Queen Mary Hospital

McCauley , M. (2001 ). Continuous quality improvement initiatives at Queen Mary Hospital. Recuperado de Ia base de datos de Centre for Asian Business Cases (HKU131) (018240)

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Continuous Quality Improvement Initiatives at Queen Mary Hospital Drastic cuts in government funding coupled with rising healthcare costs in I 995 forced the adoption or new management techniques in the healthcare industry in Hong Kong. A management technique that had gained prominence in the United States from 1995 to 2000 in the healthcare industry was continuous quality improvement, or CQI. Also in 1995, hospitals in Hong Kong adopted CQI as a stra.tegy for change and for improving quality while containing costs. Queen Mary Hospital (QMH), in particular, established a CQI Unit that focused ent.ircly on improving the quality of its services to its patients. The CQI model that the unit adopted followed the four steps of Focus, Analyse, Develop and Execute (FADE). This model helped QM H to achieve the CQJ objectives in its project "Pre-Operative Skin Preparation: Shaving and Pre-Operative Baths". The CQI Unit's intention was to administer the same CQI model in other areas, one of which was the "Food Wastage :vli nirn i~a tion" project. Would the same FADE model, the methodology, the approach and the success factors in the implementation be applicable to this new CQI undertaking? What were the critical CQ! characteristics that would contribute to a significant outcome in minimising food wastage at QtvfH? A critical factor was how the CQI Unit should implement other changes using CQl. How sho uld the CQJ Unit respond to organisational resistance am] managing professionals through change? The Unit also had to reckon with where and how to collect data in determining areas for CQJ application. What were the key elements tbat had to be considered to achieve co-operation and support of everyone at QMH, particularly the medical professionals, who were recognised as critical decision-makers?

The Global Perspective of CQJ and the Concept of Quality in the

Hea lthcare Sector CQI in healthcare was pioneered in the US, where, in 1996, there were as many as 80,000 deaths every year due to medical errors and negligence.' This prompted the US government to initiate discussions on creating a Federal Agency of Patient Safety. The hcalthcare profession around the world was beset with challenges and difficulties concerning patient care and had to hold up under extreme pressure to change. The scrutiny from the outside 1 Brashier, L. W ., ct a!., "lmplcmcntntion or TQMiCQI in the llc:ollhcarc lndu.,try," 1Jenchnwrkin /IJr Qut~liry Mlln11!:<'111<'111 & 0 Technolugy, I April, 1996.

Marissa McCauley prepared this co.i
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Continuous Quality Improvement Initiatives at Queen Mary Hospital

environment focused on protracted and more frequent hospitalisation due to misdiagnoses, substandard surgery, improper drug therapies and hospital-acquired ,infections. Other factors that contributed to the decline in hospital care included the rising employee turnover rates, the delegating of patient care to under-qualified and inexperienced staff, the increasing number of lawsuits resulting from poor medical outcomes and other internal weaknesses driven by the need to reduce hospital operating and administration costs due to decreasing annual budgets. Quality management, some doctors believed, would have a significant role in minimising the many problems associated with the medical field. There were certain important trends that characterised the healthcare system that led to the development of the growing attention to quality improvement:

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The market became progressively more competitive. Healthcare insurers and providers competed for market share based mainly on economic consideratiotlS and an expectation of value for money. Growth in the consumption ofprivate health services. In an environment predominantly characterised by the marketing of the need to have private medical insurance cover to bridge the gap between basic public hospital care and the perceived benefits and fmancia l security of private care, the share of private services increased. A market growth in consumers ' awareness of their rights, even in the area of healthcare services.1

Many hospitals were under pressure from the hcalthcare indusli)' and were urged by the Joint Commission on Accreditation of Healthcare Organisations (JCAHO), an acc.rediting body that was responsible for about 7,000 hospitals in the US, to change and improve their services. This pressure compelled the hospitals to jump on the total quality management (TQ\1)/continuous quality improvement (CQI) bandwagon. The JCAHO adopted the CQl philosophy in the late 1980s. The medical field realised that something had to be done to improve the delivery of health services to patients, and the initial step was to critically review the processes involved. The JCAHO in its 1994 report stated it clearly:

It is a mistaken belief that patient outcomes are qffected solely by the patient's severity of illness and the quality of direct hands-on care.... Most opportunities for improvement reside in processes. CQI has been described as:

A managerial philosophy that seeks to create organisation-wide participation in examining. planning and implementing improvements in the quality of services as defined by customers. J A compreheJ!SiVe management philosophy that focuses on improvement by applying scientific methods to gain knowledge and control over variation in work processes! CQI advocated certain procedures: data collection and analysis to diagnose problems a fo rmulation of hypotheses for improvement • conducting of experiments and the collection and analysis of data about their results 2

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• revision of interventions based on such research The importanct; of CQI in the medical field cannot be overemphasised, a.~ hospitals had yery fragmented development processes, tJ-ie procedures involved were often too complicated, and patients were complex individuals with their own unique needs and specific problems . .

The Healthcare Sector in Hong Kong Hong Kong was considered to have one of the most advanced healthcare sectors in Asia.5 It had well-developed public sector healtbcare and offered very expensive private healthcare, yet wrestled with probkms and oppommitics created by rising costs, new technology and government policies. Private hospitals accounted for less than 15 per cent of the overall services provided; the Hospital Authority (HA) controlled the remainder. A statutory body established in December 1990, the HA took over from the Government the management and operation of 46 public hospitals and a staff of 50,000 with a total budget of HK$20 billion. 6·' The HA was responsible for providing a full range of secondary and tertiruy specialist care and rehabilitation at prices set by the Government, and the Government guaranteed that no one should be denied access to medical service for l:lck of funds.• ' Hospitals in Hong Kong adopted and implemented CQI in the mid-1990s, despite the lack of training and support to perform CQI. Each hospital implemented CQI either as a mandatory undertaking, wher~ each unit was required to come up with a yearly CQI project, or bY. creating a separate w1it to oversee the overall CQT implementation in the hospital based on the spedfic needs of the different units.

The Queen Mary Hospital Queen Mary Hospital opened in 1937, had I ,400 patient beds and a staff of over 4,000, and provided a comprehensive range of services. QMH was the research centre and the primary teaching hospital of The University of Hong Kong. Annual surgical admissions totalled 25,000.• The Queen Mary Hospital specialised in: Assisted Reproductive Programme Bums and Reconstructive Surgery Cancer Referral Management Coronary Care • Lithotripter Service Neurosurgery Oral Maxillo-facia l Surgery Organ and Tissue Trmsplant Paediatric Surgery Renal Dialysis Quality M anagement Organi sa tional Stru cture at QMH

The Quality Executive Committee (QEC) was in charge of the overall quality management of the hospital [Figure 1). Under the QEC were two separate unil~:

1 Stone, E., -Kcmedics ror Hcallh Can:," Asiun Btwnr.u. April. 19'12. 6 Yeung. C., "Ch:lllenge to Streamline," South China Morning Post. 20 December. 1999.

1 US$ 1 - H KSS 1 Mal<.

C.. "Healing HoOJ; Kong's Hospitals,"SecurityManagemtnJ, January, 1') 97.

9 URL: hNp://www.ba.org.hklhesdfnsapildr... , 25 Jwnwy. 2000.

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Continuous Quality Improvement Unit. In 1994, the Quality Improvement Support Unit and the Infection Contro l Unit were integrated a!\ one W1it, as they performed similar · functions. Referred to as the CQJ Unit, it facilitated the start-up seminar, education and training in CQI, collection of data, identification of problem areas, priority projects and implementation of quality improvement initiatives. Clinical Audit Unit. At QMH, the Clinical Audit was separated from the CQJ Unit mainly for reasons that auditors were often viewed with suspicion. The Clinical Audit's main objective was to fulfi l all of the auditing mandate required by the administmtion. On an annual basis, each unit was required to submit specific data that the Clinical Audit analysed. Any problems identified were submitted to the CQJ Unit. The CQ I Unit facilitated the improvement required to address the problems.

