Dottoressa Enkeleida Thartori Pediatra, CHUT “Madre Teresa”
Servizio di Oncoematologia Pediatrica Tirana-Albania
“Progetto di Dottorato in medicina materno-infantile”
Universita di Trieste
Scuola di Dottorato di ricerca in SCIENZE DELLA RIPRODUZIONE -indirizzo MEDICINA MATERNO INFANTILE PERINATOLOGIA, XXV ciclo
Il progetto dal titolo “Valutazione e miglioramento della qualita delle cure in oncoematologia pediatrica in Albania con particolare referimento alla cura delle LLA” consiste nello sviluppo di uno strumento di valutazione delle cure , derivato da quello proposto dall’OMS per le cure pediatriche e gia utilizzato in Albania, nel suo utilizzo per la valutazione della qualita delle cure nelle LLA presso il reparto di oncoematologia pediatrica a Tirana, nella definizione di un programma di intervento su alcune delle aree di maggiore criticita, e nella valutazione dei cambiamenti introdotti
Tutori: GIORGIO TAMBURLINI
GIULIO ANDREA ZANAZZO
(IRCCS “Burlo Garofolo”, Trieste)
KNOWLEDGES
At the beginning of this project, first of all, we needed an information about the albanian contest of children suffering from Acute Leukemia Diseases including lymphoblastic and myeloid leukemia.
The Albanian children 0-14 years old are about 900 000 it means 24%
of the total population of the Albanian Republic, and there are all about 40 000- 45 000 newborns for one year.
There is only one center of pediatric oncoematologic service in the capital Tirana in the University Hospital Center “Mother Teresa” and there is not or doesn’t exist a National Center of Bone Marrow Transplantation and it exist only one Unique Center of Blood Banc.
During the years 2005 till 2010 in Albania there has been done the diagnosis of LLA for 144 children (24 new cases for one year) and 20 children with LAM (3.3 new cases/in one year).
About the Italian Journal of Paediatrics , 2011, Rondelli et al The majority of foreign children treated for a cancer in Italy, there has been Albanian children, about 21,5%.
The 20% of foreign children treated in Italy for a cancer have been recovered in the Friuli Venezia Giulia Region.
The overall survive about ten years for this foreign children treated in Italy for LLA according to AIEOP Protocols Treatments is about 71%.
There is so much migration of the children from Albania to Italy or others foreign countries and the most important thing is the majority of hospital lack cytostatics (antineoplastic) drugs to use and this problem is likely to be found at the level in the procurement and distribution of drugs, lack of uses of CVC (central venous catheterization) as a very important procedure to treat these children, also the lack of sedation procedure etc. It should however be recognized that the availability of drugs and equipments is only one of the reflection of the quality of care. There is not an adequate support therapy, lack of diagnostic supplies and equipments, lack of palliative care in these children.
Even there is the low that in the hospital all the care service for a child is free, in realty the family should care to support the treatment, the equipments etc to have an adequate and appropriate medical care during the treatment therapy.
The WHO Assessment Tool for assessing the quality of care of hospital paediatric care.
The WHO (World Health Organization or OMS) has developed un assessment tool or instrument that consists of protocols and a questionnaire to be completed by a respondent, and the protocol to be completed by the assessors during the observation visit. At the end of the hospital visit , assessors and hospital administration agree on a plain of action for quality improvement. This tool help to assess and to monitor the hospital care in children in the developing and in transition economic countries. This tool has been elaborated based on international standards, protocols or guide-lines for different pediatrics diseases.
In 2009, using this tool, WHO in collaboration with the Ministry of Health (MOH) in Albania have done an assessment of paediatric hospital care in three regional pediatric hospital, Shkodra, Korca and Vlora and in One Maternity, third level hospital (university center) in Tirana. The most important purpose of the assessment it was to find out the area that need to improve the quality of hospital care in children based on a concrete plan of action. This assessment has been very important like an help to improve the pediatric hospital care even into a national quality improvement programme.
Assessment tool for the quality of hospital care for children with LLA
This tool is a revised and updated version of the assessment tool of the pediatric hospital care developed by WHO CAH in 2001 and since then widely used globally including European Region. The last revision was made by Giorgio Tamburlini (Institute for Maternal and Child Health Burlo Garofolo, Trieste, Italy – WHO Collaborating Centre for Maternal and Child Health) in a consultative process with the WHO Regional Office for Europe.
OBJECTIVES
This tool is an adapted tool for children with LLA, to assess the hospital care of a child suffering from LLA, to find out the most critical areas and after this period of assess, to agree for a plan of action for quality improvement.
