KPJ Healthcare

CONFERENCE & EXHIBITION

22 24 August 2014, Putrajaya

CHALLENGES IN IMPLEMENTING THE PATIENT

SAFETY GOALS & CLINICAL INDICATORS:
The KPJ Experience

Dato Dr Shahrudin Mohd Dun

Chairman KPJ Group Clinical Governance Action Committee
Medical Director & PIC KPJ Selangor Specialist Hospital

KPJ SELANGOR SPECIALIST HOSPITAL

PRACTICAL ELEMENTS IN CLINICAL GOVERNANCE

1. Patient Safety Goals (PSG)

2. Clinical Indicators (CI)

IMPLEMENTATION

1. Patient Safety Goals 2010

2. Clinical Indicators 2000

PSG - Background
2002 55th World Health Assembly Resolution
PATIENT SAFETY

WHO - World Alliance for Patient Safety

GLOBAL INITIATIVE ON PATIENT SAFETY

Malaysia Commitment on patient safety

KPJ Healthcare Berhad

Group Medical Advisory Committee 4/3/2008
# 7 Patient Safety Goals
# Adopt & Implement in all 19 hospitals
# Aim is to improve safety & minimize clinical errors

PATIENT SAFETY GOALS

1. Identify patients correctly
2. Improve effective communication
3. Improve the safety of using medications
4. Accurately and completely reconcile medications
across the continuum of care
5. Ensuring correct-site, correct-procedure and
correct-patient for surgery

6. Reduce the risk of healthcare-acquired infections

7. Reduce the risk of patient harm resulting from falls

CLINICAL INDICATORS (20)

1. Rate of LSCS (Caesarian Section)
2. Length of hospital stay > 5 days after elective LSCS
3. Length of hospital stay > 5 days after emergency LSCS
4. Time lapsed from declaration of emergency LSCS to start of
surgery
5. Rate of white appendix
6. Percentage of cases with HPE done for Appendicectomy
7. Myocardial infarction (MI) case fatality rate
8. Percentage of MI patients receiving thrombolytic therapy within 1
hour of their presentation at the A&E
9. Rate of CT scan done for head injury
10.Occurrence of adverse events during the recovery period in OT
11.Unplanned admission to the ICU within 24 hours of surgery
12.Laparoscopic cholecystectomy discharges within 48 hours
13.Rate of reactionary post-tonsillectomy bleeding
14.Incident rate of neonatal hyperbilirubinaemia > 20mg/dL
15.Incident of casting (neurovascular) complications
16.Adequacy of PAP smear study
17.Apgar score of baby at 5 minutes for emergency LSCS
18.Mild-to-moderate head injury case fatality rate
19.Dengue fever fatality rate
20.Percentage of post-operative cataract patients with BCVA less than
6/9 at three months after surgery

IMPLEMENTATION of PSG & CI

- Advantages of being a group

1. Can be done in stages

2. Workload is shared
3. Problems are shared & solved together

IMPLEMENTATION of PSG & CI

- Advantages of being a group (2)
1. Clinical & Corporate work together
2. Everyone must understand PSG & CI
3. Principles applications benefits

Aim Advocate patient safety

IMPLEMENTATION of PSG & CI

- KPJ experience (1)

1. PSG & CI are not implemented overnight

2. New idea Huge challenge & arduous task

3. Implementation process several stages

IMPLEMENTATION of PSG & CI

- KPJ experience (2)
The implementation process involved several phases
1 Training & Education
2 - Hospital-wide Awareness Most challenging part
Medical / Nursing / Allied Health / Other hospital staff
Patient & Relative awareness
Time factor
3 - Development of tools, posters, booklets
4 - Upgrading of facilities
5 - Audit schedule

IMPLEMENTATION of PSG & CI

- KPJ experience (3) The Journey
4/3/2008 KPJ MAC Directive

# KPJ Group 19 hospitals, varying sizes & resources

CHAMPION HOSPITALS
* Subcommittee for designated patient safety goal (PSG)
* Develop workable generic guidelines/procedures, to be
implemented throughout the Group
* Develop, pilot study, monitor, evaluate by November 2008

