1. Facility Level Reviews Photo from: http://cbid-ethiopia.blogspot.com/2011/08/team-ethiopia-south-yirgalem-hospital.html

2. Learning objectives By the end of this session, participants will be able to: Complete a facility review form Generate and present case summaries List the 5 decisions a facility MDR committee should make Complete the review reporting form to send to the next level

3. Overview 1. Role of data collector – Tools: MDR Facility review – Ensuring data quality – Maximising data capture – Summarising cases for presentation at review 2. MDSR Facility committee – Roles and responsibility – Tools: report form to next level – Constructive discussion and taking key decisions

4. Facility level tools Facility reporting form Report from facility to next level  Consider translation into local language  Anonymise records and keep any data that identifies individuals in a secure place  Provide data collectors with on-the-job training

5. Data quality improves when...  All members of staff understand the purpose of the data collection  There is good coordination across the facility departments for collecting and synthesising data  Multiple sources are used (case notes, records from admission, surgery theatre, mortuary etc)  Notes are legible Once the process of data collection becomes routine, reporting and quality often improve as staff realise their notes and records will be looked at and used!

6. Data capture Include all sources of information if women received care at multiple sites Every effort should be made to include family interviews A summary of the chain of events should be generated (description of events leading to the death)

7. Transferring Notes to Facility Summary Form Individual Workbook Exercise

8. Reminder: Committee Roles  Multi disciplinary to bring in different perspectives and ideas  Preserves the anonymity of patients and staff (through non-disclosure pledge)  Maintains a “No Blame” culture  Reports objectively on cases  Identifies actions and provides required feedback to all concerned  Coordinates with community reviews – essential to build a complete picture

9. Confidentiality: a Code of conduct Local data collectors and involved health care workers are the only staff who see the names of deceased Knowledge contained within review committees All individuals (including committee members) who access identifying data sign a non-disclosure confidentiality agreement (kept on record)

10. Draft Disclaimer (Non-disclosure confidentiality agreement) We, the members of the ---- review committee, agree to maintain anonymity and confidentiality for all the cases discussed at this meeting, held on [DATE]. We pledge not to talk to anyone outside this meeting about details of the events analysed here, and will not disclose the names of any individuals involved, including family members or health care providers.

11. Hospital committee membership Obstetrician & Gynaecologist IESO officer Senior Midwife Anaesthesiologist /Anaesthetist CEO Medical Director Pharmacy case unit head Quality officer of the hospital

12. During the “Set Up” phase, facilities should:  Raise awareness and provide training for all staff  Schedule regular, routine facility reviews  Appoint a MDSR co-ordinator who relates well to other staff, is supportive and respected  Invite local experts to join committee from backgrounds other than medical/midwifery  Engage senior staff and managers

13. Key Challenges Blame culture Lack of ownership Lack of leadership Missing documentation Lack of feedback

14. Committee discussion Five key decisions 1.Cause of death 2.Death classification Direct/indirect/incidental 3.Relevant delays 4.Preventability Lessons learnt are applied to prevent further deaths 5.Actions

15. Reporting Form to next level (Appendix 4) DelaysContributory factorsresponse Delay 1Harmful traditional practices Family poverty Failure of recognition of the problem Lack of decision to go to health facility Delayed referral from home Delay 2Delayed arrival to referred facility Lack of roads Lack of transportation No facility within reasonable distance Delay 3Delayed arrival to next facility from referral from another facility Delayed management after admission Delayed or lacking supplies and equipments(specify) Human error or mismanagement

16. Case discussions  Practical session aimed at simulating Facility MDR committee meeting  Groups of approx 6-8  Described in Workbook

17. Summary Points  Quality of notes and records are vital to the success of facility based reviews  Data must be obtained from all relevant sources (departments where woman treated, other health services she attended, family members)  The whole team should review cases and contribute to taking the key 5 decisions  Accurate reporting to next level will ensure quality of data maintained through system