Quality Management in Hospital Practice “Q” issue? Management... · 2016-02-05 · Q u a l i t y & S a f e t y Quality Management in Hospital Practice ... TQM CQI TQM 6 Sigma6

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in Hospital Practice

Current Movement and issues of Quality and Risk Management

in Hospital Authority醫管局品質及風險管理新動向

Dr. Lui Siu FaiConsultant (Q&RM), HAHO

Chairman, Central Committee Quality & Risk ManagementFor Management Seminar Workshop, Hong Kong College of Emergency Medicine

8 Jan 2008

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QUALITY

“Q” issue?

What “Q”?

Why “Q”?

How “Q”?

我萬二分的憂慮醫管局行政總裁蘇利民

Group Internal Audit

HAHO Organizational Structure 2006

Quality & Safety

ClusterServices

Strategy & Planning

Human Resources

CorporateServices Finance

7 CCEs

CE

HAHOQuality & Safety

Division(Dr P Y Leung)

Infection, Emergency

& Contingency(Dr S H Liu)

Clinical Specialty

Coordination(Dr M Y Cheng)

Clinical Standards

& Technology Assessment(Dr H W Liu)

Quality &

Risk Management(Dr David Lau)

Central Committee on Quality

& Risk Management(Dr. SF Lui)

Central Committeeon Infectious Disease

& Emergency Response(Dr. PY Leung)+ Dr. WH Seto

A new era of Working together to achieve a safe and high quality healthcare system

for our patients and staffSF Lui, David Lau, PY Leung

Central Committee on Quality and Risk Management10 April 2007

醫療失誤

醫療失誤

醫療失誤

醫療失誤

醫療失誤

醫療失誤

醫療失誤

醫療失誤

一些醫療潛在的

風險或併發症

誤解為

「醫療事故」

「醫療失誤」

突發(自然)死亡

誤解為

「醫療事故」

「醫療失誤」

Does HA has a Q issue ?

13797No of incidents report via AIRS (for 12 months)

5%740Investigation5

6%822Access, Admission, Transfer, Discharge4

14%1,994Medication3

17%2,328Staff (OSH)2

40%5,521Patient (injury/ behaviours)1

Incidents* reported by all clustersfor 12 months

Apr 06 - Mar 07

5,64321Severity Index

ExtremeMajorModerateMinorInsignificantTOTAL

* Not all reported incidents are medical incidents or errors, include general incidents

Complaint / FeedbackHospital Authority 2006

9902

2208

0

2000

4000

6000

8000

10000

Complaint Feedback

SETTLEMENT & COST FOR

MEDICAL ERRORS / NEGLIGENCE

$$,$$$,$$$.00

The Hospital AuthorityThe Hospital Authority41 Hospitals with inpatient service

15 Emergency Departments49 Specialist Outpatient Clinics23 Family / Integrated Clinics75 General Outpatient Clinics

53,468 staff

7,000,000 Patient records1,140,288 Inpatient admissions

2,028,569 Emergency visits1,867,377 Allied Health consultations

4,893,528 General Outpatient consultations 5,978,021 Specialist consultations338,161 Operation consultations

12,172 Ultra Major Operation107,758 Intermediate Operation

134,988 Major Operation187,904 Major Operation

41,683,593 Prescribed Drug Items

Complaint / Feedback / AppreciationHospital Authority 2006

2208

24821

9902

0

5000

10000

15000

20000

25000

Complaint Feedback Appreciation

What is Q?

Different views of Qs

(可作為頭條新聞的醫療事故)Media

平 靚 正 (快)Public / Patients

Fair working conditionAble to do good work

Staff

“Do as told / allowed / possible”Department / COS

X$ → XF → XE (Money, Food, Eat)

Cluster / Hospital

Patient-centred以人為本

HAHO

Definition of quality• the degree to which health services

for individuals and populations increase the likelihood of desired health outcomesand [the degree to which they] are consistent with current professional knowledge

• A scale, not an end state

Institute of Medicine: Crossing the Quality Chasm

Safety

EfficacyPatient-

Centredness

Timeliness (Access)

Effic

iency

Equi

ty

Crossing the Quality Chasm: A New Health System for the 21st Century. Institute of Medicine, 2001

Quality ServiceHaving the right service

for the right peopleat the right time

at an right (optimum) cost.

為有需要、適合的人在適當的時候

以適當的價錢提供適當的服務

Meeting the expectation* of the patient(*appropriate / realistic expectation)

Why Q?

PROFESSIONLISMOUR DUTYOUR PRIDE

Our patientsexpect of us

depend on ustrust on us

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Adverse events 74,400 to 1,243,200 annually, 98,000 death / yr8th leading cause of death > RTA, Breast Cancer, AIDS

“To cause harm to our patient”

- we, as professionalssurely do not want

it to happen,nor should we let it happens

The harm can be very serious,even death.

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A tourniquet left on after insertion

of iv catheter on a 21 years old

patient, gangrene of fingers required

amputation of part of all

5 fingers.Photofrom

a medical journal

What have What have we learnt ?we learnt ?

What must What must we learn ?we learn ?

A tourniquet left on after insertion

of iv catheter on a 21 years old

patient, gangrene of fingers required

amputation of part of all

5 fingers.Photofrom

a medical journal

A safe & A safe & high qualityhigh quality

healthcare systemhealthcare systemfor our patientsfor our patients

& staff& staff(Staff is / can be a second victim of the adverse incident)

How Q?

