Presentation on International Patient Safety Goals (JCI)

STUDY REPORT ON
AWARENESS ABOUT INTERNATIONAL PATIENT SAFETY GOALS (IPSG) AMONG THE
CLINICAL STAFF OF DR. B. L. KAPUR MEMORIAL HOSPITAL (DELHI)
SUBMITTED TO
DELHI PHARMACEUTICAL SCIENCES AND RESEARCH UNIVERSITY
AS FINAL (4TH) SEMESTER THESIS REPORT FOR
MASTER’S IN HOSPITAL MANAGEMENT
Under Guidance Of:
Dr. Navin Chaudhary
(D.M Quality Dept., Dr. B. L. Kapur Memorial Hospital )
Dr. J. Swaminathan
(Mentor and Faculty , DPSRU)
Submitted by:
Dr. SONAL
Roll no.-6/ MHM / DPSRU 2016

AIM OF STUDY
 To determine the Compliance percentage of Hospital’s
Clinical Staff Awareness in terms of
1. Knowledge,
2. Attitude and
3. Practices
Towards International Patient Safety Goals as per
hospital’s policies according to JCI standards given for
International Patient Safety Goals .

OBJECTIVE OF STUDY
 Objective of this study is to Access the level of awareness of
Hospital’s Clinical Staff (Residents and Nursing Personnel)
regarding
 International Patient Safety Goals as per Joint Commission
International Accreditation Standard (JCI).
 Also regarding the Hospital’s Policies based on those
standards.
 To find out the compliance level for each individual IPSG
goal as per hospital policy.
 Also to interpret the results and assess compliance level of
the hospital procedures and processes to JCI standards.

BACKGROUND
 Patient safety is one of the main components of health
services quality means to avoid getting into any kind of
patient injury, while providing health care.
 It includes medicinal failures, surgical procedures, diagnosis
failures, machinery and equipment failures and other items
such as hospital infections, patient falls and bedsore.
Impact of Unsafe Services
 Unsafe Service have unpleasant after effects for patient and
his/her family, It introduced psychological pressure on
health system staff and society members, Create a huge
economic burden on health care system and society.

BACKGROUND
 Adverse events resulted from an error made by a person who
was capable of performing the task safely
 We cannot change the aspects of human cognition that
causes error , So need design systems that reduce error and
make them safer for patients.
 The ultimate goal of evaluation of patient safety is to improve
patient safety in hospitals and create situations that lead to
safer services and subsequently protecting the society form
avoidable damages and reducing unwanted adverse events in
the hospital setting

INTRODUCTION OF JCI
 Full form- Joint Commission International
 Establish- 1998
 Latest edition – 6th
 Vision- create culture of ethic, quality and Patient
safety with in Healthcare Organization to improve
patient care process.
 Chapter- 16 + Introduction
 Divided into 4 Parts
1. Assessment participation Requirement
2. Patient Centered Standard – 8 (IPSG part of it)
3. Organizational Centered Standard - 6
4. Academic Medical Center Hospital Standard -2

INTRODUCTION OF IPSG BY JCI
There are Six IPSG goals as per JCI those are-
Goals-1: Identify Patients Correctly
 Use at least two (2) ways to identify a patient when giving
medicines, blood or blood products; taking blood samples and
other specimens for clinical testing, or providing any other
treatments or procedures. The patient's room number cannot
be used to identify the patient.
Goal-2 Improve Effective Communication
 Implement a process/procedure for taking verbal or
telephone orders or for the reporting of critical test results
that requires a verification procedure "read-back" of the
complete order or test result by the person receiving the
information.
Goal-3 Improve the Safety of High-alert Medications:
 Remove concentrated electrolytes (including, but not limited
to, potassium chloride, potassium phosphate, sodium chloride
>0.9%) from patient care units.

