GOALS OF PRESENTATION

HEALTHCARE QUALITY AND PATIENT SAFETY: THE MALAYSIAN EXPERIENCE

1.To Know Malaysia and the healthcare System. 2.Why Quality and Safety 3.Approaches 3 Approaches to improve Quality and Patient Safety
BY Assoc.Prof.Dr.Kadar Marikar CEO,MSQH 5 Feb.2009

4.Foster comparative discussions of strategies for quality of care & safety

Malaysia
The country is made up of two regions, Peninsula Malaysia and East Malaysia (Borneo) across the South China Sea. The Peninsula Malaysia is divided into the 'east coast' and the 'west coast' by the Main Range in the middle. East Malaysia is geographically rugged, with a series of mountain ranges running through the interiors of both Sabah and Sarawak. The Crocker Range in Sabah is the site of Mt Kinabalu, the highest peak in South East Asia.
Peninsula Malaysia

East Malaysia (Borneo)

Population of over 26 million people. Multi-cultural and multi-racial population consists of Malays, Chinese, Indians and numerous natives. Ethnic Groups: 59% Malay and other indigenous indigenous, 32% Chinese and 9% Indian.

Malay is the official language but English is widely spoken, especially in business. Official religion is Islam, but its people are free to observe any religion of their choice. It is common to see temples, mosques and churches located in close proximity. Languages: Malay, English, Chinese, Tamil and other tribal languages. Religion: Muslim (primarily Malays), Buddhism (Chinese), Hindu (Indian), Christianity. (Indian) Christianity

Malaysia is generally warm throughout the year with temperatures ranging from 21 to 32 C in the lowlands. This can however be as low as 16 C in the hills and highlands. Annual rainfall is heavy at 2,500mm (100 inches). On a rainy day, thunder and lightning often accompany the heavy downpour which normally lasts for less than two hours. The humidity level is high at 80% throughout the year. Generally, Malaysia has two seasons. The dry season is from May to September and the rainy season is from November to March.

 Malaysia has 12 states and 3 Federal Territories. The Capital City is Kuala Lumpur

MALAYSIAN HEALTH SECTOR:

MINISTRY OF HEALTH Inpatient care services -Total 138 hospitals -Primary -Secondary -Tertiary -Specialized services (Range of beds 40-2000)

Public Health Services Out-patient services: -Health Centre (10,000 centre) -Community Clinics (2,000 Clinics)
(Estimated every 5 kilometers radius -> 1CC)

Private Sectors -Private Hospitals: 328 (Range of beds 2-350 beds)

- Private Medical clinics: 6000 - Maternity Centres : - Hemodialysis centers : - Day care centers : - Nursing Homes:

-In remote areas: Flying Doctors Services.

(Especially for Sabah & Sarawak)

Preventive and Health Promotion services Medical Training Institutions-University Hospitals: 3 Ministry Of Defence: 3 + 1

Corporatised Hospital : National Heart Institute (IJN) 262 beds

VISION FOR HEALTH

Malaysia is to be a nation of healthy individuals, families and communities, through the health system that is equitable, affordable, efficient, technologically appropriate, environmentally adaptable and pp p , y p consumer friendly, with emphasis on quality, innovation, health promotion and respect for human dignity and which promote individual responsibility and community participation towards an enhanced quality of life.

Reasons for Supporting Quality of Care Agenda

REDUCE COSTS OF WASTES & ERRORS THROUGH CLINICAL QUALITY

Purchasers:
1) Control costs + assess quality = VALUE (cost-effectiveness for money spent) 2) Ensure access to care (government)

Suppliers / hospitals / doctors: S li h it l d t

1) Demonstrate quality and value to purchasers 2) Improve safety and reduce medical errors 3) Attract patients to maintain revenue

Patients / consumers:
1) Get high-quality, affordable care when needed 2) Maintain choice of doctors and hospitals

Stakeholders for Quality of Care

Purchasers: National & state governments Private health insurers Suppliers: Health Industry Drug and device companies Providers: Doctors and professional societies Hospitals, Clinics etc..