CQITQMCQITQM

6 Sigma6 Sigma

Lean ThinkingLean

Thinking

Quality Circle

Quality Circle

StandardsAccreditationStandards

Accreditation

Clinical Governance

Clinical Governance

Clinical Audit

Clinical Audit

Quality Control

Quality Control

Risk Management

Risk Management

Risk RegistryRisk Registry

RCARCA

FMEAFMEA

RiskReduction Programs

RiskReduction Programs

Quality AssuranceQuality

AssuranceBalance

ScorecardBalance

Scorecard

StructurePeople

Process

Outcome

To focus on the approachDonabedian Model

Avedis Donabedian 1919-2000

HAHOQuality & Safety

Division(Dr P Y Leung)

Infection, Emergency

& Contingency(Dr S H Liu)

Clinical Specialty

Coordination(Dr M Y Cheng)

Clinical Standards

& Technology Assessment(Dr H W Liu)

Quality &

Risk Management(Dr David Lau)

Central Committee on Quality

& Risk Management(Dr. SF Lui)

Central Committeeon Infectious Disease

& Emergency Response(Dr. PY Leung)

Central Committee on Quality & Risk Management

• Provide strategic advice on best practice thinking to drive quality improvement and risk management

• Lead and coordinate improvements in Q&S, including standards, quality assurance, accreditation

• Monitor and report on Q&S

• Disseminate knowledge for sharing, learning and advocate for Q&S

CCQRM Membership

Chairperson: appointed by D(Q&S) Consultant (Q&RM) or CM(Q&RM)

Members:

• Chairperson of 7 cluster’s Q&RM Committee

• Co-Chairpersons of CCQRM Subcommittees

• 1 Medical representative (CSC)• 1 Nursing representative• 1 AH representative • 1 CPO representative• 1 BSS representative• 1 IT representative

Ad hoc members:• Subject officers / coordinators

In Attendance: • Legal• Complaint Management• GIA

• 1 CS Division representative • 1 S&P Division representative • HAHO Q&S Division

(IEC, CSC, CS&TA, Q&RM)

± Cluster’s Q&RM Manager / deputy

Central Committee on Quality

& Risk Management(Dr. SF Lui)

Quality &

Risk Management

(Dr David Lau) CM (Ms. Annie Au) M

(Ms. Becky Ho) SNO

Clinical Standards

& Technology Assessment

(Dr H W Liu)

HKEC QRM CommitteeHKWC QRM CommitteeKCC QRM CommitteeKEC QRM CommitteeKWC QRM CommitteeNTEC QRM CommitteeNTWC QRM Committee

HAHO Q&RM - RM Unit- Risk Data TeamAIRS Working group

- Risk Reduction Program Teams - Sentinel event / rapid response team

- Q&RM IT Working group

HAHO Q&RM - Q Unit

- Standards & Accreditation Subcommittee

Complaint Management

Clinical Ethics

CC (Q&RM)Dr. HY So

PWHQ&RM

CoordinatorDr. KC Wong

SHQ&RM

CoordinatorDr. CM Lum

BHQ&RM

CoordinatorDr. Raymond Lo

SCHQ&RM

CoordinatorDr. WC Ip

AHNHQ&RM

CoordinatorDr. Nancy Leung

TPHQ&RM

CoordinatorDr. Emily Kun

NDHQ&RM

CoordinatorDr. Michael Cheung

DeptQ&RM

Coordinator

DeptQ&RM

Coordinator

DeptQ&RM

Coordinator

DeptQ&RM

Coordinator

DeptQ&RM

Coordinator

DeptQ&RM

Coordinator

DeptQ&RM

Coordinator

Manager (Quality)(vacant)

Manager (RM)Ms. Ellen Wong

HAHO CC Q&RM

SD (Q&RM)Dr. SF Lui

Organization Chart for NTEC Q&RM

HAHO CC Q&RM

StructurePeople

Process

Outcome

To focus on the approachDonabedian Model

PROCESS : Approach …..….. A safe and high quality healthcare system

for patients and staff..... Systematic, focused, prioritized, pragmatic

...... Meeting the needs of our patients (appropriately)...... Address the needs and concerns of our staff

Avoid adding (reduce) unnecessary workload for staff

….. To establish a safety and quality culture...... To facilitate system improvement

...... To enhance accountability (via Governance)

..... An incremental approach of rapid transformation- basic quality: FIRST DO NO HARM to highest CQI

- From Standards to ? Accreditation

….. Everyone’s business and duty, a core part of “Professionalism”

POLICY

A commitment for Safety & Quality at all levels

through a Risk Management and Quality culture, system and movement.

Quality: Ensure basic quality

Strive for highest appropriate quality improvement

Risk management: A proactive, reporting and learning culture

A Just culture will be adopted

Safety cultureSafety culturePatient and Staff Safety Patient and Staff Safety -- paramount importanceparamount importance

ProactiveProactivecultureculture

JustJustcultureculture

ReportingReportingcultureculture

LearningLearningCultureCulture

Quality & Risk Management FrameworkHospital Authority

QUALITYRISK

MANAGEMENT

CENTRAL COMMITTEE ON QUALITY & RISK MANAGMENT

RiskData

Risk Reduction Programs

Risk Circle

Quality assurance

QualityInitiatives

Quality Circle

3RsRM

3QsQM

Risk Circle

Learning & Sharing

Knowledge Management

RISK DATA

Components of 3Rs

RISK REDUCTION

PROGRAMMES

Risk Circle

Learning & Sharing

Knowledge Management

RISK DATA

Components of 3Rs

RISK REDUCTION

PROGRAMMES

RISK DATA

1a. Risk Observatory (data source)- Advance Incidents Reporting System

- Legal / public liability- Coroner case report

- Complaints- Safety Walk round

1b. Risk registry

13219

TOTAL

1Insignificant

2Minor

3Moderate

4Major

5,6Extreme

Incidents reported by all clusters for 12 months Apr 06 - Mar 07ACTUAL OUTCOME

Remote

Unlikely

Possible

Likely

Almost Certain

1

Insignificant

2

Minor

3

Moderate

4

Major

5,6

Extreme

POTENTIAL OUTCOME

2.2%

0.2%

1.7%

0.2%

3.0%

0.3%

0.6%

17.6%1.5%

41.8%3.4%

15.1%3.0%

1.9%

5.6%0.2%

6.2%%

Total No. of Case(s):Miscellaneous

Information System & Technology

Medical Device, Equipment & Pharmaceutical Products

Food Safety & Hygiene

Environment

Infection Control

Staff Related Issues (other than OSH)

