problem identification & ptioritisation

Problem Identification, Opportunity for Improvement & PrioritisationDr. Ngian Hie Ung

Quality Assurance

Cycle

ProblemIdentification

Re-evaluation ofthe Problem

Implementation ofRemedial Actions

Identification ofRemedial Actions

Quality Assurance

Study

ProblemAnalysis

ProblemPrioritisation

Identify Problems/Opportunity for Improvement Look at your CORE BUSINESS

WHO are your CUSTOMERS

What is QUALITY SERVICE in THEIR eyes (Expectations)

Core Business Obstectrics

Admission of mothers Antenatal care Delivery Postnatal care Discharge

Core Business Medical Records Data collection & analysis

Coding, HMIS

Bed Head Ticket Management Storage/Tracking Medicolegal Police case

Medical Report Case notification

Customers Internal External Expectations Level of education Income Experience Promises Perception Environmental factors

How to Identify Problem??

Identify Problems/Opportunity for Improvement1. Assign responsibility2. Scope of care3. Identify important aspects of care

Assign Responsibility Administrative leader leads TEAM - Shared responsibility YOU – “THE CHOSEN ONES”

Core Business

Scope of care

Important aspects of care ??

Scope of Care/Service The scope must answer the

question “What does your service do for the patient and organisation?”

Identify aspects of care & service FOCUS of Monitoring & Evaluation

Scope of Care/Service Who are your customers

- types of patients/clients served Conditions/situation managed Activities performed to serve clients Range of personnel involved Site where care is provided or service is

offered Time when care is provided or service

rendered

Another approach…

Structure Process Outcome

Activities in patient careCategorised into: Clinical Patient Care (care of illness and

related problems) Hospitality Services (providing a

conducive environment for the above) Administration and Communication

procedures (ensuring order and efficiency)

Clinical Patient Care Medical history Physical examination Investigation Treatment Counseling Home visit

Hospitality Services Reception Lodging Food Comforts Privacy, safety, security Entertainment Information Communicational utilities Transport facilities Facilities for social interaction

Administration and Communication Procedures

Registration/admission procedures Briefing/orientation Consent Billing Discharge procedures Scheduling

Sources of Problem Suggestions & views from staff Problems & issues raised at meetings Clients’ complaints/satisfaction survey Findings of morbidity & mortality

meetings Medical records Annual report Brainstorming session HPIA feedbacks IR

Identify Important Aspects of Care/Service

Importance Greatest impact on quality patient

care controlled by the unit

Should be reflective of High volume High risk or problem-prone aspects of

care

Identify Important Aspects of Service

High impact High volume - Involve a large

number of patient High risk or problem prone High cost Known to cause problems in the

past

5Ws+1H What - what is the problem Where - which part of process Why - causes Who- people involved When - time How - possible causes

Areas of Concern/Opportunities

Areas of Concern related to Morbidity Mortality Disability Complications Adverse reactions Wide and unnecessary variations in

practice Unnecessary hospitalisation

Areas of Concern related to Improvement in function Improvement in quality of care High-risk areas High cost areas High volume/common conditions

Areas of Concern - Examples… Long waiting time at clinic Long turnaround time for URGENT lab specimen Increased incidence of nosocomial infection High incidence of misplaced OPD cards High incidence of AOR Increased incidence of perinatal

mortality/morbidity Increased incidence of POMR or perioperative

morbidity Late payment of bill High incidence of unsafe delivery High incidence of adolescence pregnancy High incidence of PPH

Problem Prioritisation Important problem Within our Control Benefits Outweigh Cost & Efforts to

solve it

Problem Prioritising Technique Nominal group technique Brainstorming Prioritisation Matrix Multivoting Consensus

Multivoting• Long list of items• Each member pick a set of

items from the pool

Rank-ordering • Shorter list, <10 choices

Rating scales

• Each item is rated on a scale from 1 to 5, or 1 to 6, or even as much as 1 to 10, tend to be more accurate Rate

according to a set of criteria

Decision Matrix

• SMART criteria

Nominal Group Technique The group with common interest

for quality improvement Number 7-12 Chairperson Source of information

Nominal Group Technique - Process1. Chairperson requests co-operation of everyone2. Focus on problem identification 3. List down all problems in exact words4. Serial discussion:

- Clarify, elaborate, defend, dispute5. Problem may be:

- Reworded, grouped, deleted or modified6. Rank the problem – Vote/rank with score7. Announce result8. Discussion of vote & reprioritise9. Revote Final choice may need approval from people with

financial & administrative authority

Patient fall

Delay in detection of deterioration of cerebral event in head injury patients

Delay in getting treatment in A&E

High incidence of fall

High morbidity of head injury cases

Long waiting time at A&E

Rephrasing into QA problem format

Eg. of problems:

Basis of Ranking – SMART Criteria Serious/Specific Measurable Appropriate Remediable Timeliness

SMART CriteriaSeriousness Life at stake? Pain? Permanent disability? Causing distress to patient? Impact on patient, community & KKM

image Impact on cost & resources Frequent occurrence though not serious Large ABNA

SMART Criteria Measurable

Process clearly defined Starting & ending points

Indicators identifiable with problems Proxy indicator e.g. pain score, CSS Data collected to quantify extent of problem

Appropriateness Related to Core Business Objectives consistent with organisational

goals

SMART Criteria Remediable

Resource & expertise available Solution possible Within capacity of the group

Timeliness Current issue No current operational, financial or political

issues which might affect the success of project

Social, political, ethically acceptable Does not take very long

Rate & Rank

Determine the RATE (1-3 or 1-5)1=Least 3 or 5=MOST

Ranking For rating of 1-3, vote 3 times on each criteria (individual)


High morbidity of HI cases


Too many cardiac arrests over weekend

S M A R T Total

1

2

3

Rating scale: 1 = low, 2 = medium, 3 = high

Rating For rating of 1-5, rate each problem (individual), e.g.





