STRATEGIC PLAN - Nkozi Hospital Strategic plan.pdfof the advanced age group in our society have all translated to increased morbidity and mortality from conditions such as hypertension,

OUR LADY HEALTH OF THE SICK

NKOZI HOSPITAL STRATEGIC PLAN

2015/16 - 2019/20

October 2015

NKOZI HOSPITAL Strategic plan: 2015/16 - 2019/20

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OUR LADY HEALTH OF THE SICK

NKOZI HOSPITAL

STRATEGIC PLAN2015/16 TO 2019/20

October 2015


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Our Lady Health Of The Sick

Nkozi Hospital

Contact:

Tel.: +256 (0) 392842207;

Fax: +256(0) 38 410100

Email: [email protected]


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ContentsFOREWORD 4PREFACE 6ACKNOWLEDGEMENTS 8EXECUTIVE SUMMARY 10

Section one: BACKGROUND 131.1 History 131.2 General Overview 131.3 Morbidity and mortality trends 141.4 National context: 14 1.5 Development process 14

Section two: ORGANISATIONAL ARRANGEMENT 162.1 Hospital organisation 162.2 Hospital functions/services 17

Section three: REVIEW OF THE PREVIOUS STRATEGIC PLAN (2009/10-2014/15) 19Goal 1: Improving human resources in Nkozi hospital through effective utilization of the employment manual 19Goal 2: Ensure a sustainable financial base 20Goal 3: Increase utilization of services offered at Nkozi hospital 21Goal 4: Improve hospital governance and management 22Goal 5: Contribute to improved health for people living in Mawokota South HSD 22

Section four: SITUATIONAL ANALYSIS: 244.1 Strength and opportunities and proposed strategies for improvement 254.2 Weaknesses and threats and proposed strategies for mitigation 314.3 Performance review analysis 35

Section five: STRATEGIC DIRECTION 365.1 VISION 365.2 MISSION 365.3 GOAL 365.4 MOTTO 365.5 GUIDING PRINCIPLES 365.6 CORE VALUES 375.7 STRATEGIC OBJECTIVES: 37

Section six: MONITORING AND EVALUATION OF THE STRATEGIC PLAN 50MONITORING AND EVALUATION FRAMEWORK FOR NKOZI HOSPITALSTRATEGIC PLAN FOR 2015/16 – 2019/20 50BUDGET FOR NKOZI HOSPITAL STRATEGIC PLAN FOR 2015 /16– 2019/20 106


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FOREWORDOur lady Health of the sick, Nkozi Hospital, is one of the longest serving catholic founded hospitals in Uganda. Having been started by the Missionary of the White Sisters of Our Lady of Africa in as far back as 1942, it gives me a lot of joy to make my contribution to the effort started almost seventy three years ago but is now being carried on with the development of this new five year strategic plan. This relates very well with the goal of the hospital which emphasises provision of high quality services that are accessible and sustainable.

For all human beings living on earth, life is the most valuable gift received from God and we always work hard to keep it in the best desirable condition possible. It is therefore important to note that all those people called up on to serve in the field of healthcare are privileged and honoured to contribute to this noble cause. The leadership of Kampala Archdiocese wishes to acknowledge the tremendous work done by the staff of Nkozi Hospital in serving and caring for the sick. I wish to thank you very much for the commitment and excellent service offered to the community in the surrounding area and beyond. Similarly, I would also like to thank the management and the Board of Governors for successfully steering Nkozi Hospital forward and having it prepared for the next phase of implementing the new strategic plan.

As many of you could know, the health sector continues to face a growing number of challenges more especially the increase in non-communicable diseases. The changing lifestyles, the improving infrastructure as well as increasing number of the advanced age group in our society have all translated to increased morbidity and mortality from conditions such as hypertension, diabetes mellitus and road traffic accidents to take place. That aside the battle against HIV/AIDS, tuberculosis, malaria, chest infections, and other diseases is still a thorn in flesh to our community. I have confidence that this strategic plan has been developed with a lot of consideration for these changes in the community. I wish to urge all health service providers to continue with a lot of enthusiasm the drive for health promotion and prevention campaigns to prevent further spread of these conditions. The plan to have an emergence unit is a timely innovation which should be pursued to the end so that those suffering more especially from accidents and other injuries can be attended to in time and give them new hope to regain their normal lives.

I am aware that a number of stakeholders have supported Nkozi Hospital to make it shine and reach out to those suffering with various illnesses. Let me use this opportunity to thank the Uganda Catholic Medical Bureau, the Government of


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Uganda, Mpigi district Local Government and the donors for their support and commitment to work with Nkozi Hospital. Your contribution has always made a difference in the way the hospital has continued to function over the past period. It is my prayer that this support shall continue and even increase to come in the coming years of operationalising the new strategic plan to make our dream for Nkozi Hospital to excel become a reality.

As I conclude, allow me to thank the team that has participated in the development of this strategic plan. We are all very proud of your dedicated effort and love for Nkozi Hospital. I wish you God’s blessings and prosperity in your work. I also wish the management and staff for Nkozi Hospital a successful period of implementing the new strategic plan 2015/16 to 2019/20. May God be with you and guide you all the time.

+Cyprian Kizito LwangaARCHBISHOP OF KAMPALA ARCHDIOCESE


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PREFACEThis strategic plan is the third version to be developed by Nkozi Hospital in recent history. I would like to congratulate the Hospital Management Team for building a culture of setting priorities right and planning for long term improvement to take place for the Hospital. The Board of Governors, which was inaugurated early this year, takes pride to be associated with this spirited effort and shall give full support towards successful implementation of the strategic plan for Nkozi Hospital.

The Health Sector Development Plan (HSDP 2015/16 to 2019/20) by the Ministry of health has been finalised this year 2015. This coincided with development process for Nkozi Hospital strategic plan 2015/16 to 2019/20. The HSDP goal is “To accelerate movement towards Universal Health Coverage with essential health and related services needed for promotion of a healthy and productive life”. The goal for Nkozi Hospital is, “To provide sustainable, accessible and high quality services to uplift health standards of the community”. Universal Health Coverage emphasises improving access, equity and high quality of services for the community served. The hospital strategic plan has been aligned with the HSDP to keep the hospital focused with the Government programmes on health services.

The Board of Governors shall take keen interest in the implementation process of the strategic plan for Nkozi Hospital. The monitoring process should be carried out regularly to make sure that the strategic objectives are followed to meet the set targets. The Hospital management shall be expected to provide regular updates to the Board of Governors and also plan ahead for the mid-term and end of term review of the strategic plan.

I would like to point out, that the hospital highly appreciates the valuable contribution received from the different stakeholders who have continued to work and support Nkozi hospital. These include the hospital staff, the local community in the catchment area, Kampala Archdiocese through the Sisters of the Immaculate Heart of Mary Reparatrix Ggogonya, the Ministry of health, the Local Government of Mpigi and District Health Officer’s office, the Uganda Catholic Medical Bureau, the donors and all the rest. The Board of Governors wishes to commend all of them for the support they have extended to Nkozi Hospital up to now. Thank you very much for this effort and may we look forward to more collaboration and success during the coming period of implementation of new hospital strategic plan.

Finally I allow me to thank wholeheartedly all those that worked tirelessly to produce this strategic plan. Special thanks go to the staff, the management and Board of Governors for Nkozi Hospital, the consultant who spearheaded the


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process, Prof. John Mugisha and the Uganda Catholic Medical Bureau for the guidance. Thank you very much for your support.

Dr. Ssendyona Martin (MD, MPH)Chairman Nkozi Hospital Board of Governors


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ACKNOWLEDGEMENTSThere has been a lot of effort put into the production of this strategic plan; many individuals have spent a lot of their energy and time to do this work. On behalf of the hospital’s management team, I would like to express our heartfelt gratitude for each contribution from all people who were involved in generating this plan. I will now thank only a few in a special way.

Let me start with Associate Professor Dr. John Mugisha who has been the consultant facilitator during the development of this plan. He has been committed to interacting with all the stake holders in order to generate a realistic and achievable strategic plan. He has also made drafts for the hospital management and Board of Governors to work with during this exercise.

Allow me then to thank the Village Health Teams of Mawokota South Health Sub-District for their contributions during the workshops organized for SWOT analysis. This information made this strategic plan focused on the needs of the catchment population.

The Nkozi Hospital staff especially those in charge of departments were also very helpful during the SWOT analysis, giving their input in order to make a realistic plan.

My fellow management team members, as a whole, cannot be forgotten for their tireless efforts to ensure that the strategic plan is made with involvement of all stake holders.

The Board of Governors has been very helpful in giving their advice, moral support and guidance to the management team. They were also involved in the SWOT analysis.

I also like to thank the Uganda Catholic Medical Bureau which has been reminding us to make and follow a strategic plan in order to put forward organized development in this hospital.

The hospital partners who have been always there for Nkozi Hospital cannot be forgotten because their support indirectly helps management to fulfill its obligations, for example, Mpigi District Local Government, Ministry of Health, Manos Unidas, Stitching Porticus, MIVA, UEC-ACT Program, MildMay, Lilian Foundation, Uganda Martyrs University, PACE, Insurance Institute of Uganda, AFA, etc.


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To all of those who have contributed towards this achievement thank you very much.

Alfred Lumala

Medical Director


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EXECUTIVE SUMMARY Nkozi Hospital has engaged all its stakeholders in a participatory planning process to come up with this second strategic plan 2015/16- 2019/20. This plan has also been based on the achievements of the previous strategic plan 2009/10-2014/15 with knowledge of the local, regional and global challenges. The strategic plan is intended to guide the effectiveness and efficiency of service delivery of Nkozi Hospital while remaining faithful to the mission of providing high quality health services to the people of God.. It explains our vision, mission, objectives, core values and partnership principles. Nkozi hospital aims to deliver by; increasing utilisation of services at Nkozi hospital, contributing to improved health for the people living in Mawokota South Health Sub-District (HSD), ensuring sustainable financial base for the hospital, improving human resource capacity, expanding and furnishing hospital infrastructure and improving hospital governance and management.

The process for developing this plan commenced with the strategic planning workshop held at the Hospital for two days 22nd and 23rd November 2014 facilitated by Dr. John F. Mugisha of Uganda Martyrs University with full participation of all staff members, the Hospital management and at a later date by Board Members. The strategic plan articulates the vision, mission, core values and objectives; and also provides the strategies which require to be implemented in order to give Nkozi Hospital considerable service delivery capacity in the next five years. The five strategic objectives include:

1. To Increase utilisation of services in Nkozi hospital

This is the raison d’etre of the hospital, which therefore constitutes the main hospital function. To achieve this goal the hospital will improve on the range of clinical and nursing services, expand the ancillary services, expand Clinical Pastoral Care and Counseling, improve on medical records management (patient data collection, recording, analysis, storage, retrieval and reporting), and expand and furnish the facilitating hospital infrastructure as the main strategic objectives.

2. Improve Human Resources in Nkozi Hospital

The hospital has been losing staff at a fairly high rate. In the next 5 years of the plan, it is hoped that this trend will be stopped, reversed and the human resource situation of the hospital stabilized. To realise this goal, a number of strategies will be undertaken: (i) ensure competitive and equitable salaries for the staff, (ii) put in place attractive and welfare terms and conditions, (iii) establish a trans-


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generational bond between the hospital and the staff, (iv) develop differential skills among staff through specific professional training and development programs, (v) determine the actual workload-based requirements for staffing and improve staff retention within the hospital.

3. Ensure sustainable financial base for the Hospital

In the next 5 year period of the plan, efforts will be made to stabilize the financial situation of the hospital because it is one factor that will improve general hospital functioning and service delivery. This strategic goal will be pursued through several strategic objectives: reduce non-critical expenditure in the hospital, improve financial management, Increase local revenues from different sources for hospital activities and mobilize resources for continued income generation and sustainability.

4. Improving Governance, Management And Operational Systems of the Hospital

This plan seeks to consolidate the existing governance and management structures of the hospital and to establish and institutionalize a quality management systems for the routine operations of the hospital, in order to reduce over-reliance on specific individuals. This will be achieved through increasing the effectiveness of the Board of Governors (BOG), strengthening the role of the Managing institute (through an official agreement e.g. the establishment and implementation of a Memorandum of understanding (MoU)) in supporting the hospital, the performance of the Management Team and the general management systems including management of equipment, space, infrastructure and the human resources.

5. Contribute to improved health for the people living in Mawokota South Health sub-district (HSD)

In the next 5 years, the hospital will continue to make its contribution by focusing on 5 strategies of: (i) strengthening PHC department, (ii) preventing the spread of communicable diseases, (iii) contributing to reduction of maternal and neonatal mortality, (iv) improving hospital ambulatory services and (iv) improving infection control.

Some indicators of quality of care have been declining e.g. annual number of normal deliveries has been declining from 1342 to 1260 in the last five years; Annual live births have been declining from 1671 to 1522 in the last five years.


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Activities to be accomplished in the next five years have been identified and elaborated in a logical framework with clear and understandable indicators. To realize the intentions of this strategic plan, stakeholders have to consider the following: will need constant networking, participatory planning, learning and commitment, to provide an excellent opportunity to build a sense of teamwork.

This strategic plan will be communicated to all its users to make a case for the prioritized strategic choices to avoid over ambitiousness of the plan.

This plan will provide an excellent opportunity to build community consensus, promote learning and build commitment of staff and other social sectors. However the hospital is mindful of its limits both internally and externally.

The plan will progressively be monitored and reviewed in the mid-term in order to make strategic adjustments and bring on board new development as staff continue to heed the core values and mission that are key in the implementation of the plan.

The Plan will be financed by both public and private resources, with about 25% being Government contribution, 50% User fee contribution, 7% Income generating projects and 12% from donations and fund raising.

The common disease cases reported at the hospital during the past strategic plan period are Malaria, upper respiratory tract infections(URTI), Anemia, malnutrition, pneumonia, Diarrhea, HIV/AIDS, trauma following Road traffic accident (RTA), Urinary tract Infection (UTI), Typhoid, Hypertension, Hernia .

Most of the diseases are infectious diseases than life style, malaria contributes most 37%, URTI 13%,

Trauma following road accidents (RTA) contributing 6%.

Our main focus will be Trauma following RTA and other non- communication diseases like Diabetes, Hypertension, eye diseases, gynecology because the Government already supports infectious diseases.


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Section one: BACKGROUND1.1 History

Nkozi hospital was founded by the White Sisters of Our Lady of Africa from the Netherlands in 1942. The Management of the hospital was transferred in 1994 to the local Institute of the Sisters of the Immaculate Heart of Mary Reparatrix – Ggogonya, Headquartered in Kisubi. These Sisters are still serving as the managing Institute under the guidance of the Board of Governors, which is appointed by the Archbishop of Kampala Archdiocese.

Currently the legal and registered owner of the Hospital is the Roman Catholic Archdiocese of Kampala in the person of the Registered Trustees of the Archdiocese.

The hospital is affiliated to and is accredited by the Uganda Catholic Medical Bureau (UCMB), which is responsible for coordination of services for several other health facilities and training schools owned and operated by the Roman Catholic Church in Uganda.

1.2 General Overview

Nkozi hospital is a Catholic founded Private-Not-For-Profit (PNFP) hospital which operates within Kampala Archdiocese. The hospital is located adjacent to Uganda Martyrs University main Campus, in Nkozi sub-county, Mpigi district. The distance from Kampala, Uganda capital city along Kampala – Masaka highway is about 83 kms and then you turn on the right hand-side at Kayabwe trading center for 2.5 kms before reaching the hospital.

Nkozi hospital enjoys good collaboration with Government of Uganda (GoU) and is the referral health facility for Mawokota South Health Sub-District (HSD), in Mpigi district. The hospital hence functions as a referral health facility for the HSD which has an estimated population of 109,984 occupying the three sub-counties of Nkozi (37,079), Buwama (48,643) and Kituntu (24,262). The hospital serves as the most accessible health unit for the population of about 30,000 people in the surrounding community of Nkozi Sub-county.

The hospital is located in a rural community where majority of the people being served are peasant farmers, mainly carrying out subsistence agriculture, small scale fishing and poultry keeping. This has implications on setting of user fees and clients’ ability to pay as majority of the catchment population comprises low income groups that can only pay a very small proportion of the real cost


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of treatment and care. In fact, majority of the people in the catchment area live below the poverty line.

1.3 Morbidity and mortality trends

malaria and HIV/AIDS are the leading causes of death in the hospital although there are several efforts to contain them. Children below 5 years of age are the worst hit by malaria. There is a high number of reported trauma cases due to road traffic accidents because of the busy Kampala Masaka high way that links to neighboring countries of Rwanda, Tanzania and the Democratic Republic of Congo (DRC). On many occasions, the demand for services exceeds the hospital’s capacity and depletes the limited resources available in the hospital. There are also maternal deaths due to delay of mothers in the community many times under the care and support of the Traditional Birth Attendants (TBAs). Most of these mothers who deliver with TBAs cannot access basic services such as elimination of Mother To Child Transmission (e-MTCT) services, which exposes their new born babies to HIV infection.

1.4 National context:

Nkozi hospital operates under the regulations governing hospital management in the Ministry of Health. The hospital strategic plan has been developed within the broad context of the Uganda National Development Plan (NDP 2015/16 to 2019/20); The Second National Health Policy (NHP II 2010/11-2019/20) and The Health Sector Development Plan (HSDP 2015/16 to 2019/20). The theme of this 2nd NDP is to see “Strengthening Uganda’s Competitiveness for Sustainable Wealth Creation, inclusive Growth and Employment.” The Hospital being part of the national health system roots deeply into this theme. The catholic network has been part of the national effort to support the implantation of the NHP and will form part and parcel of the HSDP whose period of operation rhymes with that of Nkozi Hospital Strategic plan.

1.5 Development process

This process has been participatory to involve the key stakeholders before coming up with the key priorities for the next five year. A consultant was hired from Uganda Martyrs’ University and a workshop was organised in July 2014 for representatives from Heads of Department, the Management Team, the community (Village Health Teams) and Board of Governors. Participants worked in teams on different Vision, Mission, Core values, Goals, strategic objectives and interventions to needed to be carried out and reported back in the plenary. Some of the issues discussed in the team and later in the plenary included scope


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of services that the hospital should provide, funding sources and expenditure patterns, physical infrastructure, primary health care activities, communication within the hospital and internal management systems, just to mention a few.

Further to the workshop, the process of making this strategic plan involved a thorough analysis of major hospital documents such as annual analytical reports, strategic plan for 2009-2014, long term master plan of the hospital, hospital charter, procurement and disposal of hospital assets manual, employment manual, job descriptions handbook, financial and material resources manual, among others. The analysis of these documents focused on identifying major hospital functions and activities, staffing, infrastructure and other resources, community out-reaches, sources of funding and main areas of expenditure, burden of disease in the community being served by the hospital and collaborations between the hospital and different partners.

Finally, the writing team conducted a physical tour of the hospital and its various units to acquaint itself with the state of hospital infrastructure, equipment, scope of services, safety of assets, in-service pathways, patient flow area, water resources, electricity, compound, incinerator, vehicles, staff houses, land and other issues that required observation. This strategic plan was a result of analysis of data from all these activities.


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Section two: ORGANISATIONAL ARRANGEMENT

2.1 Hospital organisation

this has the hierarchal set up at Nkozi hospital as summarised in the organogram below:

NKOZI HOSPITAL ORGANOGRAM

BOARD OF TRUSTEES:

Delegation of powers

Board of Governors

Nkozi Hospital

Management Team Headed by a Medical Director and

consisting of the heads of the main departments

Head of the Medical Department -Medical Director

Head of the Nursing Department -Senior Nursing Officer

Head of the Administration Department-Administrator.

Advisory Assembly Nkozi Hospital

UCMB

Local Government/ Office of the District Health Officer (DHO)

Medical and paramedical departments / staff; Diagnostic departments Pharmacy

Nursing departments; Nurses and Nursing Assistants.

Accounts / Administration, Cleaning/ Maintenance infrastructure, equipment and grounds; Transport; Support Staff.

Head of Public Health Department or Public Health Director

Community Health/ HSD services and activities.

