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1.1. Background of Union Background of Union Hospital Hospital
2.2. Development StagesDevelopment Stages
3.3. Project ObjectivesProject Objectives
4.4. ImplementationImplementation
5.5. Findings and ResultsFindings and Results
6.6. LimitationLimitation
7.7. Way ForwardWay Forward
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1. Background of UH1. Background of UH
• Opened in July 1995
• 1996: 110 beds
• 2013 : 433 beds
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1. Background of UH1. Background of UH
• Comprehensive private hospital with 433 beds Registered Comprehensive private hospital with 433 beds Registered with Department of Health in 1994with Department of Health in 1994
• Newest private hospital in Hong Kong Newest private hospital in Hong Kong
• Staffing above 1500 Full Time plus 100 Part Time Staffing above 1500 Full Time plus 100 Part Time
• 2012 Service volume 2012 Service volume o EMC (ER) attendance: 85,238
o Specialist OPD: 95,664
o Admissions: 36,438
o Operations: 24,798
o Deliveries: 7,393
o Occupancy rate (midnight census): 68.9%
o Bed utilization rate: 101.46%
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1. Background of UH1. Background of UH
Value, Mission, Vision Value, Mission, Vision
Professional, Reliable, Efficient, Friendly, Ethical and Resourceful
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1. Background of UH1. Background of UH
Management SystemManagement System
• 1999 to now : ISO Quality Management System (QMS) 9000 1999 to now : ISO Quality Management System (QMS) 9000 series series
• 1999 to 2010 : UK Trent Accreditation Scheme (TAS)1999 to 2010 : UK Trent Accreditation Scheme (TAS)
• Staff : SHS : General and work related Staff : SHS : General and work related OSH Ambassador WalkRounds : IOD OSH Ambassador WalkRounds : IOD
7. Number of self assessment risk issues and PSWR raised issues :7. Number of self assessment risk issues and PSWR raised issues :
5. Findings and Results5. Findings and Results
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8. Interview : Question mostly asked or mentioned : As indicated by 8. Interview : Question mostly asked or mentioned : As indicated by PSWR PSWR members, the following were asked most from the scribe’s report members, the following were asked most from the scribe’s report
5. Findings and Results5. Findings and Results
The other 9 were not asked at all.
Nos Question
18 When you observe the environment, what aspects of the environment do you think are likely to lead to patient harm?
18 Is there any recent incidents (eg sentinel events, medication errors) incurred in the department that lead to patient harm?
