11/6/2012. Central Board of Accreditation for Healthcare Institutions. CBAHI Theme. Majdah A. Shugdar

Transcription

1 Majdah A. Shugdar MSc. CPHQ, MBA,, PGDRM - Bradford university School Of Management Academic associate University of Cardiff institute UWIC UK CBAHI Director of Hospital Accreditation department KFH Jeddah- Director of TQM 1 2 Patient Safety Culture Improvement Fundamental Change - (PSCIFC) A Case Study in King Fahd Hospital Jeddah, Kingdom of Saudi Arabia Doctorate of Business Administration (DBA) Thesis 2012 Cardiff Metropolitan University UWIC CBAHI Theme PREPARATION تحضير ACCREDITATION اعتماد MONITORING متابعة 5 6 1

2 Central Board for Accreditation of (CBAHI) Doctorate Research Non profit organization Emerged from the council of health services Saudi official agency authorized to grant healthcare accreditation Governmental and private healthcare institutions operating today in the Saudi Arabia. nearly 5,000 Primarily responsible for setting the quality and safety standards CMAT: SPSC Change Management Using Accreditation Tools Sustainable Patient Safety Culture - Tool Kit (SPSC) 7 8 When Healthcare Workers Make Mistakes.. Is the Health Care A Safe Environment? Everyone makes mistakes. Unfortunately, in the healthcare field, A mistake can cost someone their life Health Care System Patient Safety Concept Complex Prevents errors Adverse healthcare High-risk Patient Safety No Harm Learns from the errors events may lead to death and injury Error prone Patient Safety culture (Staff & Patient ) Kenneth Kizer Director of New Institute for Population Health Improvement (IPHI) Kizer, K. and Blum, L.N Safe practices for better health care 11 (Aspden P, Corrigan J, Wolcott J, et al, 2004). 12 2

3 Patient Safety Systems The Culture Error Emergency Room Admissions Laboratory Transfers Physicians Pharmacy Nurses Patient / Family Reason, J. (2000). Human error: models and management. BMJ, 320: Barrier/Defense Is shaped internally between members and with external environment to build the mutual trust and transparency across the organization; this collectively generates the spirit that drives the culture O'Connell, C. (1999). A Culture of Change or a Change of Culture? Nursing Administration, 23, pp 17: Patient safety culture. How can accreditation help in organizational operational plan Freedom from accidental injury. Patient safety Quality Aspects Accreditation Patient Safety & accreditation Standards Patient Safety & survey process QM.15. The hospital adopts a process that requires (2) patient identifiers IC.42. Hand hygiene is strictly observed in the hospital: Interview Facility surveys and tours Documents review Clinical And System QM.17. There is a standardized list of approved and forbidden abbreviations, acronyms, and symbols Unit Visit (observation, Interview) Tracer Methodology Personnel record review Medical record review (closed, open)

4 Study steps Doctorate research question : This study was implemented in King Fahd Hospital Jeddah KFHJ. 599 beds KFHJ has been part of the Saudi National Hospital Accreditation Program, Central Board for Accreditation of (CBAHI). The CMAT - SPSC Toolkit is proposed to be the answer to this question CMAT SPSC effectiveness has been evaluated following the implementation at the KFHJ, Research Hypothesis Mix Qualitative Quantitative Change the Pteitn Safety Staff Cultre PSCIFC implementation realted to Hospital Accrediation Score Research milestones over the research period Patient Safety Culture Dimensions Pre-SPSC CMAT -SPSC April 2009 February 2010 Developing a Sustainable Patient Safety Culture (SPSC) Post-SPSC This assessment tool was built on many dimensions, primarily on a strong Unit Level : Patient Safety Culture Dimensions awareness and a clear perception among the health caregivers about safety Supervisor/manager expectations and actions promoting safety Leadership Hospital level : Safety culture dimensions January - March 2009 Apr 2009 Accreditation Intervention Feb March 2010 Organizational Learning Continuous Improvements Teamwork Within Hospital Units Hospital Management Support for Patient Safety First: Pre-intervention Hospital Survey on Patient Safety Culture (HSOPSC) First: Mock Accreditation Central Board for Accreditation of Health Care Institutions (CBAHI) Development and Implementation of the SPSC Toolkit Second: Post-intervention Hospital Survey on Patient Safety Culture (HSOPSC) Second: Final Accreditation Central Board for Accreditation of Health Care Institutions (CBAHI) Communication openness Feedback and Communication Teamwork Across Hospital Units Outcome Measures about Errors Re-evaluation of the SPSC and modification of the model to be generalized and capable for replication in similar experience Non-punitive Response to Error Hospital Handoffs & Transitions Frequency of Event Reporting Number of events reported Patient Safety Grade within your working area/unit Overall Perceptions of Safety. Staffing

