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CHALLENGES IN IMPLEMENTING THE PATIENT

SAFETY GOALS & CLINICAL INDICATORS:

The KPJ Experience

KPJ Healthcare

CONFERENCE & EXHIBITION

22–

 24 August 2014, Putrajaya

Dato’ Dr Shahrudin Mohd Dun 

Chairman –  KPJ Group Clinical Governance Action Committee

Medical Director & PIC –  KPJ Selangor Specialist Hospital

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KPJ SELANGOR SPECIALIST HOSPITAL

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PRACTICAL ELEMENTS IN CLINICAL GOVERNANCE

1. Patient Safety Goals (PSG)

2. Clinical Indicators (CI)

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IMPLEMENTATION

1. Patient Safety Goals – 2010

2. Clinical Indicators – 2000

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2002 – 55th World Health Assembly Resolution

PATIENT SAFETY

WHO - World Alliance for Patient Safety

GLOBAL INITIATIVE ON PATIENT SAFETY

Malaysia – Commitment on patient safety

KPJ Healthcare BerhadGroup Medical Advisory Committee – 4/3/2008

# 7 Patient Safety Goals

# Adopt & Implement in all 19 hospitals

# Aim is to improve safety & minimize clinical errors

PSG - Background   

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  1. Identify patients correctly

2. Improve effective communication

3. Improve the safety of using medications

4. Accurately and completely reconcile medications

across the continuum of care

5. Ensuring correct-site, correct-procedure and

correct-patient for surgery

6. Reduce the risk of healthcare-acquired infections

7. Reduce the risk of patient harm resulting from falls

PATIENT SAFETY GOALS  

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CLINICAL INDICATORS (20)  

1. Rate of LSCS (Caesarian Section) 

2. Length of hospital stay > 5 days after elective LSCS 

3. Length of hospital stay > 5 days after emergency LSCS 

4. Time lapsed from declaration of emergency LSCS to start ofsurgery 

5. Rate of white appendix 

6. Percentage of cases with HPE done for Appendicectomy 

7. Myocardial infarction (MI) case fatality rate 

8. Percentage of MI patients receiving thrombolytic therapy within 1

hour of their presentation at the A&E 9. Rate of CT scan done for head injury 

10.Occurrence of adverse events during the recovery period in OT 

11.Unplanned admission to the ICU within 24 hours of surgery 

12.Laparoscopic cholecystectomy discharges within 48 hours 

13.Rate of reactionary post-tonsillectomy bleeding 

14.Incident rate of neonatal hyperbilirubinaemia > 20mg/dL

15.Incident of casting (neurovascular) complications 16.Adequacy of PAP smear study 

17.Apgar score of baby at 5 minutes for emergency LSCS 

18.Mild-to-moderate head injury case fatality rate 

19.Dengue fever fatality rate 

20.Percentage of post-operative cataract patients with BCVA less than

6/9 at three months after surgery 

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IMPLEMENTATION of PSG CI

- Advantages of being a group

1. Can be done in stages

2. Workload is shared

3. Problems are shared & solved together

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IMPLEMENTATION of PSG CI

- Advantages of being a group (2)

1. Clinical & Corporate work together

2. Everyone must understand PSG & CI

3. Principles – applications – benefits

Aim – Advocate patient safety

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IMPLEMENTATION of PSG CI

- KPJ experience (1)

1. PSG & CI are not implemented overnight

2. New idea – Huge challenge & arduous task

3. Implementation process – several stages

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IMPLEMENTATION of PSG CI

- KPJ experience (2)

The implementation process involved several phases 

1 – Training & Education

2 - Hospital-wide Awareness –  Most challenging part  • Medical / Nursing / Allied Health / Other hospital staff

• Patient & Relative awareness

• Time factor

3 - Development of tools, posters, booklets

4 - Upgrading of facilities5 - Audit schedule

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  # KPJ Group – 19 hospitals, varying sizes & resources 

CHAMPION HOSPITALS 

* Subcommittee for designated patient safety goal (PSG)

* Develop workable generic guidelines/procedures, to be

implemented throughout the Group

* Develop, pilot study, monitor, evaluate by November 2008

IMPLEMENTATION of PSG CI

- KPJ experience (3) – “The Journey” 

4/3/2008 – KPJ MAC Directive

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IMPLEMENTATION of PSG CI

- KPJ experience (4) – “The roup Initiatives” 