We have also utilize the opportunity for the initiative collaboration into IRCCS “Burlo Garofolo” Trieste,Italy and CHUT “Mother Teresa” Tirana, Albania with the aim to improve the quality of hospital care, especially in oncohematologic pediatric service.
The objective of the assessment were to:
1. identify critical issues concerning the quality of LA children health care provided by Pediatric oncohematological service in CHUT “Mother Teresa”
2. suggest actions to improve quality in this service taking into account the underlying factors influencing QoC
3. provide an opportunity for a team of assessors to get familiar to the assessment tools and methods for further assessment can be carried out especially in developing countries
This assessment exercise was also meant to :
contribute to introduce the concept of peer review and quality improvement in hospital management and health professional in oncological pediatric services
The Methods
This assessment tool helps to evaluate the quality of care (QoC) for children in oncological department, especially for those with LA (LLA and LAM), based on standards derived from WHO Pocket Book of Hospital Care for Children and in a limited number of areas not included in the WHO Pocket Book but from International guidelines (see main references) and protocols from AIEOP-Italy for onco- haematological diseases.
It includes a series of forms to collect:
- general information on the physical structure of the paediatric oncohematologic department, and, when appropriate, outpatient and day hospital; (patient flow)
- information on available equipment, drugs and supplies;
- information on (about?) management of common conditions which are usually dealt with the onco-haematologic paediatric department in specialized hospitals (tertiary care), including essential surgery when appropriate ex; CVC and sedation protocol
- views of staff and mothers/carers of sick children.
The information has been collected from four different sources of information:
hospital statistics,
medical records,
direct observation of cases, and
interviews with staff and with mothers/caretakers.
Through the combination of information from different sources the tool allows to build an overall diagnosis of the quality of care and to single out those areas that are most critical and in need of action to improve QoC.
A scoring system is proposed to identify the most critical areas:
3 = good quality of care according to international standards;
2 = need for some improvement to reach standard care (suboptimal care but no significant hazard to health);
1 = need for substantial improvement to reach standard care (suboptimal care with significant health hazards, e.g. omission of evidence based interventions and use of diagnostic and treatment which are not effective according to international standards and may also be potentially harmful to children);
0 = need for very substantial improvements (totally inadequate care and/or harmful practice with severe hazards to the health of these children).
Summary tables are included in each section to facilitate a quick synthesis of the findings, and a summary evaluation sheet is included to provide an overview of the situation, monitor department improvement over time and make inter-department comparisons when appropriate. All sections leave some space for comments by the assessors and for relevant additional information.
AGENDA AND PARTICIPANTS
The assessment will be conducted by external assessors, usually two, at least one should have a significant experience in onco- haematological clinical paediatrics and be totally familiar with the reference protocols for LA. This assessment was carry out between 27- 28 june 2012 in the Oncohematologic Pediatric Department at CHUT
“Mother Teresa” Tirana, Albania from Dr. Giulio Andrea Zanazzo, paediatrician in oncohematologic service in IRCCS “Burlo Garofolo”
Trieste,Italy skillfully as a pediatrician with huge experience in the oncohematologic field.
These activities are included under the collaboration between the IRCCS “Burlo Garofolo” and Ministry of Health of Albania.
Information(s) regarding sections 1 to 4 has been collected before the assessment then analysed before the visit and whenever possibly checked during the direct visit. It is suggested to spend as much time as possible on the onco-haematological paediatric department to gain first hand information by direct observation, especially on the case management of LLA and LAM. Also, the assessors have checked the existence and contents of clinical protocols of LA, and whether the drugs and equipment listed are available.
We emphasise that the assessment is an exercise which is part of the initiative to help the Paediatric Oncohaematological Department in Albania to improve the quality of paediatric care, aimed at identifying areas of care that need improvement and a very clear definition of a program to intervene immediately in those areas that express really a huge lack.
The assessors have explained that they will also interview staff and mothers/carers about hospital routines for these children and practices and that they would like to observe care of as many children patients as possible, already admitted as well as new arrivals.
The assessment has normally start with a tour of the onco- haematological department asking to be shown all areas that will be of relevance to paediatric care. In addition to the department the tour have had included the following areas, as they exist: intensive care unit, pharmacy, laboratory, blood bank, radiology surgical department.
