INSTITUTE OF QUAILTY MANAGEMENT

Health Care TQM Diploma

Sharq El Madina Hospital was constructed at 1977 and started the open cardiothoracic surgery

activities at 1996 .

The cardiology & open cardiothoracic surgery became the core competence of the hospital which is evident by performing about 10,000 open heart surgeries & about 17,000 diagnostic & therapeutic cardiac catheter in the period from 1996 – 2007.

                                                                                                         

The surveillance rate for open heart surgical site wound infection suddenly raised from 3.8%(the global accepted ratio 5.1 %) in December 2010 to 8.1% in Jan 2011 &11.1% in Feb. 2011

Our reputation as center for open heart surgery in Alex was threatened

Infection control team started to discover the root causes

We use the six sigma steps in our project

Appendix

References : oxford journals-medicine-American journal of epidemiology-Volume 161,isuue 7- Pp>661-671

الشهر نسبة العدوي

10نوفمبر-0%

10ديسمبر1%

11يناير-8.00%

11فبراير-11.10%

SSI- Open Heart surgery-

Project benefitsProject benefitsFinancial and operational Financial and operational

benefitsbenefitsEach post operative infection cause

readmission for debridement and closure of wound and approximately increase LOS by 10 days at cost of an additional 6000 LE in extra charge

An averaged 5 infections per month ,approximately 60 infection per year at a total cost of 360,000 LE

If infection decreased to 4% a saving of about 235,000 LE will take place

Soft BenefitsSoft BenefitsTo follow the best practice for

aseptic techniques methodsTo improve patient safety and

customer confidenceTo save the good reputationTo be adherent to the global

percentage of post operative infections

Six sigma stepsSix sigma steps

problem statement The surveillance for surgical site infection

of post operative cardiac surgery show an increase of infection rate on Feb.2011 to 11.1% ( about 2.7 )

The accepted infection rate is up to 5.1%This leads to increase rate of

readmission to cardiac center with raising cost

This may lead to loss of reputation

D

PlayersPlayersRoles & responsibilityRoles & responsibilityExecutive leadersDr, Mahmoud Eldamaty ,medical director

Champions: Dr, A Basioni, Infection control Team leader

Process area( measurement areas ):

Operating RoomOpen Heart ICUWordOutpatient Clinic dressing room

D

Project GoalProject Goallowering and preventing post

operative cardiac surgery wound site infection

To minimize the infection rate to less than 5.1% (3.3 )

Keep the good reputation of cardiothoracic center

D

Project scopeProject scopeOpen heart surgery start from

physician order of entry & ends by ensure complete healing after discharge by one month

D

Project teamProject team( Cross-functional ( Cross-functional team )team )

Infection control team ( Dr./abdelfatah basioni ,Miss/kamilia Sami, Miss/Hayat Ibrahim )

Quality director (Dr./Sali abdulraof)

Operating Room manager ( Dr./Alaa Omar)

Open Heart surgery manager ( Dr./Farid El-Medany)

Bacteriology specialist ( Dr. Fatma Hamdy)

D

Project teamProject teamCentral Sterilization Unit

manager ( Dr./Houda Ramadan)

Head nurse of Open Heart & ICU ( Miss/Houda Tolba – Miss/ Doha Gaber)

Link nurses in measurement areas

D

VOCVOC

VOCCCRCTQsTarget

Wound infection

Clean woundClean woundUp to 4%wound infection

ReadmissionNo No readmission

No readmission

Secondary suture

No secondary suture

Clean woundClean wound

Long stay No more than the average LOS

Average LOSAverage 7days

D

Project Project planplan

D

Tools

M

SuppliersInputs(Specifications)

Process(blood transfusion)

Outputs(Requirements)

Customer

Cardiothoracic physicianAnesthesiacistOperating room nursesICU nursesWord nurses Patient

CVPDressingchest tubeThoracic canulaORH LUNG MachineICUSuction JarsDressing carAntibiotics Inf set & Inf pumpTables , beds, monitors )Safety box

