Manila Doctors Hospital Department of Otorhinolaryngology Department of Otorhinolaryngology Continual Improvement Program MBFI Hall August 3, 2010

Manila Doctors HospitalDepartment of Otorhinolaryngology

Department of Otorhinolaryngology

Continual Improvement Program

MBFI HallAugust 3, 2010

IntroductionIntroduction


The Department of ORL caters to service patients in the hospital’s Outpatient Department

In 2009: 74 elective ORL surgical cases

Length of stay of CSR patients were noted to be longer than that of private patients

Prolonged stay was attributed to several causes

HistoryHistory


THE CIP TEAM

1. Dr. Cesar Villafuerte Jr. –Department Chairman 2. Dr. Manuel Villegas Jr. –Consultant CIP coordinator 3. Dr. Edmund Ong- Consultant CIP assistant coordinator 4. Dr. Leah Grace Penaranda-Barrato-Consultant CIP assistant coordinator 5. Dr. Angelo Ian Sampelo – Department Chief resident 6. Dr. Katrina Louise Reyes –Resident CIP coordinator

TitleTitle


Prolonged Hospital Stay of ORL-CSR patients undergoing the top 3 elective ORL surgical cases in MDH


Problem identification and prioritization Root cause analysis (Ishikawa diagram)3 root causes identification (PARETO diagram)

Problem IdentificationProblem Identification


Gaps and areas of improvement identified from:

1.Authorized functions2.Corporate objectives3.JCI standards4.Department Annual Reports5.Department Census6.Customer Satisfaction Surveys

Problem Identification and PrioritizationProblem Identification and Prioritization


Specific gaps and areas of improvement:

1.Increased in the length of stay of patients: 1st

2.There is a delay in the patient’s pre-op and post-op management in terms of clearance and follow-up: 2nd

3.There is a need for pilot study improving quality service: 3rd

Area of ImprovementArea of Improvement


There is a need to improve the promptness, effectiveness and efficiency in the pre-admission, admission, management and discharge of ORL CSR patients in Manila Doctors Hospital to be able to decrease the length of stay

Statement of the ProblemStatement of the Problem


Prolonged Hospital stay of ORL-CSR patients undergoing the top 3 elective ORL surgical cases in MDH

Understanding the Present SystemUnderstanding the Present System


Records of previous MDH ORL-CSR admission from January-December 2009 reviewed:

-total specific OR procedures-average length of stay(admission-discharge)



Table 1.Total number of specific procedures done in January to December 2009

Procedure JAN

FEB

MAR

APR

MAY

JUN

JUL

A U G

SEP

OCT

NOV

DEC

TOTAL

% Distribution

Thyroidectomy - 2 1 - 1 - - 3 - 3 2 - 12 16.2

FESS 1 1 1 1 1 1 - - - 3 1 - 10 13.5Tonsillectomy - 1 2 2 - 2 1 - - 1 - - 9 12.1

Foreign body removal

- 1 - - 1 - - 1 - 2 - 1 6 8.1

Cheiloplasty - 1 - - - - - 19 - - - - 20 27



Total number of specific procedures done in January to December 2009Procedure J

AN

FEB

MAR

APR

MAY

JUN

JUL

A U G

SEP

OCT

NOV

DEC

TOTAL

% Distribution

Tympano-mastoidecto

my

- - - - - - - 2 - 2 - - 4 5.4

Medical management

- 1 - 1 - - - - 2 2 1 - 7 9.5

Hemiglossectomy

- - - - - 1 - - - - - - 1 1.4

Excision Ranula

- - - - - 1 1 - - - - - 2 2.7

Excision Cyst

- - - - - 1 - - - - - 1 2 2.7

TOTAL 2 7 4 4 3 6 2 25 2 13 4 2 74 100%



Table2. Average Length of Stay of ORL-CSR Patients per procedure in January-December 2009