Observation over time is important and new arrivals and new admissions with LA to the hospital has been closely observed. It was an advantage that the hospital staff is asked to alert them when new
patients arrive. The assessors should not interrupt, interfere or guide medical work in any way. It is important that they are allowed to move around freely and are free to interview parents and staff. There is no time limit to the assessment and the more observations the better.
Allow for sufficient time to prepare the findings for presentation. We have transfered all findings on the summary sheet of findings and action for discussion. A feedback meeting held at the end of the assessment with the chief of service and the other doctors was aimed at involving staff in discussing the findings as well as the suggested actions. Standards and assessment tools are essential but not per se sufficient to promote a sustained effort to departments quality improvement. A crucial component of quality development is represented by the commitment of hospital managers and health professionals. By its participatory nature and particularly through its final session, which is clearly inspired by a problem-solving approach, the process is aimed at building awareness about the existence of quality issues and the potential for improvement. This tool includes a suggested framework for final discussion and identifications of tasks and responsibilities of the various staff members and levels. The focus on case management of a child suffering of LA and management issues rather than on structure and staffing is crucial to promote the idea that substantial change is possible without major external input and resources.
Interviews with mothers about the quality of care provided to them and their children, clearly represent a novelty to most professionals.
Incorporating the views of mothers on several aspects of care is per se a way to promote child, mother and family-friendly attitudes among staff, as well as awareness among mothers and children about their own rights.
After assessing the planned sample of facilities, the assessors have prepared a report summarizing findings and recommendations. In the next step the assessment process might be included into a National Quality Improvement Programme or it might be done by interested health authorities at UHC “Mother Teresa” and MOH involving the onco- haematological paediatric department hospital walk-through observation. After a predefined period of time, the assessment can be repeated to document improvement.
First, to apply an intervention plan according to priority and feasibility using this assessment tool especially taking the results from the last list where we are able to find out the most critical area where is necessary and feasible to intervene because this are areas that have a
great impact to morbidity and mortality. As a very important point for a LA child is having the adequate treatment,
it means to be present in every time in the service (hospital) the cytostatics drugs or antineoplastic drugs, that are very special in treatment of the children with LA (such as ARA-C, Asparaginasis, metotrexate etc)
to improve the laboratory support, to be done always when it’s necessary the PCR, blood culture in a septic condition, different analyses for serological exam of viruses et others etc
and with the very high importance the use of CVC (central venous cathetherisation) as a method to prevent the high frequency of blood samples and medications
using the pain sedation for all the invasive procedure such as:
bone marrow aspiration, lumbar punction
improving the support treatment, nutrition, the nurses records etc
RESULTS
Nearby, we have posted the final list of the summary score taken in the assessment tool of 27-28 June 2012 in Tirana in CHUT “Mother Teresa” Oncohematologic Pediatric Service, it means the assessment of the quality of care in LA children in terms of numbers, helping us to assess and then to create an action plan according to different levels, in the pediatric service, hospital management or in the high level in government lows.
The assessment showed that quality of care (QoC) for children with LA in Albania was often substandard, in some cases poor:
the case management of the most common condition in LA children and in most important complications is often not complying with international standards and AIEOP protocols
the integration and continuity of care between professionals and services, between subsequent admissions is insufficient and the palliative care for this children in the other levels of care is not available, or is not present( home service nursery) and the hospital provide services that should be ensured by other components of health systems.
This situation may not be dealt with the real rights for a quality of life of a child suffering with LA.
The situation is due to a combination of factors including: lack or updated of international standards; insufficient use of diagnostic and
therapeutic protocols; lack of integrated of team work to ensure consistency and continuity of care; lack of essential equipment, drugs and supplies. There were also several examples of good and even excellent quality of care, showing that ensuring quality is possible not with standing in health system organization, hospital or ward infrastructure and availability of equipments, drugs and supplies.
Given the complex of the problem and the underlying determinants, the improvement of health care of children in Albania require a combination of health system improvement and some policies regarding:
1. the managements of resources and particularly the training, distribution and continuous education of human resources, staff who work with oncohematological children
2. financing issues including accountability and incentives
Immediate, short term actions that may not require major changes include:
technical support to LA protocols for example Pain control or Sedation procedure to be implemented
training for support in different conditions of the disease including preventing infection, complications, follow up, palliative care etc
development and adoption of information and case management such as medical and nursing records, monitoring charts, ideally based on formats to be agreed on LA diseases standards.
For the purpose of the assessment in Albania the Paediatric LLA tool has been slightly revised and adopted for LLA diseases as one of the most important pediatric cancer taking as a gold standard of treatment the AIEOP-ITALY Protocols and studies.