.EFFECTIVE PROCEDURE OF OPERATION

PatientHospitalMOH

SIPOC Diagram open heart surgerySIPOC Diagram open heart surgery

Physician order for surgery

surgery

discharge

dressing & ttt for 5 days

Dressing and F up in OP clinic

ICU for 48 hrs

Transf to word

Admission and prepared for surgery

Check by anesthesia sp

M

S

EComplete healing of the wound within 1 month

Flow diagram – open heart surgery & f-up in OPC dressing room Admission

operation

Post op 48 hr

ICU

WordDressing &

ttt5 days

weaning

No

yes

Discharge & f-upOP

Clean wound

yes

No

Clean wound

yes

No

End of process

Readmission

M

Data collectionData collection

Sample unit : (patient) candidate for open heart surgery process( random choice)

Sample size : 20 ptSample method : simple random

sampling Type of data : ( discrete- no of

errors in each process )

M

Areas of measurementAreas of measurementM

Collected dataCollected data1- Commitment to antibiotic policy

( preoperative- postoperative – type )

2-Predisposing factors (diabetic –immunity )

3- positive Swabs from potential places( areas of measurement )

4- Commitment to antiseptic measures (in measurement areas )

5- Type of Surgical procedure ( graft- valve-…..)

6- Surgical team (Relation between each team and infection)

7- Operation time ( long- more than average time )

M

Data collection Data collection planplan

Project name

Six sigma improvement of post operative infection rate in OHS

Process name

Decrease rate of surgical site wound infection for open heart surgery

Data plan prepared by

Dr, abdelfatah basioni

Period from and to

1-3-2011 to 15-5-2011

(what?)Operational Def

Who is responsible for collection

When will data be collected

Haw will be data collected

Where will the data be collected

Clean wound

The patient must discharged within 7 days with clean wound and follow up in OP clinic for 30 days without complication 0r developing wound infection

Infection control teamQuality teamLink nurses

Randomly from the start of the process till the end of the process

Computing the no of errors in each process By documenting all data related to area of measurement through sampling

Points of measurement

M

Haw data collected Haw data collected Computing the no of errors through the steps of the process

( As is ;)

Number of non Hand washing during deal with each sample unit

Number of non Wearing of PPB during deal with each sample unit

Number of Positive swabs from area surrounding the patient at ( measurement area)

Number of positive swabs from medical equipment Number of Non commitment to Antibiotics policy

( patient file ) Number of immunocompromised pt

M

Culture & Sensitivity Culture & Sensitivity TestTest

M

Surveillance Surveillance FormForm

M

HH & PPBHH & PPBMاسم المريض رقم العينة

القسم

Data collectionData collection HH &PPB HH &PPB

procedureHH

Sample size20

( done+) ve6

-Ve14

M

Suction Suction JarsJars

procedureSwab C&S test

Sample size20

Contaminated with yeast & Gm –ve bacilli

11

Not contaminated9

M

Immune compromised Immune compromised PatientPatient procedurePatient Immunity

)....…-(DM- low immunity

Sample size20

Uncontrolled ( insulin therapy ) 1

Good immune19

M

Swabs from outpatient Swabs from outpatient dressing room dressing room

procedureSwabs from Op dressing room

Sample size20

Contaminated with gm –ve bacilli(drums)

7

Not contaminated 13

M

Swabs from Heart-Lung Swabs from Heart-Lung machinemachine

procedureSwabs from Heart lung machine

Sample size20

positive0

negative20

M

Current situationCurrent situationWe tracked the errors in each

situation & arrange them in descending order

M

Current situation ( As, Is ) Current situation ( As, Is ) Type of errorsFrequency

of occurrenc

e

No H H or PPB14

Contaminated suction jars with (mainly yeast, few Gm-ve bacilli )

11

Rust Contaminated equipment in OP dressing room7

Contaminated antiseptic sol in OP dressing room6

Positive swab patient's bed 2

Immunecompromised Patients 1

Long time surgery1

Positive nasopharyngeal swab for m staff 0

improper use of antibiotics0

M

Line Line chartchart

M

A

Brain stormingBrain stormingcausative causative defects defects

Identifies the possible cause of the problem

Identifies potential remediesIdentifies potential resistance to

remedies

A

•Cause and effect diagram Cause and effect diagram Fish bone diagram-Ishikawa Fish bone diagram-Ishikawa diagram diagram