Procedure JAN

FEB

MAR

APR

MAY

JUN

JUL

A U G

SEP

OCT

NOV

DEC

AVELOS

Thyroidectomy - 3.5 4 4 4 - - 7.5 - - 3.5 - 4.4

FESS 3 3 4 4 4 4 2 - - 3.6 3 - 3.4

Tonsillectomy - 5 3.5 3.5 - 3 2 - - 2 - - 4

Direct laryngoscopy

3 - - - - - - - - - - - 3

Foreign body removal

- 3 - - 2 - - 1 - 2 - 5 2.6

Cheiloplasty - 3 - 3 - - - 3 - - - - 3



Average Length of Stay of ORL-CSR Patients per procedure in January-December 2009Procedure J

AN

FEB

MAR

APR

MAY

JUN

JUL

A U G

SEP

OCT

NOV

DEC

AVELOS

Tympano-mastoidectomy

- - - - - - - 5 - 5 - - 5

Medical management

- 3 - 1 - 9 - - 3 2 - - 3.6

Hemiglossectomy

- - - - - 10 - - - - - - 10

Excision Ranula

- - - - - 4 4 - - - - - 4

Excision Cyst - - - - - 3 - - - - - 2 2.5

FLOWCHART OF KEY TASKSFLOWCHART OF KEY TASKS




Diagram 1. Flowchart of Key Tasks

PATIENT

OPD Consultation/Resident’sAssessment

DIAGNOSTICS

Presentation to Consultant in

charge

ADMISSION

DISCHARGE

Clearance

PLAN FOR

SURGERY

Schedule of OR

FinalClearance

Co-management

SURGICAL

MEDICAL

Post-OpManagem

ent

ACTUALSURGERY

PLAN

Pre-operativeConference/Consultant

Staff consensus

Co-management

ANALYSIS OF THE PROBLEMANALYSIS OF THE PROBLEM


Analysis of the ProblemAnalysis of the Problem


Probable root causes were identified using the fishbone and prioritized using the Pareto diagram



MATERIAL

MAN ENVIRONMENT

METHOD

MACHINE

Culture of patientsAttitude of Nurses

Attitude of Doctors

Attitude of other staff

Delay in securing materials from implant companies

Delay in securing other materials for ORby patient

Availability of complete set of materials/equipment

Recruiting/proper identification of a good surgical candidateCensus tracking of length of stay not emphasized

Length of stay of patients and issues regarding prolonged admission and discharge of CSR patients not reviewed by resident staff in endorsement rounds

No management review of CSR patient management

No structured collaborative effort to address delayin discharge of ORL CSR patients

No System for discharging patients established, reviewed,implemented, monitored, and modified

Diagram 3. A Fishbone Diagram of Probable Root Causes



Diagram 4. A Pareto Diagram of Probable Root Causes

% Frequen

cy

Causes

LEGEND

1 = Census tracking of length of stay not emphasized/ Length of stay of patients and issues regarding prolonged admission and discharge of CSR patients not reviewed by resident staff in endorsement rounds

2 = Culture of patients

3 = Attitude of Doctors

4= No Written System for discharging patients established, reviewed, implemented, monitored, and modified 5= Residents do not have list of estimated costs for OR for patients 6= Delay in securing other materials for OR by patient 7= Availability of complete set of Materials/equipment for CSR patients (e.g. priority is given to the Pay patients)

SUMMARY OF MAJOR ROOT CAUSESSUMMARY OF MAJOR ROOT CAUSES


Summary of Major Root CausesSummary of Major Root Causes


Man Leaders Leadership issue Reactive only to irregular monitoring of bills of the patient

Management issue Lack of a comprehensive holistic system approach to admit, manage and discharge ORL CSR patients using a checklist

Communication issue Delay in the referral of patients to their consultants (other services)No written patient instructions for admissionNo written guidelines for residents for the admission and discharge of patients with specific surgical problems (e.g. thyroid,tonsil,sinus) Need of other labs by other services causing delay in the clearanceNo communication plan