IMPLEMENTATION of PSG & CI

- KPJ experience (4) The Group Initiatives

Hospitals identified to champion the PSG

PSG
PSG
PSG
PSG
PSG
PSG
PSG

1
2
3
4
5
6
7

KPJ Ampang Puteri Specialist Hospital

Tawakal Hospital
KPJ Johor & Puteri Specialist Hospitals
KPJ Johor & Puteri Specialist Hospitals
KPJ Ipoh & Kuantan Specialist Hospitals
KPJ Damansara & KPJ Penang Specialist Hospitals
KPJ Selangor & KPJ Seremban Specialist Hospitals

IMPLEMENTATION of PSG & CI

- KPJ experience (5) The Group Initiatives
* KPJ Medical Workshop
Mid-year 2008
- Initial work presentation by champion hospitals
- Corrections
- Improvements
- Tailoring to generic

* KPJ Medical Conference

December 2008
- Progress
- Evaluation
- Initial pilot study results

IMPLEMENTATION of PSG & CI

- KPJ experience (6) The Group Initiatives
* KPJ Medical Workshop
Mid-year 2009
- KPJ Patient Safety Goals Manual approved
- Distributed to all hospitals

* Datelines in 2010
June
- Audit on implementation status
December
- Full implementation

KPJ GROUP INITIATIVES (7)

Patient Safety Goals MANUAL / CD

KPJ GROUP INITIATIVES (8)

Patient Safety Goals MANUAL / CD
# For each Goal
* 1.0 Patient Safety Guideline Content
- Introduction
- Policy Statement
- Objective/Definition
- Scope of Guidelines
- Training/Guideline monitoring
- Conclusion/References
* 2.0 Standard Operating Procedure (SOP)
* 3.0 Training Module
* 4.0 Appendices

KPJ SELANGOR - PSG IMPLEMENTATION (1)

* HOSPITAL CLINICAL GOVERNANCE COMMITTEE

Hospital level MAC (HMAC)
- MD/Chairman
- Supervise PSG implementation

* PSG Subcommittee
- MD & CEO as Co-Advisors
- Implementation schedule
- Monitors progress
- Reports to HMAC & Hospital Board

KPJ SELANGOR - PSG IMPLEMENTATION (2)

PSG SUBCOMMITTEE
* MD & CEO
* Chief Nursing Officer

- Advisors
- Chairperson PSG Subcommittee

Clinical
Physician
Orthopaedic Surgeon
Chief Pharmacist
OPD Unit Manager

Non-Clinical
Operation Manager
Quality Manager
Risk & Safety Officer
Chief Physiotherapist
Chief Radiographer
Medical Records Executive

+ Personnel-in-charge of each Goal

KPJ SELANGOR - PSG IMPLEMENTATION (3)

* PSG Subcommittee
# Management support & cooperation
# KPJ-PSG implementation dates

PSG
PSG
PSG
PSG
PSG
PSG
PSG

7
6
1
2
3
4
5

11/2/09 (Champion hospital)

20/5/09
7/12/09
7/12/09
17/2/10
17/2/10
1/3/10

KPJ SELANGOR - PSG IMPLEMENTATION (4)

* IMPORTANT FACTS
- Clinical & Corporate cooperation
- Everyone to understand the goals

Hospital-wide Awareness
Understands principles, application, benefits
Adherence to goals

ADVOCATING PATIENT SAFETY

KPJ SELANGOR - PSG IMPLEMENTATION (5)

IMPLEMENTATION PROCESS

* Staff Training & Education

* Hospital-wide AWARENESS
- Most challenging
- Medical & Hospital staff
- Patients & Relatives
* Development of posters, booklets, pamphlets, tools
* Upgrading of facilities
* Continuous surveillance
* Audit Regular / Random

KPJ SELANGOR - PSG IMPLEMENTATION (6)

BACK TO BASICS

FORMALIZING THE BASICS

PSG 1 Identify patients correctly (1)

Checklist for verifying identity of patient

ID bands
Admission letter
Inpatient admission form
Inpatient orientation form
Laboratory request form
Imaging request form
Drug administration record
Discharge summary
Discharge checklist

Death registration
Body identification form
Burial permit form
Outpatient registration form
Outpatient transfer form

PSG 1 Identify patients correctly (2)

PSG 2 Improve effective communication (1)

