GOALS OF PRESENTATION HEALTHCARE QUALITY AND 1.To Know Malaysia and - - PDF document

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1 HEALTHCARE QUALITY AND PATIENT SAFETY: THE MALAYSIAN EXPERIENCE

BY Assoc.Prof.Dr.Kadar Marikar CEO,MSQH 5 Feb.2009

GOALS OF PRESENTATION

1.To Know Malaysia and the healthcare System. 2.Why Quality and Safety 3 Approaches to improve Quality and Patient Safety 3.Approaches to improve Quality and Patient Safety 4.Foster comparative discussions of strategies for quality of care & safety

Malaysia

• The country is made up of two

regions, Peninsula Malaysia and East Malaysia (Borneo) across the South China Sea.

• The Peninsula Malaysia is

divided into the 'east coast'

Peninsula Malaysia

and the 'west coast' by the Main Range in the middle.

• East Malaysia is

geographically rugged, with a series of mountain ranges running through the interiors of both Sabah and Sarawak. The Crocker Range in Sabah is the site of Mt Kinabalu, the highest peak in South East Asia.

East Malaysia (Borneo)

• Population of over

26 million people.

• Multi-cultural and

multi-racial population consists

• f Malays, Chinese,

Indians and numerous natives.

• Ethnic Groups:

59% Malay and

• ther indigenous
• ther indigenous,

32% Chinese and 9% Indian.

• Malay is the official language but English is widely

spoken, especially in business.

• Official religion is Islam, but its people are free to observe

any religion of their choice. It is common to see temples, mosques and churches located in close proximity.

• Languages:

Malay, English, Chinese, Tamil and other tribal languages.

• Religion:

Muslim (primarily Malays), Buddhism (Chinese), Hindu (Indian) Christianity (Indian), Christianity.

• Malaysia is generally warm

throughout the year with temperatures ranging from 21° to 32° C in the lowlands. This can however be as low as 16° C in the hills and highlands.

• Annual rainfall is heavy at

2,500mm (100 inches). On a rainy day, thunder and lightning

• ften accompany the heavy
• ften accompany the heavy

downpour which normally lasts for less than two hours. The humidity level is high at 80% throughout the year.

• Generally, Malaysia has two

seasons. The dry season is from May to September and the rainy season is from November to March.

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• Malaysia has 12

states and 3 Federal Territories.

• The Capital City is

Kuala Lumpur

MALAYSIAN HEALTH SECTOR:

MINISTRY OF HEALTH Inpatient care services

• Total 138 hospitals
• Primary
• Secondary
• Secondary
• Tertiary
• Specialized services

(Range of beds 40-2000) Public Health Services Out-patient services:

• Health Centre (10,000 centre)
• Community Clinics (2,000 Clinics)

(Estimated every 5 kilometers radius -> 1CC)

• In remote areas: Flying Doctors Services.

(Especially for Sabah & Sarawak)

Preventive and Health Promotion services Medical Training Institutions-University Hospitals: 3 Ministry Of Defence: 3 + 1 Private Sectors

• Private Hospitals: 328 (Range of beds 2-350 beds)
• Private Medical clinics: 6000
• Maternity Centres :
• Hemodialysis centers :
• Day care centers :
• Nursing Homes:

Corporatised Hospital : National Heart Institute (IJN) 262 beds

VISION FOR HEALTH

Malaysia is to be a nation of healthy individuals, families and communities, through the health system that is equitable, affordable, efficient, technologically appropriate, environmentally adaptable and pp p , y p consumer friendly, with emphasis on quality, innovation, health promotion and respect for human dignity and which promote individual responsibility and community participation towards an enhanced quality of life.

Reasons for Supporting Quality of Care Agenda

Purchasers:

1) Control costs + assess quality = VALUE (cost-effectiveness for money spent) 2) Ensure access to care (government)

S li / h it l / d t

REDUCE COSTS OF WASTES & ERRORS THROUGH CLINICAL QUALITY

Suppliers / hospitals / doctors:

1) Demonstrate quality and value to purchasers 2) Improve safety and reduce medical errors 3) Attract patients to maintain revenue

Patients / consumers:

1) Get high-quality, affordable care when needed 2) Maintain choice of doctors and hospitals

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3 Stakeholders for Quality of Care

Purchasers:

• National & state governments
• Private health insurers

Suppliers:

• Health Industry
• Drug and device companies

Providers:

• Doctors and professional societies
• Hospitals, Clinics etc..

