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Implementation of quality improvement program in hospitals

A quality improvement program in hospitals aims to continuously monitor and improve quality through systematic activities organized by the hospital. The document outlines the steps to implement a quality improvement program which includes selecting a quality improvement project, assembling a team, developing aim and measure statements, identifying change ideas by analyzing current processes, testing changes, and sustaining improvements. The goal is to improve patient outcomes, clinical and managerial processes, and safety through engaging staff and using a systematic approach of planning, testing, and measuring changes.

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IMPLEMENTATION OF QUALITY IMPROVEMENT PROGRAM IN HOSPITALS Dr. Lallu Joseph Quality Manager, CMC Vellore Secretary General, CAHO
“Every problem has a solution. You just have to be creative enough to find it”. ■ Travis Kalanick, Co-founder of Uber “Problems will never be solved within the culture in which they were created”. Albert Einstein
Quality ■ Quality is meeting or exceeding patients/customers expectations each time. ■ A better way to define quality is "Conformance to requirements“ ■ Degree to which a set of inherent characteristics fulfils patients’ requirements, stated or implied
History of Quality Quality in prehistoric era Post world war Japan  Deming, Juran  Focussed on improving processes through people who used them  1980- NBC- “If Japan can… why can’t we?”  The U.S. response- not only statistics but approaches entire organization- TQM  ISO 9000 series published in 1987
Quality Movement in Healthcare India, China – 1st Century AD (Standards on who should Practice) Licensed Medical Practitioners in Italy 1140 US- 1917- American College of Surgeons- minimum standards to eliminate poor care- evolved into accreditation Shift from Quality Assurance to CQI/ TQM
Surge of Accountability in Indian Healthcare ■ The staggering rise in healthcare costs ■ Search for cheaper alternatives- Competition ■ Loss of credibility of the professionals ■ Increased level of education and income ■ Quality awareness
Hospitals “Healthcare Organizations are the most complex organizations to manage” Peter Drucker “Running a Hospital isn’t Brain Surgery…. …..Its Harder
Patient interface in healthcare ■ Complex interactions ■ Many stakeholders involved ■ Every patient is different ■ Every situation is different ■ Highly sensitive and emotional ■ Errors cannot happen
Who is this? Why is he like this? 1. Little kingdoms 2. Territorial 3. Intrusion into the autonomy 4. Threat 5. Unnecessary
Who are these super hero ???
Quality Manager.. 1. Knowledgeable 2. Team player 3. Team leader 4. Assertive 5. Listener 6. Perseverance 7. Learner 8. Work around people 9. Communicator 10. Trainer 11. Presenter 12. Manipulator 13. Always smiling 14. Should remain calm 15. Public relations 16. Impartial
Principles of Quality Management ■ Strengthen systems and processes ■ Encourage staff participation and teamwork. ■ Base decisions on reliable information ■ Improve communication and coordination ■ Measurement of Quality ■ Continuous Improvement ■ Optimum utilization of resources ■ Demonstrate leadership commitment.
Quality Improvement (QI) ■ Quality Improvement (QI) consists of systematic and continuous actions that lead to measurable improvement in health care services and the health status of targeted patient groups. ■ The Institute of Medicine (IOM), defines quality in health care as a direct correlation between the level of improved health services and the desired health outcomes of individuals and populations.
What is a QI Program? ■ Involves systematic activities that are organized and implemented by an organization to monitor, assess, and improve its quality. ■ The activities are cyclical so that an organization continues to seek higher levels of performance. ■ A QI program typically envelops all QI activities within an organization
Why do you need a QI Program? ■ Improved patient health (clinical) outcomes that involve both process outcomes (e.g., provide recommended screenings) and health outcomes (e.g., decreased morbidity and mortality). ■ Improved efficiency of managerial and clinical processes by reducing waste and costs associated with system failures and redundancy. ■ Streamlined and reliable processes are less expensive to maintain. ■ Proactive processes making care, reliable and predictable.
STEPBYSTEPGUIDETO IMPLEMENTQUALITY IMPROVEMENT
Select a QI project ■ Choosing the right project is important. ■ First venture- choose one that will be successful and produce results to have buy-in ■ It does not have to be a large project; sometimes smaller projects that produce results have a great impact ■ Ideas- Gemba Walk to gather ideas, accreditation results, financial performance, client/staff satisfaction surveys, KPI. ■ Short time frame- small scale and show results within 3 months? ■ How confident are you that the project can be completed successfully? ■ Does the project have the “Wow! Factor”? Is it an area that desperately needs improvement? ■ What is the resistance level from staff/managers/leaders? Choose an initial project that has low resistance.
Assemble the QI team ■ Choose your team members based on their knowledge of, and involvement in, the processes that will be affected by your selected improvement project. ■ Core team of 4-8 individuals, though "ad-hoc" team members can be added. ■ A Project Sponsor has executive authority and serves as a link to management. Need not be a day-to-day participant but should review the progress on a consistent basis. ■ QI Team Lead should have clout to implement changes and influence over areas that are affected by the change. Ex: Medical Director, Nursing Director ■ QI Experts- Familiarity with all processes and QI tools ■ Local Experts- Front line staff ■ Outside Perspective- Fresh perspective to the project ■ QI Project Manager is the QI Team leader, driver, help the team stay on track by developing timelines, monitoring progress, facilitating team meetings.
Develop an Aim Statement (What are we trying to accomplish?) ■ An aim statement acts as your compass to guide and focus. ■ It is an explicit statement of the desired outcome of your improvement project. ■ Specific, Measureable, Achievable, Relevant, and Time bound. ■ A good aim statement includes the following components: – What are we trying to accomplish? – Why is it important? – Who is the specific target population? – When will this be completed? – How will this be carried out? – What are our measurable goals?
Develop measures (How will we know the improvement?) Three types of measures, which are linked to your project aim and goals. These measures include: ■ Outcome - the ultimate results you are trying to achieve Examples: Overall wait time for outpatient visit ■ Process - what you do to achieve your outcome Examples: Number of steps the patient takes during their visit. ■ Balancing - what could we “mess up” while trying to improve the process Examples: Accuracy and completeness of a form when trying to streamline a process, etc.
