QAP in QAP in KKMKKM

Dr Suhazeli AbdullahDr Suhazeli AbdullahFamily Medicine SpecialistFamily Medicine SpecialistKlinik Kesihatan MarangKlinik Kesihatan Marang

Courtesy slides from Dato’ Dr Abdul Jamil Abdullah, Head of Surgery Department, HSNZ

What is What is QUALITY?QUALITY?

Excellence, goodnessExcellence, goodness

mutu - mutu - baik buruk sesuatubaik buruk sesuatu

Kamus DewanKamus Dewan

Vision for HealthVision for HealthMalaysia is to be a nation of healthyMalaysia is to be a nation of healthy

individualsindividuals families families and and communities,communities,

through a health system that is through a health system that is equitableequitable affordableaffordable efficientefficienttechnologically appropriatetechnologically appropriate environmentally adaptable environmentally adaptable andand consumer-friendlyconsumer-friendly

, ,

MOH’s vision……MOH’s vision……with emphasis on with emphasis on qualityquality innovationinnovation health promotion health promotion and and respect for human dignity,respect for human dignity,

which promotes which promotes individual responsibility individual responsibility and and

community participation community participation

towards an enhanced quality of lifetowards an enhanced quality of life

RegistrationRegistration Doctors & ParamedicalsDoctors & Paramedicals

LicensingLicensing Hospital, PharmacyHospital, Pharmacy

AccreditationAccreditation CredentiallingCredentialling

Code of conduct, code of ethicsCode of conduct, code of ethics

Quality activities of MOHQuality activities of MOH

Morbidity & mortality reviewsMorbidity & mortality reviews Perinatal MR, MMR, POMRPerinatal MR, MMR, POMR

Committee meetingsCommittee meetings Infection control, OT, DrugInfection control, OT, Drug

AuditsAudits Medical, NursingMedical, Nursing

Quality activities of MOHQuality activities of MOH

ReviewsReviewsUtilisation, Peer, CPCUtilisation, Peer, CPC

InvestigationsInvestigationsSentinel events, public complaintsSentinel events, public complaints

GuidelinesGuidelines CPG, SOP, checklistCPG, SOP, checklist

ISO, QCC, TQM,ISO, QCC, TQM, PKPA, HTAPKPA, HTA

Quality activities of MOHQuality activities of MOH

Up to 1980’s - coverage, target & goal Up to 1980’s - coverage, target & goal

1985 - introduce element of Quality in 1985 - introduce element of Quality in Healthcare:Healthcare:

QAP for In-Patient Care ServicesQAP for In-Patient Care Services

14 pilot Hospitals & 12 indicators 14 pilot Hospitals & 12 indicators 19 indicators for all Hospitals19 indicators for all Hospitals

Two approaches : NIA & HSATwo approaches : NIA & HSA

QA milestone in KKMQA milestone in KKM

Bil. Programme Year of Implementation

Current No. of Indicators

1. Patient Care Services

1985 19

2. Pharmaceutical Services

1990 7

3. Public Health Services

1990 13

4. Engineering Services

1992 7

5. Dental Services 1992 9

6. Laboratory Services 1992 11

7. Training & Manpower

1996 5

8. Planning & Development

1998 3

AimsAims To improve the quality, To improve the quality,

efficiency and effectiveness of efficiency and effectiveness of the delivery of health servicesthe delivery of health services

To facilitate the planned and To facilitate the planned and systematic evaluation of systematic evaluation of quality processquality process

QA - KKM QA - KKM definitiondefinition

““Securing Securing optimum achievable resultoptimum achievable result for for each patienteach patient,,avoidance of iatrogenicavoidance of iatrogenic complications complicationsand giving attention and giving attention to the to the patientpatientand and family needsfamily needsin a mannerin a mannerthat is that is cost effectivecost effectiveand reasonably and reasonably documenteddocumented

Adapted from ThomsonAdapted from Thomson

QA APPROACHESQA APPROACHES

National Indicator Approach (NIA)National Indicator Approach (NIA)

Hospital Specific Approach (HSA)Hospital Specific Approach (HSA)

FeaturesFeatures HSAHSA NIANIAProblem identificationProblem identification Hosp levelHosp level KKM levelKKM level

Specificity of problemSpecificity of problem Specific to hospSpecific to hosp Common to allCommon to all

Priority for hospitalPriority for hospital HighHigh VariableVariable

Setting of standardsSetting of standards Hospital levelHospital level KKM levelKKM level

Problem verificationProblem verification Related dataRelated data Data collectedData collectedin hospitalin hospital for indicatorfor indicator

QA studyQA study Similar Similar approachapproach

Re-evaluationRe-evaluation Decided byDecided by Once a yearOnce a yearhospitalhospital

NIANIA

* MOH set & provides:* MOH set & provides: -- a a standardstandard for each for each indicatorindicator

-- monitoring format for data collection , monitoring format for data collection , analysis & reportinganalysis & reporting

-- protocols & format for protocols & format for SIQSIQ investigation.investigation.