Education issue Inadequate information regarding the patient’s projected expenses/ estimated OR costsNeed to emphasize PCSO/Philhealth subsidies to alleviate burden of high expenses and encourage patients to avail benefits



Man Staff Attitude of Nurses (care for CSR patients versus pay patients)Attitude of Doctors(care for CSR patients versus pay patients)Attitude of other staff(care for CSR patients versus pay patients)

Patients Non-compliance of patients to CSR requirementsLack of funds for important diagnostic examinationsDifficulty obtaining PCSO/Philhealth subsidies (several requirements/ inaccessibility of office)



Methods Recruiting/proper identification of a good surgical candidateSystem for admitting and discharging patients established, reviewed, implemented, monitored, and modifiedCensus tracking of length of stay however not emphasizedResidents do not have list of estimated costs for OR for patientsLength of stay of patients not reviewed by resident staff in endorsement roundsNo management review of CSR patient managementNo continual improvement being madeNo evaluation tool to elicit CSR patient feedbackNo structured collaborative effort to address delay in discharge of ORL-CSR patients

Materials Delay in securing materials from implant companiesDelay in securing other materials for OR by patient

Machine Availability of complete set of materials for CSR patients (e.g. priority is given to the Pay patients)

Environment

Culture of patients -patients coming a day after due admission date -unenthusiastic in availing PCSO/Philhealth benefits

SELECTION OF THE BEST ALTERNATIVE SELECTION OF THE BEST ALTERNATIVE SOLUTIONSOLUTION


AbstractAbstract


Possible solutions generated with selection of the best alternative solution (Multiple Criteria Assessment tool)

Solution chosen and used as intervention:Comprehensive Holistic System approach in the Patient Flow for

elective ORL surgeries

Selection of the Best Alternative SolutionSelection of the Best Alternative Solution


ROOT CAUSE

SOLUTION ADVANTAGE

DISADVANTAGE

CriteriaCOST

EFFECTIVEBREAKTHROUG

HOPPORTUNITY

ACCEPT-ABILITY

MAN 1. Communicate to the patient and coach them about the necessary requirements for admission, management and discharge

a. Create an admission checklist for patients

b. Explain importance of being admitted on time with the necessary OR materials and coordination with implant companies

c. Relay important contact numbers

Decrease in Length of

Stay

Systematic way of

admitting patients

Patient will be guided on the process

8 10 10

Table3. Multiple Criteria Assessment



ROOT CAUS

E

SOLUTION ADVANTAGE

DISADVANTAGE

CriteriaCOST

EFFECTIVEBREAKTHROUG

HOPPORTUNITY

ACCEPT-ABILITY

MAN 2.Coach residents for the prompt discharge of patients with specific surgical problems using written guidelines for their discharge

a. Chief resident creates an induction module for new residents and an update module for continuing residentsb. Consultant training officer meets the residents to emphasize effective, efficient and prompt discharge of duties and responsibilities

3.Get the cooperation of all consultants, residents and relevant units for the plan

a. Present proposal plan to consultants b. Seek approval for implementation

No delay in patient

management

Residents will be guided

8

9

10

10

10

9



ROOT CAUSE

SOLUTION ADVANTAGE

DISADVANTAGE

CriteriaCOST

EFFECTIVEBREAK-

THROUGHOPPORTUNI

Y

ACCEPT-ABILITY

METHODS

1.Create a comprehensive holistic system approach to admit, manage and discharge ORL CSR patients using a checklist

a. Create clinical pathways for the most common surgical cases with a portion that includes a discharge checklist

2. Create a structured reporting of the length of stay of ORL CSR patients.

a. Incorporate in Daily Censusb. Incorporate in Monthly of Censusc. Create list of estimated OR costs and projected expense on specific procedures

