Transcript Reaching the Gold Standard (HA, JCI)

“TQA for APS”
Thailand Quality Award for
Acute Pain Service
Vimolluck Sanansilp, M.D.
Dept. of Anesthesiology,
Faculty of Medicine Siriraj Hospital
Mahidol University
Vimolluck Sanansilp, Siriraj
Reaching the Gold Standard
(HA, JCI):
Acute Pain Service
Vimolluck Sanansilp, M.D.
Dept. of Anesthesiology,
Faculty of Medicine Siriraj Hospital
Mahidol University
Vimolluck Sanansilp, Siriraj
Reaching the Gold Standards…
HA – Hospital Quality Improvement
& Accreditation
JCI – Joint Commission International
Accreditation Standards for Hospitals
“According to JCI and HA standards, you should…..,
….., ……, and …… .”
Vimolluck Sanansilp, Siriraj
Reaching the Gold Standards…
HA
JCI
Vimolluck Sanansilp, Siriraj
Reaching the Gold Standards…
HA
JCI
- Oh! I know it well. Anything new?
- Yeh! I know some, but I’m not interested in it.
(= Why should I care? It’s not for me!!)
or - Uhmm! I’m not sure. You can talk about it.
Vimolluck Sanansilp, Siriraj
Reaching the Gold Standards…
HA
JCI
- Oh! How can I do it?
- I’m an Ac Pain Dr., not the expert in this area!
- I’ll try my best to learn what it is.
and - Uhmm! I’ll share what I’ve learned with you.
Vimolluck Sanansilp, Siriraj
Reaching the Gold Standards…
HA
JCI
and - Uhmm! I’ll share what I’ve learned with you.
…for Acute Pain Service…
Vimolluck Sanansilp, Siriraj
Reaching the Gold Standards…
HA
JCI
HA standard has been adapted….to reach
Thailand Quality Award (TQA) criteria.
Vimolluck Sanansilp, Siriraj
Reaching the Gold Standards…
HA
HA standard has been adapted….to reach
Thailand Quality Award (TQA) criteria.
Vimolluck Sanansilp, Siriraj
TQA Criteria for Performance Excellence: System Viewpoints
Organizational Profile
Environment, Relationships, Strategic situation
2.
Strategic
Planning
5.
Workforce
Focus
7.
Results
1.
Leadership
3.
Customer
Focus
6.
Operations
Focus
4.
Measurement, Analysis, and Knowledge Management
Vimolluck Sanansilp, Siriraj
TQA Criteria for Performance Excellence: System Viewpoints
Vimolluck Sanansilp, Siriraj
Hospital Accreditation (HA)
Framework
12
Vimolluck Sanansilp, Siriraj
Hospital Accreditation (HA)
Framework
13
HA “Quality Improvement & Learning Cycle”
Act
(A)
Plan
(P)
Study
(S)
Do
(D)
Process: “P-D-S-A”
Vimolluck Sanansilp, Siriraj
TQA – Scoring System  HA
Integration
(I)
Learning
(L)
PDSA
KPI
Approach
(A)
PDSA
Deployment
(D)
PDSA
Process Evaluation: “A-D-L-I”
Vimolluck Sanansilp, Siriraj
TQA – Scoring System  HA
Integration
(I)
Harmonize with others
Comparisons
(C)
Benchmark
KPI
Levels
(Le)
Goal
Trends
(T)
3-point Trend
Result Evaluation: “Le-T-C-I”
Vimolluck Sanansilp, Siriraj
From our practice…
back to the standards
From standards…
go to practice
Vimolluck Sanansilp, Siriraj
From our practice…
back to the standards
I’ll share Siriraj APS’s
experience
Vimolluck Sanansilp, Siriraj
TQA Criteria for Performance Excellence: System Viewpoints
Organizational Profile
Environment, Relationships, Strategic situation
2.
Strategic
Planning
5.
Workforce
Focus
7.
Results
1.
Leadership
3.
Customer
Focus
6.
Operations
Focus
4.
Measurement, Analysis, and Knowledge Management
Vimolluck Sanansilp, Siriraj
TQA Criteria for Performance Excellence: System Viewpoints
Organizational Profile
Environment, Relationships, Strategic situation
Vimolluck Sanansilp, Siriraj
We ask ourselves
1. Do my hospital need an Acute Pain
Service?
2. What kind of “Organizational profile”
do we plan to have?