Patients / consumers

Why Measure Quality of Care?

Quality & effectiveness of health care essential to:

Improve health Improve abnormal risk factors & prognosis

(high blood pressure or high glucose) (high blood pressure or high glucose)

Lower morbidity Lower mortality

US National Library of Medicine

MEDICAL STAFF LEADERSHIP ORGANISATIONAL CULTURE & VALUES FOCUS ON PATIENT FOCUS ON PROCESS SAFETY COMPETENCY ACCESSIBILITY COMPETENCY

QUALITY FRAMEWORK

ENHANCED QUALITY OF LIFE QUALITY

APPROPRIATENESS

EFFICIENCY

CONTINUOUS QUALITY IMPROVEMENT

PEOPLE FOCUS EFFECTIVENESS

MSQH

OPERATIONAL MODEL

STRUCTURE PROCESS OUTCOME

(What are the things that you have) (What do you do With these things) (What is the result of what you do with these things that you have)

ORGANISATIONAL STRUCTURE

• 1. National level
• 2. Programme level
• 3. State level
• 4. Hospital/Institutional level

QUALITY ASSURANCE PROGRAMME QUALITY ASSURANCE PROGRAMME IN MINISTRY OF HEALTH IN MINISTRY OF HEALTH

– Launched in 1985 (with implementation of Launched in 1985 (with implementation of Patient Care Services QA Programme) Patient Care Services QA Programme) – QAP expanded to QAP expanded to

• Public Health Services

Public Health Services (1990) (1990)

• Pharmaceutical Services

Pharmaceutical Services (1990) (1990)

• Dental Services

Dental Services (1992) (1992)

• Engineering Services

Engineering Services (1992) (1992)

• Laboratory Services

Laboratory Services (1992) (1992)

• Training & Manpower

Training & Manpower Services Services (1996) (1996)

• Planning Division

Planning Division (1997) (1997)

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Quality Improvement Activities

Hospital based

ACTS AND REGULATIONS

• PRIVATE HEALTHCARE FACILITIES

AND SERVICES ACT 1998 AND SERVICES ACT 1998

• REGULATIONS 2006

QUALITY IMPROVEMENT ACTIVITIES QUALITY IMPROVEMENT ACTIVITIES IN THE MOH MALAYSIA IN THE MOH MALAYSIA

• NATIONAL INDICATOR APPROACH (NIA)

NATIONAL INDICATOR APPROACH (NIA)

• HOSPITAL SPECIFIC APPROACH (HSA)/

HOSPITAL SPECIFIC APPROACH (HSA)/

• DISTRICT SPECIFIC APPROACH (DSA)

DISTRICT SPECIFIC APPROACH (DSA)

• MATERNAL MORTALITY REVIEW/

MATERNAL MORTALITY REVIEW/

• PERINATAL MORTALITY REVIEW

PERINATAL MORTALITY REVIEW

• PERIOPERATIVE MORTALITY REVIEW (POMR)

PERIOPERATIVE MORTALITY REVIEW (POMR)

• MEDICAL AUDIT

MEDICAL AUDIT

• TOTAL QUALITY MANAGEMENT

TOTAL QUALITY MANAGEMENT

• QUALITY CONTROL CIRLCE

QUALITY CONTROL CIRLCE

• QUALITY CONTROL CIRLCE

QUALITY CONTROL CIRLCE

• QUALITY CONTROL

QUALITY CONTROL

• INFECTION CONTROL

INFECTION CONTROL

• CLINICAL PRACTICE GUIDELINES (CPG)

CLINICAL PRACTICE GUIDELINES (CPG)

• INCIDENT REPORTING

INCIDENT REPORTING

• CORPORATE CULTURE

CORPORATE CULTURE

• CLIENT’S CHARTER

CLIENT’S CHARTER

• INNOVATIONS

INNOVATIONS

• RENAL REGISTRY

RENAL REGISTRY

• Credentialing and Privileging

Credentialing and Privileging

• Accreditation of Healthcare Facilities and Services

Accreditation of Healthcare Facilities and Services

Strategic Plan For Quality

• Late 1996 & 1997: Evaluation of 17 Quality

Initiatives in MOH was carried out at National Level.