5 Lewin Kotter CBAHI Accreditation chapter Leadership And Quality Leadership Quality Management and Patient Safety Social Workers Management of information medical record Patients and family rights Medcial Medical Staff and Provision of Care Anesthesia Intensive Care Unit: Adult, Pediatric, Coronary Care Unit, Neonate Operating Room Haemodialysis Emergency Room Radiology Burn Care Ambulatory Care Services: Ambulatory Care, Dental Services Change Management Models Nursing Nursing Rehabilitation Service Patient & Family Education and Rights Specialized Areas: Respiratory Services, Dietary Service Pharmacy Laboratory Facility Management And Safety infection control Lewin s Change Management Models Kotter s Change Management Models 1 Establishing a sense of urgency 2 Creating the guiding coalition 3 Developing a vision and strategy 4 Communicating the change vision 5 Empowering broad-based action 6 Generating short-term wins Consolidating gains and producing more 7 change Anchoring new approaches in the 8 culture Comparison between the change modules of Kotter and Lewin SPSC Sustainable Patient Safety Culture Module Un freeze Transition Freeze 1 st HOSPSC Mock Survey 1- Leadership Momentum 2-ASC 3- Accreditation Teams 1 Creating a climate for change Engaging and enabling the whole organization 2 3 Implementing and sustaining change 4-Accreditation Team Vision 5- Education, Training 6- SPSC Tool Kit 8-SACT 9-Facilitate 10- Quick win Celebrate 2nd HOSPSC Real Survey 小

6 Pitfalls to Avoid PSCIFC (CMAT- SPSC) Un freeze Transition Freeze Top leaders give lip service to the process, but are totally unrealistic in what it will take to achieve it in terms of time and resources Creating a climate for change Engaging and enabling the whole organization Implementing and sustaining change 1-2- Creating a climate for change 3-6 Engaging and enabling the whole organization Staff end up feeling that accreditation is extra work for which they are not rewarded or recognized 1- LD Momentum 2-ASC 3-Accreditation teams 4-Accreditation teams vision 5-Education, training 6- SPSC Over-eager managers use the standards as a stick rather than as a carrot --- can make entire accreditation process feel punitive and inspecting 7- CQI 8- SACT 9-Facilitate 10-Quick win Celebrate 11- CQI 12- Adopt a hospital wide project (s) rather than motivating Implementing And Sustaining Change 35 SPSC Toolkit SPSC Toolkit 1. Scope of Services 2. Scope of Service Data Base 3. Quality Management and Patient Safety 4. Administrative Policy & Procedure 5. Internal Policy & Procedure 6. Policy and Procedure Review Checklist 7. Committee Forms 7.1 Committee Terms of Reference 7.2 Agenda 7.3 Review of Previous Decision 7.4 Minutes of Meeting 7.5 Accreditation Steering Committee Minutes of Meeting 7.6 Attendance Sheet 7.7 Distribution List 7.8 Committee Status Report 7.9 Notification of Inclusion in the Membership 7.10 Notification of Exclusion from Membership 7.11 Annual Review Report 8. Accreditation Steering Committee (ASC) 9. Job Description 10. Performance Improvement SPSC Toolkit Training Topics Based on CBAHI Standards 10.1 Focus PDCA Worksheet 11. Occurrence, Variance Report Form 14. Focused Professional Practice Evaluation Report 10.2 Improvement Methodology 11.1 Hospital OVR Log Sheet 15. Departmental Employee Personnel File Check List 10.4 Performance 10.3 PDCA Worksheet Improvement (PI) Application Form 11.2 Occurrence, 12. Root Cause Variance, Report (OVR) Analysis Worksheet Forms 15.1 Medical 15.2 Nursing 10.5 Hospital Plan Template 13. OVR Log Sheet 15.3 Administrative Standard # PFR Implementation Targeted Group Lectures PFR Awareness of General Principles of PFR All Hospital LD Patients Rights All Hospital NR Patients & Family Rights All Hospital Consent process All Hospital PFR Patients Rights are Informed All Hospital PFR Ethical Standards All Hospital AS NURSE All Hospital AS PHYSICIAN All Hospital AS Administrator All Hospital AS LEADER All Hospital PFR Complaint Management All Hospital Infection Control IC Evid. of implementation of handling of spills & disposal of medical wastes (biomd,hd) IC Awareness of all Infection Control Guidelines Medical /clinical staff 16. Confidentiality Agreement Format 17. Hospital / Departmental Documents 18. Hospital Administrative Policy & Procedure 19. Hospital Accreditation Status Report 20. Hospital Plan Database IC Staff Hygiene & Health is Supervised by Infection Control Medical /clinical staff IC Laundry functions are supervised by Infection Control (Laundry) IC Environment & Functions are Supervised by Infection Control Medical /clinical staff IC Evidence of Compliance with Current CSSD Polices Medical /clinical staff IC Evid. of awareness of reporting communicable diseases Medical /clinical staff 21. Training Topics Based on CBAHI Standards Awareness about appropriate reporting of exposure to needle IC Medical /clinical staff stick. IC Knowledge & Skills on Handling Sharps Medical /clinical staff IC. Evidence of Awareness of Standards and Isolation Precaution Medical /clinical staff PH Availability of Infection Control Manual Medical /clinical staff

