hand hygiene cqi strategies
TRANSCRIPT
REGULATORY MANDATE
DEPARTMENT OF HEALTH
AO 2006-0002Establishment of the Continuous Quality
Improvement (CQI) Program
and Committee in DOH Hospitals
PHILIPPINE HEALTH INSURANCE
CORPORATION
The Philhealth Benchbook
by Dr. BH Manlapat presented during the 21st PHICS Annual
Convention, 27-28 May 2015
DEPARTMENT OF HEALTH
ADMINISTRATIVE ORDER 2006-
0002Establishment of the Continuous Quality
Improvement (CQI) Program
and Committee in DOH Hospitals
by Dr. BH Manlapat presented
during the 21st PHICS Annual
Convention, 27-28 May 2015
Congruent with the requirements of hospital licensure and the intent of Department
Order Nos. 310-J s. 2001 and 172-C s. 2003 on “The Creation of the DOH Steering
Committee and Technical Working Group for the Establishment of CQI Program for the
Health Regulation Cluster and DOH Hospitals” and its amendment respectively, to
consistently deliver and continuously improve the quality of health care to our people,
there is a need to institutionalize and establish the Continuing Quality Improvement.
ADMINISTRATIVE ORDER
No.2006-0002by Dr. BH Manlapat presented
during the 21st PHICS Annual
Convention, 27-28 May 2015
PHILHEALTH BENCHBOOK
RA 7875 Section 1 National Health
Insurance Act of 1995
Section 2 Guiding Principles
IRR Title V Section 50 – Accreditation and
Quality Assurance of the NHIPby Dr. BH Manlapat presented
during the 21st PHICS Annual
Convention, 27-28 May 2015
Continuous Quality Improvement in the Hospital
by Dr. BH Manlapat presented
during the 21st PHICS Annual
Convention, 27-28 May 2015
In view of this, starting January 1, 2007, Philhealth shall require all
hospitals applying for accreditation, to have a Continuous Quality
Improvement (CQI) Program as described in Part III of the Philhealth
Benchbook. Likewise, accredited government hospitals are advised to
refer to DOH Administrative Order No. 2006-0002 for additional guidance.
PHILHEALTH CIRCULAR
No. 12 S-2006
by Dr. BH Manlapat presented
during the 21st PHICS Annual
Convention, 27-28 May 2015
SOURCE: PHIC Benchbook, 2004
by Dr. BH Manlapat presented
during the 21st PHICS Annual
Convention, 27-28 May 2015
SOURCE: PHIC Benchbook, 2004
by Dr. BH Manlapat presented
during the 21st PHICS Annual
Convention, 27-28 May 2015
PROBLEM SOLVING METHODOLOGY
PROBLEM IDENTIFICATION & PROBLEM PRIORITIZATION
UNDERSTANDING THE PRESENT SYSTEM
ANALYSIS of the ROOT CAUSES
SELECTION OF BEST ALTERNATIVE SOLUTIONS
PROJECT PRESENTATION
SOLUTION IMPLEMENTATION
Project Evaluation
STANDARDIZATION
SELF-EVALUATION & FUTURE PLANNING
Plan
Do
Check
Action
Quality Circle Practitioners Association of the Phils.
by Dr. BH Manlapat presented
during the 21st PHICS Annual
Convention, 27-28 May 2015
by Dr. BH Manlapat presented
during the 21st PHICS Annual
Convention, 27-28 May 2015
Problem Identification and
Problem Identification
• Statement of the Problem
• Hand hygiene compliance in Manila Doctors Hospital in 2012 was at 60%. In 2013, however, compliance decreased to almost 50%. This prompted the Infection Prevention and Control Office to implement strategies that could increase hand hygiene compliance to 70%.
by Dr. BH Manlapat presented
during the 21st PHICS Annual
Convention, 27-28 May 2015
Intervention
• Using the Pareto Principle, the 3 areas
that assessed as key areas needed to
addressed are:
• Damaged Skin,
• No role models on Hand Hygiene
• Visual Reminders.
