QUALITY IMPROVEMENT

AT THE SHELL HOSPITAL, WARRI

DR. OLUFEMI MOSURO

Dr. Okuns Ohiosimuan

Dr. Rita Akintola

Mrs. Nkem Osakwe

SHELL IA HOSPITAL, OGUNU

SHELL IA HOSPITAL, OGUNU

3

• To protect and preserve

the health of staff ensuring

a healthy workforce.

FOCUS OF SHELL HEALTH

STAFF

STAFF FAMILY

CONTRACTORS

IMMEDIATE COMMUNITIES

• Preventive & Curative Health

• Occupational Health

• Community Health

• Projects & products

SCOPE

OBJECTIVES OF SHELL HOSPITAL WARRI

5

To deliver effective and quality Health strategies and services in order to optimise the health of the stakeholders (employees, dependant, contractors and Neighbours)

QUALITY IN HEALTHCARE

6

Doing the right thing

At the right time

In the right way

For the right persons

&

Having the best results/OUTCOME possible

7

CRITICAL SUCCESS FACTORS IDENTIFIED

Quality of staff.

Quality of infrastructure and equipment.

High quality drugs and consumables.

Ready access to quality information, whilst maintaining confidentiality.

Quality of procedures and controls.

Timely emergency response capabilities.

Visible management commitment and adequate funding.

Good communication process in place.

ACCIDENT & EMERGENCY

HISTORY

9

Before 2oo0 Health and Safety audits Site and facility inspection / audits Total Quality Management process External Clinical audits 2 yearly 2000 to 2003 HSE-MS ISO 14001 validation in 2000 Revalidation in 2003. 2005 UK IHC (SAQ) was used as a template to assess our quality of care 2007 In-House quality improvement program initiated with the partogram in labour review

May 2008 Enrolled in the COHSASA(ISQua) quality improvement and accreditation program

August 2010 Awarded Certificate of Accreditation for 27 elements of the hospital services

QA / QIP STRATEGIES

10

Awareness lectures Part of Individual Tasks and Target (GPA) for yearly assessment

Developed a written guideline for implementation of QA and QI process

Defined roles and responsibilities (organisation chart)

Training in the use of IT tools (excel, PowerPoint, etc) and PDSA cycle.

Organisation Structure for Warri QIP

1

1

STRATEGIES

12

Individual projects Sectional projects

Cross sectional projects Cross divisional projects

WORKING GROUPS Malaria, Infection Control, Medical Emergency Response, Resuscitation, HIV/AIDS, Patient Medical Association, Communication (newly implemented) OTHERS: Computerisation of clinical process (SHIMS)

METHODOLOGY

13

Areas for improvement identified by: Gap analysis of status quo against identified goals

Gold standard of practice (EBM)

ISQua requirements (COHSASA)

National policy on health

Patient preferences, etc

KPIs

Benchmarks

Learnings from Training updates

Customer satisfaction surveys

Transit time measurement

Management targets and business plan.

CRITICAL ACTIVITIES

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Data collection: quality of data is very critical

Data analysis and reporting

Audits:

Nursing Audits Documentation Audits Housekeeping audits Case outcome reviews Review and development of guidelines, protocols and policies Ensure ownership of all documentations and procedures (bottom up approach) Ensure value and quality of projects Proposal reviewed to assess value of projects

Tools: Training to use:-

Excel spreadsheet / PowerPoint etc PDSA cycle (Plan-do-Study Act) COHSASA SAQ

QUALITY IMPROVEMENT CYCLE

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Do rapid PDSA

cycles of

improvement

Identify improvement

opportunities

Measure

Quality Assurance Indicators

OPD & ER QA INDICATORS

0.00%

20.00%

40.00%

60.00%

80.00%

100.00%

Q1 Q2 Q3 Q4

92.69%

90.08%

90.47%

90.16%

Out patients satisfaction

Q1

12:48:58 AM

12:51:50 AM

12:54:43 AM

12:57:36 AM

1:00:29 AM

1:03:22 AM

1:06:14 AM

Q1 Q2 Q3 Q4

12:59:00 AM

1:04:00 AM

12:54:30 AM

12:54:30 AM

OPD transit time for 2010

Q1 Q2 Q3

12:00:00 AM

12:00:43 AM

12:01:26 AM

12:02:10 AM

12:02:53 AM

12:03:36 AM

12:01:00 AM

12:01:00 AM

12:01:00 AM

Average time to nurses care in Casualty Q1

Average time to nurses care in Casualty Q2

Average time to nurses care in Casualty Q3

12:00:00 AM

12:07:12 AM

12:14:24 AM

12:21:36 AM

12:28:48 AM

12:36:00 AM

Average time to doctors care in Casualty Q1

Average time to doctors care in Casualty Q2

Average time to doctors care in Casualty Q3

Average time to doctors care in Casualty Q4

CHRONIC ILLNESS QA INDICATORS

84%

86%

88%

90%

92%

94%

Q1 Q2 Q3 Q4

88%

92% 93% 91%

%HbA1c less that 7.5% (Diabetics)