Why Measure Quality of Care?

Quality & effectiveness of health care essential to: Improve health Improve abnormal risk factors & prognosis (high blood pressure or high glucose) Lower morbidity Lower mortality
US National Library of Medicine

Patients / consumers

QUALITY FRAMEWORK
LEADERSHIP ORGANISATIONAL CULTURE & VALUES MEDICAL STAFF FOCUS ON PATIENT FOCUS ON PROCESS

OPERATIONAL MODEL

ACCESSIBILITY EFFICIENCY EFFECTIVENESS

SAFETY COMPETENCY COMPETENCY

STRUCTURE
(What are the things that you have)

PROCESS
(What do you do With these things)

OUTCOME
(What is the result of what you do with these things that you have)

QUALITY

PEOPLE FOCUS

APPROPRIATENESS

CONTINUOUS QUALITY IMPROVEMENT ENHANCED QUALITY OF LIFE

MSQH

ORGANISATIONAL STRUCTURE

QUALITY ASSURANCE PROGRAMME IN MINISTRY OF HEALTH

Launched in 1985 (with implementation of Patient Care Services QA Programme) QAP expanded to Public Health Services (1990) Pharmaceutical Services (1990) Dental Services (1992) Engineering Services (1992) Laboratory Services (1992) Training & Manpower Services (1996) Planning Division (1997)

1. National level 2. Programme level 3. State level 4. Hospital/Institutional level

Quality Improvement Activities

ACTS AND REGULATIONS

Hospital based

PRIVATE HEALTHCARE FACILITIES AND SERVICES ACT 1998 REGULATIONS 2006

QUALITY IMPROVEMENT ACTIVITIES IN THE MOH MALAYSIA

NATIONAL INDICATOR APPROACH (NIA) HOSPITAL SPECIFIC APPROACH (HSA)/ DISTRICT SPECIFIC APPROACH (DSA) MATERNAL MORTALITY REVIEW/ PERINATAL MORTALITY REVIEW PERIOPERATIVE MORTALITY REVIEW (POMR) MEDICAL AUDIT TOTAL QUALITY MANAGEMENT QUALITY CONTROL CIRLCE QUALITY CONTROL INFECTION CONTROL CLINICAL PRACTICE GUIDELINES (CPG) INCIDENT REPORTING CORPORATE CULTURE CLIENTS CHARTER INNOVATIONS RENAL REGISTRY Credentialing and Privileging Accreditation of Healthcare Facilities and Services

Strategic Plan For Quality

Late 1996 & 1997: Evaluation of 17 Quality Initiatives in MOH was carried out at National Level. Outcome of the evaluation was deliberated in the 1998 National Conference on Quality in Health Care held in March 1998.

Strategic Plan for Quality in Health

Implementation Plan of the Strategic Plan for Quality in Health 14 Manuals: Corporate Culture PKPA NIA MMR Incident Reporting CPG POMR Renal Registry Nosocomial Infection Innovations Quality Control Client Charter Quality Control Circle MS ISO 9000

The National Indicator Approach

Use of common indicators to assess the quality of care For each indicator a standard is set, against which the performance is compared If do not meet standards carry out investigations standards, to identify contributing factors or reason for shortfalls in quality Remedial measures are identified so as to overcome these shortfalls The cycle is then repeated

Report on a decade of NIA Performance by Programmes

These document have also been distributed for use by the Private Health Care providers - to assist them towards compliance of the Private Healthcare Facilities and Services Act 1998.

