quality beyond accreditationquality beyond accreditation
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Quality Beyond AccreditationQuality Beyond AccreditationProfessor Anupam Sibal
Group Medical Director
Apollo Hospitals Group
Senior Consultant
Pediatric Gastroenterologist and Hepatologist
CertificationCertification
ISO 9001:2008
ISO 22870:2006
ISO 14001
Accreditation
Benefits of accreditationBenefits of accreditation
E t bli h ll b ti l d hi th t t i f ll iEstablishes collaborative leadership that strives for excellence in quality and patient safety
Ensures a safe and efficient work environment
Stimulates continuous improvement in clinical care processes
Builds a culture open to learning from adverse events and safety concerns
Improves public trust
What really mattersWhat really matters
Desired clinical outcomes – clinical excellenceNo adverse or unanticipated event – patient safetyp p yValue for money – operational excellence or “efficiency”Care culture – service excellence
Effi iEfficiency
“Avoiding waste, including waste of
i t li id d ”equipment, supplies, ideas and energy”
Institute of Medicine
“Highest Value Hospital” recognitionHighest Value Hospital recognition – Leapfrog Group
Incorporates quality and cost
Perform exceptionally well in clinical processes
and outcomes and resource use
Achieving Efficiency: Lessons from Four Top-Performing Hospitals July 2011 The Commonwealth FundHospitals, July 2011 - The Commonwealth Fund
4 of the 13 Leapfrog Group’s “Highest Value4 of the 13 Leapfrog Group s Highest Value
Hospitals” in 2008
Fairview Southdale Hospital, Minnesota
North Mississippi Medical Center MississippiNorth Mississippi Medical Center, Mississippi
Park Nicollet Methodist Hospital, Minnesota
Providence St. Vincent Medical Centre, Oregan
Efficiency follows excellence
“We don’t have goals for efficiency. It’s a byproduct of
Efficiency follows excellence
g y yp
our success in focusing on what’s right for the patient
and excellence in quality of care (It is)a trailingand excellence in quality of care…….(It is)a trailing
indicator”
Dennis Noonan
Former CFO, Providence St Vincent Medical Centre
Examples of Improvements initiated
Improving patient flow to serve more patients
Integrated care plans to improve post dischargeIntegrated care plans to improve post discharge
outcomes and continuity of care
Computerized test results in the Emergency
Building the CultureBuilding the Culture
“Our management has always sought ways ofOur management has always sought ways of
supporting staff. The philosophy behind shared
i l h b i h i d igovernance is to let the brightest minds sit
together, and get out of their way”
Martie MooreCNO, Providence St Vincent medical Center
Building the CultureBuilding the Culture
An example:An example:Employees to submit at least two improvement ideas
each year Submitted directly to decision makers Employees get “points” for approved ideasAs high as 37% of the ideas approved
Building the CultureBuilding the CultureExamples:Self governance model – each staff member
represented on a clinical or operational councilA l b t d t t ti litAnnual bonuses to departments meeting quality
and cost goalsRegular discussion between Medical directors and egu a d scuss o bet ee ed ca d ecto s a d
physicians identified as “outliers”
Staff relationships and roles matter p
Examples:Service lines with clinical and administrative leadersStaff huddles before start of a surgery to reduce
operating room delaysoperating room delaysBed huddles twice a day which focus on discharge
timing, potential bottlenecks
Staff relationships and roles matter
Examples:
p
Need based “loaning” of staff from other unitsSharing of patient information with patient’s family
d it h i iand community physicianPreserving nurse patient ratiosL f t ffi i il f h i i h dLoss of staffing privileges for physicians who do
