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| Sunday, 11 January 2004 |
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Features |  |
| News Business Features Editorial
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Creating 'Toyotas' in health service : Hospitals learn from industrial sector 'Professionals for the Nation' conducted a multi-disciplinary seminar on December 7 at the Faculty of Medicine, University of Peradeniya. Below is an edited version of the address by Dr. K.K.W. Karandagoda, Director, Castle Street Hospital for Women, Colombo 8. The concept of 'Improving quality and safety in health care' was designed through experiences where we have failed in 'quality' in our hospitals. Even today deaths are taking place in hospitals due to system failures in very simple areas, and as we treat patients as patients and not human beings. That was our main concern during the last two to three decades. Therefore, a system change was needed and we have introduced this, i.e. Quality health care Instead of going to "quality" straight away, we need to organize our hospital systems at the grass-roots level. Organizing needs the participation of all employees and the patients or the customers, in order to provide a good health care in our hospitals. Actually, during the last few years we have found that numerous deaths take place in hospitals, not due to lack of resources but due to very simple mistakes, negligence, not caring, not following procedures and disorganization of the hospital sector. We have learnt lessons from the industrial sector as to how they have organized themselves and here we have tried to fit some of the same concepts to the health sector. My presentation will concentrate on introducing some basic nomenclature about 'quality' and 'quality assurance'. I will then describe how we have introduced it at Castle Street Hospital for Women in Colombo and how we have progressed step by step to reach this goal. Quality assurance introduced during 1989-90 where the 'quality' was introduced in the form of 'quality assurance' had failed more often than not. The reason for failure was its introduction in a compartmentalised fashion without taking into consideration the health services or the hospital sector as a total. Thus, most of our staff took no interest in the 'quality assurance' program and hence the hospitals did not transform as a whole. There were many system failures and this program could not be carried forward as there was no participation from the administrators, financial planners, managers and the clinicians. Our present concept has and will concentrate on the employee participation as a whole. In simple language, quality means "doing the best possible things to satisfy the customer or the patient" and not doing the best things. If we think in a more professional way it is the degree of adherence to the standards consistent with the current professional knowledge. What do you mean by standard - and it is a professionally agreed level of performance for a particular setting, which is desirable, achievable and measurable. The quality assurance program, which we initiated at Castle Street Hospital for Women, was a set of system activities, which enables the production of a defined service to an agreed standard within a framework of available resources. Productivity We need to understand the difference between quality and productivity. Productivity mainly speaks about the efficiency of the production (services), whereas the quality speaks about the excellence in performance. Productivity is also maximization of the production (services) using the given resources. How could we improve quality if the hospitals are disorganised, with an unhygienic environment, with piled up unwanted items everywhere leading to poor arrangements in duty areas and unwanted inventory burden upon our sisters and other staff. Thus, staffs are compelled to look after their inventories more than their patients. As a consequence delays in supplies (as you are aware today's newspaper headlines states that 30 essential drugs are not available in government hospitals for which who is to blame, but the system failure) staff disputes (our health sector has the worst 'caste' problems amongst our staff, filled with arguments of who is going to do which work rather than to get the work done) are inevitable. For example, recently a mother brought back to the ward from the operating theatre after caesarian section was kept waiting for 45 minutes unobserved on a trolley because of an argument that could not decide who is going to put a mackintosh on the bed, is it the nurse or the attendant or the midwife. Most complicated procedures in hospitals can be simplified. That is also a cause for poor documentation. Poor documentation in hospitals is becoming worse due to lack of supervision. Those days you can remember that our directors came to hospitals frequently and prepared constructive documents after supervising us and we were guided. Nowadays this is not happening from top to bottom. The heads of the institutions are not supervising the sections, and the sectional heads do not supervise the sections. Currently we don't collect data with regard to quality, quality of care and customer care. We just keep on collecting conventional data in health services. Unfortunately in most of the institutions, the officers in charge are not interested to organize and improve the quality of care. Therefore how could we improve quality in our hospitals ? That is why Prof. Donald Berwick, a paediatrician and the pioneering chairman of the Institute of Health Care Improvement in USA say, "the quality fails when the system fails". What is a system; the hospital system ? We have to identify the interrelationships of a hospital system. Hospitals are very complicated institutions in our country. Japanese 5s system In order to understand this system and interconnect its components and quality, we addressed quality through healthcare productivity. Productivity concepts are well described in the industrial sector and Japanese are almost obsessed with it. We addressed the quality issue in our hospital at three different levels in a very simplified way, without drawing up complicated 5 year or ten-year plans, master plans, or performance improvement plans. We got together and discussed with our staff and other people and designed a simple program, which starts at the base level. That was to layout the foundation and buildup the quality pillars on this foundation. Therefore, we first started organising ourselves in our hospitals by using Japanese 5 Ss system, which describes very clearly in a very simplified manner how we could organize ourselves. Thereafter we kept on improving the efficiency of institution by using the productivity concepts, which I will describe later. Whilst improving efficiency and organising the institution, the performance in excellence was targeted by applying the principles of total quality management. The 5 Ss are: 1. Seiri - clearing - unwanted items to be removed from the hospitals in a very systematic way, making our hospitals look nicer. 