Faster and more

efficient manage-ment of patients

Increased awareness of patients to expense/

need to obtain more

budget

8

10

10

10

8

9



ROOT CAUSE

SOLUTION ADVANTAGE

DISADVANTAGE

CriteriaCOST

EFFECTIVEBREAK-

THROUGHOPPORTUNI

Y

ACCEPT-ABILITY

METHODS

3.Review the policy on OR scheduling of CSR Patients

a. Review and possible revision of OR scheduling of CSR patients policy

4.Check the implementation of compliance of the residents in the effective and efficient admission, management of patients as well as their prompt discharge

a. Daily endorsement rounds of Chief resident with residents

b.Monthly Resident Staff meeting c. Check the implementation of

management review and continual improvement on prompt discharge of ORL CSR patients.

Patient may be admitted a day before their procedure

Proper patient management will be monitored

10

10

9

9

10

10



ROOT CAUSE

SOLUTION ADVANTAGE

DISADVA

NTAGE

CriteriaCOST

EFFECTIVEBREAK-

THROUGHOPPORTUNI

Y

ACCEPT-ABILITY

METHODS

d. Designation of at least 2 Monthly Resident Staff meeting as a management review meeting (full documentation)e. Implementation of this Continual Improvement Proposal Plan

5.Create a communication plan for this proposal/plan (for patients)

• Obtain template• Write plan• Consult with BDD• Seek approval

More structured and organized patient management

8 10 10



ROOT CAUSE

SOLUTION ADVANTAGE

DISADVANTAG

E

CriteriaCOST

EFFECTIVEBREAK-

THROUGHOPPORTUNI

Y

ACCEPT-ABILITY

MATERIALS

Provide a list of needed materials for specific procedures

Patient/Re-sidents will be

guided and reminded

10 10 10

MACHINE 1.Develop separate OR sets for ORL CSR patients. a. Review which OR sets require additional sets for CSR patients (e.g. Tonsillectomy set, FESS set, Thyroid Set)

Adequate time management

8 10 10

ENVIRON-MENT

Provide reserved beds for ORL patients onlyPCSO/Philhealth representative at MDH in charge of checking the requirements

No need to be admitted 2 days

before the operation

No need to go to the main office

10

10

10

10

9

8



Solution chosen and used as intervention:Comprehensive Holistic System approach in the Patient Flow for elective ORL surgeries



Leadership strategy Get the cooperation of all consultants, residents and relevant units for the plan Management strategy

Create a comprehensive holistic system approach to admit, manage and discharge ORL CSR patients using a checklist

Review the policy on scheduling of CSR patients Develop a separate OR sets for ORL CSR patientsCheck the implementation of compliance of the residents in the effective and

efficient admission, management of patients as well as their prompt discharge

Check the implementation of management review and continual improvement on prompt discharge of ORL CSR patients



Communication strategy

Communicate to the patient and coach them about the necessary requirements for admission, management and discharge of patient in MDH

Create a structured reporting of the length of stay of ORL CSR patients Communication with the Admitting Service regarding timing of admissions

for elective surgical cases

Educational, mentoring, coaching strategy

Coach residents for the prompt discharge of patients with specific surgical problems using written guidelines for their discharge

SOLUTION IMPLEMENTATIONSOLUTION IMPLEMENTATION


ObjectivesObjectives


(1)to ensure that department is able to admit, manage and discharge the most number of patients with the least span of time possible without

compromising the quality of care of ORL CSR patients

(2) to guarantee that the department has a program to change the attitude of the stakeholders in the prompt, effective and efficient pre-admission,

admission, management and discharge of ORL CSR patients (3) to ascertain that the department has a comprehensive holistic system approach to admit, manage and discharge ORL CSR patients.