not show respect to nurses
Technology as a toolTechnology as a tool
Examples:Electronic health records (EHR) shared between
t ti t d i ti t tti t idoutpatient and inpatient settings to avoid duplication of tests
Clinical decision support systems integrated intoClinical decision support systems integrated into EHR
Technology as a toolTechnology as a tool
Examples:Examples:Wireless technology that connects technicians in
ambulances to the emergency, transmits ECGsg y,Real time data collection for quality indicatorsElectronic bed boards / bed tracking systemsg y
Standardize processes and suppliesStandardize processes and supplies
The goal is to help “steer physicians towards
efficiency by using surrogate measures, using their
language and breaking it down into pieces they
understand and can manage”g
Mark Williams
North Mississippi Health Services
Standardize processes and suppliesStandardize processes and supplies
Clinical pathwaysClinical pathwaysClinical practice guidelinesStandard Operating ProceduresStandard Operating ProceduresBulk purchasesBar code scanning for tracking suppliesBar code scanning for tracking supplies
Quality Improvement Tools and Q y pStrategies
“If you keep looking at the data, and you have a
competitive spirit you keep getting better”competitive spirit, you keep getting better
St h B tti tStephen BattistaQuality Improvement DirectorFairview Southdale Hospital
Quality Improvement Tools and Q y pStrategiesKaizen Method, Lean, PDCAImportant that clinical and operations staff outside
the quality department are trainedthe quality department are trained
Benchmark performance against internal goals andBenchmark performance against internal goals and external benchmarks using dashboards
Dashboards incorporate quality and efficiency related indicators
Continuous quest for excellenceJCI accredited Apollo hospitals
Continuous quest for excellence
Delhi (first JCI accredited hospital in India)
ChennaiHyderabad (first JCI accredited stroke
program in the world)LudhianaDhaka BangaloreKolkata
Clinical excellence at ApollopBest clinicians
Clinical practice guidelines
Clinical pathways
Grand rounds
Apollo clinical excellence forum
A ll M di i J lApollo Medicine Journal
Research promotion
Apollo Gold Medals
Clinical excellence dashboard – ACE @ 25Clinical excellence dashboard – ACE @ 25
RACE
Mortality review
Clinical performance indicators for individual consultantsp
Departmental reviews
ACE @ 25ACE @ 25
Clinical balanced scorecard
25 parameters assessed against international25 parameters assessed against international
bench marks
Apollo Light House
CABG mortality rateCABG mortality rateBenchmark: 0.60%
Numerator: Number of in-hospital deaths after CABG
Denominator: Total number of CABG conducted
Indicator Benchmark Range ScoreIndicator Benchmark Range Score
CABG mortality rate 0.60% ≤0.80 4
Cleveland Clinic 0.81-1.20 3
1.21-1.60 22
1.61-2.00 1
>2.00 0
ACE @ 25
Parameters scored as a percentage
ACE @ 25
p g
Maximum score attainable 100
Over all hospital cumulative scores 50 - 75Over all hospital cumulative scores
> 75
50 75
< 50
ALOS post liver transplantALOS post liver transplantBenchmark: 14 days
Numerator: Total number of inpatients days post liver transplant to date of discharge of liver transplant patients
Denominator: Total number of liver transplants performed
Indicator Benchmark Range ScoreIndicator Benchmark Range Score
ALOS post liver transplant 14 days Cleveland Clinic ≤14.00
4
14.01-16.003
216.01-18.00 2
18.01-20.001
>20.000
Patient safetyy
Infection control
Medication safety
Surgical SafetySurgical Safety
Patient falls prevention
Communication safety
Facility safetyFacility safety
Apollo quality programApollo quality program
Clinical handoversClinical handovers
Surgical safety