Staff (Occupational Safety & Health)Visitor (injury/ Behaviours)

Patient (injury/ Behaviours)Blood Transfusion

MedicationCommunication and Consent

Treatment/ Care and Monitoring

InvestigationExamination & Assessment

Access, Admission, Transfer, Discharge

13,219

286

30

220

30

397

44

83

2,328195

5,521445

1,994390

245

74027

822Total

# 2

# 1

# 3

# 5

# 4

Incidents reported by all clusters for 12 months Apr 06 - Mar 07

821

22

8

6

2

30

1

20

25515

2176

10534

10

763

762007

100.0%

2.7%

1.0%

0.7%

0.2%

3.7%

0.1%

2.4%

31.1%1.8%

26.4%0.7%

12.8%4.1%

1.2%

9.3%0.4%

9.3%%

Total No. of Case(s):Miscellaneous

Information System & Technology

Medical Device, Equipment & Pharmaceutical Products

Food Safety & Hygiene

Environment

Infection Control

Staff Related Issues (other than OSH)

#1Staff (Occupational Safety & Health)Visitor (injury/ Behaviours)

#2Patient (injury/ Behaviours)Blood Transfusion

#3MedicationCommunication and Consent

Treatment/ Care and Monitoring

#4InvestigationExamination & Assessment

#4Access, Admission, Transfer, DischargeIndications

REPORTS BY A&E DEPARTMENT, ALL HA UNITS

0.7%1.1%2.6%22.5%73.2%

89561023201655All HA

121

95

93

146

120

41

39

0,1

Insignificant

35

31

32

9

49

14

31

2

Minor

8

5

3

2

4

1

0

3

Moderate

2

3

1

0

0

0

4

4

Major

0

1

0

1

2

0

2

5,6

Extreme

166

135

129

158

175

56

76

TOTAL

REPORTS BY A&E DEPARTMENT, ALL HA UNITS - OUTCOME

39301361771Medication

5826958341478162All

313431616621758Fall

Suicide 32

1

Insignificant

50

2

Minor

11

3

Moderate

2

4

Major

30 (death)

5,6

Extreme

Incidents reported by all clusters for 12 months Apr 06 - Mar 07ACTUAL OUTCOME

No. of Incidents (by cluster)No of reported incidents (by cluster)

0

50

100

150

200

250

300

Jul-06 Aug-06 Sep-06 Oct-06 Nov-06 Dec-06 Jan-07 Feb-07 Mar-07 Apr-07 May-07 Jun-07

Month / year

No

of re

porte

d in

c C1C2C3C4C5C6C7

C1

C5C4C3/6C2

C7

No. of Incidents (total)No. of reported incidents (total)

800

900

1000

1100

1200

Jul-06 Aug-06 Sep-06 Oct-06 Nov-06 Dec-06 Jan-07 Feb-07 Mar-07 Apr-07 May-07 Jun-07

Month / year

No

of re

porte

d in

cide

nts

Number

線性 (Number )Trend line

Risk Circle

Learning & Sharing

Knowledge Management

RISK DATA

Components of 3Rs

RISK REDUCTION

PROGRAMMES

RISK REDUCTION PROGRAMS

Clinical risks- Identification: Patient identification - UPI

Correct site, procedure - TimeoutInformation transfer – SBAR,Talk back [2008]

- Procedures: RestrainerNG TubePatient transfer

- Medication: Concentrated electrolytes (KCl) AllergyMedication reconciliation [2008]

- Fall- Patient missing- Suicide

- Consumables: single use devices- Devices: infusion pump

- Infection- Emergency & Contingency

Barcode scanning system(full implemented by Q1 2008 – except A&E) SepAugJulJunMayAprMarFebJan

151Request or sampling

2143312Miscellaneous

11Blood/ Component Administration - 1

11Blood issue and reporting

1Blood Bank (Pre-analytic)

11Blood Bank (Analytic)

12163534Adverse Transfusion Reaction - Minor

1Adverse Transfusion Reaction – Major

1Adverse Transfusion Reaction – Delayed

2531031265Blood Transfusion

RISK REDUCTION PROGRAMSOther risks

- Staff issues - Manpower - Competency- OSH

- Information technology- Facilities- Property- Finance- Corperate- Others

Risk Circle

Learning & Sharing

Knowledge Management

RISK DATA

Components of 3Rs

RISK REDUCTION

PROGRAMMES

RISK CIRCLEKnowledge Management Unit

Sharing, Learning (Communication)

Skills and tools transfer

- Forum, meetings(HA / cluster / hospital / department)

- iQR platform

- Circulars, flyers, posters, video clips

SKILLS & TOOLS:

• Root cause analysis (reactive)• Failure Mode Effect & Analysis (proactive)

• Tracer methodology• Safety Walk Round

• Self leaning tool (SLT)

SKILLS & TOOLS:The Self Learning Tool (SLT)• Aims:

- To provide a rapid and cost effective method to ensurelearning and retention of practical knowledge relevantto the practice of Emergency Medicine

- To provide an open platform to share knowledge andexperience.

