implementation of quality standards to build a patient safe hospital.ppt
TRANSCRIPT
IMPLEMENTATION OF QUALITY STANDARDS TO
BUILD A PATIENT SAFE HOSPITAL
Dr. Lallu Joseph
Quality Manager
CMC, Vellore
HOSPITALS
“Healthcare Organizations are the most complex organizations to manage”
Peter Drucker
“Running a Hospital isn’t Brain Surgery….
…..Its Harder
How we want the hospitals to be……
How hospitals are……
Source: 2002. IHI. Leape
MEDICAL ERROR
Source – The Philadelphia Inquirer
PATIENT INTERFACE IN HEALTHCAREComplex interactions
Many stakeholders involved
Every patient is different
Every situation is different
Highly sensitive and emotional
Errors cannot happen
IC
U
Ward
SWISS CHEESE MODEL
TEAM WORK IN HOSPITALS
When caregivers work together- benefits for the employees, the patients and the health-care facility
Patients receive thorough care when providers collaborate
Providers can concentrate on their areas of expertise, knowing they are part of a team looking after the whole patient- shared responsibility
Quality of care improves
Hospitals save money with effective team care
TEAMWORK IS ENHANCED BY QUALITY MANAGEMENT AND
ACCREDITATION
ACCREDITATION, TEAM WORK AND PATIENT SAFETYAccreditation is proven to be the best possible tool to achieve quality and safety
Top management involvement is the key to effective implementation
All stakeholders to be involved from the chairman to the doorman
The right intent has to be understood and Implementation should focus on the intent
Accountability at all levels and processes
Checks and balances at all levels
Continuous Monitoring
SHARED RESPONSIBILITY AND COMMUNICATION IS THE KEY
ACCREDITATION STANDARDS
Basic minimum standards
Achievable
Non- negotiable
Based on evidences
Best practices
INFRASTRUCTURE AND FIRE SAFETY
AMRI HOSPITAL, KOLKOTTA
Occurrence of accident 2:15 AM Fire started from the basement.
3:30 AM Smoke started spreading through AC ducts
4:10 AM Fire Brigade called
4:30 AM Rescue process started
7:30 AM Firemen broke the wall of basement and started flooding the wall. Could not enter due to smoke and poisonous gas
8:00 AM Snorkel arrived and rescue by breaking the glasses of the building facade
ROOT CAUSE ANALYSISThe basement was full with Inflammable article like paper, cotton, mattress, chemicals etc
Alarm did not get activated as it was made inactive, due to many false alarms
Fire extinguishers at the basement did not work as they were not checked.
No evacuation was initiated even after 1 ½ hrs.
Central AC system and electricity supply were not stopped
Carbon monoxide gas started spreading through AC ducts
No trained person to deal the emergencies, specially how to evacuate critically ill patients.
No signage for emergency exits.
No arrangement for alternate ventilation.
No escape route.
Set back around the building had vehicles parked.
STANDARDS ON FIRE SAFETY-NABHCHAPTER STANDARDS TEAM
RESPONSIBLE
ROM 2a, 2b, 2c, 2d
Fire installation as per NBC and fire license, implementation of the requirements, updation and amendments
Top Management
FMS 1a, 1d, 1e, 1f
Safety committee to oversee the activities, facility rounds Multidisciplinary team
FMS 6a Provisions for detection, abatement and containment of fire emergencies and checked periodically/ maintenance
Engineering/ fire team
FMS 6b Documented safe exit plan and provisions Engineering/ fire team
FMS 6c, 1g Staff awareness and training of their role in emergencies HR/ Training dept/ fire team
FMS 6d, CQI 4b
Mock drills conducted periodically and audit of the deviations
Top management/ quality/ safety committee/ fire
POWER OUTAGE AT PUDUCHERRY HOSPITAL KILLS THREE DIALYSIS PATIENTS
March 9th 2017
Indira Gandhi Medical College and Research Institute (IGMCRI)-Pondicherry
Three patients, including two women-undergoing haemodialysis died
No battery back up
Generator supply restored after 15 minutes
Previous incident- 21 died in Gandhi Hospital, Hyderabad, 2016
Source: NDTV
ROOT CAUSE ANALYSISBack up battery supply for 20 minutes
Generator supply- delay in starting
Emergency response by the clinical team
Machine maintenance
Emergency alarms
STANDARDS ON ELECTRICAL, EQUIPMENT AND PATIENT SAFETY-NABHCHAPTER STANDARDS TEAM RESPONSIBLE
FMS 2f Electricity is available round the clock Engineering
FMS 2g Alternate sources for electricity are provided for backup for any failure/ shortage
Engineering
FMS 2h The alternate sources are regularly tested Engineering
FMS 3f, 3h Operational and maintenance plan for all utility equipment, maintenance plan for electrical systems
Engineering
FMS 4d Qualified and trained personnel operate and maintain medical equipment
Top management/ biomed Engineering/ clinical depts
FMS 4e, 4f Proper inspection, calibration and maintenance of equipment
biomed Engineering/ clinical depts
COP 7 Qualified personnel perform and monitor during procedures
Clinical depts
DOCTORS OPERATE ON WRONG LEG OF 24-YEAR-OLD
June 22, Fortis Hospital, Delhi
Fractured right foot due to fall in the stair case
Operated on the healthy left ankle of a 24 year old
Multiple screws placed on the left ankle
Temporary cast placed on the fractured foot
STANDARDS ON SURGICAL SAFETY- NABHCHAPTER STANDARDS TEAM RESPONSIBLE
COP 15b Pre-operative assessment and documentation
Surgical dept
COP 15d Identification tags and checking of tags when the patient enters the OT
Nursing
COP 15d Appropriate surgical site marking and checking of the same
Surgical and nursing team
COP 15d Surgical safety checklist and cross checks Surgical, anaesthesia and nursing team
COP 15d, CQI 3e
Surgical time out and audit of the same Surgical, anaesthesia and nursing team
CQI 2 Patient safety program, patient safety officer, audits and monitoring of the implementation of IPSG
Top management/ Safety team
15 HOSPITALISED AFTER WRONG DRUG INJECTED BEFORE STERILIZATION
12 Jan 2017, Kamalapur, Ballari district
15 women admitted for tubectomy, for tubectomy
Hospitalised after being injected wrong medicine before the surgery.
