the microsystem festival 2013 - a4. use of clinical ... · nurses doctors health ... ward nurse ect...
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Clinical Microsystem Approach in Re‐designing Electroconvulsive Therapy (ECT) Service inInstitute of Mental Health, Singapore
Feb 2013
Our Mission and Vision
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Strategic Thrusts
Purpose
Re‐design the current ECT process to achieve the best
possible outcomes for patients by providing safe care
and effective treatment with no incidental harm, no
pain, no wait and no anxiety
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Training by the Gurus
Ms Pernilla Söderberg August 2012 Mr Goran Hendriks September 2012
Dr Jason Stein November 2012
Senior Management Support
IMH CEO and CMB at the training on clinical microsystem
Senior Management Members with Ms Pernilla Söderberg
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Evidence for re‐design
•High cancellation rate, resulting in delay to patient
care
– 45 cases from Jan 2011 to Apr 2012 (cancellation occurs in every 10 days )
•Unsafe practices from JCI audits
– medications not labeled
– time out not properly conducted
Introduction – Reason/s for Action
• Year 2010 >>> 1351 I/P cases and 103 O/P cases
• Year 2010 >>> 1497 I/P cases and 96 O/P cases
Annual increase of
9.5%
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Patient
Who are our patients
Inpatients who are :
– Acutely unwell
– Highly suicidal
– Disturbed
– Catatonic
– Treatment resistance
Outpatients who require maintenance ECT
Process /Facilities Review WorkshopObjectives:
To evaluate our current process / procedures, manpower, facilities and equipment for ECT services.
Sponsors:
Our CEO and COO
Team members:
The multi‐disciplinary team, support staff, administrator and patients
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Patient
Anesthetist
Nurses
DoctorsHealth Care
Assistant
Patient Service Associate
Professionals
Staff Survey
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2
4
5
2Medical Officer
Anesthetist
Ward Nurse
ECT Nurse
Others
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1
Y
N
1. Please indicate your role in ECT:MO ‐Medical OfficerA ‐ AnesthetistWN ‐Ward NurseECTN ‐ ECT NurseO ‐ Others
2. Are there clear guidelines which list the required (i) preparation/ (ii) administration/ (iii) post‐therapy procedures for ECT? Y ‐ YesN‐ No
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Staff Survey
3. Which of the following are valid sources of information which helps you to execute your tasks? WI ‐Written InstructionsI‐ IntranetIB ‐ ECT Information BookletOJT ‐ On‐job TrainingVI ‐ Verbal Instructions
4. What gap(s )can you identify among existing ECT processes/procedures?
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4
10
10
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3
0 2 4 6 8 10 12
Written Wis
Intranet
ECT Information Booklet
On-job Training
Verbal Instructions
Others
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4
3
2
1
Invalid lab investigationresults
Documentation/ systemgaps
Long reaction time forsending and fetching ofECT pts
Ward staff unfamiliarwith ECTprocesses/forms
Too many ECT cases ina day
ECT Survey
5. What are your suggestion(s) for improvement(s), if any?
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3
2
3
3
1
1
1
Permanent ECT team
Enhanced competency levelsof ward nurses
Prompt sending and fetchingof pts
Moderated workload
Accurate iPharm records
Pts to be restrained beforeECT procedure starts
Expansion of ECT room andaddition of equipment
Use number cords to identifysequence of pts receivingtreatment
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0,0%
20,0%
40,0%
60,0%
80,0%
100,0%
Waited for long timeExperienced anxiety while waitingInformed of duration of procedureExperienced pain/discomfort during procedur
Yes
Patients’ Needs
• Findings from a survey conducted in May revealed that patients want:
‐ Clear information (pre & post procedure)
‐ Shorter fasting duration
‐ Shorter turn around time
‐ Convalescent environment
0,0%
20,0%
40,0%
60,0%
80,0%
100,0%
Noisy Chaotic, disorganised No privacy Warm
Environment of…
Wants shorter turn around time
Wants no pain/discomfort during procedure
Wants no anxiety while
waiting
Wants clear information
Wants quiet & restful
environment
Wants privacy
Wants cooling environment
Wants organized
environment
Process Map
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Current Gaps and Future State (Key points)
Current gaps Future state Projected benefits
Process (before procedure)
2) Ward staff send inpatients to ECT room by batches and end up waiting at holding area.
2) Inpatients are scheduled by appointment basis. Ward staff will prepare patient 30mins before appointment. ECT staff will bring patient down with proper handover conducted.
2) Minimal waiting time as there is no batching of patients. Increase in patients’ safety as proper handover is conducted. One piece flow as patients will be pushed into procedure area upon reaching ECT room.
3) Outpatients will register at clinic B before being directed to ECT room.
3)Outpatients will register at ECT room directly.
3) Reduce unnecessary touch points. Increase patients’ satisfaction.
