was belowstandards with regard to infrastructure, equipment and staffing. Staffing was inadequateand among those staff who were available, some lacked the appropriate skills to manageemergencies. Health assistants who were not trained in emergency care were sometimes theonly ones available to provide such care. Although GHS and WHO collaborated to organizePage 26

Assessment of quality of care for children in selected hospitals in Ghanatraining in ETAT for health staff in the northern and southern sectors, coverage is very lowand the desired impact is thus not felt.Case management was better in facilities where there were paediatricians. This may be dueto the fact that in‐service training in emergency care has not been institutionalized thereforemedical doctors and other staff were not given opportunities to update their knowledge andskills.3.7 Case managementCough and difficult breathingThe assessment of sick children for pneumonia was not complete as patients with thedisease were not classified for severity. As a result, patients with severe conditions were notproperly monitored and complications were not identified.In general, the use of antibiotics was good. In a few facilities, the excessive use of thirdgenerationantibiotics may contribute to the development of resistance to antimicrobials.There were rarely problems with oxygen administration, but there were concerns about thereuse of nasal prongs as related to standards for infection prevention and control.Asthma was considered in the differential diagnosis of wheezing; however managementand follow up need to be improved. The management of TB followed national guidelines,however the storage of TB drugs at district health directorates rather than in hospitalpharmacies was surprising.DiarrhoeaAlthough diarrhoea was common, the condition was not well managed in most cases.Rehydration plans were not used and monitoring was poor, with widespread lack ofmonitoring charts. The feeding of children was left to their caretakers and was not includedin the management plan, therefore it was not supervised. Antibiotics were used in twofacilities when there was no indication. It was encouraging to note that anti‐diarrhoealagents were not used in any facility in accordance with the recommended standards.FeverThe diagnosis and management of fever did not meet national standards. In a majority ofthe facilities, ear, nose and throat, and urinary infections were not considered for fever cases.Lumbar puncture and CSF microscopy were not carried out due to lack of skills. Monitoringof meningitis was generally poor, with little consideration for common complications in halfof the facilities surveyed.Cost appears to be a barrier to testing for random blood sugar which, if found to be low, canoften be easily corrected. On the other hand, the inability to diagnose low blood sugar can befatal. The preferred use of intravenous fluids to the passage of nasogastric tubes for feedingunconscious patients could be due to the shortage of staff or lack of skills. This practicePage 27

Assessment of quality of care for children in selected hospitals in Ghanacould adversely affect the nutritional status of children in prolonged states ofunconsciousness.All of the assessed facilities were able to confirm malaria diagnosis due to the availability ofmicroscopy or rapid diagnostic tests. The management of severe malaria varied amonghospitals and included the inappropriate use of injection artemether and intravenousquinine in patients who were not monitored. Rapid administration of parenteral quinine isunsafe. 1MalnutritionLess than half of the facilities diagnosed and managed malnutrition well. Areas of concerninclude inadequate assessment and investigation, lack of availability of rehydrationsolutions (i.e. Resomal) and preparations for feeding, inadequate feeding and poordocumentation. This was due to inadequate staffing and the absence of protocols in mostfacilities. Although the training in management of Severe Acute Malnutrition (SAM) hasstarted, coverage of this training is still very low and the impact is not obvious.Case management and care of sick newbornsAs with older children, case management for sick neonates was below standards. The samereasons given above for inadequate care for older children apply. There were no writtenguidelines for neonatal resuscitation in almost all the facilities visited. Neonatal sepsisdiagnosis was based on clinical signs and symptoms. Appropriate investigations, includingurine and CSF microscopy, blood culture and full blood count, were not done.Children with HIV/AIDSManagement for HIV/AIDS patients was good. This was attributable to the level of supportand funding for this programme which, over the years, has ensured training, availability ofguidelines, protocols, equipment and drugs. The connection between home‐based care andhospital care remains an issue.3.8 Supportive careIn most hospitals, supportive care for in‐patients was inadequate. The nutritional status ofchildren who were admitted was not usually assessed, there was no monitoring plan, andmonitoring was infrequent and poorly documented. Charts for monitoring (i.e. input‐outputcharts, feeding charts, etc.) were not available in some facilities. Where they were available,documentation was poor. The weak internal supervision could be a contributory factor.3.9 Hospital support systemsSurgical facilitiesSurgical facilities were not available in four out of the 10 facilities visited. Facilities did nothave written standard procedures and guidelines for safe use of local anaesthetics, and postoperativepain management guidelines were also unavailable.1Guidelines for the treatment of malaria ‐‐ 2nd edition. WHO Publication.Page 28

Assessment of quality of care for children in selected hospitals in GhanaPost‐operative notes were scanty and there were weaknesses in post‐operative monitoring.This aspect of care has not received much attention, even at the national level.3.10 Hospital administrationPerformance of auditsThis activity, as well as clinical meetings, occurred infrequently and follow‐up actions couldnot be determined. Not all relevant staff participated when meetings were held. Lack ofnational guidelines and weak supervision at all levels could be among the contributingfactors.Transport for referralsMost of the facilities have ambulances, however a majority of these were not in goodcondition. Coverage by the national ambulance service was limited to regional capitals and afew districts. There are plans to pool together ambulances to serve entire districts instead ofindividual facilities. This should improve the referral system.Care seekingAmong those seeking care in hospital, delays in care were attributed to cultural beliefs, useof other systems, such as chemical sellers and traditional healers, and financial barriers (i.e.hospital fees for the uninsured). Care seeking has not been properly addressed as a strategyfor improving child health.Caretakers’ viewsCaretakers gave mixed reviews of health workersʹ attitudes, a trend that has also beenreported in other studies. GHS is concerned about the poor attitude of health workers andhas instituted a customer care programme.Sleeping and toilet facilities for caretakers were inadequate and they sometimes slept on thehard floor because of a lack of lodgings.Health worker interviewHealth workers who were interviewed confirmed that staffing is inadequate in severalcategories for both inpatient and outpatient care. They were concerned about delays inattending to children in the OPD, including insufficient contact time with children andwards being managed by non‐professional staff, particularly at night and weekends. Aboutone‐third of them identified this state of affairs as a possible cause of child deaths in healthfacilities.Dissatisfaction among staff was common with some of the reasons including work overload,lack of motivation and capacity building, lack of involvement in decision‐making, andinadequate communication between staff and management. Inadequate infrastructure,equipment and other resources for work were also mentioned as cause for frustration.It is refreshing to note that health workers were not only concerned about their own welfare,but also that of the children in their care, as well as the comfort and safety of children’sPage 29

Assessment of quality of care for children in selected hospitals in Ghanacaregivers. Issues raised in this regard included the lack of feeding facilities or the poorquality of food provided for inpatients and the inadequate or, in some cases, poorlymaintained toilet facilities.Common causes of death among children as identified by staff conform to the nationalpicture, with malaria, pneumonia, diarrhoea, neonatal sepsis and malnutrition among thelist of conditions. The consequences of delay in seeking care were most often identified ascontributing to these deaths. This was followed by a lack of staff resulting in a parallel lackof care and monitoring. A majority of those who were surveyed did not identify insufficientdrugs, equipment or laboratory diagnosis as contributors to death.Staff believe they have the requisite skills to care for children. However, they also mentionedemergency care and paediatric procedures/protocols as areas where many wish to receivetraining. The case management findings mentioned earlier, corroborates the trainingrequisites made by staff as areas of weakness.Customer care was also identified as an area for improvement. The Ghana Health Servicecustomer care package is currently available for training. GHS’ suggestion to use their ownfacilities and colleagues for on‐site training is laudable and may be a more cost effective andefficient means for scaling up in‐service training programmes.Useful suggestions were given on how to improve communication to caretakers and how toinvolve them in the provision of care. They identified the need for appropriate audio‐visualsfor this purpose. Although the customer care materials partly address this issue,information, education, and communication (IEC) materials on paediatric conditions aregenerally lacking. Fortunately, many health facilities have audio‐visual equipment, whichcan be put to better use than is currently being done.4. Recommendations4.1 Leadership and advocacy for improvement in quality of careThe Paediatric Society must press for the improvement of services for children in line withthe recommendations in this report and promote local leadership for improvement amongits members.4.2 Improving hospital layout and facilities for childrenThere should be separate facilities for children in health facilities. The separation must beincorporated in the design and construction of new health facilities. For older facilities withimproved staffing and adequate space, hospital management should designate a separateoutpatient department (OPD) for children. For existing facilities where there are nopossibilities for creating a separate OPD, one or two practitioners should be assigned toattend to the children. Care needs to be taken to assign an adequate number of staff to coverthe case load of children under the age of five. These practitioners should receive regularupdates on current practices in child health.Page 30

Assessment of quality of care for children in selected hospitals in GhanaWithin the records department, a separate window for serving children must be created.Hospital management should also commit resources to help ward make facilities morechild‐friendly. This includes the provision of toys, children’s books, and decoratingchildren’s wards and rooms in colours and schemes that are attractive to children.In designing new facilities, consideration should be given to providing adequate space forand situating nurses’ stations within the wards.Hostel facilities should be provided for mothers in health facilities where children areadmitted.4.3 Improving the quality of data on paediatric careThe review of the DHIMS and consequent upgrade to DHIMS2 should include allstakeholders and provide for the disaggregation of children’s statistics in order to providemore data for better planning. Facilities should be encouraged to analyse their data, providefeedback to staff and use reports to improve services.4.4 Improving the availability of medicines and suppliesFacility management should ensure that medicines are available in emergency areas andwards, and should determine ways for health staff to document what has been given outand account for their use. Making medicines available in the emergency area will preventdelays in providing care for sick children and save lives.Procurement of paediatric equipment should be incorporated into facility and nationalprocurement plans.4.5 Improving case managementCase management needs to be improved through the provision of clinical care guidelines,including monitoring charts, job aids and training. The WHO Pocket Book of Hospital Carefor Children needs to be adapted.Hospitals should invest in training their staff using local resources. In this regard, trainingand orientation in Integrated Management of Neonatal and Childhood Illness (IMNCI),Severe Acute Malnutrition (SAM), Emergency Triage, Assessment and Treatment (ETAT),Essential Newborn Care, and Hospital Care for the Newborn must be scaled up to addressgaps in paediatric care at various levels.The policy on hospital feeding must be enforced and preparation of food by hospital caterersshould be mindful of admitted children.Training of nurses in paediatric care should be a priority and negotiations that are currentlyunderway should be accelerated to ensure early implementation of the programme.Page 31

Assessment of quality of care for children in selected hospitals in Ghana4.6 Strengthening quality assurance mechanisms within hospitalsGuidelines for clinical audits must be developed and staff trained in their use. The regularconduct of such audits must be included in hospital managers’ performance indicators.Caretakers’ concerns and views may be addressed by regular patient satisfaction surveys,and their views incorporated into health facility quality improvement initiatives.The GHS customer care training should also be scaled up with hospitals buying into theprogramme.Facilitative and clinical supervision must be strengthened at all levels to ensure compliancewith standards.The MOH/GHS should designate best practice hospitals in paediatric care and use them forstudy tours and training sites, and promote regular peer reviews.4.7 Improving human resourcesThe health sector is implementing strategies to improve human resource output, andmechanisms for fair distribution must be instituted, as well as adequate compensationpackages.Communication between hospital management and staff can be improved by holdingregular meetings/durbars and involving all categories of staff in such meetings, as well asconducting staff satisfaction surveys.4.8 Improving access to health facilitiesHealth education materials for the education of caretakers should be developed in locallanguages and a variety of media used for their dissemination.Cost of hospital care is a significant barrier and communities must be educated regardinghow to register children in the NHIS as they are in the exempt category.Page 32

Assessment of quality of care for children in selected hospitals in GhanaReferences1. Assessment of Quality of Care for the Sick Child in Ghanaian hospitals. Accra, Ghana HealthService and World Health Organization, 2005.2. Emergency Triage Assessment and Treatment: Manual for Participants. Geneva, WorldHealth Organization, 2005. Available at:http://whqlibdoc.who.int/publications/2005/9241546875_eng.pdf.3. Emergency Triage Assessment and Treatment: Facilitator Guide. Geneva, World HealthOrganization, 2005. Available at:http://whqlibdoc.who.int/publications/2005/9241546883_eng.pdf4. Pocket Book of Hospital Care for Children, Guidelines for the management of commonillnesses with limited resources, Geneva, World Health Organization, 2007. Availableat: http://www.who.int/ child_adolescent_health/documents/9241546700/en/index.html.5. Better Medicines for Children. World Health Assembly Resolution 60.20. World HealthOrganization, 23 May 2007. Available at: http://www.who.int/childmedicines/publications/ WHA6020.pdf.6. Framework for Improving Hospital Care for Children in Developing Countries.Geneva, World Health Organization, 2009.7. Assessment of the quality of care for children in hospitals: A generic assessment tool. Geneva,World Health Organization, 2008.8. Standard Treatment Guidelines. Accra, Ministry of Health, Ghana National DrugsProgramme, 2010.9. Standards for the care of children and adolescents in health. Sydney, The Royal AustralasianCollege of Physicians, 2008. Available at:www.wcha.asn.au/index.cfm/spid/1_7.cfm?paction=doc...id...Page 33