Identify change ideas (changes to be made for the improvement?) ■ Understand the Current Condition ■ Document each step of the process ■ Record the time it takes to complete each process step (cycle time) ■ Record the time it takes to complete the entire process from start to end (lead time) ■ Record any wait times between each process step or during the process step ■ Document any “waste” you see in the process from your customer’s point of view. ■ Create a value stream map. This visual depiction of your process greatly helps the team analyze the process, see where the flow is interrupted or stopped, and highlight opportunities to reduce waste and improve the process. Depending on your aim statement
Value Stream Map PVT/Current scenario Pre-registration Online filling/600 Collect token TRIAGE Payment Permission for PVT Collect token ISSCC Block Payment Permission for GEN 492 20 mins 30mins 10 mins 30 mins 10 mins 10 mins 5 mins 30 mins 10 mins 40 mins20 mins 10 mins 10 mins 10 mins 2 mins 2 mins Process 1@ PVT Total VA Time = 37 mins Total NVA Time = 100mins % VA Time = 37/137 = 27% Process 2 (PVT to GEN) Total VA Time = 54 mins Total NVA Time = 160mins % VA Time = 54/214 = 25% early appt PVT If no Pvt available
Proposed Value Stream Map PVT Pre-registration Online filling/600 Collect token TRIAGE Payment Permission for PVT/Gen 20 mins10 mins 30 mins 10 mins 10 mins 5 mins 30 mins 10 mins 10 mins 2 mins Process @ PVT Total VA Time = 37 mins Total NVA Time = 100mins % VA Time = 37/137 = 27% early appt PVT
■ Including focus groups, surveys, spaghetti diagrams, swim lane chart, focus groups, and interviews with staff and customers. ■ Identify opportunities for improvement. Review current process through the eyes of client What activities are value added? What activities are non-value added but necessary? What activities are non-value added? ■ You want to focus your improvement efforts on eliminating non-value added activities and reducing non-value added but necessary activities. ■ Do not put a “Band-Aid” on the problems, make sure to drill down to the root cause of the problem using the 5 Whys or fishbone diagram.
Identify and Prioritize Change Ideas ■ Brainstorm ideas and use an affinity diagrams to organize ideas ■ Identify evidence-based and promising practices ■ Collect feedback from staff and clients on ideas for improvement ■ Prioritize the change ideas to work on first (e.g. changes that are easiest to implement and will have the largest benefits to
Test change ideas ■ TEST, TEST, TEST before you implement any change ideas on a large scale. ■ Due to potential staff resistance, it's important to test changes on a small scale ■ Include feedback from customers and staff when developing the tests of change
Sustaining project improvements ■ Involve and inform your senior leaders ■ Assign ownership to an individual (i.e., QI Coordinator, team lead—there is not a right answer and may vary by project) ■ Hardwire improvements by involving all staff (i.e., training for staff, job performance, hiring criteria, job descriptions, etc.) ■ Communicate improvements to clients and allow them to create accountability ■ Continuously measure and monitor results to ensure your new process is still working
Questionnaire Agree (%) Jul-12 May-14 May-16 Jul-17 Aug-18 I have adequate CSSD items for use in my ward/area 91 90 93 96 95 I am comfortable with collection time of un sterile items by the CSSD attenders 83 84 88 95 88 I am comfortable with the delivery time of sterile items from CSSD 90 81 75 89 86 The trolley that delivers sterile items is clean 93 90 93 95 91 The trolley are smooth and noise free 28 28 44 53 61 Items delivered by CSSD have  no stains 78 93 95 92 94  no damage 61 58 70 83 83  are completely sterile 80 88 91 91 93  are in working condition 52 55 60 71 67 I am satisfied with the packing 77 94 94 87 89 Expiry dates are available in all CSSD items 92 95 100 92 99 The quantity of items present in dressing packs is adequate and are not wasted once opened 73 79 75 79 85 Items are not missing in the packs 40 47 39 54 52 The exact number of items sent for sterilization are received back from CSSD (No due) 20 15 55 68 65 CSSD attenders wear gloves and masks while handling un-sterile items in my ward/area 9 15 27 34 47 CSSD attenders are polite and approachable 52 49 59 77 79 Office staff in CSSD respond to queries promptly 78 80 81 89 79 CSSD is innovative and updates to latest technologies/techniques 60 55 74 69 72 CSSD provides regular updates on handling items, pre cleaning etc. 47 47 66 75 74 I am aware of CSSD practices that are being followed in CMC 95 93 94 97 98 I am fully satisfied with the service provided by CSSD 54 47 66 83 81
28 28 44 53 61 0 10 20 30 40 50 60 70 80 90 100 2012 2014 2016 2017 2018 Percentage Year Smooth and noise free CSSD trolleys
Smooth and Noise Free ■ Many complaints from patients in the patient feedback surveys about noise ■ Same was echoed by the nurses in the CSSD user satisfaction survey of 2012 with 72% of the nurses endorsing that the trolleys were noisy. ■ Quality improvement team- Mechanical engineering department along with the CSSD department and Quality Management Cell ■ Nylon to heavy duty polyethylene wheels. Body of the trolleys- reengineered a sample trolley from stainless steel body to corrosion free aluminium alloy folded body. ■ A central rib structure running through the trolley was made to support the body and reduce the vibration of the large trolleys. ■ The interventions helped to bring down the level of noise which was visible from the response of the nurses, 72% responding that the trolleys were noisy in 2012 to 39% responding that the trolleys were noisy in 2018.
Quality of the delivered items 78 93 95 92 94 61 58 70 83 83 80 88 91 91 93 52 55 60 71 67 0 10 20 30 40 50 60 70 80 90 100 2012 2014 2016 2017 2018 Percentage Year no stains no damage are completely sterile are in working condition
Interventions taken ■ Problem of stains, the pre-wash items from the wards were manually washed in CSSD, and checked for stains. If stains persisted, they were soaked in stain remover, washed again with running water before they were sent to washer disinfector. ■ The washed and dried instruments are checked again for stains before they are assembled, packed for sterilization. If found to be stained, the entire cleaning process is repeated.
Sharpness check Sharpness protection Patency check
Wastage of items ■ Reduced usage of drums ■ Disposables used for dressing and small procedures was less. Decided to go for single use disposable packs for consumable like cotton balls, dressing pads, bandages and roller pads. ■ Dialogued with the users and reduced the consumable and instruments according to their usage ■ Custom made sets, for ex: Perm Cath insertion set for dialysis and small suture pack for MICU
