Sar 2011_Dr. Bikash Gauchan

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