The items included in the assessment were chosen to provide a comprehensive assessment of four dimensions of quality of care:
1. be based on scientific evidence
2. be family centered, respecting confidentiality, privacy, culture, belief and emotional needs of children, families
3. ensure involvement of parents in decision-making for options of care
4. ensure continuum of care including multidisciplinary approach The assessment tool proved to be effective to collect all the information and to analyse the quality of care of a child with LA according to the international standards.
The main findings for the oncohematologic pediatric ward in CHUT
“Mother Teresa” of Tirana, Albania are reported in table 1 and 2 respectively. Scores represent the average score of the items included in respective areas. For each problem identified, a list of actions to address the issues is suggested. The list of suggested action is the result of discussions within the assessor’s team, both international and national and of the discussion held in the debriefing session with the team of the oncohematological pediatric ward.
Summary evaluation score (table 1)
This summary helps identifying the most critical areas as a basis for identifying priorities and work plan to guide the discussion with senior hospital staff at debriefing.
Good To be improved
Summary score 3 2 1 0
1. Information system and medical records x
2. Essential drugs, supplies and equipment x
3. Laboratory support x
4. Emergency care x
5. Oncohematologic department facilities x 6. Case management of LLA ; 6.1 Hemorrhage x
6.2 Anemia x x
6.3 Fever conditions x
6.4 Pain x
6.5 Neurotoxicity x
6.6 Metabolic complications and other conditions x
7. Child friendly services x
8. Monitoring and follow up x
9. Guidelines and auditing x
10. Access to hospital and feedback to primary health care x x 11. Satisfaction of mothers or other care takers x
12. Health workers interview x x
Debriefing and action plan (table 2)
We have discussed above summary of hospital findings with the chief of service and the doctors staff giving details as appropriate.
We have discussed their perception of the findings, and how action could be taken to improve services for children. We have discussed importance in terms of morbidity and mortality, and the feasibility to take action. We have developed a plan of action, using the following list.
ITEMS
Summary score Impact on mortality and morbidity
Feasibility Action needed Priority Timetable and responsible person
To be stronglyimproved To be improved Not to be improved
H i g h
L o w
H i g h
L o w
H i g h
L o w
1.
x x x x
2. x x x To be improved hospital
government
x
3. x x x idem x
4. x x x idem x
5. x x x idem x
6. x x idem x
7. x x Parents Association x
8. x x x Nurses Record x
9. x x To be improved department
government
x
10. x x x
11. x x x
12. x x x x
Hospital summary score (oncohematologic department)= total score 27.5 ……the maximal scores = 51
Conclusions and Recommendations
How to improve the quality of care for children with LLA in Albanian oncohematologic paediatric hospital service
SITUATION
The assessment showed that quality of care for children suffering with LLA was often substandard and sometimes poor, particularly in the dimensions of information, communication, and confidentiality and holistic care of these children.
The main problems that were identified were :
a) the case management of common conditions and complications of LA was often non complying with international standards and AIEOP protocols; (not present CVC, not in use sedation for invasive procedures etc)
b)the integration and continuity of care between professionals and services was insufficient and the important information for the care of these children is not readily available (e.g there is only in this hospital that should offer health care for these children even for subsequent admissions for the same patient coming from all over the country);
c)out of pocket payments by parents and caregivers are frequent include buying drugs, cytostatics or antineoplastic and supplies which are lacking in the hospital
d)infrastructure and hygienic facilities, such as running hot water, heating etc are frequently deficient, and infiltration area in ward doesn’t exist
The situation besides putting at risk the health of children, causes inefficient use of resources, may cause some real emergencies not to be dealt with promptly and appropriately and frequently cause financial strain.
It is important to underline that examples of good and even excellent quality of care were also observed, showing that ensuring quality is possible notwithstanding the existent deficiencies in health system organisation, hospital and ward infrastructure and availability of equipment, drugs and supplies.
