Marchal et al. BMC Public Health 2010, 10:787 http://www.biomedcentral.com/1471-2458/10/787 Phase 5 - Rebuilding the systems While the CMT tackled weaknesses in some administra- tive and management systems early on (see phase 3), the strategic plan ‘Rising the internal strength’ presented a long-term vision to improve the clinical quality assur- ance systems, administrative functions, and management of infrastructure and logistics. Figure 2 presents a time- line of the main interventions and managerial outcomes. First, several initiatives were taken to institutionalise quality assurance. A series of training workshops in the use of the GHS quality assurance manual was organised for all staff, and special ward conferences addressed particular issues. In 2008, the maternal mortality audit committee was re-launched and maternal mortality audits organised. Observational studies of waiting time at the OPD and the patient satisfaction survey led to a workshop for OPD staff during which the patient flow was reorganised with the aim to reduce waiting time and improving privacy. The data collection, analysis and use of routine health information were improved. For instance, when the Health Information Office picked up a sharp increase in stillbirths in 2007, a training workshop in resuscitation skills was organised in response. The laboratory set up formal quality assurance systems. At the pharmacy, pre- scriber behaviour was analysed and discussed with the providers. In 2007, the CMT organized an external Page 8 of 16 review by a peer visitation team, a first in the Volta Region. During this peer review of the Hospital, health professionals from other hospitals in the Volta Region visit one hospital and review all its activities using a scoring system. Management and operational systems are reviewed through observation and review of func- tions and practices. Second, several administrative and management systems were addressed, starting with the strategic planning capa- city by the very development of the strategic plan. Finan- cial management was strengthened by hiring additional accountants. Procurement of drugs was streamlined. Third, after the emergency repairs in 2006, major rehabilitation works started in 2007, leading to the opening of the rehabilitated maternity ward in 2007, and of the pharmacy, laboratory and the offices of the Health Information System (HIS) department in 2008. At the outpatient department, the roofing of the build- ing was reconstructed and an extension was made to the structure. A start was made with the installation of networked computers at every service point, the accounting and HIS offices. The organisational climate The organisational climate is defined as the atmosphere that employees perceive, which in turn is created in their Figure 2 Sequence of management steps and outcomes.