Custom made set 73 79 75 79 85 0 10 20 30 40 50 60 70 80 90 100 2012 2014 2016 2017 2018 Percentage Year Figure- 8: Satisfaction with quantity of items present in dressing packs adequate and are not wasted once opened
Number sent for sterilization (No due) ■ Due to shortage, the damaged items and missing items were often replaced with delay, which amounted to CSSD having dues with the ward supplies. ■ The buffer stock in the wards and also in CSSD were increased which led to the reduction in dues from CSSD. ■ The number of dues was made as an indicator for CSSD and continuously monitored. ■ With the monitoring and active intervention, the feedback improved from 20%in 2012 to 65% in 2018
S. NO ITEMS 2015 2016 2017 2018 1. PER MONTH 143 61 14 6 2. PER YEAR 1716 732 168 72 20 15 55 68 65 0 10 20 30 40 50 60 70 80 90 100 2012 2014 2016 2017 2018 Percentage Year Figure 10: Satisfaction with exact number of items sent for sterilization are received back from CSSD (No due) REDUCED
Usage of PPE  Continuous training and reiteration on universal precaution, occupational hazards and infection control practices.  Discussion of day to day incidents with the attenders and all staff with frequent department meetings and explaining the hazards  Trolleys were fabricated with slots for having gloves, hand-rub to have them accessible for the attenders as they move from ward to ward, thereby increasing compliance
9 15 27 34 47 0 10 20 30 40 50 60 70 80 90 100 2012 2014 2016 2017 2018 Percentage Year Figure- 11: Satisfaction with usages of PPEs (gloves and masks)
Attenders behaviour ■ CSSD department took up various measures over the years to engage with the attenders and to make them polite and approachable. ■ The staff training department organized in-service programs covering soft skills and professional etiquettes every year focussing on continuous reiteration. ■ The attenders were encouraged to speak out with supervisors and in the CSSD department meetings about their feeling and experiences at the user end and were given solutions for handling such situations. These interventions started showing gradual improvement in the behaviour of the attenders.
52 49 59 77 79 0 10 20 30 40 50 60 70 80 90 100 2012 2014 2016 2017 2018 Percentage Year Figure- 12: Satisfaction with politeness and approachability of CSSD attenders
Old New
Overall satisfaction with the service provided by CSSD ■ The overall satisfaction of the users with the CSSD services increased from 54% in 2012 to 81% in 2018. ■ The difference between 2012 and 2018 is 27%. ■ It is statistically significant with p value =0.022 (95% CI: -0.38, - 0.03). 54 47 66 83 81 0 10 20 30 40 50 60 70 80 90 100 2012 2014 2016 2017 2018 Percentage Year Figure- 17: Overall satisfaction with the service provided by CSSD
BME Management ■ Data split into two parts; before calibration (2007-2010) and after (2011-2014) ■ Electrosurgical units, Ventilators, Defibrillators, Infusion Pumps and ECG Machines were taken
Breakdown in percentage 0 50 100 150 200 250 300 350 400 450 500 2007 2008 2009 2010 2011 2012 2013 2014Percentageofbreakdown Year Infusion Ventilators Defibrillator ESU ECG Breakdown of • Electro Surgical Units (ESU) reduced from 453% in 2007 to 54% in 2014 • Ventilators decreased from 455% to 140% • Defibrillators reduced from 116% to 29% • ECG from 183% to 77% • Infusion devices reduced from 379% to 196%
TEDS Audit: How many patients have been given TEDS stockings after they were prescribed?
Introduction ■ TEDS stockings are well-documented to prevent the occurrence of DVTs and PE’s both in surgical and medical, non-mobile patients (VTE reducing the risk (June 2015) NICE guidelines CG92)
Audit Criteria ■ 100% of patients should receive TEDS stockings if they are prescribed ■ If TEDS stockings are not given to patient, there should be a reason why they are not given The audit was performed between 12th June to 18th June
Method ■ Auditor checked: – Are TEDS prescribed on drug chart – Are they worn by the patient? ■ Patient criteria – TEDS must be prescribed to be included in audit – Patient should be under general surgery, located in CMC in P1,P2,P3 Ward
Cycle 1 results Ward Standard Achieved Not achieved P1 100% of patients should receive prescribed TEDS stockings 36/44 81.8% 8/44 18.8% P2 100% of patients should receive prescribed TEDS stockings 20/25 80% 5/25 20% P3 100% of patients should receive prescribed TEDS stockings 37/44 84.09% 7/44 15.9% Total 100% of patients should receive prescribed TEDS stockings 93/113 82.3% 20/113 17.6%
Changes implemented in order to re-audit the TEDS audit ■ Discussion with Sisters in charge at CMC ■ Nurses stated these problems: – The storage of TEDS stockings in the right size and quantities are not available at pharmacy – Doctors do not document clearly whether TEDS should be given – Patients are not checked for TEDS stockings ■ Suggestions: – To bleep the admitting doctor to ask whether TEDS should have been prescribed or not – To include a TEDS tick box in the vascular section of the proforma – To check patients for TEDS prior to departure from CMCH casualty or OPD to the inpatient wards – To try and give TEDS stockings within the first hour of admission, when the other paper work is being done.
Cycle 2 results Ward Standard Achieved Not achieved P1 100% of patients should receive prescribed TEDS stockings 42/44 95.45% 2/14 4.5% P2 100% of patients should receive prescribed TEDS stockings 25/25 100% 0/25 0% P3 100% of patients should receive prescribed TEDS stockings 43/44 99% 1/44 1% Total 100% of patients should receive prescribed TEDS stockings 133/136 97.79% 3/136 2.3%
Changes between cycles 1 and 2 Cycle 1 Cycle 2 Percentage difference Total prescribed and given TEDs 82.3% 97.79% 15.49% (more than double percentage)
For future auditing ■ Another re-audit to assess for long-term improvements ■ Implementation of suggestion listed above (following discussions with the ward sisters), namely: – To bleep the admitting doctor to ask whether TEDS should have been prescribed or not – To include a TEDS tick box in the vascular section of the Doctors Order Sheet – To check patients for TEDS prior to departure to the inpatient wards from CMCH Casualty/OPD – To try and give TEDS stockings within the first hour of admission, when the other paper work is being done.
Systems awareness and systems design are important for health professionals, but are not enough. They are enabling mechanisms only. It is the ethical dimension of individuals that is essential to a system’s success. Ultimately, the secret of quality is love. You have to love your patient…., you have to love your profession, you have to love your God. If you have love, you can then work backward to monitor and improve the system. Avedis Donabedian

