Diocese of Embu Consolata Hospital Kyeni199.34.229.100/uploads/4/9/3/4/49341121/consolata... · Kenya Cooperative Agreement No. AID-623-LA-10-0003. ... government of Kenya and the

Diocese of EmbuConsolata Hospital Kyeni

Strategic Plan (2013-2018)

Funding for the development and printing of this document was provided by the United StatesAgency for International Development (USAID) through the Management Sciences for Health (MSH) Leadership, Management and Sustainability (LMS) programme under the Kenya Cooperative Agreement No. AID-623-LA-10-0003.

Table of Contents

FOREWORD..............................................................................................................................................6

ACKNOWLEDGEMENTS............................................................................................................................7

ABBREVIATIONS.......................................................................................................................................8

EXECUTIVE SUMMARY.............................................................................................................................9

1.CONTEXT DESCRIPTION.........................................................................................................................1

1.1Background.....................................................................................................................................1

1.2Diocese of Embu.............................................................................................................................1

1.3Embu County...................................................................................................................................1

1.4Health Policy Framework................................................................................................................3

1.5Consolata Hospital Kyeni................................................................................................................3

1.5.1Patient Care.............................................................................................................................3

1.5.2Governance and Management................................................................................................6

1.5.3Human Resources....................................................................................................................6

1.5.4Financial Management............................................................................................................7

1.5.5Infrastructure and Equipment Management..........................................................................7

1.5.6Chaplaincy Services..................................................................................................................8

1.5.7Training Services......................................................................................................................8

1.6Strengths, Weaknesses, Opportunities and Threats (SWOT) Analysis.........................................10

2.STRATEGIC DIRECTION........................................................................................................................11

2.1Vision.............................................................................................................................................11

2.2Mission..........................................................................................................................................11

2.3Core Values /Guiding Principles....................................................................................................11

2.4Strategic Goals and Corresponding Strategies.............................................................................11

2.5Strategy Implementation Matrix..................................................................................................16

2.PERFORMANCE MANAGEMENT.........................................................................................................29

2.6Performance Monitoring..............................................................................................................31

2.7Evaluation of Plan Implementation..............................................................................................31

2.8Plan Assumptions and Risks..........................................................................................................31

2.9Summary of Estimated Budget.....................................................................................................32

APPENDICES...........................................................................................................................................33

Appendix 1: Preliminary Staffing Needs Identification......................................................................33

Appendix 2: Equipment Prioritization Schedule................................................................................34

Appendix 3: Consolata Hospital Kyeni Organisational Structure......................................................35

FOREWORD

Consolata Hospital, Kyeni owes its origin and growth to thecharity and commitment of many stakeholders including thefounders (Consolata Missionaries), the Diocese of Embu, thegovernment of Kenya and the people of Embu’s Kyeni Parish.As the hospital continues to grow with the support of thesestakeholders, the environment has continued to change andthus calling for greater keenness in crafting responses tosucceed in the changing environment.

The Diocese of Embu leadership as well as the hospital leadership and management have thusreviewed the hospital’s readiness and capacity to respond to this changing environment. This is in abid to be more proactive in building on its strengths, eliminating its weaknesses, exploiting existingopportunities, and minimizing threats identified. In so doing, we sought the views of our criticalstakeholders including our esteemed clients, board, staff, community leaders, government, Parishleadership and current and potential funders. We identified strategic issues in service delivery aswell as in areas that support our service delivery such as leadership and governance, humanresources, infrastructure and equipment capacity, and financial management. These issues guidedand inspired the crafting of our common strategic direction as articulated in our mission statement,goals and specific objectives.

I appreciate the commitment and support of our Bishop, hospital governing board, hospital staff andpartners in the development of this plan and their expression of willingness to continue withsupporting us as we implement the strategies and activities included in this plan.

Hospital Administrator

Rev. Fr. Dominic Muriuki

ACKNOWLEDGEMENTS

This Strategic Plan (2013-2018) for Consolata Hospital Kyeni is a culmination of combined efforts ofseveral stakeholders.

The hospital leadership wishes to thank all the stakeholders who made contributions at variousstages of development of this strategic plan. Firstly, the clients of the hospital who inspire us tocontinue seeking excellence towards meeting their needs; the staff of the hospital whose views feltlike the “pulse”, the management team and hospital Governing Board for mobilizing and sustainingcommitment during the entire process; the county government of Embu; the Kenya Conference ofCatholic Bishops Secretariat for their valuable insights and the Bishop of Diocese of Embu forsupport and approval.

The hospital is also grateful to the United Stated Agency for International Development (USAID),who through the Leadership Management Sustainability Program implemented by ManagementSciences for Health (MSH), provided financial and technical support for the development of thisStrategic Plan. Finally, we appreciate the support of all other stakeholders, who provided valuableinsights and suggestions.

ABBREVIATIONS

AIDs Acquired immune deficiency syndrome

ALOS Average Length of Stay

ANC Antenatal

ART Anti-Retro viral Therapy

AWP Annual Work Plan

CCC Comprehensive Care Centre

CHAK Christian Health Association of Kenya

CME Continuing Medical Education

ENT Ear Nose and Throat

FBO’S Faith Based Organization

HIV Human Immune - Deficiency Virus

HCT HIV Counselling and Testing

HMT Hospital Management Team

ICT Information Communication Technology

KDHS Kenya Demographic Health Survey

KEPH Kenya Essential Package for Health

KUDHEIHA Kenya Union of Domestic, Hotel, Educational Institutions, Hospitals & Allied Workers

MCH Maternal Child Health

MEDS Missions for Essential Drugs Supply

NCD Non Communicable Diseases

NGOs Non- Governmental Organization

NHIF National Hospital Insurance Fund

NHSSP National Health Sector Strategic Plan

OPD Outpatient Department

PGH Provincial General Hospital

PMTCT Prevention of Mother to Child Transmission of HIV

SWOT Strength, Weakness, Opportunity and Threats

VCT Voluntary Counselling and Testing

EXECUTIVE SUMMARY

The desired future of Consolata Hospital Kyeni is to be a Centre of high quality healthcare andmedical training. To realize this vision, the hospital has developed a strategic plan that clearlydefines its focus from 2013-2018. The hospital reviewed documents and used a participatoryapproach, involving stakeholders to develop this strategic plan.

Consolata Hospital Kyeni is located in Embu County and falls under the jurisdiction of the Diocese ofEmbu. Currently, the facility has 167 beds, serves a primary catchment population of about 200,000as well as a primary referral hospital for numerous facilities within the Diocese of Embu. The hospitaloperates as a Level 4 (now Tier 3) hospital, providing primary level of curative services.

A context analysis revealed gaps in patient care, management and governance, human resources,financial management, and infrastructure and equipment management. The changing policy andlegal environment also poses a challenge to the hospital, requiring it to design measures to keep upwith the changing times. On the other hand, the analysis revealed numerous opportunities andassets that the hospital could leverage to realize its goals. These include opportunities fornetworking, devolved government that makes it possible to closely work with the government,presence of international donors in the county who could be approached to finance theimplementation of the strategic plan and immense support from the catchment population.