International patient safety goals
Medication errors
Apollo quality programMonitoring Parameter Scoring
Clinical Handovers
Percentage compliance to completion of In house transfer1
Percentage compliance to completion of In house transfer form before patient transfer >90% 80-90% <80%
2Percentage compliance to use of nursing handover form for patient handover >90% 80-90% <80%
Percentage compliance to use of physician handover form3
Percentage compliance to use of physician handover form for patient handover >90% 80-90% <80%
4
No. of instances (per month) where Clinical Handovers were one of the proximate causes for the adverse clinical events and outcomes <1 1 >1
IPSGs
5 IPSG 1 Tracker score 100% 90-99.9% <90%
6 IPSG 2 Tracker score 100% 90-99.9% <90%
7 IPSG 3 T k 100% 90 99 9% 90%7 IPSG 3 Tracker score 100% 90-99.9% <90%
8 IPSG 4 Tracker score 100% 90-99.9% <90%
9 IPSG 5 Tracker score 100% 90-99.9% <90%
10 IPSG 6 Tracker score 100% 90 99 9% <90%10 IPSG 6 Tracker score 100% 90-99.9% <90%
Surgical Care Improvement
11Percentage of patients receiving antimicrobial prophylaxis one hour before surgery >95% 90-95% <90%
12Percentage of patients excluded from SSI calculation due to lack of follow up for the requisite time frame <20% 20-30% >30%
13 SSI <2.2% 2.21-2.85% >2.86%
14Number of instances of wrong patient, wrong side, wrong procedure surgery None Any
15Compliance to communicating sponge and instrument count to surgeon before skin closure >95% 90-95% <90%
16 Incidents of retained foreign body during surgery None Any
Medication Safety
17 Medication errors per 100 discharges <2.2% 2.21-2.85% >2.86%
18Medication errors due to sound alike look alike drugs as a percentage of total errors <2% 2-4% >4%
Remain focused
The Apollo Standards for Clinical CareThe Apollo Standards for Clinical Care
Apollo Critical Policies Plans 125Apollo Critical Policies, Plans 125and Procedures
Apollo Clinical Excellence @ 25 100Apollo Clinical Excellence @ 25 100Rocket ACE 100Apollo Quality Programme 100Apollo Quality Programme 100Apollo Mortality Review 50Apollo Incident Reporting System 25Apollo Incident Reporting System 25
Operational excellenceOperational excellence
The Apollo WayCost control
The Apollo Way
A new platform at Apollo to offer better patient experience
The Apollo Way
A new platform at Apollo to offer better patient experience through improved services
An operations-improvement programme
Deliver and sustain “Apollo Way benchmark” performance around key operational metrics
Through process improvement and capability building
Cost Control
Centralized purchase of supplies
Cost Control
Centralized purchase of supplies
Central purchase directly from manufacturers
Standardized supplies across the GroupStandardized supplies across the Group
Lean methodology
Service excellenceService excellence
VOCVOC
Performanometer
Apollo TLCApollo TLC
Patient Satisfaction
WEEKLYPERFORMANOMETER
MEDICAL SERVICES TEAM
5.0
4.9
MEDICAL SERVICES TEAM
4.94.8
5.03T1
4
4.84.74.54.6
4.7
MEDICAL
HOSPITAL
4.5
4.4
4.64.57
4 14.24.34.4PHYSIOTHERAPY
LAB SERVICES
6T1
4.24
4.1
4.3
3.83.94.04.1PAIN
RADIOLOGY
PROCEDURE
3.83.94.0
3.53.63.7
PROCEDURE
BLOOD BANK
EMERGENCY
Voice Of Customer is a Customer Feedback Programme being run byIndraprastha Apollo Hospitals.
Each patient is asked for a feedback at the time of discharge on a especially designed feedback form consisting of 40 odd questions.
Each question is marked on scale of 1 to 5.On the basis of Voice Of Customer, the scores of specialties , services and
floors are tracked on a weekly and monthly basis.
3.73.6
“Your attitude, not your aptitude, determines your altitude”determines your altitude”
Zig Zagler
S b 3 & 20 2 li l i iSeptember 13 & 14, 2012 ●Melia Hotel ● Hanoi, Vietnam
Dr. Ravinder UberoiChief Quality Officer, Indraprastha Apollo Hospitals