- To enable organizational memory by passing onindividual clinical experience and building corporate-wide knowledge base.

• Expected outcomes - Trainees learn about essential clinical knowledge and

local AED guidelines- Most importantly, retention of these knowledge - Pass on past experience

a

RISK ALERT

A Risk Management Newsletter for Hospital Authority Healthcare Professionals

Message from CE Dear Colleagues, Ensuring our patients’ safety is our most fundamental responsibility. I’m pleased to introduce the first issue of HA Risk Alert (HARA), a periodic publication to keep everyone updated with local & overseas risks in healthcare settings. Sharing and learning are the cornerstones to improve patient safety. It is only by increasing our awareness and understanding of the potential risks that we can prevent medical errors from occurring. As part of the implementation of HA Sentinel Event policy, HARA serves as a communication channel for us to learn together from the sentinel events. Together we can bring in a positive change in patient safety. In this issue, the HARA covers some medical incidents that were previously reported to HAHO which would have been classified as Sentinel Event. We have also highlighted some “Near Misses” which have occurred locally, as well as risk alerts from overseas.

We wish to provide a Safe and High Quality Healthcare Service – Let’s do it together!

Shane Solomon, CE, HA

Message from CE

Sentinel Event sharing & learning

。Vincristine given in wrong route 。Retained gauze in patients

Local risk scanning

Global risk scanning

EDITORIAL BOARD ______________________________________-______________________________

Editors-in-chief

Dr SF LUI, Consultant (Q&RM), HAHO Dr David LAU, CM (Q&RM), HAHO

Board Members

Dr Nelson WAT, CD (PR&CA), HKWC Ms Anna LEE, SP (P&CSD), HAHO Ms Bonnie WONG, CM (Q&RM), NTWC Ms Becky HO, SNO (Q&RM), HAHO

LOCAL SENTINEL EVENT (1) Fatal error of Vincristine being given intra-thecally (wrong route)

At a busy ambulatory oncology centre, it was already 3 pm in the afternoon but many patients were still waiting for their intravenous chemotherapy treatment. A 21-year-old patient was waiting for her maintenance dose of intrathecal chemotherapy drug (c-ARA). She was also to receive her other chemotherapy drug – vincristine to be given intravenuously. After receiving one treatment procedure, she went home and was readmitted with headache. What had happened?

MAJOR CONTRIBUTING FACTORS

1. “System factors” – 2 drugs (one for IV and one for IT administration) were delivered together by pharmacy to the clinical area, the administration of the 2 drugs were at the same time and in the same location, imperfect labeling of the drugs, inadequate checking of the medication and route of administration by the staff.

2. “Education factors” - insufficient awareness that intrathecal administration of vincristine is fatal.

3. “Human error” - failure to follow existing guidelines in drug administration.

KEY RECOMMENDATIONS

1. Only specially trained and designated oncology staff should prescribe, prepare, dispense and administer cytotoxic medication.

2. Must use a formal checking procedure to ensure the “5 RIGHTS”, that is, right drug is given at the right dose, by the right route, at the right time and to the right patient.

3. Intrathecal chemotherapy must only be administered in an area where no other cytotoxic drugs are available & at a different time from other systemically administered drugs.

4. Vincristine should be prepared in a small-volume intravenous bag (minibag).

LEARNING POINT Vincristine can only be given intravenously

HOW DID IT HAPPEN?

Both IV vincristine and IT cytarabine were prescribed together for this patient on the same prescription sheet by Doctor A in the morning

Both drugs were supplied together in the same bag

Both drugs were put together on the same trolley prepared for the LP and

IT chemotherapy administration (Nurse A was not aware of the different routes for the 2 drugs)

In the afternoon, this patient (for IT & IV chemotherapy) was waiting with other patients who came for IV chemotherapy. Doctor B handled her

first to meet the closing time for laboratory test half an hour later.

Doctor B & nurse B checked the prescription but were not aware of the two different routes prescribed

Doctor B reviewed previous prescription sheet and noted the same drugs

had been given previously

Both vincristine and cytarabine were given INTRATHECALLY

IN THIS ISSUE

ISSUE 1 NOV 2007

Quality Circle

Learning & Sharing

Knowledge Management

QUALITY ASSURANCE

Components of 3Qs

QUALITYIMPROVEMENT

QUALITY ASSURANCE

Yardsticks1. Clinical Practice Protocols

2. Standard Operation Protocols3. Standards

Measurement / monitoring (data) 1. Key Performance Indicators

(Service performance indicators) (Clinical outcome indicators)

2. Audits 3. Standards

(Accreditation)

Clinical Practice ProtocolsStandard Operation Protocols

HA wide vs. Local version - StandardisationEasy reference - Day to day application

Standards (Section 3)

StructurePeople

Process

Outcome

To focus on the approachDonabedian Model

QUALITY ASSURANCE

Yardsticks 1. Clinical Practice Protocols

2. Standard Operation Protocols3. Standards

Measurement / monitoring (data)1. Key Performance Indicators

- Service performance indicators - Clinical outcome indicators

2. Audits

3. Standards (Section 3)(Accreditation)

OUTCOME

Service Performance KPIs

(Report Period : 1.7.2006 - 30.6.2007)

HA wide / Cluster

Framework: Service Performance KPIsFramework: Service Performance KPIs

Access Access (23 KPIs)(23 KPIs) Quality Quality (12 KPIs)(12 KPIs) Efficiency Efficiency (16 KPIs)(16 KPIs)1. Waiting TimesWaiting Times• A&E WT

