Clinical Governance in the Neonatal Service

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Clinical Governance in the Neonatal Service

• Neil McKerrow
• Department of Paediatrics
• Pmb Metropolitan Hospitals Complex

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Millennium Development Goal
MDG 4 U5MR 20/1,000 MDG 5 MMR
38/100,000 Not on rack to meet our target
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Neonatal Health Indicators

• Delivery rate in facility
• RSA 81.1 (55.9 - 98.4)
• CS rate
• RSA 18.4 (10.7 - 24.4)
• NVP uptake in NN
• RSA ? (86.2 105.3) !!

• LBW rate
• RSA 8.9 (0.6 - 24.4)
• Stillbirth rate
• RSA 24,8 (4.0 38.3)
• PNMR
• RSA 34,5 (5.2 40.0)
• NNMR
• RSA 14.4 (6.0 15.3)

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Provincial comparisons
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Perinatal mortality rate in facility, 2006/07
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Why?

• Access
• Health system
• Appropriate level of care

Emmaus Hospital
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Why?

• Poor infrastructure
• Facilities
• Equipment
• Poor systems
• Procurement
• Management
• Referral

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Why?

• Mahatma Gandhi Hospital (2005)
• 23 Klebsiella related deaths
• Allegations of previous events
• Edendale Hospital (2006)
• 16 cases of NEC including 6 deaths
• No clear microbiological cause
• Why?
• Inappropriate infrastructure
• Inadequate equipment
• Overcrowding
• Understaffing
• Breakdown in infection control systems

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• The care of the newborn is only effective and
  safe in the setting of a well organized health
  care system.
• ..
• Outbreaks of nosocomial infections represent a
  systems failure.
• Recommendations
• KZN Task Team for Infection Control in Newborn
  Care.
• 2005

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Systems failure

• Facilities
• Services
• Equipment
• Staffing
• Policies protocols

• Poor infrastructure
• Shared equipment
• Overcrowding
• Understaffing
• Breakdown in infection control

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Broader Health System

• System
• Poorly aligned structurally disconnected
• Information
• No effective information systems
• Choices
• Decision-making incorrectly located
• Health Sector Roadmap DBSA, November 2008
• Clinical Governance

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Clinical Governance

• Framework for organizations to
• Continuously improve quality of service
• Safeguard high standards
• By
• Creating an environment in which clinical care
  will flourish
• National Health System, UK

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NHS Principles

• Focus
• Access
• Equity
• Efficiency
• Effectiveness

• Requirements
• Responsibility
• Authority
• Accountability

Norms Standards Framework
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Clinical Governance Framework

• Elements of each level
• Position in hierarchy
• Interaction between levels
• Norms
• Standards
• Coverage
• Responsibility/Accountability

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Information

• Required for
• Planning
• Resource allocation
• Service delivery
• QAP
• ME
• Type
• Population
• Workload
• Pt profile
• Services
• Utilization

DHIS Pt database Ward register Equipment
register ..
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Infrastructure

• 1o level Maternity ward
• 2o 3o Neonatal nursery
• Facilities
• Services
• Equipment
• Support
• Standardized
• Related to workload
• Related to function

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Facilities

• Single access point
• Support services separated
• from patient area
• Patient area
• Work area
• Support areas
• Isolation cubicle
• Hand basin at entrance
• Controlled environment

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Spacing High care/ICU bed
2 m
1,5 m
2,5 m
5 m2
2 m
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Services per bed
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Equipment

• No sharing
• With other units
• Between patients
• General
• Patient specific
• High care / ICU beds

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Staffing

• Cadre
• Core vs support
• Skills
• Basic, post basic, specialist
• Numbers
• Need vs availability
• Deployment
• Core vs rotation
• Development

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Nursing numbers
Required number of staff on duty
Barlow HJ. MCur Thesis. University of
Stellenbosch, 2003.
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Systems

• Facilitate services
• HR
• Procurement
• Referral
• Outreach
• Development
• Support

• Support clinical care
• Policies protocols
• STG
• Unit Mx structures
• Clinical records
• Reference / resource materials

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Referral / Support System
Health System Tertiary Hospital Regional
Hospital District Hospital CHC /
Clinic GP Home
Knowledge Skills Staff Resources
Patients
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Care

• Environment
• Infrastructure
• Skills
• Logistics
• Clinical resources
• Clinical guidelines
• Compliment compatible with EDL
• Protocols
• Care plans

• Systems
• Procurement
• Information
• Referral

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ME

• Statistics Register DHIS
• Mortality audit Child PIP
• Document audit
• Utilization review
• Clinical audits

Templates included in CHeRP CD
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How??

• Awareness
• Adoption of clinical governance
• Responsibility
• Accountability
• Tools
• Accreditation process

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Accreditation

• Based on Clinical Governance framework
• Graded
• Progressive realization
• Facilitation
• LINC
• NELS

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Conclusion

• Health indicators are poor
• System is dysfunctional
• Turnaround requires a
• framework
• ! Clinical governance
• provides one