S M A R T Total

2 5 5

3 3 5

5 5 5

1 5 3

Rating scale: 1 = low, 2 = medium, 3 = high

Ranking of Problems - total the score





S M A R T Total

1 3 2 4 1 11

3 2 3 2 3 13

3 3 3 1 2 12

1 3 1 1 1 6

NB: Individual voting

Deciding on Problems





S M A R T Total

1 3 2 4 1 11

3 2 3 2 3 13

3 3 3 1 2 12

1 3 1 1 1 6


Voting

Ranking of Problems by Vote





S M A R T Total

3 2 3 2 3 13

3 3 3 1 2 12

1 3 2 4 1 11

1 3 1 1 1 6


Ranking of problems by VOTERevote after results to confirm priority




S M A R T Total

3 2 3 2 3 13

3 3 3 1 2 12

1 3 2 4 1 11

NB: Individual/Group voting

Deciding on Problem High morbidity

of HI cases



S M A R T Total

3 2 3 2 3 13

3 3 3 1 2 12

1 3 2 4 1 11

NB: Individual/Group voting

Prioritisation Matrix Criteria Problems Weights – assign a weight to each

criteria Scores – based on a ratio scale

(e.g. 0-5)

Prioritising by giving weihtage according to the ‘SMART’ criteria

Proposed topics

SeriousWt=3

MeasurableWt=2

AppropriateWt=2

RemediableWt=2

TimelinessWt=1

Total

High incidence of fallHigh morbidity of HI casesLong waiting time at A&E

Rating scale: 1-5 (1 = low, 5 = high) Weight : 1 - 3Done as a group or individual

Prioritisation Matrix

Consensus Latin word, meaning "shared

thought“ Does not imply complete

agreement, but does involve seeking a decision with which everyone is reasonably comfortable

Everyone needs a fair opportunity to be heard

Building Consensus Write out the issue. Suggest many alternative answers

(candidates). Reduce a long list (10+ items) using a

multivote. Carefully discuss the remaining candidates.

Take notes on each. Decide which criteria you will use to evaluate

your candidates. Do a rating vote. Look at areas of disagreement, and discuss

them further. Vote again, if necessary. Discuss the outcome of the vote. Has

everyone been heard? Can everyone support the decision?

Found your Area of Concern?

Or…….

Opportunity Statement Opening statement of a project Explaining what it is What are the effects What are the possible causes Why we want to do the study

Delay in Emergency Surgery for Compound Long Bone Fracture

Orthopaedic patients with long bone fractures have to wait for a long time in A&E/ward before they are operated upon. (PROBLEM)

This may lead to an increased morbidity especially with regards to infection. A delay in surgery can cause distress to patient and his relatives. (EFFECTS)

Delay may be due to the inavailability of OT, consent, blood or appropriate investigations. (POSSIBLE CAUSES)

We hope to identify factors contributing to the long waiting time and propose remedial actions. (WHAT THE STUDY AIM TO ACHIEVE)

Management of compound fractures forms a major part of the workload of the Orthopaedic Dept (INTRODUCTION) Patients with compound fractures should be treated promptly and effective rapid uncomplicated recovery (DESIRABLE OUTCOME/ EXPECTATION)

There are ample opportunities to make this possible in our setting. (OPPORTUNITIES)

We hope to identify areas that can be improved by carrying out a study using certain indicators. (INTENT TO IMPROVE)

IMPROVING MANAGEMENT OF COMPOUND LONG BONE FRACTURES

Improving Portable X-ray Service in Hospital Kuala Terengganu

- Portable x-ray service plays a very vital role in the management of acutely ill patients in the hospital

- Ensuring the services to be performed in the shortest time without compromising the quality and minimizing any unnecessary procedures

Improving Portable X-ray Service in Hospital Kuala Terengganu

- There are possible improvements of the services in order to enhance a better medical health care

- We are looking forward to identify areas of improvement and carry out study by referring to certain indicators

Study Objective General

Related to topic 1-2 statement

Specific What are intended to be carried out Address the study questions Questions to be answered at

conclusion

Objectives General

To improve the management of head injury patient

Specific To determine SIQ in various steps of care in

management of head injury patient

To investigate causes of any SIQ found

To carry out appropriate remedial measures

Objective General To ensure availability of investigation results

done at external laboratory in a timely mannerSpecific To assess the current status of TAT of

investigation results done at external lab To identify contributing factors to the

delay/misplacement of results To suggest and implement remedial measures

to improve the TAT of external lab results

Thank You

problem identification & ptioritisation

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