In light of the foregoing, the hospital formulated a vision and mission statements that summed uptheir aspirations for the five years. The hospital’s vision is to be “a centre of high quality healthcareand medical training”. The mission is “To provide quality healthcare services and medical trainingthat is affordable and accessible to all, in a comprehensive, integrated and sustainable manner, andin line with Gospel values and the social teachings of the Catholic Church “.

The hospital has also articulated a set of core values that will guide all its undertakings. They include:

Respect Compassion Integrity Healing Teamwork Excellence

Consolata Hospital, Kyeni has identified strategic goals that would serve as critical pillars towardsachievement of the vision. These goals are: improvement of overall patient’s quality of careexperience; upgrading infrastructure and equipment standards to match desired level of servicedelivery; strengthening hospital leadership, management and governance; strengthening humanresource management capacity, strengthening financial management and resource mobilization; andstrengthening the hospital’s training function. Each of these goals have been broken down furtherinto specific objectives and salient activities that need to be undertaken to achieve the desiredvision. To ensure effective monitoring of performance, a set of indicators for each of the strategicgoals has been identified and targets established. The hospital management and leadership willapply ongoing monitoring and separate evaluation methods to keep tabs on the progress ofachievement of the set targets. The hospital estimates that it will need to mobilize KSh 216,460,000to successfully implement this strategic plan.

1. CONTEXT DESCRIPTION

1.1 Background

Consolata Hospital Kyeni, located in Embu County and falling under the jurisdiction of the Diocese ofEmbu, was established in 1930 by the Consolata Missionaries. The facility began as a dispensary;thereafter (in 1956) it was upgraded to a 20 bed capacity hospital and has continued to experiencetremendous growth. Currently, the facility has 167 beds, serves a primary catchment population ofabout 200,000 as well as a primary referral hospital for numerous facilities within the Diocese ofEmbu, including but not limited to 15 mission run dispensaries. The hospital operates as a Level 4(now Tier 3) hospital where services provided are primary level of curative services. Referrals aremade to Embu Provincial General Hospital (PGH), the secondary referral facility that is nearest to thehospital.

1.2 Diocese of Embu

The Diocese of Embu‘ s strategic plan for the period 2012- 2016 lays out the mission of the Diocese“to seek the redemption of the human race through spreading of the word of God and in accordancewith the social teachings of the Church“ anchored on the values of commitment, unity in diversityand stewardship. The delivery of the mission is under four strategic platforms of pastoral care,improved quality of life, economic empowerment, and democracy and governance. In order toimprove quality of life, the diocese plans to continue with investments and focus on health andeducation. Under healthcare, the diocese’s focus is on improving health facilities, establishingstructures for addressing community health as well as establishment of an elaborate healthcoordination structure with equipment and modernized services. The specific activities envisagedare: increasing publicity through the church networks, review of the health care charges, educationon enrolment to medical schemes, equipping facilities and improving structures, networking withregional bodies such as government and civil society; and motivating practitioners. As the facilityranking highest in the referral hierarchy under the diocese, Consolata Hospital’s contributiontowards the achievement of the healthcare objectives of the diocese cannot be underestimated. Thehospital is expected to continue receiving referrals from the primary healthcare facilities (Tier 2) thatfall within the diocese.

1.3 Embu County

Consolata Hospital, Kyeni is part of the referral system of Embu County, serving as a primaryhospital. It falls under the Embu East area estimated to have a catchment population ofapproximately 200,000. The area has over twenty primary health facilities that refer cases to KyeniHospital. These facilities include: Karurumo, Kanja, Gichiche, Kathanjuri, Mukuuri, St Michael andKasafari. AN analysis of key facts and figures on Embu County reveals some indicators are abovewhile others are below national averages.

1

Embu County Key Facts and Figures

Embu County

(Population and

Demographics)

Population: 516,212 (36th most populous county as per KNBS, 2010)

Poverty Index: 42% (compared to country average of 47.2%)

Fully immunised population < 1 year (2010/2011): 33.4% (National average of 64%)

Malaria (as % of all first outpatient visits): 42.8% (National: 27.7%)

TB in every 10,000 people (2009/2010): 62

HIV + antenatal care clients (% 2010): 4.0%(National 5.9%)

Population with primary education (%): 71.3% (National 66.6%)

Population with secondary education (%): 15.5% (National 12.7%)

Improved water (% households 2009): 62.1% (National 66.5%)

Improved sanitation (% households 2009): 98.2% (National 87.8%)

Good/fair roads (% of total roads): 33.7% (National 43.5%)

Deliveries in a healthcare facility: 60.4% (National 37.5%)

Qualified medical assistant during birth: 62.5% (National 37.6%)

Had all vaccinations: 87.9% (National 75.0%)

Literacy – can read and write: 92.7% (National 66.4%)

2

1.4 Health Policy Framework

The overall goal of the Kenyan health sector as articulated in the draft Health Sector PolicyFramework and Kenya’s Vision 2030 is attainment of the highest possible standard of health in amanner responsive to the needs of the population through supporting provision of equitable,affordable and quality health and related services at the highest attainable standards to all Kenyans’.Towards achieving this overall goal, the national policy, informed by prevailing health sectorchallenges, identified six paramount areas of focus as: elimination of communicable diseases;halting, and reversing the rising burden of Non Communicable Diseases (NCD); reducing the burdenof violence and injuries; provision of essential health care; minimizing exposure to health riskfactors; and strengthening collaboration with health related sectors.

These policy objectives are to be achieved through a devolved health care delivery systemcomprising a multiplicity of players – public sector, private for profit, private not for profitstakeholders, and the community. Faith based facilities coordinated under their umbrella networkshave an immense contribution in complementing the government’s efforts towards ensuringimproved health care standards. The Kenyan government, in 2008, signed a memorandum ofunderstanding with the faith based networks (including the Kenya Episcopal Conference, now theKenya Conference of Catholic Bishops (KCCB) on health services. This framework outlines agreeditems regarding partnership and support with a focus on service delivery, policy and dialogue,governance and management, funding mechanism and accountability, human resources, drugs andmedical supplies, medical equipment and infrastructure, planning as well as monitoring andevaluation. The overarching issue is appreciation of the need for the government to continuesupporting and engaging the faith based facilities in enhancing service delivery. In the context of thedevolved governance structure, the engagement mechanisms between the faith based facilities andthe county governments remain critical.

1.5 Consolata Hospital Kyeni

1.5.1 Patient Care

Consolata Hospital Kyeni provides both outpatient and inpatient services. The casualty is open for 24hours a day and provides comprehensive emergency services as well as receiving patients referredfrom primary health care facilities and clinics in the environs. It has a theatre where minor and majorprocedures are performed. The top most cases of morbidity and mortality at the hospital are:malaria, pneumonia, upper respiratory tract infections, hypertension and trauma for adults inaddition to diarrhoea, anaemia and malnutrition for children.