Vimolluck Sanansilp, Siriraj
We ask ourselves
1. Do my hospital need an Acute Pain Service?
Equation of “Problem”:
What
What
x Concern
Problem = should –
is
be
Vimolluck Sanansilp, Siriraj
We ask ourselves
1. Do my hospital need an Acute Pain Service?
Equation of “Problem”:
What What
Problem = should –should x Concern
be
be
Vimolluck Sanansilp, Siriraj
We ask ourselves
1. Do my hospital need an Acute Pain Service?
Equation of “Problem”:
What
What
x
Problem = should –
is
be
zero
Vimolluck Sanansilp, Siriraj
We ask ourselves
2. What kind of “Organizational profile”
do we plan to have?
Vimolluck Sanansilp, Siriraj
Acute Pain Service (APS) models
1.Anesthesiologist-based APS
2.Nurse-based,
anesthesiologist-supervised APS
3.Nurse-based, surgeon collaborated,
anesthesiologist-supervised APS
Vimolluck Sanansilp, Siriraj
Acute Pain Service (APS) models
1.Anesthesiologist-based APS
-Patient-controlled analgesia (PCA)
-Epidural analgesia with opioid and/or LA
-IV infusion
-Regional blocks
Superior pain relief
Vimolluck Sanansilp, Siriraj
Acute Pain Service (APS) models
1.Anesthesiologist-based APS
Require special
monitoring
Frequent assessment
- pain,
- treatment efficacy
Documentation
High cost
Superior pain relief
Need teamwork
Not enough anesthesiologists 16/07/58
Vimolluck Sanansilp, Siriraj
Acute Pain Service (APS) models
2.Nurse-based, anesthesiologist-supervised APS (1)
Aim: every patients undergoing surgery
include day-case surgery
Simpler & less expensive
Routine pain management
- not need anesthesiologist
--need standard orders, protocols
Vimolluck Sanansilp, Siriraj
Acute Pain Service (APS) models
2.Nurse-based, anesthesiologist-supervised APS (2)
Main role of anesthesiologists =
- in-service training for medical & nursing staff
- supervise Acute Pain Nurse
- maintain cooperation
Acute Pain Nurse
- effective liaison between
surgeon, anesthesiologist and ward nurse
- “trouble shooting” (epidural, PCA)
- check pain assessment documentation
APS Nurse role is crucial
Vimolluck Sanansilp, Siriraj
Acute Pain Service (APS) models
2.Nurse-based, anesthesiologist-supervised APS (3)
Ward nurses
-Patient education of pain score
-Ask patient to grade pain severity & record on
specially reserved place on vital sign chart =
routine pain scoring = “5th Vital Sign”
Neither Acute Pain Nurse nor anesthesiologist
guarantees good pain management on wards
Ward nurse quality is crucial
Vimolluck Sanansilp, Siriraj
Acute Pain Service (APS) models
3.Nurse-based, surgeon collaborated,
anesthesiologist-supervised APS

Surgeons have roles in taking care of their
patients receiving anesthetic pain control
(intraspinal opioid and/or local anesthetics)
Surgeon can order PCA/contin. IV infusion
& know how to take care these patients
Surgeons need to know how to collaborate
with nurse ward and APS team
Vimolluck Sanansilp, Siriraj
? Non-standardized model ?
IM p.r.n. q 6 h + Oral p.r.n. q 6 h
-Prescribed by surgeon
-Administered by ward nurse
-Confusing with “Which med to give first?”
