HBI Awards 2018: New clinical governance and quality framework cuts readmissions and medical errors
A family-run, 100 bed hospital in Kuwait with 2017 revenue of $75m.
New Mowasat has created a Clinical Governance and Quality Framework to integrate all processes and activities which impact patient care into one strategy. Only in place since March 2017, it has already achieved improved outcomes in multiple areas. Select improvements include reducing unplanned admission after day surgery from 4% to beneath 2%. It has also successfully reduced medication errors in its pharmacy from 1.2 to less than 0.75%.
Full application
1. Briefly describe the organisation giving number of facilities, staff, revenue numbers.
New Mowasat Hospital (NMH) is a family owned hospital and one of the first private hospital in Kuwait. New Mowasat healthcare also owns New Mowasat Clinics providing premiere healthcare services for more than 12 specialties in the areas surrounding the Ahmadi Governorate in the south of Kuwait with superb medical care. The hospital is 100 beds with 800 employees and is among the leading private providers of inpatient and outpatient care in Kuwait with the revenue of over USD 75 million in year 2017.
2. Please briefly describe the medical service, which the organisation is delivering in which it has deployed the best quality data model
Clinical Governance and quality data model is fundamental to the delivery of safe and high quality care. The robust clinical governance and quality framework demonstrates:
• Sound resource management and accountability.
• A culture whereby existing practices can be professionally challenged and lessons can be learned to facilitate effective quality improvement
• Mechanisms for gathering clinical data and information and using this to inform and improve clinical risk management and quality of care.
The domains that are included in the clinical governance reporting framework are:
Safety
• To include an analysis of all AOR’s.
Clinical effectiveness
• To include key performance indicator data
• To include Doctor’s Scorecard to evaluate performance
• To include clinical audit
• To include changes to practice: light of new evidence e.g.
– International Reports / Guidance
– Professional body evidence
Patient focus
• To include patient feedback from
Patient satisfaction surveys
Complaints management system
Accessible and Responsive Care
• To include service reviews from Specialty Groups
• Care Environment and Amenities
• To include summary of HR activities
• To include staff education and training activities
In order to get maximum benefit from the CGQ framework, Continuous Quality Improvement (CQI) is instituted at NMH. CGQC framework is implemented and measurement of success is done through use of various available tools.
We follow the methodology of the following to achieve the success of our Quality Model:
• Plan Do Check Act (FOCUS-PDCA)
• Six Sigma
• Root cause analysis
• Performance Improvement plan
• Balance Scorecard /Physician Scorecard
This New CGQC data model provides a framework for continuous improvement of processes and systems at NMH. It is based on the vision and values of the organization and is aimed at creating a sustainable quality improvement model for the hospital to continually improve its clinical practices, patient care, and service standards.
Involvement of all stakeholders is ensured in this plan and the framework provides an interdisciplinary approach to all improvement initiatives. This plan sets forth the strategy, structure, methodologies, and measurement system for the improvement of the overall performance of the organization.
CGQC Framework Objective
The Clinical Governance and Quality aims to ensure structure, process and systems are in place to:
• Ensure the Board of Directors/Governance Executive Committee receives appropriate information relating to clinical governance and quality of care.
• Collect clinical data and analyze it to extrapolate information, knowledge and wisdom.
• Increase individual accountability, responsibility and commitment.
• Allow teams to develop the culture towards that of a “learning organization”.
• Clearly evidence closure of loops, safeguarding of patients (and other stakeholders) and developments in clinical practice.
All the above-mentioned Performance Improvement Plans are focused on creating an organization wide quality focused environment with an internal structure to support a comprehensive performance improvement effort throughout the Hospitals.
The major goal of this effort is to: meet or exceed the needs and expectations of all of its customers, most especially those of the patients, their families, and their support systems.
In order to meet these goals, the Hospitals would establish and maintain an effective structure to support the organization’s ability to gather, assess, monitor, evaluate and communicate the appropriate indicators of quality, timeliness, safety, respect, efficiency and efficacy of care throughout the unit, including data on risk management occurrences and information regarding the effectiveness and appropriateness of care.