Outpatient attendance has been growing with 17,882 and 20,540 visits recorded in 2011 and 2012respectively. The hospital provided services to 9,717 inpatients in 2012, has an approved bedcapacity of 167 but actual bed capacity that currently stand at 190 distributed as follows:

3

Unit Approved beds Actual beds

Female ward 46 51

Male ward 29 32

Maternity ward 38 38

Children ward 35 50

Cots 19 19

Total 167 190

Nursing care is delivered with the support of 33 nurses spanning across eight departments. Thehospital has undertaken a number of initiatives aimed at improving the quality of services offeredincluding but not limited to: daily ward rounds, continuous renovation of facilities and clinical auditsmeetings.

4

Table 2: An overview of some of the services offered and workload

Category WorkloadMaternal Child Health(MCH)The unit offers antenatal care, PMTCT services, provider initiated testing and counselling, cervical cancer screening, standard based method of family planning, Immunisation services as well as outreaches

2131 antenatal attendances in 2012 2700 immunisation attendances in

2012 883 mothers received awareness on

family planning (FP) services in 2012Maternity The unit has maintained high quality of care as evidenced by low maternaldeaths, low still births, and low neonatal deaths. Maternal death auditsare undertaken on a regular basis and ward rounds done daily, led bymedical officers as a way of ensuring that the high quality standards aremaintained.

1568 deliveries in 2012 407 caesarean sections in 2012

TheatreThe hospital has one theatre room for carrying out minor and majoroperations. Major operations are carried out by a surgeon who operatesat the hospital twice per week. The major operations are caesareansections, abdominal hysterectomy and laparotomy. Minor operationsinclude secondary sutures and excisions.

643 and 742 operations in 2011 and2012 respectively

Comprehensive Care Clinic (CCC)The CCC is manned by one clinical officer, pharmaceutical technologist anda nurse. This clinic has been supported under the Dream project inpartnership with MoH. The unit provides VCT services, HIV Counselling andTesting (HCT) services, cancer screening as well as anti-retro viral therapyand nutritional guidance.

982 clients on care in 2012

Physiotherapy The facility employed a physiotherapist in 2010 and has since been offering physiotherapy services. The most common conditions are lumbago, hemiplegia, delayed milestones in children, osteoarthritis, fractures, post –operative, spinal cord injuries and geriatric complications.

• The facility undertook 4,055 and4984 sessions in 2011 and 2012respectively.

Dental The dental unit is manned by two dental technologists and offers thefollowing services: extraction of teeth, replacements, scaling, orthodontics(braces), filling, root canal treatment and treatment of dental infections.

Average workload of 10 cases perday.

X Ray and Ultra sounds The department has one old X-ray machine and undertakes only standard X-rays as opposed to contrast X-rays. The most common investigations arechest X-rays and orthopaedic X-rays.

1950 and 2900 X-rays in 2011 and2012 respectively

Ultrasounds undertaken throughsupport of a visiting technician on aweekly basis were 1052 and 1203 in2011 and 2012 respectively

Laboratory The hospital laboratory conducts both routine and special tests. Tests undertaken include haematology, biochemical, microbiology, parasitology,blood transfusion and testing and counselling. The facility procured a biochemistry analyser and an automatic haematology analyser in 2010.

28,361 and 35,819 tests recorded in2011 and 2012 respectively

NutritionThe facility hired a nutritionist in 2012 and has since introduced nutritionsupplementary program for clients, has initiated a diabetes support group,provides nutritional support services to the CCC and advises andsupervises the services rendered by the hospital kitchen.

Averages 15 clients per day.

MortuaryThe facility mortuary has a body capacity of 30, has a pathology area andoffices for staff.

Body capacity of 30

5

1.5.2 Governance and Management

The hospital is governed by a board of 13 members who are responsible for policy and overalldirection. The board has three sub committees namely finance and resource mobilization, healthcare quality committee and health training committee. The board was inducted in October 2012with the newly developed governance guidelines and has since been meeting on a quarterly basis.The subcommittees meet on a quarterly basis too. The board has identified its priorities asinauguration, orientation, induction, preparation of strategic plan, training of committees, trainingof HMT as well as holding a workshop to formulate policies for the hospital.

The hospital management team comprises the following five members: Hospital Medical Officer incharge; Hospital Administrator, Hospital Accountant, Hospital Matron and Principal Tutor. TheHospital Medical Officer also doubles as the diocesan health coordinator, a function that entailsoverseeing 13 health facilities/dispensaries that are under the Diocese of Embu. Previously, thediocesan heath coordination role was assigned to a full-time staff, who has since left, but noreplacement has been made.

A recent attempt has been made to determine the staff needs by departments. Though not deemedcomprehensive by management, it alludes to the fact that there are critical staff gaps that requirefilling or rationalization. For instance, the functions of human resources and information technologyneed to be rationalized while critical gaps in clinical areas, pharmacy need to be filled.

The hospital is structured into various departments, headed by unit in charges. The departments are:Outpatient, Accounts, Dental, Laboratory, Physiotherapy, MCH, Maternity, Female wards, Malewards, Paediatric, Theatre, X Ray, Pharmacy, Fidenza School of Nursing, Kitchen, Mortuary, Cleaningand Maintenance, Comprehensive Care Clinic, and Nutrition. The organization design impliesmultiple lines of communication and accountability. There is division of responsibilities betweenunits that are functionally linked. This causes a crossing in lines of accountability and dividedresponsibility, resulting in incoherent approach and frustration for both management and staff. Theprincipal of the school and the Nursing Officer in-charge, for example report to both theadministrator and the Medical Officer in charge.

1.5.3 Human Resources

The hospital currently has 99 staff of whom 25 joined in 2012. In addition, the hospital has aconsultant surgeon who operates two days every week. It outsources information technologysupport and receives technical support in financial management from a Spanish volunteer, who visitsthe hospital in the month of August. Staff turnover at the hospital has been minimal.

The hospital has no designated human resource manager. So the roles of recruitment, staffperformance management, disciplinary, grievance handling are managed by departmental heads.Records of staff are maintained by hospital accountant. The hospital has developed a staff appraisalsystem that entails annual reviews of performance that forms the basis for rewards. In addition, thehospital has union sable staff who are members of the Kenya Union of Domestic, Hotel, EducationalInstitutions, Hospitals, and Allied Workers (KUDHEIHA) and has signed Collective BargainingAgreement with the Union. The hospital provides for gratuity as it has not enrolled the staff in apension scheme. Currently, there are considerations to outsource the management of the staff

6

retirement fund to enhance effectiveness. In terms of staff development, there is no structuredprogram for development of managers and staff other than the regular – weekly continuous medicaleducation (CME) program. Although there is no approved structure and cadre of staff, there arestaffing gaps in various departments and units.