• WT for SOP New Case Booking

• WT for specific investigation / treatment

1. AppropriatenessAppropriateness• Admission Rate for AED Pts

2. SafetySafety

• Unplanned readmission rate

• Infection rate

3. Service CoverageService Coverage

• HbA1c test

• VMO scheme

• New Psy drugs

4. Responsiveness Responsiveness

• (being dev)

1.. CostCost

• Drug cost

2. Efficient Use of Efficient Use of ResourcesResources

• Day Surgery Rate

• Bed occupancy rate

• Bed Management

• ALOS

• New case ratio for SOP service

• Utilization Rate of GOP service

KEY PERFORMANCE INDICATORS(KPIs)

Service performance KPIClinical outcome KPI

SATISFACTION SURVEYPatient Satisfaction Survey

(HA wide – to be implemented 2008)

Staff Satisfaction Survey

AUDITS

• AUDITS ++

• HA wide (GIA, COCs) Local / Department

• Need - Coordination - Clear aims, purpose- Methodology- Sharing of learning points- Follow up action

AUDITS – HA GENERAL INTERNAL AUDITS

HAHOQuality & Safety

Division(Dr P Y Leung)

Infection, Emergency

& Contingency(Dr S H Liu)

Clinical Specialty

Coordination(Dr M Y Cheng)

Clinical Standards

& Technology Assessment(Dr H W Liu)

Quality &

Risk Management(Dr David Lau)

Central Committee on Quality

& Risk Management(Dr. SF Lui)

Central Committeeon Infectious Disease

& Emergency Response(Dr. PY Leung)

HA surgical performance can be improved with the implementation of Surgical Outcomes Monitoring System – Conclusion from the two comparative

audits on Esophagectomy

Yuen WC1, Kwan TL1, Andy Wai1, Florence Lai2, Deska Siu21Central Surgical Audit Unit, HAHO 2Statistics and Research Section, HAHO

Presentation by CSAU

Mortality rates in HA

The mean in-hospital mortality rate in HA was 11%.It varied from 8% to 15%.

0%

2%

4%

6%

8%

10%

12%

14%

16%

1997 1998 1999 2000 2001

Presentation by CSAU

Hospital variation of mortality

One hospital was significantly better than othersTwo hospitals were significantly inferior to other hospitals

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

A B C D E F G H I J K L M N

?

?

*

Presentation by CSAU

Significant reduction in overall mortality

11.4%

5.3%

0%

2%

4%

6%

8%

10%

12%

2002 audit 2006 audit

P< 0.05

Presentation by CSAU

Trend of hospital mortalityThe reduction started in 2002 and dropped down to 2.8% in 2005

0

5

10

15

20

1997 1998 1999 2000 2001 2002 2003 2004 2005

%

Presentation by CSAU

Hospital variations

One hospital continued to be significantly better No hospital was significantly inferior to other hospitalFour hospitals showed significant improvement

*0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

20%

A B C D E F G H I J K L M N

Mortality rate

#

##

#

HK: 1 death in 16277

AUDITS by COC (Nursing)

Dendrite System

CSTA Report to CC(Q&RM) 12 Oct 07

• IT software for a HA-wide Clinical Audit Register

• IT software for Surgical Outcomes Monitoring and Improvement Programme

• Clinical indicators• Clinical staff competency

QUALITY ASSURANCE

Yardsticks

1. Clinical Practice Protocols2. Standard Operation Protocols

3. Standards

Measurement / monitoring

1. Key Performance Indicators(Service performance indicators)

(Clinical outcome indicators)

2. Audits

3. Standards - Section 3

(Accreditation)

Cluster X Hosp 1 Hosp 2 Hosp 3 Hosp 4 Hosp 5 Hosp 6 Hosp 7Level L1 L2 L3 L1 L2 L3 L1 L2 L3 L1 L2 L3 L1 L2 L3 L1 L2 L3 L1 L2 L3

Standard 1 Accident and EmergencyStandard 2 AccessStandard 3 Patient assessmentStandard 4 Hospital bed utilizationStandard 5 Discharge and transferStandard 6 Patient rights and responsibilitiesStandard 7Standard 8Standard 9 Informed consentStandard 10Standard 11 Media communicationStandard 12 Public and patient feedbackStandard 13 Assessment and documentationStandard 14Standard 15 Laboratory servicesStandard 16 Point of care testingStandard 17 Radiology servicesStandard 18 Care delivery for all patientsStandard 19 Missing patientsStandard 20 ResuscitationStandard 21 Blood and blood productsStandard 22 DialysisStandard 23 Physical restraintStandard 24 Patient fallsStandard 25 Prevention of pressure soresStandard 26 Anaesthesia careStandard 27 Surgical careStandard 28 Intensive careStandard 29 Medication managementStandard 30 Food therapy and nutrition therapyStandard 31 Risk managementStandard 32 Infection ControlStandard 33 Fire safetyStandard 34 Emergency preparednessStandard 35 Clinical and radioactive waste managementStandard 36 Medical equipment managementStandard 37 Water and electricity supplyStandard 38 SecurityStandard 39 Occupational safety and healthStandard 40 Food safety and hygieneStandard 41 Procurement and materials managementStandard 42 TelecommunicationStandard 43 Patient transport (non-emergency)Standard 44 Hospital Linen supplyStandard 45 Environmental managementStandard 46 Human resourcesStandard 47Standard 48Standard 49Standard 50Standard 51 Patient clinical recordStandard 52 Information managementStandard 53 Information to suport continuous patient

careStandard 54 Management of informationStandard 55 Finance

Summary of Scores for all Standards

Yes Y0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Partial P0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