18 Have there been any near misses that could have been prevented?
18 What do you think the likelihood of occurrence / recurrence of the incident could be?
18 Is there anything we can do to prevent that incident? (eg alterations in the teamwork / environment / workflow)
18 When you make an error, do you always report it?
18 If you make or report an error, are you concerned about personal consequences?
6 Do you know what happens to the information that you report?
6 What do you think this department could do on a regular basis to improve patient safety?
6 Can you think of a way in which the system/environment fail you on a consistent basis?(eg information availability/clarity)
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9. Quantitative Data :9. Quantitative Data :
5. Findings and Results5. Findings and Results
Mth Jul Aug Sep Oct Oct Nov Nov Dec Dec Jan Jan Feb Feb Feb Feb Feb Mar Mar
Dept RMC UNEEMC ICU RDC CSSD OPT OFC EDC W09 W07 TDC TMEI TRMC TDHI THMC W10 W11 TotalNo of
Pre & Post WalkRounds among Pre & Post WalkRounds among
Staff in similar magnitudeStaff in similar magnitude
Commitment from Commitment from Management is very StrongManagement is very Strong
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10. Qualitative Data :10. Qualitative Data :
5. Findings and Results5. Findings and Results
• Facilitate communicate to build open culture Facilitate communicate to build open culture
• Assist staff to focus on patient safety and staff safety Assist staff to focus on patient safety and staff safety
• Willingless of staff and department head to discuss department issues Willingless of staff and department head to discuss department issues enhanced enhanced
• Timing control Timing control
• No cancellation of any planned WalkRoundsNo cancellation of any planned WalkRounds
• Raised issues entered as Risk Registry for close monitoring Raised issues entered as Risk Registry for close monitoring
• Specific environmental issues were included in new building plans Specific environmental issues were included in new building plans
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11. System Environment and Facilities Issues :11. System Environment and Facilities Issues :
5. Findings and Results5. Findings and Results
• Examples on Self Assessment Examples on Self Assessment
• Care and concerns onCare and concerns on : :
Patient Patient :: Privacy issue due to limited space Privacy issue due to limited space StaffStaff :: staff toilet, medical grade refrigerator, storage space, staff toilet, medical grade refrigerator, storage space, security of DD security of DD System System :: Power Failure DrillPower Failure Drill
• Concerns on environmentConcerns on environment : :
Commented by Hospital Chief Commented by Hospital Chief Executive Executive
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AchievementsAchievements……
5. Findings and Results5. Findings and Results
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AchievementsAchievements……
5. Findings and Results5. Findings and Results
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6. Limitations6. Limitations
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6. Limitations6. Limitations
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5)
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7. Way Forward7. Way Forward
Leadership Commitment : Leadership Commitment : Bennis et al remarked that: Major progress requires a multifaceted Bennis et al remarked that: Major progress requires a multifaceted leadership approach, implemented and revisited over time, and leadership approach, implemented and revisited over time, and includes activities, such as assessing a culture for safety, responding includes activities, such as assessing a culture for safety, responding to data, striving for high reliability, requiring transparency, foster to data, striving for high reliability, requiring transparency, foster communication and teamwork, setting meaningful goals and sharing communication and teamwork, setting meaningful goals and sharing outcomeoutcome
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7. Way Forward7. Way Forward
2)
1)
3)
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ReferenceReference
1. Kirkman-Liff B 2004 The structure, processes, and outcomes of Banner Health’s corporate-wide strategy to improve health care quality. Quality Management in Health Care 13(4):264-78
2. Frankel A.S., et al.: Patient Safety Leadership WalkRounds Guide.2004 Institute of Health Improvement3. Frankel A., Haraden C.: Shuttling toward a safety culture: Healthcare can learn from probe panel’s findings
on the Columbia disaster. Mod Healthc 34:21, Jan. 20044. Frankel A, et al 2009 The Essential Guide for Patient Safety Officer, Joint Commission resources, Illinois 5. Building a safer NHS for patients 2001. UK Department of Health website:
http://www.doh.gov.uk/buildsafenhs/ch6.htm6. Joint Commission Resources 2008 Patient Safety Rounds: A How-To Workbook, USA7. Leape L. Can we make health care safe? In: Reducing medical errors and improving patient safety. A
report of the National Coalition on Health Care and the Institute for Healthcare Improvement. Available at: http://www.qualityhealthcare.org/ihi/uploads/medical_errorsACT.pdf. Boston: ACT:2000 Feb
8. Peter C, Aly H 2009 Patient Safety First : Leadership for Safety: Supplement 1 : Patient Safety Walkrounds, UK
9. Hospital Authority (2012). Hong Kong Hospital Authority Clinical Governance Review Report. Available :http://www.ha.org.hk/haho/ho/pad/clinical_governance_review_en.pdf
10. Australian Health Care Facilities. The Australian Council on Health Care Standards, Sydney11. Connor M., et al.: Creating a fair and just culture: One institution’s path toward organizational change. Jt
Comm J Qual Patient Saf 33:617-624, Oct 200712. Institute of Medicine: To Err Is Human: Building a Safer Health System Washington, DC National Academy
Press, 200013. Joint Commission Resources 2012 Even More Mock Tracers, USA14. International Patient Safety Goals, Joint Commission Resources 15. Agency for Healthcare Research and Quality: 30 Safe Practices for Better Health Care.