Sar 2011_Dr. Bikash Gauchan

Implementing a Systems-Implementing a Systems-Oriented Morbidity and Oriented Morbidity and Mortality Conference in Mortality Conference in Remote Rural Nepal for Quality Remote Rural Nepal for Quality ImprovementImprovement

Dr. Bikash GauchanJunior Resident (Batch-July 2011)

Department of General Practice & Emergency Medicine

B. P. Koirala Institute of Health Sciences (BPKIHS)

Dharan, Nepal

ContentsContents

IntroductionSettingAchham DistrictType of the studyObjectives of the studyStrategy for changeProgram designMethodologySeven DomainsEffects of changeLessons learntConclusion

Introduction:Introduction:

Simple, effective tools are needed to improve quality in resource-limited health facilities

The morbidity and mortality conference (M&M) is a well-established practice globally

However, there is limited experience with M&M as a hospital-wide quality improvement strategy in resource-limited settings

Given that M&Ms are common throughout the world, a re-focusing of the M&M as a systems-level quality improvement intervention could be feasible in many resource-limited settings

Setting:Setting:

Bayalpata Hospital (BH): One of two Primary Care Hospitals in Achham District of Far Western Nepal

BH is government hospital, run by non-profit organization Nyaya Health (NH) in collaboration with Nepali Ministry of Health and Population (MOHP)

Achham District:Achham District:

One of nine districts of Far Western Region of Nepal

One of the remotest district in Nepal

It has a primarily agrarian (60%) population of 266,000

Median annual household income is $141 USD with literacy rates of 52% for males and 14% for females

Chronic malnutrition rates for children under five are 63.5%, and maternal mortality rates are 231 per 100,000

Type of the study:Type of the study:

Qualitative Observational Study

Duration of the study: 9 months

Objectives of the study:Objectives of the study:

To implement morbidity and mortality conference involving clinical and non-clinical staffs

To identify challenges and areas for quality improvement in healthcare delivery

To facilitate structured analysis and improvement of patient care

Strategy for change:Strategy for change:

Prior to this program, BH lacked a mechanism for systems-level reflection enabling staff to identify challenges and areas for quality improvement in healthcare delivery

We hypothesized that a hospital-wide M&M would be a feasible quality improvement initiative aimed to facilitate structured analysis and improvement of patient care

Successful change was defined as the implementation of this M&M with staff-wide involvement and tangible changes seen in healthcare delivery at BH

Program Design:Program Design:

We designed an M&M involving clinical and non-clinical staff in conducting root-cause analyses of healthcare delivery at our hospital

Weekly conferences focused on seven domains of causal analysis: operations, supply chain, equipment, personnel, outreach, societal, and structural

Each conference focused on assessing the care provided, and identifying ways in which services can be improved in the future

Methodology:Methodology:

Complicated case was selected by Medical Director (Senior most clinician) with input from staffs (HAs and Nurses)

Case summary was written and sent to each member of Nyaya Health for feedback via email

Weekly conference was held for 60 minutes

Medical Director acted as the principal facilitator for discussions

Methodology…..Methodology…..

Discussions focused on case history followed by analyses of seven domains

The details of the conference were recorded in the conference hall

Each M&M concludes with a review of lessons learnt and recommendations, and responsible personnel and timelines are identified for implementation of recommendations

Seven Domains:Seven Domains:

1.Clinical operations – concerns with patient flow, intake, or processing in clinical departments, laboratory, radiology, or pharmaceutical operations

2.Supply chains – challenges in obtaining reliable supplies of quality medicines or equipment

3.Equipment – issues in the functioning, quality, or availability of equipment

4.Personnel – factors pertaining to training, professionalism, management, or collaboration

Seven Domains………Seven Domains………

5.Outreach – issues in recruiting patients into timely and appropriate care through community engagement

6.Societal – challenges faced by gender, caste, economic, or other social status

7.Structural – factors related to infrastructure such as roads, telecommunications, educational or healthcare facilities

Example:Example:

Case: 28 year old male / Suicide attempt with Underlying Depression with Psychotic features

Problems identified: Lack of mental health service, antidepressants in the pharmacy and low socioeconomic status

Domains of causal analysis: Clinical operations, Personnel, Supply chain, Societal and Structural

Example…….Example…….

Recommendations: a)Medical Director develops emergency referral

list and crisis-line with Psychiatrists in the capital

b)Procurement of at least two different antidepressants medicines and identifying long term suppliers

Effects of Change:Effects of Change:

Improved communication between junior and senior staff members

Better understanding of clinical operations among non-clinical staff

Improved collaboration and team-based learning

More rigorous case analysis and identification of areas for improvement

Effects of Change…..Effects of Change…..

Knowing staff level challenges as a team

On-site clinical trainings

Better procurement of drugs in the pharmacy

Better definition of job description

Lessons learnt:Lessons learnt:

I. Involvement of clinical and non-clinical staff will help to identify systems-level issues to impact patient care

II. Structured discussions with a systems-level perspective

III. Fostering senior managerial commitment

IV. Use of M & Ms to guide resource utilization

Conclusion:Conclusion:

Systems-oriented morbidity and mortality conference can act as a feasible tool for quality improvement in resource-limited settings

Thank you allThank you all