Hospital Management Committee

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I Quality Executive Committee (QEC)

I C linical Audit Unit (CA)

I Continuous Quality lmpro vcm ~:nt Unit (CQI)

I Quality Improvement Support Unit (QIS)

Infection Control Unit (IC)

Figure I : Quality Management Organisational Structu r e at QMH

Dr. Seto and the CQI Team Under the direction and guidance of Dr. Seto Wing Hong and Ms. Patricia Ching, QMH 's Head Nurse, the QM H CQl Unit was established in 1994. Their vision was to introduce CQl throughout the hospital, such that CQI would be a contin uous undertaking in streamlining all the processes within the hospital. Dr. Seto believed that CQT would help meet customer satisfaction in the medical field. The medical field was complex, and, in most cases, the customer or the patient was not in a position to evaluate quality. QM H defined quality based on the delivery of quality, not the content quality. Content quality focus ed mainly on whether or not the operation was done well, which the patient might not necessarily be able to judge. Content quality was evaluated based on the peer review process. Delivery quality, on the other hand, focu sed mainly on how content was delivered to the customer, or if the delivery met customers' expectations. Here, the process of delivery was the focus of evaluation, something that CQI could help address. If delivery of quality was important to a hospital, then there would be a need for CQI. At the CQJ Unit, CQI was defined as a process of management that involved the participation of everyone in the hospital, understanding the departmental fW1ctions, and streamlining the

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complex processes involved w ith a view to delivering the utmost quality of service to the hospital's internal and external customers. As a consultant in Clinical Microbiology and Infectious Diseases, Dr. Seto was also the Chairman of Infection Control and Director of Quality Improvement. He was not a full-time member of staff in the CQI Unit. Ms. Ching, on the other hand, was the head of both the Quality Improvement Support Unit and the Infection Control Unit. Dr. Seto and Ms. Ching were the only Asians in the entire Asia-Pacific region who had, in 1994/ 1995, received the title Certified Professiona l in Health Care Quality, a qualification given by Certification Board of the National Association for Health Care Quality in the US. On top of their main responsibilities, both were actively involved in all of the CQI projects at QMH. In the US, dedicated full-time staff a.~ certified profe ssionals in healtheare implemented CQI. Dr Seto commented:

In a sense, the hospital got our services at a discount; I am not paid.for doing all this, it is gratis. The hospital's chief executive said I do it out of good intentions driven by good ethics. Hospitals in Asia generally considered quality management of secondary importance, and as such the concept was not given priority and full-time attention, whilst in the US, it was acknowledged as important, and most quality improvement initiatives were implemented by full-time staff. Wncn quality improv~::mcnt was first introduced at QMH, support was weak. It was considered more important to treat the patient and ensure his or her health, and not be bothered by quality improvement and its associated outcomes-good or bad. According to Dr. Seto, the meagre support for CQI at QMH was due mainly to the lack of awareness and understanding of what CQI was. He added that it was not clear to many hospital personnel that quality improvement required expertise and manpower. The primary function of any hospital involved patient treatment; therefore it was crucial to get doctors involved. Tile biggest problem in implementing CQI in hospitals was getting doctors on board. Doc~ors were indifferent; many worked on their own and sometimes prefen·ed to be treated as prima donnas. There was a lack of interest in CQI and the concept was treated as citing peng ('making cakes' in Cantonese) or not a big deal, by both physicians and nurses, mainly because of the lack of training in CQI. The hospital was also very territorial: there were all kinds of walls and barriers that had to be broken down. The relatio nships in the hospital were complex-apart from the hospital workforce, QMH al$0 had staff based at the Hong Kong University campus and in the Hospital Authority offices. Each group within the QMH guarded their own autonomy. The departments were neither venical nor horizontal in structure, and others were created out of traditional practices. Dr. Seto and Ms. Ching conducted training in healthcare quality and CQI because they were certified and qualified. Jt was important that they possessed the necessary qualifications because their credibility a.Jld capability in healthcare quality training was important to the people they were training. Consultants and specialists from abroad were: also invited to some of the training sessions. However, Dr. Seto and Ms. Ching conducted the majority of the training sessions. Dr. Seto attempted to introduce CQI by giving nwnerous lectures within QMH, only to be met with indiff~:rence. He and Ms. Ching embarked on CQI projects that would provide empirical evidence to the hospital workforce of the benefits of CQ I and how it could be implemented. CQI was first introduced into the process analysis for the Surgery and Medicine units.