* Hospital has to carry out remedial * Hospital has to carry out remedial actions & relook of its effectiveness.actions & relook of its effectiveness.

NIANIA

Indicator Std.Indicator Std.1. Typhoid CFR1. Typhoid CFR 002. Elective cholecystectomy deaths2. Elective cholecystectomy deaths 003. Death due to haemorrhage of pregnancy3. Death due to haemorrhage of pregnancy 004. Eclampsia CFR4. Eclampsia CFR 005. Gross death rate5. Gross death rate 2.13% 2.13%6. POP cast complication 6. POP cast complication <5%<5%7. Clean Wound Infection 7. Clean Wound Infection <4%<4%8. Pressure sores in bed-ridden pts8. Pressure sores in bed-ridden pts<5%<5%9. BOR 9. BOR 50 - 80% 50 - 80%10. ALOS 10. ALOS 3 - 6.3 days3 - 6.3 days

NIA IndicatorsNIA Indicators

Indicator Std.Indicator Std.1. AMI CFR1. AMI CFR <34.7%<34.7%2. AGE CFR in children2. AGE CFR in children <0.6%<0.6%3. Head injury CFR3. Head injury CFR <7%<7%4. ARI CFR4. ARI CFR <3.1%<3.1%5. Lab specimen rejection rate5. Lab specimen rejection rate <0.86%<0.86%6. Proportion of urgent lab test6. Proportion of urgent lab test <19.6%<19.6%7. Proportions of Ops undergoing x-rays7. Proportions of Ops undergoing x-rays <8%<8%8. Proportions of Ips undergoing x-rays8. Proportions of Ips undergoing x-rays <70%<70%9. Proportions of x-ray films rejected9. Proportions of x-ray films rejected <10%<10%

NIA IndicatorsNIA Indicators

Communicable DiseaseCommunicable Disease TB Sputum Conversion RateTB Sputum Conversion Rate 85%85%

Average Notification Time Index for Average Notification Time Index for TyphoidTyphoid <14 days<14 days

Morbidity Index for TyphoidMorbidity Index for Typhoid <2<2

Vector Borne DiseaseVector Borne Disease Dengue Notification Time IndexDengue Notification Time Index

80% within 24 hours80% within 24 hours

Dengue Outbreak Control IndexDengue Outbreak Control Index100% controlled within 14 days of 2100% controlled within 14 days of 2ndnd case case

Dengue Law Enforcement IndexDengue Law Enforcement Index80% positive premise taken legal action80% positive premise taken legal action

Malaria DeathMalaria Death No deathNo death

Family HealthFamily Health Incidence Rate of EclampsiaIncidence Rate of Eclampsia

8 per 10,000 deliveries8 per 10,000 deliveries

Incidence Rate of Severe Neonatal Incidence Rate of Severe Neonatal JaundiceJaundice< 100 cases per 10,000 live births< 100 cases per 10,000 live births

Incidence Rate of Tetanus Incidence Rate of Tetanus NeonatorumNeonatorum 0 case per 10,000 live births0 case per 10,000 live births

HSAHSA

Hospital/Unit/Dept. Hospital/Unit/Dept. identify own identify own areas of weakness to remedyareas of weakness to remedy

Idea of local people solving local Idea of local people solving local problems problems

Useful tool in improving quality Useful tool in improving quality servicesservices

HSAHSA

To ensure that To ensure that the patient, family the patient, family and communityand community obtain obtain the the

optimum achievable benefitoptimum achievable benefit from the services of MOH from the services of MOH

within the within the available resourcesavailable resources

General ObjectiveGeneral Objective

With unlimited resourceWith unlimited resource ideal level of careideal level of care

