Challenges in quality implementation in teaching hospitals and a good model based of implementation based on experience in a large teaching hospital

1. Journey towards achieving and
sustaining quality in teaching hospitals
Dr. Lallu Joseph
Quality Manager
Christian Medical College
Vellore

2. Non- teaching Hospital

3. Teaching Hospitals

4. Challenges
 Multiple hats
 Teaching – Patient care – Research
 Autonomy and independence
 All areas
 Difficult to bring them together
 Different protocols
 Large turn over of trainees
 Continuous training
 Training in batches
 Apprentice model of training
 On the job
 Difficulty in maintaining standards

5. Challenges
 Multiple accrediting agencies
 Multiple inspections
 Differences in the expectations
 Confused about inspections
 Staffing pattern and hierarchy
 Standardization Vs Innovation
 Size of the institution
 Patient load and complexity
 Difficulty in performance linked appraisals

6. Christian Medical College Vellore

7. CMC Vellore
 Dr. Ida Sophia Scudder - 1900
 Leading referral tertiary care hospital
 2645 beds
 Outpatients (March 2015-2016) - 25, 60, 377
 In- patients (March 2015-2016) - 1, 35, 329

8. Best Practices
“UNESCO describes best practices as having four
common characteristics: they are innovative; they
make a difference; they have a sustainable effect; and
they have the potential to be replicated and to serve as
a model for generating initiatives elsewhere.”[1]
“Strategies, activities, or approaches that have been
shown through research and evaluation to be effective
and/or efficient.” [2]
[1] Johns Hopkins University Bloomberg School of Public Health. Best Practices. http://www.infoforhealth.org/practices.shtml
[2] Florida Department of Education. Best Practices in Florida's Community Colleges and Workforce Education.
http://www.fldoe.org/cc/Retention/

9. Quality Management Program
1. Top management commitment and involvement
2. Accreditation- Means to an end and not an end in itself
3. Focussed to the mission and vision of the organization
4. Consultative decision
5. Effective and multidisciplinary involvement
6. Documentation- Processes and responsibilities to achieve
objectives
7. Patient centered and cost effective
8. Methods to measure processes should be defined and
implemented
9. Quality measurements to guide improvement
10. Ensuring standards
11. Team work and well informed

10. 1. Top management commitment and
involvement
 Quality Team- Dedicated team
 Position in the hierarchy
 Visible commitment to quality
 Publicize the commitment

11. 2. Accreditation- Means to an end and
not an end in itself
QMC
Documentatio
n & Process
development
Accreditation
System Study
Audits / Audit
cycle
completion
Performance
Indicators
Research
Training

12. 3. Focussed to the mission and vision of
the organization
“Christian Medical College seeks to be a witness
to the healing ministry of Christ through
excellence in Education, Service and Research”
 Balancing is essential
 Temptations to deviate

13. 4. Consultative decision
No. ACTION
PERSON
RESPONSIBLE
YEAR
BEGIN COMPLETE
1 Set up Quality Audit Facilitation Cell
Director/Deputy Director
(Quality)
2010
2010
2
Evaluate the existing patient feedback system and
make changes.
” 2011
3 Set up the Patient Grievance Cell
MS/NS/
Director/Deputy Director
(Quality)
2011
4 Apply for accreditation and pre assessment
Director/Deputy Director
(Quality)
2011
5 Set up internal reporting system for Audits ” 2012
6 Conduct training programs in audits and standards ”
2011
Ongoing
7
Complete the documentation of departments/
hospitals processes and policies
” 2012
8
Develop Key Performance Indicators (KPIs) and
establish the reporting mechanism.
” 2012

14. No. ACTION
PERSON
RESPONSIBLE
YEAR
BEGIN COMPLETE
9 Get NABH Accreditation for the main hospital
Director/Deputy
Director (Quality)
2011 2012
10 Develop a system for Audit Compliance ”
2012
2013
11 Set up the scorecard and management dashboard ” 2014
12 Get the NABL accreditation for all Labs ” 2014
13 Establish systems for resources optimization ” 2013 2014
14 Establish EQAS for all labs ” 2014 2015
Consultative decision (Contd….)

15.  Department Quality Managers (DQMs)
 Middle level faculty / staff
 Representation from every unit
 Long term commitment
 Currently 180
 Quality Council
 All DQMs
 Meets once in three months
 Quality Steering Committee
 Multidisciplinary
 Members serve for 2 years
 Meets once a month
5. Effective and multidisciplinary involvement

16. 6. Documentation- Processes &
responsibilities to achieve objectives

17. Documentation contd….
 Clinicians General Guidelines Booklet
 Nursing Procedure Manual
 HIC Manual
 Safety Manual
 Departmental Procedure Manual
 Quality Manual

18. 7. Patient Centered
 Quality Management System- Patient centered
 All policies and procedures must be patient
centered
 Benefits should reach the patients
 Staff should be aware of the intend of the program

19. 8. Methods to measure processes should be
defined and implemented
 Audits- Facilitation vs policing
 Audit team meeting
 Developing proforma, methodology and time
frame.
 Conduct audit
 Analysis and interpretation by QMC
 Key Performance Indicators
 Management Dashboard
 Institutional, Department wise

20.  Evidence based- backed by data
 All audit reports presented to the respective
groups for corrective action and
implementation
 KPIs analyzed for reasons and reported for
corrective action
 Clinical audits
9. Quality measurements to guide
improvement

21. 10. Problems – due to processes and not
people
 Sentinel events and root cause analysis
 Mortality audits

22. 11. Ensuring standards
 Accreditation standards as the minimum
requirement and as a guide
 Continuous follow-up/ audits and improving on
benchmark/expectations
 Internal inspections

23. 12. Team work and well informed
 Publicize improvements and success
 Every activity- multidisciplinary involvement
 Teams and task forces
 Celebrate success

25. TEAM
 Together
 Everyone
 Achieves
 More