TAWAKAL SPECIALIST HOSPITAL

Checklist for nurses reporting to a doctor

Alert communication for critical test results
Guidelines on hand-over of a patient
Guidelines on verbal telephone orders
Guidelines on abbreviations

PSG 2 Improve effective communication (2)

PSG 3 Improve the safety of using medications

KPJ JOHOR & PUTERI SPECIALIST HOSPITALS

Monitoring checklist
SOP labeling of medications
SOP issuance of drugs to out/in-patients
Identification & handling of LASA drugs

PSG 4
Accurately/Completely reconcile medications across the continuum of care
KPJ JOHOR & PUTERI SPECIALIST HOSPITALS
Monitoring checklist staff awareness/implementation
SOP Reconciling medications
Medication diary

PSG 5
Ensure Correct-Site, Correct-Procedure, Correct-Patient for Surgery
KPJ IPOH & KUANTAN SPECIALIST HOSPITALS

SOP Consent
SOP Operation Theatre
Sign-in, time-out, sign-out checklist
SOP Diagnostic Imaging
SOP Radiotherapy & Oncology
SOP Verification Correct Site for invasive procedure
Posters

 Consent
Correct Patient
Correct Procedure
Correct Side and

Site

PSG 6
Reduce the risk of healthcare-acquired infections
KPJ DAMANSARA & PENANG SPECIALIST HOSPITALS
SOP Hand Hygiene Hand washing
SOP Hand Hygiene Hand rub
SOP management of various services (17)

PSG 7
Reduce the risk of patient harm resulting from falls
KPJ SELANGOR & SEREMBAN SPECIALIST HOSPITALS
Standard risk (Std precautions)
v High risk (Strict precautions)
SOP Fall Risk
Fall Risk Assessment Tool
SOP Lifting & Transferring of Patients
Checklist for fall precautions

PATIENTS STICKER

IMPLEMENTATION OF
FALL RISK ASSESSMENT
TOOLS

USE THE
STANDARD
OR
STRICT FALL
PRECAUTIONS
CHECKLIST

Public & Staff awareness

DISPLAY OF FALLS POLICY

DISPLAY OF
SIGNAGE

 Correct footwear

Assess environment for safety hazards

FALL AWARENESS CAMPAIGN

PICTURE WITH BADGE / BANNER
BROCHURES

Useful points to consider

When youre from lying down to standing up

Sit on the bed for a minute before you stand up

Move your ankles up and down to get your blood

pumping

Get your nose over your toes before you stand up

Push off the bed or chair; dont pull up

Wait a minute before you start to walk

When youre walking

Take your time when turning around. Count

each step to help pace yourself

If you have a walking aid, make sure its in good

condition

Use your walking aid appropriately. Dont grab for

furniture

Wear suitable footwear that is non-slip and

comfortable

CARE

You will be checked regularly for toileting needs and

general nursing care

Make sure footwear is appropriate:

Well fitting
Soles in good repair
Low heels

Dont walk in stocking

Clothing should be hemmed well enough to avoid

slipping or tripping over it

Wear glasses if you have them

ASSISSTANCE
Ask for help from staff when
transferring or walking
Use the call bell and make sure
you leave it within easy reach
RECOVER
Rest regularly to give your body time to recover
Use medicine for pain relief, to reduce
unnecessary
strain physically and mentally to aid your recovery
EXERCISE
Your physiotherapist will show you exercise you
can
do on your own or with supervision or assistance,
to regain your strength and mobility
DIET
It is important to eat a nutritious diet that
includes
foods rich in:
Calcium e.g. dairy products, broccoli
Vitamin A e.g. carrots, yellow or orange
fruit or vegetables
Vitamin C e.g. citrus fruits and tomatoes
Vitamin D
These foods promote healing, calcium
absorption
and bone rebuilding

KPJ GROUPS OF HOSPITALS

TRAINING & EDUCATION WORKSHOP

KPJ SELANGOR - PSG IMPLEMENTATION

COMPLIANCE & EFFECTIVENESS

* PSG Subcommittee regular / weekly meetings
* Continuous surveillance
* Audit Regular / Random
* Statistical data / report December 2010

