2012 Report. Improving Healthcare Quality In Nigeria. 6 th September Collaboration with the West African Health

Transcription

1 6 th September sharing healthcare best practices Improving Healthcare Quality In Nigeria 2012 Report Collaboration with the West African Health N O 8 M A R I N E R O A D A P A P A L A G O S, N I G E R I A

2 Conference Report A 3 day conference which kicked off on the 5 th of September, 2012 and ended on the 7 th of September, 2012 was held at the New Convention Centre of Eko Hotel, Lagos, and was jointly organized by West African Health and Society for Quality Heath in Nigeria (SQHN) was a successful event. SQHN organized and presented a Quality Assurance Workshop on the 6 th of September, 2012 which boasted of such Speakers as Professor S.A. Kuranga, Professor Emmanuel Otolorin, Professor Ibironke Akinsete, Mr. Ola Oresanya, Dr. Modupeola Oludipe, Dr. Abayomi Sule, Dr. Segun Ebitemi, Dr. Ngozi Onyia and Dr. Bosede Afolabi. The event attracted over 176 delegates who were in attendance representing prestigious organizations from the Health Care industry to be a part of the conference seminars and exhibition. 17 individuals became members of the Society on this day as well. The Seminar provided a forum for Doctors, nurses, health practitioners, health consultants and a variety of other professionals related to the Industry to analyze the developments in the industry and how to consistently improve the Healthcare quality in Nigeria. The Theme for this year s conference was Improving Healthcare Quality in Nigeria which allowed presenters to cover topics such as Role of Standards in Quality Healthcare delivery, Repositioning Clinical Laboratory for Quality Healthcare Delivery, Biomedical Waste Management in Lagos State Hospitals, Introducing International Standards & Stepwise recognition model to improve Quality of Care and a number of other interesting topics. Following the event SQHN provided delegates with certificates of attendance, acknowledging their presence for being part of such an audacious event. A total of 4 CME points were also awarded the attendees in line with the MDCN Regulation. This is indeed a landmark event as it is the first time the SQHN will be collaborating with any other organization and also the first time CME Points will be awarded at the event. We like to thank everyone who was a part of organizing and coordinating the event and we hope we can replicate the success of this event in subsequent ones to come. Page 2 of 13

3 Thursday, 6 th September 2012 Time Activity Speaker 8:00 am- 9:20 am Registration of Participants West African Health 9:35 am 9:40 am Welcome Address Workshop Co-ordinator- West African Health 9:45 am 9:55 am Chairman s Opening Speech Prof. S. A Kuranga, Former Chief Medical Director UITH & Vice President SQHN 10:00 am 10:50 am The Role of Standards in Quality Healthcare Delivery Prof. Emmanuel Otolorin, Country Director, JHPIEGO 10:50 am 11:40 am Repositioning our Clinical Laboratory for Quality Healthcare Delivery 11:40 am 11:50 am Q & A Session 11:50 am 12:00 pm Tea Break Prof. Ibironke Akinsete, Chairman Clinical Laboratory Pathcare 12:05 pm 12:25 pm Biomedical Waste Management in Lagos State Hospitals Mrs. Ola Oresanya, MD/CEO Lagos State Waste Management Authority (LAWMA) Mrs. A. A. Jijoho-Ogun, GM Admin & Special Duties, LAWMA 12:25 pm 1:10 pm Introducing International Standards & Stepwise Recognition Model to Improve Quality of Care Dr. Modepeola Oludipe, Senior Quality Manager & Quality Coordinator, PharmAccess Nigeria 1:15 pm 1:20 pm Q & A Session 1:20 pm 2:30 pm Rational Investing in Healthcare Quality Improvement Dr. Peju Adenusi, Executive Director, Hygeia Foundation Dr. Abayomi Sule, Business Development, Medical Credit Fund 1:40 pm 2:15 pm The Drive to Deliver Quality in the Hospital- The Role of Information Technology Dr. Segun Ebitanmi, Managing Director, Synapsis Limited 2:15 pm 2:25 pm Q & A Session 2:30 pm 3:30 pm Imperatives of Quality Dr. Ngozi Onyia, Specialist Paediatrician, Paelon Clinic 3:30 pm 4:00 pm Evidence Based Medicine in the 21 st Century Dr. Bosede Afolabi, Consultant Obstertrician & Gynaecologist, LUTH 4:00 pm 4:15 pm Q & A Session 4:15 pm 4:30 pm Wrap Up and Lunch Rapporteur Page 3 of 13

