STEPS to achieving Quality Improvements in Hospitals
Learning Objectives
What participants will learn
1.
Participants will learn how to identify and meet community needs from the patient’s
perspective using a standard community needs assessment
2.
Participants will learn about the LOOK and FEEL of an improved hospital
3.
Participants will review the key ways of determining root causes of poor quality care
4.
Using DMAIC effectively when implementing a quality improvement program
5.
Standards of performance
BEFORE we attempt to initiate Quality improvements we
must hear from residents of our catchment areas
GOLD STANDARD QUESTIONS TO ASK DURING YOUR CHNA
 What aspects of your community do you like the most or the least?
 What are the major challenges facing your community?
 Considering the availability of HEALTH SERVICES in your community, your top three
concerns are; Your top three concerns regarding the DELIVERY OF HEALTH SERVICES in your
community are;
 Considering the PHYSICAL HEALTH in your community, your three concerns in relation to
community members are :
 Health status and accessibility problems amongst vulnerable populations
 What barriers do you and other community members face when attempting to access
health services within the community?
Remember that the patient determines how improvements should be
made-What a patient considers poor quality healthcare may be dependent on race, age,
ethnicity, educational levels, culture & socio-economic status
The Rationale for integrated healthcare
 According to Priya Shetty, at an online Scientific forum, at least
80% of Asians and Africans still use traditional medicine for primary
care
 In China alone, over 75% of the population accounted for$14
billion dollars worth of traditional medicines in China and over 80%
had applied ACUPUNCTURE therapies to cure illnesses
 ARTEMESIN Anti malaria therapies were originally derived from
ARTEMESIA ANNUA or the CHINESE SWEET WORMWOOD plant
 INTEGRATION NOW URGENTLY REQUIRED- Multi drug resistant drugs
now the norm, and new therapies are taking years to research
and years to gain federal drug agency approvals
 CHALLENGES, Regulation weak, inadequate testing, inadequate
evidence based practices, poor documentation
In the USA, the National Center for Complimentary and Alternative Medicine
(NCCAM) is investing $128.8 million on RESEARCH on herbal drugs,
Acupuncture, and osteopathy cures for cancers and other conditions
WHAT IS NIGERIA DOING?
Papaya plants for drug resistant
malaria
CASSIA and other anti –malaria plants
have been found to be effective
INTEGRATING CULTURE & SOCIAL NORMS INTO
HEALTHCARE- LESSONS FROM THE USA
Research studies have shown the physician’s
perspective may differ from the patient’s perspective
HERE IS HOW
SOME HEALTH
PROFESSIONALS
DEFINE QUALITY
CARE
MODERN HEALTH SERVICES IN A TYPICAL IMPERSONAL
PRIVATE HOSPITAL ENVIRONMENT
TYPICAL HEALTHCARE SCENARIO IN A TRADITIONAL SETTING
 Consultations take place in a cosy
home setting
 Patients are assured confidentiality
and privacy- no crowd of patients
waiting , because of space
constraints
 Only the expert to provide the full
SCOPE of care- so that there is
continuity.
 The traditional doctor is available any
time, and adds counselling and
emotional support
 Care is personalized & WHOLISTIC
and the doctor takes time to listen to
all complaints both physical, spiritual
and emotional
OPTIONS FOR LABOR AND DELIVERY IN AN INTEGRATED
SETTING IN THE UK- BIRTHING CENTERS
HOME DELIVERIES IN SA
Birthing options in developed nations have
integrated traditional birthing options – this
improves acceptability and outcomes
Typical patient perspectives of health services in
some nations- what is the root/underlying complaint here?
Without integration, our hospitals may become more and
more unsafe, since we allow a large volume of people to
congregate within the same spaces
REAL TIME 2016 DATA on MEDICATION ERROR RATES IN 2
PRIVATE & 1 PUBLIC HOSPITAL IN LAGOS
Affirmation rates for medication errors within the last 6 months
Patient given a medication that was stopped
misread prescription leading to wrong dosing
wrong dilution of medication
wrong route right drug
wrong timing of medication
wrong dose prescribed
Patient overdosed by mistake
0
5
10
Hospital G
15
Hospital R
Hospital S
20
25
30
So what’s the key problem so far
Quality & Safety Perspective mismatch??