No N0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Not applicable NA0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Total0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

(Y: yes, P: partial, N: no, or NA: not applicable)

STANDARDS REPORTS 2007-2008 (As of 31 Mar 2008)Cluster

(Y: yes, P: partial, N: no, NA: not applicable)

HAHO CCQRMStandards & Accreditation Subcommittee

• Co-Chairpersons: Dr. Loretta Yam (accreditation), Dr. CC Luk (standards), Dr. SF Lui

• Members

Ms Kate Choi Clinical Audit Manager (CND) HKWC representativeDr. Anne Kwan CC(3), UCH, KEC representative Ms. Eva Liu CC(RM), KCC representative Dr. KL Chung SD(Q&RM), NTWC representativeDr. HY So CC(QM), NTEC representative

Dr. Derrick Au KCCDr. Patrick Li KCCDr. Andrew Yip KCCDr. Joseph Lui KWCMs. Sylvia Fung KWCMs Mary Wan HKECMr. Jimmy Wu

• In attendanceDr. Beatrice Cheng, HOCS CM, CS(CP) (HAHO CS representative)Dr. Alywin Chan, HOS&P SM(PC) (HAHO S&P representative)Dr. David LauDr. HW LiuDr. PY LeungChairperson of HAHO NQRM

• Ad hoc members - subject officers as required.

Consultancy Report on Quality at HA& The way forward

Report from Subcommittee on Standards & Accreditation12 October 2007

Dr. Charles Shaw and Ms. Francis Smithwith HA for 10 days in June 2007

To review, in an international context, existing policies, structures, methods and resources

applied to improving quality and safety in HATo make recommendations to strengthen

coordination and development of Q&S

Recommendations1. Policy

HA should

• Develop explicit quality policy and strategiesfor improvement to reduce existing variations in perception over the scope/dimensions/principles of managing Q&S

• Engage internal and external stakeholdersin formulating policy and celebrating achievements

• Reflect the recognition of quality and performancein hospital funding and anticipate future competition for resources

• Ensure best practices are shared systematicallyacross staff in all hospitals/clinics, and disseminate accurate and positive messages to the publicon service availability and performance

Recommendations2. Organization and management

• HA should identify equivalent units/cells of the HA Q&S Division in other HA divisions, clusters and DH towards clarity and consistency in communication/practice.

• COCs should define clinical standards/systems, measure/ demonstrate effective clinical practice/outcome improvement for objective assessment, change management and impact evaluation across clusters.

• Responsibility and authority for clinical governance and formal organisation of medical staff should be defined and documented.

• Quality is everybody’s business: Every staff should share ownership and participate in scheduled peer reviews.

• HA should issue general guidance to clusters on effective organization, methods and resources required for continuous quality improvement.

Recommendations3. Methods

• The currently voluntary annual self-assessment against Section 3 Standards should be made mandatory, to ensure hospitals comply with statutory requirements and monitor progress against annual plan.

• HA should review the aggregated results of the self-assessment tool (adapted from WHO EURO) completed by clusters towards a general impression of how Q&S are institutionalised at the cluster level, and to validate and explore the gaps/variations identified.

• A system is required to pool methods/results/ benchmarks and share problems/solutions/learning among clusters/hospitals.

• Hospitals should submit standard profiles of projects to a secure virtual centre moderated by the Division of Q&S.

• HA could develop a technical manual of methods and templates to support standardization /dissemination.

• All surveys/audits/reviews must feed into the management process, to ensure explicit actions locally or centrally through operational and strategic planning processes in order to change the behaviour of people and organizations.

• Standardised surveys of patients’ experience should be applied by clusters to assess compliance to the HA Charter, and the results provided to HA Board ± the public at large.

• A program should be developed to define/measure/ improve organisational and clinical standards, incorporating key features for effective organisational development, including:

• Programme governed but not dominated by stakeholders• Standards/system developed locally with stakeholders • Compliance measured by self-assessment, peer review and statistical indicators• Recommendations for improvement based on the standards• Standards, processes and headline results of hospital assessments in the public domain

Recommendations

Option 1• Program development in HA involving frontline and

stakeholders according to internationally recognized principles.

Option 2• Using external accreditation

Option 3• Explore the feasibility of partnering with an organization

which is currently offering an internationally recognized external accreditation program

Clinical Governance• Clinical Governance is the system

by which the governing body manages and clinicians share responsibility and are held accountable for patient care, minimizing risks to consumers and for continuously monitoring and improving the quality of clinical care.

• Can be used as the operation modeat hospital / department level to ensure quality

Australian Council on Healthcare Standards ACHS News 2004; 12:1-2

Quality Circle

Learning & Sharing

Knowledge Management

QUALITY ASSURANCE

Components of 3Qs

QUALITYIMPROVEMENT

QUALITY IMPROVEMENT

1. CQI

2. Technology Assessment

CONTINUOUS QUALITY IMPROVEMENTS

• Continuous improvement of basic operation• Thrive for excellence

• Explore / apply alternative CI methods

Quality Circle

Learning & Sharing

Knowledge Management

QUALITY ASSURANCE

Components of 3Qs

QUALITYIMPROVEMENT

QUALITY CIRCLEKnowledge Management Unit

Sharing, Learning (Communication)

Skills and tools transfer

- Forum, meetings(HA / cluster / hospital / department)

- iQR platform

- Circulars, flyers, posters, video clips

Add: Q&RM

Useful information on the website +++

HA intranet website for Q&S

will be updated

Keynote speaker : Dr Lee Chien EarnEnsuring Healthcare Performance at Hospital Level – Singapore Experience