• Outcome of the evaluation was deliberated in

the 1998 National Conference on Quality in Health Care held in March 1998.

• Strategic Plan for Quality in Health

– Implementation Plan of the Strategic Plan for Quality in Health – 14 Manuals:

• Corporate Culture

PKPA

• NIA

MMR

• Incident Reporting

CPG

• POMR

Renal Registry

• Nosocomial Infection

Innovations Nosocomial Infection Innovations

• Quality Control

Client Charter

• Quality Control Circle

MS ISO 9000

Report on a decade of NIA Performance by Programmes

These document have also been distributed for use by the Private Health Care providers - to assist them towards compliance of the Private Healthcare Facilities and Services Act 1998.

The National Indicator Approach The National Indicator Approach

• Use of common indicators to assess the quality of

Use of common indicators to assess the quality of care care

• For each indicator a standard is set, against which

For each indicator a standard is set, against which the performance is compared the performance is compared

• If do not meet standards carry out investigations

If do not meet standards carry out investigations

• If do not meet standards, carry out investigations

If do not meet standards, carry out investigations to identify contributing factors or reason for to identify contributing factors or reason for shortfalls in quality shortfalls in quality

• Remedial measures are identified so as to

Remedial measures are identified so as to

• vercome these shortfalls
• vercome these shortfalls
• The cycle is then repeated

The cycle is then repeated

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NATIONAL INDICATOR APPROACH NATIONAL INDICATOR APPROACH

• Patient Care Services

Patient Care Services

• 51 indicators

51 indicators

• Public Health Services

Public Health Services

• 13 indicators

13 indicators

• Oral Health

Oral Health

• 14 indicators

14 indicators

• Pharmacy

Pharmacy

• 6 indicators

6 indicators

• Laboratory

Laboratory

• 8 indicators

8 indicators y

• Engineering Services

Engineering Services

• 2 indicators

2 indicators

• Human Resource & Training

Human Resource & Training

• 5 indicators

5 indicators

• Planning & Development Division

Planning & Development Division -

• 3 indicators

3 indicators THE HOSPITAL SPECIFIC APPROACH (HSA)/ THE HOSPITAL SPECIFIC APPROACH (HSA)/ DISTRICT SPECIFIC APPROACH (DSA) DISTRICT SPECIFIC APPROACH (DSA) Concept: Local staff identify and Concept: Local staff identify and solve local problems solve local problems

⇒Hospitals/Districts identify areas of Hospitals/Districts identify areas of shortfalls specific to each individual shortfalls specific to each individual shortfalls specific to each individual shortfalls specific to each individual hospital/district hospital/district ⇒Study the process of provision of care to Study the process of provision of care to detect weakness detect weakness ⇒Identify remedial measures Identify remedial measures ⇒Implement solution to overcome Implement solution to overcome weaknesses weaknesses ⇒Impact evaluation by reassessing quality Impact evaluation by reassessing quality Incident/Event Reporting Incident/Event Reporting

• is a system of reporting any unintended

is a system of reporting any unintended

• ccurrences of certain processes or outcomes
• ccurrences of certain processes or outcomes

(quality related) which could have or did harm (quality related) which could have or did harm to the patient to the patient

• Concept (HSA)

Concept (HSA) p ( ) p ( ) * local problems * local problems * local solutions * local solutions

• Principles

Principles * simple process * simple process * highlight good ideas * highlight good ideas * non punitive * immediate remedy * non punitive * immediate remedy * feedback * feedback

Incident/Event Reporting Incident/Event Reporting INDICATORS INDICATORS -

• examples

examples

• Nosocomial infection

Nosocomial infection

• Nosocomial infection

Nosocomial infection

• Adverse drug reactions

Adverse drug reactions

• Falls and accidents

Falls and accidents

• Greater than 24 hours waiting time

Greater than 24 hours waiting time for emergency surgery for emergency surgery

HOSPITAL INFECTION CONTROL (HIC) HOSPITAL INFECTION CONTROL (HIC)