Satisfied Patient

Utilize, Incorporate, Standardize

Decreased Cost

Speedy delivery

Development of and compliance to Clinical Pathways, Admission and Discharge Checklist

Prioritize Clinical Cases to address

Recognized Gaps / Needs and Advantages

Outcomes

Report, Share or Publish Outcomes

Compliance

Existing System:ORL-CSR Services (Top 3 elective surgeries)

Increased Access

Improved Outcomes

Continual Improvement

Improved Safety

ComprehensiveHolistic System Approach forORL-CSR patients

Solution ImplementationSolution Implementation


Admission and Discharge Checklists formulated and approved by ORLChairman and Consultants (Feb2010)

Orientation of ORL residents/ENT-Surgical-Pediatric ward staff

and endorsement of clinicalpathways, admission and discharge checklists

Requirements checked using the admission checklist

Checklists and clinical pathways for specific surgical case attached to chart

Daily inspection of checklists and clinical pathway

Final completion of checklists prior to patient’s discharge

Collection and compilation of checklists/clinical pathway



Communication with the Admitting Service regarding timing of admissions for elective surgical cases enabled the department to admit patients a day before their contemplated procedure



Checklists

Clinical pathways



Diagram 1. Flowchart of Key Tasks

PATIENT

OPD Consultation/Resident’sAssessment

DIAGNOSTICS

Presentation to Consultant in

charge

ADMISSION

DISCHARGE

Clearance

PLAN FOR

SURGERY

Schedule of OR

FinalClearance

Co-management

SURGICAL

MEDICAL

Post-OpManagem

ent

ACTUALSURGERY

PLAN


Staff consensus

Co-management

Improving the system the Present SystemImproving the system the Present System


Diagram . Flowchart of Key Tasks on Implementation of the Program

PATIENT

OPD Consultation/Resident’s Assessment

DIAGNOSTICS

Presentation to

Consultant in charge

ADMISSION

DISCHARGE

Clearance

PLAN FOR

SURGERY

Schedule of OR

FinalClearance

Co-management

SURGICAL

MEDICAL

Post-OpManagem

ent

ACTUALSURGERY

PLAN


Staff consensus

Co-management

Checklists/Clinical pathways

Checklists/Clinical pathways finalized

Checklists/Clinical pathways

EVALUATIONEVALUATION


EVALUATIONEVALUATION


Indicators for comparison:

1. length of hospital stay (actual time the patient is admitted in Admitting Section to the time the patient leaves the hospital)

2. cost of hospital stay

EvaluationEvaluation


Table 4. Average Length of Stay of ORL-CSR Patients per procedure in March-May 2010

Procedure MARCH APRIL MAY Average LOS in days

FESS 3 3 2.5 2.8Tonsillectomy 3 - 2.75 2.8

Thyroidectomy - - 4.5 4.5



Table 5. Total number of specific procedures done in March to May 2010

Procedure MARCH APRIL MAY TOTAL Percent Distribution

(%)FESS 1 2 3 6 15.7

Tonsillectomy 1 - 3 4 10.5

Thyroidectomy - - 2 2 5.2

Others 3 2 21 26 68.6

TOTAL 5 4 29 38 100%



Table 6. Comparison of the Average Length of Stay(in days) of ORL-CSR Patients in March-May 2009 vs March-May 2010

Procedure 2009 2010FESS 4 2.8

Tonsillectomy 3.5 2.8

Thyroidectomy 4 4.5

Table 7. Total number of specific procedures done in March to May 2009 vsMarch to May 2010

Procedure 2009 2010FESS 3 6

Tonsillectomy 4 4

Thyroidectomy 2 2

Subtotal 9 12



March-May(2010) vs March-May 2009: Tonsillectomy:

Average length of stay(LOS) decreased (2.8 from 3.5days)

Functional endoscopic sinus surgery(FESS): Average length of stay decreased (2.8 from 4 days)

Thyroidectomy: Average length of stay increased (4.5 from 4days) attributed to: 1)type of thyroid pathology and

2)extent of resection



Table 6. Comparison of the Average Length of Stay(in days) of ORL-CSR Patients in March-May 2009 vs March-May 2010