IMPLEMENTATION PSG & CI

Summary of challenges faced
1 - Mindset change Focus on safety first, quality will then follow
2 - Create a workplace culture that encourages self-reporting
3 - Update infrastructure involves costs
4 - Transition systems slowly time factor
5 - Failure to communicate
6 - Work/staff inefficiency
7 - High error rate with tasks involving academic skills making mistakes
8 - Problems learning a sequence of tasks
9 - Time management & social skills
10 - Diversity of opinion and interpretation
11 - Employee-employee/employer interaction
12 - Motivation & productivity - Boredom, stress & burnout
13 - Handling criticism

IMPLEMENTATION CHALLENGES

TO HAVE A STRONG WORKING CLINICAL

GOVERNANCE IN PLACE
1. Group MAC 2002
2. Hospital level MAC @ HCGC

CHAMPIONS OF CLINICAL GOVERNANCE

Tan Sri Dato Dr Abu Bakar Suleiman

Former KPJ Group MAC Chairman

Datin Paduka Siti Sadiah Sheikh Bakir

Former KPJHB Managing Director

IMPLEMENTATION CHALLENGES
CLINICAL GOVERNANCE

1. Group MAC oversees implementation

2. Hospital MAC
- oversees locally
- addresses local problems
- reports back to Group MAC

STRUCTURE OF CLINICAL GOVERNANCE KPJ SELANGOR

KPJHB BOARD

KPJ MEDICAL ADVISORY COMMITTEE

KPJ SELANGOR
BOARD OF DIRECTORS

KPJ SELANGOR
BOARD OF MANAGEMENT

CLINICAL GOVERNANCE POLICY COMMITTEE

CLINICAL GOVERNANCE ACTION COMMITTEE
CLINICAL RISK MANAGEMENT COMMITTEE

MEDICAL DIRECTORS COMMITTEE

HOSPITAL MEDICAL ADVISORY COMMITTEE (HMAC)
RESEARCH & DEVELOPMENT

CLINICAL ETHICS COMMITTEE

13 HOSPITAL COMMITTEES

6 CLINICAL COMMITTEES

7 HEADS OF CLINICAL DISCIPLINES

IMPLEMENTATION CHALLENGES
CLINICAL GOVERNANCE

What does the clinical governance mean?

Effective working relationship between
Consultants
Nursing Staff
Management & other hospital staff (Non-clinical)

CLINICAL GOVERNANCE

ORGANIZATION / STRUCTURE
# 2014 Example Hospital & Clinical Committees in KPJ Selangor

Hospital Medical Advisory Committee

Clinical Committees (per KPJ By-Laws) - 6
Credentials, Audit, Ethics, Peer Review & Education
Mortality Review Committee
Infection Control Committee
Pharmacy & Therapeutics Committee
Medical Records Committee
Surgical & Medical Intervention Committee
Hospital Committees (per PHFSA / R & other requirements) 13
OSH & Risk Management Committee
Quality Assurance Committee
Patient Complaints & Conflict Resolution @ Feedback Committee
Transfusion & Laboratory Committee
Hospital Credentialing & Privileging Committee
Hospital Disaster Management Committee
Hospital Radiation Committee
Hospital Building Committee
Accreditation Committee
Lactation Management Committee @ BFHI
Code Blue Committee
Emergency Cardiovascular Care Training Committee
Consultant Fees Review Committee

CLINICAL GOVERNANCE
ORGANIZATION / STRUCTURE

Meetings - interactions within the structure

(3) Management / Non-clinical Staff

Clinical & Hospital

Committee meetings

HOS / MR meetings
HMAC & BOM
meetings

(1) Consultants
Ward / Unit / Department meetings

(2) Nursing Staff

IMPLEMENTATION CHALLENGES

Group MAC
- oversees implementation PSG & CI
- coordinates
- lessons learned shared & distributed

IMPLEMENTATION CHALLENGES

ORGANISED WAY OF DEALING WITH

CHALLENGES IN ANY CLINICAL ISSUES
ALLOWS STRENGTHS & SOLUTIONS TO BE
DEVELOPED THAT CAN BE EFFECTIVELY
SHARED WITHIN THE GROUP

IMPLEMENTATION CHALLENGES
PIVOTAL ROLE OF KPJ NURSES

Thank You