Ministry of Health

Managing Organization IHMR - Sisters

Nkozi Hospital is owned by the Board of Trustees which chaired by the Arch-bishop of Kampala Archdiocese. The Sister of the Immaculate Heart of Mary Reparatrix (IHMR) Ggogonya, Kisubi were given the mandate to manage the Hospital on behalf of Kampala Archdiocese. The Board of Governors is the supreme body responsible for governance and advising on managerial and policy-making issues related to the


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Hospital. The Hospital Management Committee (HMT) is headed by the Hospital Director and reports to the Board of Governors. The Team is charged with the day to day running of the hospital, implementing the policies set up by the BOG, and the national programmes for health service delivery in the catchment area. Other key stakeholders in the running of the Hospital are the Local Government through the office of the DHO, Uganda Catholic Medical Bureau (UCMB) and the Hospital Advisory Assembly as summarized in the organogram above.

2.2 Hospital functions/services

The hospital operates 24 hours and offers preventive, curative and promotive health services both on site and through outreach activities. The core functions of the hospital are the following:

•Outpatient Services

o General Outpatient Clinic

o HIV/AIDS Clinic

o Dental Clinic

o Immunization Clinic

o Antenatal and Postnatal Clinic.

o Physiotherapy & Occupational therapy

o Psychiatry Inpatient/Admission services

o General medical, Paediatric and Surgery sections (Female, Male and Children)

o Delivery/maternity services ( beds capacity)

o Private ward

•Support Services

o Diagnostic services

Laboratory

X-ray services

Dental x-ray

Ultra sound scan services


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o Pharmaceutical services

o Theater services

o Blood Transfusion services

•Community Health

o Expanded Programme for Immunisation EPI) services

o Antenatal services

o Village Health Teams (VHTs)

•Administration services

o Human Resource Management section

o Finance and Administration

o Health Management Information System (HMIS/Records)

o Pastoral care (clinical and holistic)

o Maintenance services

•Health Sub-district (HSD) services

o Planning, budgeting and coordination PHC services for the HC IIIS and HC IIs.

o Support supervision, monitoring and technical support services to the lower level health services

o Support for community services


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Section three: REVIEW OF THE PREVIOUS STRATEGIC PLAN (2009/10-2014/15)Review of Nkozi Hospital Strategic Plan for 2009/10-2014/15 was conducted to appreciate the achievements and challenges met in the implementation process. The Strategic plan had four goals to accomplish as outlined below:

1) Improved the human resource in Nkozi hospital

2) Ensuring financial sustainability base

3) Increasing utilization of services offered at Nkozi hospital

4) Improving hospital governance, management and operational systems

5) Contributing to improved health for the people living in Mawokota South Health Sub-District

During the period of the previous strategic plan, a number of achievements were made by the hospital in areas the management had set out to accomplish. The following review highlights the summary of the hospital performance in respect of achieving the just concluded strategic plan. After each set of achievements is a brief commentary on each strategic goal in respect of what the key achievements were supposed to be:

Goal 1: Improving human resources in Nkozi hospital through effective utilization of the employment manual

1) The hospital was able to recruit more staff that included 1 extra Doctor, 1 radiographer, clinical officers, nurses, midwives. In this way, the hospital was able to fill the key human resource gaps which was a key objective

2) The hospital was able to develop a staff career development plan although it is now due for revision

3) The hospital managed to conduct Continuing Professional Development (CPD) sessions for staff, which are well institutionalized and are still on-going.

4) A staff revolving fund worth UGX 10 million was set up as planned and some staff are benefiting from the fund.


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Commentary Although the hospital managed to make some important achievements towards realizing the goal of improving the human resource, a number of activities remained undone, rendering some objectives to remain unachieved.

• There was increase in staff salaries during the previous planning period mainly for nurses, midwives and nursing assistants. However, there was no increase of salaries for Doctors some of whom are also seconded by government. Work of constructing staff hostels, which were targeted to improve staff welfare, began in August 2014 but is not yet completed.

• The number of government seconded staff increased to six, although by the time of making this plan, one was on study leave and another one was not active.

• A staff revolving fund was set up as planned and some staff are benefiting from the fund.

Goal 2: Ensure a sustainable financial base

On this strategic goal, the hospital was able to register a number of achievements, viz:

1) Management wrote funding proposals and was able to receive some resources e.g.:

a. Construction of private ward (by the Stiching Porticus)

b. Equipment from Brothers of Brothers – USA, Computers from Dr. Kabuye, Autoclave from Mirembe Foundation, UEC/ACT programme

c. Brand new Double Cabin pick-up (MIVA)

d. Staff – 2 midwives (Mildmay – Uganda)

2) Producing financial statements

3) Auditing financial books of accounts

4) Procured the tipper but it was later disposed off due to the increasing expenses on it with very little income. Instead, Management bought a small


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pick-up for the small duties and such as transporting the tents.

5) Procured tents and chairs for rent

6) Planted eucalyptus trees

Commentary

It is recognized that the hospital managed to make very important achievements towards realizing this goal for which management should be commended. However, there are few activities that remained unaccomplished during this period, namely:

• A hospital restaurant was not constructed as planned

• A hospital hostel was not constructed for renting out to get money

Goal 3: Increase utilization of services offered at Nkozi hospital

On this 3rd strategic goal, the hospital was able to achieve a number of targeted objectives, where the following were most outstanding:

1) Stock-outs of essential medicines was reduced significantly in the hospital

2) A number of laboratory reagents were procured as and when needed

3) 50 percent of the computers needed for data management were procured

4) The general ward and the private ward were expanded and furnished

5) Fire extinguishers were procured and installed within the key points

6) Health Sub District meetings were held quarterly

Commentary

It is also recognized that the hospital managed to make some vital achievements towards realizing this goal for increasing utilization of hospital services at Nkozi. However, the areas that remained unsatisfied include the following:

• Patients did not access medicines at reduced user fees

• An automatic liver and renal function machine was not procured


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• An ECG machine was also not procured

• Filling cabins were not procured as planned

• Maternity ward was not expanded and a theatre was not put

• The HIV/AIDS clinic was not renovated

• A kitchen and a shelter for patients’ attendants were not constructed

• The 4 Television sets and Radio for patients were not bought

Goal 4: Improve hospital governance and management

As far as this strategic goal was concerned, the hospital was able to realize a number of achievements, which included the following:

1) Some members of the Health Management Team were trained in Health Services Management

2) Quarterly Board of Governors’ Meetings were held

3) Weekly Management meetings were held

4) One annual stakeholders meeting was held in 2012

5) Quarterly Health Sub District meetings were held

Commentary:

All activities for this goal were achieved, except 1 annual stakeholders meeting was held instead of 5.

Goal 5: Contribute to improved health for people living in Mawokota South HSD

The hospital supported the HSD services as indicated below

1) Quarterly planning and budgeting functions

2) Regular performance review meetings

3) Regular support supervision functions

4) Coordinated HSD Child Days activities which are planned at the national level.


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5) Coordination of HSD Village Health Team (VHT) services

6) Supported health services delivery in the HSD including HIV/AIDS, TB and Malaria services.

7) Distributed mosquito nets to some members of the community

CommentaryThe hospital did a lot to achieve several targets within this strategic goal. Only a few things such as procurement of an ambulance for improved referral and movement of the patients was not done. On the whole, the hospital did a commendable job in achieving the goals and objectives set out in the previous strategic plan.


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Section four: SITUATIONAL ANALYSIS:

This section provides e situational -analysis of Nkozi Hospital in form of Strengths, Weaknesses, Opportunities, Threats (SWOT) and the key priority areas for the five – year period of the Plan. The purpose of the SWOT analysis is to clearly identify the internal strengths that can be built upon, the weaknesses that need to be addressed and the external threats that require mitigation as well as the opportunities that the hospital should take advantage of.

The table below summaries for each service area the strength, opportunities and focus for improvement; weaknesses and threats with the proposed mitigation actions:


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on

utilit

y bi

lls b

y co

nsid

erin

g so

lar p

ower

so

urce

and

rain

wat

er

harv

estin

g.


26

Serv

ice

Area

Stre

ngth

Opp

ortu

nitie

sSt

rate

gies

for I

mpr

ovem

ent

2. S

ervi

ce D

eliv

ery.

Refe

rs to

all

inte

rven

tions

th

at tr

ansf

orm

inpu

ts to

ou

tput

s in

the

hosp

ital

(incl

udin

g in

fras

truc

ture

an

d eq

uipm

ent a

vaila

ble)

.

•N

kozi

is

the

refe

rral

he

alth

fa

cilit

y fo

r th

e H

SD

with

a

catc

hmen

t pop

ulati

on.

•Ex

pand

ing

capa

city

for

spec

ialis

ed c

are

for G

ener

al

Surg

ery

and

Obs

tetr

ics

and

Gyn

ecol

ogy.

•Av

aila

bilit

y of

dia

gnos

tic

serv

ices

in fr

om o

f X-r

ay a

nd

Ultr

a-so

und

scan

ser

vice

.

•Ex

tra

spac

e (la

nd) f

or fu

rthe

r ex

pans

ion

and

deve

lopm

ent.

6.

•Bu

ildin

g an

d eq

uipm

ent f

or

basic

ser

vice

del

iver

y

•Ve

hicl

es in

clud

ing

ambu

lanc

e an

d a

four

whe

el v

ehic

les

used

fo

r ser

vice

del

iver

y.

•In

crea

sing

dem

and

for s

ervi

ces.

•Ea

sy

acce

ss

for

patie

nt w

ith in

jurie

s fo

llow

ing

road

traffi

c ac

cide

nts

•As

soci

ation

with

sis

ter h

ospi

tals

with

gr

eate

r cap

acity

su

ch a

s N

sam

bya

,Lub

aga

and

Kito

vu

Hos

pita

ls.

•La

ck o

f a n

urse

s’

trai

ning

sch

ool

with

in th

e di

stric

t an

d be

yond

.

7.

•M

aste

r pla

n de

velo

ped

to

guid

e fu

ture

de

velo

pmen

ts fo

r th

e la

nd

•Im

prov

e re

ferr

al sy

stem

. St

reng

then

gen

eral

se

rvic

e de

liver

y fo

r Nko

zi

hosp

ital.

•Im

prov

e m

anag

emen

t fo

r em

erge

ncy/

caus

ality

se

rvic

es

•Co

nsid

er e

stab

lishi

ng a

Co

mpr

ehen

sive

Nur

ses’

Tr

aini

ng S

choo

l.

•W

iden

sco

pe fo

r sp

ecia

lised

ser

vice

s w

ith

focu

s of

Pae

diat

ric a

nd

inte

rnal

med

icin

es.

8.

•Bu

ild st

rong

ass

ocia

tions

w

ith s

ister

hos

pita

ls fo

r tec

hnic

al s

uppo

rt

(Con

sider

mon

thly

or

wee

kly

visit

s as

cap

acity

is

built

).


27

Serv

ice

Area

Stre

ngth

Opp

ortu

nitie

sSt

rate

gies

for I

mpr

ovem

ent

3.

Gov

erna

nce

and

Lead

ersh

ip

•Ca

thol

ic fo

unda

tion

back

grou

nd fo

r the

hos

pita

l

•Fu

nctio

nal b

oard

of G

over

nors

an

d ot

her m

anag

emen

t st

ruct

ure.

•Es

tabl

ished

gov

erna

nce

and

man

agem

ent s

truc

ture

s th

at

are

func

tiona

l.

•Av

aila

bilit

y of

test

ed a

nd k

ey

man

agem

ent t

ools

in fo

rm o

f th

e H

ospi

tal C

hart

er, a

Man

ual

on F

inan

cial

and

Mat

eria

l Re

sour

ces

Man

agem

ent,

Empl

oym

ent M

anua

l, Pr

ocur

emen

t and

Disp

osal

of

Hos

pita

l Ass

ets

Man

ual e

tc.

•Po

litica

l sup

port

from

op

inio

n le

ader

s

•Cl

ose

colla

bora

tion

and

supp

ort f

rom

th

e M

oH a

nd L

ocal

G

over

nmen

t.

•Su

ppor

t fro

m th

e co

ordi

natio

n bo

dy

UCM

B

•Su

ppor

t fro

m th

e Lo

cal G

over

nmen

t th

roug

h th

e DH

O

•Bu

ild c

apac

ity fo

r th

e G

over

nanc

e an

d M

anag

emen

t tea

ms.

•St

reng

then

com

mun

ity

parti

cipa

tion

in h

ealth

se

rvic

e de

liver

y

•Ex

plor

e av

aila

ble

supp

ort

from

UCM

B an

d ot

her

agen

cies


28

Serv

ice

Area

Stre

ngth

Opp

ortu

nitie

sSt

rate

gies

for I

mpr

ovem

ent

4. F

inan

ce m

anag

emen

t •

Esta

blish

ed fi

nanc

e m

anag

emen

t sys

tem

with

the

requ

ired

man

pow

er a

nd to

ols.

•Re

gula

r fun

ding

from

use

r-fe

es.

•Ad

ditio

nal s

ourc

es o

f rev

enue

w

hich

incl

ude:

Ban

ks s

avin

gs;

Bana

na p

lant

ation

s; T

ents

an

d ch

airs

; euc

alyp

tus

tree

pl

anta

tion,

etc

.

•Pr

esen

ce o

f ext

erna

l au

dit s

yste

m

(qua

rter

ly) f

or th

e ho

spita

l

•Do

nor s

uppo

rt fo

r H

IV/A

IDs

serv

ices

and

ex

tern

al s

uppo

rt fo

r ca

pita

l inv

estm

ents

.

•Fu

ndin

g su

ppor

t fr

om G

oU fo

r de

lega

ted

fund

s.

•Im

prov

e effi

cien

t uti

lisati

on o

f ava

ilabl

e fu

nds

•St

reng

then

the

finan

cial

ba

se fo

r the

hos

pita

l. M

ore

focu

s on

the

addi

tiona

l sou

rces

of

reve

nue.

•H

arm

onise

util

izatio

n of

do

nor s

uppo

rt e

spec

ially

fo

r HIV


29

Serv

ice

Area

Stre

ngth

Opp

ortu

nitie

sSt

rate

gies

for I

mpr

ovem

ent

5. H

ealth

Info

rmati

on

Man

agem

ent

•Pr

esen

ce o

f a tr

aine

d re

cord

s offi

cer.

•Av

aila

bilit

y of

har

d w

are

com

pute

r and

soft

war

e fo

r H

IV/A

IDS

prog

ram

mes

•Es

tabl

ishes

cap

acity

for d

ata

man

agem

ent i

n th

e ho

spita

l an

d H

SD.

•Av

aila

bilit

y of

tool

s fo

r dat

a m

anag

emen

t •

Pres

ence

of N

kozi

Hos

pita

l w

ebsit

e.

•Irr

egul

ar p

erfo

rman

ce

revi

ew m

eetin

gs

(CM

Es a

nd H

SD)

•Av

aila

bilit

y an

d ha

ving

acc

ess

to

the

elec

tron

ic H

MIS

(D

istric

t Hea

lth

Info

rmati

on S

yste

m-

DHIS

-2)

•Pr

obab

le s

uppo

rt fr

om

stak

ehol

ders

MoH

, U

CMB

etc.

on

data

m

anag

emen

t

•St

reng

then

kno

wle

dge

man

agem

ent a

nd d

ata

utilis

ation

in th

e ho

spita

l •

Expa

nd o

n th

e el

ectr

onic

da

ta m

anag

emen

t: Pr

ivat

e w

ard,

Fin

ance

m

anag

emen

t etc

. •

Conti

nuou

s ca

paci

ty

build

ing

on d

ata

man

agem

ent.


30

Serv

ice

Area

Stre

ngth

Opp

ortu

nitie

sSt

rate

gies

for I

mpr

ovem

ent

6. M

edic

ines

vac

cine

s an

d ot

her r

elat

ed

supp

lies

•Es

tabl

ished

disp

ensa

ry a

nd

stor

e fo

r med

icin

es a

nd h

ealth

su

pplie

s.•

Avai

labi

lity

of th

e es

senti

al

med

icin

es a

nd h

ealth

sup

plie

s.•

Cont

rol s

yste

m fo

r med

icin

es

and

supp

lies

man

agem

ent

•Av

aila

bilit

y gu

idel

ines

on

use

of

med

icin

es a

nd s

uppl

ies

•Re

liabl

e su

pply

fo

r med

icin

es a

nd

supp

lies

from

Join

t M

edic

al S

tore

.•

Occ

asio

nal s

uppo

rt fo

r m

edic

al s

uppl

ies

from

M

oH

•M

iddl

e cl

ass

clie

nts

(insu

ranc

e an

d U

MU

) w

ho c

an b

enefi

t fro

m

bran

ded

med

ical

su

pplie

s

•H

ave

regu

lar s

uppl

y fo

r m

edic

ines

and

sup

ply

•Ex

plor

e po

ssib

ility

to st

ock

bran

ded

med

ical

sup

plie

s •

Impr

ove

stoc

k m

anag

emen

t


31

4.2

Wea

knes

ses a

nd th

reat

s and

pro

pose

d st

rate

gies

for m

itiga

tion

Tabl

e 2:

Wea

knes

ses a

nd th

reat

s and

pro

pose

d st

rate

gies

for m

itiga

tion

Serv

ice

area

Wea

knes

ses

Thre

ats

Stra

tegi

es fo

r miti

gatio

n

1.

Hum

an R

esou

rces

fo

r Hea

lth:

•In

adeq

uate

staff

•N

onco

mpe

titive

re

mun

erati

on

•H

igh

turn

over

of s

taff

•Re

stric

tive

care

er p

ath

•Fe

w st

aff le

adin

g to

wor

k ov

er lo

ad

•La

ck o

f inc

entiv

es to

att

ract

he

alth

wor

kers

•Att

racti

ve s

alar

y fr

om

Gov

ernm

ent a

nd o

ther

he

alth

insti

tutio

ns

•St

rong

job

secu

rity

for s

taff

in p

ublic

hea

lth fa

ciliti

es

•St

reng

then

hum

an

reso

urce

man

agem

ent

syst

em

•In

trod

uce

inco

me

gene

ratin

g st

aff

asso

ciati

ons

(SAC

CO)

•As

sess

staffi

ng n

eeds

ba

sing

on w

ork

load

.


32

Serv

ice

area

Wea

knes

ses

Thre

ats

Stra

tegi

es fo

r miti

gatio

n

2. S

ervi

ce D

eliv

ery

9.

•W

eak

qual

ity im

prov

emen

t sy

stem

•Co

mm

on c

ondi

tions

for

heal

th c

entr

es m

anag

ed a

t th

e H

SD re

ferr

al h

ospi

tal

•Sp

ecia

lised

car

e no

t st

ream

lined

to m

eet d

eman

d in

the

catc

hmen

t are

a

•O

ld in

fras

truc

ture

(old

bu

ildin

gs, d

iagn

ostic

ser

vice

s an

d ot

her e

quip

men

t)

• H

igh

oper

ation

cos

ts fo

r so

me

serv

ices

suc

h as

am

bula

nce

and

pow

er

supp

ly

•Im

prov

ing

heal

th s

ervi

ce

deliv

ery

with

in th

e ca

tchm

ent a

rea

for N

kozi

ho

spita

l

•In

crea

sing

num

ber o

f dru

g sh

ops.

•In

trod

uctio

n of

ser

vice

pr

ovid

er in

the

UM

U

•Pr

ogra

mm

e (A

RT c

linic

) sp

ecifi

c su

ppor

t for

ser

vice

de

liver

y

•O

pera

tiona

lise

qual

ity

impr

ovem

ent f

ram

ewor

k

•St

reng

then

and

focu

s m

ore

on s

peci

alise

d ca

re

•Im

prov

e th

e in

fras

truc

ture

(o

ld b

uild

ings

, fen

cing

, di

agno

stic

serv

ices

and

ot

her e

quip

men

t)

•In

crea

se e

ffici

ency

with

am

bula

nce

and

pow

er

supp

ly


33

Serv

ice

area

Wea

knes

ses

Thre

ats

Stra

tegi

es fo

r miti

gatio

n

3.

Gov

erna

nce

and

Lead

ersh

ip•

Insu

ffici

ent c

apac

ity fo

r go

vern

ance

lead

ersh

ip a

nd

man

agem

ent f

or th

e ho

spita

l es

tabl

ishm

ent

•In

adeq

uate

co-

ordi

natio

n of

th

e M

anag

emen

t str

uctu

res

hosp

ital.

• W

eak

syst

em fo

r the

HSD

co

ordi

natio

n.

•To

o m

any

com

mitm

ents

for

Boar

d m

embe

rs.

