QUALITY IMPROVEMENT AT THE SHELL HOSPITAL, WARRI DR. OLUFEMI MOSURO Dr. Okuns Ohiosimuan Dr. Rita Akintola Mrs. Nkem Osakwe SHELL IA HOSPITAL, OGUNU
QUALITY IMPROVEMENT
AT THE SHELL HOSPITAL, WARRI
DR. OLUFEMI MOSURO
Dr. Okuns Ohiosimuan
Dr. Rita Akintola
Mrs. Nkem Osakwe
SHELL IA HOSPITAL, OGUNU
SHELL IA HOSPITAL, OGUNU
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• To protect and preserve
the health of staff ensuring
a healthy workforce.
FOCUS OF SHELL HEALTH
STAFF
STAFF FAMILY
CONTRACTORS
IMMEDIATE COMMUNITIES
• Preventive & Curative Health
• Occupational Health
• Community Health
• Projects & products
SCOPE
OBJECTIVES OF SHELL HOSPITAL WARRI
5
To deliver effective and quality Health strategies and services in order to optimise the health of the stakeholders (employees, dependant, contractors and Neighbours)
QUALITY IN HEALTHCARE
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Doing the right thing
At the right time
In the right way
For the right persons
&
Having the best results/OUTCOME possible
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CRITICAL SUCCESS FACTORS IDENTIFIED
Quality of staff.
Quality of infrastructure and equipment.
High quality drugs and consumables.
Ready access to quality information, whilst maintaining confidentiality.
Quality of procedures and controls.
Timely emergency response capabilities.
Visible management commitment and adequate funding.
Good communication process in place.
ACCIDENT & EMERGENCY
HISTORY
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Before 2oo0 Health and Safety audits Site and facility inspection / audits Total Quality Management process External Clinical audits 2 yearly 2000 to 2003 HSE-MS ISO 14001 validation in 2000 Revalidation in 2003. 2005 UK IHC (SAQ) was used as a template to assess our quality of care 2007 In-House quality improvement program initiated with the partogram in labour review
May 2008 Enrolled in the COHSASA(ISQua) quality improvement and accreditation program
August 2010 Awarded Certificate of Accreditation for 27 elements of the hospital services
QA / QIP STRATEGIES
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Awareness lectures Part of Individual Tasks and Target (GPA) for yearly assessment
Developed a written guideline for implementation of QA and QI process
Defined roles and responsibilities (organisation chart)
Training in the use of IT tools (excel, PowerPoint, etc) and PDSA cycle.
Organisation Structure for Warri QIP
1
1
STRATEGIES
12
Individual projects Sectional projects
Cross sectional projects Cross divisional projects
WORKING GROUPS Malaria, Infection Control, Medical Emergency Response, Resuscitation, HIV/AIDS, Patient Medical Association, Communication (newly implemented) OTHERS: Computerisation of clinical process (SHIMS)
METHODOLOGY
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Areas for improvement identified by: Gap analysis of status quo against identified goals
Gold standard of practice (EBM)
ISQua requirements (COHSASA)
National policy on health
Patient preferences, etc
KPIs
Benchmarks
Learnings from Training updates
Customer satisfaction surveys
Transit time measurement
Management targets and business plan.
CRITICAL ACTIVITIES
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Data collection: quality of data is very critical
Data analysis and reporting
Audits:
Nursing Audits Documentation Audits Housekeeping audits Case outcome reviews Review and development of guidelines, protocols and policies Ensure ownership of all documentations and procedures (bottom up approach) Ensure value and quality of projects Proposal reviewed to assess value of projects
Tools: Training to use:-
Excel spreadsheet / PowerPoint etc PDSA cycle (Plan-do-Study Act) COHSASA SAQ
QUALITY IMPROVEMENT CYCLE
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Do rapid PDSA
cycles of
improvement
Identify improvement
opportunities
Measure
Quality Assurance Indicators
OPD & ER QA INDICATORS
0.00%
20.00%
40.00%
60.00%
80.00%
100.00%
Q1 Q2 Q3 Q4
92.69%
90.08%
90.47%
90.16%
Out patients satisfaction
Q1
12:48:58 AM
12:51:50 AM
12:54:43 AM
12:57:36 AM
1:00:29 AM
1:03:22 AM
1:06:14 AM
Q1 Q2 Q3 Q4
12:59:00 AM
1:04:00 AM
12:54:30 AM
12:54:30 AM
OPD transit time for 2010
Q1 Q2 Q3
12:00:00 AM
12:00:43 AM
12:01:26 AM
12:02:10 AM
12:02:53 AM
12:03:36 AM
12:01:00 AM
12:01:00 AM
12:01:00 AM
Average time to nurses care in Casualty Q1
Average time to nurses care in Casualty Q2
Average time to nurses care in Casualty Q3
12:00:00 AM
12:07:12 AM