NATIONAL INDICATOR APPROACH

Patient Care Services Public Health Services Oral Health Pharmacy Laboratory y Engineering Services Human Resource & Training Planning & Development Division - 51 indicators - 13 indicators - 14 indicators - 6 indicators - 8 indicators - 2 indicators - 5 indicators - 3 indicators

THE HOSPITAL SPECIFIC APPROACH (HSA)/ DISTRICT SPECIFIC APPROACH (DSA) Concept: Local staff identify and solve local problems

Hospitals/Districts identify areas of shortfalls specific to each individual hospital/district Study the process of provision of care to detect weakness Identify remedial measures Implement solution to overcome weaknesses Impact evaluation by reassessing quality

Incident/Event Reporting
- is a system of reporting any unintended occurrences of certain processes or outcomes (quality related) which could have or did harm to the patient p ( ) - Concept (HSA) * local problems * local solutions - Principles * simple process * highlight good ideas * non punitive * immediate remedy * feedback

Incident/Event Reporting

INDICATORS - examples
Nosocomial infection
Adverse drug reactions Falls and accidents Greater than 24 hours waiting time for emergency surgery

HOSPITAL INFECTION CONTROL (HIC)

HOSPITAL INFECTION CONTROL (HIC)

* MOH focus on HIC in late 1980s * Factors contributing to HIC include: -b l below satisfactory standards of nursing care ti f t t d d f i - inadequate facilities (equipment & overcrowding) - misuse and abuse of Antibiotics - improper use of sterilization and disinfection procedures

* Outcome of Research Projects on HIC - Institutionalization of Nosocomial Infection Control Programme in all hospitals - An Antibiotic Policy - Disinfection & Sterilization policies

HOSPITAL INFECTION CONTROL (HIC)

* Publications produced:
- Principles & Practices in Hospital Sterilization and Disinfection ( (Slides on Infection Control in Malaysian Hospitals) y p ) -Disinfection and Sterilization Policy & Practice - Guidelines On The Use Of Antibiotics

PeriPeri-operative Mortality Review (POMR)

*Started in 1990 Aim: Aim: To systematically assess the quality of Anesthetic and Surgical services and quality of supporting services,with the ultimate aim of identifying Shortfalls and taking remedial measures. measures. All cases of peri-operative death during the periwhole hospital stay is being investigated * For the 6th cycle (from 1/1/98 onwards) the POMR committee will review periperi-operative deaths that occur in 5 targeted areas. areas.

PeriPeri-operative Mortality Review (POMR)

5 targeted areas Neurotrauma Obstetrics Colorectal surgery Polytrauma Pediatric Surgery

ACHIEVEMENTS
1. 2 yearly reports have been produced. The 3rd report has been published. 2. Developments of policies and guidelines. 3. Improvement in OT, ICU and HDU services. 4. Improvement in Training and Supervision. 5. Computerised OT Documentation System. 6. Provide inputs for future development of Surgical, Anesthetic and Trauma Services, facility development and human Resource planning for the 8th Malaysian plan.

* Anaesthetic management in these 5 areas will also be reviewed. The parallel reporting system will continue to monitor all peri-operative deaths perias a baseline review.

CLINICAL PRACTICE GUIDELINES (CPG)

* Since 1993, MOH has initiated the Medical Consensus Development Programme with the Academy of Medicine * In October 1996, both MOH & , Academy of Medicine Malaysia took another step forward in developing evidence-based evidenceClinical Practice Guidelines * Since November 1997: MOH, Academy of Medicine and UKM conducted yearly Systemic Review Workshop (Evidence Based)

CLINICAL PRACTICE GUIDELINES (CPG)

Clinical Practice Guidelines Systematically developed statements to assist practitioner and patients decision about appropriate health care for specific clinical circumstances

CLINICAL PRACTICE GUIDELINES (CPG) Why Clinical Practice Guidelines?

- as a tool to address the issue of unjustifiable variations in clinical practice for a clinical condition p - assists practitioner to make the right decision, one which is appropriate, effective & reasonably cost effective - attempt to make the best use of available resources to achieve the best possible outcome - as standard of Clinical Practice

Examples of Consensus & Clinical Practice Guidelines available Prophylaxis of Venous Thrombo-embolism Management of Chronic Obstructive Airway Disease Management of Dengue and Dengue Hemorrhagic Fever in the Pediatric Population Management of Idiopathic Nephrotic Syndrome in Childhood Screening for Hepatocellular Carcinoma

MEDICAL STAFF CREDENTIALLING

HEALTH TECHNOLOGY ASSESSMENTS (HTA)

