Journey towards achieving and sustaining quality in teaching

hospitals

Dr. Lallu JosephQuality Manager

Christian Medical CollegeVellore

Non- teaching Hospital

Teaching Hospitals

Challenges Multiple hats

Teaching – Patient care – Research Autonomy and independence

All areas Difficult to bring them together Different protocols

Large turn over of trainees Continuous training Training in batches

Apprentice model of training On the job Difficulty in maintaining standards

Challenges Multiple accrediting agencies

Multiple inspections Differences in the expectations Confused about inspections

Staffing pattern and hierarchy Standardization Vs Innovation Size of the institution Patient load and complexity Difficulty in performance linked appraisals

Christian Medical College Vellore

CMC Vellore

Dr. Ida Sophia Scudder - 1900 Leading referral tertiary care hospital 2645 beds Outpatients (March 2015-2016) - 25, 60,

377 In- patients (March 2015-2016) - 1, 35, 329

Best Practices“UNESCO describes best practices as having four common characteristics: they are innovative; they make a difference; they have a sustainable effect; and they have the potential to be replicated and to serve as a model for generating initiatives elsewhere.”[1]

“Strategies, activities, or approaches that have been shown through research and evaluation to be effective and/or efficient.” [2]

[1] Johns Hopkins University Bloomberg School of Public Health. Best Practices. http://www.infoforhealth.org/practices.shtml

[2] Florida Department of Education. Best Practices in Florida's Community Colleges and Workforce Education. http://www.fldoe.org/cc/Retention/

Quality Management Program1. Top management commitment and involvement

2. Accreditation- Means to an end and not an end in itself

3. Focussed to the mission and vision of the organization4. Consultative decision5. Effective and multidisciplinary involvement6. Documentation- Processes and responsibilities to

achieve objectives7. Patient centered and cost effective8. Methods to measure processes should be defined and

implemented9. Quality measurements to guide improvement 10. Ensuring standards11. Team work and well informed

1. Top management commitment and involvement

Quality Team- Dedicated team

Position in the hierarchy

Visible commitment to quality

Publicize the commitment

2. Accreditation- Means to an end and not an end in itself

QMC

Documentation &

Process developmen

t Accreditation

System Study

Audits / Audit cycle completion

Performance

Indicators

Research

Training

3. Focussed to the mission and vision of the organization “Christian Medical College seeks to be a

witness to the healing ministry of Christ through excellence in Education, Service and Research”

Balancing is essential

Temptations to deviate

4. Consultative decision

No. ACTION PERSONRESPONSIBLE

YEAR

BEGIN COMPLETE

1 Set up Quality Audit Facilitation Cell Director/Deputy Director (Quality)

2010

2010

2 Evaluate the existing patient feedback system and make changes. ” 2011

3 Set up the Patient Grievance CellMS/NS/

Director/Deputy Director (Quality)

2011

4 Apply for accreditation and pre assessment

Director/Deputy Director (Quality) 2011

5 Set up internal reporting system for Audits ” 2012

6 Conduct training programs in audits and standards ”

2011

Ongoing

7Complete the documentation of departments/ hospitals processes and policies

” 2012

8Develop Key Performance Indicators (KPIs) and establish the reporting mechanism.

” 2012

No. ACTION PERSONRESPONSIBLE

YEAR

BEGIN COMPLETE

9 Get NABH Accreditation for the main hospital

Director/Deputy Director (Quality)

2011 2012

10 Develop a system for Audit Compliance ”

2012

2013

11 Set up the scorecard and management dashboard ” 2014

12 Get the NABL accreditation for all Labs ” 2014

13 Establish systems for resources optimization ” 2013 2014

14 Establish EQAS for all labs ” 2014 2015

Consultative decision (Contd….)

Department Quality Managers (DQMs) Middle level faculty / staff Representation from every unit Long term commitment Currently 180

Quality Council All DQMs Meets once in three months

Quality Steering Committee Multidisciplinary Members serve for 2 years Meets once a month

5. Effective and multidisciplinary involvement

6. Documentation- Processes & responsibilities to achieve objectives

Documentation contd….

Clinicians General Guidelines Booklet Nursing Procedure Manual HIC Manual Safety Manual Departmental Procedure Manual Quality Manual

7. Patient Centered

Quality Management System- Patient centered

All policies and procedures must be patient centered

Benefits should reach the patients

Staff should be aware of the intend of the program

8. Methods to measure processes should be defined and implemented Audits- Facilitation vs policing

Audit team meeting Developing proforma, methodology and

time frame. Conduct audit Analysis and interpretation by QMC

Key Performance Indicators Management Dashboard Institutional, Department wise

Evidence based- backed by data All audit reports presented to the

respective groups for corrective action and implementation

KPIs analyzed for reasons and reported for corrective action

Clinical audits

9. Quality measurements to guide

improvement

10. Problems – due to processes and not people Sentinel events and root cause analysis Mortality audits

11. Ensuring standards Accreditation standards as the minimum

requirement and as a guide

Continuous follow-up/ audits and improving on benchmark/expectations

Internal inspections

12. Team work and well informed

Publicize improvements and success

Every activity- multidisciplinary involvement

Teams and task forces

Celebrate success

TEAM

Together Everyone Achieves More