1.5.4 Financial Management

The hospital’s revenue has increased over the last ten years as a result of strengthening internalcontrol processes, improved supply chain management leading to better relationship with suppliers,motivated staff owing to improved terms of service, improved hospital environment and overallpatient experience – walk ways, mobilization of clients to enrol with National Hospital InsuranceFund (NHIF). The hospital disaggregates the budgets for the hospital and the school. The budgets forthe units/departments are not captured separately and performance is tracked by item lines as perthe chart of accounts. Revenue sources are distinctly captured for some sources – inpatients,outpatients, mortuary, and farm – but the expenditure attributable to these revenue centres is notseparated.

The accounts department is inadequately staffed with only four staff led by the hospital accountantwho is responsible for hospital financial management. The hospital has made efforts to computerizethe financial management system by utilizing QuickBooks for inpatient accounts, and a separatehospital management system for managing outpatients’ accounts and cash collections. Nevertheless,these initiatives are fragmented.

The hospital does not have a manual defining financial management policies, procedures andguidelines but has recently made attempts to define policies through the recently set up finance andresource mobilization committee of the governing board. Information technology (IT) support isoutsourced and support is called for on a need basis. The hospital does not have an IT strategy or ITpolicy manual.

1.5.5 Infrastructure and Equipment Management

Owing to growth, hospital’s infrastructure is currently overstretched as evidenced by ward and officespace limitations across the various departments as well as medical and non-medical equipmentgaps. The hospital has in the plan an expansion project which has already been drawn, legalapprovals obtained and currently at tendering stage. The plan broadly aims to expand theoutpatient department with more consultation rooms, triage, pharmacy, laboratory, ear, nose andthroat (ENT), voluntary counselling and testing (VCT), dental, eye clinic and clinical support services(registry, cashier). The project also includes expansion of the inpatient capacity with additionalwards (both general and private).

The maintenance unit of the facility is inadequate in terms of space, has only two staff and lacksequipment for effective support of other hospital units. The hospital management has identifiedgaps in medical equipment maintenance as well as effective preventive maintenance. Amongst thealready identified gaps in equipment include:

7

Laboratory Human reader CD 4 counter Binocular microscope Biochemistry analyser

Pharmacy Pallets

X Ray X Ray machine and viewer Ultra sound machine Automatic processing unit for films

Theatre Theatre – monitor modern operating bed

MCH Vaccines fringe with compartment

Dental Dental chair accessories Assorted extraction equipment ( forceps, elevators, pliers)

Maternity Incubator Beds Linen

1.5.6 Chaplaincy Services

Chaplaincy services are facilitated by the Kyeni Parish of the Diocese of Embu. The unit has adopteda holistic approach to patient support services that includes counselling and administration ofsacraments guided by the Catholic Faith. Specifically, Holy Mass is celebrated three times a week(Tuesday morning, Thursday afternoon and Saturday evening) followed by distribution of HolyEucharist to patients in wards. Baptism of children and anointing of the sick are also undertaken on aneed basis. The hospital chaplain also organizes monthly talks for the students of Fidenza School ofnursing during the monthly recollection days The Chaplaincy intends to conduct Holy Mass on a dailybasis and as such needs a full-time chaplain. The location of the Chapel also needs to bereconsidered to enhance accessibility in view of the new projects being undertaken.

1.5.7 Training Services

Fidenza School of Nursing derives its name from the diocese of Fidenza in Italy that provided theinitial support to build the school in 1965. The school offered certificate courses until 2006 when itbegan to offer diploma courses. The school has a population of 105 students comprising of threecohorts admitted in March 2010, March 2011 and March 2012 respectively. The staff comprises ofseven teaching staff, a secretary and a cleaner. The performance of the school in Nursing Council ofKenya examinations has been consistently above 80% pass rate. The school has recently acquired abus.

8

The school is an integral part of the hospital and shares some services such as kitchen, andaccounting unit with the hospital. The governance arm (board of governance) is also shared. Theschool has been partnering with Embu Provincial General Hospital (PGH), Mathari Mental Hospital,Chuka District Hospital, Kianjakoma Sub District Hospital, Kibugu Heath centre, Kiritiri Sub-DistrictHospital and Karurumo Rural Training Health Centre in delivering practicum training for nursingstudents. Recently, it was supported by Jhpiego, through Christian Health Association of Kenya(CHAK) with five computers to put up a resource centre for training. The school experiences anumber of challenges in the in areas such as library books, accommodation space, effectivecommunication, technology (computer skills, internet), lack of dedicated librarian, and inadequatecareer mentoring.

A summary of performance of Consolata Hospital Kyeni is presented in the table below:

Table 3: Summary of Performance of Consolata Hospital Kyeni

Category Performance indicators

Clinical 1. Average Length of Stay(ALOS) is 5.1 days (6.8 days in general wards, 4.9 days in paediatrics and 3.5 days in maternity)

2. The workload for the last two years reveals a growing trend in both outpatient and inpatient attendances with the hospital attending to 20,546 outpatients and 7,917 inpatients.

3. Occupied Bed Days stood at 65.97%in 2012 and 106% in 2011. 4. Maternal deaths (0.09% in 2012 and 0% in 2011); General adults deaths

(4.2% in 2012 and 3.5% in 2011) while paediatrics stood at 6.7% in 2012 and 3% in 2011)

Financial 5. Progressive revenue growth with 93% derived from inpatient fees, 3.3% fromoutpatient fees and 2% from School of Nursing ‘s net revenue

6. Surpluses of about 20% recorded in the past three years 7. Non- operating revenue from farming (animals and seeds) minimal but

profitability of these units remains uncertain 8. Non- operational revenues from donations not in budget or financial

summary9. Staff costs, drugs and medical supplies kitchen and stores as well as utilities

account for the largest expense items at 36%, 24%,6% and 2% of revenue. 10. Low spend on technology in past periods. Current budget has 3.3 % of

projected revenue provision. 11. Working capital – Debt/Revenue ratio for 2012 (24%) with 37.6% of the debt

being over 90 days. Quick Ratio 7 (2012) and 18 (2011)

9

1.6 Strengths, Weaknesses, Opportunities and Threats (SWOT) Analysis

Strengths

Revitalised and committed management Good collaboration with Embu County

Government and Health Management teams Available Partners/Donors to support the

strategic plan financially Good reputation within the region Accreditation status with Kenya Episcopal

Secretariat and Nursing Council of Kenya Good relation with the surrounding

communities The hospital is registered with the

Government of Kenya and performs in accordance with the National Health Policy

Chaplaincy services facilitated by Kyeni Parish

Minimal staff turnover

Weaknesses

Gaps in infrastructure and equipment

Gaps in staff numbers and skills Fragmented information system Internal communication gaps Managerial and governance gaps Inadequate organisational

structure with defined roles and responsibilities

Poor information documentation and management

Lack of adequate specialist skills (consultants)

Some services not offered (ENT, Intensive Care)

Opportunities

Collaboration with local public and private hospitals

Exchange field attachment with local and foreign training institutions

Twining arrangement/MoU with foreign catholic institutions

Presence of International partners/donors in Kenya and the County

Devolution and thus closer interaction with county governments

Demand for clinical services (including those not offered currently)

Demand for medical and related courses New outpatient scheme rolled out by NHIF

Threats

Declining and unpredictable financing from donors and government

Poor economic status of the community affecting local income generation

Uncertainty on new policies by ruling government regarding health (Free Maternal Health, Free Primary Health care in government facilities)

Emergence of other facilities offering same level of services

10

2. STRATEGIC DIRECTION

2.1 Vision

The vision of Consolata Hospital Kyeni is:

“A Centre of high quality in healthcare and medical training”

2.2 Mission

The mission of Consolata Hospital, Kyeni is:

“To provide quality healthcare services and medical training that is affordable and accessible to all, in a comprehensive, integrated and sustainable manner, and in line with Gospel values and the socialteachings of the Catholic Church “

2.3 Core Values /Guiding Principles

The hospital will strive to uphold a set of core values in all its undertaking. These include:

Respect: Treat everyone in our community with dignity.

