Implementing a Systems-Oriented Morbidity and Mortality Conference in Remote Rural Nepal for Quality Improvement Dr. Bikas...
Contents <ul><li>Introduction </li></ul><ul><li>Setting </li></ul><ul><li>Achham District </li></ul><ul><li>Type of the st...
Introduction: <ul><li>Simple, effective tools are needed to improve quality in resource-limited health facilities  </li></...
Setting: <ul><li>Bayalpata Hospital (BH): One of two Primary Care Hospitals in Achham District of Far Western Nepal </li><...
 
Achham District: <ul><li>One of nine districts of Far Western Region of Nepal </li></ul><ul><li>One of the remotest distri...
Type of the study: <ul><li>Qualitative Observational Study </li></ul><ul><li>Duration of the study: 9 months </li></ul>
Objectives of the study: <ul><li>To implement morbidity and mortality conference involving clinical and non-clinical staff...
Strategy for change: <ul><li>Prior to this program, BH lacked a mechanism for systems-level reflection enabling staff to i...
Program Design: <ul><li>We designed   an M&M involving clinical and non-clinical staff in conducting root-cause analyses o...
Methodology: <ul><li>Complicated case was selected by Medical Director (Senior most clinician) with input from staffs (HAs...
Methodology….. <ul><li>Discussions focused on case history followed by analyses of seven domains </li></ul><ul><li>The det...
Seven Domains: <ul><li>1.Clinical operations  – concerns with patient flow, intake, or processing in clinical departments,...
Seven Domains……… <ul><li>5.Outreach  – issues in recruiting patients into timely and appropriate care through community en...
Example: <ul><li>Case: 28 year old male / Suicide attempt with Underlying Depression with Psychotic features </li></ul><ul...
Example……. <ul><li>Recommendations :  </li></ul><ul><li>Medical Director develops emergency referral list and crisis-line ...
Effects of Change: <ul><li>Improved communication between junior and senior staff members </li></ul><ul><li>Better underst...
Effects of Change….. <ul><li>Knowing staff level challenges as a team </li></ul><ul><li>On-site clinical trainings </li></...
Lessons learnt: <ul><li>Involvement of clinical and non-clinical staff will help to identify systems-level issues to impac...
Conclusion: <ul><li>Systems-oriented morbidity and mortality conference can act as a feasible tool for quality improvement...
Thank you all
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Sar 2011_Dr. Bikash Gauchan