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Assessment of quality of care for children in selected hospitals in GhanaAppendix I: Assessment of the quality of care forchildren in hospitalsA generic assessment tool adapted for use in GhanaJune 2010IntroductionThis generic assessment tool helps to evaluate the quality of care for children in hospitals,based on standards derived from the WHO Pocket Book of Hospital Care for Children, and otherrelevant WHO materials. Before use in a country, the assessment tool should be reviewed byhealth professionals for its consistency with national standards and guidelines, such as anessential drugs list, and prevalence of diseases and adapted where necessary.This generic tool attempts to be comprehensive but not exhaustive in addressing the areasthat are important to provide care for children in hospitals. The assessment tool providessome prioritization as it is recognized that some aspects of care for children are essential. It issuggested that hospitals ensure that these essential aspects are put in place first and otherareas, though important, may be addressed later. Priority areas include triage, hygiene(including hand‐washing), availability of emergency and first‐line drugs, availability ofupdated standard treatment guidelines, emergency care and assessment and management ofcommon conditions including cough and difficulty breathing, diarrhoea, fever, HIV/AIDSand newborn care. The assessment tool includes the following sections:1. General hospital information– Layout of health facility2. Hospital support systems– Hospital health statistics– Essential drugs, equipment and supplies– Laboratory support3. Emergency care– Patient flow– Staff– Layout and structure of emergency area– Drugs equipment and supplies– Case management of emergency conditions4. Childrenʹs ward– Staffing and layout– Standards and criteriaPage 35

Assessment of quality of care for children in selected hospitals in Ghana5. Case management of common diseases:– Cough or difficult breathing– Diarrhoea– Fever conditions– Malnutrition– Children with HIV/AIDS6. Supportive care7. Monitoring8. Neonatal care– Nursery staffing and layout– Routine neonatal care– Nursery facilities– Case management and sick newborn care9. Paediatric surgery and rehabilitation10. Other hospital wards with children11. Hospital administration12. Access to hospital careThe tool also includes a section that can be used to organize a Debriefing and action plan. In theannexes questionnaires for interviews with caretakers and health workers can be found.The tool is designed in sections so that during adaptation, sections may be removed ifconsidered not to be a priority for a specific country. For example:– A section on management of dengue fever will only be necessary in South‐EastAsia or Central and South America.– In some countries or parts of countries, the malaria component in the feversection may not be necessary.– Paediatricians may only wish to assess medical care so the paediatric surgicalsection will not be required in this case.– Hospitals may wish to assess only particular conditions or areas of care, forexample, assessment of emergency care before and after implementation of atraining course, such as emergency triage assessment and treatment (ETAT).Overview of the assessment processThe hospital assessment may be embedded into a national quality improvement programme,or interested health authorities at a provincial, district, or hospital level, involving one orseveral hospitals, might conduct the assessment. After a period of change, the process ofassessment can be repeated to document improvements.Page 36

Assessment of quality of care for children in selected hospitals in GhanaThe core of the assessment is a hospital visit which lasts about two days. Assessors completethe assessment tool recording form. One recording form is used for each hospital.Information is collected from various sources as explained in detail below. At the end of thehospital visit, assessors and hospital administration meet for a debriefing and agree on aplan of action for immediate and later improvements.Training of assessorsBefore conducting the assessment, all the assessors need to be made thoroughly familiar withthe standards, the guidelines as contained in the Pocket Book, and the assessment tool. Sucha training course takes about three days, with training sessions on the Pocket Book (forwhich the case‐based studies in the CD accompanying the Pocket Book can be used), reviewof the forms, and practical sessions on hospital wards to become familiar with the forms andto agree between the assessors on scoring.Guide to the assessment toolTo evaluate the different aspects of paediatric care in district hospitals, information iscollected in various formats including:– Brief questionnaires on hospital layout and structure with yes or no answers, andspace for written information to be completed during observation when on thehospital visit or through interviews with staff;– Checklists for equipment, drugs and supplies for completion;– Forms documenting the management of different medical conditions based onaccepted standards of care and criteria to meet these standards. The formsprompt documentation of whether practices are good or need improvement,summarize strengths and weaknesses, and require a final score of the area ofobservation.Questionnaires and checklistsThe first part of the assessment tool is in the form of a questionnaire with checklists thatfocus on information expected to be of importance for planning quality improvementinterventions. Examples of information in this section include: hospital layout and structure,admission rates, case fatality rates for the most common conditions, availability of essentialdrugs, availability of diagnostic support and of therapeutic equipment. Information from thequestionnaires/checklists will have to be reviewed together with information from on siteobservations of quality of care when interventions for individual hospitals are planned.Information from questionnaires or checklists should be cross‐checked during the hospitalvisit.Hospital visitThe sections of the assessment tool for completion during the hospital visits includeinformation from observations of case management and the physical environment, withinformation from interviews with hospital staff and caretakers of sick children. It issuggested that as much time as possible is spent on the children’s ward to gain first‐handPage 37

Assessment of quality of care for children in selected hospitals in Ghanainformation by direct observation, especially on the management and care of children in thehospital. Try to establish by direct observation if the drugs and equipment are available inthe emergency room, on the ward or in pharmacy. Also visit other wards in the hospitalwhere children are being cared for. If possible have a look in theatre/operating room to checkif paediatric‐size equipment is available. Try to verify information provided by the hospitalstaff or patients while observing during the visit.Sources of informationInformation for the hospital assessments may be collected from:Case observations: For clinical case management, this is the preferred source of information,and should be used wherever possible. The care for new arrivals and admitted children tothe hospital should be observed without interference from the assessors. This iscomplemented by discussion of the case with staff, review of the case records andmonitoring charts, and interviewing the mothers.Records: Assessors obtain information on the quality of care for admitted and recentlydischarged patients by checking records. If there are insufficient patients for direct caseobservations, assessors should ask staff if it is possible to review records. This source ofinformation is particularly important for relatively rare, but severe conditions, such asmeningitis, where there might be no case admitted during the time of the visit.Interviews: Assessors conduct interviews with hospital staff and caretakers to gain someidea of their perception of care for children in the hospitals. The assessment tool provides anoutline for interviews with caretakers as well as health workers that can be found in Annexes1 and 2 respectively. Also, if there are not enough cases for direct review of casemanagement, simulated cases are presented to staff to assess clinical case management.Hospital visit: This concerns mainly items amenable to direct observation during thehospital visit and the round of the hospital, such as cleanliness and availability of items tomothers. Areas of doubt can be clarified by interviews.Documenting and scoring the hospital assessmentEach section is scored based on standards and criteria to meet these standards. Standards arethe minimum requirements for good quality of care for children. For the case managementsections, the instructions in the assessment tool provide guidance to the standards, but donot cover all aspects of a given standard, and therefore reference is made to the guidelines inthe sections of the WHO Pocket Book of Hospital Care for Children, indicating the relevantpages.All sections of the assessment tool leave sufficient space for comments and personalobservations. Where possible additional information should be noted, especially on how theinformation has been obtained (chart review, staff interview, observation of care provided).Each of the different topics ends with a summary table, in which the findings can becondensed, marking strengths and weaknesses, to facilitate a quick overview of each chapter.This helps with remembering important points which should be covered during the finalPage 38

Assessment of quality of care for children in selected hospitals in Ghanadebriefing of the hospital director and staff. Finally, all topics are to be marked in a summaryscore in the summary evaluation sheet. This is particularly useful to monitor hospitalimprovement over time and to enable inter‐hospital comparison.Scoring system: For overall scoring, numbers from 5 to 1 are awarded, 5 being good practicecomplying with standards of care, 4 showing little need for improvement to reach standardsof care, 3 meaning some need for improvement to reach standards of care, 2 indicatingconsiderable need for improvement to reach standards of care and 1 being services notprovided, totally inadequate care or potentially life‐threatening practices.Table 1: Scoring system, summary scoreSummary score essential drugs, equipment and supplies Good To be improved(to be circled) 5 4 3 2 1Please indicate the quality of support by marking one of the 5 numbers; 5 indicates good support, 4 to 1indicating levels of necessary improvement (4=small need for improvement, 1=urgent need for improvement).Finally, all topics are marked in a summary score in the summary evaluation sheet. This canassist in monitoring hospital improvements over time and to make inter‐hospital comparisonpossible. Note that if sections of the tool are removed or edited, the total potential summaryscore should be revised.Composition of the hospital assessment teamsThe assessment teams should be composed of people with complementary backgrounds, toput the findings into perspective, such as a paediatrician, a general physician or clinicalofficer working in a hospital similar to the one which is being assessed, and a nurse withexperience in caring for children. Depending on the purpose of the assessment, the teams canbe composed of internal assessors only or a combination of internal and external assessors.This will have cost implications.Conducting the hospital visitThe observation visit requires two working days, including the possibility to do observationsalso during the evening or night. The hospital director must have been informed in advanceand have agreed to the assessment. It facilitates the work if the questionnaire/checklists (Part1) have been forwarded to the hospital in advance or if the hospital administrator has beenasked to prepare the requested information before the assessors arrive.Page 39

Assessment of quality of care for children in selected hospitals in GhanaSuggested timetable for the visit:Day 1: The assessors should arrive at the hospital on the day prior to the assessment or inthe morning of the same day. Hospitals are usually busiest in the mornings with newadmissions. Observations can be conducted irrespective of the day of the week. However,since the assessment begins and ends with hospital staff meetings the schedule should allowfor these meetings during regular working hours.Introductory meetingSchedule a meeting with the hospital director and his/her staff prior to the start of theassessment. Introduce the purpose of the assessment and describe the assessment process.Emphasize that the assessment is a voluntary exercise that is part of an initiative to helphospitals improve the quality of paediatric care. The purpose of the assessment is to identifyareas of care with a large potential for improvement. Explain that you will interview staffabout hospital routines and practices and that you would like to observe care of as manypatients as possible, those already admitted as well as new arrivals. Schedule a debriefingmeeting at the end of the assessment. The debriefing can be planned in advance of the visit toensure the participation of key staff.Hospital visitThe assessment will normally start with a tour of the hospital. Ask to be shown all areas ofthe hospital that will be of relevance to paediatric care. In addition to the paediatric ward(s),the tour should include the following areas when they exist: the delivery ward, the neonatalnursery, intensive care unit, other wards where children might be admitted, such as surgicalor infectious diseases ward, emergency area, outpatient department, pharmacy, laboratoryunit, blood bank, and the radiology department.The assessors will then continue with the assessment, which does not have to be conductedin a certain order. Observation over time is important and new arrivals and new admissionsto the hospital should be closely observed. It is an advantage if the assessors can sleep in thehospital and if the hospital is asked to alert them when new patients arrive. The assessorsshould not interrupt, interfere or guide medical work in any way. It is important that theyare allowed to move around freely and are free to interview parents and staff.Day 2: Continue the assessment including interviews with staff and caretakers, caseobservations and going through records. Make sure that the necessary information in theprotocol is obtained for all areas. This requires repeated review of the assessment tool formissing items still to be completed. The team might break up into sub‐teams to fulfil certaintasks. Findings should, however, be discussed by the whole team at certain intervals. Allowfor sufficient time to prepare your findings for presentation at the debriefing. Transfer allfindings onto the summary sheet of findings for discussion with hospital authorities at thedebriefing.Page 40

Assessment of quality of care for children in selected hospitals in GhanaDebriefing visit with the hospital authoritiesEach hospital will receive immediate feedback at the end of the visit. The purpose of thefeedback meeting is to review the assessment findings and commence planning forimplementation of the improvement process. The meeting should be attended by the medicaldirector, senior management and all staff participating in the assessment so that all thoseinvolved will continue to be involved in the planning and implementation of improvementinterventions in their hospital. The hospital staff should be thanked for their cooperation andfirstly the strengths should be highlighted and then the weaknesses discussed. Throughdiscussion, three areas for improvement should be prioritized for action, based on thefeasibility of improvement and their impact on mortality. It is best to select areas in whichthe hospital can actively engage leaving more structural problems aside for later action. Itshould be clear to everyone what the problems are and what can be done to improve thesituation. An action plan should be constructed that will identify:– what tasks are to be carried out;– when each task will be carried out;– who will carry out the task;– how much it will cost to carry out each task, and where the budget will comefrom for this work.Responsible persons should be assigned for each of the three identified areas. Any financialresources, supplies and equipment, training or supervision needs or other technical inputsshould be identified and a time set when the hospital will review progress.Page 41