Optimal Achievable LevelOptimal Achievable Level targeted level within targeted level within

meansmeans

ABNAABNA difference between OA & difference between OA &

present levelpresent level QA aims at narrowing or QA aims at narrowing or

eliminating the gapeliminating the gap0

25

50

75

100

ABNA}IdealOptimum

Actual

ABNAABNA

Problem Problem PrioritisationPrioritisation

Problem Problem AnalysisAnalysis

Quality Quality Assurance Assurance

StudyStudy

Identification of Identification of Remedial ActionsRemedial Actions

Implementation of Implementation of Remedial ActionsRemedial Actions

Re-evaluation of the Re-evaluation of the ProblemProblem

Problem Problem identificationidentification

Quality Quality Assurance Assurance

CycleCycle

QA QA OrganisatOrganisat

ionion

QAP - Organizational QAP - Organizational StructureStructure

The MOH Steering Committee

Programme Level QAP Committee

State QAP Steering Committee

State QAP technical sub-committee

Hospital / District QAP Committee

Hospital / District QAP Hospital / District QAP CommitteeCommitteeChairman: Pengarah Hospital / MOHChairman: Pengarah Hospital / MOHSecretary: AMRO (*)Secretary: AMRO (*)Members: - Clinical co-coordinator Members: - Clinical co-coordinator

(*)(*) - - Unit / Dept. HeadUnit / Dept. Head- M&HO /Matron / Supervisors- M&HO /Matron / Supervisors

- Co-opted members- Co-opted members (*) for hospital(*) for hospital

Hospital/District QA Hospital/District QA CommitteeCommittee

To meet at least once in 3 months to:To meet at least once in 3 months to:

Inform & motivate staff of the need Inform & motivate staff of the need and implementation of QAand implementation of QA

Plan & initiate QA activitiesPlan & initiate QA activities Monitor & evaluate the Monitor & evaluate the

implementation & remedial actionsimplementation & remedial actions Identify problems for QA studiesIdentify problems for QA studies Appoint investigators for QA studiesAppoint investigators for QA studies

Functions…Functions…

Appoint appropriate members Appoint appropriate members Discuss & forward relevant reports / Discuss & forward relevant reports /

recommendations to State Committeerecommendations to State Committee Co-ordinate, train and support QA Co-ordinate, train and support QA

activities planned & conducted by the activities planned & conducted by the individual units.individual units.

……FunctionsFunctions

QA QA APPROACHESAPPROACHES

OutcomeOutcomeStructureStructure Process/systemProcess/system

•Organizations•Personnel•LicensureLicensure•RegistratiRegistrationon•CertificatiCertificationon•AccreditatAccreditationion

•Protocols•CPGs•Policies•Incident Reporting

•Mortality Mortality reviewreview

•MorbidityMorbidity

•NIA/HSANIA/HSA

WHO define WHO define QUALITY?QUALITY?

These may seem varied, butThese may seem varied, butthey almost sound similar;they almost sound similar;

thethe requirements of the requirements of the customercustomer are always a are always a consideration in a valid consideration in a valid definition of qualitydefinition of quality

Patients/RelativesPatients/Relatives Pleasant Staff & Pleasant Staff &

EnvironmentEnvironment ResponsivenessResponsiveness ReliableReliable CompetenceCompetence

KKM DefinitionKKM DefinitionSecuring Securing optimum achievable result optimum achievable result

for for each patienteach patient,,Avoidance ofAvoidance of (MINIMISE)(MINIMISE) iatrogenic iatrogenic

complicationscomplicationsand giving attention and giving attention

to the to the patientpatientand and family needsfamily needs

in a mannerin a mannerthat is that is cost effectivecost effective

and reasonably and reasonably documenteddocumentedAdapted from ThomsonAdapted from Thomson

ASSURANCEASSURANCE

Implies one party is Implies one party is convincing another convincing another that certain that certain standardsstandards will be will be maintainedmaintained

Quality Quality AssuranceAssurance

In general terms In general terms means that means that

all the measures are takenall the measures are taken in in order that the customer or order that the customer or interested party will be interested party will be consistently provided with quality.consistently provided with quality.

(show them what you are doing)(show them what you are doing)

WhyWhy we need we need QualityQuality

Professional NeedProfessional Need related to the fundamental responsibility related to the fundamental responsibility

of all professionals – appropriateness & of all professionals – appropriateness & necessitynecessity

for the highest standards of excellence.for the highest standards of excellence.

EffectivenessEffectiveness

Standardization (reduced variance)Standardization (reduced variance)

Safety Safety

A Social NeedA Social Need related to the accountability of every related to the accountability of every

profession to the society profession to the society

from which the profession obtain from which the profession obtain authorization and economic support authorization and economic support to practice their skillsto practice their skills

EthicalEthical

A Practical NeedA Practical Need The need for continuous The need for continuous

improvementimprovement Where errors are costlyWhere errors are costly

CostsCosts

““, it is always the , it is always the result of high result of high

intentions, sincere intentions, sincere effort, intelligent effort, intelligent

direction and direction and skillful execution”skillful execution”

Quality Quality is never an is never an accidentaccident

Quality is a Quality is a journey, notjourney, not

a destinationa destination