Based on observations and the information collected, the described situation can be attributed to a combination of factors including:
1)lack of diagnostic and therapeutic use protocols of LA based on international standards
2)lack of essential equipments, drugs and supplies (lack of antineoplastic, laboratory not performed CRP, Procalcitonin in sepsis condition, lack of serological exam offered by laboratory)
3) not at all in use the Central Venous Cathetherisation, CVC that is indispensable for such blood samples during the treatment of LA and intensive therapy or chemiotherapy occording to international protocols
4) lack of some basic infrastructure and facilities, such as running hot water and hygienic services
5) lack of using the sedation procedures as a standard during the invasive procedure such as bone marrow aspiration, lumbar punction etc
6)lack of sufficient awareness of the importance of providing adequate information to parents and taking care of then holistically
7)lack of a precise definition of roles and responsibilities of health service and health professionals across the different levels of care etc
Underlying causes can be identified in the following:
the curricular background and the post curricular training of most health professionals doesn’t provide the scientific, methodological basis to ensure compliance with international standards, continuous updating, collaborative team work and responsiveness to the LA children’s need
the current organization of work in this service, including the relevant information/clinical records and information system doesn’t allow to address in periodical updates, revision of protocols etc
there are no incentives to efficient use of resources
Table 1. Summary of assessment of quality of LA children care and relevant suggestions
Areas Main problems Actions
Information system
and medical records Substandard clinical records keeping, lack of nurses records Computerized data collections mainly for administrative and not for clinical use
Basic indicator system to be used by team for both administrative and practice
improvement
Disseminate and use existing good models of clinical records Improve clinical
records keeping,
involving all
professional’s team members
Essential drugs,
supplies and
equipment
Frequent lack of essential, basic drugs supplies and laboratory
Decentralized
budgeting and
accountability
Specific investment plan for essential equipment and drugs (especially
antineoplastic ones) Laboratory support Key basic low cost
equipment/supply
not available
(genetic diagnostic for LA, serologic exam etc)
Ensure the essential equipment and lab support
Ensure condition and better use of available equipment
Emergency care No national
guidelines and
protocols
No diagnostic criteria and available space for treatment
In some cases structural problems
Development and use of national protocols on major complications of LA Improved curricular
training and
continuous medical education(quality improvement and
managing LA
complications workshop) Oncohematologic
department facilities Excess painful and inappropriate
procedures
Lack of different equipments to apply some procedures like (BMAspiration,
lumbar punction, CVC)
Absence of optic microscopic using in
Improved the pain control on LA treatment and the complications
Effective training of staff using the CVC
the ward, only in lab;
lack of different size of lumbar needles etc
Case management
of LA No protocols and
algorithms for major complications(only
some examples
among the different doctors
Case management
varies among
doctors
Setup national
working group for LA clinical protocols, development and use of these protocols
Child friendly
services Insufficient
communication with
mothers or
caregivers
Effective training course
Improved
communication with mothers and families
Health workers
interview Conditions and
incentives Improving conditions of work, payments and incentives
Monitoring and
follow up Monitoring actions are reportedly performed but not appropriately
recorded
For some severe conditions
monitoring not frequent enough There is no link
between nurse
chart and medical chart
Improved record
keeping and
communication between staff
Disseminate to the ward existing good models of clinical records (e.x. those used in Burlo-Trieste)
Guidelines and
auditing Case management
varies among
doctors
No protocols and algorithms for major conditions of LA
Set up national working group for oncohematological paediatric care
Development and use of national adapted protocols
Access to hospital and feedback to primary health care
overhospitalization Improved relationship between district and hospital level
Improved
communication with mothers and families of LA children
Collaborate to ensure implementation of golden standard of LA health care
Satisfaction of mothers and other care takers
Insufficient
communication with mothers
Inappropriate use of space, cleanness and sterility not ensured
Improved
communication with mothers and families
Irrespective of the specificities of each area of care the assessment in the oncohematological ward, in hospital laboratory and in general in the hospital identified several common critical aspects:
Case management of most common conditions and complications of LA is often substandard with respect to established international standards according to AIEOP-ITALY protocols. The main problems are : lack of use of appropriate drugs as essential in chemotherapy treatment; failure to use international classification of LA (not present the genetical or biological diagnosis). The reasons belong to two main groups of factors:
deficiencies in health professional knowledge, attitude and skills
lack of essential drugs and supplies, which was particularly frequent during these last years (citostatics drugs) and not available treatment of recidives of disease, the bone marrow transplantation is not offered
lack of essential lab examination and treatment equipment, which make it often difficult to comply with international standards when they have been adopted. The situation is substantially better for LLA (acute lymphoblastic leukaemia) then LAM(acute myeloid leukaemia), due to adoption and good compliance of international standards.
The medical records in the ward are generally well kept and including the most essential information but is evident not a good integration between nursing and medical notes and poor monitoring and recording of all important parameters.
Although limited in number due to time constraints, the interviews with health professionals (one doctor, one nurse, one mother of an ill child) provided interesting insights into issues related with quality of care.