2. Seiton - organising the orderliness of our hospitals 3. Seiso - cleaning - this is not adhoc cleaning as we did during the dengue epidemic (e.g. dengue perahera, TV programs etc) which stopped continuing. Thereafter, when another few patients died, we again started shramadana campaigns, TV programs etc - this is not like that. What is meant here is a very systematic cleaning program, cleaning protocols, cleaning schedules etc. 4. Seiketsu - standardising - instead of having a scientific standard indicator develop a very simple one for your ordinary staff. This allows them follow the principles easily. 5. Switzuke - training and self-disciplining - this is to train your staff in order to self-discipline themselves. This need small pocketed training programs for your staff. Whilst these 5 Ss being organized in order to get the staff involved, arrange work improvement teams in different wards, clinics, and laboratories. Give them an opportunity to get together and discuss their own problems and their own improvements and interaction with each other at a monthly meeting with the sectional heads, which allows sorting out problems. Implement a suggestion scheme where we could have a feed back from the patients, their relatives and employees. When the hospital becomes creative, organised and orderly, our people become mentally settled and become more creative and innovative. They suggest a lot of things to improve the hospital in order to avoid mistakes. Kaizon Next we go for a concept called kaizon. Kaizon is to identify mistakes and make small improvements daily i.e. a continuous process of obtaining suggestions and improving the hospital step by step. Once your staff has got used to this type of management, we can then gradually implement principles of total quality management and target higher levels. There we introduce more things about customer focus (for example the waiting time, response time, and customer satisfaction) and leadership, which is very important for quality improvement. Develop leaders at all levels of the hospital, from the director to sectional heads and ward sisters and even at shift level. To improve our processes, protocols, guidelines, check lists are needed. For systematic continuous improvement, information analysis is essential. We introduced a system of collecting quality information in the hospital, for example, infection rates, case fatality rates due to infections, re-admission rates, hospital-based accidents. We instituted a very simplified approach for quality improvement. We first prepared a situation report about the institution, i.e. a video or a photo album of the weak areas or the weak procedures prevalent in the hospital services. Then we discussed the problems with staff and identified the key areas for improvement in consultation with staff. Thus, it was not the director who chaned the institution, but the customers and whole staff. We identified and recorded our mistakes in each and every ward and discussed it with the work improvement teams and in monthly meetings. We rectified something to avoid that mistake in the future. For example, a mother was discharged from hospital after five days whilst having swinging temperature. The house officer discharged this patient where the nurse also forged the husband's signature and then allowed the patient to go home. After two days the mother was re-admitted to the hospital with peritonitis and died two days later. Her husband with their elder child came to my office with a photocopy of the temperature chart of the hospital notes and cried asking why his wife was discharged while she was having fever. We enquired as to why she was sent home from the house officer and it transpired that he had not checked the hospital notes properly. The nurse excused herself claiming that she was sent home as the doctor had discharged the patient. The problem here was system failure. This should not happen again. Thereafter we prepared a discharge checklist for the nurse-in-charge to scrutinize before sending any patient home. Without her signature on this checklist, no patient could be sent home. Thus, the patient was handed over to his/her relatives in a scientific way. We learnt this benchmarking from the industrial sector. An advertisement placed by Indra Traders sometime ago on TV claimed of a checklist that should be passed before a vehicle is sold. We do a waiting time survey and a customer and employee satisfaction survey periodically. In brief, we did a big cleaning out of the hospital, trained staff on kaizon and productivity, for no additional cost. Thereafter we established work improvement teams, organized monthly meetings and kept on organizing step by step and with a monitoring system. We introduced a staff friendly environment and reward scheme. We selected the best ward, best labour room, best garden and the best work improvement team. Finally, here are some of the conclusions of the South Asia Pacific Forum on quality improvement, which we attended recently. They also mentioned that system failure is a problem in the whole world health sector. Thus, the forum concentrated mostly on leadership improvement and improving systems during the next decade in hospitals. You have no shortcuts for quality; we have to address it in a very systematic way. The conclusion of the Asia Pacific Forum was to create 'Toyotas' in health service. This is because the Toyota Motor Corporation has become one of the most successful vehicle manufacturing companies in the world by applying the very simple technique of mistake proofing and work improvement teams. They produce best vehicles at the lowest cost. |
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