Still most commonly used
Vimolluck Sanansilp, Siriraj
TQA – Scoring System
Integration
(I)
Harmonize with others
Comparisons
(C)
Benchmark
KPI
Levels
(Le)
Goal
Trends
(T)
3-point Trend
Result Evaluation: “Le-T-C-I”
Vimolluck Sanansilp, Siriraj
KPI
This is what we begin with…
Set “Measurable Outputs”  “Results”
KPI - reported regularly - every month
 Peer review – “problems”
Vimolluck Sanansilp, Siriraj
KPI
Level
Comparison
1-2. Pain scores (q 1 h x4, q 2 h x4, q 4 h x3 ~ 11 times)
1. PS ≥ 7 x 2 successively
< 10% of patients
2. PS ≥ 6
< 20% of patients
C 3. Pain scores ≥ 6 (q 4 h x6)
4-6. Side effects from analgesics
4. Respiratory depression
5. Hypotension
6. Motor weakness
< 15% of patients
- once is counted
< 1% of patients
< 5% of patients
< 10% of patients
7-8. Patient outcomes - interviewed
7. Cannot sleep well - pain
< 10% of patients
8. Very satisfied - APS service > 90% of patients
Vimolluck Sanansilp, Siriraj
Trends
KPI 2
%
Number
of ่ Patient
with
PS ≥ 6 ่ั (KPI:
< 20%)
้ ไป ใน 24 ชวโมง
จำนวนผูป
้ ่ วยทีม
ี PS ≥ 6 2 ครงขึ
ั้ น
(KPI < 20%)
Record q 1 h x4, q 2 h x4, q 4 h x3 (~ 11 times)
22
20
18
16
14.2
12.8
14
11.9
12
10
8
6
4
2
0
2010
2011
2012
Year
Vimolluck Sanansilp, Siriraj
Trends
KPI 3
%
Number of Patient with PS ≥ 6 (KPI: < 15%)
่ั
้ ไปเมือว
จำนวนผูป
้ ่ วยทีม
่ ี PS ≥ 6 2 ครงขึ
ั้ น
่ ัด ทุก 4 ชวโมง
< 15%
Record q 4 h (6 times)
18
16
14
12
C
10
8
5.9
7
6
4.6
3.8
4
2
0
2010
2011
2012
Year
Vimolluck Sanansilp, Siriraj
Trends
KPI 5
resp.depression (KPI: < 1%
KPI <of
1%)patients)
Respiratory depression
1
0.8
0.6
0.4
0.2
0.1
0.1
0
0
2010
1
2011
2
2012
3
Year
Vimolluck Sanansilp, Siriraj
TQA – Scoring System  HA
Integration
(I)
Learning
(L)
PDSA
KPI
Approach
(A)
PDSA
Deployment
(D)
PDSA
Process Evaluation: “A-D-L-I”
Vimolluck Sanansilp, Siriraj
KPI
Process Evaluation: “A-D-L-I”
Vimolluck Sanansilp, Siriraj
KPI
Process Evaluation: “A-D-L-I”
Vimolluck Sanansilp, Siriraj
Hospital Accreditation (HA)
Framework
43
Vimolluck Sanansilp, Siriraj
KPI
1. Leadership
A- Vision, gatherer, committee (Hospital  APS),
team, plan together; Audits & Research
D- Committee meeting regularly; every mo/wk
L - Data & Problems presented  solve together
I - Join with surgeons’ & ward nurses’ plans
including work & research areas
Vimolluck Sanansilp, Siriraj
KPI
2. Strategic Management
A- 1) SWOT analysis; 2) Plan to convey knowledge
to
all personnel, pilot project  generalized;
3) IV inj. approval; 4) JCI helps push APS forward
D- 1) Training - nurse, residents; 2) CPG; 3) Aiming at
the goals needs data to benchmark with others
I - 1) Set “KPI” & look for “Benchmark”; 2) Nurses crucial Role - pain assessment & IV algorithm use
3) Not all surgeons involved - need system to help
Vimolluck Sanansilp, Siriraj
CPG – Clinical Guidance…in Siriraj Hospital
Vimolluck Sanansilp, Siriraj
KPI
3. Patient Focus
A- 1) Specify type of patients in service; 2) Patient’s
need heard; 3) survey level of satisfaction patients, surgeons, nurses
D- Analgesic techniques: CEA, PCEA, IV inf., IV-PCA,
CPNB, PCRA, IV algorithm, oral a.t.c./p.r.n.