4 Prof. Emmanuel Otolorin Country Director, JHPIEGO The Role of Standards in Quality Healthcare Delivery Professor Otolorin began by defining Standards as an explicit statement of expected quality, and a standard operating procedure as chronological steps to follow and decisions to make in carrying out a task or function. He stated that a lack of exposure to Quality care usually leads to some healthcare professionals and managers to set low performance standards. In Nigeria, the Garbage-In-Garbage-Out (GIGO) syndrome of poor infrastructure, fake/cheap drugs, fake/cheap equipment, poorly trained health workers and the inadequate funds in the health sector usually lead to adverse effects, increased morbidity, increased mortality, patient dissatisfaction and insecurity. He pointed out that the available professional bodies need to step up the enforcement of standards in health facilities in Nigeria. he stressed that Regulation is the key to eliminating or controlling sub-standard and/or fake products and services in the communities. According to Prof. Otolorin, performance standards provide a road map for all healthcare practitioners, as well as a starting point for quality improvement. The need to move from systematic reviews of evidence to Guidelines and standards is very necessary to bridge the gap. He emphasized that it is very necessary to draw maps for our services to know how simple or complex they are. Designing a Quality Assessment Tool A Quality Assessment Tool encompasses the following: Client Preferences Provider Input Service Delivery Guidelines National Policies/priorities He identified the 4 steps of JHPIEGO s Standard-Based Management of Healthcare service delivery as: 1. Set standards: Providers should not only be told what to do, but should be told how to do it. Follow up is necessary to map out core and support functions for inclusion in assessment tool. Test the tool in selected facilities and after the due processes, finalize based on test result then begin to implement. 2. Implement standards: Distinguish between the desired and actual performance, identify the gap and cause analysis, and implement the standards. 3. Measure progress: Progress should be measured at every point and noted accordingly. No stone should be left unturned. 4. Reward achievement He concluded by saying that set standards should focus on evidence-based healthcare practices that are known to lead to desired outcomes. Nigeria needs to assure basic standards in healthcare delivery and put an end to medical tourism by improving our own quality of care. This can be achieved by coordinating efforts (Federal, State and Local Governments and through such bodies as SQHN) for quality assurance and to raise quality of care consciousness in Nigeria Page 4 of 13

5 Professor Ibironke Akinsete Chairman, Pathcare Clinical Laboratory Repositioning our Clinical Laboratory for Effective and Efficient Quality Healthcare Delivery Professor Ibironke Akinsete began with an overview of Clinical Laboratories and said they are essentially for the analysis of biological samples for purposes of screening, diagnosis, follow-up, treatment and prevention of diseases. The aim of a laboratory is to provide accurate results within a reasonable turn-around time while ensuring respect for ethics and assuring the safety of patients and staff. Although human error is inevitable, process should be designed to minimize as much as possible or to prevent mistakes from occurring. She went further to explain the structure of a clinical laboratory department as well as the challenges they face such as: Lack of implementation of National Policy and Development of Strategic Plan for Laboratory Services. Low recognition for laboratories in national and state health delivery systems Insufficient funding. Inadequately trained staff at all levels. Insufficient monitoring of test quality Old/inadequately services equipment Weak laboratory infrastructure Lack of essential consumables Limited Quality Assurance and control protocols Three sources of Laboratory Errors which she explained are: 1. Pre-Analytical Error: this includes: a. Patient identification b. Interference from patient medication c. Patient preparation d. Specimen collection (Most times from the wrong patient) e. Specimen mix-up (Tube wrongly labeled) f. Specimen transport- deterioration may occur due to heat, light and time g. Data Input errors h. Transcription errors i. Lack of Standard Operation Procedures to serve as a guide. 2. Analytical Error: They usually occur if; a. SOP s are not followed closely b. Poor methodologies are used c. Competence is compromised d. There are incompetent analyst e. There is infrequent use or expired control material f. Accuracy is not guaranteed g. Poor calibration/expired calibrators h. Failure to recalibration on reagent change i. Poorly maintained equipment j. Sampling errors/insufficient sample 3. Post-Analytical Errors: a. Transcription errors b. Wrong calculation c. Results on wrong form d. TAT e. Wrong patient results phoned out Page 5 of 13