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Assessment of quality of care for children in selected hospitals in GhanaAssessment of the quality of hospital care for children Date: __/__/__/Country: ____________________ Initials of Health Facility: __/__/Initials of Assessor:__/__/1. General hospital informationSource: Hospital walk‐through observation, and interviews with matron/staff.Instructions: Collect information on numbers and time. Several questions have space for you todescribe your answer in more detail.Date of assessment:Name of interviewer(s):Name of the health facility:__/__/__/__________________________________________District: _____________________ Region: _____________________Type of health facility:District Hospital Regional Hospital Ownership of facility:PublicPrivateMission (faith‐based)Quasi HospitalPage 43

Assessment of quality of care for children in selected hospitals in Ghana1.1 Layout of health facilityDoes the health facility have a separate outpatient department? Y N Comments:Is the paediatric outpatient separate from the adult outpatient department? Y N Comments:At what time does the paediatric outpatient department open? _____________________ hrsAt what time does the paediatric outpatient department close? _____________________ hrsDoes the health facility have a separate emergency department/unit? Y N Is it open 24 hours? Y N If not, what hours is it open? _____________________ hrsDoes the health facility have a ward for admitting children? Y N If so, how many beds?How many cots?__________________________________________Does the health facility have a separate ward or room for admitting sick newborns? Y N If so, how many beds?How many cots?How many incubators?_______________________________________________________________Does the health facility have a separate room or ward for admitting paediatric infectious cases(isolation ward)? Y N If so, how many beds?_____________________If so, is this separate from the adult infectious cases? Y N Describe:Where are children with surgical conditions admitted?Describe:Page 44

Assessment of quality of care for children in selected hospitals in GhanaWhere are children with severe conditions requiring special or intensive care admitted?Describe:Are the most seriously ill children cared for in a section where they receive closest attention?(near the nursing station)Describe:Is a qualified nurse (State Registered Nurse or Enrolled Nurse) available 24 hrs per day on thechildrenʹs ward? (check duty roster)Describe:What is the estimated HIV prevalence in your region?Page 45

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Assessment of quality of care for children in selected hospitals in GhanaAssessment of the quality of hospital care for children Date: __/__/__/Country: ____________________ Initials of Health Facility: __/__/Initials of Assessor:__/__/2. Hospital support systemsSource: This information should be obtained during the hospital visit, and complemented byinterviews with staff. Tick as applicable. Note in comments if supplies are irregular.Emergencyarea/OPDWardIs electricity continuously available? Is there a back‐up power supply inthe case of a power cut (generator, solar panels, etc)?Is there running water? (pipe‐borne) If no: is there water for handwashingavailable in the area?Are there soap and/or disinfectantavailable?Is there a sharps disposal boxavailable?Is there a functioning fridgeavailable for drugs?Is there a functioning fridgeavailable for vaccines?Is there an information desk orcomplaints or suggestion box on thehospital premises, or a formal way that patients can communicate withthe hospital?CommentsPage 47

Assessment of quality of care for children in selected hospitals in Ghana2.1 Hospital health statisticsSource: Routine statistics. Collect the information from the hospital administration early in the visit.Make use of routine statistics; adjust the categories accordingly (e.g. age groups) where necessary.2.1.1 Patient loadIndicate the total number of paediatric medical outpatient visits, emergency visits and admissionsper year by age groups and as a total. Include all medical diagnosis but exclude children dead onarrival.Note: If data are not disaggregated according to the suggested age‐groups, compile the dataavailable indicating the age‐groups compiled.Year: 20090 – 28 daysOutpatientvisitsEmergencyvisitsAdmissionsDeathsAgespecificfatalityrate_________ _________ _________ _________ ________1 up to 12 months1 up to 5 years>5 yearsTotal (all age groups)_________ _________ _________ _________ _________________ _________ _________ _________ _________________ _________ _________ _________ _________________ _________ _________ _________ ________2.1.2 Admission detailsList the five most frequent medical reasons (diagnoses) for outpatient visits, emergency visits andhospital admissions in children under fiveOutpatientvisitsEmergencyvisitsHospitaladmissionsDeaths *Diagnosis‐specificcase fatality rate1.2.3.4.5.* This refers to any data available on malaria, diarrhoea and other conditions.Page 48

Assessment of quality of care for children in selected hospitals in Ghana2.1.3 Paediatric surgery detailsSource: Routine statistics. Collect the information from the hospital administration early in the visit.Make use of routine statistics.Most common paediatric surgical procedures performed in 20091.ProcedureAnnual number ofproceduresPerformed by – healthworker category2.3.4.5.How often are the following paediatric surgical procedures performed?Regularly Infrequently NeverPerformed by– healthworkercategoryReferred toanotherfacilityCircumcisionHernia repairFracturesSkin graftingLaparotomy includingappendectomyIncision and drainagefor abscesses/pyomyositis2.2 Essential drugs, equipment and suppliesSource: Collect the information from the emergency area, the ward and the pharmacist early in thevisit, and adjust drugs according to local alternatives.2.2.1 DrugsAvailability of drugs varies considerably in different regions. Please indicate the drugs available. Forthose drugs marked with an asterisk (*), local adaptations of use might be necessary. If drugs are onlyavailable for sale and not freely available for children, make a note. Check for the presence of drugsand enquire with staff whether drugs are regularly available. Check expiry dates. Note whether drugswith the earliest expiry date are for first use (in the front‐row). Comment on how readily availabledrugs are for the non‐insured, insured and the poor.Page 49

Assessment of quality of care for children in selected hospitals in GhanaEmergencyPharmacy/WardareastoreGlucose 50% IV Glucose 10 % IV Glucose 5 % IV Normal saline IV (0.9%) Ringer’s lactate IV Epinephrine (adrenaline, I in1000) subcutaneously Salbutamol IV Corticosteroids IV or oral Furosemide IV First‐line anti‐convulsant:*Diazepam IM, IV *Phenobarbital IM, IV. Antibiotics*Ampicillin/amoxicillin Benzylpenicillin *Anti‐staphylococcal penicillin(e.g. flucloxacillin) *3rd generation cephalosporin– e.g. ceftriazone *Chloramphenicol Ciprofloxacin Gentamicin Co‐trimoxazole Comments*All anti‐TB drugs needed according to the national TB control programmeEthambutol Isoniazid Pyrazinamide Rifampicin *All anti‐malaria drugs needed according to national malaria control programmeArtemether‐lumefantrine Artesunate‐amodiaquine Dihydroartemisininpiperaquine Injection artesunate Quinine Rectal artesunate Page 50

Assessment of quality of care for children in selected hospitals in GhanaEmergencyareaAll anti‐HIV drugs according to HIV programmeWardPharmacy/storeCombivir Efavirenz Lamivudine Lopinavir Nelfinavir Niverapine Ritonavir Stavudine Zidovudine Other:………………………… Other:………………………… Fluconazole Digoxin Iron syrup Iron tablets ____ mg Vitamin‐mineral mix(vitamins + iron preparation) Vitamin A oral Vitamin K IM injection ORS BCG vaccine Measles vaccine Polio vaccine Pentavalent vaccine(diphtheria pertussis tetanushaemophilus influenza,hepatitis B) Yellow fever vaccine Comments2.2.2 Equipment and suppliesSource: Collect the information in the emergency area, the ward and the pharmacy/store early duringthe visit.Is the following equipment available in the emergency area, on the ward, or in the pharmacy orgeneral store? Check the information during the visit to the ward, the emergency area and to thepharmacy or general store. Ask the person in charge of the area/ward for the items to be shown toyou, and check that they are safe, hygienic and in good working order. Check that the size isadequate for use in infants and children.Page 51

Assessment of quality of care for children in selected hospitals in GhanaEmergencyareaWardPharmacy/storeResuscitation table/area Torch Otoscope Weighing scales for children Measuring board to measurelength and height(lying/standing, according toage) (length) (height)(length)(height)(length)(height)Stethoscopes Thermometers Heat source* Oxygen sourceoxygencylinderoxygenconcentrator Commentscentral supply Flow‐meters for oxygen Equipment for theadministration of oxygen Indicate which nasal prongs equipment youusecatheters masks *Note this refers to radiant warmers and not hot water bottles.Page 52

Assessment of quality of care for children in selected hospitals in GhanaEmergencyareaWardPharmacy/storeSelf‐inflating bags for resuscitationMasks Infant size Child size Adult size IV‐transfusion (giving) sets withchambers for paediatric use Butterflies and/or cannulae inpaediatric sizes (21‐25) NG‐tubes, paediatric size (No 5,8, 12) Equipment for intra‐osseousfluid administration (wide bore needle)Suction equipment Chest tubes Nebulizers for theadministration of salbutamol Indicate type Electricityof nebulizer: driven Oxygen driven Foot pumpdriven Spacers with masks for theadministration of metered doses(spray) of salbutamol CommentsPage 53

Assessment of quality of care for children in selected hospitals in Ghana2.2.3 Standards for drugs, equipment and suppliesAn adequate essential drugs list exists for the hospital with all drugs being available.Essential equipment is ready to use and in good working order.Paediatric size anaesthesia equipment is available and in good working order. See p 44.Please note: Refer to the completed tables above to mark this section.Standards and criteriaGoodTo beimprovedCommentsAvailability of essential drugsAn essential drugs list exists in the hospital (or aNational Health Insurance Medicine List) and isavailable to prescribers.Drugs on the list are adequate for themanagement of most common conditions.Essential drugs are available on the ward and inthe emergency area and immediately accessible.Drugs are not expired.Oldest drugs are used first.Availability of supplies and equipmentEssential equipment is immediately available foruse.Essential equipment is safe and in working order.Essential supplies are available immediately,and are adequate for use in children.Summary table essential drugs, equipment and suppliesEssential drugs are available, not expired andold drugs are used first.Paediatric‐size anaesthesia equipment is availableand in good working condition (child‐sized mask,ventilation bag and mask).Adequate equipment is available in theemergency area and on the ward.GoodTo beimprovedThere is an adequate range of IV fluids. CommentsSummary score essential drugs, equipment and supplies Good To be improved(to be circled) 5 4 3 2 1Please indicate the quality of support by marking one of the 5 numbers; 5 indicates good support, 4 to 1indicating levels of necessary improvement (4=small need for improvement, 1=urgent need for improvement).Page 54

Assessment of quality of care for children in selected hospitals in Ghana2.3 Laboratory supportSource: Collect the information from the laboratory and chief laboratory technician early in the visit .Try to see as many essential laboratory investigations being carried out as possible. Are the followinglaboratory investigations and their results available reasonably quickly at this hospital? (E.g. bloodglucose, Hb, PCV within 30 minutes, other investigations 1‐2 hours). If available, indicate the timenormally taken to obtain the results.NotavailableAvailableTime toget resultsCommentsBlood glucose Haemoglobin Haematocrit (PCV) Microscopy for malaria parasites Rapid diagnostic test (RDT) for malaria CSF microscopy Urine microscopy Urine dip‐stick (albumin, glucose, nitrite,leukocytes; please indicate)HIV‐serology Blood grouping and cross‐matching Bilirubin CD4 counts according to nationalguidelinesPage 55

Assessment of quality of care for children in selected hospitals in GhanaStandards of essential laboratory tests are reliably carried out and results deliveredspeedily.Standards and criteriaEssential laboratory tests (blood glucose,haemoglobin or haematocrite [PCV)),microscopy for malaria, microscopy for cells inCSF and urine, blood grouping and crossmatching,HIV test) are available all the time(including holidays and weekends) and theirresults are delivered in a timely fashion to theward/emergency area.Financial barriers do not deprive patients of theuse of essential laboratory testing (NationalHealth Insurance, or an exemption scheme is inplace for poor children).Is there any laboratory quality control system (Ifyes, ask to see the results).GoodTo beimprovedCommentsTests for emergencies are given priority. Summary score laboratory support Good To be improved(to be circled) 5 4 3 2 1Please indicate the quality of support by marking one of the 5 numbers; 5 indicates good support, 4 to 1indicating levels of necessary improvement (4=small need for improvement, 1=urgent need for improvement).Page 56

Assessment of the quality of hospital care for children Date: __/__/__/Country: ____________________ Initials of Health Facility: __/__/Initials of Assessor:__/__/3. Emergency careStandardsPatients are assessed for emergency or priority signs before administrative procedures.The emergency area is adequately equipped and stocked with drugs for the most commonemergencies.A qualified health professional carries out triage and can implement the emergency guidelines; e.g. forconvulsions, neurological deficits, shock and respiratory distress.3.1 Patient flowSource: Visit to the emergency department and interviews with staff dealing with emergencies.Instructions: Interview staff where emergencies present: who is seeing patients; how are senior staffbeing called; and where and how are severe conditions being handled?Where are patients with an emergency medical or surgical condition received?Describe patient flow of a typical emergency (patients presenting as an emergency to hospital):How are severely ill patients diagnosed and handled in the outpatient department (i.e. patientspresenting normally to the outpatient department, but severely ill)?Describe patient flow.Is there any system in place to prioritize severely ill children (triage)?If so, describe:Yes No Is there an emergency management area equipped to take care of children?If so, describe:Yes No Page 57