This Performance Improvement Plan exists to identify opportunities to improve the care and services of the Hospitals by:
• Organizing an approach to improve systems and continuously the quality of patient care
• Reporting department based indicators of quality, at the Hospital Management Committee and CGQC meeting to monitor trend and track improvement
• Reporting information about incidents and occurrences within the organization that cause an adverse outcome for patients or have the potential to cause an adverse outcome
• Establishing collaborative multi-disciplinary work teams to evaluate work processes and to identify opportunities to make improvements that will improve care, reduce expenses associated with unnecessary or inappropriate care and increase the patient satisfaction.
• Providing necessary tools and information to staff to take deliberate steps to plan appropriately the services, intervene in problematic processes, evaluate the effectiveness of the interventions and to work collaboratively to meet the needs of the internal and external customers.
• Reporting to senior management on the quality of care at the Hospital including safety of services within the Hospital
• Compiling information available from a multitude of sources including patient satisfaction instruments; reports from external regulatory, agencies and relevant bench-marking with comparative databases.
• To include service reviews from Specialty Groups
• Care Environment and Amenities
• To include summary of HR activities
• To include staff education and training activities
In order to get maximum benefit from the CGQ framework, Continuous Quality Improvement (CQI) is instituted at NMH. CGQC framework is implemented and measurement of success is done through use of various available tools.
We follow the methodology of the following to achieve the success of our Quality Model:
• Plan Do Check Act (FOCUS-PDCA)
• Six Sigma
• Root cause analysis
• Performance Improvement plan
• Balance Scorecard /Physician Scorecard
This New CGQC data model provides a framework for continuous improvement of processes and systems at NMH. It is based on the vision and values of the organization and is aimed at creating a sustainable quality improvement model for the hospital to continually improve its clinical practices, patient care, and service standards.
Involvement of all stakeholders is ensured in this plan and the framework provides an interdisciplinary approach to all improvement initiatives. This plan sets forth the strategy, structure, methodologies, and measurement system for the improvement of the overall performance of the organization.
CGQC Framework Objective
The Clinical Governance and Quality aims to ensure structure, process and systems are in place to:
• Ensure the Board of Directors/Governance Executive Committee receives appropriate information relating to clinical governance and quality of care.
• Collect clinical data and analyze it to extrapolate information, knowledge and wisdom.
• Increase individual accountability, responsibility and commitment.
• Allow teams to develop the culture towards that of a “learning organization”.
• Clearly evidence closure of loops, safeguarding of patients (and other stakeholders) and developments in clinical practice.
All the above-mentioned Performance Improvement Plans are focused on creating an organization wide quality focused environment with an internal structure to support a comprehensive performance improvement effort throughout the Hospitals.
The major goal of this effort is to: meet or exceed the needs and expectations of all of its customers, most especially those of the patients, their families, and their support systems.
In order to meet these goals, the Hospitals would establish and maintain an effective structure to support the organization’s ability to gather, assess, monitor, evaluate and communicate the appropriate indicators of quality, timeliness, safety, respect, efficiency and efficacy of care throughout the unit, including data on risk management occurrences and information regarding the effectiveness and appropriateness of care.
This Performance Improvement Plan exists to identify opportunities to improve the care and services of the Hospitals by:
• Organizing an approach to improve systems and continuously the quality of patient care
• Reporting department based indicators of quality, at the Hospital Management Committee and CGQC meeting to monitor trend and track improvement
• Reporting information about incidents and occurrences within the organization that cause an adverse outcome for patients or have the potential to cause an adverse outcome
• Establishing collaborative multi-disciplinary work teams to evaluate work processes and to identify opportunities to make improvements that will improve care, reduce expenses associated with unnecessary or inappropriate care and increase the patient satisfaction.
• Providing necessary tools and information to staff to take deliberate steps to plan appropriately the services, intervene in problematic processes, evaluate the effectiveness of the interventions and to work collaboratively to meet the needs of the internal and external customers.