Unit set up in 1995 Is the systematic evaluation of the properties & the effects of Health Technology gy Focus is on * safety * efficacy/effectiveness * feasibility

Process of ensuring those who provide health care services are fully competent to do so * Right person for the right job * If providers not skilled enough ability to achieve Quality Outcomes will be questionable * Life time qualifications may no longer be valid

HEALTH TECHNOLOGY ASSESSMENTS (HTA)

WORLD ALLIANCE FOR PATIENT SAFETY Launched by WHO in October 2004 in response to World Health Assembly Resolution 2002 urging WHO and member states to pay the closest possible attention to Patient Safety.

Among topics studied: Stereo tactic Radio-Surgery Radio Spinal Cord Stimulation Electromagnetic Prostatectomy Routine Pre-operative Investigation Pre Electronic Fetal Monitoring

PATIENT SAFETY COUNCIL MALAYSIA (PSCoM)

Formed in Feb.2003 Committed to WHO World Alliance for Patient Safety strategies and action plans. MSQH i a member of th PSC M . is b f the PSCoM Strategies and action plans developed by PSCoM is adopted and given emphasis in the MSQH Hospital Accreditation Standards and Compliance assessment .

Goals of Patient Safety Programs

Create the safest possible environment for patients: Reinforce patient safety as top priority & p y pp y
create culture of safety

Measure & evaluate patient safety Change processes identified as unsafe Adopt technology that enhances safety

Patient safety
Patient safety is an outcome of safe health care process. While patient safety is the ultimate goal, it is a safer health care environment in the course of the process of patient care which ultimately determines safety. Safety is one dimension of the broader construct of culture culture, which includes aspects of organisational and clinical culture e,g related to specialities and professions. Communication is vital to patient safety in many ways: thus supporting mutual understanding across cultures is essential in the general development of patient safety.

HOSPITAL ACCREDITATION PROGRAMME

- started in late 1995 with the 1st National Workshop on Accreditation of hospitals - Assistance - WHO Consultant - is a process in which quality of health care services in a particular hospital is compared against established professionally accepted standards - voluntary programme conducted by a nonnongovernmental organisation

Memorandum of Understanding
1st October 1999
MOH MMA

HOSPITAL ACCREDITATION PROGRAMME Objectives

establishes standards of services among health care providers ensure quality of healthcare throughout the country enhance organization and management of healthcare institutions achieve optimum results from available resources increase accountability to customers and stakeholders

PARTNERSHIP & CONSENSUS

MSQH

The Malaysian M l i Healthcare Accreditation Program

COLLABORATION & SUPPORT

APHM

Active Participation of the Public, Private Sectors & Professional Organisations

HOW DO SYSTEMS OF CARE IMPEDE QUALITY & SAFETY?

Systems fragmented and often designed to serve needs of providers, not patients System deficits affect all providers and patients Patients fall through the cracks in complex systems of care Several small problems in multi-step processes can trigger severe adverse events Problems arise even when providers well intentioned

Key Challenge
The biggest challenge is to get people in hospitals- physicians, pharmacists, nurses, and administrators administrators- to recognize that errors are systems problems and not people problems.
Lucian Leape, MD Harvard School of Public Health

CULTURE OF SAFETY
Unreported errors cannot be investigated First, need to create a culture of safety, similar to the aviation industry
Even highly trained people make mistakes Reduce fear of reporting Move beyond blaming & punishing, toward improving the system

CONCLUSIONS & IMPLICATIONS

Many quality & safety tools now available to health policy-makers & health-care leaders:
Information technology Evidence-based quality standards Performance reports Financial incentives Focus on leadership, teamwork & coordination of care

Shift focus from blaming people to improving system

DO IT RIGHT FIRST TIME, ANYTIME

INCREASING PRODUCTIVITY

THANK YOU FOR YOUR ATTENTION

www.msqh.com.my msqh@msqh.com.my

REDUCE COSTS OF WASTES, ERRORS & REWORK THROUGH ENHANCING CLINICAL QUALITY