7 (Differences in the overall mean scores) (Differences in the overall mean scores) Central Board of Accreditation for 1. Comparing the pre-intervention mean agreement scores on sub-items of safety, according to the job of the participants. Sub-items of safety dimension Physician Nurse Technician P* Results Discussion Mean±SD Mean±SD Mean±SD 3.22± ± ± Supervisor/manager Expectations and Actions Promoting Safety 2.84± ± ±1.23 <0.001 Organizational Learning Continuous Improvements Teamwork within Hospital Units 3.49± ± ± Communication Openness 3.09± ± ±1.08 <0.001 Feedback and Communication about Errors 2.95± ± ±1.07 < ± ± ± Non-punitive Response to Error 2.63± ± ± Staffing 3.17± ± ± Hospital Management Support for Patient Safety Teamwork Across Hospital Units 3.01± ± ± Hospital Handoffs & Transitions 2.89± ± ± Frequency of Event Reporting 2.93± ± ± Overall Perceptions of Safety 3.12± ± ± Comparing the Post-intervention mean agreement scores on sub-items of safety, according to the job of the participants. 2. Comparing the overall mean scores of agreement on items of safety dimension before and after intervention according to job of the participant Sub-items of safety dimension Physician Nurse Technician P* Mean±SD Mean±SD Mean±SD Supervisor/manager expectations and actions promoting 3.80± ± ± safety Organizational Learning Continuous Improvements 3.73± ± ± Teamwork Within Hospital Units 3.70± ± ± Communication Openness 3.66± ± ±0.87 < Feedback and Communication about Errors 3.30± ± ±1.10 <0.001 Non-punitive Response to Error 3.69± ± ±1.15 <0.001 Staffing 3.46± ± ± Hospital Management Support for Patient Safety 3.51± ± ± Teamwork Across Hospital Units 3.29± ± ± Hospital Handoffs & Transitions 3.07± ± ±0.76 <0.001 Frequency of Event Reporting 3.27± ± ± Overall Perceptions of Safety 3.21± ± ± Pre Physicians Nurses Technicians Post The changes in the overall agreement mean scores on items of safety dimension after intervention according to job of the participant 4. Changes in the percentages achieved on accreditation achievement percentage score for each item after intervention % 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Pre Post Physicians Nurses Technicians p<

8 Differences in the accreditation achievement percentage score for each item after intervention 5. Scatter plot for the correlation between pre- and post-intervention accreditation evaluation Intensive Care Units Radiology Pharmacy Haemodialysis Emergency Room Ambulatory Care Services -7.2% -3.3% -1.6% 4.2% 4.4% 4.9% Anesthesia Quality Management and Patient Safety Management of Information Medical Staff and Provision of Care Leadership Burn Care Infection Control Nursing Operating Room Laboratory 8.9% 10.8% 10.9% 11.0% 11.0% 11.1% 11.4% 14.8% 15.2% 23.3% Patient & Family Education and Rights Facility Management and Safety 31.0% 32.9% Specialized Areas 42.4% -10.0% 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% Limitations: Limitations: Language is one of the limitation as Arabic is the national language and hospital staff was unable to understand the instructions. Lack of understanding, knowledge and training and development programmes. Hospital staff was unaware of the concept of patient safety and other measures which need to be taken to enhance the quality of service and hygiene factors. Lack of awareness about the benefits of accreditation and patient safety among the management. Accreditation of hospitals concept in Saudi Arabia is pretty new and even hospital staff do not have much information regarding the importance and advantages of accreditation. Lack of leadership skills among the physicians and other medical practitioners. due to their engagements and work load. Multi lculture of the hospital because of the different country nationals Conclusion Conclusion This case study is not generalizable, but it suggests that Kotter s model could be a useful tool in activate the CMAT initiative in hospital accreditation process

9 Accreditation process Can Drive The Culture Change Conclusion Quality Aspects Patient safety Accreditation standards Majdah Shugdar 28 March 2011 Kingdom Hosp Majdah Shugdar 28 March 2011 Kingdom Hosp