Hospitals identified to champion the PSG 

PSG 1 – KPJ Ampang Puteri Specialist HospitalPSG 2 – Tawakal Hospital

PSG 3 – KPJ Johor & Puteri Specialist Hospitals

PSG 4 – KPJ Johor & Puteri Specialist Hospitals

PSG 5 – KPJ Ipoh & Kuantan Specialist Hospitals

PSG 6 – KPJ Damansara & KPJ Penang Specialist HospitalsPSG 7 – KPJ Selangor & KPJ Seremban Specialist Hospitals

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  * KPJ Medical Workshop 

Mid-year 2008

- Initial work presentation by champion hospitals

- Corrections

- Improvements

- “Tailoring” to generic 

* KPJ Medical Conference 

December 2008- Progress

- Evaluation

- Initial pilot study results

IMPLEMENTATION of PSG CI

- KPJ experience (5) – “The roup Initiatives” 

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 * KPJ Medical Workshop 

Mid-year 2009

- KPJ Patient Safety Goals’ Manual approved 

- Distributed to all hospitals

* Datelines in 2010 

June - Audit on implementation statusDecember - Full implementation

IMPLEMENTATION of PSG CI

- KPJ experience (6) – “The roup Initiatives” 

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Patient Safety Goals – MANUAL / CD

KPJ GROUP INITIATIVES (7) 

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Patient Safety Goals – MANUAL / CD

# For each Goal 

* 1.0 Patient Safety Guideline Content

- Introduction

- Policy Statement- Objective/Definition

- Scope of Guidelines

- Training/Guideline monitoring

- Conclusion/References

* 2.0 Standard Operating Procedure (SOP)

* 3.0 Training Module

* 4.0 Appendices

KPJ GROUP INITIATIVES (8) 

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  * HOSPITAL CLINICAL GOVERNANCE COMMITTEE

Hospital level MAC (HMAC)

- MD/Chairman

- Supervise PSG implementation

* PSG Subcommittee 

- MD & CEO as Co-Advisors- Implementation schedule

- Monitors progress

- Reports to HMAC & Hospital Board

KPJ SELANGOR - PSG IMPLEMENTATION (1) 

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  PSG SUBCOMMITTEE 

* MD & CEO - Advisors

* Chief Nursing Officer - Chairperson PSG Subcommittee

Clinical   Non-Clinical 

Physician Operation Manager

Orthopaedic Surgeon Quality Manager

Chief Pharmacist Risk & Safety Officer

OPD Unit Manager Chief Physiotherapist

Chief RadiographerMedical Records Executive

+ Personnel-in-charge of each Goal

KPJ SELANGOR - PSG IMPLEMENTATION (2) 

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  * PSG Subcommittee # Management support & cooperation

# KPJ-PSG implementation dates

PSG 7 - 11/2/09 (Champion hospital)

PSG 6 - 20/5/09

PSG 1 - 7/12/09

PSG 2 - 7/12/09PSG 3 - 17/2/10

PSG 4 - 17/2/10

PSG 5 - 1/3/10

KPJ SELANGOR - PSG IMPLEMENTATION (3) 

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  * IMPORTANT FACTS - Clinical & Corporate cooperation

- Everyone to understand the goals

Hospital-wide Awareness

Understands principles, application, benefits

Adherence to goals

ADVOCATING PATIENT SAFETY

KPJ SELANGOR - PSG IMPLEMENTATION (4) 

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“BACK TO BASICS” 

FORMALIZING THE BASICS

KPJ SELANGOR - PSG IMPLEMENTATION (6) 

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PSG 1 Identify patients correctly (1)

• Checklist for verifying identity of patient

• ID bands

• Admission letter

• Inpatient admission form

• Inpatient orientation form

• Laboratory request form

• Imaging request form

• Drug administration record

• Discharge summary

• Discharge checklist

• Death registration

• Body identification form

• Burial permit form

• Outpatient registration form

• Outpatient transfer form

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PSG 1 Identify patients correctly (2)

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PSG 2 Improve effective communication (1)

TAWAKAL SPECIALIST HOSPITAL

• Checklist for nurse’s reporting to a doctor • Alert communication for critical test results

• Guidelines on hand-over of a patient

• Guidelines on verbal telephone orders

• Guidelines on abbreviations

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PSG 2 Improve effective communication (2)

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PSG 3 Improve the safety of using medications