Compassion: Provide the best care, treating patients and all other people we encounter withsensitivity empathy and charity.

Integrity: Adhere to the highest standards of professionalism, ethics and personal responsibility.

Healing: Inspire hope and nurture the physical, psychological, mental, emotional and spiritual needs.

Teamwork: Value the contributions of all, blending the skills of individual staff members in unsurpassed collaboration.

Excellence: Deliver the highest quality service and holistic formation and training.

2.4 Strategic Goals and Corresponding Strategies

The hospital has an overall goal of improving the health status and thus contributing to the overallimprovement of socio-economic conditions of the people of Embu, through provision of qualityhealthcare. In order to attain this goal, the hospital has identified the following six strategic thruststhat it will implement over the planned period (2013 – 2018):

1. Improve overall patient quality of care experience 2. Upgrade infrastructure and equipment standards to match desired level of service delivery3. Strengthen financial management and resource mobilisation 4. Strengthen human resource management practices at the hospital 5. Improve hospital leadership and governance 6. Strengthen the hospital’s training capacity

These goals will be achieved through a number of corresponding strategies.

11

1. Improve overall patients’ quality of care experience

The hospital aims to achieve excellent outcomes in quality, patient safety and patient satisfaction. Inthis regard, the hospital seeks to consolidate and expand services delivery. Caution will be exercisedto ensure that the services are responsive to demand and are feasible. At the same time, thehospital will seek to create and foster a culture that supports the quality and patient safety so as toensure that such initiatives are sustained. Specifically, the hospital will:

Increase the scope of clinical service provision in a feasible manner Create culture that supports quality and patient safety

Accolade for Maternity Services

Hospital staff during a ward round

12

2. Upgrade infrastructure and equipment standards to match desired level of service Delivery

New Hospital Block under construction at Consolata Hospital Kyeni

The hospital will scale up the renewal of facilities and equipment in recognition of the fact thatmodernization of facilities, equipment and technology is an important driver to improving thedelivery of health care services and the overall patient experience. The hospital will adequately planfor the completion and continuation of major capital investments in buildings, equipment andtechnology.

In order to achieve this goal, the hospital will focus on the following key strategic objectives:

Undertake well planned investment in infrastructure development and equipment to improveservice delivery and quality of care:

o Pursue highest and best use of existing outpatient and inpatient clinical space o Create new physical capacity

Upgrade the hospital equipment capacity and maintenance sustenance

3. Strengthen hospital leadership and governance

The hospital is dedicated to strengthening its capacity in stewardship to ensure that there is inspiredcommitment to the overall mission and vision. Through strengthening governance, leadership andmanagement, the hospital envisages that the spectrum of relationships with key stakeholders will beimproved and that staff of the hospital will align their objectives to the overall hospital strategies.The hospital will continue to pursue and adopt new systems, solutions and technologies in order toensure that hospital staff have access to the best available evidence for planning, provide access to

13

data that informs improvements in quality of care and also to contribute in training role and valuefor money. Further, the hospital recognizes the importance of communications in supporting thestrategic initiatives through ensuring shared understanding and fostering internal and externalcollaboration. Specifically, the hospital will seek to:

Embrace good governance practices at the hospital and benchmark for performance Develop focused capacity building programs for both the hospital management board and

hospital management team Streamline and strengthen the capacity of hospital governance subcommittees Redesign the hospital organisation and management structure to create effective linkages and

improve communication Enhance the utilisation capacity of information management systems, solutions and

technologies in support of service delivery Augment internal and external communication to enhance collaboration and recognition in

service delivery

4. Strengthen human resource management practices at the hospital

Consolata Hospital Kyeni acknowledges the critical role played by staff, as the most valuable asset, indelivering its mission. The hospital has identified the key priorities in developing and supporting itshuman resource as: enhancing staff satisfaction and retention, improving the human resourcefunction, tools and capacity for change. These will be addressed through the following strategicobjectives:

Recruit and retain a highly competent workforce Continuously improve hospital staff satisfaction Foster a culture of teamwork and accountability at the hospital Enhance the work environment Strengthen human resource functions and tools

5. Strengthening financial management and resource Mobilisation

The hospital will diversify its revenue base for sustainability as well as ensure that adequate capacity is built in the entire systems of financial management. In particular, the hospital will:

Streamline policy, procedures that govern financial management to improve accountability at all levels

Scale up resource mobilization program

Strengthen the financial management system including budgeting, reporting and audit

6. Strengthen the hospital’s teaching function

Consolata Hospital Kyeni appreciates the need to consolidate its training function throughstrengthening of the Fidenza School of Nursing. This is in recognition of the critical linkage betweenpatient care and education. The hospital also acknowledges the importance of entrenching thelearning culture within its departments and among its staff in a bid to become a truly learningorganization. A critical component of this goal is strengthening of collaborative linkages with current

14

and prospective institutions in order to improve the student experience, its training roleeffectiveness, institutional learning opportunities and ultimately patient care. Specifically, thehospital will:

Reinforce School’s teaching and technical capacity Strengthen collaboration between school, alumni and other teaching institutions

Fidenza School of Nursing 2012 Graduation (Chief Guest was His Lordship Bishop of Embu)

15

2.5 Strategy Implementation Matrix

Strategic Goal 1: Improve overall patients’ quality of care experience

Strategic Objective

Initiatives YEAR Output Responsibility Budget Estimate

1 2 3 4 5Increase the scope of clinical services in a feasible manner

Introduce scaling, filling and root canal services in the Dental Unit

X Upgraded dental services

Head of Dental unit

Expand the scope of laboratory services(include services such as complete haematology, biochemistry and microbiology, virology and parasitological tests)

X Upgraded laboratory services

Head of Laboratory 5,000,000

Introduce High Dependency Unit Services X Increased capacity in critical care

Medical Officer in charge

5,000,000

Create culture that supports the quality and patient safety

Conduct survey of workforce quality and patientsafety culture

X Baseline established Hospital Medical Officer in Charge

100,000

Undertake site visits to at least two institutions identified as leaders in quality and patient safety