•In

adeq

uate

faci

litati

on fo

r H

SD s

ervi

ces.

•Lo

w c

omm

unity

pa

rtici

patio

n in

ser

vice

de

liver

y.

•Bu

ild c

apac

ity fo

r th

e G

over

nanc

e an

d M

anag

emen

t tea

ms.

•St

reng

then

com

mun

ity

parti

cipa

tion

in h

ealth

se

rvic

e de

liver

y

•Ex

plor

e av

aila

ble

supp

ort

from

UCM

B an

d ot

her

agen

cies

.

4. F

inan

ce

man

agem

ent

•H

igh

oper

ation

cos

ts fo

r se

rvic

e de

liver

y

•W

eak

finan

cial

bas

e fo

r the

ho

spita

l

•In

effec

tive

syst

em fo

r deb

t co

llecti

on

•Lo

w h

ouse

hold

inco

me

for

clie

nts

in th

e ca

tchm

ent

area

• In

crea

sing

dono

r de

pend

ence

and

don

or

fatig

ue

•Irr

egul

ar G

oU fu

ndin

g an

d re

leas

es

•In

crea

sing

debt

ors

to th

e ho

spita

ls

•St

reng

then

fina

ncia

l sy

stem

s in

the

hosp

ital t

o m

inim

ize d

ebto

rs e

tc.

•St

ream

line

dono

r fu

ndin

g in

to th

e ho

spita

l sys

tem

(pla

n fo

r su

stai

nabi

lity)


34

Serv

ice

area

Wea

knes

ses

Thre

ats

Stra

tegi

es fo

r miti

gatio

n

5. H

ealth

Info

rmati

on

Man

agem

ent

•In

adeq

uate

cap

acity

on

data

m

anag

emen

t for

staff

•

Lack

of e

quip

men

t for

kn

owle

dge

man

agem

ent

•W

eak

syst

ems

for

com

mun

icati

on in

clud

ing

the

web

site

•Pa

ralle

l sys

tem

s fo

r dat

a co

llecti

on b

y pr

ojec

ts in

the

hosp

ital/H

SD•

Irreg

ular

sup

ply

of m

edic

al

stati

oner

y an

d ot

her

logi

stics

from

MoH

•H

arm

onise

repo

rting

in th

e ho

spita

l and

HSD

•Pr

ioriti

se a

vaila

bilit

y of

m

edic

al st

ation

ery

6. M

edic

ines

vac

cine

s an

d ot

her r

elat

ed

supp

lies

•In

crea

sing

cost

for m

edic

ines

an

d he

alth

sup

plie

s •

Lim

ited

rang

e of

med

icin

es

prov

ided

at t

he h

ospi

tal

•U

ncoo

rdin

ated

pre

scrip

tion

prac

tice.

• Im

prov

ed a

vaila

bilit

y fr

ee

med

icin

es (A

CTs,

anti

bioti

cs

etc.

) and

ser

vice

s in

the

HSD

•Re

view

and

stre

amlin

e m

edic

ines

and

hea

lth

supp

lies

to th

e ho

spita

l •

Build

cap

acity

for

med

icin

es a

nd h

ealth

su

pplie

s m

anag

emen

t


35

4.3 Performance review analysis

Nkozi hospital has registered improved outputs for in all the service delivery areas of outpatients, inpatients, deliveries, surgical operations, immunisation and antenatal and postnatal services. There has been steady increase in common disease conditions like malaria and Respiratory Tract Infections (RTI) and even trauma and injury cases. The majority of the surgical operations during the period under review were caesarian sections. Surgical cases for chronic conditions have been also increased when the services of a surgeon became available from 2012.

The General ward was expanded which improved space for management of admissions for private patient services. There is need for more reorganization of the ward to have distinct male and female sections and also to improve sanitation services available.

Support services expanded with the refurbishment of the laboratory services where more informative tests can now be conducted to guide advanced management of patients. There is still room for improvement especially regarding diagnostic services with ultrasound and X-ray services. Having one theater has been a limitation for emergence obstetric and gynecological cases in the maternity wing.

The Hospital has been supporting HSD services in collaboration with the DHO’s office. There has been steady improvement with increased patient load in all health facilities in the HSD. This has been coupled with improved infrastructure and staffing in these facilities enabling more access to free services to the community.


36

Section 5: STRATEGIC DIRECTIONThe strategic focus for the next five year shall focus on improving service delivery for Nkozi hospital and ensure high quality and sustainability of the different interventions as outlined below.

5.1 VISION

A Centre of Excellence for Holistic and Quality Health Care Service Delivery with Christian Values, so that they may have life and have it more abundantly.

5.2 MISSION

To uplift the health standards of the community with preference to the most vulnerable ones through a sustainable comprehensive model of high quality health service delivery.

5.3 GOAL

To provide sustainable, accessible and high quality services to uplift health standards of the community.

5.4 MOTTO

In God, We Serve and Care

5.5 GUIDING PRINCIPLES

• Christian focus: Working to emulate the work of Christ in order to meet the needs of the patients particularly the most vulnerable.

• Team work: Working as a dependable one family. Networking and relying on one another.

• Quality of Care: Serving as a model for comprehensive health service delivery through ethical and professional conduct with mutual esteem at all time.

• Results oriented: Focusing on activities that yield the desirable outputs• Social obligation: To contribute to community development through

improved health by networking with all the stakeholders to ensure accessible services


37

5.6 CORE VALUES

• Graciousness: God is able in all we do

• Compassion: Have feelings for those we serve and work with.• Ethical conduct of conduct: Respect our clients and work professionally.• Quality Assurance: Striving for excellence in all we do with adherence to

the required standards.• Transparency: Be accountable and trustworthy. • Self-motivation: Interest with ambition to progress on and on.• Team work: Working as a dependable one family. Networking and

relying on one another• Results oriented: Focusing on activities that yield the desirable outputs

5.7 STRATEGIC OBJECTIVES:

The four strategic objectives to be pursued during this period are the following:

1) Increase utilization of services at Nkozi hospital.

2) Improve the human resource management in Nkozi hospital.

3) Strengthen the financial system of the hospital.

4) Improve hospital governance, leadership and management.

5) Improve health standards for the community living in Mawokota South Health Sub-District (HSD)

The strategic objectives have been based on both the current needs and what was not achieved during the previous planning period. More emphasis is put on what needs to be done to improve than on the routine activities that need to be done in any hospital setting.

5.7.1 Strategic objective1: Increase utilisation of services at Nkozi Hospital

This is the raison d’etre of the hospital, which therefore constitutes the main hospital function. To achieve this goal the hospital will improve on the range of clinical and nursing services, expand the ancillary services, expand Clinical Pastoral Care and Counseling, improve on medical records management (patient data collection, recording, analysis, storage, retrieval and reporting), and expand and furnish the facilitating hospital infrastructure as the main strategic objectives.


38

Strategy 1: Improve on the existing range of clinical and nursing services provided:

Interventions:• Plan for steady supply of medicines and health supplies • Improving patient clinical and nursing care • Ensure availability of adequate blood supply in the hospital.• Introduce specialised clinics progressively during the implementation

period (Obstetrics and Gynecology; Surgical clinic, Diabetes, Hypertension,).

• Expand dental care services

Recruit one dental assistant

Install modern dental equipment• Improve and expand on diagnostic services

Procure Electrocardiogram (ECG); Automated Liver and Renal function machines

Introduce culture and sensitivity testing and hematology investigations

Strategy 2: To improve the quality of care offered in the Hospital

Interventions • Operationalise quality improvement committees • Training staff in customer care• Developing or adapting and adopting technical quality of care protocols

and standards (e.g. Standard Operating Procedures for the laboratory) • Carry out quality of care performance assessment and awards• Conduct patient satisfaction survey


39

Strategy 3: To improve patient safety in the Hospital

Interventions• Training staff on patient safety• Develop /adopt and implementing patient safety protocols for the

Hospital (e.g. for surgical procedures, for vaginal delivery, for prescription practices etc.)

• Beginning / strengthening error reporting mechanisms in various hospital departments

• Establishing an Infection Control Committee• Establishing an isolation unit within the hospital

Strategy 4: Expand on the Clinical Pastoral Care (CPC) and Counseling

Interventions:• Training staff in CPC (target: at least 2 staff trained per year)• Training staff in counseling services (the other option is to recruit

qualified counselors)• Recruiting a qualified counsellor• Recruit a medical social worker

Strategy 5: Improve health information management

Interventions: • Capacity building in data management • Plan to increase data utilisation in the hospital and HSD• Computerize the data management system in all departments• Create new office space for records.• Provide logistical support for data management • Improve and maintain Nkozi Hospital website


40

Strategy 6: Expand and furnish hospital infrastructure

Interventions:• Expanding the Maternity ward and construct a theatre.• Constructing a kitchen and a shelter for patients’ attendants• Provide more recreation facilities (Television and radios for patients)• Renovating the HIV/AIDS clinic• Shelter the pathways connecting wards and theatre• Provide a shade at the pharmacy• Improve the hospital parking yard • Procure more tents and chairs for hire• Construct an accident & emergency unit• Reduce on utility bills by introducing water harvesting tanks and solar

power supply • Construct a new chapel• Construct a wall fence and CCTV Cameras• Improve the quality of buildings in the hospital (replace asbestos sheets

with iron sheets)

5.7.2 Strategic objective 2: Improve human resources management in Nkozi Hospital

Human resources for health play an important part in service delivery. The next five years shall focus on improving the number and quality of cadres for the hospital. It is also important to address the challenges of attraction and retention of staff during this period:

Strategy 1: To improve the working and welfare terms and conditions for staff

Interventions• Establishing a Space Management and Utilisation Policy for the hospital

(which governs eligibility and entitlement for accommodation and office space, duration of tenancy, sharing of space etc.)

• Conducting regular salary reviews and adjustment to improve on the remuneration for staff and make them competitive.

• Provide accommodation for all key staff of the hospital who should be


41

housed on site.• Introduce medical insurance cover for the hospital staff.• Computing and communicating the monetary value of all benefits

currently provided by the hospital to the staff• Reviewing the package of fringe benefits provided to staff every two

years with a view to increase them and keep them attractive (e.g. funeral expenses, medical care etc.)

Strategy 2: To establish a “Trans-generational” bond between the hospital and the staff

Interventions:• Establishing a policy on “Trans-generational” relationship between the

hospital and staff (to ensure that staff are committed for a long term, and to reward staff who have been committed to the hospital for a very long time)

• Identifying and supporting children of long-serving staff in their education (e.g. with recommendation for scholarship by donors, offering them hospital scholarships in the NTS, preference in recruitment as hospital staff etc.)

• Assisting long serving staff to acquire loans for personal development e.g. house construction, motor-vehicle purchase etc.

Strategy 3: To develop different skills among staff through specific professional training and development programmes

Interventions • Conducting Training Needs Assessment (TNA) annually• Establishing a Staff Development Policy for the hospital (which covers

issues like eligibility for sponsorship/recommendation for sponsorship, conditions for recommendation for further studies, which courses will be sponsored etc.)

• Preparing a Staff Development Plan for the hospital (which covers issues like what skills, knowledge or expertise are currently required for the hospital, which people will be sponsored over the next 5 years and in what order etc.)

• Developing an internal Continuous Professional Development (CDP)


42

plan (including exchange visits) • Conducting training to develop specific knowledge, attitudes and skills

among the staff • Searching for and identifying short courses for which staff of the

hospital can be sent, in order to develop local capacity (NB: In some cases, there are some short courses which have a scholarship already attached – e.g. UCMB courses, Stichting Porticus, a Dutch Organisation, which offers scholarships mainly for religious people for bachelors and masters degrees. The hospital could tap into this to develop a number of Ggogonya sisters into health professionals who can carry more responsibilities in the hospital.

• Providing staff with opportunities for sharing information especially on return from courses in which they represented the hospital (including exchange visits)

• Developing a policy on mentoring for the hospital (NB: This may need training of staff in mentoring)

Strategy 4: To improve staff requirement for the hospital basing on actual workload status

Interventions • Determining the actual staffing requirements basing on the workload

levels using a suitable approach (e.g. WISN method)• Reorganize and distribute available staff equitably on the basis of

workload e.g. during roster of nurses

Strategy 5: To improve staff retention within Nkozi hospital

Interventions:• Determine and analyze regularly reasons for staff exist and retention.

This will involve conducting exit interviews with all departing staff to determine their causes of departure to make strategies for improved retention of the existing staff. Post-exit interviews shall be conducted with staff who left the hospital earlier, to obtain their views on how the work environment of the hospital can be improved

• Increasing the channels for conflict prevention and resolution within the hospital

• Establishing staff incentive schemes (e.g. salary advance, hospital loans,


43

security for loans, staff SACCO, awards for long service, extra privileges for long service etc.)

• Conducting staff expectations surveys/frontline provider assessment to determine staff expectations and how they can be met by the hospital annually

• Refining the staff appraisal system of the hospital, with the participation of the staff

• Introducing a system of public acknowledgement of staff (e.g. on end-of-year parties, on notice boards etc.)

Strategy 6: Strengthening the human resources management systems

Interventions:• Implementing fully the Human Resource Management Manual• Establishing a Staff Performance Review Board to advise the Management

Team on staff performance• Establishing a Workplace Policy on HIV/AIDS and other chronic illnesses• Establishing a Staff and Patient Safety Policy for the hospital (covering

issues such as hospital-acquired infection, violence, sexual assault etc.)

5.7.3 Strategic objective 3: IMPROVE FINANCIAL MANAGEMENT FOR THE HOSPITAL

The hospital has three main sources of funding which are the user fees; PHC delegated funds and donor support through various programmes such as CRS, World Vision, Friends from abroad etc.

The following strategies shall aim at enabling better mechanisms for mobilizing resources and ensure efficient and effective utilisation in order to achieve the expected goal of the hospital.

Strategy 1: To reduce non-critical expenditure in the hospital

Interventions • Establishment of a Hospital Efficiency Committee (whose role is to

identify, monitor and help to plug areas of wastage in the different aspects of the hospital including utilities, personnel costs, medicines and supplies)


44

• Strengthen the medicines and Therapeutics Committee (MTC)• Conducting regular (e.g.bi-annual) pharmaceutical audits • Conducting cost-consciousness/awareness training sessions for all

hospital staff

Strategy 2: To improve financial management for the hospital

Interventions: • Training accounting and finance staff in the use and maintenance of the

installed accounting package • Implementing fully the hospital’s Financial Management Manual• Networking finance and accounting computers for easy sharing of

information• Appointment of a substantive Internal Auditor for the hospital• Opening and depositing funds on reserve fund accounts for all key

capital items• Investing annual surpluses in high-return ventures (e.g. treasury bills

and fixed deposit accounts)

Strategy 3: Increasing local revenues from different sources for hospital activities

Interventions• Appointing a full-time focal person for fundraising activities for specific

hospital projects (feasibility to be further explored)• Increasing the Bed Occupancy Rate in the private ward through

improved client care both clinical and non-clinical care (which bring in more revenue)

• Regularly review user fees in the hospital to ensure proper costing and revenue collection.

• Ensuring full time availability of a medical officer for private ward patients on weekends.

• Soliciting for capital donations (e.g. medical and office equipment) from alumni and other local individual and corporate friends of the hospital

• Build capacity for the hospital in preparation for the proposed National Health Insurance Scheme (NHIS)


45

• Advocating for an increase of the PHC Conditional Grant (PHC-CG) from the central government (using UCMB, DLG etc)

• Establish Associations that can support the hospital such as: 1) Born or Delivered) in Nkozi Association to support Maternity Services, 2) Friends of Nkozi to support general services.

Strategy 4: To create additional sources of revenues for the hospital (Income generating activities)

Interventions:• Identification of external partners who can support the hospital

financially (to consider friends, research institutions, NGOs, charitable organizations, foreign governments, the Holy See, banks, bilateral and multilateral agencies)

• Writing project proposals for external support • Soliciting for in-kind support from the government and external partners

e.g. staff secondment, volunteer health workers etc.• Reviewing the financial feasibility of taking bank loans for critical capital

investments e.g. construction of hostel which will bring in more financial resources

• Mobilize for an endowment fund for investing in an income generating venture such as students hostels or building a hospital restaurant

5.7.4 Strategic objective 4: IMPROVING GOVERNANCE, MANAGEMENT AND OPERATIONAL SYSTEMS OF THE HOSPITAL

The governance and management structure were described is as described in chapter two. The next five years of implementing the strategic plan shall lay emphasis on the need to strengthen the organisation and operations of the established structure for governance and management of the hospital. This section outlines the objectives and strategies to be used to achieve this objective:

Strategy 1: To increase the effectiveness of the Board of Governors (BOG)

Interventions • Build capacity for leadership and management for the members of the

BOGs. o Conduct induction/orientation of the new members of the new BOG


46

o Conduct a Training Needs Assessment (TNA) for the skills necessary for BOG members

o Training members of the BOG in specific skills necessary to perform their responsibilities

• Develop and implement monitoring and evaluation system on performance of the BOGs.

• Establishing a mechanism for following up the implementation of BOG decisions

Strategy 2: To strengthen the performance of the Management Team

Interventions • Develop and implement monitoring and evaluation system on

performance of the Hospital Management Team• Strengthen capacity for leadership and management among the senior

hospital staff (including the Hospital Management Team).• Providing exposure opportunities (e.g. through study visits, scientific

talks etc. ) to members of the BOG, Management Team, Managing Congregation and staff

• Establishing a mechanism for following up the implementation of Management Team decisions

• Conducting joint retreats between the BOG and Management Team (e.g. one every two years, in which the BOG emphasizes the strategic direction of the hospital and their expectations to the Management Team)

• Conducting retreats of the Management Team members (at least once a year, for team-building and to consider and approve the annual plan of the following year, among others)

Strategy 3: Strengthening the general management systems

Interventions• Review and update the existing hospital constitution• Review and update the existing management hospital manuals:

Employment manual; Financial management manual, etc.)• Develop Quality Assurance Guidelines and Standards (QAGS) for the


47

hospital• Constituting internal support supervision teams • Conduct regular general staff meetings (at least twice a year)• Implement the hospital financial management manual

Strategy 4: Strengthening the equipment, space, plant and infrastructure management systems

Interventions • Developing a Space and Housing policy for the hospital (covering issues

such as acquisition, use, equitable distribution, tenancy, maintenance, master planning, location of buildings, location of activities, etc.)

• Establishing a Space and Housing committee for the hospital • Establishing a policy on the management of equipment and plant

(covering issues such as acquisition, maintenance, use, user-training and disposal)

• Instituting regular inventory, inspection and maintenance of equipment, buildings and plant

• Establish a system for monitoring (reporting, recording and responding to reports of breakages and malfunction) equipment.

5.7.5 Strategic objective 5: IMPROVE HEALTH STANDARDS FOR THE COMMUNITY LIVING IN MAWOKOTA SOUTH HEALTH SUB-DISTRICT (HSD)

Nkozi hospital shall continue to support HSD service delivery. The core functions HSD include planning and budgeting, support supervision, resource mobilisation and coordination of service delivery in the HSD. Nkozi hospital is the referral health facility for the catchment area and beyond.

Strategy 1: Strengthen coordination of HSD services

Interventions • Support and coordinate Government/MoH health programmes in the

HSD.• Conduct regular planning and budgeting meeting.• Coordinate regular (quarterly) HSD performance review meetings• Conduct regular support supervision for the HSD


48

• Strengthen PHD department at Nkozi Hospital (HSD transport, computer, staff, logistical requirements etc.)

Strategy 2: Strengthen Primary Health Care (PHC) activities

Interventions • Coordinate community health focused interventions (immunization,

health education and promotion)• Participate and coordinate in Government health programmes

o Child Days Plus and Mass Immunization campaigns, etc.• Conduct integrated community outreaches• Conduct school health programmes

Strategy 3: Coordinate control of communicable diseases

This shall focus is on reduction of mortality and morbidity rates and improve standard of living among people living in Mawokota South HSD

Interventions:• Operationalise Integrated Community Case Management (ICCM) in the

HSD• Coordinate TB, Malaria and HIV counselling and Testing services • Procure and distribute commodities for prevention of communicable

diseases such the Insecticide Treated Mosquito nets (ITNs) • Improve sanitation services by coordinating effort to improve latrine

coverage and access to safe water.