Adrenaline administered instead of Atropine sulfateinjection
Women felt giddy, began to vomit and felt their hearts race and rushed to Taluk Hospital
Root Cause: LOOK ALIKE MEDICINES
STANDARDS ON MEDICATION SAFETY- NABHCHAPTER STANDARDS TEAM RESPONSIBLE
MOM 3d Look alike and sound alike medications are identified in all areas
Pharmacy/ Nursing in wards/ OT
MOM 3d LASA medications are stored separately Pharmacy/ Nursing in wards/ OT
MOM 4j High risk medications are identified and double checked before administration
Nursing/ Clinical team
MOM 6d Medication is verified from the order and physically verified before administration
Nursing/ Clinical team
TWO STUCK TO MRI MACHINE FOR 4 HRS
Nov 11, 2014, Tata Memorial Hospital
7 pm at the Tata Memorial-run (ACTREC)
Attending doctor asked attendant to get oxygen mask.
Attendant who never worked in MRI room, had no idea that no metal is allowed anywhere near the machine, brought oxygen cylinder.
2 staff stuck for 4 hours
ROOT CAUSE ANALYSISNo staff training
Communication issues
Metal detectors and other entry restrictions not in place
Emergency run down/ quenching de-activated
STANDARDS ON EQUIPMENT, PATIENT SAFETY- NABHCHAPTER STANDARDS TEAM RESPONSIBLE
AAC 11c Patients are appropriately screened for safety in imaging
Radiology team/ Safety team
AAC 11g Imaging and ancillary personnel are trained in radiation safety
Radiology team/ Safety team
AAC 11h Signage are prominently displayed Radiology team/ Safety team
FMS 4e Equipment are periodically inspected for their proper functioning
Radiology team/ Biomedical Engg
HOSPITAL SAFETY PROGRAM
CAPA ANDSYSTEM CORRECTION
INCIDENT REPORTING
EDUCATION AND TRAINING
SYSTEM AND ACCOUNTABILITY
PREVENTIONANDCONTROL
RISKIDENTIFICATION
HOSPITAL SAFETY PROGRAM
SURGICAL PATIENT SAFETY
CAPA ANDSYSTEM CORRECTION
INCIDENT REPORTING&AUDITS
EDUCATION AND TRAINING
SYSTEM AND ACCOUNTABILITY
PREVENTIONANDCONTROL
RISKIDENTIFICATION
HOSPITAL SAFETY PROGRAM
Wrong patient can be operated
1. Patient ID Tag2. UHID3. Surgical safety checklist
1. Nurse in ward to
check tag
2. To countercheck
with chart and
patient
3. Checklist at
holding bay-
nurse
4. Intra-OP- Time
out by surgeon,
anaesthetist and
scrub nurse
5. Post OP for
count
If incidents happen to be reported
Continuous audits for compliance to protocol
Training to HCW
RCA by multidisciplinary committee, change in protocol if required
IMPLEMENTATION OF QUALITY STANDARDS AND BUILDING SAFE HOSPITALIt is a continuous improvement process
It does not happen overnight
Every effort and every passing day brings improvement and innovations
Safety culture needs to be built and inculcated
Top management involvement in safety initiatives is a must
Manage through committees
Encourage reporting and learning from mistakes- Avoid blame and shame
Accreditation acts as a good reminder and a guide towards a formal safety program
With every assessment, improvement and culture change will be evidenced
Perseverance is the key
THE PATIENT……
THE SOLE BREAD WINNER OF THE FAMILY,
HE IS THE FATHER OF A SMALL KID,
SON OF AN OLD FATHER,
HUSBAND OF A YOUNG LADY,
AND IS NOW YOUR RESPONSIBILITY
TO TREAT HIM AND SEND HIM SAFE TO HIS LOVED ONES
IMAGINE YOUR OWN THERE
TAKE CARE OF HIM LIKE YOUR BROTHER
Dr. Lallu Joseph