Other speakers : Dr Leung Pak Yin, D(Q&S), HOQ&SDr S F Lui, SD(Q&RM), NTEC/Cons(Q&RM), HOQ&SDr Nancy Tung, SD(CS), NTEC/HCE, AHNH & TPH

16 June 2007 (Saturday)9:00am – 1:00pm (Registration at 8:45am)Shaw Auditorium, School of Public Health,CUHK, PWH

:::

DateTimeVenueCME

A survey on the adequacy & effectiveness of information to ICU patients’ relatives upon admission

Healthcare utilisation in morbidly obese patients with obstructive sleep apnoea syndrome

Quality of Life in Chinese Patients with Hepatobiliary Cancers under Palliative Care

Empowering and relieving stress of caregivers of infirmary patients

Waiting For Rehabilitation Or Rehospitalization At Private Old Aged Homes? The Enlightening Solution-Service Purchasing

A study on the knowledge of Accident &Emergency Nursing Staff in the preparation of inter-facility transport in Hong Kong

Correct Identification (CID) in Blood Sampling in Critical Care Medical Unit

Clinical Pharmacist Intervention Program: The Management of Hyperphosphatemia in Patients with Stage 5 Chronic Kidney Disease in a Specialist Outpatient Clinic

An evaluation of performance following the introduction of inter-facility transport triage guideline

Experience in providing night time inter-facility transport services by AED of AHNH

A Public Private Partnership Project – The “Tai Po Viral Hepatitis B Search"

Inter-facility Transport Triage Guideline (IFTTG): Achieving an improvement in compliance

Comparison of outcome between two groups of first episode psychosis (FFP) patients with different pathways to care

An overview of the inter-facility transport of surgical patients from AED of AHNH

‘We Care’ - Geriatric assessment program in Accident & Emergency Department --The role of Community Nurses

Physical Restraints in Acute Medical Wards – Promoting Staff Competence

Clinical experience of a cognitive behavioural-based pain management programme for Chinese chronic pain patients

A Nurse-led Urinary Catheter Weaning Program in Geriatric Day Hospital

Physical Restraints in Acute Medical Wards – From Guideline to Practice

Innovation in medical clinical crisis training using a human patient simulator

A Survey of Traditional Chinese Medicine Treatment in Chinese Patients with Chronic Pain

Caring for Staff: Assessing Measures to Improve Healthcare Provisions for Carers

A survey on workplace safety and care measures

Focused Geriatric Assessment (FGA) in the Observation Ward (O Ward) of an AED reduces admission to the Medical Ward

One nurse one plan in New Territories East Cluster

Telephone triage in peritoneal dialysis population

Trauma care systems: a comparison of trauma care in Victoria, Australia and Hong Kong, China

The Evolution of Advanced Practice Role of Operating Room Nurse during Computer Assisted Orthopaedic Surgery

Knowledge, perceptions, and preferences of prenatal tests for Down syndrome among Hong Kong Chinese Women

Pharmacist-managed anticoagulation clinic in PWH – A new model in pharmaceutical care

Cardiopulmonary resuscitation (CPR) drill: a study to examine the staff’s perception

Non-compliance of Hip Protectors in Hip Fracture Elderly

An expenditure-saving cluster-wide cyclosporin A service with improved analytical performance

Work Smart with Confidence to built Quality Control Systems; Enhance Efficiency though innovation and support

Enhance competency in peri-operative anaesthetic nursing through a three-levels training program

To Evaluate Staff’s Perception on Functional Teams in Ward Management and Clinical Improvement Activities

Frontline nurses need a practical guideline: revised 3 checks and 5 rights on drug administration

Cost effectiveness analysis of protocol driven barium enema performed by radiographers – one year experience

Successful Reduction of Septic Complication in Transrectal Ultrasound Guided Prostatic Biopsy with Aggressive Combination Antibiotic Regimen and Fleet Enema Prophylaxis

An audit of out patient referral letter to specialist out patient clinic with reference to the Clinical Management System(CMS)

Quality assurance program on management of acute retention of urine for geriatric hip fracture patient

Bicycle-related injuries presenting to a trauma centre in Hong Kong

Quality of life of patients with nasopharyngeal cancer further to 5 years after curative treatment

Lifestyle Habits of Healthcare Staff

Impact of social support on the regimen compliance of pregnant women diagnosed with gestational diabetes mellitus in Hong Kong

Red alert drill - get ready to fight the germ battle

Nutrition Therapy Improved Metabolic Outocmes on Chinese Diabetic Elderly

Prognostic Use of Circulating Plasma Nucleic Acid Concentrations in Patients with Acute Abdominal Pain

Prediction of poor outcome for critically ill patients in emergency department

Adult epiglottitis in Hong Kong

Senior medical presence at triage improves service time in the emergency department

A case control study on risk factors of arm lymphedema after treatment for breast cancer

Why should we run the joint replacement preparatory program?

Patient empowerment programmes in General Out-patient Clinic: sharing of 3-year experience

Audit programme on manipulating patients with tunnel catheter

The effectiveness of the ambulatory infusion program for colorectal cancer patients receiving chemotherapy based on Quality of life assessment

Supportive program for old age homes in caring of elderly peritoneal dialysis patients

An exploratory study in sexuality among Chinese stoma patients and their spouses in Hong Kong

Production of Orthopedics Tool Kit to enhance Nurses Competency on skeletal traction management

Peri-operative Nursing Care and Education for Patient undergo Arthroscopic Surgery with Local Anaesthesia

NTEC Infection Control Program for the Prevention of Nosocomial Norovirus Infections

A Cost Effective Program to Reduce Unnecessary Drug Monitoring of Vancomycin

‘2E-C Wound assessment method’ (Easy, Economical & Compatible)

A review on cluster-based p riority infirmary placement in the New Territories East Cluster

An audit on the use of psychotropic drugs in a long-term facility

Mental health day in the hospital and in the community. Program

Diabetes control in patients with type 2 diabetes who received group education based nutrition therapy provided by dietitians

Functional Classification of Geriatric Hip Fractures Rehabilitation

Psychosocial Aspect in Geriatric Hip Fracture Patients – The Phenomenological Perspective

Rehabilitation outcomes in relation to weight bear status in geriatric hip fractures.