Assessment of quality of care for children in selected hospitals in GhanaIs this separate from the normal outpatient facility dealing withnon‐referred children?If so, describe:Yes No Do patients come with referral notes when they have been referred from first level units?Never Sometimes Always Comments:Are there any job aids/guidelines/protocols (wall charts, chart booklets)displayed for the management of paediatric emergencies?Yes No If so, describe what aids/guidelines/protocols are provided, and comment on their adequacy:Distance from the reception area to the emergency management area:In the same building, distance (meters/walking time):In another building, distance (meters/walking time):Distance from consultation area to emergency management area:In the same building, distance (meters/walking time):In another building, distance(meters/walking time):Page 58

Assessment of quality of care for children in selected hospitals in Ghana3.2 Staff dealing with emergenciesThis concerns staff who are immediately available to deal with emergencies and their level oftrainingDuring workinghoursAfter workinghoursTrained inassessmentTrained inmanagement/Cadre of Present/not Present/not of aspects ofstaff presentpresent emergency emergencyCommentsIf present,numberIf present,numberconditionsYes/NoconditionsYes/NoGatemanRecordsclerkTriagenurseNurseAuxiliaryMedicalassistantMedicalofficerPaediatricspecialist3.3 Layout and structure of emergency areaStandardsPatients are assessed for emergency or priority signs before administrative procedures.The emergency area is adequately equipped and stocked with drugs for the most commonemergencies.A qualified health professional carries out triage and can implement the emergency guidelines; e.g. forconvulsions, neurological deficits, shock and respiratory distress.Standards and criteriaChildren are assessed for severity/priority signs(triaged) immediately upon arrival.Patients do not have to wait for their turn,registration, payment etc. before a firstassessment is done and action taken.A wall chart or job aid for identifying childrenby severity of condition is located in theemergency admissions area.GoodTo beimprovedCommentsPage 59

Assessment of quality of care for children in selected hospitals in GhanaStandards and criteriaGoodTo beimprovedCommentsDrugs, equipment and supplies* (see below)Essential drugs for emergency conditions(anticonvulsants, glucose, IV fluids) are alwaysavailable without prior demand for payment.Essential laboratory tests (glucose, Hb or PCV)are available and results are obtained in a timelymanner.Essential equipment (needles and syringes,nasogastric tubes, oxygen equipment, selfinflatingresuscitation bags with masks ofdifferent sizes, nebulizers or spacers) isavailable.StaffingA qualified staff member is designated to carryout triage.A health professional is available without delayto manage children determined to have anemergency condition.Case management** (see below)Staff doing triage are trained in the ETATguidelines and can implement themappropriately, particularly when the emergencyroom gets busy during peak hours.Staff are skilled in the management of commonemergency conditions and start treatmentwithout delay: management of severerespiratory distress, shock, convulsions, lethargyand severe dehydration.Page 60

Assessment of quality of care for children in selected hospitals in Ghana*3.4 Drugs, equipment and supplies(See above p10‐15)Please refer to the tables above. Please note when judging the adequacy of supplies that some drugs(e.g. oxygen, anticonvulsants) need to be immediately available, whereas for others (e.g. antibiotics) itsuffices if access is assured.**3.5 Case management of emergency conditionsSource: Information is obtained by case observation of cases presenting, as far as possible, andthrough interviews with staff about the routine practice. If you cannot observe one to two cases,describe scenarios to staff of two to three cases with convulsions, severe respiratory distress, andshock.Case management is observed during and after working hours. If no cases with emergency conditionspresent, staff is interviewed about how they would manage such conditions. Enquire about themanagement of a child presenting with convulsions, with lethargy, with severe respiratory distress,and with severe dehydration.Summary table emergency areaLayout and physical structure of theemergency department.GoodTo beimprovedAdequate staffing. Notes on cases and commentsAvailability of essential drugs. Availability of essential laboratorysupport. Availability of essential equipment. Practice and case management ofemergency conditions. Summary score emergency area Good To be improved(to be circled) 5 4 3 2 1Please indicate the quality of support by marking one of the 5 numbers; 5 indicates good support, 4 to 1indicating levels of necessary improvement (4=small need for improvement, 1=urgent need for improvement).Page 61

Assessment of quality of care for children in selected hospitals in GhanaPage 62

Assessment of quality of care for children in selected hospitals in GhanaAssessment of the quality of hospital care for children Date: __/__/__/Country: ____________________ Initials of Health Facility: __/__/Initials of Assessor:__/__/4. Children’s ward4.1 Staffing and layoutSource: Observation during the visit to the ward, and interviews with staff and guardians of patients.How many beds does the ward have?How many patients are currently admitted? Is this high‐season for paediatric admissions or offseason?Has the number of paediatric patients increased over the last three years? Please comment:Which age groups are admitted to the paediatric ward?____ to ____ yearsPaediatric ward staffingDuring week daysStaff category atpostDoctorsNursesOthers (pleasespecify)No. duringmorning shiftNo. duringafternoonshiftNo. duringnight shiftCommentsDuring weekends/holidaysStaff category at No. duringpost morning shiftDoctorsNursesOthers (pleasespecify)No. duringafternoonshiftNo. duringnight shiftCommentsPage 63

Assessment of quality of care for children in selected hospitals in GhanaLayoutCheck the followingIs there a toilet in the ward?For patients?For staff?Is the toilet clean?Are the beds safe (bedside railing) and well maintained?Are the beds well spaced (one meter apart)Are there mattresses?Do patients receive bed‐sheets?Are the beds clean?Is there an emergency management area in or near to the ward?Is there a heat source on the ward?Are Insecticide treated bed nets available for patients’ use?Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Comments and observations:4.2 Standards and criteria in the children's wardStandardsChildren are seen in OPD by a designated health professional only.Closest attention for the most seriously ill children is ensured.There is a separate childrenʹs ward or room for children.There is a separate room for sick neonates with their mothers.Hygienic and sufficient services facilitate the stay of mother and child.Staff can wash their hands on the ward and there are sharps disposals available.Page 64

Assessment of quality of care for children in selected hospitals in GhanaStandards and criteriaChildren are only seen in OPD by thedesignated health professional in thedesignated room/area.Closest attention for the most seriously ill childrenThe most seriously ill children are cared for in asection where they receive closest attention.This section is close to the nursing station sothat children can be directly observed most ofthe time.Separate ward for children.Children are kept in a separate ward orseparate area of a ward.GoodTo beimprovedCommentsSeverely ill children are kept apart from adultsin wards such as those for infectious diseases orintensive care.Children with surgical conditions are at leastkept in a separate room, with staff aware of thespecial needs for children, such as feeding andwarmth.Arrangements are made to meet these needs.In cold weather children are kept warm(blankets etc...).Separate room for sick neonates with their mothersSick newborns are kept separate from healthybabies.Mothers of sick newborns are rooming in withtheir babies, and have adequate facilities.Hygiene and accident preventionStaff have access to hand washing facilities(tap/veronica bucket, soap and single usetowels. The ward is kept clean and dangerousitems are inaccessible for children.Sharps are disposed of in a special container,preventing accidents.Page 65

Assessment of quality of care for children in selected hospitals in GhanaStandards and criteriaGoodTo beimprovedCommentsHygienic and sufficient services facilitate the stay of mother and childThere are sufficient and adequate toilets whichare easily accessible.Mothers have access to running water and to anappropriate space, near the ward, to washthemselves and their child.Mothers have access to a washing facility, inorder to wash themselves and their child’sclothes.Patients are kept in a bed/cot with a cleanmattress.Patients receive bed sheets.Beds are equipped with insecticide‐treated bednets.Summary table paediatrics wardGoodTo beimprovedNotes on cases andcommentsThere is a separate ward for children. There is a separate room for sick newbornbabies with their mothers.The hygiene of services for children and theirmothers is adequate.Closest attention is provided for the mostseriously ill children.Hygiene and accident prevention is in place.Summary score childrenʹs ward and facilities Good To be improved(to be circled) 5 4 3 2 1Please indicate the quality of support by marking one of the 5 numbers; 5 indicates good support, 4 to 1indicating levels of necessary improvement (4=small need for improvement, 1=urgent need for improvement).Page 66

Assessment of quality of care for children in selected hospitals in GhanaAssessment of the quality of hospital care for children Date: __/__/__/Country: ____________________ Initials of Health Facility: __/__/Initials of Assessor:__/__/5. Case management of common diseases:5.1 Cough/difficult breathing (p 69‐107*)5.2 Diarrhoea (p109‐130)5.3 Fever conditions (p133‐171)5.4 Malnutrition (p173‐196)5.5 HIV/AIDS (p199‐224)Source: This information should be collected by observing the treatment and care of children with therelevant condition and interviewing staff and carers, and reviewing patient’ records (5‐10 records)* Please note: the page‐references refer to the English version of the WHO Pocket Bock of HospitalCare for Children.5.1 Cough or difficult breathingStandardsPneumonia is diagnosed and classified based on diagnostic signs.Appropriate antibiotics are administered to children who need them.Oxygen therapy is administered to all children who need it.Correct indications for chest X‐ray are applied.Children with wheezing receive correctly administered inhaled bronchodilators.TB treatment is given according to national guidelines.Adequate monitoring and supportive care is ensured.Standards and criteriaGoodTo beimprovedCommentsAssessment of pneumoniaHealth workers correctly diagnosepneumonia and classify/recognize severitypp 69‐74,78.Signs such as chest‐indrawing, respiratoryrate, presence of cyanosis and generalcondition are used pp 70‐73.Administration of appropriate antibioticsAntibiotics are given only to children withcough and difficult breathing who need them(pneumonia, severe pneumonia, very severepneumonia or very severe disease).pp 74,75,79,80Not to children without signs of pneumoniaor unless there is another reason forPage 67

Assessment of quality of care for children in selected hospitals in GhanaStandards and criteriaantibiotics p 82.Appropriate antibiotics at correct doses andduration are administered for pneumoniaaccording to severity and weightpp 74,75,79,80.If child has not improved after two days orcondition worsens, a health professionallooks for complications or considers otherdiagnoses pp 76, 79.GoodTo beimprovedCommentsOxygen therapyOxygen is administered to all children whoneed it. pp 75,79,281‐284.Oxygen is not given if there is no clinicalindication for oxygen therapy (sign ofhypoxaemia) p 75.Oxygen is administered correctly (prongs orcatheter, correct flow, no interruptions) andmonitored.Oxygen mask and headbox are avoided dueto waste of oxygen and risks pp 281‐284.Use of chest X‐rayChest x‐rays are performed when signs ofpneumonia are present in:Young infantsCases with very severe pneumoniaCases with suspected complications (e.g.empyema, pneumothorax, abscess)Patients not responding to appropriateantibiotic treatment for > 48 hoursChest x‐ray is not performed in patients withuncomplicated pneumonia or cough and coldunless there is a clear indication pp 76‐77.WheezingChildren in need of bronchodilators arecorrectly identified/diagnosed pp 87,88.Inhaled bronchodilators are correctlyadministered (way, dose and frequency) byspacer or nebulizer pp 88‐89.Inhaled bronchodilators are affordable(without prior demand for payment).Children with asthma who are dischargedhave follow‐up treatment prescribed andexplained to parents p 91.Page 68

Assessment of quality of care for children in selected hospitals in GhanaStandards and criteriaGoodTo beimprovedCommentsTB treatmentCorrect anti‐tuberculous treatment is givento children with suspected TB according tonational guidelines pp 101‐104.TB is considered as differential diagnosis ofun‐resolving pneumonia and malnutritionp 76.Not every child with malnutrition receivesanti‐TB treatment (balance of the likelihoodof having TB) p 192.Monitoring and supportive careSee monitoring and supportive care, sections10 and 11 pp 261ff and 289ff.Summary table cough/difficult breathingGoodTo beimprovedNotes on cases and commentsSeverity of pneumonia is correctly assessedand diagnosed.Appropriate antibiotics are administered forpneumonia and other respiratory diagnoses.Oxygen is correctly administered whennecessary.Correct use of chest X‐ray. Appropriate diagnosis and management ofTB.Inhaled bronchodilators are givenappropriately when indicated.Patient monitoring appropriately performedand charted (seesection 11).Supportive care provided appropriate forcondition (see section 10).Page 69

Assessment of quality of care for children in selected hospitals in GhanaMain strengths:Main weaknesses:Summary score cough and difficult breathing Good To be improved(to be circled) 5 4 3 2 1Please indicate the quality of support by marking one of the 5 numbers; 5 indicates good support, 4 to 1indicating levels of necessary improvement (4=small need for improvement, 1=urgent need for improvement).Page 70