* * MOH focus on HIC in late 1980’s MOH focus on HIC in late 1980’s * Factors contributing to HIC include: * Factors contributing to HIC include: b l ti f t t d d f i b l ti f t t d d f i

• below satisfactory standards of nursing care

below satisfactory standards of nursing care

• inadequate facilities (equipment & overcrowding)

inadequate facilities (equipment & overcrowding)

• misuse and abuse of Antibiotics

misuse and abuse of Antibiotics

• improper use of sterilization and disinfection procedures

improper use of sterilization and disinfection procedures

HOSPITAL INFECTION CONTROL (HIC) HOSPITAL INFECTION CONTROL (HIC)

* * Outcome of Research Projects on HIC Outcome of Research Projects on HIC

• Institutionalization of

Institutionalization of Nosocomial Infection Control Programme Nosocomial Infection Control Programme in all hospitals in all hospitals

• An Antibiotic Policy

An Antibiotic Policy

• Disinfection & Sterilization policies

Disinfection & Sterilization policies

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HOSPITAL INFECTION CONTROL (HIC) HOSPITAL INFECTION CONTROL (HIC)

* * Publications produced: Publications produced:

• Principles & Practices in Hospital Sterilization

Principles & Practices in Hospital Sterilization and Disinfection and Disinfection (Slides on Infection Control in Malaysian Hospitals) (Slides on Infection Control in Malaysian Hospitals) ( y p ) ( y p )

• Disinfection and Sterilization Policy & Practice

Disinfection and Sterilization Policy & Practice

• Guidelines On The Use Of Antibiotics

Guidelines On The Use Of Antibiotics

Peri Peri-

• operative Mortality Review
• perative Mortality Review

(POMR) (POMR)

*Started Started in in 1990 1990 Aim Aim: : To To systematically systematically assess assess the the quality quality of

• f Anesthetic

Anesthetic and and Surgical Surgical services services and and quality quality of

• f supporting

supporting services,with services,with the the ultimate ultimate aim aim of

• f identifying

identifying Shortfalls Shortfalls and

and taking taking remedial remedial measures measures

Shortfalls Shortfalls and

and taking taking remedial remedial measures measures. .

All All cases cases of

• f peri

peri-

• operative
• perative death

death during during the the whole whole hospital hospital stay stay is is being being investigated investigated * For For the the 6 6th th cycle cycle (from (from 1 1/ /1 1/ /98 98 onwards)

• nwards)

the the POMR POMR committee committee will will review review peri peri-

• operative
• perative deaths

deaths that that occur

• ccur

in in 5 5 targeted targeted areas areas. .

Peri Peri-

• operative Mortality Review
• perative Mortality Review

(POMR) (POMR)

Neurotrauma Neurotrauma Polytrauma Polytrauma Obstetrics Obstetrics Pediatric Surgery Pediatric Surgery Colorectal surgery Colorectal surgery 5 targeted areas 5 targeted areas * * Anaesthetic management in these 5 areas Anaesthetic management in these 5 areas will also be reviewed. will also be reviewed. The parallel reporting system will continue The parallel reporting system will continue to monitor all peri to monitor all peri-

• operative deaths
• perative deaths

as a baseline review. as a baseline review.

ACHIEVEMENTS

• 1. 2 yearly reports have been produced. The

3rd report has been published.

• 2. Developments of policies and guidelines.
• 3. Improvement in OT, ICU and HDU services.
• 4. Improvement in Training and Supervision.
• 4. Improvement in Training and Supervision.
• 5. Computerised OT Documentation System.
• 6. Provide inputs for future development of

Surgical, Anesthetic and Trauma Services, facility development and human Resource planning for the 8th Malaysian plan.