Mental function in relation to functional measures in geriatric hip fractures

Hip Protectors for Prevention of Second Hip Fractures - An in-patient training programme to improve compliance and efficacy.

"We Care" - A screening program conducted by acute and rehabilitation geriatric team in the Department of Accident and Emergency

Impact of reduction in staff numbers on the efficiency of stroke rehabilitation in non acute hospital

Use of Accident & Emergency Department (AED) and hospitalization by residential care institutions in Hong Kong

Bridging Program for Chronic Psychiatric In-patient

Fall Prevention Program in Shatin Hospital

Minimizing fall – is it possible?

Conversion from Modified Barthel to Barthel Index scores in the Outcome Measures of stroke patients with a newly designed conversion scheme

Practice innovation on Fall Prevention Program in a rehabilitative medical and geriatric Ward

Associated factors of falls in nursing home residents in Hong Kong and the role of restraints: a cross-sectional survey using the Resident Assessment Instrument (RAI) 2.0

High fiber intake alone can improve constipation on severely debilitated infirmary patients

6-year Analysis of epidemiology of bacteriology in a long term care hospital: the way towards a more cost-effective antibiotics usage

Is gender a factor affecting outcome of traumatic brain injury in multiple trauma

Profile of Elderly Fallers Presenting to Accident & Emergency Department and Its Implications to Current Elderly Health Service in NTEC: Preliminary Results

Abstracts submitted by NTEC for HA Convention 2007

101 abstracts submittedmany CQI projects

But so what, if front page news are …………. 呂小琳

Died 07.07.2007 aged 21At PWH

Fought bravely to overcome acute leukemia but succumbed to a tragic death from a medical mishap.

From: Siu Fai LUI Dr, NTEC SD(RM&QA)/HOQ&S Cons(Q&RM)To: NTEC COSs; NTEC DOMsCC: NTEC HCEs, DHCEs & C(CS)s; NTEC Operations Meeting; NTEC RM&QA Committee; Sent: Sun Jul 08 2007 02:57

Subject: Tragic death from a medical mishap - what have we learnt, what we must learn?

Dear All,

With great sadness and sorrow, I am writing on the death of “小琳”, aged 21, who fought bravely to overcome acute leukemia but succumbed to a tragic death from a medical mishap.

Professor Anthony Chan and I were with the family of 小琳 as they said their last goodbye to her. On behalf of the Hospital and our staff, we have once again expressed our deepest apology and condolence to the family, but ... no word can adequately express our regrets, grief and sorrow.

The relatives have requested that we must ensure 小琳's tragic death shall not be in vain – in that her tragic death would forever remind all medical and nursing staff to be careful and vigilant at all times when giving treatment to patients.

On the afternoon of 15th June, Dr. So Hing Yu and I were working with Dr. Fung Hong on the key message for the NTEC Quality Forum to be held on 16th June, entitled “Achieve Quality through Basics”. Ironically it was on that same afternoon that this most unfortunate medical mishap took place. I would like to share with you that key message we have chosen for NTEC. 確保基本質素 Ensure basic quality堅守基本手則 Always comply with basic steps- 高度專注 - Attentive at all time- 嚴守指引 - Strictly follow protocols- 絕不假設 - Never assume - 莫貪方便 - Not to cut corner

The safety of our patients and staff is of paramount importance to us. It is everyone’s business to ensure “Safety”.

It is important we, senior staff, will lead by example and to take appropriate action to ensure / enhance the "Safe" operation within a department / ward. We are aware and appreciate that our staff are often working under pressure and have to handle tremendous workload. Hence especially for under these situations, we have to enhance the "Safe" provision of treatment. Extra measures which can be taken to enhance "Safety" does not necessarily require a lot of extra time.

We sincerely hope this tragic incident will draw our attention to the need to ensure Basic Quality (First do no harm), while strive for continuous quality improvement of highest appropriate quality care for our patients. We must work together to ensure this.

SF Lui NTEC SD(Q&RM)

確保基本質素 - 不可引至傷害Ensure basic quality – First do no harm

堅守基本手則

Always comply with basic steps

• 高度專注 Attentive at all times• 嚴守指引 Strictly follow protocol• 絕不假設 Never assume • 莫貪方便 Not to cut corners

Does HA has a Q issues ?

Overall Quality Good value for money

Some area / some times Not so good

When things go wrong ……………..

Ways Forward

Key steps in the Prevention of Errors

• Design safe systems / process

• Creating a learning culture via reportingsupported by an open, fair and Just Culture

• Behaviors – A safety culture(managerial and staff)

A duty to avoid causing unjustifiable risk or harm

Take home messageSYSTEM & CULTURE

FOR QUALITY & SAFETYStructure / people / process / outcome

Staff engagementPatient engagement

RiskData

Risk ReductionPrograms

Quality assurance

QualityInitiatives

Quality & Risk CircleLearning & Sharing

☺

A safe and satisfactory journey

through hospitalgoing home feeling better and smiling

A Patient’s journey through the hospital

☺

A staff’s day to day journey through the Hospital

Happy working

environment

Wantingto come to work

☺

☺

Do a good day’s work Happy going home