• Reporting to senior management on the quality of care at the Hospital including safety of services within the Hospital
• Compiling information available from a multitude of sources including patient satisfaction instruments; reports from external regulatory, agencies and relevant benchmarking with comparative databases.
3. Please briefly describe the medical service, which the organisation is delivering in which it has deployed the best quality data model
New Mowasat Hospital (NMH) Clinical Governance and Quality Framework place emphasis on the focus of improvements being on systems and processes rather than on the individual; Clinical governance is a framework which helps clinicians – including nurses and Allied Health Professionals- to continuously improve quality and safeguard standards of care. It aims to integrate all the activities that impact on patient care into one strategy. Clinical Governance combines risk management with quality management.
This involves improving the quality of information for patient care, promoting collaboration, team working, and partnerships, as well as reducing variations in practice, and implementing evidence-based practice.
CGQC data Model focuses on the customer (be they internal or external customers), supported by structures, processes, capability development, and outcomes.
CGQC Model Annexure 1. The implementation of CGQC data model is done through various Quality Tools used by Quality Systems Management at NMH. Under this model NMH has completed selected various Quality Improvement projects (Clinical and Non-Clinical).
Few examples for the projects under CGQC data model are:
Project 1: Reducing waiting time for MRI, CT scan and Ultrasound. Annexure 3
Project 2: Implementation of Doctor’s Scorecard to monitor ongoing physician performance Annexure 4
Project 3: Reducing Medication Errors through Pharmacist Interventions. Annexure 5
Project 4: Reducing unplanned admissions after day surgery. Annexure 6
Project 5: Administering Aspirin on Arrival and Discharge for all patients with MI.Annexure 7
Project 6: Stat Turnaround time for Cretinine and Electrolytes. Annexure 8
4. What new quality data has the organisation created?
Focused Areas for Data Collection
The important processes on which the organization collects internal data to re-evaluate and enhance the quality improvement priorities or resource allocation priorities and to evaluate the quality of services provided include, but are not limited to, the following:
• The use and management of medications
• Utilization Management activities regarding the appropriateness of admissions and length of Hospital stay
• The clinical pertinence and timeliness of medical records
• The effectiveness of the Infection control program
• The results of patterns and trends of risk management data on incidents and focused occurrences
• The effectiveness of the Safety Management Program
• The pharmacy and therapeutics function including adverse drug reactions, drug-drug and drug-food interactions, pharmacist interventions and medication errors
• The clinical laboratory function as well as the diagnostic radiology function
• The needs, expectations, and satisfaction of patients
• The staff views regarding performance and improvement opportunities; and
• The data from important processes and outcomes quality control activities
This data is monitored analyzed and made available through various tools such as Hospital Balance scorecard ( Annexure 9), Quality Indicators ( Annexure 2) and doctors’ scorecard ( Annexure 4).
5. How has that new quality data been used to change the way that health care services are delivered?
METHODOLOGY
Each Department/Specialty services of the Hospitals would participate in the monitoring the Key Performance Indicators (KPI) using accepted methods of quality assessment, quality control as appropriate, continuous quality improvement and risk management. Each department, service or function would use a systematic and continuous process of planning, monitoring, evaluating, and improving the quality of care. Each department, service or function would:
• Designate an individual (s) responsible for departmental monitoring and quality improvement
• Identify the most important functional aspects of the department or service
• Identify measurable indicators to monitor the quality of important Functions of care such as incidents, sentinel events, patterns, comparative databases with other organizations, and rate-based indicators
• Collect data for indicators based on volume, problem-prone or high-cost or high-risk nature of the care utilizing the dimensions of performance that include efficacy, availability, effectiveness, safety, respect and caring, appropriateness, timeliness, continuity and efficiency
• Organize the data in a meaningful way, in order to effectively identify the need for further assessment or evaluation of the care to identify opportunities to improve the quality of care or services provided to patients
• Prioritize the need for corrective action{s) based on the volume of patients, the degree of risk to patients or staff; the extent to which the issue contributes to problems in patient care and the cost of quantity of resources required to correct the issue
• Take action or develop an intervention to improve the issue identified
• Develop corrective actions if the initial action is ineffective or continue monitoring if it is initially effective in correcting the problem
• Evaluate the effectiveness of quality improvement monitoring
• Present reports to the relevant committee
Each department /specialty services in the organization establishes departmental goals and objectives annually and develops a department specific Performance Improvement Plan based on the major function and services within the unit and the additional parameters of high volume, high risk, high cost and problem prone nature of the issue. They would first define the core components for development of the plan by stating the Mission and Goals of the Department; current and planned services: patient population served; staffing patterns and quality monitoring and improvement initiatives. Each unit would then report on the results of its performance monitors or outcomes on a regularly scheduled calendar to the respective committees and core quality team. Each unit also reports the results of the departmental monitoring to the regularly scheduled department meeting and quality review meeting to facilitate the involvement of all staff members in the quality improvement process.
