Surgical Care at the District Hospital
Part 1 2 3 4 5 6 Primary Trauma Care Manual
Organizing the District Hospital Surgical Service
Organizational and management of the district surgical service
The District Hospital
Leadership, team skills and management
Record Keeping
Disaster and trauma planning
The surgical domain: creating the envioronment for surgery
Infection control and asepsis
Operating room
Cleaning, sterilization and disinfection
Waste disposal

To evaluate means to judge the value, quality or outcome of something against a predetermined standard.

At a district hospital, the act of evaluation will generate information that will enable a judgement to be made on whether the hospital is providing high standards of care and is making the best possible use of resources, including:

:: Performance of staff, equipment or a particular intervention
:: Clinical effectiveness of a type of treatment
:: Efficiency in relation to the use of resource (cost-effectiveness).
:: It may be a community in its own right
:: It must be involved in community public health education and political solutions to common health problems.

Evaluation is part of a continuous loop of information gathering, analysis, planning, intervention and further evaluation and involves the following steps.

1 Set goals and targets.
2 Define indicators (previously stated standards, intended results or norms) that can be used to assess whether these goals and targets are being met.
3 Collect information to measure observed achievements.
4 Compare achievements with goals and targets.
5 Identify any deficiencies or failures and analyse the causes.
6 Identify, plan and implement any interventions required for improvement, such as training.
7 Re-evaluate and identify any further interventions required.

Evaluation may be as simple as asking the question “Are all babies weighed in the outpatients department?” If the answer is “No”, the next step is to ask the question “Why not?” and to use the answer to identify possible steps to resolve the problem.

Evaluation will often be more complex, however. For example, a hospital recognizes that it has very high postoperative wound infection rates. All potential sources and causes of postoperative infection are studied and, after careful review and consultation, a plan is developed and implemented. After a defined period of time, a review of postoperative wound infections is again undertaken as a measurement of observed achievement. This is then compared with both previous results and expected outcomes.

If there has been a drop in the infection rate, the team can decide whether the desired outcome has been achieved and whether the measures taken should be adopted as regular practice. By changing only one thing at a time, it is possible to determine whether any improvement is related to the intervention. If the intervention does not result in the desired change, it is important to identify why it has been unsuccessful before trying another intervention.

Chart audit
Patient charts contain important information about individuals, their illnesses and course in hospital. This is valuable information for evaluation. If records are kept after patients have been discharged, a chart audit can assist in monitoring the services provided by a hospital, diagnosing areas of concern and identifying areas for improvement, including:

:: Consistency of approach
:: Infection rates
:: Length of patient stay
:: Transfusion rates
:: Complication rates.

A chart audit involves the following steps.

1 Ask a specific question, such as “What is our postoperative wound infection rate?”
2 Define the period of time for which the charts to be monitored will be selected.
3 Define the size of the sample of charts to be reviewed.
4 Develop a system for tabulating the data.
5 Make a systematic review of the charts of patients who had surgery during the defined time period.
6 Collate, analyse and interpret the results.

Once the wound infection rate has been documented, it is possible to assess whether it is acceptable. If it could be lowered, an improvement strategy can be devised and implemented. After a period of time, a second chart review can be undertaken, the change evaluated and adjustments made to practice.

Evaluation takes time and effort, but is a necessary part of a commitment to quality care.

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  Kep Points  
Evaluation is an essential part of ensuring high quality care

With any change:
– Plan (observe, consult and set goals)
– Implement the change
– Evaluate the outcome.