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The Uganda Martyrs Hospital Lubaga COHSASA International Accreditation Journey

The core leadership team, the “COHSASA High Command” coordinated the accreditation processes at the newly launched Archbishop Cyprian Kizito Lwanga Specialist Centre. From left to right: Executive Director; Dr. Julius Luyimbaazi (Management areas), Mr. Arthur Egulu (Quality Assurance Manager), the Infection prevention and control officer; Sr. Ruth Nkwangu (Hotel services), Ms. Reginah Nakyeyune Zziwa (Quality Assurance Officer), Medical Director; Sr. Dr. Grace Nannyondo (Clinical areas), Laboratory Manager; Mr. Alex Kisekka (Clinical support services) and the Hospital Administrator; Mr. Alex Oloya (Technology)

Uganda Martyrs hospital Lubaga is a 240-bed hospital operating in the heart of Kampala city. Founded in 1899 by Missionary Sisters, and the second oldest in Uganda, the hospital has always been at the centre of healthcare service delivery in the country.

We are proud of the great achievement of having our hospital internationally accredited by COHSASA. We celebrated 125 years of excellence in 2024, and we simultaneously witnessed an improvement in the hospital’s infrastructure, its resources and in its processes which have been re-engineered to achieve better patient outcomes.

Our intentional journey to establish an evidence-based hospital Quality Management System started in 2017 with the appointment of a Quality Assurance Manager who drove the implementation of SafeCare standards in the hospital.

In 2019, the hospital embraced the COHSASA accreditation programme starting with a baseline evaluation and a series of self-evaluation periods (EVPs) over a period of four years until the external survey in January 2024.

Under the steadfast leadership of the Executive Director Dr. Julius Luyimbaazi, achieving COHSASA accreditation was a clear objective of our 2021-2026 Strategic Plan. This plan was endorsed by the Board of Governors to ensure that Lubaga improved its services to clients.

Dr. Julius Luyimbaazi noted that, “This hospital accreditation is not just a certification; it is a reflection of our commitment to healthcare excellence. It reassures our patients and their families that they are in safe hands. We anticipate that this will lead to better health outcomes and increased patient satisfaction.”

Sr. Regina Nakachwa, the Principal Nursing Officer (PNO) and Sr. Lilian Nakayiza, the Deputy PNO said: “Achieving COHSASA accreditation is a proud moment for us. It validates the hard work and dedication of our nursing staff at the forefront of patient care. This recognition motivates us to maintain and exceed these standards. As nurse managers, we appreciated the power of teamwork, commitment, and determination as major levers for success in the accreditation journey. We continue to uphold these principles to ensure that we sustain our accreditation.”

The Quality Assurance Manager, Mr. Arthur Egulu, shared highlights of the accreditation journey and noted: “The hospital accreditation process was an incredible learning experience for us. It has provided a structured framework to improve our services continuously. We believe that this accreditation will significantly benefit our patients by ensuring they receive the highest quality care.”

The baseline score of 33 in November 2020 highlighted the need for concerted effort and significant resource investment to achieve the goal of international accreditation. Many structural and process gaps were identified – a lot of work was needed to gain compliance.

The Executive Director, with support from the quality assurance office, appointed “service element” leaders, usually heads of departments, to drive quality processes in their respective units. They were trained to understand and implement the standards. Several sessions of staff training were undertaken to demystify areas of quality improvement, resuscitation, infection prevention and control as well as risk management.

The Quality Assurance office coordinated the development of all key documents through hospital committees, especially the Quality Assurance and the Clinical Quality Improvement committees. These documents included policies, manuals, guidelines, standard operating procedures, forms, logs, and templates – both clinical and non-clinical. Staff are continuously trained to use and implement what is written in the documents so that they do not gather dust on a shelf.

An internal audit team was established to support the ongoing self-evaluation cycle. This same team was appointed to mentor and coach staff in poorly performing services.

Following the self-evaluation, the teams were tasked with conducting gap analyses and action planning guided by the Quality Assurance office. This enabled staff to identify specific requirements for resource planning.

