IMPLEMENTATION OF QUALITY STANDARDS TO

BUILD A PATIENT SAFE HOSPITAL

Dr. Lallu Joseph

Quality Manager

CMC, Vellore

HOSPITALS

“Healthcare Organizations are the most complex organizations to manage”

Peter Drucker

“Running a Hospital isn’t Brain Surgery….

…..Its Harder

How we want the hospitals to be……

How hospitals are……

Source: 2002. IHI. Leape

MEDICAL ERROR

Source – The Philadelphia Inquirer

PATIENT INTERFACE IN HEALTHCAREComplex interactions

Many stakeholders involved

Every patient is different

Every situation is different

Highly sensitive and emotional

Errors cannot happen

IC

U

Ward

SWISS CHEESE MODEL

TEAM WORK IN HOSPITALS

When caregivers work together- benefits for the employees, the patients and the health-care facility

Patients receive thorough care when providers collaborate

Providers can concentrate on their areas of expertise, knowing they are part of a team looking after the whole patient- shared responsibility

Quality of care improves

Hospitals save money with effective team care

TEAMWORK IS ENHANCED BY QUALITY MANAGEMENT AND

ACCREDITATION

ACCREDITATION, TEAM WORK AND PATIENT SAFETYAccreditation is proven to be the best possible tool to achieve quality and safety

Top management involvement is the key to effective implementation

All stakeholders to be involved from the chairman to the doorman

The right intent has to be understood and Implementation should focus on the intent

Accountability at all levels and processes

Checks and balances at all levels

Continuous Monitoring

SHARED RESPONSIBILITY AND COMMUNICATION IS THE KEY

ACCREDITATION STANDARDS

Basic minimum standards

Achievable

Non- negotiable

Based on evidences

Best practices

INFRASTRUCTURE AND FIRE SAFETY

AMRI HOSPITAL, KOLKOTTA

Occurrence of accident 2:15 AM Fire started from the basement.

3:30 AM Smoke started spreading through AC ducts

4:10 AM Fire Brigade called

4:30 AM Rescue process started

7:30 AM Firemen broke the wall of basement and started flooding the wall. Could not enter due to smoke and poisonous gas

8:00 AM Snorkel arrived and rescue by breaking the glasses of the building facade

ROOT CAUSE ANALYSISThe basement was full with Inflammable article like paper, cotton, mattress, chemicals etc

Alarm did not get activated as it was made inactive, due to many false alarms

Fire extinguishers at the basement did not work as they were not checked.

No evacuation was initiated even after 1 ½ hrs.

Central AC system and electricity supply were not stopped

Carbon monoxide gas started spreading through AC ducts

No trained person to deal the emergencies, specially how to evacuate critically ill patients.

No signage for emergency exits.

No arrangement for alternate ventilation.

No escape route.

Set back around the building had vehicles parked.

STANDARDS ON FIRE SAFETY-NABHCHAPTER STANDARDS TEAM

RESPONSIBLE

ROM 2a, 2b, 2c, 2d

Fire installation as per NBC and fire license, implementation of the requirements, updation and amendments

Top Management

FMS 1a, 1d, 1e, 1f

Safety committee to oversee the activities, facility rounds Multidisciplinary team

FMS 6a Provisions for detection, abatement and containment of fire emergencies and checked periodically/ maintenance

Engineering/ fire team

FMS 6b Documented safe exit plan and provisions Engineering/ fire team

FMS 6c, 1g Staff awareness and training of their role in emergencies HR/ Training dept/ fire team

FMS 6d, CQI 4b

Mock drills conducted periodically and audit of the deviations

Top management/ quality/ safety committee/ fire

POWER OUTAGE AT PUDUCHERRY HOSPITAL KILLS THREE DIALYSIS PATIENTS

March 9th 2017

Indira Gandhi Medical College and Research Institute (IGMCRI)-Pondicherry

Three patients, including two women-undergoing haemodialysis died

No battery back up

Generator supply restored after 15 minutes

Previous incident- 21 died in Gandhi Hospital, Hyderabad, 2016

Source: NDTV

ROOT CAUSE ANALYSISBack up battery supply for 20 minutes

Generator supply- delay in starting

Emergency response by the clinical team

Machine maintenance

Emergency alarms

STANDARDS ON ELECTRICAL, EQUIPMENT AND PATIENT SAFETY-NABHCHAPTER STANDARDS TEAM RESPONSIBLE

FMS 2f Electricity is available round the clock Engineering

FMS 2g Alternate sources for electricity are provided for backup for any failure/ shortage

Engineering

FMS 2h The alternate sources are regularly tested Engineering

FMS 3f, 3h Operational and maintenance plan for all utility equipment, maintenance plan for electrical systems