•by Dr. BH Manlapat presented
during the 21st PHICS Annual
Convention, 27-28 May 2015
Best Alternative Solution• Implementation of link nurses system
which will monitor and encourage healthcare workers to be compliant.
• Handrub tolerability testing survey was done to address irritation issues.
• Visual reminders were also placed.
• The lack of hand hygiene facilities was also addressed by instillation of more hand rubs. by Dr. BH Manlapat presented
during the 21st PHICS Annual
Convention, 27-28 May 2015
Evaluation of Results
• The Office required all units to have an
assigned Infection Control Link Nurse
which serves as our monitor/role model/
buddy system to monitor healthcare
workers to do hand hygiene. This was
started in August 2014.
by Dr. BH Manlapat presented
during the 21st PHICS Annual
Convention, 27-28 May 2015
Evaluation of Results
• A pilot area was selected wherein the link
nurses was empowered and trained to be
a Hand Hygiene Advocate. Her role is to
monitor compliance, encourage other
nurses / residents to call any healthcare
personnel that do not comply.
by Dr. BH Manlapat presented
during the 21st PHICS Annual
Convention, 27-28 May 2015
Evaluation of Results
• Within the 6-month period, hand hygiene
compliance in the ICU has increased for
healthcare workers from 20% to 77%.
Furthermore, healthcare associated
infection rate (HAI) decreased from 16% in
January 2013 to 8% in December 2014.
by Dr. BH Manlapat presented
during the 21st PHICS Annual
Convention, 27-28 May 2015
Results of Pilot Study
Post-intervention
Pre-Intervention
Aug - Sep 2014
Oct - Dec 2014
HH Compliance 20% 60% 77%
by Dr. BH Manlapat presented
during the 21st PHICS Annual
Convention, 27-28 May 2015
Conclusions
• Improvement can be achieved through a
multimodal interdisciplinary approach
which involves appropriate facilities for
proper hand hygiene, monitoring and
feedback of hand hygiene compliance and
promoting an institutional culture of patient
safety.by Dr. BH Manlapat presented
during the 21st PHICS Annual
Convention, 27-28 May 2015
by Dr. BH Manlapat presented
during the 21st PHICS Annual
Convention, 27-28 May 2015
Link Nurses Trainingby Dr. BH Manlapat presented
during the 21st PHICS Annual
Convention, 27-28 May 2015
2014 Compliance rate per moment
M1 C 29/142 18%
NC 113
M2 C 22/5 39%
NC 34
M3 C 23/37 62%
NC 14
M4 C 36/112 32%
NC 76
M5 C 23/101 23%
NC 78
Total Compliance 133/448
30% Overall compliance Rate on hand hygiene
by Dr. BH Manlapat presented
during the 21st PHICS Annual
Convention, 27-28 May 2015
Monitoring and
Evaluation
by Dr. BH Manlapat presented
during the 21st PHICS Annual
Convention, 27-28 May 2015
5 Components of the WHO multimodal hand
hygiene improvement strategy
by Dr. BH Manlapat presented
during the 21st PHICS Annual
Convention, 27-28 May 2015
The step wise approach
Facility
PreparednessBaseline evaluation Implementation
Follow-up
Evaluation
Review and
Planning
by Dr. BH Manlapat presented
during the 21st PHICS Annual
Convention, 27-28 May 2015
References:• As part of their ongoing commitment to reduce
HCAI, WHO Patient Safety has developed this
revised Guide to Implementation and a series
of tools to support health-care workers in
establishing and sustaining good hand hygiene
practices by health-care workers and reducing
HCAI at health-care facilities worldwide. This is
part of the long-term SAVE LIVES: Clean Your
Hands initiative.
by Dr. BH Manlapat presented
during the 21st PHICS Annual
Convention, 27-28 May 2015
Required Organizational Practices
(ROPs)
• are evidence-based practices addressing
high-priority areas that are central to
quality and safety.
• Accreditation Canada International defines
an ROP as an essential practice that client
organizations must have in place to
enhance patient/client safety and minimize
risk.
by Dr. BH Manlapat presented
during the 21st PHICS Annual
Convention, 27-28 May 2015