6 f. Incorrectly heard phone call The Way Forward: 1. Situation analysis: useful for collecting quantitative and qualitative data on current status of laboratory services 2. Revision and implementation of existing national laboratory policy: Focus should be structure and coordination, staff retention, training and motivation, establishment of SOP s for equipment and technologies at each level, integration of services, equipment and maintenance. This can be achieved via problem definition-> agenda setting-> policy development-> implementation->policy evaluation. 3. Formulation of a National Laboratory Strategic Plan (NLSP): When developed, the strategy will form a basis for harmonized planning and realistic operational plans that will address technical, legal logistics, quality and financial issues. 4. Establish & strengthen Laboratory Leadership: this will make for effective operation and sustainability of laboratory services. 5. Set up a National Public Health Reference Laboratory: This must be ISO accredited to coordinate National laboratory networks, provide training and continuing education. 6. Strengthen laboratory supply and distribution systems 7. Establish and strengthen laboratory quality assurance systems 8. Strengthen Laboratory Staff Training 9. Maintenance of Laboratory Equipment 10. Strengthen Laboratory Management Information Systems 11. Monitoring & Evaluation of Laboratory Services 12. Ensure adequate funding Accreditation and Clinical Laboratory Accreditation is a process in which an entity assesses the laboratory to determine if it meets a set of requirements designed to improve quality of care. Accreditation is usually awarded to a laboratory if they comply with international criteria and are competent to carry out their routine tasks. The WHO Regional Office for Africa (WHO AFRO) has established a 5-star scale as a basis for measuring accreditation standards. If laboratories fail to achieve an assessment score of at least 55%, they will not be awarded a star ranking. Some benefits to be attained with the WHO AFRO Accreditation include- Easy accessibility to public sector hospitals Affordability Scalability as plans are developed that involve regional, provisional and district laboratories within a few years. sustainability Page 6 of 13

7 Mrs. A. A. Jijoho-Ogun, GM Admin & Special Duties, LAWMA Biomedical Waste Management in Lagos State Hospitals Mrs. Jijoho-Ogun started by giving a brief demography and attributes of Lagos State, with emphaseis on the Industrial Estates, Business Districts, GDP contribution, available Health facilities, and the Nation s Tax position. Then she went ahead to explain the function of the Lagos Waste Management Authority (LAWMA). The Agency was created in 2005 by Edict No.5 to provide commercial and domestic waste services throughout Lagos State. LAWMA is responsible for collection and disposal of solid and medical waste. She explained that the objective of LAWMA was to transform Lagos into Africa s model Megacity while conforming to the MDG s Environmental Health, Education & Poverty Alleviation. She characterized healthcare waste as comprising of: 1. General Household waste- Non-risk waste which usually comprises 75-90% 2. Risk waste- comprises 10-25% Components of Biomedical Waste Management include: Waste segregation at point generation Collection and conternerization within the healthcare facility Containment and packaging Transport to treatment location Treatment or decontamination Transport to disposal site Discharge to solid waste landfill Challenges faced in Healthcare Waste Management include: 1. Inadequate planning for Healthcare Waste Management (HCWM) centrally by the three tiers of government. 2. Few healthcare facilities have HSE or Hospital Infection Control Committees 3. Inadequate funding for waste management in government owned or private healthcare facilities 4. Inadequate personnel training 5. High rate of personnel turn-over 6. Limited knowledge of hospital workers Solution to the above challenges: 1. Define the roles of all tiers and the healthcare facilities which include: a. Segregation of waste at every point of generation b. Use of appropriate primary collection equipment with appropriate colour coding i. Black= Non infectious waste (paper, food, packaging material etc) ii. Yellow = infectious waste (gloves, gauze/dressing, blood, IV fluid lines etc) iii. Red = highly infectious waste (Anatomical waste- teeth, placenta- and pathological wastesputum container, test tubes with specimen) iv. Sharps waste box= infusion sets, broken slides, ampoules or vials, scalpels, blades, needles, lancet, 2. All healthcare facilities must provide a budget line with sufficient funds and manpower dedicated to HCWM. Page 7 of 13

8 3. Provide facilities for all hazardous healthcare waste produced 4. Engage the services of registered healthcare waste collector to dispose waste properly. 5. NGO s can educate the communities on healthcare waste management. She concluded by encouraging people to partner with LAWMA in treatment projects and be an advocate for change. She also informed all that the State plans to purchase and install the Ecodas/Tanit Medical Treatment in all the TLS in future. Page 8 of 13