INTRODUCTION OF IPSG BY JCI
Goal-4 Eliminate Wrong-site, Wrong-patient, Wrong-
procedure Surgery
 Use a checklist, including a "time-out" just before starting a
surgical procedure, to ensure the correct patient procedure and
body part. Develop a process or checklist to verify that all
documents and equipment needed for surgery are on hand and
correct and functioning properly before surgery begins. Mark the
precise site where the surgery will be performed. Use a clearly
understood mark and involve the patient in doing this.
Goal-5 Reduce the Risk of Health Care–acquired Infections
 Comply with current published and generally accepted hand
hygiene guidelines.
Goal-6 Reduce the Risk of Patient Harm Resulting from fall
 Assess and periodically reassess each patient's risk for falling,
including the potential risk associated with the patient's
medication regimen, and take action to decrease or eliminate any
identified risks.

MATERIAL AND METHODOLOGY
 RESEARCH STUDY DESIGN: Descriptive study design
 SOURCE OF DATA: Clinical staff of Inpatient wards and ICU’s
at Dr. B.L KAPUR MEMORIAL HOSPITAL.
 TIME PERIOD OF STUDY: Observed over a span of three
months.
 STUDY TYPE: Quantitative Cross-Sectional study
 SAMPLE SIZE: Consists of 100 Nursing Staff and 50 Resident
Doctors.
 SAMPLING TECHNIQUE: Non probability convenience
sampling technique is adopted for selecting the sample.

 Inclusion criteria
1. Both male and female nurses and resident doctors.
2. The clinical staff those are willing to participate and
cooperate for the study.
3. Clinical Staff present at the time of study.
4. Clinical Staff who can understand either Hindi or
English
5. Clinical Staff who are willing to participate in this study.
 Exclusion criteria
1. Clinical Staff who are not willing to participate in this
study.
2. Clinical Staff who are not available during the time of
data collection.

 Data collection tool include 2 questionnaire on IPSG .
IPSG QUESTIONNAIRE
FOR
NUMBER OF QUESTIONS TYPE OF
QUESTIONNAIRE
RATING SCALE CRITERIA
NURSING STAFF 26 OPEN ENDED LIKERT SCALE
1. COMPLIANCE
2. PARTIAL
COMPLIANCE
3. NON COMPLIANCE
RESIDENT DOCTOR 17 OPEN ENDED LIKERT SCALE
1. COMPLIANCE
2. PARTIAL
COMPLIANCE
3. NON COMPLIANCE

 NOTE- All the questions described to participant in their
understandable language (Hindi/English).
 Data Analysis using MS Excel with the help of
appropriate statistical tool like PERCENTAGE on Likert
scale for each questionnaire.
 Ethical Clearance been obtained from my institution.

ANALYSIS OF STUDY
 Awareness Compliance Percentage among Clinical
Staff(Resident and Nursing Personnel) for each IPSG
Goal.
IPSG IPSG 1 IPSG 2 IPSG 3 IPSG 4 IPSG 5 IPSG 6
59.30%
84.70% 92.10%
73% 78.40%
95.80% 95%
PERCENTAGE OF AWARENESS ON IPSG IN CLINICAL
STAFF
PERCENTAGE OF IPSG UNDERSTANDING IN CLINICAL STAFF

ANALYSIS OF STUDY
 Awareness Compliance Percentage among Clinical Staff
(Resident and Nursing Personnel Individually).
IPSG GOALS
PERCENTAGE OF IPSG
UNDERSTANDING IN
RESIDENTS
PERCENTAGE OF IPSG
UNDERSTANDING IN
NURSING STAFF
IPSG 14% 77%
IPSG 1 72.60% 89.25%
IPSG 2 74.60% 96.50%
IPSG 3 50% 80.60%
IPSG 4 68% 81%
IPSG 5 80% 91.40%
IPSG 6 86% 97.25%

IPSG IPSG 1 IPSG 2 IPSG 3 IPSG 4 IPSG 5 IPSG 6
14%
72.60% 74.60%
50%
68%
80%
86%
77%
89.25%
96.50%
80.60% 81%
91.40%
97.25%
AWARENESS PERCENTAGE ON IPSG
PERCENTAGE OF IPSG UNDERSTANDING IN RESIDENTS
PERCENTAGE OF IPSG UNDERSTANDING IN NURSING STAFF

RESULTS
 Above Tables and Graphs shows that the Hospital’s Clinical
professionals in the Inpatient wards and ICU’s have overall
compliance percentage
1. 66.4% in Residents
2. 90.03% in Nursing staff.
In Clinical Staff
 Highest compliance percentage found in IPSG 5- 95.08%,
 Lowest compliance percentage found in IPSG (understanding)
59.03%.