12:14:24 AM
12:21:36 AM
12:28:48 AM
12:36:00 AM
Average time to doctors care in Casualty Q1
Average time to doctors care in Casualty Q2
Average time to doctors care in Casualty Q3
Average time to doctors care in Casualty Q4
CHRONIC ILLNESS QA INDICATORS
84%
86%
88%
90%
92%
94%
Q1 Q2 Q3 Q4
88%
92% 93% 91%
%HbA1c less that 7.5% (Diabetics)
Q1
85%
90%
95%
100%
Q1 Q2 Q3 Q4
92%
97%
90% 91%
Diastolic less that 90mm of Hg
Q1
Q2
0%
20%
40%
60%
80%
100%
Q1 Q2 Q3 Q4
83% 92%
100% 100% % Viral load
undetectable (HIV)
Q1 Q2
85%
86%
87%
88%
89%
90%
91%
92%
93%
Q1 Q2 Q3 Q4
88%
92% 93%
91%
%HbA1c less that 7.5% (Diabetics)
Q1
OBGY & INFECTION CONTROL QA INDICATORS
0.00%
0.05%
0.10%
0.15%
0.20%
0.25%
0.30%
Q1 Q2 Q3 Q4
0.27% 0.29%
0.00% 0.00%
Hospital wound infection rate
Q1
Q2
Q3
0%
5%
10%
15%
20%
25%
30%
35%
Q1 Q2 Q3 Q4
35%
18% 14%
35% Emergency CS rate for
2010
Q1
0
50
100
Q1 Q2 Q3 Q4
41.67
0 0
117.65
Perinatal mortality rate for 2010
(per 1000 live Births)
0.00%
1.00%
2.00%
3.00%
4.00%
5.00%
Q1 Q2 Q3 Q4
2.86% 3.03%
4.76% 4.35%
Malaria in pregnancy rate for 2010
Q1
Q2
Q3
Some unit based QI projects
Pain management
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0.0
0.5
1.0
1.5
2.0
2.5
3.0
Ohr 4hr 24hr 48hr
Year 2009 Average
2.9 2.5
1.7 1.4
Score 2009
Year 2009 Average Ohr
Year 2009 Average 4hr
Year 2009 Average 24hr
Year 2009 Average 48hr
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
4.5
Quarter 1
Ohr
30 MIN
4 HRS
24 HRS
48 HRS
ON DISH
•Prior to 2009, there was no formal policy on pain management in the children’s ward. Pain scales existed but there was no documentation of their use. •Training of nursing staff and doctors was undertaking using formal and informal lectures •A significant improvement in documentation was noted in 2000 in scores in the first 48 hours •There was a decision to further expand the monitoring and documentation period and Q1 of 2010 shows more scores of zero at 48hr and on discharge •Monitoring will be quarterly to maintain this quality of care that has bee attained Score Q1 2010
Partogram use in labour
Many patients (30%) were delivering without a properly filled partogram as at 2007 An intervention was initiated that involved an in-house training of our midwives on the use of the WHO partogram Result: partogram use is now 100% Repeated randomised checks are in place to insure that this is sustained
Partograms analysed
Complete and
Accurate
2%
Incomplete but
useful
58%Unhelpful
10%
None
30%
Documentation in A&E case notes
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0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0%
33%
0% 0%
13%
100% 100%
73% 73%
87%
2009 Compliant Notes
2010 Compliant Notes
•Attempts at analysis the doctor’s response time to the A&E revealed in 2008 that entry into the case note for critical times were not consistently entered. •In spite of appeals to improve on this, the analysis of data from 2009 showed still no significant improvement. •Following some brainstorming sessions, a decision was reached to implement a stamp in which these times are entered. •Result: A significant improvement in time entry. Some gaps still remain and this is currently been addressed.
Cost of suture materials during surgery
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2.5
6.6
8.5
2.0 2.3
5
7.5
1.8
0
1
2
3
4
5
6
7
8
9
QRT 1 2010 AV. SUTURES
QRT 2 . 2010 AV.SUTURES
•Prior to February 2009, suture wastage in the theatre was high as sutures were routinely opened and not used. • This practice was based on traditional Peri-op teaching which emphasises the anticipation of the surgeon’s needs •It was decided that sutures should only be opened when requested. •Analysis of the first two quarters of 2010 suggest that there is some decline in suture use
Result of the COHSASA Continuous Quality Improvement evaluation
COHSASA - Major System Scores
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COHSASA - Departmental Service Scores
27
GAINS
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•Improvement in team work •Better focus on work process and outcomes •Focus on appropriate skills and competences •Ownership of hospital processes by the grass root •Continuous improvement of services and outcomes. •QA trending helps to ensure faster response to quality issues •Externally assured quality of service
CHALLENGES
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•Erratic IT tool – encouraging manual data collection •Inadequate budget for learning and development •Business continuity challenges