Public Health Needs: Quality of Care and Sustainability an International Overview Dr. David Jaimovich President
Presentation Outline Present sustainable targeted projects that led to improvement in hospitals with limited financial resources Describe outcomes that: Successfully reduced waste of tangible and human resources Increased patient and personnel satisfaction Improved quality of care and patient safety Review how these strategies can be replicated in any setting
How Do We Select Projects? Leadership must be committed What are the needs of the organization? What will provide greatest return on investment? Is project aligned with the strategic plan and vision? Does this project have clear parameters and clearly defined goals? Will there be visible, measurable benefits for the client?
How Do We Select Projects? Cont. Targeted projects Realistic challenging but achievable goals Measurable results Start with a project that will be non-controversial and will not eliminate jobs Selection team leading the project Engagement of staff
Core Elements Education Team leading project Hospital staff Self-assessment standards Project design using healthcare Six Sigma methodology Measurement tools and tracer methodology Focus on solutions with the most return on investment
PDSA Cycle Quality Management System If goal is not reached introduce corrective and preventative actions Act Plan What do we want to do? How to do it? Track the performance of process Complete data analysis Verify correlation plan/results Study/Verify Do Do as planned Implement process and operational standards
Snowball Effect Act Plan Study/Verify Do
Peoples Republic of China
Chinese Hospital Association (CHA) Two year multi-hospital Quality and Safety Project Tier 3 hospitals selected by the CHA Hospital projects focused on: Medication Management IV Safety Hospital Acquired Infections Expanded to an additional year to include more hospitals
Multidisciplinary participation Educational Seminars Opportunity to collaborate applying basic and advanced tools Applied practical real-life examples Interaction amongst represented institutions
Solution Oriented Projects Used standardized project documentation and data collection tools: Project form Flow Diagram Process map Gnatt Chart Chronogram Function Deployment Matrix Pareto Chart Cause-Effect Diagram Strategic Plan Indicator Sheet Improvement Plan
Project Form Samples
Solution Oriented Projects Collected baseline data Used Six Sigma methodology to find defects Finalized and implemented improvement plans Confirm core processes and key customers Define customer needs Baseline measurement phase Analyze and set goals Implement improvements Control April May June July August September October November December Ongoing data collection to measure improvement over time
Validation Study Visits to each hospital by expert QRIntl consultants to review and validate data Validation reports were completed for each of the hospitals visited Included action plan report using the self assessment standards Recommendations for improvements based on findings
Closing Conference Focused on sustainable strategies for on-going quality and safety improvement Presentations by each hospital on their individual project and outcomes Educational Seminar - Yellow Belt Six Sigma certification training
The journey of a thousand miles begins with a single step Lao Tzu Examples of Projects
Hospital Quality Improvement Project Reduce Hospital-Acquired Infections Improve Hand Hygiene Compliance Among ICU Staff Tianjin Third Central Hospital
Baseline Observations and Implemented Measures Developed a hand hygiene questionnaire Learn about hand hygiene conditions Influencing factors (according to questionnaire responses) of hand hygiene practice Unannounced observers collected data on hand washing practices
Baseline Observations and Implemented Measures (cont.) Provided feedback for survey respondents implemented solutions as appropriate Example I: Busy work schedule Examined manpower distribution Calculated the time for performing hand hygiene Calculation was based on the total time spent on hand hygiene/day/healthcare personnel: 3 48 15 = 2160 seconds = 36 minutes (Each person is in charge of 3 beds and is expected perform an average of 48 hand hygiene procedures, each taking 15 seconds) Demonstrated that caseload should allow for time needed for adherence to hand washing
Baseline Observations and Implemented Measures (cont.) Example II: Water temperature is low in winter and hands are cold after hand washing or Frequent hand washing is damaging to the skin Provided the feedback to leadership - water temperature adjusted Added quick-drying, gel or disinfectant for hands with skin lotion added Provided training to share facts and eliminate concerns
Implemented Measures Provided education and added hand washing posters Designated personnel from the Department of Infectious Diseases perform monthly unannounced on-site inspections Nursing representatives monitor hand hygiene performance in the video surveillance room (periodically, unannounced) Head nurses report results of unannounced inspections to their staff Results of surveillance and the consumption of hand disinfectants and sanitizers are integrated into the staff performance assessment
Comparison of Hand Hygiene Compliance Before and After Intervention Utilized SPSS 11.0 for statistical analysis and compare the data between groups by using χ 2 test. A p<0.05 indicates the difference is statistically significant Group Times hands were washed Times hand were not washed Times hand washing was required Hand hygiene compliance Before intervention 38 37 75 51% After intervention 68 32 100 68% The compliance rate after the intervention was higher than before the intervention (p<0.05) Group 7:00 AM - 10:00 PM 10:00 PM - 7:00 AM Times hands were washed Times hand were not washed Times hand washing was required Hand hygiene compliance 68 32 100 68% 31 40 71 44% Comparison of Hand Hygiene Compliance Between 7:00 AM - 10:00 PM, the hand hygiene compliance rate was 68% Rate between 10:00 PM - 7:00 AM was 44% Hand hygiene compliance rate at night is lower (p<0.05)
Snow Ball Effect Added hand hygiene training for new staff, including advanced students, interns and visiting scholars Expanded to all departments Continuing to refine the hand washing surveillance system and explore effective surveillance methods hospital wide
Ecuador
Leadership Long-term Vision Internal External
Short Term Targeted Projects A public hospital and a Social Security Administration Hospital in Guayaquil Goals: Improve patient safety and clinical care quality Increase patient and staff satisfaction Reduce waste and misspending / corruption
Emergency Department Process Input Triage Registration Bed Throughput Care process Staffing Availability of specialists / diagnostic services Documentation systems Output Hospital admission Treat and discharge Death
Input Reorganized physical layout of department Introduced an urgent care area Rapid triage using Andorran Model Physician meets ambulance to triage, provide immediate care Nursing triage Quick registration process Focused history taking Focused assessments / reassessments Charge nurse focus on Traffic control Discharge and opening up beds Increased accountability and patient focus
Throughput Throughput and Output Team Approach to care Maintain consistency in communication Reduced the number of interactions Clear process to provide specialist care and diagnostic services Adjusted provider and nursing staffing patterns to revised patient volumes Output Discharge is a priority: Established timelines for patient transfer Streamlined reporting SBAR Observation unit Limit time holds
Results 1400 1200 1000 800 600 400 200 0 Ave. Patients per Day *Patients per Day range between 250-340
Snow Ball Effects Improved ED patient flow and triage system has allowed the transfer of staff to other areas With leadership support revising care processes for other departments Plans to expand to additional Social Security hospitals In process of implementing patient satisfaction process Evidence in media reports and social media that patient satisfaction has improved
Replicating Strategies Leadership support Practical support - time, resources, effort, cooperation Staff education and team development Important gateway to buy-in Always use: Systematic processes Standardized tools and methods Consistent methodology framework Quantifiable measurable data Realistic goal setting with incremental goals Constructive critical evaluation of performance
We can t solve problems by using the same kind of thinking we used when we created them - Albert Einstein
djaimovich@qrintl.com www.qrintl.com @QRIntl Quality Resources International, Inc.