CLINICAL PRACTICE GUIDELINES CLINICAL PRACTICE GUIDELINES (CPG) (CPG)

* * Since 1993, MOH has initiated the Since 1993, MOH has initiated the Medical Consensus Development Programme Medical Consensus Development Programme with the Academy of Medicine with the Academy of Medicine * In October 1996, both MOH & * In October 1996, both MOH & , Academy of Medicine Malaysia took another step Academy of Medicine Malaysia took another step forward in developing evidence forward in developing evidence-

• based

based Clinical Practice Guidelines Clinical Practice Guidelines * Since November 1997: * Since November 1997: MOH, Academy of Medicine and UKM MOH, Academy of Medicine and UKM conducted yearly Systemic Review Workshop conducted yearly Systemic Review Workshop (Evidence Based) (Evidence Based)

Clinical Practice Guidelines Clinical Practice Guidelines ‘ Systematically developed statements to assist ‘ Systematically developed statements to assist

CLINICAL PRACTICE GUIDELINES CLINICAL PRACTICE GUIDELINES (CPG) (CPG)

practitioner and patient’s decision about practitioner and patient’s decision about appropriate health care for specific appropriate health care for specific clinical circumstances ’ clinical circumstances ’

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Why Clinical Practice Guidelines? Why Clinical Practice Guidelines?

• as a tool to address the issue of unjustifiable

as a tool to address the issue of unjustifiable variations in clinical practice for a clinical condition variations in clinical practice for a clinical condition

CLINICAL PRACTICE GUIDELINES CLINICAL PRACTICE GUIDELINES (CPG) (CPG)

p

• assists practitioner to make the right decision,

assists practitioner to make the right decision,

• ne which is appropriate, effective &
• ne which is appropriate, effective &

reasonably cost effective reasonably cost effective

• attempt to make the best use of available resources

attempt to make the best use of available resources to achieve the best possible outcome to achieve the best possible outcome

• as standard of Clinical Practice

as standard of Clinical Practice

• Examples of Consensus & Clinical Practice

Guidelines available – Prophylaxis of Venous Thrombo-embolism – Management of Chronic Obstructive Airway Disease – Management of Dengue and Dengue Hemorrhagic Fever in the Pediatric Hemorrhagic Fever in the Pediatric Population – Management of Idiopathic Nephrotic Syndrome in Childhood – Screening for Hepatocellular Carcinoma

MEDICAL STAFF CREDENTIALLING MEDICAL STAFF CREDENTIALLING

Process of ensuring those who provide Process of ensuring those who provide health care services are fully competent health care services are fully competent to do so to do so * * Right person for the right job Right person for the right job * If providers not skilled enough ability * If providers not skilled enough ability to achieve Quality Outcomes will be to achieve Quality Outcomes will be questionable questionable * Life time qualifications may no longer * Life time qualifications may no longer be valid be valid

HEALTH TECHNOLOGY ASSESSMENTS HEALTH TECHNOLOGY ASSESSMENTS (HTA) (HTA)

• Unit set up in 1995

Unit set up in 1995

• Is the systematic evaluation of the

Is the systematic evaluation of the properties & the effects of Health properties & the effects of Health Technology Technology gy gy

• Focus is on

Focus is on * safety * safety * efficacy/effectiveness * efficacy/effectiveness * feasibility * feasibility

HEALTH TECHNOLOGY ASSESSMENTS HEALTH TECHNOLOGY ASSESSMENTS (HTA) (HTA) Among topics studied Among topics studied:

• Stereo tactic Radio

Stereo tactic Radio-

• Surgery

Surgery

• Spinal Cord Stimulation

Spinal Cord Stimulation

• Electromagnetic Prostatectomy

Electromagnetic Prostatectomy

• Routine Pre

Routine Pre-

• operative Investigation
• perative Investigation
• Electronic Fetal Monitoring

Electronic Fetal Monitoring

WORL RLD ALLIANCE ALLIANCE FOR R PATIEN TIENT S SAFET FETY Launche Launched b by WHO WHO in in Oct Octobe ber 2004 in r 2004 in resp response t to W World rld Health Assem Health Assembly resp response t to W World rld Health Assem Health Assembly Reso solu lutio tion 2002 urging WHO 2002 urging WHO and and member er stat ates es to p pay t y the closest est possible at possible attentio ntion t n to P Patient Saf ent Safety.

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• Formed in Feb.2003
• Committed to WHO World Alliance for

Patient Safety strategies and action plans. MSQH i b f th PSC M

PATIE TIENT T SAFET SAFETY COUNCIL MALA COUNCIL MALAYSIA IA (PSC (PSCoM)

• M)
• MSQH is a member of the PSCoM .
• Strategies and action plans developed by

PSCoM is adopted and given emphasis in the MSQH Hospital Accreditation Standards and Compliance assessment .