KPJ JOHOR & PUTERI SPECIALIST HOSPITALS

• Monitoring checklist• SOP labeling of medications

• SOP issuance of drugs to out/in-patients

• Identification & handling of LASA drugs

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PSG 4

Accurately/Completely reconcile medications across the continuum of care

KPJ JOHOR & PUTERI SPECIALIST HOSPITALS 

• Monitoring checklist – staff awareness/implementation

• SOP Reconciling medications

• Medication diary

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PSG 5

Ensure Correct-Site, Correct-Procedure, Correct-Patient for Surgery

KPJ IPOH & KUANTAN SPECIALIST HOSPITALS

• SOP Consent

• SOP Operation Theatre

• Sign-in, time-out, sign-out checklist

• SOP Diagnostic Imaging

• SOP Radiotherapy & Oncology

• SOP Verification Correct Site for invasive procedure

• Posters

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Consent

Correct Patient

Correct Procedure

Correct Side and

Site

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PSG 6

Reduce the risk of healthcare-acquired infections

KPJ DAMANSARA & PENANG SPECIALIST HOSPITALS

• SOP Hand Hygiene – Hand washing

• SOP Hand Hygiene – Hand rub

• SOP management of various services (17)

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PSG 7

Reduce the risk of patient harm resulting from falls

KPJ SELANGOR & SEREMBAN SPECIALIST HOSPITALS

• Standard risk (Std precautions)v High risk (Strict precautions)

• SOP Fall Risk

• Fall Risk Assessment Tool

• SOP Lifting & Transferring of Patients

• Checklist for fall precautions

PATIENT’S STICKER  

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IMPLEMENTATION OF

FALL RISK ASSESSMENTTOOLS

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USE THE

STANDARD

ORSTRICT FALL

PRECAUTIONS

CHECKLIST

& S ff

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Public & Staff awareness

DISPLAY OF FALLS POLICY

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DISPLAY OFSIGNAGE

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Correct footwear Assess environment for safety hazards

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FALL AWARENESS CAMPAIGN

PICTURE WITH BADGE / BANNER

BROCHURES

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Useful points to consider

When you’re from lying down to standing up  Sit on the bed for a minute before you stand upMove your ankles up and down to get your blood

pumpingGet your “nose over your toes” before you stand up Push off the bed or chair; don’t pull up Wait a minute before you start to walk

When you’re walking  Take your time when turning around. Count

each step to help pace yourselfIf you have a walking aid, make sure it’s in good

condition

Use your walking aid appropriately. Don’t grab forfurniture

Wear suitable footwear that is non-slip andcomfortable

CARE

You will be checked regularly for toileting needs andgeneral nursing care

Make sure footwear is appropriate:Well fittingSoles in good repairLow heels

Don’t walk in stocking Clothing should be hemmed well enough to avoid

slipping or tripping over itWear glasses if you have them

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ASSISSTANCE☺ Ask for help from staff when

transferring or walking☺ Use the call bell and make sure

 you leave it within easy reach

RECOVER☺ Rest regularly to give your body time to recover☺ Use medicine for pain relief, to reduce

unnecessarystrain physically and mentally to aid your recovery

EXERCISE☺ Your physiotherapist will show you exercise you

can

do on your own or with supervision or assistance,to regain your strength and mobility

DIET☺ It is important to eat a nutritious diet that

includesfoods rich in:☺ Calcium e.g. dairy products, broccoli☺ Vitamin A e.g. carrots, yellow or orange

fruit or vegetables☺ Vitamin C e.g. citrus fruits and tomatoes☺ Vitamin D

☺ These foods promote healing, calciumabsorptionand bone rebuilding

KPJ GROUPS OF HOSPITALS 

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TRAINING & EDUCATION WORKSHOP

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  COMPLIANCE & EFFECTIVENESS 

* PSG Subcommittee regular / weekly meetings

* Continuous surveillance

* Audit – Regular / Random

* Statistical data / report – December 2010

KPJ SELANGOR - PSG IMPLEMENTATION

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IMPLEMENTATION PSG CI

Summary of challenges faced

1 - Mindset change – Focus on safety first, quality will then follow

2 - Create a workplace culture that encourages self-reporting

3 - Update infrastructure – involves costs

4 - Transition systems slowly – time factor

5 - Failure to communicate

6 - Work/staff inefficiency

7 - High error rate with tasks involving academic skills – making mistakes

8 - Problems learning a sequence of tasks

9 - Time management & social skills

10 - Diversity of opinion and interpretation

11 - Employee-employee/employer interaction12 - Motivation & productivity - Boredom, stress & burnout

13 - Handling criticism

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IMPLEMENTATION CHALLENGES

TO HAVE A STRONG WORKING CLINICAL

GOVERNANCE IN PLACE 

1. Group MAC – 2002

2. Hospital level MAC @ HCGC

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CHAMPIONS OF CLINICAL GOVERNANCE