1)Lack of consultation with Anaesthetist resulting in
cancellation of ECT for patient
1) Email consult on patient’s medical condition and abnormal results between doctor and anesthetist
1) Decrease the number of patients sent to ECT room with unstable medical condition
Current Gaps and Future State (Key points)
Current gaps Future state Projected benefits
Process (during procedure)
1) No standard protocol for timeout
1) ECT nurses will be trained to conduct timeout according to SOP
1) Enhance patients’ safety
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Current Gaps and Future State (Key points)
Current gaps Future state Projected benefits
Process (recovery)
2) Excess waiting as only the anesthetist can discharge patients
2) Only patients with medical history and abnormal parameters need to be reviewed by anesthetist. ECT nurse can discharge patients with no abnormalities after treatment.
2) Discharge procedure is hastened without compromising on patients’ safety. There will be lesser patients at the recovery bay and hence less traffic. More space for staff and trolleys to maneuverer.
1)Excess movement due to the need to hook patients onto monitoring devices
1) Each recovery baywill be equipped with
monitoring device.
1) Increase patients’ satisfaction and safety. Reduce movement waste as staff need not push patients around.
Current Gaps and Future State (Key points)
Current gaps Future state Projected benefits
Infrastructure
2) ECT room is warm and stuffy
2) ECT room will be air‐conditioned
2) Increase patients’ satisfaction and comfort
1) No access to toileting facilities
1) En‐suite toilet will be built for access to toilet facilities
1) Increase patients’ satisfaction. Reduce delay associated with toileting needs
3) Unsightly wirings and conduits are exposed at the ceiling
3) Ceiling boards will be installed to cover the exposed ceiling
3) Increase aesthetic and makes the environment more convalescent for patients
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Current Gaps and Future State (Key points)
Current gaps Future state Projected benefits
Documentation
2) Forms are in hardcopy 2) Electronic templates will be implemented
2) Prevent misplacement of form. Information can be readily accessible by authorized staff
1)Several forms with similar information need to be completed
1) Forms will be revised with duplicated information removed
1) Process is streamlined and standardized
Timeline
Activity Planned Date Actual Date Status
2P for ECT Feb to Apr 2012 Feb to Apr 2012 Completed
FMEA May to Sept 2012 May to Sept 2012 Completed
Patients’ survey May to June 2012 May to June 2012 Completed
PDCA 1 – Zero Cancellation for patients going for ECT treatment in all acute ward
October 2012 May to October 2012
Completed
Pilot – To Perform ECT procedure in the morning
March 2013 Planned
Review pilot results and refine process March to April 2013
Planned
Full scale future state ECT implementation
May 2013 Planned
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Current Gaps and Future State (Key points)
Current gaps Future state Projected benefits
Process (before procedure)
1)Lack of consultation with Anaesthetist resulting in cancellation of ECT for patient
1) Email consult on patient’s medical condition and abnormal results between doctor and anesthetist
1) Decrease the number of patients sent to ECT room with unstable medical condition
Cause & Effect Diagram
Cancellation of patient’s ECT treatment
Lack of system reminder for medication omission
Lack of integrated work instructions
Design not incorporated
Specific instruction for nurse and doctor, respectively
Doctors did not review patient before next ECT shock
Such work instruction is not stated in the official protocol
Instruction is not synchronised
System/ MaterialsSystem/ Materials
Medical records unavailable
Medical records misplace
Previous ECT records unavailable
Lack of competency in medical drug effects
Medical conditions unstable e.g. ECG, hypo count, fever
Lack of medical physician
Unstable mental states/ Aggressive behaviours
Inadequate RT
Patients intake food/water
Fasting time unbearable/ too long
Patients refuse ECT
Bad experiences of ECT side effects
No insight Fear of ECT Patient lack of
knowledge
PatientPatient
Too many forms
Nurse lack of training in medical condition
Absentism Staff MC
Lack of manpower
Staff overloads
Distraction by unpredictable situations
Staff multitasking
Did not follow work instructions
Not aware of work instructions
No proper orientation
Incomplete pre ECT assessment
Awaiting anesthetist's decision
Investigation results not reviewed by doctors
Doctors unavailable
Insufficient monitoring
Medical conditions reviewed but still continue
Lack of consultation with anesthetist
ECT scheduled in afternoon
Lack of in‐house anaesthetists
Patient medically unwell, but still continue
Consent expired
Invalid consent
Readmitted after transfer to other
hospital
Incomplete consent form
Number of treatments not stated
No signatures (patient/relative, witness, doctor)
Lack of knowledge in ECT preparation
New staff
Attrition
Lack of training
No regular training programme available
Inconsistent OJT training
No patients in certain wards going for ECT procedures
StaffStaff
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Pareto Chart
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5
4 4
3
2 2
1
30,2%
57,1%
66,7%
74,6%
81,0%
87,3%92,1%
95,2%98,4% 100,0%
80%
0%
20%
40%
60%
80%
100%
0
2
4
6
8
10
12
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Lack ofconsultation
withanesthetist
ECTscheduled inafternoon
Too manyforms
Patient lackof
knowledge
No regulartraining
programmeavailable
Badexperiencesof ECT sideeffects
Lack ofmedicalphysician
InadequateRT
Nurse lack oftraining inmedicalcondition
No insight
Number of Votes
Reasons of ECT Cancellation
Intervention ‐ Lack of Consultation with Anaesthetist
Root Cause Predictions Start DateImplementation Location
People Involved
Lack of consultation with anaesthetist
↓ 100% rate of pa ent being sent for ECT while patient situation is not stable or unwell
03 Oct 2012 All acute wards AnaesthetistDoctorsWard staff
Discussion with Consultants & Physician↓Discussion with Anaesthetist
1st Intervention Suggested anaesthetist to allow doctor email consult on patient’s medical condition or abnormal result prior to ECT
Email to MOsGuide for StaffCPIP ECT New Intervention Guide
1. MOs
Preparation before ECT comprises of a pre‐anaesthetic assessment which include a full
physical examination, laboratory and radiological investigations to assess patient’s
overall fitness for anaesthesia.