X X Benchmarks established and adopted

Hospital Medical Officer in Charge

100,000

Undertake client satisfaction survey on a quarterly basis

X X X X X Improved client satisfaction

Hospital Matron 500,000

Develop and implement a framework for qualityand patient safety measurement

X Improved client satisfaction


Undertake regular training on ‘patient-centred’ perspective / customer care training

X X X X X Improved client satisfaction


16

Strategic Objective


1 2 3 4 5Develop and implement a framework for regular clinical audits

X X X X X Improved client satisfaction and experience


Refocus and regularize Continuous Professional Education programme at the hospital

X X X X X Improved CPD Hospital Administrator

1,000,000

Improve pharmaceutical department functions

Strengthen Medical and Therapeutics Committee role in pharmacovigilance through regular meetings

X X X Improved rational drugs use

Head of Pharmacy 100,000

Develop a hospital drug formulary X X Improved rational drugs use


Procure and implement a pharmaceutical stock management software

X Improved drug stockmanagement


Strategic Goal 2: Upgrade infrastructure and equipment standards to match desired level of service delivery

Strategic Objective

Initiatives YEAR Output/Outcome Responsibility Budget Estimate

1 2 3 4 5Pursue highest and best use of existing outpatient and inpatient clinical space

Complete the construction of the recently launched Outpatient & Inpatient Hospital Block

X X X Improved space for OPD and IPD


120,000,000

Renovate and equip the Maternity Unit and New Born Unit (including increasing bed capacity)

X X Upgraded Maternal unit


5,000,000

Rehabilitate staff houses X X X Improved staff housing capacity


3,000,000

17

Strategic Objective


1 2 3 4 5Put up a Rectory (Father’s house) X Improved staff

housing capacity Hospital Administrator

3,000,000

Renovate the hospital entrance and car park X Improved parking space & entrance


1,000,000

Renovate the hospital Kitchen X Improved hospital kitchen services


200,000

Complete renovation of hospital walkways / pavements

X Improved hospital pathways


1,000,000

Put up a hospital cafeteria, candy shop and cyber-cafe

X Improved work climate


4,000,000

Complete the hospital perimeter wall X X X Improved security Hospital Administrator

2,000,000

Expand the hospital nursery (Paediatrics) X Improved space at the Paediatrics ward

Hospital Matron

Restructure the operations theatre to create extra operations room and minor theatre

X Improved Theatre services


1,000,000

Restructure the physiotherapy room and the paediatric dining hall to increase bed capacity for wards

X Improved Inpatients bed capacity


Expand the school’s dormitory capacity X Improved accommodation capacity at the School

School Principal 15,000,000

18

Strategic Objective


1 2 3 4 5Liaise with Kyeni Parish to provide temporary accommodation space for students

X Improved accommodation capacity for the School

School Principal / Kyeni Parish Priest

Upgrade the hospital’s equipment capacity

Conduct survey of equipment needs and gaps X Baseline established Hospital Administrator

30,000

Expand the hospital technical workshop X X Improved maintenance capacity


1,000,000

Procure food trolleys for transporting patients’ food

X Upgraded kitchen services


Procure laundry equipment (large capacity washing machine and accessories) to strengthen laundry unit services

X Upgraded laundry services


2,500,000

Procure a hospital hearse X Improved referral services


2,500,000

Renovate the hospital incinerator X X Improved hospital waste management


1,000,000

Procure a laboratory biochemistry analyser and CD Machine

X Improved laboratory services

Head of Laboratory

5, 000,000

Procure assorted equipment for the hospital theatre (operation tables, anaesthesia machine and accessories)

X Improved capacity oftheatre


3,500,000

19

Strategic Objective


1 2 3 4 5Procure assorted hospital ward and maternity equipment (including heart monitors, diagnosticsets, delivery sets)

X Improved capacity in maternity and wards


3,000,000

Purchase beds and mattresses X Improved hospitality services


6,000,000

Procure assorted dental unit equipment (dental chair, compressor, dental mirror, orthodontic wire, processing clamp, kidney dishes)

X X Improved capacity ofdental unit

Head of Dental unit

3,000,000

Strategic Goal 3: Strengthen hospital leadership and governance

Strategic Objective


1 2 3 4 5

Embrace good governance practices at the hospital and benchmark for performance

Hold effective quarterly hospital governing board meetings

X X X X X Well documented quarterly meetings

Hospital governing board chair

800,000

Hold effective monthly hospital management team (HMT) meetings

X X X X X Well documented HMT meetings


500,000

Undertake benchmarking meetings with selected two facilities

X X Improved hospital governance and management


200,000

Develop focusedcapacity buildingprogram for

Establish the capacity gaps for board and senior management team

X Capacity gaps identified

Hospital Administrator / Board Chair

30,000

20

Strategic Objective


1 2 3 4 5both the hospitalboard and management staff

Identify and deliver a leadership developmentprogram for hospital management teams

X X X Empowered hospital management team

Hospital Administrator / Medical Officer in charge

1,000,000

Redesign the hospital management structure to create effective linkages, improve accountability and enhance service delivery

Review the hospital organization structure in consultation with the Kenya Catholic Conference of Bishops and ensure alignment to the delivery of this strategic plan

X Reviewed organigram

Hospital Administrator/ Medical Officer in charge

50,000

Sensitize all hospital staff on the revised hospital governance and management structure

X Improved reporting and communication


150,000

Revise job descriptions for staff in line with the new organigram and this strategic plan

X Positive staff evaluations, Policy Document


300,000

Enhance the capacity to use information technology systems, solutions and technologies in (and in support of)service delivery

Develop a hospital Information Technology and Communication (ICT) Strategy incorporating every aspect of current and future ICT systems needs and cost analysis

X Completed ICT Strategy approved

Hospital Administrator / ICT Manager

Undertake computerization initiatives as outlined in the ICT roadmap (including implementation of integrated hospital management information system and procurement of computers)

X X X X Hospital Computerization completed as per ICT Roadmap


7,000,000

Equip staff with necessary skills to embrace the ICT

X X X All staff equipped with necessary ICT skills


1,000,000

21

Strategic Objective


1 2 3 4 5Augment internal and external communication capacity to support service delivery

Undertake a comprehensive review of strategic internal and external communications opportunities

X Communication Strategy unveiled


50,000

Upgrade the hospital internal communication (Intercom) system including email platform

X Improved internal communication

Hospital Administrator /I CT Manager

500,000

Develop a hospital website X Improved internal communication


200,000

Publicize and champion the hospital mission, vision and values using identified materials including brochures, banners, notice boards and website and email communication

X X X Improved community perceptions and relations


200,000

Install internet services at the hospital X X Improved internal and external communication


500,000

Establish a hospital library and at least one common room

X Improved interactions amongst staff, andcommon room andlibrary established


22

Strategic Goal 4: Strengthen human resource management capacity and practices at the hospital

Strategic Objective


1 2 3 4 5Recruit and retain a highly competent workforce

Undertake a comprehensive, workload based,staff needs analysis and develop a plan for recruitment (review preliminary needs assessment as per appendix I)