Strategy 4: Contribute to reduction of maternal and neonatal morbidity and mortality

This strategy shall aim at increasing number of mothers delivering in health units, reduce maternal and neonatal mortality rates and reduce HIV mother-to-child transmission. The following strategies shall be used:

Interventions• Coordinate provision of sexual and reproductive health services within

the community and at the lower level health units.


49

• Coordinate HSD regular (quarterly) maternal and peri-natal death review meetings.

• Strengthen provision of the comprehensive emergence obstetric and neonatal care (EmONC) services.

• Strengthen antenatal and the elimination of mother to child transmission of HIV/AIDS (e-MTCTC) and safe delivery.

Strategy 5: Improve HSD transportation services

The HSD requires vehicle for effective coordination of services at the different levels of service delivery. This include transportation of the sick to the referral HSD health facility and beyond to the bigger referral units depending on the condition of the patient. The lower level health facilities require motor cycles and bicycles.

Interventions • Mobilise resources to procure low fuel consumption ambulance; multi-

purpose HSD vehicle; motor cycles and bicycles for the HSD.• Plan and coordinate regularly maintenance of HSD vehicles.• Plan for availability of sufficient fuel for the vehicles

Strategy 6: Improve HSD quality of services

This strategy shall priorities operationalisation of the health sector quality improvement framework and strategic plan by the MoH. There shall be additional emphasis on improving safety, infection control and waste management.

Interventions • Introduce and operationalise quality improvement (QI) structures

(Quality Improvement Committees/Teams-QIC/Ts and Work Improvement Teams-WITs)

• Coordinate regular quality improvement meetings and reporting • Plan and budget for provision of logistical supplies for QI • Develop workers and patient safety guidelines

o Maintaining well serviced fire extinguisherso Construct a perimeter wall around the hospital


50

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54

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pro-

toco

ls an

d st

anda

rds

Cond

uctin

g an

d uti

lizin

g su

rvey

s on

pati

ents

’ ex-

pect

ation

s

Num

ber o

f sur

-ve

ys c

ondu

cted

Num

ber o

f rec

-om

men

datio

ns

impl

emen

ted

Surv

ey re

sults

/ re

port

Activ

ity re

port

MD

and

ad-

min

istra

tor

Org

anisi

ng o

pen

foru

ms o

n a

quar

-te

r bas

is

Num

ber o

f ope

n fo

rum

s co

nduc

ted

Atten

danc

e lis

t an

d m

inut

esM

D/Ad

min

Cond

uctin

g an

d us

ing

patie

nts’

ex-

perie

nce

surv

eys

to im

prov

e qu

ality

of

car

e

Num

ber o

f sur

-ve

ys c

ondu

cted

Num

ber o

f rec

-om

men

datio

ns

impl

emen

ted

Surv

ey re

sults

/ re

port

Activ

ity re

port

MD

and

ad-

min

istra

tor


56

Cond

uctin

g an

d uti

lizin

g fin

ding

s of

pati

ent s

atisf

ac-

tion

surv

eys

Num

ber o

f sur

-ve

ys c

ondu

cted

Num

ber o

f rec

-om

men

datio

ns

impl

emen

ted

Surv

ey re

sults

/ re

port

Activ

ity re

port

MD

and

ad-

min

istra

tor

Cond

uctin

g te

ch-

nica

l eva

luati

on

of q

ualit

y of

car

e/se

rvic

e pr

ovisi

on

asse

ssm

ent

Num

ber o

f eva

lu-

ation

s ca

rrie

d ou

tEv

alua

tion

re-

port

MD

and

ad-

min

istra

tor

Stra

tegy

4: T

o im

prov

e pa

tient

safe

ty in

the

Hosp

ital

Trai

ning

staff

in

patie

nt sa

fety

Num

ber o

f sta

ff tr

aine

d in

pati

ent

safe

ty

Staff

list

Nur

sing

dire

c-to

r


57

Deve

lopi

ng /

adop

ting

and

impl

emen

ting

pa-

tient

safe

ty p

roto

-co

ls fo

r the

Hos

pi-

tal (

e.g.

for s

urgi

-ca

l pro

cedu

res,

for

vagi

nal d

eliv

ery,

for p

resc

riptio

n pr

actic

es e

tc)

Num

ber o

f saf

ety

prot

ocol

s av

ail-

able

/ disp

laye

d in

th

e ho

spita

l

Prop

ortio

n of

staff

w

ith k

now

ledg

e ab

out t

he s

afet

y pr

otoc

ols

Disp

laye

d pr

o-to

cols

MD

Begi

nnin

g /

stre

ngth

enin

g er

ror r

epor

ting

mec

hani

sms i

n va

rious

hos

pita

l de

part

men

ts

Num

ber o

f inc

i-de

nts

repo

rted

Inci

dent

repo

rt-

ing

form

sAs

sista

nt N

urs-

ing

dire

ctor

Esta

blish

ing

an

Infe

ction

Con

trol

Co

mm

ittee

Infe

ction

Con

trol

Co

mm

ittee

in

plac

e

Min

utes

N

ursin

g di

rec-

tor

Hos

pita

l can

ad

equa

tely

fu

nd c

om-

mitt

ee a

c-tiv

ity

Esta

blish

ing

an

isola

tion

unit

with

-in

the

hosp

ital

Num

ber o

f clie

nts

adm

itted

in th

e iso

latio

n un

it

Isol

ation

uni

t in

plac

eM

DRe

sour

ces

are

avai

labl

e


58

Stra

tegy

5:

Expa

nd o

n th

e Cl

inic

al P

asto

ral C

are

(CPC

) and

Cou

nsel

ing

Trai

ning

staff

in

CPC

(tar

get:

at le

ast 2

staff

tr

aine

d pe

r yea

r)

Num

ber o

f sta

ff tr

aine

d in

CPC

Staff

list

Nur

sing

dire

c-to

r

Trai

ning

staff

in

coun

selli

ng s

er-

vice

s (t

he o

ther

op

tion

is to

recr

uit

qual

ified

cou

nsel

-lo

rs)

Num

ber o

f tra

ined

co

unse

llors

ava

il-ab

le

Staff

list

Nur

sing

dire

c-to

r

Recr

uitin

g a

qual

i-fie

d co

unse

llor

Qua

lified

cou

nsel

-lo

r in

plac

eSt

aff li

stN

ursin

g di

rec-

tor

Recr

uit a

med

ical

so

cial

wor

ker

Med

ical

soc

ial

wor

ker i

n pl

ace

Staff

list

MD

Stra

tegy

6:

Impr

ove

med

ical

reco

rds m

anag

emen

t

Com

pute

rize

the

data

man

agem

ent

syst

em in

all

de-

part

men

ts

Data

man

agem

ent

syst

em c

ompu

t-er

ized

Depa

rtm

enta

l co

mpu

ters

Com

pute

rized

da

ta a

cces

s po

ints

Adm

inist

rato

r an

d Ac

coun

-ta

nt

Com

pute

rs

avai

labl

e,

pack

ages

av

aila

ble,

st

aff tr

aine

d


59

Crea

te n

ew o

ffice

sp

ace

for r

ecor

dsRe

cord

s offi

ce/

depa

rtm

ent i

n pl

ace

Reco

rds

office

Adm

inist

rato

r

Proc

ure

fillin

g ca

bins

Num

ber o

f filli

ng

cabi

nets

pro

cure

dPr

ocur

emen

t do

cum

ents

Inve

ntor

y

Adm

inist

rato

r Re

sour

ces

avai

labl

e

Stra

tegy

7.

Ex

pand

and

furn

ish

hosp

ital i

nfra

stru

ctur

e

Expa

ndin

g th

e M

ater

nity

War

d an

d pu

t The

atre

Mat

erni

ty w

ard

expa

nded

Mat

erni

ty th

e-at

re in

pla

ce

Bed

capa

city

of

mat

erni

ty w

ard

Adm

inist

rato

r De

man

d fo

r m

ater

nity

se

rvic

es

keep

s ris

ing,

fu

nds

be-

com

e av

ail-

able

Cons

truc

tion

of

the

acci

dent

and

em

erge

ncy

unit

Relo

catio

n of

the

ante

nata

l clin

ic t

o cr

eate

spac

e fo

r pa

rkin

g

Acci

dent

and

Em

erge

ncy

unit

in

plac

e

Ante

nata

l clin

ic

relo

cate

d

A& E

Bui

ldin

g

Ante

nata

l clin

ic

in a

diff

eren

t lo

catio

n

Adm

inist

rato

r

Avai

labi

lity

of fu

nds


60

Cons

truc

ting

a ki

tche

n an

d a

shel

-te

r for

pati

ents

’ att

enda

nts

Patie

nts’

she

lter

and

kitc

hen

con-

stru

cted

Patie

nts’

she

lter

Patie

nts’

kitc

hen

Adm

inist

rato

r

Proc

urin

g te

levi

-sio

n se

ts a

nd ra

di-

os fo

r pati

ents

Num

ber o

f TV

sets

an

d ra

dios

pro

-cu

red

Phys

ical

ver

ifi-

catio

nAd

min

istra

tor

Reno

vatin

g th

e HI

V/AI

DS c

linic

HIV

/AID

S cl

inic

re

nova

ted

Reno

vatio

n re

-po

rts

Adm

inist

rato

r

Shel

ter t

he p

ath-

way

s con

necti

ng

war

ds a

nd th

eatr

e

Num

ber o

f pat

h-w

ays

shel

tere

dSh

elte

red

Path

-w

ays

Adm

inist

rato

r Fu

nds

are

avai

labl

e

Cons

truc

t a sh

ade

at th

e ph

arm

acy

Phar

mac

y sh

ade

in p

lace

Cons

truc

tion

re

port

Adm

inist

rato

r Fu

nds

are

avai

labl

e

Dem

arca

te a

pla

ce

for h

ospi

tal p

ark-

ing

Hos

pita

l par

king

ar

ea in

pla

ceDe

signa

ted

park

ing

area

in

plac

e

Adm

inist

rato

r Sp

ace

avai

l-ab

le fo

r reo

r-ga

niza

tion


61

STRA

TEG

IC O

BJEC

TIVE

2:

IM

PRO

VE H

UM

AN R

ESO

URC

ES IN

NKO

ZI H

OSP

ITAL

Stra

tegy

1:

En

sure

ther

e ar

e co

mpe

titive

and

equ

itabl

e sa

larie

s for

staff

of N

kozi

Hos

pita

l

Cond

uctin

g bi

an-

nual

sala

ry a

nd

wor

king

con

di-

tions

surv

eys i

n eq

uiva

lent

insti

-tu

tions

with

in th

e re

gion

just

for

com

paris

on

Num

ber o

f sur

-ve

ys c

ondu

cted

Surv

ey re

port

sH

ospi

tal A

c-co

unta

nt

Cond

uctin

g a

re-

view

of s

alar

ies

ever

y tw

o ye

ars,

w

ith a

vie

w to

in

crea

se a

s and

w

hen

the

mea

ns

allo

w

Prop

ortio

n of

st

affs

who

had

a

sala

ry in

crea

se

Payr

olls

Revi

ew re

port

s

Hos

pita

l Ac-

coun

tant


62

Mak

ing

the

pay-

men

t str

uctu

re o

f th

e ho

spita

l mor

e eq

uita

ble

inte

rnal

-ly

and

ext

erna

lly

Sala

ry s

cale

in

plac

eSa

lary

sca

le

Payr

oll

Hos

pita

l Ac-

coun

tant

Stra

tegy

2:

P

ut in

pla

ce a

ttra

ctive

wor

king

and

wel

fare

term

s and

con

ditio

ns

Esta

blish

ing

a Sp

ace

Man

age-

men

t and

Util

isa-

tion

Polic

y fo

r the

ho

spita

l (w

hich

go

vern

s elig

ibili

ty

and

entit

lem

ent

for a

ccom

mod

a-tio

n an

d offi

ce

spac

e, d

urati

on o

f te

nanc

y, sh

arin

g of

spac

e et

c)

Spac

e m

anag

e-m

ent a

nd u

tiliza

-tio

n po

licy

in p

lace

Polic

y do

cu-

men

tAd

min

istra

tor

Prov

idin

g ho

usin

g fo

r all

key

staff

of

the

hosp

ital w

ho

shou

ld b

e ho

used

on

site

Num

ber o

f key

st

aff h

ouse

d at

the

hosp

ital

Staff

acc

omm

o-da

tion

repo

rtAd

min

istra

tor


63

Prov

idin

g su

itabl

e ho

usin

g fo

r all

hous

ed h

ospi

tal

staff

by

refu

rbish

-in

g ho

uses

that

ne

ed it

Num

ber o

f sta

ff ho

uses

refu

rbish

ed

to b

e m

ore

suit-

able

for t

he st

aff

Phys

ical

ver

ifi-

catio

nAd

min

istra

tor

Mak

ing

stat

utor

y co

ntrib

ution

s to

the

Soci

al S

ecu-

rity

of a

ll st

aff

empl

oyed

by

the

hosp

ital

Prop

ortio

n of

staff

fo

r who

m st

atu-

tory

con

trib

ution

s ar

e m

ade

Staff

list

Payr

oll

Adm

inist

rato

r

Mak

ing

stat

utor

y de

ducti

ons t

o-w

ards

PAY

E fo

r al

l elig

ible

staff

em

ploy

ed b

y th

e ho

spita

l

Prop

ortio

n of

elig

i-bl

e st

aff fo

r who

m

stat

utor

y de

duc-

tions

are

mad

e

Staff

list

Payr

oll

Adm

inist

rato

r


64

Assis

ting

staff

to

obta

in re

gula

r fin

anci

al st

ate-

men

ts o

n th

eir

NSS

F de

posit

s

Prop

ortio

n of

staff

ac

cess

ing

stat

e-m

ents

of t

heir

NSS

F de

posit

s

Verb

al in

terv

iew

Adm

inist

rato

rPr

esen

ce o

f co

mpu

ters

Staff

com

-pu

ter s

kills

an

d w

illin

g-ne

ss is

gua

r-an

teed

Intr

oduc

e an

d im

-pl

emen

t a p

olic

y on

term

inal

ben

e-fit

s for

long

-ser

v-in

g st

aff o

f the

ho

spita

l

Term

inal

ben

efits

po

licy

in p

lace

Bene

fits

polic

yAd

min

istra

tor

Prov

idin

g aff

ord-

able

med

ical

in-

sura

nce

cove

r for

th

e st

aff o

f the

ho

spita

l

Prop

ortio

n of

staff

co

vere

d by

the

med

ical

insu

ranc

e sc

hem

e

Staff

list

Adm

inist

rato

r


65

Com

putin

g an

d co

mm

unic

ating

th

e m

onet

ary

val-

ue o

f all

bene

fits

curr

ently

pro

vide

d by

the

hosp

ital t

o th

e st

aff

Num

ber a

nd

mon

etar

y va

lue

of

bene

fits

prov

ided

by

the

hosp

ital t

o its

staff

Bene

fits

polic

y do

cum

ent

Adm

inist

rato

r

Revi

ewin

g th

e pa

ckag

e of

frin

ge

bene

fits p

rovi

ded

to st

aff e

very

two

year

s with

a v

iew

to

incr

ease

them

an

d ke

ep th

em

attra

ctive

(e.g

. fu

nera

l exp

ense

s,

med

ical

car

e et

c.)

Num

ber o

f rev

iew

s on

frin

ge b

enefi

ts

prov

ided

to th

e st

aff

Revi

ew re

port

s

Bene

fits

polic

y

Adm

inist

rato

r


66

Stra

tegy

3:

Esta

blis

h a

“Tra

ns-g

ener

ation

al”

bond

bet

wee

n th

e ho

spita

l and

the

staff

Esta

blish

ing

a po

l-ic

y on

“Tr

ans-

gen-

erati

onal

” re

la-

tions

hip

betw

een

the

hosp

ital a

nd

staff

(to

ensu

re

that

staff

are

co

mm

itted

for a

lo

ng te

rm, a

nd

to re

war

d st

aff

who

hav

e be

en

com

mitt

ed to

the

hosp

ital f

or a

ver

y lo

ng ti

me)

Num

ber o

f lon

g se

rvin

g st

affs

Num

ber o

f sta

ff be

ing

recr

uite

d

Num

ber o

f sta

ff le

avin

g th

e ho

s-pi

tal

Tran

s-ge

nera

-tio

n po

licy

Staff

att

rition

ra

te

Nur

sing

dire

c-to

r


67

Iden

tifyi

ng a

nd

supp

ortin

g ch

il-dr

en o

f lon

g-se

rv-

ing

staff

in th

eir

educ

ation

(e.g

. w

ith re

com

men

-da

tion

for s

chol

-ar

ship

by

dono

rs,

offer

ing

them

hos

-pi

tal s

chol

arsh

ips

in th

e N

TS, p

ref-

eren

ce in

recr

uit-

men

t as h

ospi

tal

staff

, req

uesti

ng

for s

chol

arsh

ip

from

the

Uni

vers

i-ty

, etc

)

Num

ber o

f lo

ng-s

ervi

ng st

aff

who

se c

hild

ren

are

bene

fiting

from

th

e ho

spita

l sup

-po

rt

Tran

s-ge

nera

-tio

n po

licy

Bene

ficia

ries

regi

ster

Adm

inist

rato

r

Assis

ting

long

se

rvin

g st

aff to

ac

quire

loan

s for

pe

rson

al d

evel

op-

men

t e.g

. hou

se

cons

truc

tion,

m

otor

-veh

icle

pur

-ch

ase

etc.

Num

ber o

f sta

ff w

ho a

cces

sed

loan

s fo

r per

sona

l de

velo

pmen

t with

ho

spita

l ass

istan

ce

Bene

ficia

ries

regi

ster

Adm

inist

rato

r


68

Stra

tegy

4:

D

evel

op d

iffer

ent s

kills

am

ong

staff

thro

ugh

spec

ific

prof

essi

onal

trai

ning

and

dev

elop

men

t pro

gram

mes

Cond

uctin

g Tr

aini

ng N

eeds

As

sess

men

t (TN

A)

annu

ally

Num

ber o

f ass

ess-

men

ts c

arrie

d ou

tAs

sess

men

t re-

port

sN

ursin

g di

rec-

tor

Esta

blish

ing

a St

aff

Deve

lopm

ent P

oli-

cy fo

r the

hos

pita

l (w

hich

cov

ers i

s-su

es li

ke e

ligib

ility

fo

r spo

nsor

ship

/re

com

men

datio

n fo

r spo

nsor

ship

, co

nditi

ons f

or re

c-om

men

datio

n fo

r fu

rthe

r stu

dies

, w

hich

cou

rses

will

be

spon

sore

d et

c)

Staff

Dev

elop

men

t Po

licy

in p

lace

Staff

Dev

elop

-m

ent P

olic

yM

D


69

Prep

arin

g a

Staff

De

velo

pmen

t Pla

n fo

r the

hos

pita

l (w

hich

cov

ers

issue

s lik

e w

hat

skill

s, k

now

ledg

e or

exp

ertis

e ar

e cu

rren

tly re

quire

d fo

r the

hos

pita

l, w

hich

peo

ple

will

be

spon

sore

d ov

er

the

next

5 y

ears

an

d in

wha

t ord

er

etc)

Staff

Dev

elop

men

t Pl

an in

pla

ceSt

aff D

evel

op-

men

t Pla

nAd

min

istra

tor

Deve

lopi

ng a

n in

-te

rnal

Con

tinuo

us

Prof

essio

nal D

e-ve

lopm

ent (

CDP)

pl

an (i

nclu

ding

ex

chan

ge v

isits

)

Inte

rnal

CPD

pla

n in

pla

ceCP

D sc

hedu

le

CPD

plan

MD


70

Cond

uctin

g tr

ain-

ing

to d

evel

op

spec

ific

know

l-ed

ge, a

ttitu

des

and

skill

s am

ong

the

staff

Num

ber o

f tra

in-

ing

sess

ions

con

-du

cted

Num

ber o

f sta

ff tr

aine

d

Trai

ning

regi

ster

MD

Sear

chin

g fo

r an

d id

entif

ying

sh

ort c

ours

es fo

r w

hich

staff

of

the

hosp

ital c

an

be s

ent,

in o

rder

to

dev

elop

loca

l ca

paci

ty (N

B: In

so

me

case

s, th

ere

are

som

e sh

ort

cour

ses

whi

ch

have

a s

chol

arsh

ip

alre

ady

attac

hed

– e.

g. U

CMB

cour

ses,

Stic

hting

Po

rticu

s, a

Dut

ch

orga

nisa

tion,

Num

ber o

f sho

rt

cour

ses

supp

orte

d by

the

hosp

ital

Certi

ficat

es o

f gr

adua

tes

Bene

ficia

ry li

st

MD

and

Ad-

min

istra

tor


71

whi

ch o

ffers

sch

ol-

arsh

ips

mai

nly

for

relig

ious

peo

ple

for b

ache

lors

and

m

aste

rs d

egre

es.