The concept called Clinical Governance and Quality Framework is implemented to measure medical outcome over the whole treatment process.
Starting from initial conditions and indication criteria, to treatment processes and complications/mortality during the hospital stay and outcome from patient and expert view. All these numbers and results are aggregated and presented in the monthly CGQC meetings.
Firstly, the quality data model ensures that all data is comparable (because of explicit definitions and defined data collection processes) and benchmarking (internal or external, national or international) is possible (which is one of the most important requirements to drive quality improvements).
Secondly, data collection is totally integrated into care and treatment processes. Relevant data will be collected in real time at the point of care. So initial demographics like age, gender etc. are collected only once during the first encounter while data like pain scoring or wound observations are collected every day on the wards by nurses. This process makes it possible to collect data in a very efficient way, reduce double documentation and improve data validity.
Most of the data management is automated, all the relevant data is extracted, merged, transformed, analyzed and visualized automatically through our HMIS system.
When we implemented CGQC framework at NMH it took us some time to get implement accurate valid databases for some of the indicators selected by department. But with time a clear strategy for defining and collecting useful quality data and indicators was provided, lot of emphasis was put on staff training for collecting and presenting valid and accurate data. The team designed standardized format for reporting each indicator and QI project. Each QI project was driven by a team leader for regular discussion and further developments with our expert teams, the effects started from the time we started reporting data within the hospital.
A second aspect, which stimulates these focused discussions in our expert groups, was the voluntary publication of outcome measures at hospital website.
6. When did the quality data model start affecting service delivery?
Month : March
Year : 2017
7. What are the main key performance indicators? How does the organisation measure the success of the project?
The main key performance indicators are all included in the Quality Indicators List for 2017-2018 (Annexure 2) with a focus on the following key topics:
• Patient outcome (e.g. Code Blue outcome, surgical site infection, etc.),
• Patient safety (infection control, safety of high risk medication etc.)
• Patient experience (e.g. complaint management, patient satisfaction survey score etc.).
Several best practice projects (e.g. pharmacist interventions to reduce medication errors, reducing unplanned admission after day surgery, Aspirin on Arrival and at Discharge for MI patients.) or significant changes in treatment pathways after analyzing and discussion outcome during our Multidisciplinary Specialty Groups meetings show the success of CGQC framework data model at New Mowasat Hospital.
In addition, we measure the success of our quality performance indicators based on the compliance reports from regulatory inspections, patient satisfaction surveys, third-party surveys /assessment – Accreditation surveys, and statistical indicators and internal process review audits.
The compliance to regulatory Inspection which is done by health authorities helps us measure minimal requirements for the safety of patients and personnel.
We conduct Patient Satisfaction surveys which help us address what is valued by patients and the general public including specific domains of patient experience and satisfaction.
Third party assessments /Accreditation Surveys help us know compliance with international standards for quality systems and supports our journey of continuous quality improvement. Statistical indicators which are captured under managerial indicators, clinical indicators and nonclinical indicators help us understand topics for performance management, quality improvement, and further analysis.
8. Additional Documentation
Results 1
Results 2
Results 3
Results 4
Results 5
Results 6
Results 7