Assessment of quality of care for children in selected hospitals in Ghana5.2 DiarrhoeaStandardsDehydration is correctly assessed on admission.An adequate rehydration plan according to severity of dehydration is followed and monitored.Appropriate antibiotics are only given when necessary.Appropriate feeding is continued during diarrhoea.Monitoring and supportive care is adequate.Standards and criteriaGoodTo beimprovedCommentsAssessment of dehydrationThe degree of dehydration is assessed in allpatients with diarrhoea p 111.Dehydration is correctly classified based onrecommended signs(*) according to theControl of Diarrhoeal Diseases (CDD)/IMCIguidelinespp 18,111‐113.Children with dysentery and severemalnutrition and young infants with bloodin stool are properly assessed and admittedp 127.Management according to rehydration planThe correct rehydration plan is chosen basedon the assessment of dehydration (Plan A,Plan B, Plan C)pp 114,117,120.Rehydration is correctly administered.The amount of fluids by weight and time iscorrectly calculated for Plans B and Cpp 114,117.Signs of dehydration are monitored duringrehydration.Fluid intake and rate of infusion aremonitored and adjusted, if necessary p 115.Use of antibiotics for diarrhoeaAntibiotics are given only to children withbloody diarrhoea or suspected cholerapp 110,128,129.Antibiotics are not given to childrenwith only watery diarrhoea andwithout any other condition requiringantibiotic treatment p 122.Correct choice of antibioticsaccording to national guidelines andnational adaptations pp 128‐129.Page 71

Assessment of quality of care for children in selected hospitals in GhanaStandards and criteriaAnti‐diarrhoeal drugs are not givenp 110.Continued feedingGoodTo beimprovedFeeding (breast milk and/or other food) iscontinued and encouraged for children with diarrhoea pp 118‐119.Frequent small feedings are offered. Monitoring and supportive careSee monitoring and supportive care chapters10 and 11 pp 261ff & 289ff.Summary table diarrhoeaGoodTo beimprovedDehydration is correctly assessed. CommentsNotes on cases and commentsThe rehydration plan is appropriate toseverity of dehydration, and appropriatelymonitored.Appropriate antibiotics only given whennecessary.Appropriate (continued) feeding givenduring diarrhoea.Main strengths:Main weaknesses:Page 72

Assessment of quality of care for children in selected hospitals in GhanaSummary score management of diarrhoea Good To be improved(to be circled) 5 4 3 2 1Please indicate the quality of support by marking one of the 5 numbers; 5 indicates good support, 4 to 1indicating levels of necessary improvement (4=small need for improvement, 1=urgent need for improvement).5.3 Fever conditionsStandardsA differential diagnosis of fever is considered and appropriate investigations are undertaken.Meningitis is correctly diagnosed and managed.Severe complicated malaria is correctly diagnosed and managed.Measles is correctly diagnosed and managed.Other febrile conditions are correctly diagnosed and managed.Adequate monitoring and supportive care is ensured.Standards and criteriaGoodTo beimprovedCommentsDifferential diagnosis and investigationsAppropriate assessment is undertaken for allchildren with febrile conditions pp 133‐134‐history‐examination‐laboratory.Children admitted with fever have a differentialdiagnosis for possible and likely conditionsconsidered p 135.Appropriate examinations/investigations areundertaken to establish a diagnosis (lumbarpuncture, blood film for malaria, urineexamination, chest x‐ray) p 137.Diagnosis and management of meningitisLumbar puncture is performed without delaywhen meningitis is suspected p 149Adequate antibiotic treatment is started withoutdelay when bacterial meningitis is suspectedp 150.Complications of meningitis are diagnosed andtreated appropriately:‐convulsions‐hypoglycaemia etc. p 153.Appropriate patient monitoring is performedand charted p 153‐state of consciousness‐respiratory rate‐pupil size.Page 73

Assessment of quality of care for children in selected hospitals in GhanaStandards and criteriaGoodDiagnosis and management of severe or complicated malariaMalaria diagnosis is confirmed by microscopyor a rapid diagnostic test p 137.For possible cerebral malaria and malariaassociated respiratory distress, alternativediagnoses are ruled out (lumbar puncture formeningitis, x‐ray for e.g. pneumonia)pp 139‐140.Correct anti‐malarial treatment is givenpp 140‐141.Patients are monitored adequately, andcomplications such as hypo‐glycaemia areprevented pp 143‐144.Complications are correctly diagnosed andtreated pp 142‐144‐coma‐severe anemia‐hypoglycemia‐acidosis‐aspiration pneumonia etc.Diagnosis and management of measlesTo beimprovedCommentsMeasles cases are assessed for complications andtreated appropriately p 154. Vitamin A is given to all patients with measlesp 155. Appropriate nutritional support is given p 155 Public health measures are taken when a child isadmitted with measles p 157Notify Public Health/Disease Control Unit‐isolation ‐patients are checked for immunizationstatus, and‐immunized if necessaryOther severe febrile conditions are assessed and managed correctly (typhoid, mastoiditis, UTI,septic arthritis and osteomyelitis)Appropriate assessment and differentialdiagnosis performed pp 133‐138. Correct treatment given. Monitoring and supportive care (see chapters 10and 11) pp 261ff & 289ff. Page 74

Assessment of quality of care for children in selected hospitals in GhanaSummary table feverGoodTo beimprovedNotes on cases andcommentsDifferential diagnosis of fever considered andappropriate investigations undertaken.Correct diagnosis and management ofmeningitis.Severe complicated malaria correctly managed. Measles correctly managed Other febrile conditions correctly managed. Main strengths:Main weaknesses:Summary score management of fever conditions Good To be improved(to be circled) 5 4 3 2 1Please indicate the quality of support by marking one of the 5 numbers; 5 indicates good support, 4 to 1indicating levels of necessary improvement (4=small need for improvement, 1=urgent need for improvement).Page 75

Assessment of quality of care for children in selected hospitals in Ghana5.4 Severe malnutritionStandardsNutritional status is assessed by weight for age/MUAC and differential diagnoses for severemalnutrition are considered.Infections are appropriately managed by giving empiric treatment.Micronutrients are appropriately supplemented.Dehydration and electrolyte imbalance are appropriately assessed, treated and monitored.Hypoglycaemia and hypothermia are prevented, checked and managed.Feeding with correct type, frequency and amount of food in severely malnourished children isensured.Associated conditions of severe malnutrition are appropriately managed.Monitoring and supportive care is adequate.Standards and criteriaGoodTo beimprovedCommentsAssessment of nutritional status, including differential diagnoses for severe malnutritionScale available, weight for age correctlycalculated p 174.An appropriate history is taken and laboratoryexaminations done pp 174‐175.Clinical examination for: wasting, oedema, skinchanges, signs of dehydration, eye signs ofVitamin A deficiency, severe palmar pallor,localizing signs of infection, mouth ulcers,fever/hypothermia etc. pp 174‐175.Differential diagnosis considered for severemalnutrition, if doubt about protein‐energymalnutrition as likely cause (rule out TB,HIV/AIDS infection, malabsorption, etc.)pp 174‐175.Management of infection and micronutrientsBroad spectrum antibiotics are administered toall severely malnourished patients pp 182‐183.Measles vaccination if needed pp 182. Treatment of worms withmebendazole/albendazole p 183.Vitamin A given orally p 184. Vitamin/mineral supplementation givenpp 183,184.Iron only given in the recovery phase p 183 Page 76

Assessment of quality of care for children in selected hospitals in GhanaStandards and criteriaManagement of dehydrationReSoMal given orally or NG tube forrehydration pp 179‐181.IV rehydration not given except for shock andinability to take/tolerate orally p 179.Potassium and magnesium supplement givenpp 181‐182.Use of low sodium rehydration fluid and foodpreparation without salt p 182.GoodTo beimprovedPrevention and management of hypoglycaemia and hypothermiaRoutine procedures in place to preventhypoglycaemia and hypothermia pp 177‐178.Frequent feeding of malnourished children fromtime of admission p 177.If a child is deteriorating, blood glucose ischecked p 177.Correct feeding of severely malnourished childrenAppropriate (caloric intake and frequency)feeding regimen is started in all severely malnourished children p 184.Frequent feeding ‐ day and night pp 184,187. Monitoring of intake and weight gain p 188. Follow up is organized for children dischargedbefore recovery pp 193‐194. Correct management of associated conditions and supportive careCorrect treatment of associated conditions: eyeproblems, severe anaemia, dermatitis, diarrhoea,TB, HIV/AIDS pp 190‐192.Sensory stimulation and emotional support isprovided pp 189‐190.Monitoring and supportive careSee monitoring and supportive care (chapters10and 11) pp 261ff and 289ff.CommentsPage 77

Assessment of quality of care for children in selected hospitals in GhanaSummary table malnutritionNutritional status assessed by weight forage/MUAC, including differentialdiagnosis for severe malnutrition.GoodTo beimprovedNotes on cases and commentsManagement of infection. Management of electrolyte imbalance andmicronutrients.Correct management of dehydration. Hypoglycaemia and hypothermia checkedand managed in children with severemalnutrition.Correct feeding of severely malnourishedchildren.Correct management of associatedconditions in children with severemalnutrition.Main strengths:Main weaknesses:Summary score management of severe malnutrition Good To be improved(to be circled) 5 4 3 2 1Please indicate the quality of support by marking one of the 5 numbers; 5 indicates good support, 4 to 1indicating levels of necessary improvement (4=small need for improvement, 1=urgent need for improvement).Page 78

Assessment of quality of care for children in selected hospitals in Ghana5.5 Children with HIV/AIDSStandardsGuidelines are in place for counselling, diagnosing and staging of paediatric HIV.Guidelines are in place for the ART and treatment of opportunistic infections and monitoring ofantiretroviral therapy.All HIV infected children receive standard immunizations, prophylaxis/treatment of opportunisticinfections and supportive care.Monitoring and supportive care is adequate.Standards and criteriaCounselling and diagnosis of paediatric HIVGoodTo beimprovedCounselling is done in a separate room andconfidentiality is ensured pp 201‐203. During breastfeeding counselling, theimportance of exclusive breastfeeding for 6months is stressed. If breast milk substitute feeding is considered, the financial and hygienicrequirements are explained pp 219,220.Counsellors receive formal training in HIVcounselling, are regularly updated and do receive adequate supervision and support p 202.Detailed counselling‐documentation is done Women attending ANC and delivering in thehospital have been offered an HIV test. Thosefound to be positive receive breast‐feedingcounselling and learn about symptoms of paediatric HIV. A follow‐up appointment isgiven.Clinical signs of paediatric HIV infection arerecognized and an HIV test is offered routinelyfor a child with clinical signs of possible HIV infection pp 200,201.HIV testing against the will or without theknowledge of the family is prohibited. All family members of children with a positiveHIV test are offered HIV testing and counselling p 201.A high proportion of current inpatients withsevere malnutrition or TB show a documented offer of HIV screening.DNA/RNA tests are used for children 18months pp 203,204.The staging is done according to the WHOpaediatric clinical staging system pp 204‐206. CommentsPage 79

Assessment of quality of care for children in selected hospitals in GhanaStandards and criteriaGoodTo beimprovedCommentsAntiretroviral (ARV) treatment and monitoringAntiretroviral regimens are initiated andswitched according to national guidelinespp 207‐209.If possible, paediatric formulations and fixeddosecombinations are given p 207.On all follow‐up visits weight and height aretaken. In children < 24 months the headcircumference is also recorded to detect growthfailure. The dosing of ARV is done correctly andadjusted for weight‐gain regularly.CD4 percentage and/or clinical monitoring isdone according to national guidelines p 210.Opportunistic infections and supportive careImmunization‐status is checked and updatedexcept for yellow fever and BCG in symptomaticdisease.All mothers receive nutritional advice beforedischarge p 216.Correct treatment of:opportunistic infectionspersistent diarrhoeaTB (no thioacetazone)recurrent pneumonia pp 216‐219.Initiation of ARV is deferred until patient hasbeen stabilized and opportunistic infections aretreated (including TB) p 209.Supportive care and follow‐up of HIV infected childrenCarers are referred to home‐based care/palliative care‐/ support before dischargep 221‐224.Terminal care focuses on symptom controlp 221.Follow‐up is ensured for all HIV infectedchildren discharged from the ward p 220.Prophylactic co‐trimoxazole is offered to allchildren at risk of or suspected of HIVpp 214, 215.See monitoring and supportive care (chapters 10and 11) pp 261ff and 289ff.Page 80

Assessment of quality of care for children in selected hospitals in GhanaSummary table HIV/AIDSGoodTo beimprovedNotes on cases andcommentsHIV tests used correctly and when indicated. Professional counselling services are in placewith confidentiality ensured.ARV treatment follows national guidelines. Nutritional advice provided, (on exclusivebreastfeeding for 6 months/breast milksubstitute).Immunizations and co‐trimoxazoleprophylaxisgiven correctly.Opportunistic infections correctlydiagnosed/treated.Patients are referred for home‐based care andpalliative care focuses on symptom control.Main strengths:Main weaknesses:Summary score management of HIV/AIDS Good To be improved(to be circled) 5 4 3 2 1Please indicate the quality of support by marking one of the 5 numbers; 5 indicates good support, 4 to 1indicating levels of necessary improvement (4=small need for improvement, 1=urgent need for improvement).Page 81