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FADE: A CQI conceptual model adopted by QMH The CQl modd that the Q~'fH adopted wa~ FADE: Focus, Analyse, Develop and Execute. FADE was the basic conceptual model, slightly modified however to suit the various CQI initiatives (see Figure 2).

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Focus

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ldenti fy priorities through process analysis

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Priorities identified through: Hospital Management & Auditing yearly strategic plruming Department workshops initiated by the Quality Improvement Unit I Department initiatives

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Fonn team Introduce CQI to the team CQ! Unit to suggest alternatives Data collection by department to validate problem and baseline CQJ Unit interprets data

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Set objectives Establish guidelines and procedures So licit approval for the guidelines Literature research tor back-up

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Establish guidelines

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Implementation of the CQI project

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Implementation of system changes (about four to eight weeks) through intensive ~1aff education Regular meetings with the team members

Figure 2: FADE as the CQI Mod el Adopted at QMH

The team that the CQI committee created was expected to perform the following: To initiate the quality improvement process, ensure its continuity and evaluate the projects periodically To rceonunend the fom1ation of Quality Action Teams ancl govern the number of tcruns to be formed To define guidelines and outline programmes, identify resources required necessary for implementing quality improvement To co-ordinate the activities involved in all Quality Action Teams • To provide project st<~tus reports to ;til concerned • To infom1, educate and train all new hospit
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process followed was to:

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Fonn the improvement team Provide project tem1s o f refereqce Implement project

Priorities w ere identified through several ways: Hospital management- through the yearly audit and strategy planning. Department workshops - mostly initiated and facil itated by the Q IS Unit. Participation was voluntary from the middle and top management level. Conducted on Saturday morning, each workshop involved a start-up seminar that incorporated value formation, discussion of the processes involved and th e identification of problem areas. Normally about seven to I 0 issues were identi fi ed based on the list o f problems provided by the departments. 1l1e prioritisation o f issues was done by multi-voting and consensus approval. The result was a quantitati ve value of each of the issues identified, after which a final endorsement was provided to the Q IS Unit. The CQI Unit conducted eight to 10 workshops involving 15 to 20 departments. Department initiatives- people were encouraged to approach the CQI team about matters concerning quality improvement. For example, a project initiated based on this approach was the Hazard Analysis Critical Contro l Points ( HACCP), proposed by tbe QMH kitchen manager who had training in HACCP and was detem1in ed to apply the concept in h is area of responsibility. The CQJ Unit was supportive of such initiatives because HACCP wa~ a CQI W1dertaking. HACCP invo lved close analysis of the whole food production cycle, find ing critical points to monitor lor problems and fom1ulating guideli nes to improve the process. Fom1ation of the Quality Action tean1 occurred after the priorities had been identified. 1l1e team was multidisciplinary, composed of , but not limited to, doctors, surgeons, nurses. ward managers and the CQI team. The CQI team then introduced the CQ! concept and suggested how best tu proceed. 1l1c Quality Action team also detcnnined the priority pr~ject~ through multi-voting. The department responsible for the project was requested to collect data, which the CQI team collated and interpreted. The analysed data served as the baseline for the CQ! project to be implemeoted. Procedures and guide lines, including the timeframc and p lan of action, were formulateu, and these were passed around to all the team members for review, comment and approval. If necessary, the CQJ Unit also conducted liter.iturc research to back u p the ~:.ruide li nes . Finally, the project was introduced and implemented accordi ngly. It took about four to eight week s betbre the project result was measured based on the initial baseline collected. During this period, several meetings and discussions were cond ucted, which p rovided critical fee dback on the status of the project.

A CQI Project: "Pre-Operative Skin Preparation: Shaving and Pre-Operative Baths" Rationale Doctors in the medical field tend to be concerned with reference/researched data and, as a rule, would never act arbitrarily. This was one of th e reasons for the establishment in 1990 of Evidencc-B;c;ed Medicine or EBM, a movement that advocated thorough researched data to support doctors' work. Research fi ndings however took time before they could filter down to the grassroots level, because the research had to be impl emented and studied again. 111is was where CQI was best linked with EBM, because CQI' s strength was to implcm~.:nt and an1algamate within the existing system and not to conduct research. [Re fer to Fig ure 3 for the diOe rcnt tools involved in EBM and CQ I.)