X Staffing plan developed


50,000

Fill in staffing gaps based on the need analysis X X X Hospital and schooladequately staffed


100,000

Continuously improve hospitalstaff satisfaction

Undertake a baseline survey on human resource management

X Baseline on staff issues established

Hospital Administrator / Human Resources Officer

50,000

Establish a comprehensive capacity building plan for staff based on established training needs, succession planning and resource prospects

X X X X X Capacity building based on established needs

Human Resources Officer

2,000,000

Enhance current staff rewards and recognition program with a focus on results and retention

X Improved staff satisfaction


500,000

Hold quarterly staff meetings X X X X X Improved staff satisfaction


500,000

Undertake annual staff satisfaction surveys and provide feedback

X X X X X Improved staff satisfaction


150,000

23

Strategic Objective


1 2 3 4 5Introduce a staff pension or provident fund X Pension Fund set

upHospital Administrator

Foster a culture of teamwork andaccountability atthe hospital

Introducing hospital staff scheduling technology to focus on effective resource management in defined critical areas(clinical and non- clinical)

X Increased staff satisfaction


50,000

Link the performance appraisals for individual staff to this strategic plan and cascaded operational and departmental plans

X X X X X Positive staff evaluations


50,000

Enhance the work environment

Hold annual staff team-building event X X X X X Positive staff evaluations


400, 000

Engage and communicate with staff timely and accurately through holding quarterly staffmeetings

X X X X X Quarterly staff meetings held


1,000,000

Provide adequate staff housing as well as clear mechanism for allocation

X Improved staff housing


1,500,000

Dedicate and build out new staff break rooms X Improved staff satisfaction

Human Resources Manager

1,000,000

Strengthen human resource function and tools

Hire a dedicated human resource staff X Improved human resource management

Hospital Administrator / Hospital Medical Officer in charge

30,000

Initiate and implement an appropriate staff development program and evaluate results in

X X X X X Positive staff evaluations


1,000,000

24

Strategic Objective


1 2 3 4 5collaboration with the partners

Develop and disseminate a hospital staff handbook

X X Improved induction experience


200,000

Provide adequate tools (uniforms, stationery) for staff

X Positive staff evaluations


50,000

Review and strengthen staff welfare X Functional Staff Welfare


100,000

Strategic Goal 5: Strengthen the hospital teaching function

Strategic Objective


1 2 3 4 5Reinforce School’s teaching and technical capacity

Equip the school library and skills lab with current resources including electronic ones

X X A well-equipped library

School Principal / Hospital Administrator

2, 000,000

Undertake a feasibility study to introduce health records information course to commence in Year 5

X Feasibility study report


50,000

Increase enrolment capacity by 35 students X Enrolment capacityincreased


25

Strategic Objective


1 2 3 4 5Strengthen collaboration between school, alumni and other teaching institutions

Establish a placement office at the school and assign a teaching staff with clear placement responsibilities

X Updated placement database

School Principal 500,000

Review existing Memorandum of Understanding (MoU) with collaborating institutions in training

X X Reviewed MoUs 50,000

Expand the existing network of contacts with reputable medical institutions with whom to undertake practicum / attachment

X Improved linkages with health institutions and professionals

100,000

Hold quarterly career talks / mentoring sessions for graduating students

X X X X X Improved linkages with health institutions and professionals

School Principal 200,000

26

Strategic Goal 6: Strengthen financial management and resource mobilization

Strategic Objective


1 2 3 4 5Streamline policies and procedures that govern financial management to improve accountability atall levels

Update and disseminate policies on financial management and procurement

X Financial Managementand Procurement guidelines well understood across the hospital

Hospital Accountant

100,000

Review departmental service performance to identify opportunities for cost control and performance improvement

X X X X X Report on cost improvement areas


200,000

Reconstitute and strengthen the finance andresource mobilization committee

X Positive committee performance

Hospital Board chairperson

300,000

Train departmental heads on budgeting and budget monitoring

X Improved departmental budget performance

Hospital Accountant

200,000

Revitalize the internal audit function and external audit (review the scope as well as implementation of recommendations)

X Improved internal controls


100,000

Scale up resource mobilization program (fee collection, partnerships)

Develop a resource mobilization strategy X X Resource mobilization program in place

Hospital Board chairperson

50,000

Build skills of board and staff capacity in resource mobilization

X X Increased revenue Hospital Administrator

300,000

Investigate feasibility of implementing selected initiatives to increase non-operating revenue for the hospital. Consider the following:

Hospital farm improvement X X X

Increased non-operating revenue

Hospital Accountant

50,000

27

Strategic Objective


1 2 3 4 5(poultry, pigs, dairy)

Hearse services Cyber-café Consultation rooms rent Hiring-out school bus Fundraising walks Approaching partners

Increase community mobilization for enrolment with National Hospital Insurance Fund through Parishes announcements

X X Improved revenue Hospital Board Chair / Hospital Administrator

80,000

Strengthen the financial management system includingbudgeting, reporting and audit

Fine-tune procurement process across the hospital (including outsourcing arrangements)

X Compliance with financial management policies and procedures


40,000

Train and evaluate all staff on compliance issues

X Compliance with financial management policies and procedures


50,000

Implement an integrated hospital financial information system

X Improved revenue Hospital Accountant

Support finance function staff in continuous professional development

X X X X X Compliance with financial management policies and procedures

Hospital Accountant

250,000

28

2. PERFORMANCE MANAGEMENT

For effective implementation of this strategic plan, the hospital will institute mechanisms that willseek to enhance ownership and urgency to translate the plan into action. The following actions willbe undertaken towards this end:

Approval by the Hospital Governing Board and endorsement by the Diocese of Embu Dissemination of the strategic Plan to all hospital staff and key stakeholders Entrenchment of performance targets and indicators in the governing board performance

agreement and the senior hospital managers’ contracts Implementation matrix to be cascaded to individual hospital departments targets and

individual staff annual appraisals targets Resources will be mobilized and committed in line with this plan and the attendant annual

work plans Progress reviews through on-going monitoring and separate evaluations (quarterly

management and board meetings)

This Strategic Plan incorporates selected key performance targets that are to be monitored closelyduring implementation. These indicators cut across the strategic goals identified.