L - Know - 1) Suitable tech. for each type of operation;
2) Problems; 3) Prevent & solve problems;
4) Epidural techniques revision: dose, cath, taping
I - Patients/Family satisfied w information & results
Vimolluck Sanansilp, Siriraj
A
Vimolluck Sanansilp, Siriraj
A
Vimolluck Sanansilp, Siriraj
A
For patients_2011
For parents_2012
Vimolluck Sanansilp, Siriraj
A
Pamphlet  postop. analgesic techniques…by APS
Vimolluck Sanansilp, Siriraj
A
Pamphlet  postop. analgesic techniques…by APS
Vimolluck Sanansilp, Siriraj
KPI
4. Measurement, Analysis, and Knowledge Management
A- Management by facts
D- Passing on up-to-date knowledge
I - Bring information to improve performance
Vimolluck Sanansilp, Siriraj
KPI
5. Workforce Focus
A- Provide adequate manpower/potentiality to the
task; satisfied with the performance & outcomes
D- 1) Knowledge refreshment regularly - MD, nurse;
2) Increase potentiality of the newcomer;
3) Distribute some resident’s jobs to APS nurses;
4) Define JD to each APS nurse - rotation
L - 1) Manual for newcomer; 2) Increase knowledge
& skill with all capability; 3) Progress in profession
Vimolluck Sanansilp, Siriraj
KPI
6. Process Management
A- 1) Try to make the system work effectively:- reduce
loss/discrepancy;
2) Look for “KPI” indicating effectiveness
D- 1) Adequate analgesia since in the OR; 2) Early treatment
of pain; 3) Follow up before the end of each work day;
4) Prevent unnecessary lost of patient benefits - reduce
unnecessary workload and costs; 5) Pharmacy helps
produce ready-to-use analgesic preparations
L - Review, analyze, & learn how to prevent unnecessary work
I - Trace the KPI for surveillance
Vimolluck Sanansilp, Siriraj
D
Opioids in Prefilled syringe:
Vimolluck Sanansilp, Siriraj
D
100 mg/200 ml
50 mg/100 ml
Morphine dilute
in 10 mg/10 ml vial
Morphine dilute 0.5 mg/ml in bag:
50 mg/100 ml; 100 mg/200 ml
For nurse-assisted continuous IV opioid infusion
Vimolluck Sanansilp, Siriraj
D
Epidural infusion solution
Ready-to-use bupivacaine 0.0625%
Vimolluck Sanansilp, Siriraj
JCI Accreditation Standards for Hospitals
(Care of Patients)
Vimolluck Sanansilp, Siriraj
Key Points from the JCI
Pain Management Standards
• Patients have a right to pain assessment &
management – – to identify patients in pain
• Pain must be assessed at regular intervals.
Pain should be reassessed soon following an
intervention to treat pain to ensure a
response.
Vimolluck Sanansilp, Siriraj
Key Points from the JCI
Pain Management Standards
• Institutions are required to have policies and
procedures for pain assessment & treatment –
– guidelines or protocols
• Patient & family education for pain
management is mandated – – their personal,
cultural & religious beliefs
Vimolluck Sanansilp, Siriraj
Key Points from the JCI
Pain Management Standards
• Staff education concerning pain assessment &
management is required.
• Pain assessments are required as a discharge
criterion
Vimolluck Sanansilp, Siriraj
Issue 49, August 8, 2012
http://www.jointcommission.org/assets/1/18/SEA_49_opioids_8_2_12_final.pdf
Safe use of opioids in hospitals: incidence, causes
• The need for assessing and managing pain to help
avoid accidental opioid overdose (9)
• Actions suggested by The Joint Commission (9)
• Effective processes (3) – Policies
• Safe technology (1) – IT, PCA
• Appropriate education and training (4) – Staffs, Pts
• Effective tools (1) – POSS, RASS, etc.
POSS: Pasero Opioid-Induced Sedation Scale, 0-4
RASS: Richmond Agitation-Sedation Scale, 4- (-5)
Vimolluck Sanansilp, Siriraj
2012
Acute Pain Service
1997
USA
Germany
Sweden
1986
1994
1993
1991
APS – Vimolluck Sanansilp,
Siriraj
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Vimolluck Sanansilp, Siriraj
Reports of
Acute Pain Service
assessment
1993
1986
1991
APS – Vimolluck Sanansilp,
Siriraj
USA
UK
Australia
New Zealand
South Africa
1997
Canada
Germany
Malaysia
1994
Spain
Denmark
Hong Kong
Singapore
65
2012
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Vimolluck Sanansilp, Siriraj
Organized
Acute Pain Service
2012
Sep,
2006
1997 Siriraj
1994
1993
1986
1991
APS – Vimolluck Sanansilp,
Siriraj
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Vimolluck Sanansilp, Siriraj
Organized
Acute Pain Service
20__
Yours?
1997
1994
1993
1986
1991
APS – Vimolluck Sanansilp,
Siriraj
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Vimolluck Sanansilp, Siriraj
From our practice…
back to the standards
From the standards…
you go to practice
Vimolluck Sanansilp, Siriraj
Reaching the Gold Standards…
“TQA for APS”
Vimolluck Sanansilp, Siriraj
Photo taken by Virachat Sanansilp, MD., Faculty of Medicine Siriraj Hospital
Vimolluck Sanansilp, Siriraj
Thank You
Photo taken by Virachat Sanansilp, MD., Faculty of Medicine Siriraj Hospital
Vimolluck Sanansilp, Siriraj