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EBM

CQI

Identification and selection of best research findi ngs for patient care: Literature research • Medical research methods Epidemiology Biostatictics

Implementation and amalgamation within existing systems: Improvement teams CQI tools Statistical process control (SPC) FADE

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Figure 3: Tools Involved In EBM and CQI

One of the first CQI projects was the "Pre-operative skin preparation: Shaving and preoperative baths". The skin preparation project wa.~ implemented based on the EBM-CQI link. At QMH, it was a standard operating procedure (SOP) to shave patients before surgery regardless of where the patient was to be operated on. According to Dr. Seto, results of studies in the 1970s showed that shaving traumatises the skin, possibly leading to a minor infection. Bathing before surgery was not SOP at QMH, therefore patie:1ts scheduled for operation had the choice to bathe or not before surgery. It was a standard procedure that wounds and the area for operation were cleaned twice before surgery-in the ward before the scheduled surgery and in the operating theatre. Dr. Seto said there was no research data that proved cleaning a wound and the area for surgery twice lowers the infection rate. The proj ect was identified because there were documented studies and research results dating back to the 1970s proving that in pre-operative skin preparation: I . There was no need to shave unless the hair interferes with the area to be operated. 2. Bathing befo re an operation, rather than clea:'ling the operation area in the ward a day before the surgery, lowered the infection rate. [See Exhibit 1 for the medical references used in the identification of this project.] Another reason this CQI projc~: t was implemented was due to the high volume of surgeries that the hospital performed: I ,000 surgeries a month or a total of about 12,000 every year. This CQJ initiative would save the ho!t-pital resources such as nurses' time and sterile packs. The main objective was to streamline skin preparation before surgery to ensure effective skin decontamination and optimal usc of manpower (refer to Exhibit 2 for the specific clinical procedure implemented in the pre-operative skin preparation in the ward). Using FADE as the basic model, the CQI project was implemented (see Figure 4 for the application of the FADE model in the pre-operative skin preparation project).

Implementing FADE initiated by the Infection Control Unit (CQI sub-unit), the unit co-opted the assistance of s taff who would form the multidisciplinary team of 14 members: the Professor of Gynaccolo!,'Y, managers from all of the surgical wards, a surgeon each from the General Sw·gcry and Orthopaedic Uni ts, and representatives from the fnfcction Control Unit, School of Nursing and Control Supply Sterile Department (CSSD). The CQJ Unit identified the gynaecology professor as the person most suited to lead the terun because she was interested in CQJ and appreciated its objectives. Each member of the team was given a copy of the literature review . on the project, which was used as documented evidence that CQI could achieve the intended objectives.

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Continuous Quality Improvement Initiatives al Queen Mary Hospital

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Data collected and results: Patient survey on pre-opemtive bath: few patients were instructed to bathe before opemtion • Actual usage of CSSD packs for ward skin disinfection: ward skin disinfection was a common practice and CSSD (skin dressing) sets were used for ward skin preparation

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identified issues: • No shaving before surgery (unless necessary) Bathing before surgery

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All pre-op patients should have a bath before surgery, preferably using hibiscrub to ensure thorough · cleaning. Avoid hair removal, unless there is obvious obtrusion to the incision site. As much as possible, hair removal should be done by clipping or depilation cream. Proper skin disinfection is to be done in the operating theatre, not in the wards, before skin incision is made.

Implementation of ~ Intensive staffeducation: • Eight lectures to nursing staff the CQI project I Over 60% of all surgical nursing staff attended I Train the trainer System changes implemented: • Avoid prc-operative shaving I If possible use hair clipper Discontinue ward skin disinfection Educate patients to have pre-op bath (provide written instructions) Assure proper ward skin preparation by careful inspection Incident report of inappropriate skin preparation by OT staff

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Figure 4: Applicatio n of the CQI FADE Model in the Pre-Operative Skin Preparation at QMH