Health Professional &
Government perspective
Patient’s perspective
What can we do to bridge these quality and safety gaps??
How we can initiate Quality & Safety
improvements?
Toyota
Way
PLAN DO
STUDY ACT
KAIZEN
ROOT CAUSE
ANALYSIS
RCA will
always be
needed
Lean Six
SIGMA
FAILURE
MODES
EFFECT
ANALYSIS
JOSEPH
JURAN’S
TRILOGY
All Quality improvement methods have the same FOUR critical
STEPS
STEP ONE- Find out what is happening in your
organization eg Define the problem?
 REMEMBER- ASK THE PATIENT – ALLOW
SOME SPACE FOR COMMENTS
 ASK THE STAFF- LET THEM LIST
ANNONYMOUSLY THE TYPE AND
FREQUENCY OF ERRORS THEY SEE IN
THE ORGANIZATION
 ANALYZE YOUR RECORD OF
COMPLAINTS
 & errors from various departments
CHECK YOUR RECORDS OF PATIENTS
BEING HARMED ACCIDENTALLY OR
WHO SUFFERED FROM blood transfusion
reactions, pressure sores, falls etc
What problems to prioritize – seven wastes of healthcare
STEP 2 IDENTIFY ROOT CAUSES / Causal relationships OF ALL MAJOR PROBLEMS
Principles of root causes and why we must find them
The 5 WHYS – exercise 1
Root cause analysis using BARRIERS &
FACILITATORS Analysis
Specific methodologies- Lean Six Sigma concentrates on waste
reduction and cost control
Creating a culture of Lean Six Sigma
Specific methodologies – Lean Six Sigma uses the DMAIC
process
FAILURE MODES EFFECTS ANALYSIS FMEA
FMEA WITH IMPROVEMENT ACTION PLAN
APPLYING OUR TOOLS AND TECHNIQUES - CASE STUDY- WHAT ARE THE
QUALITY IMPROVEMENT NEEDS IN THIS SCENARIO?
 A 54-year-old man was admitted to the hospital for
preoperative evaluation and elective knee surgery.
On the morning of surgery, the patient was
awakened by the phlebotomist who drew his blood
for basic laboratories and type and cross-matching.
To ensure proper patient identification, the hospital
had implemented a policy requiring a registered
nurse or physician to verify the identity of all patients
screened for blood transfusion. In practice, after
verification of identity, the nurse or physician was
required to initial the patient label on the vial of
blood.
THE ERROR CASE STUDY
 As it was the change of nursing shift, the bedside nurse for the patient was not available and
 there were no physicians on the floor at the time. With another floor of patients still to see, the
phlebotomist carried the labeled vial of blood out to the nurses' station, and the label was
signed by a random nurse. The sample was sent to the laboratory for analysis.
 Later that morning, a laboratory technician noticed a large and surprising change (compared
to the previous day's sample) in the hemoglobin value for a different patient on the same floor.
She chose to investigate the discrepancy. Upon review, she realized that the vials of blood for
the 54-year-old man had been mislabeled with another patient's label by the phlebotomist.
The reason the hemoglobins were so discrepant for this other patient was that today's value
was that of the 54-year-old man, the wrong patient. On closer examination, it was determined
that all the blood samples had been mislabeled, including the vial for type and crossmatching.
 Despite the ''near miss,'' the patient suffered no harm, and another blood specimen was drawn
prior to surgery.
CASE STUDY FOR TEAMS 1 2 & 3
 SELECT A ROOT CAUSE ANAYLSIS METHOD AND APPLY IT TO THIS CASE- IMAGINE
THAT THIS ERROR WAS DETECTED AT YOUR ORGANIZATION
 AS A TEAM- DOCUMENT YOUR ROOT CAUSE PROCEDURE AND THEN DRAW UP A
QUALITY & SAFETY IMPROVEMENT PLAN
 PRESENT YOUR ROOT CAUSE ANALYSIS AND QI PLAN
POST TEST & CLOSING