These investigations include a full blood count and renal function test for all patients, as
well as a chest x‐ray and electrocardiogram for patients above 40 years of age.
In the event that these investigations are abnormal, patient may be recommended for
further work up or to seek medical attention in a general hospital.
Patients may be referred to a senior doctor/ IMH internal physician (Dr Robert Thomas
Isaacs) for further assessment on an individual basis, if further assessment is necessary.
A senior doctor/ Dr Isaacs can advise whether patient is fit for ECT treatment.
If all the above have been done, and there are still concerns or uncertainty if patient
should undergo ECT, patient may be referred to an anaesthetist for a review.
Please prepare all consultation issues before making the call to the anaesthetist to
ensure the consult is fruitful.
Please record the consultation details in the medical notes.
For ease of consultation with the anaesthetist, you may consult the anaesthetist by email/
telephone call/ whatsapp (Monday‐Friday, during office hours).
Dr Loh Meng Woei (Lead Anaesthetist in IMH)
Mobile: +65 97555577
Email: [email protected]
2. Ward Staff
Please highlight areas of concerns in medical notes and remind MOs to discuss with the
ward consultant and anaesthetist, when necessary.
Please record the details in medical notes.
If you have any queries or would like to provide us with suggestions, please contact:
Cecily Chao, Executive, Quality Management Department
Ext: 2146
Email: [email protected]
Or
Samantha Ong, Assistant Director, Nursing / Quality Management Department
Ext: 2690
Email: [email protected]
Place intervention guide in the consultation noticeboard
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1st Intervention ‐ ECT scheduled in afternoon
Root Cause Predictions Start DateImplementation Location
People Involved
ECT scheduled in afternoon
↓ 100% situa ons of pa ent taking food and water
16 Oct 2012 All acute wards Ward staff, ECT staff, Patients
2nd Intervention Patients going for ECT are divided into two groups to serve breakfast in different timing in order to reduce the duration of fasting to 7 hours only
Patients are grouped into 2 batches
Grouping Criteria
1st Batch: to serve breakfast at 7am•private patients•patients with medical conditions •patients for 1st session ECT
2nd Batch: to serve breakfast at 8am•the rest of patients
ECT team emails to Nurse Managers & Nurse Clinicians the ECT sequence list around 5pm
1.On Monday for ECT on following Wednesday
2. On Wednesday for ECT on following Friday
3. On Friday for the following Monday
On day of ECT, ECT team will call the wards to send the patients according to the listing
Outcome ‐ Run Chart
P1: 1st 10 Days during the monthP2: 2nd 10 Days during the monthP3: 3rd 10 Days during the month
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Benefits
Intangible Benefits
Improve Hospital’s Reputation
Improve Patient
Satisfaction
Relieve Staff’s
stress of monitoring patients
Tangible Benefits
Reduce LOS & the Cost to Patient
Reduce Staff’s Work Hours
Reduce the Cost to Hospital
Summary
We are still in our early phases of the Clinical MicroSystem journey and are going through multiple PDSA cycles to refine our processes
We believe that excellent care and services are attainable in microsystems, we need to understand what really matter to the patients and their family.
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Thank You
Singapore.ppt
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Imagine a world of 6 million people with 4 million in Asia
Think of the 3rd most densely populated country
per square kilometre
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One of the longest life expectancyOne of the
lowest infant mortality
One of the lowest fertility
in the World
Imagine a Singapore that was a village of 100 people, it would
be something like this…
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50
50
8 will be over 65 years of age
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24 will be below 19 years of age
74 Chinese
13 Malays9 Indians
3 Others
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33 Buddhists18 Christians15 Muslims11 Taoists
5 Hindus
17 have no religion
96 are able to read
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I divorce for every 6
marriages
88 own their own homes
74 live in a 4 room flat or larger
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Only 11 of us own cars
But we own 143 handphones
There are more doctors than lawyers
But not enough psychiatrists….
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10 will have a mental illness
1 will be seriously ill