The

hosp

ital c

ould

ta

p in

to th

is to

de

velo

p a

num

-be

r of G

gogo

nya

siste

rs in

to h

ealth

pr

ofes

siona

ls w

ho

can

carr

y m

ore

resp

onsib

ilitie

s in

th

e ho

spita

l.


72

Prov

idin

g st

aff

with

opp

ortu

nitie

s fo

r sha

ring

info

r-m

ation

esp

ecia

lly

on re

turn

from

co

urse

s in

whi

ch

they

repr

esen

ted

the

hosp

ital (

in-

clud

ing

exch

ange

vi

sits)

Num

ber o

f ses

-sio

ns p

rese

nted

by

staff

retu

rnin

g fr

om s

hort

cou

rs-

es a

nd w

orks

hops

CPD

regi

ster

MD

Deve

lopi

ng a

pol

-ic

y on

Men

torin

g fo

r the

hos

pita

l (N

B: T

his m

ay

need

trai

ning

of

staff

in m

ento

ring)

Hos

pita

l men

-to

rshi

p po

licy

in

plac

e

Staff

/ men

tors

lis

tAd

min

istra

tor

Stra

tegy

5:

Det

erm

ine

the

actu

al w

orkl

oad-

base

d re

quire

men

ts fo

r sta

ff


73

Dete

rmin

e ac

tivity

st

anda

rds (

activ

-iti

es a

nd ti

me

it ta

kes t

he st

aff to

ex

ecut

e th

em)

Num

ber o

f ser

-vi

ces

offer

ed in

ea

ch d

epar

tmen

t

Num

ber o

f acti

v-iti

es u

nder

take

n fo

r eac

h se

rvic

e

Dura

tion

of e

ach

activ

ity

Activ

ity st

an-

dard

sM

D an

d N

urs-

ing

dire

ctor

Dete

rmin

e th

e an

-nu

al w

orkl

oad

Tota

l num

ber o

f in

divi

dual

s ac

cess

-in

g ea

ch s

ervi

ce in

a

year

HM

IS a

nnua

l re

port

Depa

rtm

enta

l re

gist

ers

MD

and

Nur

s-in

g di

rect

or


74

Dete

rmin

ing

the

actu

al st

affing

re-

quire

men

ts b

asin

g on

the

wor

kloa

d le

vels

usin

g a

suita

ble

appr

oach

(e

.g. W

ISN

met

h-od

)

Num

ber o

f sta

ff re

quire

d in

eac

h de

part

men

t

WIS

N re

port

MD

and

Nur

s-in

g di

rect

or

Dist

ributi

ng a

vail-

able

staff

equ

ita-

bly

on th

e ba

sis

of w

orkl

oad

e.g.

du

ring

rost

erin

g of

nu

rses

Prop

ortio

n of

po

sition

s fil

led

by

qual

ified

staff

in

each

dep

artm

ent

Duty

pla

nsM

D an

d N

urs-

ing

dire

ctor

Stra

tegy

6:

Impr

ove

staff

rete

ntion

with

in N

kozi

hos

pita

l

Cond

uctin

g ex

it in

terv

iew

s with

all

depa

rting

staff

to

dete

rmin

e th

eir

caus

es o

f dep

ar-

ture

and

how

such

re

ason

s can

be

addr

esse

d fo

r re-

mai

ning

staff

Num

ber o

f sta

ff le

ft th

e or

gani

za-

tion

Num

ber o

f exi

t in

terv

iew

s co

n-du

cted

Staff

list

Inte

rvie

w re

-po

rts

Nur

sing

dire

c-to

r


75

Cond

uctin

g po

st-e

xit i

nter

-vi

ews w

ith st

aff

who

left

the

hos-

pita

l ear

lier,

to

obta

in th

eir v

iew

s on

how

the

wor

k en

viro

nmen

t of

the

hosp

ital c

an

be im

prov

ed

Num

ber o

f exi

t in

terv

iew

s co

n-du

cted

Inte

rvie

w re

-po

rts

Nur

sing

dire

c-to

r

Incr

easin

g th

e ch

anne

ls fo

r con

-fli

ct p

reve

ntion

an

d re

solu

tion

with

in th

e ho

spita

l

Num

ber o

f cha

n-ne

ls fo

r con

flict

pr

even

tion

and

reso

lutio

n

Flow

cha

rts

Org

anog

ram

Adm

inist

rato

r

Esta

blish

ing

staff

in

centi

ve sc

hem

es

(e.g

. sal

ary

ad-

vanc

e, h

ospi

tal

loan

s, se

curit

y fo

r lo

ans,

staff

SAC

-CO

, aw

ards

for

long

serv

ice,

ext

ra

priv

ilege

s for

long

se

rvic

e et

c)

Num

ber o

f sta

ff in

centi

ve s

chem

es

avai

labl

e

List

of s

chem

esH

ospi

tal A

c-co

unta

nt


76

Cond

uctin

g st

aff

expe

ctati

ons s

ur-

veys

/fro

ntlin

e pr

o-vi

der a

sses

smen

t to

det

erm

ine

staff

ex

pect

ation

s and

ho

w th

ey c

an b

e m

et b

y th

e ho

spi-

tal a

nnua

lly

Num

ber o

f sta

ff sa

tisfa

ction

sur

-ve

ys c

ondu

cted

Surv

ey re

port

sN

ursin

g di

rec-

tor

Refin

ing

the

staff

ap

prai

sal s

yste

m

of th

e ho

spita

l, w

ith th

e pa

rtici

pa-

tion

of th

e st

aff

Staff

app

raisa

l fo

rms

in p

lace

Num

ber o

f hos

pi-

tal s

taff

appr

aise

d

Staff

app

raisa

l fo

rm

Fille

d ap

prai

sal

form

s

MD

and

Nur

s-in

g di

rect

or

Intr

oduc

ing

a sy

s-te

m o

f pub

lic a

c-kn

owle

dgem

ent o

f st

aff (e

.g. o

n en

d-of

-yea

r par

ties,

on

notic

e bo

ards

etc

)

Syst

em o

f pub

lic

ackn

owle

dgem

ent

in p

lace

Num

ber o

f sta

ff ac

know

ledg

ed

publ

icly

Syst

em in

pla

ce

MD

and

Ad-

min

istra

tor


77

STRA

TEG

IC O

BJEC

TIVE

3: E

NSU

RE S

UST

AIN

ABLE

FIN

ANCI

AL B

ASE

FOR

THE

HOSP

ITAL

Stra

tegy

1:

Re

duce

non

-criti

cal e

xpen

ditu

re in

the

hosp

ital

Esta

blish

men

t of

a Ho

spita

l Effi

-ci

ency

Com

mitt

ee

(who

se ro

le is

to

iden

tify,

mon

itor

and

help

to p

lug

area

s of w

asta

ge

in th

e di

ffere

nt

aspe

cts o

f the

ho

spita

l inc

ludi

ng

utiliti

es, p

erso

nnel

co

sts,

med

icin

es

and

supp

lies)

Hos

pita

l Effi

cien

cy

Com

mitt

ee in

pla

ce

Num

ber o

f mee

tings

he

ld b

y th

e co

mm

it-te

e

Num

ber o

f are

as o

f w

asta

ge id

entifi

ed

Hos

pita

l Effi

-ci

ency

Com

-m

ittee

Min

utes

Adm

inist

rato

r

Ope

ratio

nalis

ing

the

med

icin

es a

nd

Ther

apeu

tics C

om-

mitt

ee (M

TC)

Com

mitt

ee in

pla

ce

Num

ber o

f mee

tings

he

ld

Com

positi

on

and

Min

utes

MD


78

Cond

uctin

g re

gu-

lar (

e.g.

bi-a

nnua

l) ph

arm

aceu

tical

au

dits

Num

ber o

f pha

rma-

ceuti

cal a

udits

car

ried

out

Audi

t re-

port

sM

D

Cond

uctin

g co

st-c

onsc

ious

-ne

ss/a

war

enes

s tr

aini

ng se

ssio

ns

for a

ll ho

spita

l st

aff

Num

ber o

f cos

t-con

-sc

ious

ness

/aw

aren

ess

trai

ning

ses

sions

hel

d

Atten

danc

e lis

t

CPD

regi

ster

MD

Stra

tegy

2:

Impr

ove

finan

cial

man

agem

ent

Inst

allin

g an

ac-

coun

ting

pack

age

suita

ble

for t

he

need

s of t

he h

os-

pita

l in

rele

vant

co

mpu

ters

with

a

suita

ble

back

-up

syst

em

Acco

untin

g pa

ckag

e in

stal

led

Back

up sy

stem

in

plac

e

Acco

untin

g pa

ckag

e

Back

up sy

s-te

m

Hos

pita

l Ac-

coun

tant


79

Trai

ning

acc

ount

-in

g an

d fin

ance

st

aff in

the

use

and

mai

nten

ance

of

the

inst

alle

d ac

-co

untin

g pa

ckag

e

Num

ber o

f sta

ff tr

aine

d in

use

and

m

aint

enan

ce o

f the

in

stal

led

acco

untin

g pa

ckag

e

Staff

inte

r-vi

ews

Hos

pita

l Ac-

coun

tant

Impl

emen

ting

fully

the

hosp

ital’s

Fi

nanc

ial M

anag

e-m

ent M

anua

l

Num

ber o

f cop

ies

of

the

man

ual a

vaila

ble

Copy

of t

he

Fina

ncia

l M

anag

e-m

ent M

an-

ual

Hos

pita

l Ad-

min

istra

tor

Net

wor

king

fin

ance

and

ac-

coun

ting

com

put-

ers f

or e

asy

shar

-in

g of

info

rmati

on

Com

pute

r net

wor

k co

nnec

ting

finan

ce

and

acco

unts

dep

art-

men

t in

plac

e

Com

pute

r ne

twor

k

Repo

rts

Hos

pita

l Ac-

coun

tant

Appo

intm

ent o

f a

subs

tanti

ve In

ter-

nal A

udito

r for

the

hosp

ital

Inte

rnal

hos

pita

l aud

i-to

r in

plac

eIn

tern

al a

u-di

tor

Adm

inist

rato

r


80

Ope

ning

and

de-

positi

ng fu

nds o

n re

serv

e fu

nd a

c-co

unts

for a

ll ke

y ca

pita

l ite

ms

Amou

nt o

f fun

ds

depo

sited

on

the

re-

serv

e fu

nd a

ccou

nt(s

)

Bank

stat

e-m

ents

Cash

flow

st

atem

ent

Hos

pita

l Ac-

coun

tant

Inve

sting

ann

u-al

surp

luse

s in

high

-ret

urn

ven-

ture

s (e.

g. tr

ea-

sury

bill

s and

fixe

d de

posit

acc

ount

s)

Tota

l of a

nnua

l sur

-pl

uses

Amou

nt o

f fun

ds in

-ve

sted

in h

igh

retu

rn

vent

ures

Bank

stat

e-m

ents

Cash

flow

st

atem

ent

Hos

pita

l Ac-

coun

tant

Stra

tegy

3:

Incr

easi

ng lo

cal r

even

ues f

rom

diff

eren

t sou

rces

for h

ospi

tal a

ctivi

ties

Appo

intin

g a

full-

time

foca

l per

son

for f

undr

aisin

g ac

-tiv

ities

for s

peci

fic

hosp

ital p

roje

cts

(feas

ibili

ty to

be

furt

her e

xplo

red)

Full-

time

foca

l per

son

for f

undr

aisin

g ac

tivi-

ties

in p

lace

Amou

nt o

f fu

nds

raise

dH

ospi

tal A

c-co

unta

nt


81

Incr

easin

g th

e be

d oc

cupa

ncy

rate

in th

e pr

ivat

e w

ard

thro

ugh

im-

prov

ed c

lient

car

e bo

th c

linic

al a

nd

non

clin

ical

car

e (w

hich

brin

g in

m

ore

reve

nue)

Num

ber o

f ind

ivid

-ua

ls ac

cess

ing

in-

patie

nt s

ervi

ces

on

priv

ate

war

d

Bed

occu

-pa

ncy

rate

fo

r priv

ate

war

d

MD

and

Nur

s-in

g di

rect

or

Incr

easin

g th

e ch

arge

s in

the

priv

ate

war

d (a

f-te

r im

prov

ing

the

qual

ity o

f ser

vice

s in

that

war

d)

Prop

ortio

n of

in-

crem

ent o

f pati

ent

char

ges

on p

rivat

e w

ard

Priv

ate

pa-

tient

s pr

ice

list

Hos

pita

l Ac-

coun

tant

Ensu

ring

full

time

avai

labi

lity

of a

m

edic

al o

ffice

r fo

r priv

ate

war

d pa

tient

s ev

en o

n w

eeke

nds.

med

ical

offi

cer f

or

priv

ate

war

d p

atien

ts

in p

lace

Doct

ors

duty

ro

taM

D


82

Intr

oduc

e 14

” co

-lo

ur T

Vs in

the

in-

divi

dual

room

s of

the

priv

ate

war

d be

ginn

ing

with

2

room

s as a

n ex

-pe

rimen

t to

see

whe

ther

the

de-

man

d in

crea

ses)

Num

ber o

f 14’

’ co-

lour

TV

sets

pro

cure

dTV

set

s

War

d in

ven-

tory

Adm

inist

rato

r

Solic

iting

for c

api-

tal d

onati

ons (

e.g.

m

edic

al a

nd o

ffice

eq

uipm

ent)

from

al

umni

and

oth

er

loca

l ind

ivid

ual

and

corp

orat

e fr

iend

s of t

he h

os-

pita

l

Num

ber o

f cap

ital d

o-na

tions

rece

ived

Rece

ipt d

oc-

umen

tsH

ospi

tal A

c-co

unta

nt


83

Positi

onin

g th

e ho

spita

l to

prov

ide

the

serv

ice

for t

he

prop

osed

Nati

onal

He

alth

Insu

ranc

e (N

HI) [

This

re-

quire

s tha

t the

ho

spita

l im

prov

es

its q

ualit

y of

car

e to

a le

vel w

here

it

can

be a

ccre

dite

d to

pro

vide

the

ser-

vice

s.].

The

hosp

ital a

ccre

dit-

ed to

pro

vide

ser

vice

fo

r NH

I

Accr

edita

-tio

n re

port

MD

and

Ad-

min

istra

tor

Advo

catin

g fo

r an

incr

ease

of t

he

PHC

Cond

ition

al

Gran

t (PH

C-CG

) fr

om th

e ce

ntra

l go

vern

men

t (us

ing

UCM

B, D

LG e

tc)

Perc

enta

ge in

crea

se

in P

HC

cond

ition

al

Gra

nt

Inco

me

stat

emen

tH

ospi

tal A

c-co

unta

nt


84

Esta

blish

Ass

ocia

-tio

ns th

at c

an su

p-po

rt th

e ho

spita

l su

ch a

s: 1

) Bor

n or

Del

iver

ed) i

n N

kozi

Asso

ciati

on

to su

ppor

t Mat

er-

nity

Ser

vice

s, 2

) Fr

iend

s of N

kozi

to su

ppor

t gen

eral

se

rvic

es.

Num

ber o

f Ass

ocia

-tio

ns e

stab

lishe

d to

su

ppor

t the

hos

pita

l

Asso

ciati

ons

regi

ster

Supp

ort r

e-po

rts

Adm

inist

rato

r

Stra

tegy

4:

M

obili

ze re

sour

ces f

or c

ontin

ued

inco

me

gene

ratio

n an

d su

stai

nabi

lity

Iden

tifica

tion

of

exte

rnal

par

tner

s w

ho c

an su

ppor

t th

e ho

spita

l fina

n-ci

ally

(to

cons

ider

fr

iend

s, re

sear

ch

insti

tutio

ns, N

GOs,

ch

arita

ble

orga

ni-

satio

ns,

Num

ber o

f par

tner

s fin

anci

ally

sup

porti

ng

the

hosp

ital

Hos

pita

l re-

port

s

List

of p

art-

ners

Hos

pita

l Ac-

coun

tant


85

fore

ign

gove

rn-

men

ts, t

he H

oly

See,

ban

ks, b

ilat-

eral

and

mul

tilat

-er

al a

genc

ies)

Writi

ng p

roje

ct

prop

osal

s for

ex-

tern

al su

ppor

t

Num

ber o

f pro

ject

pr

opos

als

writt

enPr

opos

al

docu

men

tsAd

min

istra

tor

Nur

sing

dire

c-to

r

Solic

iting

for i

n-ki

nd su

ppor

t fro

m

the

gove

rnm

ent

and

exte

rnal

pa

rtne

rs e

.g. s

taff

seco

ndm

ent,

volu

ntee

r hea

lth

wor

kers

etc

Num

ber o

f sta

ff se

cond

ed b

y go

vern

-m

ent

Num

ber o

f vol

unte

er

heal

th w

orke

rs

Staff

list

MD

and

Nur

s-in

g di

rect

or


86

Mob

ilize

for a

n en

dow

men

t fun

d fo

r inv

estin

g in

an

inco

me

gene

ratin

g ve

ntur

e su

ch a

s st

uden

ts h

oste

ls or

bui

ldin

g a

hos-

pita

l res

taur

ant

Endo

wm

ent f

und

in

plac

e

Num

ber o

f IG

A in

pl

ace

IGAs

Cash

flow

st

atem

ent

Adm

inist

rato

r an

d

Hos

pita

l Ac-

coun

tant

STRA

TEG

IC O

BJEC

TIVE

4: I

MPR

OVI

NG

GO

VERN

ANCE

, MAN

AGEM

ENT

AND

OPE

RATI

ON

AL S

YSTE

MS

OF

THE

HOSP

ITAL

Stra

tegy

1:

Incr

ease

the

effec

tiven

ess o

f the

Boa

rd o

f Gov

erno

rs (B

OG

)

Cond

uctin

g in

duc-

tion/

orie

ntati

on o

f th

e ne

w m

embe

rs

of th

e ne

w B

OG

Num

ber o

f new

m

embe

rs o

f BO

G in

-du

cted

Indu

ction

re

port

Adm

inist

rato

r

Deve

lopi

ng a

nd

impl

emen

ting

loca

l and

app

ro-

pria

te b

ench

mar

k cr

iteria

for m

oni-

torin

g th

e pe

rfor

-m

ance

of t

he B

OG

Num

ber o

f crit

eria

de

velo

ped

and

impl

e-m

ente

d

Crite

ria in

pl

ace

Adm

inist

rato

r


87

Cond

uctin

g a

Trai

ning

Nee

ds

Asse

ssm

ent (

TNA)

fo

r the

skill

s nec

-es

sary

for B

OG

mem

bers

Num

ber o

f TN

As c

ar-

ried

out

TNA

repo

rts

Adm

inist

rato

r

Trai

ning

mem

bers

of

the

BOG

in

spec

ific

skill

s nec

-es

sary

to p

erfo

rm

thei

r res

pons

ibil-

ities

Num

ber o

f mem

bers

of

the

BOG

trai

ned

Trai

ning

cer

-tifi

cate

sAd

min

istra

tor

Deve

lopi

ng a

nd

appl

ying

crit

eria

to

mon

itor t

he p

er-

form

ance

of i

ndi-

vidu

al m

embe

rs o

f th

e BO

G

Perf

orm

ance

crit

eria

in

pla

ce

Perf

orm

ance

re

port

Adm

inist

rato

r


88

Esta

blish

ing

a m

echa

nism

for

follo

win

g up

the

impl

emen

tatio

n of

BO

G de

cisio

ns

Num

ber o

f acti

on

poin

ts fr

om B

OG

m

eetin

gs im

plem

ent-

ed Follo

w u

p m

echa

nism

in

pla

ce

Min

utes

Hos

pita

l re-

port

s

Adm

inist

rato

r

Harm

onisi

ng th

e un

ders

tand

ing

of th

e ro

les a

nd

rela

tions

hips

of

the

Ow

ner,

the

Boar

d of

Tru

stee

s,

the

Boar

d of

Gov

-er

nors

, the

Man

-ag

emen

t and

the

Man

agin

g Co

n-gr

egati

on a

mon

g th

ese

diffe

rent

st

akeh

olde

rs

Polic

y do

cum

ent o

n ro

les

and

rela

tion-

ship

s of

the

diffe

rent

st

akeh

olde

rs

Polic

y do

cu-

men

tAd

min

istra

tor


89

Stra

tegy

2:

Str

engt

hen

the

role

of t

he M

anag

ing

Cong

rega

tion

in su

ppor

ting

the

hosp

ital

Deve

lopi

ng a

nd

appl

ying

ben

ch-

mar

k cr

iteria

for

mon

itorin

g th

e ro

le o

f the

Man

ag-

ing

Cong

rega

tion

Benc

hmar

k c

riter

ia

in p

lace

Crite

ria

Med

ical

Dire

c-to

r

Assis

ting

the

Man

agin

g Co

ngre

-ga

tion

in c

apac

ity

deve

lopm

ent t

o en

able

them

to

fulfi

ll th

eir r

ole

Man

agin

g Co

ngre

ga-

tion

capa

city

dev

el-

opm

ent p

lan

in p

lace

Deve

lop-

men

t pla

nAd

min

istra

tor

Stra

tegy

3:

Str

engt

hen

the

perf

orm

ance

of t

he M

anag

emen

t Tea

m

Deve

lopi

ng a

nd

appl

ying

ben

ch-

mar

k cr

iteria

for

mon

itorin

g th

e pe

rfor

man

ce o

f th

e M

anag

emen

t Te

am

Benc

hmar

k c

riter

ia

in p

lace

Perf

orm

ance

re

port

MD


90

Deve

lopi

ng a

nd

appl

ying

ben

ch-

mar

k cr

iteria

for

mon

itorin

g th

e pe

rfor

man

ce o

f th

e in

divi

dual

m

embe

rs o

f the

M

anag

emen

t Te

am

Benc

hmar

k c

riter

ia

in p

lace

Perf

orm

ance

re

port

Adm

inist

rato

r

Deve

lopi

ng m

an-

agem

ent s

kills

am

ong

seni

or h

os-

pita

l sta

ff (in

clud

-in

g M

anag

emen

t Te

am m

embe

rs) t

o de

velo

p ca

paci

ty

for m

anag

emen

t ro

les i

n th

e ho

s-pi

tal

Num

ber o

f sta

ff tr

aine

d w

ith tr

aini

ng

in m

anag

emen

t of

hosp

ital s

ervi

ces

Staff

list

Trai

ning

cer

-tifi

cate

s

Adm

inist

rato

r


91

Prov

idin

g ex

po-

sure

opp

ortu

ni-

ties (

e.g.

thro

ugh

stud

y vi

sits,

sci-

entifi

c ta

lks e

tc)

to m

embe

rs o

f th

e BO

G, M

an-

agem

ent T

eam

, M

anag

ing

Cong

re-

gatio

n an

d st

aff

Num

ber o

f mem

bers

be

nefiti

ng fo

r exp

o-su

re o

ppor

tuni

ties

Expo

sure

re-

port

s Ad

min

istra

tor

Esta

blish

ing

a m

echa

nism

for

follo

win

g up

the

impl

emen

tatio

n of

Man

agem

ent

Team

dec

ision

s

Follo

w u

p m

echa

nism

in

pla

ceIm

plem

enta

-tio

n re

port

sM

edic

al D

irec-

tor


92

Cond

uctin

g jo

int

retr

eats

bet

wee

n th

e BO

G an

d M

anag

emen

t Te

am (e

.g. o

ne

ever

y tw

o ye

ars,

in

whi

ch th

e BO

G em

phas

izes t

he

stra

tegi

c di

recti

on

of th

e ho

spita

l and

th

eir e

xpec

tatio

ns

to th

e M

anag

e-m

ent T

eam

)

Num

ber o

f joi

nt re

-tr

eats

hel

d be

twee

n th

e H

MT

and

BOG

Hos

pita

l re-

port

s

Retr

eat r

e-po

rts

Adm

inist

rato

r

Cond

uctin

g re

-tr

eats

of t

he M

an-

agem

ent T

eam

m

embe

rs (a

t lea

st

once

a y

ear,

for

team

-bui

ldin

g an

d to

con

sider

an

d ap

prov

e th

e an

nual

pla

n of

the

follo

win

g ye

ar,

amon

g ot

hers

)

Num

ber o

f HM

T re

-tr

eats

con

duct

edRe

trea

t re-

port

sM

D


93

Stra

tegy

4:

Str

engt

heni

ng th

e ge

nera

l man

agem

ent s

yste

ms

Revi

ewin

g (a

nd

upda

ting

if ne

ed

be) t

he e

xisti

ng

hosp

ital c

onsti

tu-

tion

Num

ber o

f am

end-

men

ts d

iscus

sed

and

incl

uded

in th

e ho

spi-

tal c

hart

er

Up-

to-d

ate

hosp

ital

char

ter

MD

Revi

ewin

g (a

nd if

ne

ed b

e up

datin

g)

the

existi

ng m

anu-

als o

f the

hos

pita

l e.

g. e

mpl

oym

ent

man

ual,

finan

cial

m

anag

emen

t m

anua

l etc

)

Up

to d

ate

man

uals

in p

lace

Up-

to-d

ate

man

uals

MD

Esta

blish

ing

Qua

l-ity

Ass

uran

ce

Guid

elin

es a

nd

Stan

dard

s (Q

AGS)

fo

r the

hos

pita

l

QAG

S in

pla

ceQ

AG

QAS

MD


94

Cons

tituti

ng In

ter-

nal S

uppo

rt S

uper

-vi

sion

Team

s

Inte

rnal

sup

ervi

sion

team

s in

pla

ceSu

perv

ision

sc

hedu

le

Supe

rvisi

on

repo

rts

Nur

sing

dire

c-to

r and

Ad-

min

istra

tor

Hold

ing

regu

lar

open

(tow

n ha

ll)

gene

ral s

taff

mee

t-in

gs (a

t lea

st tw

ice

a ye

ar)

Num

ber o

f ope

n ge

n-er

al st

aff m

eetin

gs

held

Min

utes

Atten

danc

e lis

t

MD


95

Stra

tegy

5:

Str

engt

heni

ng th

e eq

uipm

ent,

spac

e, p

lant

and

infr

astr

uctu

re m

anag

emen

t sys

tem

s

Deve

lopi

ng a

Sp

ace

and

Hous

-in

g po

licy

for t

he

hosp

ital (

cove

ring

issue

s suc

h as

ac

quisi

tion,

use

, eq

uita

ble

dist

ri-bu

tion,

tena

ncy,

mai

nten

ance

, m

aste

r pla

nnin

g,

loca

tion

of b

uild

-in

gs, l

ocati

on o

f ac

tiviti

es e

tc)

Spac

e an

d H

ousin

g po

licy

in p

lace

Spac

e an

d H

ousin

g po

licy

Adm

inist

rato

r St

aff a

ctive

ly

enga

ge a

nd

cham

pion

po

licy

re-

view

s as

w

ell.

Esta

blish

ing

a Sp

ace

and

Hous

-in

g co

mm

ittee

for

the

hosp

ital

Spac

e an

d H

ousin

g co

mm

ittee

in p

lace

Num

ber o

f mee

tings

he

ld

Spac

e an

d H

ousin

g co

m-

mitt

ee

Min

utes

Adm

inist

rato

r H

ospi

tal c

an

adeq

uate

ly

fund

com

-m

ittee

ac-

tivity


96

Esta

blish

ing

a po

licy

on th

e m

an-

agem

ent o

f equ

ip-

men

t and

pla

nt

(cov

erin

g iss

ues

such

as a

cqui

si-tio

n, m

aint

enan

ce,

use,

use

r-tra

inin

g an

d di

spos

al)

Equi

pmen

t and

pla

nt

polic

y in

pla

ceEq

uipm

ent a

nd

plan

t pol

icy

Adm

inist

rato

r St

affs

activ

e-ly

eng

aged

an

d ch

am-

pion

pol

icy

revi

ews

as

wel

l.

Insti

tutin

g re

gula

r in

vent

ory,

insp

ec-

tion

and

mai

nte-

nanc

e of

equ

ip-

men

t, bu

ildin

gs

and

plan

t

Num

ber o

f up-

to-

date

dep

artm

enta

l in

vent

orie

s

Depa

rtm

enta

l in

vent

ory

Insp

ectio

n re

-po

rts

Adm

inist

rato

r

Esta

blish

a sy

stem

fo

r the

repo

rting

, re

cord

ing

and

resp

ondi

ng to

re-

port

s of b

reak

ages

an

d m

alfu

nctio

n

Brea

kage

s an

d m

al-

func

tion

Repo

rting

sy

stem

in p

lace

Brea

kage

s an

d m

alfu

nctio

n re

port

s

Adm

inist

rato

r


97

Stra

tegy

6:

Str

engt

heni

ng th

e hu

man

reso

urce

s man

agem

ent s

yste

ms

Impl

emen

ting

fully

the

Hum

an

Reso

urce

Man

age-

men

t Man

ual

Esta

blish

ing

a St

aff P

erfo

rman

ce

Revi

ew B

oard

to

advi

se th

e M

an-

agem

ent T

eam

on

staff

per

form

ance

Num

ber o

f Sta

ff Pe

r-fo

rman

ce R

evie

ws

cond

ucte

d

Staff

Per

for-

man

ce R

e-po

rts

MD

Adm

inis-

trat

or

Esta

blish

ing

a W

orkp

lace

Pol

icy

on H

IV/A

IDS

and

othe

r chr

onic

ill-

ness

es

Hos

pita

l HIV

/AID

S po

licy

in p

lace

Hos

pita

l HIV

/AI

DS p

olic

yM

D

Esta

blish

ing

a St

aff

and

Patie

nt S

afe-

ty P

olic

y fo

r the

ho

spita

l (co

verin

g iss

ues s

uch

as h

os-

pita

l-acq

uire

d in

-fe

ction

, vio

lenc

e,

sexu

al a

ssau

lt et

c)

Staff

and

Pati

ent S

afe-

ty P

olic

y in

pla

ceSt

aff a

nd P

a-tie

nt S

afet

y Po

licy

MD


98

Stra

tegy

7:

Str

eam

linin

g pr

ocur

emen

t and

con

trac

ting

proc

edur

es

Form

ing

a Te

nder

-in

g Co

mm

ittee

Tend

erin

g Co

mm

ittee

in

pla

ce

Num

ber o

f mee

tings

he

ld

Tend

erin

g Co

mm

ittee

Min

utes

Adm

inist

rato

r

Revi

ewin

g pu

r-ch

ase

pric

es e

very

six

mon

ths

Num

ber o

f pur

chas

e pr

ices

revi

ews

carr

ied

out

Revi

ew re

-po

rtH

ospi

tal A

c-co

unta

nt

Issu

ing

Loca

l Pur

-ch

ase

Ord

ers o

n al

l pur

chas

es

Num

ber o

f loc

al p

ur-

chas

es

Num

ber o

f LPO

s is-

sued

Cash

boo

k

LPO

file

Hos

pita

l Ac-

coun

tant


99

Raisi

ng G

oods

Re-

ceiv

ed N

ote

on a

ll pu

rcha

ses

Num

ber o

f pur

chas

es

mad

e

Goo

ds R

ecei

ved

Not

e

Cash

boo

k

Goo

ds R

e-ce

ived

Not

e du

plic

ates

Hos

pita

l Ac-

coun

tant

Insp

ectin

g al

l the

ite

ms p

urch

ased

ea

ch ti

me

of d

e-liv

ery

Num

ber o

f pur

chas

es

mad

e

Num

ber o

f ins

pec-

tions

car

ried

out

Cash

boo

k

Insp

ectio

n re

port

s

Hos

pita

l Ac-

coun

tant

Taki

ng st

ock

mon

thly

Num

ber o

f tim

es

stoc

k-ta

king

has

bee

n ca

rrie

d ou

t

Stoc

k ca

rds

Hos

pita

l Ac-

coun

tant

Cond

uctin

g m

edi-

cine

s and

supp

lies

stoc

k-ou

t che

ckin

g qu

arte

rly

Num

ber o

f tim

es

stoc

k-ou

t che

ckin

g ha

s be

en c

arrie

d ou

t

Stoc

k bo

okH

ospi

tal A

c-co

unta

nt


100

STRA

TEG

IC O

BJEC

TIVE

5:

CO

NTR

IBU

TE T

O IM

PRO

VED

HEAL

TH F

OR

THE

PEO

PLE

LIVI

NG

IN M

AWO

KOTA

SO

UTH

HEA

LTH

SD Stra

tegy

1:

Str

engt

hen

Prim

ary

Heal

th C

are

(PHC

) Dep

artm

ent

Cond

uct i

nteg

rat-

ed c

omm

unity

ou

trea

ches

Num

ber o

f out

-re

ache

s co

nduc

t-ed

Out

reac

h sc

hedu

les

Out

reac

h re

-po

rts

MD

Cond

uct s

choo

l he

alth

pro

-gr

amm

es

Num

ber o

f sch

ool

heal

th p

rogr

ams

impl

emen

ted

Scho

ol h

ealth

pr

ogra

m s

ched

-ul

e

Num

ber o

f ben

-efi

tting

sch

ools

MD

Cove

r im

mun

iza-

tion

expe

nses

Num

ber o

f pl

anne

d im

mun

i-za

tion

outr

each

es

carr

ied

out

Out

reac

h sc

hedu

le

Out

reac

h re

-po

rts

MD


101

Parti

cipa

te in

Chi

ld

Days

Plu

s(CD

P)

and

Mas

s Im

mun

i-za

tion

Num

ber o

f CDP

ac

tiviti

es c

arrie

d ou

t

Mas

s im

mun

iza-

tion

cam

paig

ns

carr

ied

out

CDP

repo

rt

Mas

s im

mun

iza-

tion

repo

rts

MD

Stra

tegy

2 :

Pre

vent

spre

ad o

f com

mun

icab

le d

isea

ses

Inno

vate

stra

t-eg

ies t

o m

ake

mal

aria

trea

tmen

t m

ore

acce

ssib

le to

th

e co

mm

uniti

es

Num

ber o

f str

ate-

gies

inno

vate

dM

alar

ia tr

eat-

men

t cha

rges

Patie

nt s

urve

ys

Inno

vatio

ns re

-po

rt

MD

Cond

uct R

CT a

nd

VCT

for H

IVN

umbe

r of i

ndi-

vidu

als

test

edVC

T re

port

H

IV/A

IDS

clin

ic

Coor

dina

tor


102

Cond

uct H

ealth

Ed

ucati

on o

n Pr

even

tion

and

cont

rol o

f HIV

/AI

DS, T

B, M

alar

ia

and

Wat

er-b

orne

di

seas

es

Num

ber o

f hea

lth

educ

ation

ses

-sio

ns c

arrie

d ou

t

Activ

ity/ s

essio

n re

port

sN

ursin

g di

rec-

tor

Lobb

y fo

r and

dis-

trib

ute

mos

quito

ne

ts

Num

ber o

f ind

i-vi

dual

s w

ho re

-ce

ived

mos

quito

ne

ts

Proc

urem

ent

repo

rts

Dist

ributi

on re

g-ist

er

Adm

inist

rato

r

Prev

ent w

ater

- bo

rne

dise

ases

th

roug

h pr

ovisi

on

of w

ater

pur

ifier

s

Num

ber o

f pur

ifi-

ers

dist

ribut

ed to

th

e co

mm

unity

% c

hang

e in

num

-be

r of c

ases

with

w

ater

bor

ne d

is-ea

ses

Dist

ributi

on re

-po

rts

HM

IS/ C

ase

sum

mar

y sh

eet

MD


103

Iden

tify

and

col-

labo

rate

with

ot

her s

ecto

rs a

nd

part

ners

with

an

inte

rest

in d

iseas

e pr

even

tion

Num

ber o

f sec

tors

an

d pa

rtne

rs p

ar-

ticip

ating

in d

is-ea

se p

reve

ntion

Hos

pita

l rep

orts

MD

and

Ad-

min

istra

tor

Stra

tegy

3:

Co

ntrib

ute

to re

ducti

on o

f mat

erna

l and

neo

nata

l mor

talit

y

Prov

ide

sexu

al

and

repr

oduc

tive

heal

th se

rvic

es

with

in th

e co

m-

mun

ity a

nd a

t the

lo

wer

leve

l hea

lth

units

Num

ber o

f SRH

se

rvic

es o

ffere

d w

ithin

the

com

mu-

nity

Hos

pita

l rep

orts

Supe

rvisi

on re

-po

rts

LLH

U re

port

s

MD

Hold

qua

rter

ly

mat

erna

l mor

talit

y au

dit m

eetin

gs

and

whe

neve

r th

ere

is an

inci

-de

nt

Num

ber o

f mee

t-in

gs h

eld

Min

utes

M

D

Fulfi

ll Em

OC

cri-

teria

(pro

vidi

ng

com

preh

ensiv

e Em

OC

serv

ices

)

Prov

ision

of C

E-m

OC

serv

ices

EmO

C sc

ore

Eval

uatio

n re

-po

rts

MD

and

Nur

s-in

g di

rect

or


104

Prov

ision

of E

MO

C se

rvic

esN

umbe

r of o

b-st

etric

em

erge

ncy

case

s

Neo

nata

l mor

talit

y ra

tes

Mat

erna

l mor

talit

y ra

tes

HM

IS re

port

s

Annu

al re

port

s

MD

and

Nur

s-in

g di

rect

or

Sens

itize

mot

hers

du

ring

ante

nata

l vi

sits o

n PM

TCT

and

safe

del

iver

y

Num

ber o

f sen

si-tiz

ation

ses

sions

ca

rrie

d ou

t

ANC

Activ

ity re

-po

rts

Nur

sing

dire

c-to

r

Stra

tegy

4:

Im

prov

e ho

spita

l tra

nspo

rtati

on se

rvic

es

Purc

hase

a lo

w

fuel

con

sum

ption

am

bula

nce

and

van

/ lob

byin

g fr

om M

oH

New

am

bula

nce

and

van

in p

lace

Proc

urem

ent

docu

men

ts

Log

book

Adm

inist

rato

r

Regu

larly

mai

ntai

n th

e ho

spita

l veh

i-cl

es

Num

ber o

f veh

i-cl

es s

ervi

ced

and

mai

ntai

ned

Serv

ice

repo

rts

Mai

nten

ance

re

port

s

Adm

inist

rato

r


105

Ensu

re p

rovi

sion

of fu

el fo

r the

ve-

hicl

es

Prop

ortio

n of

func

-tio

nal v

ehic

leVe

hicl

e lo

g bo

okAd

min

istra

tor


106

BUDG

ET F

OR

NKO

ZI H

OSP

ITAL

STR

ATEG

IC P

LAN

FO

R 20

15 /

16–

2019

/20

STRA

TEG

IC O

BJEC

TIVE

1: I

NCR

EASE

UTI

LISA

TIO

N O

F SE

RVIC

ES IN

NKO

ZI H

OSP

ITAL

Stra

tegy

1: I

mpr

ove

on th

e ex

istin

g ra

nge

of c

linic

al a

nd n

ursi

ng se

rvic

es

Activ

ities

/ in

terv

entio

nsRe

fere

nce

Uni

tU

nit c

ost

Qua

ntity

Amou

ntSo

urce

s of

fund

ing

Ensu

ring

stea

dy su

pply

of

med

icin

es, s

undr

ies a

nd

equi

pmen

t

mon

th20

,000

,000

1224

0,00

0,00

0

Impr

ovin

g pa

tient

clin

ical

an

d nu

rsin

g ca

re a

nd

satis

facti

on

Qua

rter

ly m

eetin

g/re

view

s60

,000

424

0,00

0

Ensu

ring

that

pati

ents

ac

cess

serv

ices

at r

educ

ed

user

fees

--

-0

Proc

urin

g au

tom

atic

liver

and

rena

l fun

ction

m

achi

nes

pc20

,000

,000

120

,000

,000

Incr

easin

g av

aila

bilit

y of

an

d ac

cess

to b

lood

Pers

on tr

ansp

ort

30,0

0052

1,56

0,00

0

Intr

oduc

e a

nutr

ition

clin

ic

and

empl

oy a

nut

rition

nu

rse

Pers

on ti

me

300,

000

123,

600,

000

Food

dem

onst

ratio

n10

0,00

04

400,

000


107

Intr

oduc

e di

abeti

c an

d Hy

pert

ensio

n cl

inic

Pers

on ti

me

15,0

0012

180,

000

Intr

oduc

e ea

r, no

se a

nd

thro

at (E

NT)

uni

tQ

uart

erly

supp

ort

500,

000

42,

000,

000

Stra

tegy

2: T

o ex

pand

anc

illar

y se

rvic

es

2.1

In

trod

uce

opht

halm

olog

y se

rvic

es

- Rec

ruit

Oph

thal

mic

Cl

inic

al O

ffice

r OR

- Tra

in e

xisti

ng C

/O in

op

htha

lmol

ogy

serv

ices

Pers

on ti

me

700,

000

128,

400,

000

- Rec

ruit

Oph

thal

mic

As

sista

nts

Pers

on ti

me

300,

000

123,

600,

000

- Tra

in n

urse

s in

eye

care

Pers

on30

0,00

03

900,

000

- Pro

cure

bas

ic e

ye c

are

equi

pmen

tPc

5,00

0,00

01

5,00

0,00

0

- Pro

cure

bas

ic m

inor

su

rger

y eq

uipm

ent f

or e

ye

care

Pc5,

000,

000

15,

000,

000

2.2.