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In this document
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Overview of the presentation on Quality Improvement programs in hospitals by Dr. Lallu Joseph.

Quotes highlighting that every problem has a creative solution and that solutions must arise outside the creating culture.

Quality defined as meeting or exceeding patients' expectations and conforming to inherent requirements.

Overview of quality movements from prehistoric times to current practices, focusing on TQM and ISO standards.

Historical standards in healthcare quality, including early practices in India, Japan, and the impact of the American College of Surgeons.

Factors causing increased accountability in Indian healthcare, including rising costs and public awareness.

The complexity of managing healthcare organizations and the unique challenges faced in hospital management.

Description of complex interactions in healthcare involving various stakeholders and the need for error-free service.

Common behavioral challenges in hospital management, including territoriality and autonomy concerns.

Attributes and responsibilities of a Quality Manager defined as knowledgeable, communicative, and team-oriented.

Core principles such as strengthening processes, improving communication, and ensuring continuous improvement.

Definition and systematic actions leading to measurable quality improvements in healthcare services.

Explanation of QI programs involving systematic activities to monitor and improve organizational quality.

Necessity of QI programs for improving patient outcomes and efficiency in healthcare processes.

Basic steps outlined for effective implementation of a Quality Improvement program.

Importance of choosing the right QI project for early success and ensuring stakeholder buy-in.

Guidelines for assembling an effective QI team with defined roles for successful project implementation.

Importance of an aim statement to guide project goals, specifying outcomes and target populations.

Identification of outcome, process, and balancing measures linked to project aims and goals.

Process of documenting and analyzing current conditions to identify opportunities for improvement.

Current and proposed Value Stream Maps to analyze and improve healthcare service efficiency.

Tools like focus groups and diagrams to determine value-added activities for process improvement.

Methodology for brainstorming and prioritizing ideas based on evidence and potential benefits.

Importance of small-scale testing for change ideas to minimize resistance before larger implementation.

Methods for sustaining quality improvements through continuous leadership involvement and process monitoring.

Results of a survey measuring CSSD item availability and satisfaction among ward attendants.