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Assessment of quality of care for children in selected hospitals in GhanaAssessment of the quality of hospital care for children Date: __/__/__/Country: ____________________ Initials of Health Facility: __/__/Initials of Assessor:__/__/6. Supportive careStandardsNutritional needs of admitted children are met, breastfeeding is continued.Breastfeeding is encouraged and where necessary expressed breast milk is given.Appropriate intravenous fluids are only given where indicated and flow is monitored.Drug treatment started only where necessary, polypharmacy avoided were possible.Blood transfusions are only given where indicated and only screened blood is used.Standards and criteriaGoodTo beimprovedCommentsNutritional needs of admitted childrenNutritional needs of all patients are covered,according to age and ability to feed pp 261‐272.Breastfed infants continue to receive breast milkp 262.Appropriate complementary feedings is offeredat least 3 times a day to breastfed infants of 6‐12months of age p 262.Feedings are offered at least 5 times a day tonon‐breast‐fed infants of 6 to 24 months of agep 271.All children admitted receive their full caloricrequirement unless there is good medicalreasons for not giving it p 270.A sufficient caloric intake (100 calories/kg forchildren under 10 kg) is provided; for childrentoo sick to feed by nasogastric tube.IV‐glucose is not used as calorie source for morethan a maximum 24 hours p 273.Promotion of breastfeedingMothers of children below two years of age areencouraged and helped to breastfeedp 262‐266, 271Expressed breast milk is given with a cup orNG‐tube when the child is unable to feed or ifthe mother cannot stay with the child all thetime p 267.Page 83

Assessment of quality of care for children in selected hospitals in GhanaStandards and criteriaGoodTo beimprovedCommentsUse of intravenous fluidsIntravenous fluids are given only whenindicated p 273.Appropriate fluids are chosen p 273. The flow rate is monitored closely p 273. Drug treatment and avoidance of polypharmacyDrugs are only given for an established orhighly suspected diagnosis.No drugs are given without a good reason.No routine use of sedative drugs or antihistamines.Corticosteroids are only given for a clearindication for which steroids are useful p 151.Blood transfusionBlood is only given when indicated p 277. Only screened blood is used p 277. The flow rate is monitored p 279. Summary table supportive careGoodTo beimprovedNotes on cases andcommentsNutritional needs are met, according to age andability to feed.Breastfeeding is promoted. Intravenous fluids given only when indicated,appropriate choice of fluids, and monitoring ofrate.Drug treatment according to diagnosis,polypharmacy is avoided.Blood transfusion only when indicated, blood isscreened, rate monitored.Main strengths:Page 84

Assessment of quality of care for children in selected hospitals in GhanaMain weaknesses:Summary score supportive care Good To be improved(to be circled) 5 4 3 2 1Please indicate the quality of support by marking one of the 5 numbers; 5 indicates good support, 4 to 1indicating levels of necessary improvement (4=small need for improvement, 1=urgent need for improvement).Page 85

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Assessment of quality of care for children in selected hospitals in GhanaAssessment of the quality of hospital care for children Date: __/__/__/Country: ____________________ Initials of Health Facility: __/__/Initials of Assessor:__/__/7. MonitoringThis section covers topics which are applicable for sick children with different diagnoses. Informationshould be predominantly by care observation and review of the charts of currently admitted children.Between 3 and 5 observations should be made in this category.StandardsAll children are assessed for their nutritional status on admission.Every child has a monitoring chart according to severity of condition where individual progress ismonitored.Reassessment and monitoring is adequately done and correctly recorded by the nurses and a seniorhealth professional is called when needed.Admitted children are reassessed by a doctor regularly according to severity of illness.Follow up is arranged prior to discharge with a discharge note explaining the condition and furthertreatment needed.Standards and criteriaGoodTo beimprovedNutritional status is assessed in all admittedchildren CommentsMonitoring of individual progressAt the time of admission, a monitoring plan isprescribed according to the severity of thepatientʹs condition pp 289,290.A standard monitoring chart is used with thefollowing information: patient details; vitalsigns; clinical signs depending on condition;treatments given, feeding and outcomepp 290,369.Reassessment and monitoring by nursesKey risk signs are monitored and recorded bya nurse twice a day and at least four times aday for critically ill patients p 289,290.Doses and time are recorded for medicationsand IV‐fluids given by the nurse for everypatient receiving medication or IV‐fluidsp 289,290.Page 87

Assessment of quality of care for children in selected hospitals in GhanaStandards and criteriaAdditional special monitoring is performedand recorded appropriately when needed tofollow the progress of particular conditions:e.g. in malnourished children, fluid balance(input – output) in severe dehydration,oxygen, coma scale for unconscious childrenp 289.Nurses use the results of patient monitoring toalert the physicians of problems or changingpatient status warranting their attention.GoodTo beimprovedCommentsReassessment of admitted children by a doctorSeriously ill patients are reassessed by adoctor upon admission and reviewed at leasttwice daily until improved p 289.All patients are reassessed daily duringworking days by a doctor.Sick patients or new admissions are alsoreviewed by a physician at weekends andduring holidays p 289.Follow upBefore discharge follow up is arranged in thehealth facility closest to the patientʹs home thatprovides the necessary follow‐up treatment.All children receive a discharge noteexplaining their condition and providinginformation for the staff at the follow‐upfacilitySummary table monitoringNutritional status is assessed in all admittedchildren.Each child’s progress is individuallymonitored, and charts are used.The most ill children receive closest attention.GoodTo beimprovedNotes on cases andcommentsAll admitted children are appropriatelyreassessed by a nurse.All admitted children are appropriatelyreassessed by a doctor.Page 88

Assessment of quality of care for children in selected hospitals in GhanaMain strengths:Main weaknesses:Summary score monitoring Good To be improved(to be circled) 5 4 3 2 1Please indicate the quality of support by marking one of the 5 numbers; 5 indicates good support, 4 to 1indicating levels of necessary improvement (4=small need for improvement, 1=urgent need for improvement).Page 89

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Assessment of quality of care for children in selected hospitals in GhanaAssessment of the quality of hospital care for children Date: __/__/__/Country: ____________________ Initials of Health Facility: __/__/Initials of Assessor:__/__/8. Neonatal care8.1 Nursery staffing and layout8.2 Routine neonatal care, (pp 42‐47)8.3 Nursery facilities8.4 Case management and sick newborn care, (pp 47‐61)8.1 Nursery staffing and layoutSource: This information should ideally be collected partly before the visit (see Annex 3: postalquestionnaire), and be available for reference during the visit. If it has not been collected before, collectthe information early during the visit from the doctor/nurse in charge.Staffing of delivery room and newborn nurseryIndicate the staff Newborn nurseryDelivery roomavailable for the Day Night Day NightDoctorMedical assistantMidwivesAuxiliary staffWho is available during the weekend?If senior staff members are not available all the time, how are they called?LayoutHow many cots/beds does the nursery have? Number of cots/beds:?Up to what age are newborns admitted to the nursery? Age in days/weeks: _______ days/weeksAre out‐born infants admitted in the nursery?If so, are they admitted in a separate room?Yes No Yes No Page 91

Assessment of quality of care for children in selected hospitals in GhanaCheck the following:Where is the toilet?Is the toilet clean?Are the beds safe and well maintained?Are there mattresses?Do patients receive bed sheets?Are the beds clean?Is there an emergency management area in or near to the ward?Is there a heat source on the ward?Are insecticide treated bed nets available for patient use?Are the mattresses with covered with mackintosh?Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No 8.2 Routine neonatal careSource: Please collect the information by observing the treatment and care of children with therelevant condition and interviewing staff and carers and reviewing patients record(s) (5‐10).StandardsNeonatal resuscitation guidelines are available and staff is trained in their use.Early and exclusive breastfeeding and skin contact are ensured.Clean delivery with clean instruments and hands is practiced.Neonates are kept warm.Eye prophylaxis, Vitamin K and immunizations are given.Standards and criteriaGoodTo beimprovedNeonatal resuscitation guidelines are available and staff are trained in their useWritten guidelines for resuscitation and care ofthe newborn are available, followed, practicedand documented pp 42‐46.There is a resuscitation place with heating andequipment ready to use.A functioning self‐inflating bag with newborn‐ +premature size masks is available p 45.If a neonate is not breathing, ventilation by selfinflatingbag is initiated according to WHOguidelines p 44.There is a plan to call a senior healthprofessional for resuscitation, if required p 43.Early and exclusive breastfeeding and skin contact are ensuredWithin the first ½ hour, a newborn hasprolonged skin contact with the mother p 42.CommentsPage 92

Assessment of quality of care for children in selected hospitals in GhanaStandards and criteriaMothers are assisted with the first breastfeeding:correct attachment and positioning isdemonstrated p 42.There is no promotion of infant formula on theward or distributed to mothers/staffThere are no restrictions on the frequency orlength of breastfeedsMothers stay with their infants in the same roomday and nightClean delivery with clean instruments and handsGoodTo beimprovedThe birth attendants hands are clean duringdelivery p 46. Clean (sterile) instruments are used p 46,47. Nothing is applied to the cord p 46. CommentsChildren are kept warmNewborns are kept in a warm room, with nodraught p 46.Newborns are cleaned with dry/warm cloth, nobathing or washing p 46.Body temperature is monitored. Eye prophylaxis, Vitamin K andimmunizations are given according to localpolicy p 46.Summary table routine neonatal careResuscitation procedures are correctlyperformed.GoodTo beimprovedNotes on cases andcommentsEarly and exclusive breastfeeding is promoted,skin contact ensured.Clean delivery and newborn care is practiced. Thermal protection is practiced. Eye and vitamin K prophylaxis andimmunizations are givenPage 93

Assessment of quality of care for children in selected hospitals in GhanaMain strengths:Main weaknesses:Summary score routine neonatal care Good To be improved(to be circled) 5 4 3 2 1Please indicate the quality of support by marking one of the 5 numbers; 5 indicates good support, 4 to 1indicating levels of necessary improvement (4=small need for improvement, 1=urgent need for improvement).8.3 Nursery facilitiesStandardsThere is a separate room for sick newborn babies with their mothers.There are hygienic services for mothers.There is adequate accident prevention in place and safe disposal of sharps.Closest attention for the most seriously ill newborns/infants is provided.Standards and criteriaGoodTo beimprovedThere is a separate room for sick newborn babies with their mothersSick newborns are kept in a separate unit orroom from healthy babiesMothers of sick newborns are rooming in withtheir babies, with adequate facilities.CommentsThere are hygienic services for mothersToilets are adequate & easily available. The mother has access to running water and toan appropriate space, near the ward, to washherself and her child.Mothers have access to a washing facility, towash their own hers and their childrenʹs clothesPage 94

Assessment of quality of care for children in selected hospitals in GhanaStandards and criteriaGoodTo beimprovedThere is adequate accident prevention in place and safe disposal of sharpsThe ward is kept clean Sharps are disposed of in a special containerpreventing accidentsMothers and children sleep under insecticidetreated bed netsClosest attention for the most seriously ill newborns is providedCommentsSummary table nursery facilityThere is a separate room for sick newborn babieswith their mothersThere are hygienic services for the mothers ofthe newbornsClean ward; accident prevention and dispositionof sharps is in placeClosest attention for the most seriously illnewborn is ensuredGoodTo beimprovedNotes on cases andcommentsSummary score routine neonatal care Good To be improved(to be circled) 5 4 3 2 1Please indicate the quality of support by marking one of the 5 numbers; 5 indicates good support, 4 to 1indicating levels of necessary improvement (4=small need for improvement, 1=urgent need for improvement).Page 95

Assessment of quality of care for children in selected hospitals in Ghana8.4 Case management and sick newborn careNote: Sick newborns might be admitted in different areas, the maternity ward or the infant ward.Information should be primarily by case observationStandardsNeonatal sepsis is appropriately diagnosed and investigatedNeonatal sepsis is adequately treatedSpecific feeding needs of sick young infants and those with low birth weight are taken care ofSevere jaundice is recognized and appropriately managedStandards and criteriaGoodTo beimprovedCommentsDiagnosis and investigation of neonatal sepsisNeonatal sepsis is suspected in neonates withsigns such as fever or difficulty feeding andappropriately investigated (e.g. urinemicroscopy, foci of infection) pp 47, 53.Lumbar puncture is done to rule out/confirmmeningitis pp 49,50,316.Newborns receive oxygen if cyanosed or insevere respiratory distress p 52.Treatment of neonatal sepsisEffective antibiotics are given according to ageand weight of the baby p 49‐50,62‐66. The response to treatment is monitored p 48. Specific feeding needs of sick young infants and those with low birth weightAll efforts are made to give mother’s milk toLBW babies p 53‐55.Frequent feedings (at least 8 x per day) areprovided to LBW‐babies and intake ismonitored p 54.To children unable to feed expressed breast milkis given by cup and spoon or fed by nasogastrictube in adequate amounts according to age.Intake is monitored p 55.If IV‐fluids are given, they are recorded andprecautions are in place to prevent fluidoverload p 51,52.In LBW‐babies, heat loss is minimized bykangaroo‐care and a cap on the head p 54.Recognition and management of jaundiceFacilities for exchange transfusion are available,or there are guidelines when to refer a childp 58.Page 96