Table 4: Key Performance indicators

Performance Indicator Year 1 Year 2 Year 3 Year 4 Year 5Improve overall patients’ quality of care experienceNew services fully functional 1 2 1Increase in services utilisation 2.5% 2.5% 5% 5% 5%Number of outward referral as apercentage of total admissions

3% 1% 1% 1% 1%

Percentage of clients satisfied withhospital services based on survey

80% 85% 87.5% 90% 95%

Average waiting time in OPD 15 mins 10 mins 7 mins 7 mins 7 minsAverage waiting time for surgery Number of inpatient per annum 10,000 11,000 12,000 12,500 12,500Number of outpatients per annum 20,000 22,000 24,000 25,000 25,000Average annual bed occupancy rate 80% 80% 80% 80% 80%Recovery rate of admitted patientsfor selected conditions

100% 100% 100% 100% 100%

Number of maternal deaths 0 0 0 0 0% of complete prescriptions issued 85% 90% 100% 100% 100%Percentage of departmentsundertaking monthly clinical audits

100% 100% 100% 100% 100%

Number of drugs on essential druglist that run out of stock

0 0 0 0 0

Strengthen the nursing school training capacity/hospital teaching function Percentage of nursing studentspassing the national examinations

85% 90% 95% 95% 100%

Percentage of graduating studentsobtaining placements through theschool’s placement office

50% 60% 60% 60% 60%

Performance Indicator Year 1 Year 2 Year 3 Year 4 Year 5Strengthen hospital leadership and governance and management % Improvement in board membersperformance based on agreed andcomprehensive governance scorecard

5% 5% 5% 5% 5%

% of management team memberstrained on leadership andmanagement

15% 30% 45% 60% 100%

Number of functional hospitalcommittees

5 7 10 10 10

% of staff with revised jobdescriptions based on revitalisedorganisation structure

100% 100% 100% 100% 100%

ICT strategy developed 1% of staff utilising ICT as per ICTstrategy

50% 75% 90% 100%

% of hospital functions computerisedas per ICT strategy

20% 60% 75% 80%

Strengthen human resource capacity and practices Proportion of approved posts as perstaffing plan

80% 85% 85% 90% 90%

% increase in staff satisfaction 5% 5% 5% 5% 5%% of hospital staff pursuing trainingbased on training needs assessment

100% 100% 100% 100%

Strengthen financial management and resource mobilisation % growth in hospital revenue 5% 10% 10% 10% 10%% growth in non-operating revenue 20% 40% 50% 100% 100%% increase in rebates from NHIF andother insurance companies

25% 25% 25% 25% 25%

% savings in cost of key budget lines 5% 5% 5% 5% 5%% of staff sensitised on hospital policies and guidelines

100% 100% 100% 100% 100%

Upgrade infrastructure and equipment standards to match desired level of service delivery% of infrastructural projectscompleted as per master plan

100% 100%

% of equipment procured as perequipment enhancement andreplacement plan

100% 100% 100% 100%

Preventive Maintenance Programdeveloped

1

30

2.6 Performance Monitoring

Monitoring of this plan will be effected through existing monitoring systems so as to avoidduplications and strengthen existing systems. Where gaps do exist, tools for collection and reportingwill be introduced. The main monitoring mechanisms are:

Quarterly hospital governing board meetings and subcommittee meetings Monthly hospital management team meetings Monthly departmental meetings Quarterly Progress reporting Quarterly staff meetings Monthly financial reporting

2.7 Evaluation of Plan Implementation

Evaluation of the implementation of the plan will be undertaken on annual basis using the followingtools:

Hospital annual review: At the end of every financial year, annual progress reports will be preparedhighlighting key achievements against set targets in the annual work plan, explanations forperformance variations, lessons learned and recommendations on the way forward. The annualreport will be shared during the annual assembly /stakeholders meeting that will be held forconsultations, feedback, and accountability and sharing of hospital successes and challenges.

A mid-term review of this strategic plan will be undertaken at the end of the second year andrelevant adjustments proposed.

End of term evaluation: At the end of the five year plan period, the hospital will undertake anassessment of overall implementation performance. This assessment will be the basis for craftingthe subsequent hospital strategic plan.

2.8 Plan Assumptions and Risks

This plan is premised on the following fundamental assumptions:

The current strategic direction of the health sector as articulated in the Kenya National HealthSector Policy and Strategic Plan will remain relevant

The national and county governments will continue to support the hospital through staffsecondment

Development partners will maintain and scale up current intervention collaborations andsupport key areas in this strategic plan

There will be leadership and management goodwill and support for the implementation of thisplan

It acknowledges the following as key risks:

Political interference Unexpected, major changes in health care service delivery realignments.

31

Economic instability Emergencies of large scale nature

2.9 Summary of Estimated Budget

The estimated budget for successful implementation of this plan, based on the activities included inthe implementation framework and incremental to the hospital operational budget, is summarizedbelow:

32

APPENDICES

Appendix 1: Preliminary Staffing Needs Identification

Staff Number Remarks 1 Sonographer (X-Ray Department) 1 Recruit in year 2 2 Laboratory technicians (Laboratory Unit) 2 Recruit in year 2 3 Occupational therapist (Physiotherapy Unit) 1 Recruit in year 1 to

operate three days per week

4 School librarian (Fidenza School of Nursing) 1 Year 3 5 Student clinical instructor (Fidenza School of Nursing) 1 Year 3 6 Information Technology Officer (Hospital and School) 1 Year 1 7 Farm Manager (Administration) 1 Year 28 Ultra sound technician 1 Year 1 ( increase

number of days from 1 to 3)

9 Accounts assistant (Finance department) 1 Year 210 Human Resources Assistant/Officer 1 Year 211 Clinical officers 2 Year 312 Medical Equipment Technician (Maintenance Unit) 1 Year 4

Engagement on Locum basis 1 Obstetrician / Gynaecologist 1 Year 2

Training needs 1 Train two nurses in anaesthesiology 2 nurses In year 3 2 Customer service training Front line

staff 3 Hospital accounts clerks refresher course on billing and

revenue collection processes In year 1

33

Appendix 2: Equipment Prioritization Schedule

Category Dept Number 1 Dental chair Dental 12 Huma Reader Laboratory 13 Microscopes Laboratory 14 Spectrophotometer Laboratory 15 Biochemistry Analyser Laboratory 16 Assorted Theatre equipment Theatre7 Food trolleys Kitchen 38 Beds Maternity 9 Assorted Physiotherapy

equipment Physiotherapy

10 Modern Hearse (fully equipped) Mortuary 1

34

Hospital ChaplainPersonal Assistant

Hospital Governing Board

Medical Officer In-Charge Finance and Administration Manager

Laboratory ManagerOPD In chargePharmacy ManagerLead NutritionistHead, X-Ray and ImagingHead, TheatreMortuary In-Charge

Bishop, Diocese of Embu

Principal Tutor, Fidenza School of Nursing

AccountantsKitchen In-ChargeGeneral workersProcurement OfficerStores OfficerICT OfficerHead, Maintenance and Transport

Hospital Director

Human Resources Manager

Nursing Services Manager

Ward Nurse’s In-charges

◦ Appendix 3: Consolata Hospital Kyeni Organisational Structure

35

For more information, please contact:

The Hospital AdministratorConsolata Hospital Kyeni

P.O. Box 38 – 60103Runyenjes, Kenya

Email: [email protected]

This publication is made possible by the generous support of the United States Agency for International Development (USAID) under the Associate Cooperative Agreement No. AID-623-LA-10-0003. The contents do not necessarily reflect the views of USAID or the United States Government.

Documents

Diocese of Embu Consolata Hospital Kyeni199.34.229.100/uploads/4/9/3/4/49341121/consolata... · Kenya Cooperative Agreement No. AID-623-LA-10-0003. ... government of Kenya and the