Yearly trends on satisfaction regarding the quality of CSSD services, focusing on trolley performance.

Improvements made to reduce noise from CSSD trolleys, leading to increased satisfaction among users.

Statistics on quality assurance for CSSD items over time regarding damage and sterility.

Detailed cleaning and check processes implemented to ensure the quality of CSSD items.

Strategies employed to reduce wastage and optimize the use of consumables in medical settings.

Surveys measuring satisfaction rates regarding the adequacy of CSSD dressing pack quantities over years.

Monitoring strategies that led to a significant decrease in item due complaints in 2018.

Data illustrating improved satisfaction regarding the exact return of sterilized items to wards.

Training initiatives undertaken to promote proper utilization of PPE among CSSD attenders.

Programs implemented to enhance the approachability and behavior of CSSD staff towards users.

Changes over time in the overall satisfaction of users with CSSD services, showcasing significant improvements.

Analysis of breakdown instances in critical medical equipment before and after calibration.

Significant reductions in breakdown percentages of various critical medical devices over years.

Audit results highlighting compliance rates for prescribed TEDS stockings among patients.

Explanation of the purpose and guidelines regarding TEDS stockings for DVT and PE prevention.

Criteria set for assessing patient compliance with prescribed TEDS stockings.

Initial survey results measuring TEDS stocking compliance rates among various wards.

Identified issues from Cycle 1 and proposed solutions to improve compliance for TEDS stockings.

Improved audit results in TEDS stocking compliance after adjustments were made post-Cycle 1.

Comparison of TEDS stocking implementation between Cycle 1 and 2 showcasing percentage improvements.

Plans for continuous auditing and improvements for TEDS stocking protocols.

Reflection on the importance of ethical commitment in improving healthcare quality through love for patients.