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The project involved all patients who had undergone general surgery. The project was both patient- and process-oriented. A survey on pa~ent education on pre~opentlive bath among surgical patients was conducted. Data on the number of skin dressing kits tl~ed for preoperative and other skin preparation was also reviewed. The process analysis identified the problems in the pre-operative skin preparation. [Refer to Exhibit 3 for the process analysis used in identifying the problems and Exhibit 4 for the pre-operation skin preparation process post-protocol.] There were setbacks in the implementation:

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Nurses in the Operating 111eatre. Major resistance came mainly from the nurses in the Operating Theatre (OT). Their resistance was two-pronged: they doubted the validity of the research results, and because they had been doing the same pre-operative skin procedure for several years, they were uncomfortable with the changes being introduced into the system. The CQI Unit addressed these issues through "peer pressure". This was exerted on the OT nurses through the team leader, the professor of gynaecology, and other doctors and surgeons on the Quality Team. The CQI Unit also created an Incident Report form as a forum for the nurses to express their concerns regarding the project. Physicians, specialists and Sllrgeons. Some were still sceptical about the recommended procedures. In the first week of the project implementation, there were two minor incidents of infection that alarmed the doctors and apparently caused further scepticism. The CQT Unit immediately sent the literature · review to the doctors to show that the recommended procedures· were based on properly documented researched studies, and t!Jat it actually worked. The doctors were also em:ouraged to conduct the study themselves for confirmation of the research results. Munituring the project result. The wound infection mle was a way of monitoring the project result, such that a zero per cent change in the rate meant that the project was a success. However, using this as a monitoring device did not address the processes in the wound infection rate. Therefore, the CQl Unit utilised data on the total nun1ber of S\..'in Preparation Packs used in the hospital wards for prc-op skin preparation provided by the CSSD.

Results of the Project Because shaving was a standard procedure at QMH, I 00 per cent of the patients were shaved before surgery. This meant a patient scheduled for an ankle operation had to be shaved. Before im plementation of the project, 13.7 per cent of the patients were told to take a bath before surgery; post-protocol showed about 90 per cent were instructed to bathe before surgery.

Pre-Protocol (November 1995)

Unit

Initiate<.l by _ll3ticnts

Surgery Obstetrics & Gynaecology Orthopaedic Total Table 1:

Pr~·Protncol

Instructed by the ho~U!I

59% 100% 15% 55%

6.9% 55.6% 0.0% 13.7 'Yo

Post-Protocol (J anuarv 1996) Initiated by ~tients

84%

86% 100% 93%

Instructed by the hoS£lical

73.7% 85.7% 100.0% 88.9%

anti Pust-Prutucol Comparison of Patient 's Educaliun in Pr e-O rer~tiv e Bathing

Table 2 below showed a considerable number of skin preparation packs were used before the CQJ project was introduced. TI1cre was a significant drop in the dressing kits used after the

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Continuous Quality Improvement Initiatives at Queen Mary Hospit

CQJ intervention in all the hospital units involved in the survey. For example, within a twoweek period, the Surgery Unit used 86 dressing pocks in cleaning WOWlds; post CQl impl ementation, only 12 sets were used. TI1is meant the unit saved 74 dressin.g packs. It also saved ward nurses' time and effort in cleaning wounds by simply requiring the patients to bath a day before surgery.

Unit Surgery Otthopaedic Gynaecology Private Ward

Number ofCSSD Dressing Sets Pre-Implementation Post-lmplcmcntation 86 12 33 8 24 5 4 10

Per Cent Chan(!e -86.0 -76.0 -79.1 -60.0

Table 2: Comparison of Pre-lmpleruentatlon and Post-Implementation of Protocol of the Dressing Sets Used for Pre-operation Skin Prcparutiun

The results of the project were: 1. Patient's pre-op bath increased from 55% to 93% 2. Patient's education increased from 13.7% to HR.9"/n 3. A total of 80,000 CSSD sets were saved for a year 4. Within a two-week petiod a net saving of 18 nurse-hours resulted from elimination of woWld cleaning and shaving and instructing patients to bathe before sw·gery 5. There was no increase in the sw-gical woWld infection r&te afier the project was implemented