9 Dr. Modepeola Oludipe, Senior Quality Manager & Quality Coordinator, PharmAccess Nigeria Introducing International Standards & A Stepwise Recognition Model to Improve Quality of Care Dr. Oludipe defined Quality as: The degree of excellence as measured against standards The extent to which an organization meets client needs and exceeds their expectations Doing the right thing right, the first time Providing the right care for every person, every time. There are 3 aspects of Quality 1. Measurable- There must be adherence and compliance to standards 2. Appreciative- Excellence beyond minimal standards which require judgment of skilled and caring persons. 3. Perceptive- The degree of excellence that is perceived and judged by the recipient rather than the provider of care. The 3 aspects of Quality are important because Quality breeds Trust and paves the way for equity. Equity ensures that all groups in the society regardless of social strata or gender receive services which meet their need. Once a patient knows he (or she) is receiving good quality care when they need it, it breeds trust. She also said that information on the quality of care we provide can be obtained through Clinical audits, peer review meetings, morbidity & mortality meetings, effective use of clinical indicators, event management and incident monitoring. Achieving & Sustaining Quality Systems 1. Quality Control- All processes should be monitored to produce quality products and services 2. Quality Assurance- For the prevention of quality problems through planned and systematic documentation, training and reviewing processes. 3. Quality Management- For the management of people and issues involved in achieving sustained quality improvement. To achieve and sustain quality, every organization needs to have a quality system in place which is effective in tracking measurable quality. Tracking measureable quality entails developing and monitoring service standards. Some components of measurable quality are: Structure- the physical (environment, facilities and equipment) and organizational (staff structure) framework within which care is given. Process- procedures and practices implemented by staff. Outcome- the effect of care on the client inclusive of the cost of providing the care. Dr. Oludipe went on to introduce SafeCare by saying that it was an initiative that started in 2011 through a collaboration of PharmAccess Foundation, Council for Health Service Accreditation of Southern Africa- (COHSASA) and (Joint Commission International (JCI) with the intention to address the possibility of applying universal standards in developing countries. SafeCare was instituted to create standards that provide a solid, secure and realistic framework to ensure patients receive safe and optimal care despite resource constraints. The SafeCare structure meets the requirements of the International Society for Quality in healthcare (ISQua) and are intended for use by healthcare organizations, especially in resource constrained settings in Africa. Through the Facilities they work with, SafeCare seeks to provide the following: 1. Safe amenities for both patients and staff 2. Clinical services that meet the needs of the patients 3. Clinical support services that are available and easily accessible 4. Technical services to maintain an environment acceptable for patient care. 5. Hotel services that minimizes the risk of infection and provide a safe and clean environment. Page 9 of 13

10 6. A competent management structure to implement the required policies and procedures for an efficient organization. Quality Improvement Quality improvement is a systematic way of identifying gaps in an existing situation and looking for ways to improve and track improvement to close the identified gaps. It is based on the principles of quality management which focuses on systems; processes; use of data and teamwork. The key elements include: Quality Assessment, Quality Improvement plan and progress monitoring. Page 10 of 13

11 Dr. Peju Adenusi & Dr. Abayomi Sule, Business Development Medical Credit Fund The Drive to Deliver Quality in the Hospital- The Role of Information Technology Dr. Sule who spoke on behalf of Dr. Adenusi began by introducing the Hygeia Group, its subsidiaries with emphasis on the Hygeia Community Health Care and the Hygeia Foundation. He explained the Drivers of Quality Improvement investments and they include: 1. Management Outlook- Progressive Vs. Conservative 2. Competitors Strategy 3. Opportunities created by technological change Technophilic Vs. Technophobic 4. Status /Image Quality Image or Illogical image (superficial things) 5. Regulatory requirement 6. Market demand/customer requirement Requirements for Rational Investing in Quality Improvement 1. Triple Aim Test: The Triple Aim consists of Patient Safety, Efficiency and Client Experience. Rational investing in QI requires that the investment contribute to the attainment of the Triple Aim. 2. Strategy Alignment- investment must be in mine with the vision, strategic plan and positioning of the facility. 3. Market Demand- The market demand must be high enough to outweigh the assets. 4. The Return on Investment- distinction should be made between direct and indirect return on investment. 5. Need/priority- Is it a must have? 6. Other preconditions- Skilled staff, documented processes, integration with existing processes, maintenance costs, e.t.c. He also stated that from an Investment perspective, the major requirement for rational investment is the Positive Cash Flow. It was necessary to determine if the project will bring in more money as well as calculate the acquisition and operating costs. He concluded by saying that rational investing in QI requires a wholistic view- (from culture change, basic housekeeping, prioritizing and leadership buy in) and it is important to make a calculation before the decision is made. One should be mindful of the risk factors and be ready to invest in assets (equipments) as well as processes and skills (people). Page 11 of 13