Implementation of quality improvement program in hospitals

  • 1.
    IMPLEMENTATION OF QUALITY IMPROVEMENTPROGRAM IN HOSPITALS Dr. Lallu Joseph Quality Manager, CMC Vellore Secretary General, CAHO
  • 2.
    “Every problem hasa solution. You just have to be creative enough to find it”. ■ Travis Kalanick, Co-founder of Uber “Problems will never be solved within the culture in which they were created”. Albert Einstein
  • 3.
    Quality ■ Quality ismeeting or exceeding patients/customers expectations each time. ■ A better way to define quality is "Conformance to requirements“ ■ Degree to which a set of inherent characteristics fulfils patients’ requirements, stated or implied
  • 4.
    History of Quality Qualityin prehistoric era Post world war Japan  Deming, Juran  Focussed on improving processes through people who used them  1980- NBC- “If Japan can… why can’t we?”  The U.S. response- not only statistics but approaches entire organization- TQM  ISO 9000 series published in 1987
  • 5.
    Quality Movement inHealthcare India, China – 1st Century AD (Standards on who should Practice) Licensed Medical Practitioners in Italy 1140 US- 1917- American College of Surgeons- minimum standards to eliminate poor care- evolved into accreditation Shift from Quality Assurance to CQI/ TQM
  • 6.
    Surge of Accountabilityin Indian Healthcare ■ The staggering rise in healthcare costs ■ Search for cheaper alternatives- Competition ■ Loss of credibility of the professionals ■ Increased level of education and income ■ Quality awareness
  • 7.
    Hospitals “Healthcare Organizations arethe most complex organizations to manage” Peter Drucker “Running a Hospital isn’t Brain Surgery…. …..Its Harder
  • 8.
    Patient interface inhealthcare ■ Complex interactions ■ Many stakeholders involved ■ Every patient is different ■ Every situation is different ■ Highly sensitive and emotional ■ Errors cannot happen
  • 10.
    Who is this?Why is he like this? 1. Little kingdoms 2. Territorial 3. Intrusion into the autonomy 4. Threat 5. Unnecessary
  • 11.
    Who are thesesuper hero ???
  • 12.
    Quality Manager.. 1. Knowledgeable 2.Team player 3. Team leader 4. Assertive 5. Listener 6. Perseverance 7. Learner 8. Work around people 9. Communicator 10. Trainer 11. Presenter 12. Manipulator 13. Always smiling 14. Should remain calm 15. Public relations 16. Impartial
  • 13.
    Principles of QualityManagement ■ Strengthen systems and processes ■ Encourage staff participation and teamwork. ■ Base decisions on reliable information ■ Improve communication and coordination ■ Measurement of Quality ■ Continuous Improvement ■ Optimum utilization of resources ■ Demonstrate leadership commitment.
  • 14.
    Quality Improvement (QI) ■Quality Improvement (QI) consists of systematic and continuous actions that lead to measurable improvement in health care services and the health status of targeted patient groups. ■ The Institute of Medicine (IOM), defines quality in health care as a direct correlation between the level of improved health services and the desired health outcomes of individuals and populations.
  • 15.
    What is aQI Program? ■ Involves systematic activities that are organized and implemented by an organization to monitor, assess, and improve its quality. ■ The activities are cyclical so that an organization continues to seek higher levels of performance. ■ A QI program typically envelops all QI activities within an organization
  • 16.
    Why do youneed a QI Program? ■ Improved patient health (clinical) outcomes that involve both process outcomes (e.g., provide recommended screenings) and health outcomes (e.g., decreased morbidity and mortality). ■ Improved efficiency of managerial and clinical processes by reducing waste and costs associated with system failures and redundancy. ■ Streamlined and reliable processes are less expensive to maintain. ■ Proactive processes making care, reliable and predictable.
  • 17.
  • 18.
    Select a QIproject ■ Choosing the right project is important. ■ First venture- choose one that will be successful and produce results to have buy-in ■ It does not have to be a large project; sometimes smaller projects that produce results have a great impact ■ Ideas- Gemba Walk to gather ideas, accreditation results, financial performance, client/staff satisfaction surveys, KPI. ■ Short time frame- small scale and show results within 3 months? ■ How confident are you that the project can be completed successfully? ■ Does the project have the “Wow! Factor”? Is it an area that desperately needs improvement? ■ What is the resistance level from staff/managers/leaders? Choose an initial project that has low resistance.
  • 19.
    Assemble the QIteam ■ Choose your team members based on their knowledge of, and involvement in, the processes that will be affected by your selected improvement project. ■ Core team of 4-8 individuals, though "ad-hoc" team members can be added. ■ A Project Sponsor has executive authority and serves as a link to management. Need not be a day-to-day participant but should review the progress on a consistent basis. ■ QI Team Lead should have clout to implement changes and influence over areas that are affected by the change. Ex: Medical Director, Nursing Director ■ QI Experts- Familiarity with all processes and QI tools ■ Local Experts- Front line staff ■ Outside Perspective- Fresh perspective to the project ■ QI Project Manager is the QI Team leader, driver, help the team stay on track by developing timelines, monitoring progress, facilitating team meetings.
  • 20.
    Develop an AimStatement (What are we trying to accomplish?) ■ An aim statement acts as your compass to guide and focus. ■ It is an explicit statement of the desired outcome of your improvement project. ■ Specific, Measureable, Achievable, Relevant, and Time bound. ■ A good aim statement includes the following components: – What are we trying to accomplish? – Why is it important? – Who is the specific target population? – When will this be completed? – How will this be carried out? – What are our measurable goals?
  • 21.
    Develop measures (How willwe know the improvement?) Three types of measures, which are linked to your project aim and goals. These measures include: ■ Outcome - the ultimate results you are trying to achieve Examples: Overall wait time for outpatient visit ■ Process - what you do to achieve your outcome Examples: Number of steps the patient takes during their visit. ■ Balancing - what could we “mess up” while trying to improve the process Examples: Accuracy and completeness of a form when trying to streamline a process, etc.
  • 22.