RESULTS
A)Lowest compliance percentage of Residents
awareness found in following-
 IPSG (understanding)-14% - They don’t know about IPSG full
form and couldn’t name six goals of IPSG.
 IPSG 3-50% - They don’t know about high alert medication
and color coding for the same.
 IPSG 4- 68% - Many of them are unaware of surgical safety
policy of hospital related to their role in patient
identification and surgical site marking

RESULTS
 Lowest compliance percentage of Nursing Staff awareness -
77% regarding General Understanding of IPSG as they don’t
know about IPSG full form and six goals of IPSG.
B) Highest compliance percentage found in IPSG 6 for
 Resident 97.25%
 Nursing Staff - 86%,
Clinical Staff fully aware about -
1. the vulnerable patient category of hospital,
2. color band for vulnerable patient,
3. Precautions and measure regarding prevention of fall

CONCLUSION
 Results shows that Hospital’s clinical staff in Inpatient Wards
and ICU’s have an overall good percentage of compliance to
IPSG, in case of nursing staff its excellent, whereas residents
are having fair level of awareness regarding IPSG.
 Major area of lack of awareness found, are following:
1. IPSG full form and enumerate six goals of IPSG.
2. About High alert medication and LASA drugs, also color
coding for same.
3. Unaware of Surgical safety policy of hospital related to
their role in patient identification and surgical site marking.

RECOMMENDATIONS
 Hospital requires having more focus on IPSG awareness
training and Hospital policies for same to be included in
Induction Programme of Clinical Staff esp. for Residents.
 Hospital Dept. of Quality need to do a Periodic Audit regarding
IPSG awareness (includes Knowledge and Practice) among the
Hospital’s Clinical Staff.
 Audit Reports need to be shared with the concerned
Employees Head of Departments, so that they also support
the training programme.
 Hospital Dept. of Quality could have Periodic Training sessions
and/or Quiz for Hospital’s Clinical Staff regarding IPSG.
 Also pre and post training test could be taken to look for the
training effectiveness on enhancing IPSG Awareness among
Clinical Staff.

BIBLIOGRAPHY
 Nash, D., Goldfarb, N., 2006. The quality solution: The Stakeholder’s
Guide to Improving Health Care. First edition, UK: Jones and Bartlett.
 Frankel, A., et al, 2008. Revealing and Resolving Patient Safety Defects:
The Impact of Leadership Walk Rounds on Frontline Caregiver
Assessments of Patient Safety. Health Serve Res: 43(6), 2050–2066.
 Rockville, M, 2008. Reducing errors in health care: transferring research
to practice. AHRQ, (Mar. 14, 2013).
 Gezairy, H., 2011. Patient safety assessment manual. Egypt: World Health
Organization. Regional Office for the Eastern Mediterranean.
 A Study to Assess the Effectiveness of Self Instructional Module
regarding international patient safety goals among Staff Nurses in
Selected Hospitals at Bangalore by GIGI THOMAS,1st Year M. Sc. Nursing
, Ikon Nursing Collage.
 Bates DW, Larizgoitia I, Prasopa -Plaizier N, Jha AK (2009) Global
priorities for patient safety research. BMJ 338: 1775.
 Mathias E, Sethuraman U (2016) ABCs of Safety and Quality for the
Pediatric Resident and Fellow. Pediatric Clinics of North America 63: 303-
315

Presentation on International Patient Safety Goals (JCI)

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