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Sar 2011_Dr. Bikash Gauchan

  1. 1. Implementing a Systems-Oriented Morbidity and Mortality Conference in Remote Rural Nepal for Quality Improvement Dr. Bikash Gauchan Junior Resident (Batch-July 2011) Department of General Practice & Emergency Medicine B. P. Koirala Institute of Health Sciences (BPKIHS) Dharan, Nepal
  2. 2. Contents <ul><li>Introduction </li></ul><ul><li>Setting </li></ul><ul><li>Achham District </li></ul><ul><li>Type of the study </li></ul><ul><li>Objectives of the study </li></ul><ul><li>Strategy for change </li></ul><ul><li>Program design </li></ul><ul><li>Methodology </li></ul><ul><li>Seven Domains </li></ul><ul><li>Effects of change </li></ul><ul><li>Lessons learnt </li></ul><ul><li>Conclusion </li></ul>
  3. 3. Introduction: <ul><li>Simple, effective tools are needed to improve quality in resource-limited health facilities </li></ul><ul><li>The morbidity and mortality conference (M&M) is a well-established practice globally </li></ul><ul><li>However, there is limited experience with M&M as a hospital-wide quality improvement strategy in resource-limited settings </li></ul><ul><li>Given that M&Ms are common throughout the world, a re-focusing of the M&M as a systems-level quality improvement intervention could be feasible in many resource-limited settings </li></ul>
  4. 4. Setting: <ul><li>Bayalpata Hospital (BH): One of two Primary Care Hospitals in Achham District of Far Western Nepal </li></ul><ul><li>BH is government hospital, run by non-profit organization Nyaya Health (NH) in collaboration with Nepali Ministry of Health and Population (MOHP) </li></ul>
  5. 6. Achham District: <ul><li>One of nine districts of Far Western Region of Nepal </li></ul><ul><li>One of the remotest district in Nepal </li></ul><ul><li>It has a primarily agrarian (60%) population of 266,000 </li></ul><ul><li>Median annual household income is $141 USD with literacy rates of 52% for males and 14% for females </li></ul><ul><li>Chronic malnutrition rates for children under five are 63.5%, and maternal mortality rates are 231 per 100,000 </li></ul>
  6. 7. Type of the study: <ul><li>Qualitative Observational Study </li></ul><ul><li>Duration of the study: 9 months </li></ul>
  7. 8. Objectives of the study: <ul><li>To implement morbidity and mortality conference involving clinical and non-clinical staffs </li></ul><ul><li>To identify challenges and areas for quality improvement in healthcare delivery </li></ul><ul><li>To facilitate structured analysis and improvement of patient care </li></ul>
  8. 9. Strategy for change: <ul><li>Prior to this program, BH lacked a mechanism for systems-level reflection enabling staff to identify challenges and areas for quality improvement in healthcare delivery </li></ul><ul><li>We hypothesized that a hospital-wide M&M would be a feasible quality improvement initiative aimed to facilitate structured analysis and improvement of patient care </li></ul><ul><li>Successful change was defined as the implementation of this M&M with staff-wide involvement and tangible changes seen in healthcare delivery at BH </li></ul>
  9. 10. Program Design: <ul><li>We designed an M&M involving clinical and non-clinical staff in conducting root-cause analyses of healthcare delivery at our hospital </li></ul><ul><li>Weekly conferences focused on seven domains of causal analysis: operations, supply chain, equipment, personnel, outreach, societal, and structural </li></ul><ul><li>Each conference focused on assessing the care provided, and identifying ways in which services can be improved in the future </li></ul>
  10. 11. Methodology: <ul><li>Complicated case was selected by Medical Director (Senior most clinician) with input from staffs (HAs and Nurses) </li></ul><ul><li>Case summary was written and sent to each member of Nyaya Health for feedback via email </li></ul><ul><li>Weekly conference was held for 60 minutes </li></ul><ul><li>Medical Director acted as the principal facilitator for discussions </li></ul>
  11. 12. Methodology….. <ul><li>Discussions focused on case history followed by analyses of seven domains </li></ul><ul><li>The details of the conference were recorded in the conference hall </li></ul><ul><li>Each M&M concludes with a review of lessons learnt and recommendations, and responsible personnel and timelines are identified for implementation of recommendations </li></ul>
  12. 13. Seven Domains: <ul><li>1.Clinical operations – concerns with patient flow, intake, or processing in clinical departments, laboratory, radiology, or pharmaceutical operations </li></ul><ul><li>2.Supply chains – challenges in obtaining reliable supplies of quality medicines or equipment </li></ul><ul><li>3.Equipment – issues in the functioning, quality, or availability of equipment </li></ul><ul><li>4.Personnel – factors pertaining to training, professionalism, management, or collaboration </li></ul>
  13. 14. Seven Domains……… <ul><li>5.Outreach – issues in recruiting patients into timely and appropriate care through community engagement </li></ul><ul><li>6.Societal – challenges faced by gender, caste, economic, or other social status </li></ul><ul><li>7.Structural – factors related to infrastructure such as roads, telecommunications, educational or healthcare facilities </li></ul>
  14. 15. Example: <ul><li>Case: 28 year old male / Suicide attempt with Underlying Depression with Psychotic features </li></ul><ul><li>Problems identified: Lack of mental health service, antidepressants in the pharmacy and low socioeconomic status </li></ul><ul><li>Domains of causal analysis: Clinical operations, Personnel, Supply chain, Societal and Structural </li></ul>
  15. 16. Example……. <ul><li>Recommendations : </li></ul><ul><li>Medical Director develops emergency referral list and crisis-line with Psychiatrists in the capital </li></ul><ul><li>Procurement of at least two different antidepressants medicines and identifying long term suppliers </li></ul>
  16. 17. Effects of Change: <ul><li>Improved communication between junior and senior staff members </li></ul><ul><li>Better understanding of clinical operations among non-clinical staff </li></ul><ul><li>Improved collaboration and team-based learning </li></ul><ul><li>More rigorous case analysis and identification of areas for improvement </li></ul>
  17. 18. Effects of Change….. <ul><li>Knowing staff level challenges as a team </li></ul><ul><li>On-site clinical trainings </li></ul><ul><li>Better procurement of drugs in the pharmacy </li></ul><ul><li>Better definition of job description </li></ul>
  18. 19. Lessons learnt: <ul><li>Involvement of clinical and non-clinical staff will help to identify systems-level issues to impact patient care </li></ul><ul><li>Structured discussions with a systems-level perspective </li></ul><ul><li>Fostering senior managerial commitment </li></ul><ul><li>Use of M & Ms to guide resource utilization </li></ul>
  19. 20. Conclusion: <ul><li>Systems-oriented morbidity and mortality conference can act as a feasible tool for quality improvement in resource-limited settings </li></ul>
  20. 21. Thank you all

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