I

ntro

duce

ort

hope

dic

serv

ices

Recr

uit o

ne O

rtho

pedi

c O

ffice

r Pe

rson

tim

e70

0,00

012

8,40

0,00

0


108

Recr

uit o

ne O

rtho

paed

ic

Assis

tant

Pers

on ti

me

300,

000

123,

600,

000

Obt

ain

basic

ort

hope

dic

equi

pmen

tPc

5,00

0,00

01

5,00

0,00

0

E

xpan

d de

ntal

car

e se

rvic

es

Recr

uit o

ne D

enta

l Offi

cer

Pers

on ti

me

700,

000

125,

000,

000

Obt

ain

basic

den

tal

equi

pmen

tPc

5,00

0,00

01

5,00

0,00

0

2.4

E

xpan

d la

bora

tory

serv

ices

Intr

oduc

e cu

lture

and

se

nsiti

vity

testi

ngPc

30,0

00,0

001

30,0

00,0

00

Ensu

re c

onst

ant p

ower

su

pply

for C

ultu

re a

nd

sens

itivi

ty

Serv

icin

g 1,

000,

000

4

•

4,00

0,00

0

Intr

oduc

e ha

emat

olog

y in

vesti

gatio

nsPc

18,0

00,0

001

18,0

00,0

00

Intr

oduc

e la

bora

tory

in

vesti

gatio

ns in

diff

eren

t de

part

men

ts

Pers

on ti

me

300,

000

12*4

14,4

00,0

00


109

Stra

tegy

3: T

o im

prov

e th

e qu

ality

of c

are

offer

ed in

the

Hosp

ital

Trai

ning

staff

in te

chni

cal

qual

ity o

f car

ePe

rson

tim

e30

0,00

04

1,20

0,00

0

Trai

ning

staff

in c

usto

mer

ca

rePe

rson

tim

e30

0,00

04

1,20

0,00

0

Deve

lopi

ng o

r ada

pting

an

d ad

optin

g te

chni

cal

qual

ity o

f car

e pr

otoc

ols

and

stan

dard

s (e.

g.

Stan

dard

Ope

ratin

g Pr

oced

ures

for t

he

labo

rato

ry)

Pers

on ti

me

60,0

002

120,

000

Cond

uctin

g an

d uti

lizin

g su

rvey

s on

patie

nts’

ex

pect

ation

s

Pers

on ti

me

50,0

002

100,

000

Cond

uctin

g an

d us

ing

patie

nts’

exp

erie

nce

surv

eys t

o im

prov

e qu

ality

of

car

e

Pers

on ti

me

50,0

002

100,

000

Cond

uctin

g an

d uti

lizin

g fin

ding

s of p

atien

t sa

tisfa

ction

surv

eys

Pers

on ti

me

50,0

002

100,

000


110

Cond

uctin

g te

chni

cal

eval

uatio

n of

qua

lity

of

care

/ser

vice

pro

visio

n as

sess

men

t

Pers

on ti

me

400,

000

280

0,00

0

Stra

tegy

4: T

o im

prov

e pa

tient

safe

ty in

the

Hosp

ital

Trai

ning

staff

in p

atien

t sa

fety

Pers

on ti

me

300,

000

41,

200,

000

Deve

lopi

ng /

adop

ting

and

impl

emen

ting

patie

nt

safe

ty p

roto

cols

for t

he

Hosp

ital (

e.g.

for s

urgi

cal

proc

edur

es, f

or v

agin

al

deliv

ery,

for p

resc

riptio

n pr

actic

es e

tc)

Pers

on ti

me

40,0

001

40,0

00

Begi

nnin

g / s

tren

gthe

ning

er

ror r

epor

ting

mec

hani

sms i

n va

rious

ho

spita

l dep

artm

ents

QI m

eetin

g40

,000

624

0,00

0

Esta

blish

ing

an In

fecti

on

Cont

rol C

omm

ittee

Com

mitt

ee

func

tiona

lity

400,

000

41,

200,

000

Esta

blish

ing

an is

olati

on

unit

with

in th

e ho

spita

l

Stra

tegy

5:

Expa

nd o

n th

e Cl

inic

al P

asto

ral C

are

(CPC

) and

Cou

nsel

ing


111

Trai

ning

staff

in C

PC

(targ

et: a

t lea

st 2

staff

tr

aine

d pe

r yea

r)

Pers

on ti

me

300,

000

41,

200,

000

Trai

ning

staff

in c

ouns

ellin

g se

rvic

es (t

he o

ther

opti

on

is to

recr

uit q

ualifi

ed

coun

sello

rs)

Pers

on ti

me

700,

000

21,

400,

000

Recr

uitin

g a

qual

ified

co

unse

llor

Pers

on ti

me

700,

000

128,

400,

000

Recr

uit a

med

ical

soci

al

wor

ker

Pers

on ti

me

700,

000

128,

400,

000

Stra

tegy

6:

Impr

ove

med

ical

reco

rds m

anag

emen

t

Com

pute

rize

the

data

m

anag

emen

t sys

tem

in a

ll de

part

men

ts

pc6,

000,

000

16,

000,

000

Crea

te n

ew o

ffice

spac

e fo

r rec

ords

Offi

ce40

0,00

01

400,

000

Proc

ure

fillin

g ca

bins

pc50

0,00

010

5,00

0,00

0

Stra

tegy

7.

Ex

pand

and

furn

ish

hosp

ital i

nfra

stru

ctur

e

Proc

urin

g an

ECG

mac

hine

pc6,

000,

000

16,

000,

000


112

Expa

ndin

g th

e M

ater

nity

W

ard

and

put T

heat

reSt

ruct

ure

400,

000,

000

140

0,00

0,00

0

Cons

truc

ting

a ki

tche

n an

d a

shel

ter f

or p

atien

ts’

atten

dant

s

Stru

ctur

e50

,000

,000

210

0,00

0,00

0

Proc

urin

g te

levi

sion

sets

an

d ra

dios

for p

atien

tsPc

700,

000

64,

200,

000

Reno

vatin

g th

e HI

V/AI

DS

clin

icSt

ruct

ure

167,

000,

000

116

7,00

0,00

0

Shel

ter t

he p

athw

ays

conn

ectin

g w

ards

and

th

eatr

e

Stru

ctur

e50

,000

,000

150

,000

,000

Cons

truc

t a sh

ade

at th

e ph

arm

acy

Stru

ctur

e5,

000,

000

15,

000,

000

Dem

arca

te a

pla

ce fo

r ho

spita

l par

king

Plot

60,0

00,0

001

60,0

00,0

00

STRA

TEG

IC O

BJEC

TIVE

2:

IM

PRO

VE H

UM

AN R

ESO

URC

ES IN

NKO

ZI H

OSP

ITAL

Stra

tegy

1:

Ens

ure

ther

e ar

e co

mpe

titive

and

equ

itabl

e sa

larie

s for

staff

of N

kozi

Hos

pita

l


113

Cond

uctin

g bi

annu

al sa

lary

an

d w

orki

ng c

ondi

tions

su

rvey

s in

equi

vale

nt

insti

tutio

ns w

ithin

the

regi

on ju

st fo

r com

paris

on

Pers

on ti

me

100,

000

220

0,00

0

Cond

uctin

g a

revi

ew o

f sa

larie

s eve

ry tw

o ye

ars,

w

ith a

vie

w to

incr

ease

as

and

whe

n th

e m

eans

allo

w

Pers

on ti

me

40,0

003

120,

000

Mak

ing

the

paym

ent

stru

ctur

e of

the

hosp

ital

mor

e eq

uita

ble

inte

rnal

ly

and

exte

rnal

ly

Pers

on ti

me

100,

000

440

0,00

0

Stra

tegy

2:

P

ut in

pla

ce a

ttra

ctive

wor

king

and

wel

fare

term

s and

con

ditio

ns

Esta

blish

ing

a Sp

ace

Man

agem

ent a

nd

Util

isatio

n Po

licy

for t

he

hosp

ital (

whi

ch g

over

ns

elig

ibili

ty a

nd e

ntitle

men

t fo

r acc

omm

odati

on a

nd

office

spac

e, d

urati

on o

f te

nanc

y, sh

arin

g of

spac

e et

c)

Pers

on ti

me

200,

000

480

0,00

0


114

Prov

idin

g ho

usin

g fo

r all

key

staff

of t

he h

ospi

tal

who

shou

ld b

e ho

used

on

site

Prov

idin

g su

itabl

e ho

usin

g fo

r all

hous

ed h

ospi

tal

staff

by

refu

rbish

ing

hous

es th

at n

eed

it

3,00

0,00

02

6,00

0,00

0

Mak

ing

stat

utor

y co

ntrib

ution

s to

the

Soci

al S

ecur

ity o

f all

staff

em

ploy

ed b

y th

e ho

spita

l

3,50

0,00

012

42,0

00,0

00

Mak

ing

stat

utor

y de

ducti

ons t

owar

ds

PAYE

for

all e

ligib

le st

aff

empl

oyed

by

the

hosp

ital

3,50

0,00

012

42,0

00,0

00

Assis

ting

staff

to

obta

in re

gula

r fina

ncia

l st

atem

ents

on

thei

r NSS

F de

posit

s

Pers

on ti

me

40,0

004

160,

000

Intr

oduc

e an

d im

plem

ent

a po

licy

on te

rmin

al

bene

fits f

or lo

ng-s

ervi

ng

staff

of t

he h

ospi

tal

Pers

on ti

me

200,

000

480

0,00

0


115

Prov

idin

g aff

orda

ble

med

ical

insu

ranc

e co

ver

for t

he st

aff o

f the

hos

pita

l

Prem

ium

150,

000

150

22,5

00,0

00

Com

putin

g an

d co

mm

unic

ating

the

mon

etar

y va

lue

of

all b

enefi

ts c

urre

ntly

pr

ovid

ed b

y th

e ho

spita

l to

the

staff

Pers

on ti

me

200,

000

240

0,00

0

Revi

ewin

g th

e pa

ckag

e of

fr

inge

ben

efits

pro

vide

d to

st

aff e

very

two

year

s with

a

view

to in

crea

se th

em

and

keep

them

att

racti

ve

(e.g

. fun

eral

exp

ense

s,

med

ical

car

e et

c.)

Pers

on ti

me

200,

000

480

0,00

0

Stra

tegy

3:

Esta

blis

h a

“Tra

ns-g

ener

ation

al”

bond

bet

wee

n th

e ho

spita

l and

the

staff


116

Esta

blish

ing

a po

licy

on

“Tra

ns-g

ener

ation

al”

rela

tions

hip

betw

een

the

hosp

ital a

nd st

aff

(to e

nsur

e th

at st

aff a

re

com

mitt

ed fo

r a lo

ng te

rm,

and

to re

war

d st

aff w

ho

have

bee

n co

mm

itted

to

the

hosp

ital f

or a

ver

y lo

ng

time)

Pers

on ti

me

200,

000

480

0,00

0

Iden

tifyi

ng a

nd su

ppor

ting

child

ren

of lo

ng-

serv

ing

staff

in th

eir

educ

ation

(e.g

. with

re

com

men

datio

n fo

r sc

hola

rshi

p by

don

ors,

off

erin

g th

em h

ospi

tal

scho

lars

hips

in th

e N

TS,

pref

eren

ce in

recr

uitm

ent

as h

ospi

tal s

taff,

re

ques

ting

for s

chol

arsh

ip

from

the

Uni

vers

ity, e

tc)

Pers

on ti

me

100,

000

330

0,00

0


117

Assis

ting

long

serv

ing

staff

to a

cqui

re lo

ans f

or

pers

onal

dev

elop

men

t e.

g. h

ouse

con

stru

ction

, m

otor

-veh

icle

pur

chas

e et

c.

Pers

on ti

me

20,0

0012

240,

000

Stra

tegy

4:

D

evel

op d

iffer

ent s

kills

am

ong

staff

thro

ugh

spec

ific

prof

essi

onal

trai

ning

and

dev

elop

men

t pro

gram

mes

Cond

uctin

g Tr

aini

ng

Nee

ds A

sses

smen

t (TN

A)

annu

ally

Pers

on ti

me

600,

000

31,

800,

000

Esta

blish

ing

a St

aff

Deve

lopm

ent P

olic

y fo

r the

hos

pita

l (w

hich

co

vers

issu

es li

ke

elig

ibili

ty fo

r spo

nsor

ship

/re

com

men

datio

n fo

r sp

onso

rshi

p, c

ondi

tions

fo

r rec

omm

enda

tion

for

furt

her s

tudi

es, w

hich

co

urse

s will

be

spon

sore

d et

c)

Pers

on ti

me

200,

000

480

0,00

0


118

Prep

arin

g a

Staff

De

velo

pmen

t Pla

n fo

r the

ho

spita

l (w

hich

cov

ers

issue

s lik

e w

hat s

kills

, kn

owle

dge

or e

xper

tise

are

curr

ently

requ

ired

for

the

hosp

ital,

whi

ch p

eopl

e w

ill b

e sp

onso

red

over

the

next

5 y

ears

and

in w

hat

orde

r etc

)

Pers

on ti

me

3,00

0,00

01

3,00

0,00

0

Deve

lopi

ng a

n in

tern

al

Conti

nuou

s Pro

fess

iona

l De

velo

pmen

t (CD

P) p

lan

(incl

udin

g ex

chan

ge v

isits

)

Pers

on ti

me

200,

000

122,

400,

000

Cond

uctin

g tr

aini

ng

to d

evel

op sp

ecifi

c kn

owle

dge,

atti

tude

s and

sk

ills a

mon

g th

e st

aff

Pers

on ti

me

150,

000

460

0,00

0


119

Sear

chin

g fo

r and

id

entif

ying

sho

rt c

ours

es

for w

hich

staff

of t

he

hosp

ital c

an b

e se

nt, i

n or

der t

o de

velo

p lo

cal

capa

city

(NB:

In s

ome

case

s, th

ere

are

som

e sh

ort c

ours

es w

hich

hav

e a

scho

lars

hip

alre

ady

attac

hed

– e.

g. U

CMB

cour

ses,

Stic

hting

Por

ticus

, a

Dutc

h or

gani

satio

n,

whi

ch o

ffers

sch

olar

ship

s m

ainl

y fo

r rel

igio

us p

eopl

e fo

r bac

helo

rs a

nd m

aste

rs

degr

ees.

The

hos

pita

l cou

ld

tap

into

this

to d

evel

op

a nu

mbe

r of G

gogo

nya

siste

rs in

to h

ealth

pr

ofes

siona

ls w

ho c

an

carr

y m

ore

resp

onsib

ilitie

s in

the

hosp

ital.

Airti

me

40,0

0012

480,

000


120

Prov

idin

g st

aff w

ith

oppo

rtun

ities

for s

harin

g in

form

ation

esp

ecia

lly o

n re

turn

from

cou

rses

in

whi

ch th

ey re

pres

ente

d th

e ho

spita

l (in

clud

ing

exch

ange

visi

ts)

Hour

2 ho

urs

4896

hou

rs

Deve

lopi

ng a

pol

icy

on M

ento

ring

for t

he

hosp

ital (

NB:

Thi

s may

ne

ed tr

aini

ng o

f sta

ff in

m

ento

ring)

Pers

on ti

me

3,00

0,00

01

3,00

0,00

0

Dete

rmin

e ac

tivity

st

anda

rds (

activ

ities

and

tim

e it

take

s the

staff

to

exec

ute

them

)

Pers

on ti

me

50,0

0012

600,

000


121

Dete

rmin

e th

e an

nual

w

orkl

oad

Pers

on ti

me

200,

000

360

0,00

0

Dete

rmin

ing

the

actu

al

staffi

ng re

quire

men

ts

basin

g on

the

wor

kloa

d le

vels

usin

g a

suita

ble

appr

oach

(e.g

. WIS

N

met

hod)

Dist

ributi

ng a

vaila

ble

staff

eq

uita

bly

on th

e ba

sis

of w

orkl

oad

e.g.

dur

ing

rost

erin

g of

nur

ses

Stra

tegy

5:

Impr

ove

staff

rete

ntion

with

in N

kozi

hos

pita

l

Cond

uctin

g ex

it in

terv

iew

s w

ith a

ll de

parti

ng st

aff to

de

term

ine

thei

r cau

ses o

f de

part

ure

and

how

such

re

ason

s can

be

addr

esse

d fo

r rem

aini

ng st

aff


122

Cond

uctin

g po

st-e

xit

inte

rvie

ws w

ith st

aff w

ho

left

the

hosp

ital e

arlie

r, to

ob

tain

thei

r vie

ws o

n ho

w

the

wor

k en

viro

nmen

t of

the

hosp

ital c

an b

e im

prov

ed

Incr

easin

g th

e ch

anne

ls fo

r con

flict

pre

venti

on

and

reso

lutio

n w

ithin

the

hosp

ital

Esta

blish

ing

staff

ince

ntive

sc

hem

es (e

.g. s

alar

y ad

vanc

e, h

ospi

tal l

oans

, se

curit

y fo

r loa

ns, s

taff

SACC

O, a

war

ds fo

r lon

g se

rvic

e, e

xtra

priv

ilege

s for

lo

ng se

rvic

e et

c)


123

Cond

uctin

g st

aff

expe

ctati

ons s

urve

ys/

fron

tline

pro

vide

r as

sess

men

t to

dete

rmin

e st

aff e

xpec

tatio

ns a

nd h

ow

they

can

be

met

by

the

hosp

ital a

nnua

lly

Pers

on ti

me

100,

000

440

0,00

0

Refin

ing

the

staff

app

raisa

l sy

stem

of t

he h

ospi

tal,

with

the

parti

cipa

tion

of

the

staff

Pers

on ti

me

40,0

003

120,

000

Intr

oduc

ing

a sy

stem

of

publ

ic a

ckno

wle

dgem

ent

of st

aff (e

.g. o

n en

d-of

-ye

ar p

artie

s, o

n no

tice

boar

ds e

tc)

5,00

0,00

01

5,00

0,00

0

STRA

TEG

IC G

OAL

OBJ

ECTI

VE 3

: EN

SURE

SU

STAI

NAB

LE F

INAN

CIAL

BAS

E FO

R TH

E HO

SPIT

AL

Stra

tegy

1:

Re

duce

non

-criti

cal e

xpen

ditu

re in

the

hosp

ital


124

Esta

blish

men

t of a

Ho

spita

l Effi

cien

cy

Com

mitt

ee (w

hose

role

is

to id

entif

y, m

onito

r an

d he

lp to

plu

g ar

eas o

f w

asta

ge in

the

diffe

rent

as

pect

s of t

he h

ospi

tal

incl

udin

g uti

lities

, pe

rson

nel c

osts

, med

icin

es

and

supp

lies)

Pers

on ti

me

50,0

0015

1,25

0,00

0

Ope

ratio

nalis

ing

the

med

icin

es a

nd

Ther

apeu

tics C

omm

ittee

(M

TC)

Pers

on ti

me

50,0

006

300,

000

Cond

uctin

g re

gula

r (e.

g.

bi-a

nnua

l) ph

arm

aceu

tical

au

dits

Pers

on ti

me

40,0

002

80,0

00

Cond

uctin

g co

st-

cons

ciou

snes

s/aw

aren

ess

trai

ning

sess

ions

for a

ll ho

spita

l sta

ff

Pers

on ti

me

100,

000

550

0,00

0


125

Stra

tegy

2:

Impr

ove

finan

cial

man

agem

ent

Inst

allin

g an

acc

ounti

ng

pack

age

suita

ble

for t

he

need

s of t

he h

ospi

tal i

n re

leva

nt c

ompu

ters

with

a

suita

ble

back

-up

syst

em

(not

sure

if th

e on

e of

Dr.