Procedure 2009 2010FESS 4 2.8

Tonsillectomy 3.5 2.8

Thyroidectomy 4 4.5

Table 7. Total number of specific procedures done in March to May 2009 vsMarch to May 2010

Procedure 2009 2010FESS 3 6

Tonsillectomy 4 4

Thyroidectomy 2 2



Diagram 5. Benign vs. Malignant Tumor Distribution among CSR Patients who underwent Elective Thyroidectomy on 2009 and 2010


Improvement in the average LOS were attributed to:

1) use of a comprehensive holistic system approach in the patient flow of elective ORL surgery patients

2) policy changes in the timing of the admission prior to the day of the operation (from 2 days to1 day only)

3) Training of the residents in the use of the admission and discharge checklist with clinical pathways for the elective operations



Table 10. Estimated Cost of Hospital Stay (in pesos) of ORL CSR Patients

in terms of the Average Length of Stay in 2009 and 2010 for the Top 3 cases (based on room rates)

CASES 2009 2010

FESS Php 2360 Php 1652

Thyroidectomy Php 2360 Php 2655

Tonsillectomy Php 2065 Php 1652

There were slight decreases in the estimated cost of hospital stay



Table 11. Quality of care indicators for the Top 3 cases in 2009 and 2010

CASES 2009 2010

FESS No post-op bleeding No post-op bleeding

Thyroidectomy No hematomas, No hypocalcemia,

No hoarseness

No hematomas, No hypocalcemia,

No hoarsenessTonsillectomy No post tonsil bleeds No post tonsil bleeds

Quality of care indicators unaffected with the use of the intervention.

STANDARDIZATIONSTANDARDIZATION


StandardizationStandardization


Checklists for patient admission and discharge were made

Adoption of the comprehensive holistic system approach for ORL-CSR patients (initially for the three elective ORL procedures)

1)Incorporation with the Department Manual, 2)submission of recommendations for official hospital forms (for the admission, discharge and clinical pathways checklists)

SELF-EVALUATION AND FUTURE PLANNINGSELF-EVALUATION AND FUTURE PLANNING


Self-evaluation and future planningSelf-evaluation and future planning


The objectives of the project were met:

(1)the department was able to admit, manage and discharge the most number of patients with the least span of time possible without compromising the quality of care of ORL CSR patients

(2) the department has a program to change the attitude of the stakeholders in the prompt, effective and efficient pre-admission, admission,

management and discharge of ORL CSR patients (e.g. orientation and endorsement of clinical pathways, admission and discharge checklist) (3) the department has a comprehensive holistic system approach to admit,

manage and discharge ORL CSR patients.

Satisfied Patient

Utilize, Incorporate, Standardize

Decreased Cost

Speedy delivery

Development of and compliance to Clinical Pathways, Admission and Discharge Checklist

Prioritize Clinical Cases to address

Recognized Gaps / Needs and Advantages

Outcomes

Report, Share or Publish Outcomes

Compliance

Existing System:ORL-CSR Services (Top 3 elective surgeries)

Increased Access

Improved Outcomes

Continual Improvement

Improved Safety

ComprehensiveHolistic System Approach forORL-CSR patients



The checklists and the clinical pathways provide written guidelines for residents to follow the comprehensive and holistic approach for ORL-CSR patients improving the promptness, effectiveness and efficiency in managing the patients

With cooperation from the consultants, residents and the nursing staff, there will be a constantly effective implementation of

this project



Continuation of the study until the end of this year is recommended

Once the checklists and pathways have been fully established within the department, potential for expansion to other clinical and surgical fields to be able to utilize this comprehensive, holistic system approach will be recommended

THANK YOUTHANK YOU


Documents

Manila Doctors Hospital Department of Otorhinolaryngology Department of Otorhinolaryngology Continual Improvement Program MBFI Hall August 3, 2010