Goals of Patient Safety Programs

Create the safest possible environment for patients:

• Reinforce patient safety as top priority &

p y p p y create culture of safety

• Measure & evaluate patient safety
• Change processes identified as unsafe
• Adopt technology that enhances safety

Patient safety Patient safety

• Patient safety is an outcome of safe health care process.

Patient safety is an outcome of safe health care process.

• While patient safety is the ultimate goal, it is a safer health care

While patient safety is the ultimate goal, it is a safer health care environment in the course of the process of patient care which environment in the course of the process of patient care which ultimately determines safety. ultimately determines safety.

• Safety is one dimension of the broader construct of culture

Safety is one dimension of the broader construct of culture

• Safety is one dimension of the broader construct of culture,

Safety is one dimension of the broader construct of culture, which includes aspects of organisational and clinical culture e,g which includes aspects of organisational and clinical culture e,g related to specialities and professions. related to specialities and professions.

• Communication is vital to patient safety in many ways: thus

Communication is vital to patient safety in many ways: thus supporting mutual understanding across cultures is essential in supporting mutual understanding across cultures is essential in the general development of patient safety. the general development of patient safety.

HOSPITAL ACCREDITATION PROGRAMME HOSPITAL ACCREDITATION PROGRAMME

• started in late 1995 with the 1st National Workshop

started in late 1995 with the 1st National Workshop

• n Accreditation of hospitals
• n Accreditation of hospitals
• Assistance

Assistance -

• WHO Consultant

WHO Consultant

• is a process in which quality of health care services

is a process in which quality of health care services in a particular hospital is compared against in a particular hospital is compared against in a particular hospital is compared against in a particular hospital is compared against established professionally accepted standards established professionally accepted standards

• voluntary programme conducted by a non

voluntary programme conducted by a non-

• governmental organisation

governmental organisation

The M l i

1st October 1999

Memorandum of Understanding

MOH MMA

Malaysian Healthcare Accreditation Program

Active Participation of the Public, Private Sectors & Professional Organisations

PARTNERSHIP & CONSENSUS COLLABORATION & SUPPORT

APHM MSQH

Objectives Objectives

• establishes standards of services among health care

establishes standards of services among health care providers providers

• ensure quality of healthcare throughout the country

ensure quality of healthcare throughout the country

HOSPITAL ACCREDITATION PROGRAMME HOSPITAL ACCREDITATION PROGRAMME

• ensure quality of healthcare throughout the country

ensure quality of healthcare throughout the country

• enhance organization and management of

enhance organization and management of healthcare institutions healthcare institutions

• achieve optimum results from available resources

achieve optimum results from available resources

• increase accountability to customers and stakeholders

increase accountability to customers and stakeholders

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Systems fragmented and often designed to serve needs of providers, not patients

System deficits affect all providers and

patients

HOW DO SYSTEMS OF CARE IMPEDE QUALITY & SAFETY?

Patients “fall through the cracks” in complex

systems of care

Several small problems in multi-step

processes can trigger severe adverse events

Problems arise even when providers well

intentioned

Key Challenge

“The biggest challenge is to get people in hospitals- physicians, pharmacists, nurses, and administrators- to recognize that administrators to recognize that errors are systems problems and not people problems.”

Lucian Leape, MD Harvard School of Public Health

CULTURE OF SAFETY

• Unreported errors cannot be

investigated

• First, need to create a culture of safety,

similar to the aviation industry

– Even highly trained people make mistakes – Reduce fear of reporting – Move beyond blaming & punishing, toward improving the system

CONCLUSIONS & IMPLICATIONS

Many quality & safety tools now available to health policy-makers & health-care leaders:

• Information technology
• Evidence-based quality standards
• Performance reports

Performance reports

• Financial incentives
• Focus on leadership, teamwork

& coordination of care

Shift focus from blaming people to improving system

INCREASING PRODUCTIVITY

DO IT RIGHT FIRST TIME, ANYTIME

REDUCE COSTS OF WASTES, ERRORS & REWORK THROUGH ENHANCING CLINICAL QUALITY

THANK YOU FOR YOUR ATTENTION

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