Kabu

ye R

oger

s cap

ture

s th

is)

IN P

LACE

Trai

ning

acc

ounti

ng a

nd

finan

ce st

aff in

the

use

and

mai

nten

ance

of

the

inst

alle

d ac

coun

ting

pack

age

(if th

is be

com

es

nece

ssar

y)

Pers

on ti

me

200,

000

51,

000,

000

Impl

emen

ting

fully

th

e ho

spita

l’s F

inan

cial

M

anag

emen

t Man

ual

Net

wor

king

fina

nce

and

acco

untin

g co

mpu

ters

fo

r eas

y sh

arin

g of

in

form

ation

Net

wor

k80

0,00

02

1,60

0,00

0


126

Appo

intm

ent o

f a

subs

tanti

ve In

tern

al

Audi

tor f

or th

e ho

spita

l

Pers

on ti

me

1,00

0,00

012

12,0

00,0

00

Ope

ning

and

dep

ositi

ng

fund

s on

rese

rve

fund

ac

coun

ts fo

r all

key

capi

tal

item

s

Bank

cha

rge

20,0

0012

240,

000

Inve

sting

ann

ual s

urpl

uses

in

hig

h-re

turn

ven

ture

s (e

.g. t

reas

ury

bills

and

fix

ed d

epos

it ac

coun

ts)

Stra

tegy

3:

Incr

easi

ng lo

cal r

even

ues f

rom

diff

eren

t sou

rces

for h

ospi

tal a

ctivi

ties

Appo

intin

g a

full-

time

foca

l per

son

for

fund

raisi

ng a

ctivi

ties f

or

spec

ific

hosp

ital p

roje

cts

(feas

ibili

ty to

be

furt

her

expl

ored

)

Pers

on ti

me

500,

000

126,

000,

000


127

Incr

easin

g th

e be

d oc

cupa

ncy

rate

in th

e pr

ivat

e w

ard

thro

ugh

impr

oved

clie

nt c

are

both

cl

inic

al a

nd n

on-c

linic

al

care

(whi

ch b

ring

in m

ore

reve

nue)

Incr

easin

g th

e ch

arge

s in

the

priv

ate

war

d (a

fter

impr

ovin

g th

e qu

ality

of

serv

ices

in th

at w

ard)

Ensu

ring

full

time

avai

labi

lity

of a

med

ical

offi

cer f

or p

rivat

e w

ard

patie

nts

even

on

wee

kend

s.

Pers

on ti

me

2,30

0,00

012

27,6

00,0

00

Intr

oduc

e 14

” co

lour

TVs

in

the

indi

vidu

al ro

oms

of th

e pr

ivat

e w

ard

begi

nnin

g w

ith 2

room

s as

an

expe

rimen

t to

see

whe

ther

the

dem

and

incr

ease

s)

pc50

0,00

08

4,00

0,00

0


128

Solic

iting

for c

apita

l do

natio

ns (e

.g. m

edic

al

and

office

equ

ipm

ent)

fr

om a

lum

ni a

nd o

ther

lo

cal i

ndiv

idua

l and

co

rpor

ate

frie

nds o

f the

ho

spita

l

pc5,

000,

000

210

,000

,000

Positi

onin

g th

e ho

spita

l to

prov

ide

the

serv

ice

for t

he

prop

osed

Nati

onal

Hea

lth

Insu

ranc

e (N

HI) [

This

requ

ires t

hat t

he h

ospi

tal

impr

oves

its q

ualit

y of

car

e to

a le

vel w

here

it c

an b

e ac

cred

ited

to p

rovi

de th

e se

rvic

es.].

Advo

catin

g fo

r an

incr

ease

of

the

PHC

Cond

ition

al

Gran

t (PH

C-CG

) fro

m th

e ce

ntra

l gov

ernm

ent (

usin

g U

CMB,

DLG

etc

)

Airti

me

40,0

004

160,

000


129

Esta

blish

Ass

ocia

tions

th

at c

an su

ppor

t the

ho

spita

l suc

h as

: 1) B

orn

or D

eliv

ered

) in

Nko

zi As

soci

ation

to su

ppor

t M

ater

nity

Ser

vice

s, 2

) Fr

iend

s of N

kozi

to su

ppor

t ge

nera

l ser

vice

s.

Airti

me/

per

son

tran

spor

t40

,000

1248

0,00

0

Stra

tegy

4:

Mob

ilise

reso

urce

s for

con

tinue

d in

com

e ge

nera

tion

and

sust

aina

bilit

y

Iden

tifica

tion

of e

xter

nal p

artn

ers

who

can

supp

ort t

he h

ospi

tal

finan

cial

ly (t

o co

nsid

er fr

iend

s,

rese

arch

insti

tutio

ns, N

GOs,

ch

arita

ble

orga

nisa

tions

, for

eign

go

vern

men

ts, t

he H

oly

See,

ban

ks,

bila

tera

l and

mul

tilat

eral

age

ncie

s)

Airti

me

40,0

0012

480,

000

Writi

ng p

roje

ct p

ropo

sals

for e

xter

nal

supp

ort

Pers

on

time

1,00

0,00

02

2,00

0,00

0

Solic

iting

for i

n-ki

nd su

ppor

t fro

m th

e go

vern

men

t and

ext

erna

l par

tner

s e.

g. st

aff se

cond

men

t, vo

lunt

eer

heal

th w

orke

rs e

tc

Airti

me

40,0

0012

480,

000


130

Revi

ewin

g th

e fin

anci

al fe

asib

ility

of

taki

ng b

ank

loan

s for

criti

cal c

apita

l in

vest

men

ts e

.g. c

onst

ructi

on o

f ho

stel

whi

ch w

ill b

ring

in m

ore

finan

cial

reso

urce

s

Pers

on

time/

tr

ansp

ort

300,

000

390

0,00

0

Mob

ilize

for a

n en

dow

men

t fun

d fo

r in

vesti

ng in

an

inco

me

gene

ratin

g ve

ntur

e su

ch a

s stu

dent

s hos

tels

or

build

ing

a ho

spita

l res

taur

ant

Airti

me

40,0

0012

480,

000

STRA

TEGI

C O

BJEC

TIVE

4: I

MPR

OVI

NG

GOVE

RNAN

CE, M

ANAG

EMEN

T AN

D O

PERA

TIO

NAL

SYS

TEM

S O

F TH

E HO

SPIT

AL

Stra

tegy

1:

Incr

ease

the

effec

tiven

ess o

f the

Boa

rd o

f Gov

erno

rs (B

OG)

Cond

uctin

g in

ducti

on/o

rient

ation

of

the

new

mem

bers

of t

he n

ew B

OG

Pers

on

time

50,0

0020

1,00

0,00

0

Deve

lopi

ng a

nd im

plem

entin

g lo

cal

and

appr

opria

te b

ench

mar

k cr

iteria

fo

r mon

itorin

g th

e pe

rfor

man

ce o

f th

e BO

G

Pers

on

time

40,0

004

160,

000

Cond

uctin

g a

Trai

ning

Nee

ds

Asse

ssm

ent (

TNA)

for t

he sk

ills

nece

ssar

y fo

r BO

G m

embe

rs

Pers

on

time

100,

000

220

0,00

0

Trai

ning

mem

bers

of t

he B

OG

in

spec

ific

skill

s nec

essa

ry to

per

form

th

eir r

espo

nsib

ilitie

s

Pers

on

time

1,00

0,00

03

3,00

0,00

0


131

Deve

lopi

ng a

nd a

pply

ing

crite

ria

to m

onito

r the

per

form

ance

of

indi

vidu

al m

embe

rs o

f the

BO

G

Esta

blish

ing

a m

echa

nism

for

follo

win

g up

the

impl

emen

tatio

n of

BO

G de

cisio

ns

Harm

onisi

ng th

e un

ders

tand

ing

of th

e ro

les a

nd re

latio

nshi

ps o

f th

e O

wne

r, th

e Bo

ard

of T

rust

ees,

th

e Bo

ard

of G

over

nors

, the

M

anag

emen

t and

the

Man

agin

g Co

ngre

gatio

n am

ong

thes

e di

ffere

nt

stak

ehol

ders

Stra

tegy

2:

Str

engt

hen

the

role

of t

he M

anag

ing

Cong

rega

tion

in su

ppor

ting

the

hosp

ital

Deve

lopi

ng a

nd a

pply

ing

benc

hmar

k cr

iteria

for m

onito

ring

the

role

of t

he

Man

agin

g Co

ngre

gatio

n

Assis

ting

the

Man

agin

g Co

ngre

gatio

n in

cap

acity

dev

elop

men

t to

enab

le

them

to fu

lfil t

heir

role


132

Stra

tegy

3:

Str

engt

hen

the

perf

orm

ance

of t

he M

anag

emen

t Tea

m

Deve

lopi

ng a

nd a

pply

ing

benc

hmar

k cr

iteria

for m

onito

ring

the

perf

orm

ance

of t

he M

anag

emen

t Te

am

Deve

lopi

ng a

nd a

pply

ing

benc

hmar

k cr

iteria

for m

onito

ring

the

perf

orm

ance

of t

he in

divi

dual

m

embe

rs o

f the

Man

agem

ent T

eam

Deve

lopi

ng m

anag

emen

t ski

lls

amon

g se

nior

hos

pita

l sta

ff (in

clud

ing

Man

agem

ent T

eam

mem

bers

) to

deve

lop

capa

city

for m

anag

emen

t ro

les i

n th

e ho

spita

l

Prov

idin

g ex

posu

re o

ppor

tuni

ties

(e.g

. thr

ough

stud

y vi

sits,

scie

ntific

ta

lks e

tc) t

o m

embe

rs o

f the

BO

G,

Man

agem

ent T

eam

, Man

agin

g Co

ngre

gatio

n an

d st

aff

Pers

on

time/

tr

ansp

ort

40,0

0012

480,

000

Esta

blish

ing

a m

echa

nism

for

follo

win

g up

the

impl

emen

tatio

n of

M

anag

emen

t Tea

m d

ecisi

ons


133

Cond

uctin

g jo

int r

etre

ats b

etw

een

the

BOG

and

Man

agem

ent T

eam

(e

.g. o

ne e

very

two

year

s, in

whi

ch

the

BOG

emph

asize

s the

stra

tegi

c di

recti

on o

f the

hos

pita

l and

thei

r ex

pect

ation

s to

the

Man

agem

ent

Team

)

3,00

0,00

01

3,00

0,00

0

Cond

uctin

g re

trea

ts o

f the

M

anag

emen

t Tea

m m

embe

rs (a

t le

ast o

nce

a ye

ar, f

or te

am-b

uild

ing

and

to c

onsid

er a

nd a

ppro

ve th

e an

nual

pla

n of

the

follo

win

g ye

ar,

amon

g ot

hers

)

1,00

0,00

01

1,00

0,00

0

Stra

tegy

4 :

St

reng

then

ing

the

gene

ral m

anag

emen

t sys

tem

s

Revi

ewin

g (a

nd u

pdati

ng if

nee

d be

) th

e ex

isting

hos

pita

l con

stitu

tion

Pers

on

time

500,

000

21,

000,

000

Revi

ewin

g (a

nd if

nee

d be

upd

ating

) th

e ex

isting

man

uals

of th

e ho

spita

l e.

g. e

mpl

oym

ent m

anua

l, fin

anci

al

man

agem

ent m

anua

l etc

)

Pers

on

time

50,0

008

400,

000

Esta

blish

ing

Qua

lity

Assu

ranc

e Gu

idel

ines

and

Sta

ndar

ds (Q

AGS)

for

the

hosp

ital

Airti

me

100,

000

110

0,00

0


134

Cons

tituti

ng In

tern

al S

uppo

rt

Supe

rvisi

on Te

ams

Pers

on

time

100,

000

440

0,00

0

Hold

ing

regu

lar o

pen

(tow

n ha

ll)

gene

ral s

taff

mee

tings

(at l

east

twic

e a

year

)

Pers

on

time

100,

000

330

0,00

0

Stra

tegy

5 :

St

reng

then

ing

the

equi

pmen

t, sp

ace,

pla

nt a

nd in

fras

truc

ture

man

agem

ent s

yste

ms

Deve

lopi

ng a

Spa

ce a

nd H

ousin

g po

licy

for t

he h

ospi

tal (

cove

ring

issue

s suc

h as

acq

uisiti

on, u

se,

equi

tabl

e di

strib

ution

, ten

ancy

, m

aint

enan

ce, m

aste

r pla

nnin

g,

loca

tion

of b

uild

ings

, loc

ation

of

activ

ities

etc

)

Pers

on

time

1,00

0,00

01

1000

,000

Esta

blish

ing

a Sp

ace

and

Hous

ing

com

mitt

ee fo

r the

hos

pita

l M

eetin

g50

,000

420

0,00

0

Esta

blish

ing

a po

licy

on th

e m

anag

emen

t of e

quip

men

t and

pla

nt

(cov

erin

g iss

ues s

uch

as a

cqui

sition

, m

aint

enan

ce, u

se, u

ser-t

rain

ing

and

disp

osal

)

Mee

ting

50,0

004

200,

000

Insti

tutin

g re

gula

r inv

ento

ry,

insp

ectio

n an

d m

aint

enan

ce o

f eq

uipm

ent,

build

ings

and

pla

nt

Pers

on

time

1,00

0,00

02

2,00

0,00

0


135

Esta

blish

a sy

stem

for t

he re

porti

ng,

reco

rdin

g an

d re

spon

ding

to re

port

s of

bre

akag

es a

nd m

alfu

nctio

n

Stra

tegy

6:

Str

engt

heni

ng th

e hu

man

reso

urce

s man

agem

ent s

yste

ms

Impl

emen

ting

fully

the

Hum

an

Reso

urce

Man

agem

ent M

anua

l

Esta

blish

ing

a St

aff P

erfo

rman

ce

Revi

ew B

oard

to a

dvise

the

Man

agem

ent T

eam

on

staff

pe

rfor

man

ce

Pers

on

time

1,00

0,00

01

1,00

0,00

0

Esta

blish

ing

a W

orkp

lace

Pol

icy

on

HIV/

AIDS

and

oth

er c

hron

ic il

lnes

ses

Pers

on

time

100,

000

110

0,00

0

Esta

blish

ing

a St

aff a

nd P

atien

t Saf

ety

Polic

y fo

r the

hos

pita

l (co

verin

g iss

ues s

uch

as h

ospi

tal-a

cqui

red

infe

ction

, vio

lenc

e, se

xual

ass

ault

etc)

Pers

on

time

1,00

0,00

02

2,00

0,00

0

Stra

tegy

7:

Str

eam

linin

g pr

ocur

emen

t and

con

trac

ting

proc

edur

es

Form

ing

a Te

nder

ing

Com

mitt

eePe

rson

tim

e10

0,00

04

400,

000

Revi

ewin

g pu

rcha

se p

rices

ev

ery

six m

onth

sPe

rson

tim

e/

tran

spor

t20

0,00

02

400,

000


136

Issu

ing

Loca

l Pur

chas

e O

rder

s on

all p

urch

ases

Stati

oner

y12

0,00

01

120,

000

Raisi

ng G

oods

Rec

eive

d N

ote

on a

ll pu

rcha

ses

stati

oner

y12

0,00

01

120,

000

Insp

ectin

g al

l the

item

s pu

rcha

sed

each

tim

e of

de

liver

y

Pers

on ti

me

20,0

0012

240,

000

Taki

ng st

ock

mon

thly

Pers

on ti

me

100,

000

121,

200,

000

Cond

uctin

g m

edic

ines

an

d su

pplie

s sto

ck-o

ut

chec

king

qua

rter

ly

Pers

on ti

me

40,0

004

160,

000

STRA

TEG

IC O

BJEC

TIVE

5:

CO

NTR

IBU

TE T

O IM

PRO

VED

HEAL

TH F

OR

THE

PEO

PLE

LIVI

NG

IN M

AWO

KOTA

SO

UTH

HEA

LTH

SD Stra

tegy

1:

Str

engt

hen

Prim

ary

Heal

th C

are

(PHC

) Dep

artm

ent

Cond

uct i

nteg

rate

d co

mm

unity

out

reac

hes

Out

reac

h18

0,00

012

2,16

0,00

0

Cond

uct s

choo

l hea

lth

prog

ram

mes

Visit

150,

000

121,

800,

000

Cove

r im

mun

izatio

n ex

pens

esPe

rson

tim

e1,

330,

000

1215

,960

,000


137

Parti

cipa

te in

Chi

ld D

ays

Plus

(CDP

) and

Mas

s Im

mun

izatio

n

Mon

th1,

100,

000

22,

200,

000

Stra

tegy

2:

Pre

vent

spre

ad o

f com

mun

icab

le d

iseas

es

Inno

vate

stra

tegi

es to

m

ake

mal

aria

trea

tmen

t m

ore

acce

ssib

le to

the

com

mun

ities

Cond

uct R

CT a

nd V

CTPe

rson

tim

e1,

100,

000

44,

400,

000

HIV

prog

ram

Cond

uct H

ealth

Edu

catio

n on

Pre

venti

on a

nd c

ontr

ol

of H

IV/A

IDS,

TB,

Mal

aria

an

d W

ater

-bor

ne d

iseas

es

Pers

on ti

me

50,0

0012

600,

000

Proc

ure

and

dist

ribut

e m

osqu

ito n

ets

TASO

, M

alar

ia

Cons

ortiu

m

Prev

ent w

ater

- bo

rne

dise

ases

thro

ugh

prov

ision

of

wat

er p

urifi

ers

Pers

on ti

me

20,0

0012

240,

000

PACE

Iden

tify

and

colla

bora

te

with

oth

er se

ctor

s and

pa

rtne

rs w

ith a

n in

tere

st

in d

iseas

e pr

even

tion

Pers

on ti

me

40,0

0012

480,

000

Hosp

ital


138

Stra

tegy

3:

Co

ntrib

ute

to re

ducti

on o

f mat

erna

l and

neo

nata

l mor

talit

y

Prov

ide

sexu

al a

nd

repr

oduc

tive

heal

th

serv

ices

with

in th

e co

mm

unity

and

at t

he

low

er le

vel h

ealth

uni

ts

Pers

on ti

me

100,

000

121,

200,

000

Hold

qua

rter

ly m

ater

nal

mor

talit

y au

dit m

eetin

gs

and

whe

neve

r the

re is

an

inci

dent

Pers

on ti

me

40,0

004

160,

000

Fulfi

ll Em

OC

crite

ria

(pro

vidi

ng c

ompr

ehen

sive

EmO

C se

rvic

es)

Prov

ision

of E

MO

C se

rvic

esPe

rson

tim

e

Sens

itize

mot

hers

dur

ing

ante

nata

l visi

ts o

n PM

TCT

and

safe

del

iver

y

Pers

on ti

me

5,00

012

60,0

00


139

Stra

tegy

4:

Im

prov

e ho

spita

l tra

nspo

rtati

on se

rvic

es

Purc

hase

a lo

w fu

el

cons

umpti

on a

mbu

lanc

eVe

hicl

e20

0,00

0,00

01

200,

000,

000

Purc

hase

of a

low

fuel

co

nsum

ption

van

Vehi

cle

150,

000,

000

115

0,00

0,00

0

Regu

larly

mai

ntai

n th

e ho

spita

l veh

icle

sVe

hicl

e1,

000,

000

44,

000,

000

Ensu

re p

rovi

sion

of fu

el fo

r th

e ve

hicl

esLi

tre

250,

000

123,

000,

000


140

Our Lady Health Of The Sick

Nkozi Hospital

Contact: Tel.: +256 (0) 392842207; Fax: +256(0) 38 410100

Email: [email protected]

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Documents

STRATEGIC PLAN - Nkozi Hospital Strategic plan.pdfof the advanced age group in our society have all translated to increased morbidity and mortality from conditions such as hypertension,