CQI and its Impact on the QMH The first CQJ project implemented was deemed successful, and this lead to the implementation of 12 more projects, with 20 other projects in the pipeline yet to be implemented. There was a significant cultural change that evolved during the proc..:ss of adopting the CQ! concept at QMH. In 1994 and 1995, Dr. Seto and Ms. Ching approached each department for constructive feedback. In early 1996, other Wlits indicated their interest in CQ!; they initiated communication with the CQI Unit and discussed their concerns. In addition, the hospital chief of service or the hospital administrator referred problems or incidents to the CQl Unit, something that was not a customary practice at QMH. Such was the positive response to CQI thar, in 1999, the CQJ Unit conducted a forum for the Hospital Authority. About 400 people attended. The CQI Unit presented the four major areas ofCQl projects conducted at QHM:

1. Enhanced support service - such as administrative service (e.g., how to deliver food in a pleasing form), repair section (e.g., streamlining the number of forms needed to make a request 1or repair) and ct1iciency in the delivery of basic hospital necessities (e.g., linens, medicine) 2. Elimination of w111ecessary processes/procedures in the ward. particularly those entrenched traditional practices done for many years that had not been challenged (e.g., the pre-operative skin preparation project) 3. Improved outpatient service by providing convenience shops such as 7-1 1 4. Establishment of a cli nical practice guideline invol vi ng doctors - in the process analysis, the tasks were classified into value-added and non-value-added. Non-value-added t.'t.~ks were abandoned if considered unnecessary (e.g. regular checking of body tcmpcnilurc, urine screening and body weights, etc.).

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The future of CQI at QMH .

The provision of good literature reviews to the physicians and other hospital staff was instrumental in the creation of awareness about the CQl concept, but the results of the project itself gave credence to the claims by the CQI Unit of the benefits of CQI. Moreover, the classical CQI elements utilised in the project contributed to the successful implementation: form a multidisciplinary team, build consensus, collect data to validate problems, plan the system changes, implement the change and collect data to validate change. Application of CQI: Food Wastage Minimisation Tn addition to the clinical service standards that had to be met within the hospital, another

patient care service involved food preparation. Complaints received fi·om patients were that the food portions were either too big for female patients or too small for male patients, that the food was either indigestible or too solid for elderly patients, and that the rice served was undercookcd. In November 199R, · the hospital conducted a survey about food wastage in all wards to determine the concerns brought forward by the patients. Food wastage was defined as leftover food from patients. Survey results showed that the total food wastage was about 228 kilograms a day, and that the percentage of food wastage against production was approximately 23 per CCI\!. It was also found that there was often an excessive amount of rice, consequently leading to excess food The total amount of rice leftover was about 112 kilograms a day, and the percentage against production was 28 percent. The amount of rice cooked in the kitchen every day was the same regardless of the number of patients in the wards. The kitchen equipment, including the rice cooker/steamer, had been in place for over 30 years; the size was a problem. It was also found that the ward staff had order and request food a:1d other proprietary products from the Catering Services Unit through the Dietetics Department, and the food had to be distributed by tbe main kitchen, resulting in an inefficient task process flow and other associated problems. The set objectives for this CQl project would be to reduce the amount of food wastage and rice leftovers, and to strearnliJ1e the work process flow in the kitchen. Given all the above critical CQI points and the application of CQI to the pre-operative skin preparation, how then should the CQl Unit proceed in resolving food wastage and streamlining the process flow of ordering in the kitchen? The food preparation process was just one of the many projects that the CQI Unit intended to implement. CQI as a tool for change and improving quality required co-operation and support of the medical professionals and the whole of the QMH workforce. Other projects involved other units, and therefore involved different processes and different people. Resistance !Tom some groups would still be possible. The data required for each project also meant the CQ I Unit had to consider where and how to collect data to identify areas for CQI application. The success of each CQI undertaking depended on a number of factors, one of which was how the Unit would respond . to the different challenges and difficulties in implementation.

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EXHIBIT 1 REFERENCES ON PRE-OPERATIVE SKIN PREPARATION .