    Identify change ideas (changesto be made for the improvement?) ■ Understand the Current Condition ■ Document each step of the process ■ Record the time it takes to complete each process step (cycle time) ■ Record the time it takes to complete the entire process from start to end (lead time) ■ Record any wait times between each process step or during the process step ■ Document any “waste” you see in the process from your customer’s point of view. ■ Create a value stream map. This visual depiction of your process greatly helps the team analyze the process, see where the flow is interrupted or stopped, and highlight opportunities to reduce waste and improve the process. Depending on your aim statement
  • 23.
    Value Stream MapPVT/Current scenario Pre-registration Online filling/600 Collect token TRIAGE Payment Permission for PVT Collect token ISSCC Block Payment Permission for GEN 492 20 mins 30mins 10 mins 30 mins 10 mins 10 mins 5 mins 30 mins 10 mins 40 mins20 mins 10 mins 10 mins 10 mins 2 mins 2 mins Process 1@ PVT Total VA Time = 37 mins Total NVA Time = 100mins % VA Time = 37/137 = 27% Process 2 (PVT to GEN) Total VA Time = 54 mins Total NVA Time = 160mins % VA Time = 54/214 = 25% early appt PVT If no Pvt available
  • 24.
    Proposed Value StreamMap PVT Pre-registration Online filling/600 Collect token TRIAGE Payment Permission for PVT/Gen 20 mins10 mins 30 mins 10 mins 10 mins 5 mins 30 mins 10 mins 10 mins 2 mins Process @ PVT Total VA Time = 37 mins Total NVA Time = 100mins % VA Time = 37/137 = 27% early appt PVT
  • 25.
    ■ Including focusgroups, surveys, spaghetti diagrams, swim lane chart, focus groups, and interviews with staff and customers. ■ Identify opportunities for improvement. Review current process through the eyes of client What activities are value added? What activities are non-value added but necessary? What activities are non-value added? ■ You want to focus your improvement efforts on eliminating non-value added activities and reducing non-value added but necessary activities. ■ Do not put a “Band-Aid” on the problems, make sure to drill down to the root cause of the problem using the 5 Whys or fishbone diagram.
  • 26.
    Identify and PrioritizeChange Ideas ■ Brainstorm ideas and use an affinity diagrams to organize ideas ■ Identify evidence-based and promising practices ■ Collect feedback from staff and clients on ideas for improvement ■ Prioritize the change ideas to work on first (e.g. changes that are easiest to implement and will have the largest benefits to
  • 27.
    Test change ideas ■TEST, TEST, TEST before you implement any change ideas on a large scale. ■ Due to potential staff resistance, it's important to test changes on a small scale ■ Include feedback from customers and staff when developing the tests of change
  • 28.
    Sustaining project improvements ■Involve and inform your senior leaders ■ Assign ownership to an individual (i.e., QI Coordinator, team lead—there is not a right answer and may vary by project) ■ Hardwire improvements by involving all staff (i.e., training for staff, job performance, hiring criteria, job descriptions, etc.) ■ Communicate improvements to clients and allow them to create accountability ■ Continuously measure and monitor results to ensure your new process is still working
  • 29.
    Questionnaire Agree (%) Jul-12 May-14May-16 Jul-17 Aug-18 I have adequate CSSD items for use in my ward/area 91 90 93 96 95 I am comfortable with collection time of un sterile items by the CSSD attenders 83 84 88 95 88 I am comfortable with the delivery time of sterile items from CSSD 90 81 75 89 86 The trolley that delivers sterile items is clean 93 90 93 95 91 The trolley are smooth and noise free 28 28 44 53 61 Items delivered by CSSD have  no stains 78 93 95 92 94  no damage 61 58 70 83 83  are completely sterile 80 88 91 91 93  are in working condition 52 55 60 71 67 I am satisfied with the packing 77 94 94 87 89 Expiry dates are available in all CSSD items 92 95 100 92 99 The quantity of items present in dressing packs is adequate and are not wasted once opened 73 79 75 79 85 Items are not missing in the packs 40 47 39 54 52 The exact number of items sent for sterilization are received back from CSSD (No due) 20 15 55 68 65 CSSD attenders wear gloves and masks while handling un-sterile items in my ward/area 9 15 27 34 47 CSSD attenders are polite and approachable 52 49 59 77 79 Office staff in CSSD respond to queries promptly 78 80 81 89 79 CSSD is innovative and updates to latest technologies/techniques 60 55 74 69 72 CSSD provides regular updates on handling items, pre cleaning etc. 47 47 66 75 74 I am aware of CSSD practices that are being followed in CMC 95 93 94 97 98 I am fully satisfied with the service provided by CSSD 54 47 66 83 81
  • 30.
    28 28 44 53 61 0 10 20 30 40 50 60 70 80 90 100 20122014 2016 2017 2018 Percentage Year Smooth and noise free CSSD trolleys
  • 31.
    Smooth and NoiseFree ■ Many complaints from patients in the patient feedback surveys about noise ■ Same was echoed by the nurses in the CSSD user satisfaction survey of 2012 with 72% of the nurses endorsing that the trolleys were noisy. ■ Quality improvement team- Mechanical engineering department along with the CSSD department and Quality Management Cell ■ Nylon to heavy duty polyethylene wheels. Body of the trolleys- reengineered a sample trolley from stainless steel body to corrosion free aluminium alloy folded body. ■ A central rib structure running through the trolley was made to support the body and reduce the vibration of the large trolleys. ■ The interventions helped to bring down the level of noise which was visible from the response of the nurses, 72% responding that the trolleys were noisy in 2012 to 39% responding that the trolleys were noisy in 2018.
  • 32.
    Quality of thedelivered items 78 93 95 92 94 61 58 70 83 83 80 88 91 91 93 52 55 60 71 67 0 10 20 30 40 50 60 70 80 90 100 2012 2014 2016 2017 2018 Percentage Year no stains no damage are completely sterile are in working condition
  • 33.
    Interventions taken ■ Problemof stains, the pre-wash items from the wards were manually washed in CSSD, and checked for stains. If stains persisted, they were soaked in stain remover, washed again with running water before they were sent to washer disinfector. ■ The washed and dried instruments are checked again for stains before they are assembled, packed for sterilization. If found to be stained, the entire cleaning process is repeated.
  • 35.
  • 36.
    Wastage of items ■Reduced usage of drums ■ Disposables used for dressing and small procedures was less. Decided to go for single use disposable packs for consumable like cotton balls, dressing pads, bandages and roller pads. ■ Dialogued with the users and reduced the consumable and instruments according to their usage ■ Custom made sets, for ex: Perm Cath insertion set for dialysis and small suture pack for MICU
  • 37.
    Custom made set 73 7975 79 85 0 10 20 30 40 50 60 70 80 90 100 2012 2014 2016 2017 2018 Percentage Year Figure- 8: Satisfaction with quantity of items present in dressing packs adequate and are not wasted once opened