People PlaceMed staff not follow P&P of antiseptic tech contaminated beds

Improper HH Improper disinfection

No wearing of PPb Improper dilution of disinfectant

Rains suction jars in Pt toilet Bad habits of visitors

Medical supp Improper dressing Improper Pt contamination

Suction jars No HH or PPB

contam drums Contaminated drums Uncontrolled DM

Disinf sol Contaminated Btadine Patient's relative

contam Betadine (dressing) manipulation bad hygiene

long time surgery

Provision procedures Patrons

A

Post Operative

Wound Site Infection

Contaminated drumsContaminated drums

OP Dressing room

M

Contaminated surfaceContaminated surface

OP Dressing room

M

Rusted suction jarsRusted suction jarsM

Untrained staff- visitorsUntrained staff- visitorsM

Surface work place Surface work place contaminationcontamination

OHICU

M

Contaminated floorsContaminated floors

SMALL O R

M

Improper wastes Improper wastes disposabledisposable

Female word

M

Predisposing factorsPredisposing factors

Male word

M

Contaminated Contaminated laryngosopelaryngosope

OHICU

M

Medical suppliers Medical suppliers contamination in OHICUcontamination in OHICU

OHICU

M

Contaminated surfaceContaminated surface

Male word

M

contaminationcontamination

OHICU

M

Contaminated surfaceContaminated surface

OHICU

M

Use of pt toilet in rains M Use of pt toilet in rains M Eq. Eq.

M

Swabs C & S testSwabs C & S testM

Swab C & S testSwab C & S testM

Bilogical indicator f-up in Bilogical indicator f-up in CSUCSU

M

CSU CSU observatiobservati

onon

M

Dispensing &

Calibration unit

M

Type of errorsfrequen

cyCumulativecumulative

%

No HH or PPB141433.33

Contaminated suction jars112559.52Contaminated equipment in OP dressing room73276.19Contaminated antiseptic solution in OP dressing room63890.48

Positive swab from patients bed24095.24

Immunocompromised Pt14197.62

Long time surgery142100Positive nasopharyngeal swab from open heart team042100

Improper use of antibiotics042100

 42  

A

Pareto Pareto chart chart

A

Identify root causes Identify root causes Non compliance to policies and

procedures of antiseptic measures

Contamination of medical equipment with gm –ve bacilli

Contamination of disinfected solution with gm –ve bacilli

Contaminated out patient dressing room environment

A

ISolution alternative (corrective plan )

Remedy selection matrix

Selection matrix

CriteriaAlternatives

Remedy ARemedy 2Remedy 3

NameRains & disinfect suction jar in CSU

Reconstruction of OP dressing room

Implement policy & Procedures of antiseptic technique

Cost131

Training Time213

Benefit /cost555

Resistant331

Effectiveness555

Health & Safety

555

Rating 212220

Remedy selection Remedy selection matrixmatrix

Selection matrix

criteriaalternatives

Remedy DRemedy E

NameNew strategy for floor and work surface disinfection

Purchase new equipment

Cost25

Training Time21

Benefit /cost55

Resistant14

Effectiveness55

Health & Safety55

Rating 2025

I

Designating the Designating the remedyremedyCorrective action Corrective action

Publishing of aseptic technique policy and procedures as regards the MOH guidelines

Confirm sterilization & disinfectionReconstruction of OP dressing room New strategy for Floor and surface

wall disinfection

I

Tree Tree Diagram Diagram

I

Reconstruction of OP dressing room

Confirm sterilization and disinfection

Implement HH and PPB policy &procedures

Disinfection of floor and surface working areas

Train medical staff

Provision of supplies

Disinfection of drums in CSU

Allocate new room

Rains & disinfection of suction jars in CSU

Purchase New drums

Publishing policy & procedures

I Barriers & Aids Barriers & Aids chartchart

Decrease post surgical wound site infection

contributors

Infection control

committee agreement

incentives

Countermeasures

I

TestPositiveNegative

Date

Disinfection of suction jars in CSUDone16-4

Implementation of policy and procedures of HH & PPB during dressing

Followed16-4

Suction jars (swabs )Sterile20-4

Aseptic techniques methods followed16-4

Aseptic solution preparationperfect20-4

Out patient dressing room environment

excellent25-4

I

I

I

Implementdisinfection of suction jars

I

ImplementTraining

I

Implementfollow aseptic techniques

I

ResultsResults

The surveillance result as regards wound site infection of open heart surgery for months March and April in order as follow:

March 2011 3.2%April 2011 3.1%

I

As the team know the root causes for post surgical wound site infection of OH surgeries ,put correction plan and implemented this plan , an obvious improvement (decrease the rate of wound infection to 3.2% ) was noted

To ensure the maintenance of the project quality control spreadsheet was designed

C

Quality control Quality control spreadsheetspreadsheet

Control variable

How measured

Where measured

Standard

Who analyzes

Who acts

What done

Post operative wound site infection

•Surveillance •Reports

•Word•Outpatient dressing room

>,=4%Infection Control Team

•ICT Leader•IC team

•Sterilization steps•Antiseptic technique

Compliance with IC policy &

procedures

•Auditing •Report

•OR•ICU•Word•Outpatient dressing room

guidelines•ICT•Link nurses

•ICT leader•Link nurses

•Check staff•Training •advise

Suction jars disinfection

•Swab for C&S Test

ICU-veBacteriologist

•CSU staff•ICT

•Check disinfectant

Out patient dressing room

•Auditing •Swabs for C&S test •Reports

OP dressing room

guidelines•ICT•Link nurses

•ICT•OP dressing room link nurse

•Check staff and equipment •Training •Status of room

C

Audit the Audit the controlcontrol

C

Report resultsReport resultsFrequency of errors after Frequency of errors after improvementimprovementsample size (20patient ) sample size (20patient )

C

L.O.S(( Report resultsSample size : 20 patientC

Auditing the Auditing the control control C

Poka –yoke ( error Poka –yoke ( error proofing)proofing)

Determine methods that will ensure that a process will not allow defect

Ensure that tasks can only be done the right way

C

Pokayoke / Error Pokayoke / Error ProofingProofing

Dressing seal : dressing must be done through senior cardiologist only (signature on dressing include name and date )

All antiseptic procedures should be followed and supervised by ICT (through schedule sheets)

Antiseptic solution provided in areas of measurement (labeled with concentration and date of preparing )

Suction jars should be disinfected in CSU( packed, labeled)

C

purpose1- A prospective design for possible

ways in which failure can occur2- Eliminate the possibility of failure3- Stop a failure before it reaches

people 4- Minimize the consequence of a

failure

C

•The Joint Commission requires the proactive risk assessment of at least one high-risk process per year

•Goal is to reduce risks, improve patient safety, and enhance patient satisfaction

C

1. Constitute of multidisciplinary team2. choosing a high risk process3. Develop flow chart4. Identify all ways process could fail5. Rate each failure mode6. Determine the risk score7. Calculate primary outcome measure8. Identify failure modes greater than a

designated score and develop action plan

9. Propose steps to implement action plan

10. Rescore the primary outcome measure

C

Identify what “could” go wrong at each of the process steps on the flow chart

why

causes

effects

C

C

C

for postoperative wound site infection

Process & sub process

Failure ModeProximate causes

EffectSeverityProbabilityLikelihood of detection

RPN

Critical index

1-asses Pt.ImmunocompromisedNeglected

Wound infection

 

Uncontrolled DM

Insufficient ant diabetic Therapy

pt not received proper

therapy when indicated

        

Determine the Risk Score

C

2- antisepticTechniquecontaminated

O.Rcontaminated equipmentcontaminated surfacecontaminated floor contaminated suction jars

improper disinfection

wound inf

Delayed healing

  

diluted concentration of antiseptic solutions

non killing of micro-organisms lead to contamination and wound infection

  

improper sterilization

non killing of micro-organisms lead to contamination and wound infection

       

C

3- compliance to antiseptic technique policy and procedures ( pepper HH and PPB)

non compliance

lack of supplies

spread of contamination and infection through patient which lead to delayed healing

 resistent staff

 

untrained staff

   

C

Add the totals of all RPN scores to get a grand total

)…(

Score provided a baseline for comparison

C

Identify the failure modes that have an RPN Score of 200 or higher.

Develop an action plan

The action plan should include who, what, when, why, etc

C

Implement Action PlanC

Baseline score:

Final score:

Reduction in scored risk assessment: %

C

Thank you