References on ''No Shaving''

I. Seropian. R. and Reynolds, B. Ivl. (1971). "Wound infections after p reoperative depilatory versus razor preparation," American Journal Surgery ( 12 1), pp. 25 1-254. 2. Mishriki, S. F., Law, D. J. W., Jeffery, P. I. (1990). "Factors affecting the incidence of postoperative wound infection," J Hosp Infect (16), pp. 223-230. 3. Hamilton, W. H., Lone, F. J. (1977). "Postoperative hair removal," Can J Surge1y (20), pp. 269-275.

References· on Pre-operative Bathing

l. Hayek, L. J., Emerson, J. M., Gardner, A.M. N. (1987) " A placebo-controlled trial of the effect of two preoperative baths or showers with chlorhexidine detergent on postoperative wound infection r.1te," J Hosp lnfec ( 10), pp. 165-172. 2. Garibaldi, R. A., Skolnick, D., Lerer, T. ( 1988). "The impact of preoperative skin disinfection on p reventing interoperative wound contamination," lnfeci Control Hosp. Epidemol (9), pp. 109-113. 3. Rotter, M. L., Larson, S. 0., Cooke, E. M. (1988). "A comparison of the effect of preoperative whole-body .bathing with detergent alone and with detergent containing chlorhexidinc glucomate on the frequency of wound infections after clean surgery, " J Hosp Infect (I 1), pp. 310-320.

Source: CQI Unit, Queen Mary Hospital

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EXHIBIT 2 PROCEDURE IN PRE-OPERATIVE SKIN PREPARATipN IN WARDS

Objective: To reduce bacterial skin colonisation before surgical procedure to prevent postoperative surgical wound infection. Pre-operative wash

•

•

Patients scheduled for surgical operation should have a bath before operation, preferably using a cleansing solution with Chlorhexidine glucomate (CO). For ambulant patients, provide a 25-millimetre CO scrub to use for the pre-operative bath. Patients who will undergo laparoscopic or abdominal surgery should thoroughly clean the operative site, annpits, perineal area and the umbilicus. Bed-ridden patients, if possible, should also be bathed using CG before surgery. During an emergency surgery, bathing should only be required when the patient's hygienic condition is poor; e.g. a patient is contaminated with excretion and secretion or scum. If surgery is to be performed on an open traumatic wound, rather than a pre-operative bath, clean the wound with sterile antisepiics such as nom1al saline and cover the wound with sterile dressing before sending patients to the opemting theatre . When there is active bleeding or pressure dressing has been applied to control bleeding, do not perfom1 the existing operation site disinfecting. If hair removal is indicated, require patients to bathe or take a bath after removal of hair. Before sending patients to the operating theatre, ward nurses should ensure that preoperative skin preparations are done.

Pre-operative removal of hair • • •

•

Remove hair only when it is obstructing the incision site. Clip instead of shave hair. If shaving is required, use a depilatory crean1. Clip pubic hair only for patients scheduled for lower alxlomen surgery. For Obstetrics and Gynaecology Unit, avoid excessive clipping of pubic hair by using an electric razor. Clipping should also be done 2 centimetres away fiom the symphysis p ubis (pubic bones). For neuro-surgery patients , clipping should be done by a barber whilst shaving should be done by the surgeons in the operating theab·e.

Pre-operative skin preparation for day surgery patient Take a bath the night before coming to hospital for surgery. The use of a soap or liquid soap is acceptable. Thoroughly clean the following areas: perineum and w11bilicus. Rinse thoroughly. Put on clean clothing after bath. Do not use any talcum powder or body lotion. Inform nurse to check the operation site on admission. Source: CQI Unit, Queen Mary Hospital

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Continuous Quality lmproYement Initiatives at Q ueen Mary Hospital

EXHIBIT 3 PROCESS ANALYSIS Tp IDENTIFY PROBLEMS: PRE-PROTOCOL PRE-OPERATIVE SKIN PREPARATION PROCESS

No Ward disinfection of incision site (•)

Cover incision site with sterile OT towel

Operation

starts

# · Identified inappropriate practice * • Identified redundant practice So urce: CQ I llnit, Queen Mary Hospital

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P~E-OPERA TIVE

EXHIBIT 4 SKIN PREP,ARATIOt:J PROCESS POST-PROTOCOL

Yes

Skin disinfection in operating theatre

Operation starts

Source: CQT Unit, Queen Mary H ospital

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Queen Mary Hospital

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