  • 38.
    Number sent forsterilization (No due) ■ Due to shortage, the damaged items and missing items were often replaced with delay, which amounted to CSSD having dues with the ward supplies. ■ The buffer stock in the wards and also in CSSD were increased which led to the reduction in dues from CSSD. ■ The number of dues was made as an indicator for CSSD and continuously monitored. ■ With the monitoring and active intervention, the feedback improved from 20%in 2012 to 65% in 2018
  • 39.
    S. NO ITEMS2015 2016 2017 2018 1. PER MONTH 143 61 14 6 2. PER YEAR 1716 732 168 72 20 15 55 68 65 0 10 20 30 40 50 60 70 80 90 100 2012 2014 2016 2017 2018 Percentage Year Figure 10: Satisfaction with exact number of items sent for sterilization are received back from CSSD (No due) REDUCED
  • 40.
    Usage of PPE Continuous training and reiteration on universal precaution, occupational hazards and infection control practices.  Discussion of day to day incidents with the attenders and all staff with frequent department meetings and explaining the hazards  Trolleys were fabricated with slots for having gloves, hand-rub to have them accessible for the attenders as they move from ward to ward, thereby increasing compliance
  • 42.
    9 15 27 34 47 0 10 20 30 40 50 60 70 80 90 100 2012 2014 20162017 2018 Percentage Year Figure- 11: Satisfaction with usages of PPEs (gloves and masks)
  • 43.
    Attenders behaviour ■ CSSDdepartment took up various measures over the years to engage with the attenders and to make them polite and approachable. ■ The staff training department organized in-service programs covering soft skills and professional etiquettes every year focussing on continuous reiteration. ■ The attenders were encouraged to speak out with supervisors and in the CSSD department meetings about their feeling and experiences at the user end and were given solutions for handling such situations. These interventions started showing gradual improvement in the behaviour of the attenders.
  • 44.
    52 49 59 7779 0 10 20 30 40 50 60 70 80 90 100 2012 2014 2016 2017 2018 Percentage Year Figure- 12: Satisfaction with politeness and approachability of CSSD attenders
  • 45.
  • 46.
    Overall satisfaction withthe service provided by CSSD ■ The overall satisfaction of the users with the CSSD services increased from 54% in 2012 to 81% in 2018. ■ The difference between 2012 and 2018 is 27%. ■ It is statistically significant with p value =0.022 (95% CI: -0.38, - 0.03). 54 47 66 83 81 0 10 20 30 40 50 60 70 80 90 100 2012 2014 2016 2017 2018 Percentage Year Figure- 17: Overall satisfaction with the service provided by CSSD
  • 47.
    BME Management ■ Datasplit into two parts; before calibration (2007-2010) and after (2011-2014) ■ Electrosurgical units, Ventilators, Defibrillators, Infusion Pumps and ECG Machines were taken
  • 48.
    Breakdown in percentage 0 50 100 150 200 250 300 350 400 450 500 20072008 2009 2010 2011 2012 2013 2014Percentageofbreakdown Year Infusion Ventilators Defibrillator ESU ECG Breakdown of • Electro Surgical Units (ESU) reduced from 453% in 2007 to 54% in 2014 • Ventilators decreased from 455% to 140% • Defibrillators reduced from 116% to 29% • ECG from 183% to 77% • Infusion devices reduced from 379% to 196%
  • 50.
    TEDS Audit: Howmany patients have been given TEDS stockings after they were prescribed?
  • 51.
    Introduction ■ TEDS stockingsare well-documented to prevent the occurrence of DVTs and PE’s both in surgical and medical, non-mobile patients (VTE reducing the risk (June 2015) NICE guidelines CG92)
  • 52.
    Audit Criteria ■ 100%of patients should receive TEDS stockings if they are prescribed ■ If TEDS stockings are not given to patient, there should be a reason why they are not given The audit was performed between 12th June to 18th June
  • 53.
    Method ■ Auditor checked: –Are TEDS prescribed on drug chart – Are they worn by the patient? ■ Patient criteria – TEDS must be prescribed to be included in audit – Patient should be under general surgery, located in CMC in P1,P2,P3 Ward
  • 54.
    Cycle 1 results WardStandard Achieved Not achieved P1 100% of patients should receive prescribed TEDS stockings 36/44 81.8% 8/44 18.8% P2 100% of patients should receive prescribed TEDS stockings 20/25 80% 5/25 20% P3 100% of patients should receive prescribed TEDS stockings 37/44 84.09% 7/44 15.9% Total 100% of patients should receive prescribed TEDS stockings 93/113 82.3% 20/113 17.6%
  • 55.
    Changes implemented inorder to re-audit the TEDS audit ■ Discussion with Sisters in charge at CMC ■ Nurses stated these problems: – The storage of TEDS stockings in the right size and quantities are not available at pharmacy – Doctors do not document clearly whether TEDS should be given – Patients are not checked for TEDS stockings ■ Suggestions: – To bleep the admitting doctor to ask whether TEDS should have been prescribed or not – To include a TEDS tick box in the vascular section of the proforma – To check patients for TEDS prior to departure from CMCH casualty or OPD to the inpatient wards – To try and give TEDS stockings within the first hour of admission, when the other paper work is being done.
  • 56.
    Cycle 2 results WardStandard Achieved Not achieved P1 100% of patients should receive prescribed TEDS stockings 42/44 95.45% 2/14 4.5% P2 100% of patients should receive prescribed TEDS stockings 25/25 100% 0/25 0% P3 100% of patients should receive prescribed TEDS stockings 43/44 99% 1/44 1% Total 100% of patients should receive prescribed TEDS stockings 133/136 97.79% 3/136 2.3%
  • 57.
    Changes between cycles1 and 2 Cycle 1 Cycle 2 Percentage difference Total prescribed and given TEDs 82.3% 97.79% 15.49% (more than double percentage)
  • 58.
    For future auditing ■Another re-audit to assess for long-term improvements ■ Implementation of suggestion listed above (following discussions with the ward sisters), namely: – To bleep the admitting doctor to ask whether TEDS should have been prescribed or not – To include a TEDS tick box in the vascular section of the Doctors Order Sheet – To check patients for TEDS prior to departure to the inpatient wards from CMCH Casualty/OPD – To try and give TEDS stockings within the first hour of admission, when the other paper work is being done.
  • 59.
    Systems awareness andsystems design are important for health professionals, but are not enough. They are enabling mechanisms only. It is the ethical dimension of individuals that is essential to a system’s success. Ultimately, the secret of quality is love. You have to love your patient…., you have to love your profession, you have to love your God. If you have love, you can then work backward to monitor and improve the system. Avedis Donabedian