Assessment of quality of care for children in selected hospitals in GhanaStandards and criteriaPhototherapy and guidelines when to use it areavailable, and adequate hydration is ensuredpp 58, 59.Procedures are in place to check the bilirubinlevel.GoodTo beimprovedCommentsSummary table case management and sick newborn careGoodTo beimprovedNeonatal sepsis is appropriately diagnosed. CommentsNeonatal sepsis is appropriately treated. Specific feeding needs of sick young infants andthose with low birth weight, are met.Jaundice is adequately recognized andmanaged.Main strengths:Main weaknesses:Summary score case management and sick newborn care Good To be improved(to be circled) 5 4 3 2 1Please indicate the quality of support by marking one of the 5 numbers; 5 indicates good support, 4 to 1indicating levels of necessary improvement (4=small need for improvement, 1=urgent need for improvement).Page 97

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Assessment of quality of care for children in selected hospitals in GhanaAssessment of the quality of hospital care for children Date: __/__/__/Country: ____________________ Initials of Health Facility: __/__/Initials of Assessor:__/__/9. Paediatric surgery and rehabilitation(p. 227‐259)Source: This information should be collected by observing the treatment and care of childrenundergoing surgical treatment, interviewing staff and carers and reviewing guidelines, if available.StandardsPre‐operative care is child‐friendly and fasting is kept to a minimum.Intra‐operatively, routine procedures prevent hypothermia and hypoglycaemia.Post‐operative care ensures save recovery including monitoring, pain relief and early feeding.The surgical ward is child friendly, provides food for children and opportunities to play.Paediatric‐size anaesthesia equipment is available (see table below).Basic rehabilitation equipment is available.Standards and criteriaGoodTo beimprovedCommentsPre‐operative careStandard procedures are in place to prepare achild for surgery: weight, haemoglobin level,blood group of the child and consent of the careris recorded p 228‐229.Fasting is kept to a minimum (8hrs nosolids/6hrs no formula/4 hrs no milk or clearliquids) and children are put first on theoperating list to avoid unnecessary starvingp 228.Intra‐operative careThe child is kept warm during surgery and IVfluidscontaining glucose are given for longprocedures (e.g. 0.45% NaCl + 5% glucose)p 231.Guidelines are in place for the safe use of localanaesthetic (weight adjusted) p 229.Blood loss is monitored p 231. Page 99

Assessment of quality of care for children in selected hospitals in GhanaStandards and criteriaGoodTo beimprovedCommentsPost‐operative care and monitoringThere are specific notes from the surgeon on theprocedure performed, and necessary monitoringand treatment. There is a handover for thenurses from theatre staff.Post‐operatively, children are closely observedin a safe place and frequent recording of vitalsigns (blood pressure, pulse, respiration rateevery 15‐30 min. initially) is ensured p 232.Oxygen and equipment for resuscitation/suction are readily available and working.Nursing staff have adequate guidelines on postoperativepain relief p 233.Children are allowed to eat as soon as they havefully recovered from anaesthesia as indicated bya competent health professional p 233.Standards and criteriaThe surgical ward is child friendly, providesfood for children and opportunities to play.GoodTo beimprovedNotes on cases andcommentsRehabilitationBasic rehabilitation equipment is available forchildren (crutches…).Some form of organized physiotherapy isavailable to children.Summary table paediatric surgery and rehabilitationStandard procedures are followed for preoperativesurgical carePre‐ and post‐operative starving is kept to aminimum.Hypoglycaemia and hypothermia are preventedduring surgery.Frequent post‐operative monitoring with regularchecks of vital signs is ensured.Resuscitation equipment is available and painrelief adequately addressed.GoodTo beimprovedNotes on cases andcommentsBasic rehabilitation equipment is available. Page 100

Assessment of quality of care for children in selected hospitals in GhanaSummary score paediatric surgery and rehabilitation Good To be improved(to be circled) 5 4 3 2 1Please indicate the quality of support by marking one of the 5 numbers; 5 indicates good support, 4 to 1indicating levels of necessary improvement (4=small need for improvement, 1=urgent need for improvement).9.1 Paediatric-size anaesthesia equipmentPaediatric size are:available, in goodworking conditionnot always availablenot availableTracheal tubesFace masksLaryngoscope bladesOropharyngealairwaysBreathing valvesResuscitation bagsBlood pressure‐cuffsPage 101

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Assessment of quality of care for children in selected hospitals in GhanaAssessment of the quality of hospital care for children Date: __/__/__/Country: ____________________ Initials of Health Facility: __/__/Initials of Assessor:__/__/10. Other hospital wards with childrenCheck whether children are admitted to other hospital departments, such as the infectious diseaseward or intensive care unit. Assess the adequacy of the layout for children, staffing with paediatricexpertise, availability of supplies for children (e.g. paediatric size cannulae, food supply), andknowledge of monitoring and case management of children.Notes and comments:Layout:Staffing:Supplies and equipment for paediatric care:Monitoring of children:Page 103

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Assessment of quality of care for children in selected hospitals in GhanaAssessment of the quality of hospital care for children Date: __/__/__/Country: ____________________ Initials of Health Facility: __/__/Initials of Assessor:__/__/11. Hospital administrationThis section builds on findings in the section ʺGeneral hospital informationʺ obtained during the visit.It complements this information by findings during the visit, and might pull together items that wereobtained by different team members.StandardsAdequate and updated treatment guidelines are available and implemented.Audits with all staff participating and in regular intervals are performed.Essential drugs are stocked, a safe supply ensured and old drugs used first.Essential equipment is available and serviced.Essential lab tests are reliably performed and results speedily forwarded.Transport for referral is available.Standards and criteria Good To beimprovedAvailability of adequate and updated treatment guidelinesA recent paediatric textbook is easily available(last five years).Standard treatment guidelines are available aspocket instructions, wall charts or job aids .Recommended antibiotics for commoninfections according to hospital essential drugslist are available.Pocket guidelines, protocols and wall charts foremergency care are available.Newborn resuscitation is described in wallcharts.Performance of auditsAudits and regular staff meetings are conductedto review clinical practice and mortalityproblems with the organization at the hospital.The audits take into account monitoring,hospital flow and quality of care as well as moreacademic aspects on diagnosis.All staff categories participate in the audit.Essential drugs (see list above) are alwaysavailable and there is no demand for priorpayment p 14,15.Essential equipment (see list above) is availableand functioning properly pp 16,17.CommentsPage 105

Assessment of quality of care for children in selected hospitals in GhanaStandards and criteria Good To beimprovedEssential laboratory tests (see list above) areavailable and delivered in a timely manner p 19. Transport for referral is available. CommentsSummary table hospital administrationAdequate and updated treatment guidelines areavailable at the hospital.Audits on hospital deaths and clinical practiceare performed.GoodTo beimprovedEssential drugs are available. CommentsEssential equipment is available. Essential laboratory support is available. Transport is available for referral. Main strengths:Main weaknesses:Summary score hospital administration Good To be improved(to be circled) 5 4 3 2 1Please indicate the quality of support by marking one of the 5 numbers; 5 indicates good support, 4 to 1indicating levels of necessary improvement (4=small need for improvement, 1=urgent need for improvement).Page 106

Assessment of quality of care for children in selected hospitals in GhanaAssessment of the quality of hospital care for children Date: __/__/__/Country: ____________________ Initials of Health Facility: __/__/Initials of Assessor:__/__/12. Access to hospital care: Interview with caretakersand health workersInterview 2‐3 mothers or caretakers about their experience of care seeking before coming to hospital.This part of the form is intended to provide a background to the child’s condition, and to documentfactors which are outside the hospital. Where necessary, complement with interviews of staff to obtaintheir perspective.Standards and criteriaReferral by first level or primary health care workerPatients referred from first‐level facilities are correctlyassessed and classified for the most common conditionsrequiring referral (IMCI standards for districts where IMCIhas been implemented). Expected classifications (andreasons for referral would be: severe pneumonia or verysevere disease, very severe febrile disease, etc. ‐ see IMCIguidelines for classifications requiring referral).Check referral notes.Referred patients receive appropriate pre‐referraltreatment when indicated.Referred patients are provided with referral notes statingthe condition, reason for referral and any treatment given.Transport to hospitalLack of transport to hospital is not a cause of delayedreferral.Own or commercial transport is available to get tohospital.The hospital is geographically accessibleCost for transport does not represent a major barrier toreferral.Care seeking by parentsParents adequately recognize signs and symptoms thatrequire contact with health services.Ask the mother open questions on how her child fell illand probe into what she did, in which order and when andwhy she decided to seek help.Sick children are brought to health services withoutsignificant delay.If delays in care seeking exist, try to find out why.Parents bring their children to hospital without majordelay when advised by first‐level health staff that the childis in need of referral care.NotesPage 107

Assessment of quality of care for children in selected hospitals in GhanaStandards and criteriaEconomic barriers to hospital careHospital fees do not pose a major barrier to hospital carefor the majority of patients. (Ask about all types of fees,such as: admission fees, cost of drugs or laboratoryinvestigations, examinations, equipment used at thehospital). “major” to be defined as high enough torepresent, for some families, a barrier to seeking andobtaining hospital care or the need for the parents toborrow money to be able to have access to care.Hospital fees are clearly communicated to the carers andfees are displayed in the ward/hospital.Did carers at any point have to pay a fee without knowingwhich services payment was for?Traditional medicineWas a traditional practitioner consulted prior to going tothe hospital?If yes:Why was the traditional medicine practitioner preferred(fees, transport, culture…)?What treatment was received?How much was paid for the traditional medicine (incl.goods)?Why did they come to the hospital now (referred,…) Byhow much was the hospital visit delayed due to the visit?NotesSummary table access to hospital care interviewGoodTo beimprovedAppropriate referral by PHC. CommentsTransport easily available. Appropriate care‐seeking by parents. No significant fees or economic barriers tohospital services.Traditional medicine no barrier to access tohospital.Main strengths:Page 108

Assessment of quality of care for children in selected hospitals in GhanaMain weaknesses:Summary score access to hospital care Good To be improved(to be circled) 5 4 3 2 1Please indicate the quality of support by marking one of the 5 numbers; 5 indicates good support, 4 to 1indicating levels of necessary improvement (4=small need for improvement, 1=urgent need for improvement).Page 109

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Assessment of quality of care for children in selected hospitals in GhanaSummary evaluation scoreSummarize the individual items found above in this summary sheet to guide the discussionwith senior hospital staff at the debriefing.GoodTo be improved5 4 3 2 11. Summary score essential drugs, supplies and equipment2. Summary score laboratory support3. Summary score emergency area and management4. Summary score childrenʹs ward and facilities5. Summary score cough or difficult breathing6. Summary score diarrhoea7. Summary score fever conditions8. Summary score malnutrition9. Summary score HIV/AIDS10. Summary score supportive care11. Summary score monitoring12. Summary score routine neonatal care13. Summary score nursery facilities14. Summary score case management and sicknewborn care15. Summary score paediatric surgery andrehabilitation16. Summary score hospital administration17. Summary score access to hospitalTotal scoreHospital summary score = total score/17Page 111

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Assessment of quality of care for children in selected hospitals in GhanaDebriefing and action planDiscuss above summary of hospital findings with the senior hospital management, givingdetails as appropriate. Discuss their perception of the findings, and how action could betaken to improve services for children. Discuss importance in terms of morbidity andmortality, and the feasibility to take action. Develop a plan of action, using the following list.ItemsSummaryscoreImpact onmortalityandmorbidityAction needed Feasibility Priority Timetable andresponsiblepersonTo be stronglyimprovedTo be improvedNot to beHighLowHighLowHighLowPage 113

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Assessment of quality of care for children in selected hospitals in GhanaAnnex 1: Interviews with caretakersCaretaker's view on patient's careCaretaker interviewAge of interviewee:Date child was admitted:Relationship to patient:Education of interviewee:Length of stay:Ward1) Time on ward with child:

Assessment of quality of care for children in selected hospitals in GhanaWe are also interested in what you thought about the ward and care of your child.8) Once your child was on the ward what did you thinkabout:Better thanexpectedAsexpectedWorse thanexpected8a) The amount of space for you and your child to stay?Comment□ □ □8b) The place/bed where you and your child slept?If worse than expected what was bad about it?Comment: □ □ □8c) The place to wash and the toiletIf worse what was bad about it?Comment□ □ □8d) The cleanliness of the wardComment□ □ □8e) The number of nurses available to look after the sickchildren. The number was□ □ □8f) The care the doctor took over re‐examining your childon the ward (the completeness of his/her assessment)?□ □ □8g) Did the nurses/doctors check your child often enough?□ □ □8h) The nurses/doctors examined your child well/longenough?□ □ □9) Are there other things about the ward itself or the hospital site that concern you?We now would like to know what you thought about the medical care on the ward.10) What do you think about the actual medicaltreatment your child received:Too often/muchOKToo few/little10a) Blood was taken____ times. This was…..? □ □ □ □10b) The amount of blood taken was: □ □ □ □10c) Injections were given ____ times. This was….? □ □ □ □10d) Intravenous fluids were given: □ □ □ □N/APage 116

Assessment of quality of care for children in selected hospitals in Ghana11) What other tests/treatments were done (lumbar puncture, blood transfusion etc.)?What did you feel about each of these (were they harmful/necessary/explained/useful?)12a) What have you been told your child is suffering from?12b) From whom did you receive most information about the disease of your child?12c) Who was the person you could ask most easily about the care of your child?13) Did you want to know more about the sickness your child had and the tests and treatment s/hehad? Yes/NoIf yes, what did you want to know more about?14) Did you learn anything new on how to keep your child healthy while on the ward? Yes/NoIf yes what did you learn and who told you about it?We now want to ask you what you thought about the staff looking after your child.15) What was the attitude of the different types ofstaff towards you and your child most of the time?Polite, helpfulGood or badat differenttimesRude,unhelpful15a) Doctors □ □ □15b) Nurses □ □ □15c) Cleaning/kitchen staff/junior staff □ □ □□ □ □15d) Other hospital staff (e.g. nutritionists/x‐ray /physiotherapists/laboratory etc.)16a) Can you think of any examples or ways in which you were spoken to or dealt with well?16b) Can you think of any examples or ways in which you were spoken to or dealt with badly?Page 117

Assessment of quality of care for children in selected hospitals in GhanaFinally, we would like to ask you about your discharge from hospital.17) What do you think of the condition of your childnow (at the time of discharge)?Very good OK Still poor18) Do you think the amount of time spent in hospitalwas?Too long Just right Too short19) Is your child to be sent home on medicines? Yes/No20) Did the ward staff tell you how much to give? Yes/No21) Did the ward staff tell you how often to give the medicines to take home? Yes/No22) Did the ward staff tell you how many days you should give the medicines whenYes/Noyou are at home?23) Did you receive a follow‐up appointment to see how your child is doing?Yes/No23a) If yes, why do you have to go?If no, go to question 27.24) Did the doctor/ward staff tell you where to go? Yes/No25) Do you know when to go to the follow‐up appointment? Yes/No26) Did you receive a discharge/follow‐up note explaining the illness of your child andproviding information for the staff at the follow up clinic and the time/place of followup?* Verify that the details are included as discussed.Yes/No27a) Is your child on NHIS Yes/No27b) If no, what do you think about the cost of treatment at the hospital? (Add questions on howthe family finance the hospital stay of the child?/If costs are clearly communicated?/If they had topay fees without being clear what they were for?)28) Looking back on the time your child was in hospital what, if any, are the areas that you thinkneed most improvement to make the admission and stay easier to bear?29) Overall, how satisfied are you with the care of your child at the hospital?Page 118

Assessment of quality of care for children in selected hospitals in GhanaSummary table interviews with caretakersCaretaker is satisfied with procedures at OPD,knows reason for admission.On the ward procedures are explained and staffis supportive.Carer knows how to continue medicine andknows when and where to go for follow up.GoodTo beimprovedNotes on cases andcommentsMain strengths:Main weaknesses:Summary score caretakersʹ satisfaction with hospital care Good To be improved(to be circled) 5 4 3 2 1Please indicate the quality of support by marking one of the 5 numbers; 5 indicates good support, 4 to 1indicating levels of necessary improvement (4=small need for improvement, 1=urgent need for improvement).Page 119

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Assessment of quality of care for children in selected hospitals in GhanaAnnex 2: Interviews with health workersA 2.1 Guidance for health workers' interviewAll groups of health workers should be considered for this interview. This includes cleaners,health assistants, nurses, matron, medical assistants and doctors. We would like to record thehealth workersʹ honest opinions. For this it is important that the health workers understandthe aims of the survey and know and trust that the information will be stored and used whilemaintaining confidentiality. Please let them know that their names or initials will not bementioned in any report or to supervisors in the hospital.Please do not leave forms lying about or in a place where people who are not members of theteam can read them.Try to interview two staff each from the above mentioned categories of health workers sothat a minimum of six to eight forms should be completed during the assessment visit.Health workers are welcome to fill in the forms themselves, however, please do not let themtake the form away and return it later, due to the shortness of your stay.Ask the questions in a face‐to‐face interview in a suitable place. At the end of the interviewyou should be happy for the health worker to read whatever is written down, and theyshould be offered the chance to read the form and make any changes. Try to recordcomments as they are spoken rather than trying to summarize the views expressed.Recording the real words used often helps to properly represent what the person is trying tosay. When doing this please put the comments in quotation marks. For example:“We have a real problem with the water supply, sometimes days go by without piped water,how can we wash our hands to prevent spreading infection?”To start, please fill in the date, the hospital name and the health workerʹs initials on all fivesheets. After this, please fill in the small amount of information on the interviewee, so thatthe answers in the questionnaire can be put in better perspective.Question 1: We begin the interview with an open question. Some health workers may haveseveral things to say without prompting them with specific questions. For these people it isimportant to allow them the chance to speak and to record what they actually say as far aspossible.Question 2 : In question 1, you are asked to mark the quality of the facilities of the childrenʹsward. Please see the criteria below for the four possible responses:Page 121

Assessment of quality of care for children in selected hospitals in GhanaTable 2: Explanation of the scale ʺGoodʺ to ʺUsually inadequateʺUsually inadequateOccasionally inadequateFairGoodOn four or more out of ten times when something is used or wantedor on four or more out of ten visits to an area things are unavailableor not of an acceptable standard.On two to three out of ten times when something is used or wantedor two to three out of ten visits to an area things are unavailable orare not of an acceptable standard.On one out of ten times when something is used or wanted or onceout of ten visits to an area things are unavailable or are not of anacceptable standard.Only rarely are things unavailable or are not of an acceptablestandard.Question 3: This question is meant to highlight the understanding of the health workerabout which disease contributes most to inpatient mortality. In question 3b) difficulties in thecare of these important conditions are explored.Question 4: To answer this question please refer to Table 1.Question 5: Please write down the words as spoken by the interviewee.Questions 6‐10: To answer the questions, please refer to Table 1.Question 14: All forms of training should be considered from on‐the‐job training,introduction to new equipment/procedures to workshops or courses taught outside thehospital.Question 15: In a number of institutions, nursing staff is rotated within different wards atregular intervals. Please find out if this is the case, what the interviewee thinks about it andto which professional groups this applies.Questions 16, 17: In this question we are interested in if there are some form of meetingswhich reflect on the quality of care in the hospital/ward and the communication within thehospital.Question 18: Please mention the type of guidelines (books, posters, charts, oral guidelines,etc.).Questions 19‐21: Please refer to Table 1.Finally: Before thanking the interviewee, please ensure that all questions are answered. If ahealth worker does not want to answer a particular question please note this and proceed tothe next question. Offer the health worker the opportunity to read what you have written. Ifs/he wishes s/he should be allowed to make changes. Please thank her/him for forwardingthe information.Page 122

Assessment of quality of care for children in selected hospitals in GhanaA2.2 Health worker interviewHealth worker interviewPosition of health worker being interviewed:Current place of work (childrenʹs ward,paediatric OPD, nursery etc.):How long have you worked at this hospital?How long have you been working in the nursery,paediatric OPD or childrenʹs ward?We are first interested in your views on the childrenʹs ward.1) Are there any things about the hospital buildings/ward that you think are good or things thatcould be improved?2) For children admitted to the hospital GoodSatisfactoryOccasionallyinadequateUsuallyinadequate2a) the accommodation (space/beds) for patients is □ □ □ □2b) the toilets and washing facilities for patientsare□ □ □ □2c) the cleanliness of the ward is … □ □ □ □2d) the food given to the children is … □ □ □ □Now we would like to ask you what the causes of childrenʹs death are in the hospital.3) In your opinion what are the commonest illnesses resulting in childhood deaths in the hospital?1.234Page 123

Assessment of quality of care for children in selected hospitals in Ghana3a) Why do you think these children die?Commonest cause of death (1)……………………………Nature of the disease □ □Late presentation of children □ □Problems with laboratorydiagnosis□ □Insufficient drugs □ □Inadequate equipment □ □Lack of staff for care andmonitoring□ □Wrong treatment given □ □Other reasons:Commonest cause of death (2)…………………………….Nature of the disease □ □Late presentation of children □ □Problems with laboratorydiagnosis?□ □Insufficient drugs □ □Inadequate equipment □ □Lack of staff for care andmonitoring□ □Wrong treatment given □ □Other reasons:Yes No DetailsWe now want to ask you about the drugs, supplies and staff in the childrenʹs ward.4) The availability of (the following) are:PlentySatisfactoryOccasionallyinadequateUsuallyinadequate4a) Drugs □ □ □ □ □4b) Oxygen □ □ □ □ □4c) Blood for transfusion □ □ □ □ □4d) IV fluids □ □ □ □ □4e) Food/special milk for malnutrition □ □ □ □ □4f) Laboratory tests (e.g. haemoglobin (Hb)test)□ □ □ □ □N/APage 124

Assessment of quality of care for children in selected hospitals in Ghana5) Do you have problems with/lack any other equipment or supplies that make it hard to look aftersick children well or are supplies generally good?The availability of staff:PlentySatisfactoryOccasionallyinadequateUsuallyinadequate6) Do you think the number of staff availableto care for sick children is?□ □ □ □7) Do you think there is enough timeavailable to care for a child in the best way □ □ □ □you know how to (the way you were trained)?8) There is sufficient nursing staff during thenight.□ □ □ □9) There is sufficient nursing staff during theweekend.□ □ □ □10) If you have a problem with a sick child issupervision/support (e.g. from more senior □ □ □ □clinical staff) available to you?11) Do you think the hospital lacks any important staff to help look after sick children? Are thenumber and quality of staff in general good?12) If you have problems getting help when you think you need it is it because:...there are not enough skilled people to call?…you are unable to contact the right people?…the response to your request is too slow?…another reason?Page 125

Assessment of quality of care for children in selected hospitals in GhanaWhat do you think about the training of staff and the organization of your work?Training of staff Very good OKOccasionallyinadequateUsuallyinadequate13) How is your own knowledge about theillnesses of children?□ □ □ □13a) If it is sometimes inadequate what areas do you think you need more training on or are thereareas you would like to improve your knowledge of further?14) Are there possibilities for further in‐service training in your hospital? Please explain.15) Is there a fixed rotation of nursing staff within the hospital at regular intervals? Yes/No15a) If yes, how often do you rotate?15b) What do you think about this?16) Are there regular meetings of all nurses/other staff/doctors who work on the childrenʹs ward?Please explain who participates, frequency and nature of meetings.17) Is there a regular feedback/audit session in terms of quality of care/mortality in the childrenʹsward? Please explain.18) Do you have clear guidelines on the work you are doing. Please explain:Page 126

Assessment of quality of care for children in selected hospitals in GhanaWe would like to know what you think about the care you/the hospital give to childrenVerygoodOKOccasionallyinadequateUsuallyinadequate19) The information/explanations families aregiven about their child’s illness is …□ □ □ □20) The time you have to explain to the parentsand children about their illness is …□ □ □ □21) How do you think the caretakers view thecare on the ward?□ □ □ □22) Can you think of any ways to improve parents’ understanding of their children’s illness?23) Care of children Can you remember a child you looked after recently when you were pleasedwith how things turned out?Yes/No23a) If yes, were you pleased with how you helped the child do well?23b) What aspects of your own performance/role pleased you?24) Can you think of a child you looked after recently when you were disappointed with howthings turned out?Yes/No24a) If yes, what aspects of the child’s care/progress did you think went badly and what do youthink were the reasons for this?25) Overall are youpleased with whatthis hospital is able todo to help sickchildren while on theward?Always Often Sometimes Rarely Never□ □ □ □ □Page 127

Assessment of quality of care for children in selected hospitals in Ghana26) Are there any other things that were not mentioned yet that could be changed to improve thecare of children in the hospital?27) Have you ever suggested these improvements to matron/doctors/management and with whatresults?28) Do you think the majority of your colleagues are generally satisfied with their work in thehospital? Yes/No28a) What things do you think make people dissatisfied with their work?28b) What about the working conditions?28c) What could be improved to make people in the hospital more satisfied with their work?Page 128