12 Dr. Ngozi Onyia- Specialist Paediatrician Paelon Clinic Imperatives of Quality Dr. Onyia began with a brief introduction of herself and stated that Health care costs up to 10% of Global GDP and is increasing as a result of such factors as: Social issues that increase the cost of healthcare (e.g. Obesity, ageing population and identification and management of chronic conditions Technology A culture of waste She went on to say that with the advent of managed care and the NHIS in Nigeria, there has been anxiety and frustration experiences by participants as quality of care has become a serious issue., premiums are escalating, provider incomes are squeezed, and workdays are overwhelmed with paperwork and bureaucracy. She said there is therefore the need to try to balance cost and quality in the face of rising costs. This is because competition Is a powerful tool to drive improvement in quality and costs of products and services not just in healthcare but in all industries. Porter and Teisberg in Redefining Healthcare identified that misalignment arises from management of organizational problems. Principles of quality include: 1. Customer focus 2. Leadership and business results- leaders should create an appropriate environment to boost productivity the desire by all parties to achieve organizational objectives 3. Involvement of people at all levels 4. Process approach- efficient management of resources usually leads to desired results. 5. System approach- the understanding that the different but related processes of an organization contributes to its overall effectiveness. 6. Fact-based decision making 7. Continuous improvement- this should be a permanent objective of the organization. 8. Suppliers and partners- the relationship must be mutually beneficial to enable value creation. Dr. Onyia states that the enemies of value in healthcare were: too much care; too little care, wrong care and Waste. She went on to identity the drivers of poor quality in Nigeria and they include: Lack of consumer responsibility for cost New technology and supply driven demand Administrative costs imposed by health insurance Poor adherence to evidence Lack of focus on outcomes Zero-sum competition The Imperatives of Quality 1. Family/patient centered care 2. Measurement ) Outcomes and cost 3. Continuous improvement 4. Clarity about operations 5. Infrastructure design to fit operations 6. Appropriate elimination of waste 7. Leadership Page 12 of 13

13 Dr. Bosede Afolabi- Associate Professor & Consultant Obstertrician and Gynaecologit, LUTH Evidence Based Medicine in the 21 st Century Dr. Afolabi began by defining Evidence Based Medicine- EBM- as practicing healthcare based on real evidence, with a primary purpose to assist in clinical decisions. EBM evolved as a result of the incompetence of Mechanical based medicine. Levels of Evidence i. One properly designed randomized controlled trial ii. Well-designed controlled trials without randomization iii. Well-designed cohort or case-control analytic studies, preferably from more than one centre or research group. iv. Opinions of respected authorities, based on clinical experience, descriptive studies, case reports or reports of expert committees v. Expert opinion She also stated that although EBM is not available, the next best evidence should be used. The Five Steps to EBM Process 1. Formulate an answerable clinical question 2. Find the best evidence to answer it 3. Critically appraise the evidence for its validity, impact and applicability 4. Integrate the evidence with clinical expertise, patient values and context 5. Evaluate the efficiency & effectiveness of the above and find ways to improve performance. Advantages of EBM 1. Clinical effectiveness a. Provides the best possible effect b. The least side effects may be more than others 2. Cost effectiveness a. The use of the most effective drug available will save unnecessary costs 3. Quality a. Efficacy in diagnosis- treatment and medical b. Efficiency of prescription and management Disadvantages 1. Huge amount of information with limited time and skills 2. Good access to IT is essential 3. Evidence must be backed by experience 4. Fear of the unknown She concluded by saying that current situation should be diagnosed and goals set. (where are we? Where do we want to be?). then a strategy should be developed and an action plan to attain the pre-set goal. Method to be used must be determined and followed. Finally evaluation and monitoring should be done to ensure that processes are in line with the goal. Page 13 of 13