The interviews were also part of the assessment. The interviews were absolutely anonymous and confidential and the privacy allow to not affect the answers.
The most common cause of death or severe complications (near miss) were reported to be recidivism of the disease with underlying factors being lack of drugs, supplies and equipment and absence of Bone Marrow Transplantation.
Critical issues of quality were consistently identified in:
- lack of basic infrastructure (warm water, ventilation sterilisation system, hygiene of toilets and washing facilities for patients) - lack of supplies (sterile gloves, i.v fluids, special foods for
neutropenic conditions) and equipment;
- lack of staff in ward and periods (nights, weekends)
- insufficient training both, on the job and scheduled CME events
- also the need for better information on updated protocols and information to mothers
To address the described problems and their underlying causes, substantial changes are needed in:
- the way of stewardship and hospital governance function is including the key aspects of diagnoses, treatment and follow up of a LA child (the areas 2,3,4,5)
- the way the health service for LA children is organized and delivered including aspects as information provided to mothers or caretakers and responsiveness to non-medical needs
- the way the health system is financed (the procurement of essential drugs, “cytostatics” is made only by MOH)
- the way the resources of the health particularly the human resources are created and managed
Actions which are feasible in the short time without major system intervention based on oncohematological pediatric service resources and staff avaibility are reported in the first column. All the remaining actions require the involvement of MoH (Ministry of Health) or other Governmental sectors- like “Parents Association”.
Table 2. Framework of suggested actions
Areas Hospital
government and oncohematologic paediatric
department
National/MoH level
Stewardship and
governance Enhance role of nurses
Including stages for the best performing professionals for LA diseases
Ensure access to internet-based
management facilities for staff
identify specific needs for protocol apply searching support if
necessary with
international technical support
organize trainings events based on existing protocols that taking care and treat oncological children
Establish an information system based on essential indicators for care and run periodic team meetings to discuss but also to review clinical practice for LA and organizational issues
Redistribute staff based on actual needs by level of intensity of care
Service
oncohematological paediatric care
Improve the record
keeping and
monitoring
Improve and apply the
pain procedure
according to
international protocol use
Create together with professional societies
the “Parents
Association” for oncologic children
Financing Introduce monitoring
of main cost
indicators (drug use, antineoplastic use, patient flow etc)
Identify essential drugs and equipment list for treatment of LLA include budgetary for antineoplastics, CVC, palliative care support etc
Many of these suggested actions require major system reforms, some of them are already considered and planned within the current reform process in Albania, but the prioritization and optimal phasing is therefore a matter to be decide from hospital, CHUT “Mother Teresa”
government taking into account factors such as expected impact, feasibility, affordability with current plans for health system reform of care taking support according even by agreement between international levels, including in that case the agreement between the IRCCS “Burlo Garofolo”-Trieste,Italy and CHUT “Mother Teresa”-Albania.
RELEVANT RECOMMENDATION
It should be emphasized that the guiding principle of the assessment tool for LLA children in Albania was to find and provide results and reasonable purposes for improvement of health care of these children fitting in the hole context of health care system and context, and the most important within reasonable quantitative terms, to achieve a synthetic view of the most critical QoC issues, rather then an analytical analysis of each single aspect of care.
After these intervents action in terms of possibility, validated instruments, feasibility, affordability and sustainability within an amount of time ranging from 1 to 2 years, we should do another
reassessment using this “assessment tool” for the Oncohematological Pediatric Service in CHUT “Mother Teresa”.
After this assessment that we have done, we present:
1. We already have a “Model Tool” to assess the quality of health care of LA diseases in paediatric field
2. We have done the assessment of the unique National Pediatric oncohematologic service in Albania
3. We already have an action plan based on critical area of care for LA condition of these children and ready to introduce them
4. We suggest that this experience should be replied in the other countries that have the same context as in Albania for the hole health care system of “developing countries”
MAIN REFERENCES
- Pocket book of Hospital Care for children – Guidelines for the management of common illness with limited resources – WHO – World Health Organization, 2005
- International Network of Health Promoting Hospitals and Health Services – Self evaluation model and tool on the respect of Children’s Rights in Hospital, 2009
- AIEOP-Italy Gudelines and protocols for LLA
- Self-evaluation model and tool on the respect of Chidren’s right in hospital(HPH-CA)
- Assessment of the safety and quality of hospital care for mothers, newborn babies and children in Albania: mission report February 18, 2009; Giorgio Tamburlini-team leader
Notes: Hereby it attached the “Assessment Tool for LLA children in Albania”