Q1

85%

90%

95%

100%

Q1 Q2 Q3 Q4

92%

97%

90% 91%

Diastolic less that 90mm of Hg

Q1

Q2

0%

20%

40%

60%

80%

100%

Q1 Q2 Q3 Q4

83% 92%

100% 100% % Viral load

undetectable (HIV)

Q1 Q2

85%

86%

87%

88%

89%

90%

91%

92%

93%

Q1 Q2 Q3 Q4

88%

92% 93%

91%

%HbA1c less that 7.5% (Diabetics)

Q1

OBGY & INFECTION CONTROL QA INDICATORS

0.00%

0.05%

0.10%

0.15%

0.20%

0.25%

0.30%

Q1 Q2 Q3 Q4

0.27% 0.29%

0.00% 0.00%

Hospital wound infection rate

Q1

Q2

Q3

0%

5%

10%

15%

20%

25%

30%

35%

Q1 Q2 Q3 Q4

35%

18% 14%

35% Emergency CS rate for

2010

Q1

0

50

100

Q1 Q2 Q3 Q4

41.67

0 0

117.65

Perinatal mortality rate for 2010

(per 1000 live Births)

0.00%

1.00%

2.00%

3.00%

4.00%

5.00%

Q1 Q2 Q3 Q4

2.86% 3.03%

4.76% 4.35%

Malaria in pregnancy rate for 2010

Q1

Q2

Q3

Some unit based QI projects

Pain management

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0.0

0.5

1.0

1.5

2.0

2.5

3.0

Ohr 4hr 24hr 48hr

Year 2009 Average

2.9 2.5

1.7 1.4

Score 2009

Year 2009 Average Ohr

Year 2009 Average 4hr

Year 2009 Average 24hr

Year 2009 Average 48hr

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

4.5

Quarter 1

Ohr

30 MIN

4 HRS

24 HRS

48 HRS

ON DISH

•Prior to 2009, there was no formal policy on pain management in the children’s ward. Pain scales existed but there was no documentation of their use. •Training of nursing staff and doctors was undertaking using formal and informal lectures •A significant improvement in documentation was noted in 2000 in scores in the first 48 hours •There was a decision to further expand the monitoring and documentation period and Q1 of 2010 shows more scores of zero at 48hr and on discharge •Monitoring will be quarterly to maintain this quality of care that has bee attained Score Q1 2010

Partogram use in labour

Many patients (30%) were delivering without a properly filled partogram as at 2007 An intervention was initiated that involved an in-house training of our midwives on the use of the WHO partogram Result: partogram use is now 100% Repeated randomised checks are in place to insure that this is sustained

Partograms analysed

Complete and

Accurate

2%

Incomplete but

useful

58%Unhelpful

10%

None

30%

Documentation in A&E case notes

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0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0%

33%

0% 0%

13%

100% 100%

73% 73%

87%

2009 Compliant Notes

2010 Compliant Notes

•Attempts at analysis the doctor’s response time to the A&E revealed in 2008 that entry into the case note for critical times were not consistently entered. •In spite of appeals to improve on this, the analysis of data from 2009 showed still no significant improvement. •Following some brainstorming sessions, a decision was reached to implement a stamp in which these times are entered. •Result: A significant improvement in time entry. Some gaps still remain and this is currently been addressed.

Cost of suture materials during surgery

24

2.5

6.6

8.5

2.0 2.3

5

7.5

1.8

0

1

2

3

4

5

6

7

8

9

QRT 1 2010 AV. SUTURES

QRT 2 . 2010 AV.SUTURES

•Prior to February 2009, suture wastage in the theatre was high as sutures were routinely opened and not used. • This practice was based on traditional Peri-op teaching which emphasises the anticipation of the surgeon’s needs •It was decided that sutures should only be opened when requested. •Analysis of the first two quarters of 2010 suggest that there is some decline in suture use

Result of the COHSASA Continuous Quality Improvement evaluation

COHSASA - Major System Scores

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COHSASA - Departmental Service Scores

27

GAINS

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•Improvement in team work •Better focus on work process and outcomes •Focus on appropriate skills and competences •Ownership of hospital processes by the grass root •Continuous improvement of services and outcomes. •QA trending helps to ensure faster response to quality issues •Externally assured quality of service

CHALLENGES

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•Erratic IT tool – encouraging manual data collection •Inadequate budget for learning and development •Business continuity challenges