Engineering

FMS 4d Qualified and trained personnel operate and maintain medical equipment

Top management/ biomed Engineering/ clinical depts

FMS 4e, 4f Proper inspection, calibration and maintenance of equipment

biomed Engineering/ clinical depts

COP 7 Qualified personnel perform and monitor during procedures

Clinical depts

DOCTORS OPERATE ON WRONG LEG OF 24-YEAR-OLD

June 22, Fortis Hospital, Delhi

Fractured right foot due to fall in the stair case

Operated on the healthy left ankle of a 24 year old

Multiple screws placed on the left ankle

Temporary cast placed on the fractured foot

STANDARDS ON SURGICAL SAFETY- NABHCHAPTER STANDARDS TEAM RESPONSIBLE

COP 15b Pre-operative assessment and documentation

Surgical dept

COP 15d Identification tags and checking of tags when the patient enters the OT

Nursing

COP 15d Appropriate surgical site marking and checking of the same

Surgical and nursing team

COP 15d Surgical safety checklist and cross checks Surgical, anaesthesia and nursing team

COP 15d, CQI 3e

Surgical time out and audit of the same Surgical, anaesthesia and nursing team

CQI 2 Patient safety program, patient safety officer, audits and monitoring of the implementation of IPSG

Top management/ Safety team

15 HOSPITALISED AFTER WRONG DRUG INJECTED BEFORE STERILIZATION

12 Jan 2017, Kamalapur, Ballari district

15 women admitted for tubectomy, for tubectomy

Hospitalised after being injected wrong medicine before the surgery.

Adrenaline administered instead of Atropine sulfateinjection

Women felt giddy, began to vomit and felt their hearts race and rushed to Taluk Hospital

Root Cause: LOOK ALIKE MEDICINES

STANDARDS ON MEDICATION SAFETY- NABHCHAPTER STANDARDS TEAM RESPONSIBLE

MOM 3d Look alike and sound alike medications are identified in all areas

Pharmacy/ Nursing in wards/ OT

MOM 3d LASA medications are stored separately Pharmacy/ Nursing in wards/ OT

MOM 4j High risk medications are identified and double checked before administration

Nursing/ Clinical team

MOM 6d Medication is verified from the order and physically verified before administration

Nursing/ Clinical team

TWO STUCK TO MRI MACHINE FOR 4 HRS

Nov 11, 2014, Tata Memorial Hospital

7 pm at the Tata Memorial-run (ACTREC)

Attending doctor asked attendant to get oxygen mask.

Attendant who never worked in MRI room, had no idea that no metal is allowed anywhere near the machine, brought oxygen cylinder.

2 staff stuck for 4 hours

ROOT CAUSE ANALYSISNo staff training

Communication issues

Metal detectors and other entry restrictions not in place

Emergency run down/ quenching de-activated

STANDARDS ON EQUIPMENT, PATIENT SAFETY- NABHCHAPTER STANDARDS TEAM RESPONSIBLE

AAC 11c Patients are appropriately screened for safety in imaging

Radiology team/ Safety team

AAC 11g Imaging and ancillary personnel are trained in radiation safety

Radiology team/ Safety team

AAC 11h Signage are prominently displayed Radiology team/ Safety team

FMS 4e Equipment are periodically inspected for their proper functioning

Radiology team/ Biomedical Engg

HOSPITAL SAFETY PROGRAM

CAPA ANDSYSTEM CORRECTION

INCIDENT REPORTING

EDUCATION AND TRAINING

SYSTEM AND ACCOUNTABILITY

PREVENTIONANDCONTROL

RISKIDENTIFICATION

HOSPITAL SAFETY PROGRAM

SURGICAL PATIENT SAFETY

CAPA ANDSYSTEM CORRECTION

INCIDENT REPORTING&AUDITS

EDUCATION AND TRAINING

SYSTEM AND ACCOUNTABILITY

PREVENTIONANDCONTROL

RISKIDENTIFICATION

HOSPITAL SAFETY PROGRAM

Wrong patient can be operated

1. Patient ID Tag2. UHID3. Surgical safety checklist

1. Nurse in ward to

check tag

2. To countercheck

with chart and

patient

3. Checklist at

holding bay-

nurse

4. Intra-OP- Time

out by surgeon,

anaesthetist and

scrub nurse

5. Post OP for

count

If incidents happen to be reported

Continuous audits for compliance to protocol

Training to HCW

RCA by multidisciplinary committee, change in protocol if required

IMPLEMENTATION OF QUALITY STANDARDS AND BUILDING SAFE HOSPITALIt is a continuous improvement process

It does not happen overnight

Every effort and every passing day brings improvement and innovations

Safety culture needs to be built and inculcated

Top management involvement in safety initiatives is a must

Manage through committees

Encourage reporting and learning from mistakes- Avoid blame and shame

Accreditation acts as a good reminder and a guide towards a formal safety program

With every assessment, improvement and culture change will be evidenced

Perseverance is the key

THE PATIENT……

THE SOLE BREAD WINNER OF THE FAMILY,

HE IS THE FATHER OF A SMALL KID,

SON OF AN OLD FATHER,

HUSBAND OF A YOUNG LADY,

AND IS NOW YOUR RESPONSIBILITY

TO TREAT HIM AND SEND HIM SAFE TO HIS LOVED ONES

IMAGINE YOUR OWN THERE

TAKE CARE OF HIM LIKE YOUR BROTHER

Dr. Lallu Joseph