Several re-engineering initiatives were undertaken, including the centralisation of autoclaving by merging units into a single central sterile supply department (CSSD), restructuring the Emergency and Surgical Outpatient departments and upgrading the Paediatric ward into a fully-fledged inpatient unit.

Significant facility and equipment improvements were made, notably the renovation of operating theatres and the establishment of a state-of-the-art Organ Transplant Theatre (Dr. Rita Moser Transplant Center).

The COHSASA High Command’ chose to partner with professionals from an accredited facility to conduct an external audit to validate the competency of Lubaga’s internal quality auditors. COHSASA provided virtual support and valuable guidance through remote evaluations by their quality advisors.

To keep staff engaged and motivated, management introduced a Quality Champion recognition initiative, displaying portraits of top-performing units after each self-evaluation period.

The COHSASA Surveyors with Lubaga Hospital staff members after the final day of the survey.

A major milestone achieved during the accreditation process was the establishment of a robust risk management system. Staff were trained in incident reporting, including near misses, adverse events, and sentinel events. The hospital developed a structured approach to error reporting, encouraging a no-blame culture – Just Culture – that allows lessons to be learnt and processes to be improved. Here are some examples of ongoing wins in risk reduction:

  • Structural improvements and staff training on fall prevention reduced fall-related incidents by over 90% in inpatient units.
  • The development of a comprehensive preventive maintenance schedule reduced equipment breakdowns and downtime.
  • A structured linen management system significantly reduced hospital-acquired infections (HAIs) in wards and operating theatres.
  • Implementation of WHO surgical safety checklist improved surgical outcomes, with a reduction in post-operative complications.
  • Strengthened informed consent processes ensured patients and families fully understood procedures before undergoing surgery.
  • Installation of uninterrupted power supply (UPS) backups in high-risk areas prevented interruptions in life-saving procedures and laboratory analyses.

We have developed a facility-wide quality improvement plan for all units, fostering an evidence-based, data-driven culture. This plan has improved our ability to collect, analyse, and report data for performance monitoring and decision-making. This structured approach has led to real-time improvements in various areas with improved patient care outcomes.

A structured patient feedback system was established, enabling systematic tracking, analysis, and resolution of complaints. The introduction of a client relations desk has ensured real-time resolution of grievances, significantly improving patient satisfaction scores.

On the left: The COHSASA Surveyors with some of the senior management team. On the right: The Executive Director together with the Quality Assurance Officer and Manager, during the COHSASA Accreditation award ceremony.

Despite our commitment to achieving COHSASA accreditation, we encountered several challenges along the way:

  • The delayed implementation of the food service due to the structural investment required. A benchmarking exercise was conducted to identify best practices for integrating food services into the patient care journey.
  • Staff resistance to change. Adapting to the new quality standards required shifting long-established work habits. Continuous sensitisation and targeted training was conducted to ensure buy-in from all departments.
  • Limited resources, both financial and human, posed difficulties in implementing infrastructure improvements and procuring essential medical equipment. Strategic resource allocation and phased implementation helped us overcome these constraints.

Maintaining comprehensive documentation across all services was initially overwhelming, but with resolute quality committees and a structured documentation framework, we streamlined this process. Though significant, these challenges became learning opportunities that reinforced our commitment to continuous quality improvement.

To embed these quality improvement strategies into our daily hospital operations, we continue to set the pace for sustainable excellence. Achieving COHSASA accreditation was a milestone, but sustaining it remains our primary goal.

We continue to embed a culture of continuous quality improvement by:

  • Regular internal quality audits and staff training sessions.
  • Strengthening multidisciplinary Quality Improvement Teams.
  • Benchmarking, where we continuously learn and improve our performance in key metrics.
  • Enhancing patient safety measures and evidence-based clinical practices.
  • Fostering patient and staff engagement in the quality management process.

As we celebrate 125 years of Uganda Martyrs Hospital Lubaga, our commitment to quality healthcare remains resolute. COHSASA accreditation has not only validated our efforts but also positioned us as a benchmark for healthcare excellence in Uganda and beyond.

With this accreditation, we are confident that the hospital will continue to deliver world-class healthcare services, ensuring that every patient receives the best possible care in a safe and compassionate environment.

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