Tan Sri Dato’ Dr Abu Bakar Suleiman 

 Former KPJ Group MAC Chairman

Datin Paduka Siti Sa’diah Sheikh Bakir  

 Former KPJHB Managing Director

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IMPLEMENTATION CHALLENGES

CLINICAL GOVERNANCE 

1. Group MAC – oversees implementation

2. Hospital MAC

- oversees locally

- addresses local problems

- reports back to Group MAC

STRUCTURE OF CLINICAL GOVERNANCE – KPJ SELANGOR

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STRUCTURE OF CLINICAL GOVERNANCE – KPJ SELANGOR

KPJHB BOARD KPJ MEDICAL ADVISORY COMMITTEE

CLINICAL GOVERNANCE POLICY COMMITTEE

CLINICAL GOVERNANCE ACTION COMMITTEE

CLINICAL RISK MANAGEMENT COMMITTEE

HOSPITAL MEDICAL ADVISORY COMMITTEE (HMAC)

7 HEADS OF CLINICAL DISCIPLINES

KPJ SELANGOR

BOARD OF MANAGEMENT

KPJ SELANGOR

BOARD OF DIRECTORS

6 CLINICAL COMMITTEES13 HOSPITAL COMMITTEES

MEDICAL DIRECTORS’ COMMITTEE 

CLINICAL ETHICS COMMITTEE

RESEARCH & DEVELOPMENT

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What does the clinical governance mean?

Effective working relationship between

Consultants

 Nursing Staff

Management & other hospital staff (Non-clinical)

IMPLEMENTATION CHALLENGES

CLINICAL GOVERNANCE 

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Hospital Medical Advisory Committee

Clinical Committees (per KPJ By-Laws) - 6  

Credentials, Audit, Ethics, Peer Review & Education

Mortality Review Committee

Infection Control Committee

Pharmacy & Therapeutics Committee

Medical Records Committee

Surgical & Medical Intervention Committee

Hospital Committees (per PHFSA / R & other requirements )  – 13  

OSH & Risk Management Committee

Quality Assurance Committee

Patient Complaints & Conflict Resolution @ Feedback Committee

Transfusion & Laboratory Committee

Hospital Credentialing & Privileging Committee

Hospital Disaster Management Committee

Hospital Radiation Committee

Hospital Building Committee

 Accreditation Committee

Lactation Management Committee @ BFHI

Code Blue Committee

Emergency Cardiovascular Care Training Committee

Consultant Fees Review Committee

CLINICAL GOVERNANCEORGANIZATION / STRUCTURE

# 2014 Example –  H ospital & Clin ical Committees in KPJ Selangor

8/10/2019 Dato' Dr Shahrudin_Challenges in Implementing Patient Safety Goals and Clinical Indicators

http://slidepdf.com/reader/full/dato-dr-shahrudinchallenges-in-implementing-patient-safety-goals-and 53/57

Meetings -‘interactions

withinthe structure’

(1) Consultants

(3) Management / Non-clinical Staff

(2) Nursing Staff

Clinical & Hospital

Committee meetingsHOS / MR meetings

Ward / Unit / Department meetings

HMAC & BOM

meetings

CLINICAL GOVERNANCEORGANIZATION / STRUCTURE

8/10/2019 Dato' Dr Shahrudin_Challenges in Implementing Patient Safety Goals and Clinical Indicators

http://slidepdf.com/reader/full/dato-dr-shahrudinchallenges-in-implementing-patient-safety-goals-and 54/57

IMPLEMENTATION CHALLENGES

Group MAC

- oversees implementation PSG & CI- coordinates

- lessons learned shared & distributed

8/10/2019 Dato' Dr Shahrudin_Challenges in Implementing Patient Safety Goals and Clinical Indicators

http://slidepdf.com/reader/full/dato-dr-shahrudinchallenges-in-implementing-patient-safety-goals-and 55/57

8/10/2019 Dato' Dr Shahrudin_Challenges in Implementing Patient Safety Goals and Clinical Indicators

http://slidepdf.com/reader/full/dato-dr-shahrudinchallenges-in-implementing-patient-safety-goals-and 56/57

IMPLEMENTATION CHALLENGES

PIVOTAL ROLE OF KPJ NURSES

8/10/2019 Dato' Dr Shahrudin_Challenges in Implementing Patient Safety Goals and Clinical Indicators

http://slidepdf.com/reader/full/dato-dr-shahrudinchallenges-in-implementing-patient-safety-goals-and 57/57