Manila Doctors Hospital Department of Otorhinolaryngology Department of Otorhinolaryngology...
-
Upload
candice-williams -
Category
Documents
-
view
216 -
download
0
Transcript of Manila Doctors Hospital Department of Otorhinolaryngology Department of Otorhinolaryngology...
![Page 1: Manila Doctors Hospital Department of Otorhinolaryngology Department of Otorhinolaryngology Continual Improvement Program MBFI Hall August 3, 2010.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649eff5503460f94c1576b/html5/thumbnails/1.jpg)
Manila Doctors HospitalDepartment of Otorhinolaryngology
Department of Otorhinolaryngology
Continual Improvement Program
MBFI HallAugust 3, 2010
![Page 2: Manila Doctors Hospital Department of Otorhinolaryngology Department of Otorhinolaryngology Continual Improvement Program MBFI Hall August 3, 2010.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649eff5503460f94c1576b/html5/thumbnails/2.jpg)
IntroductionIntroduction
Manila Doctors HospitalDepartment of Otorhinolaryngology
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
![Page 3: Manila Doctors Hospital Department of Otorhinolaryngology Department of Otorhinolaryngology Continual Improvement Program MBFI Hall August 3, 2010.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649eff5503460f94c1576b/html5/thumbnails/3.jpg)
HistoryHistory
Manila Doctors HospitalDepartment of Otorhinolaryngology
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
![Page 4: Manila Doctors Hospital Department of Otorhinolaryngology Department of Otorhinolaryngology Continual Improvement Program MBFI Hall August 3, 2010.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649eff5503460f94c1576b/html5/thumbnails/4.jpg)
TitleTitle
Manila Doctors HospitalDepartment of Otorhinolaryngology
Prolonged Hospital Stay of ORL-CSR patients undergoing the top 3 elective ORL surgical cases in MDH
![Page 5: Manila Doctors Hospital Department of Otorhinolaryngology Department of Otorhinolaryngology Continual Improvement Program MBFI Hall August 3, 2010.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649eff5503460f94c1576b/html5/thumbnails/5.jpg)
Manila Doctors HospitalDepartment of Otorhinolaryngology
Problem identification and prioritization Root cause analysis (Ishikawa diagram)3 root causes identification (PARETO diagram)
![Page 6: Manila Doctors Hospital Department of Otorhinolaryngology Department of Otorhinolaryngology Continual Improvement Program MBFI Hall August 3, 2010.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649eff5503460f94c1576b/html5/thumbnails/6.jpg)
Problem IdentificationProblem Identification
Manila Doctors HospitalDepartment of Otorhinolaryngology
Gaps and areas of improvement identified from:
1.Authorized functions2.Corporate objectives3.JCI standards4.Department Annual Reports5.Department Census6.Customer Satisfaction Surveys
![Page 7: Manila Doctors Hospital Department of Otorhinolaryngology Department of Otorhinolaryngology Continual Improvement Program MBFI Hall August 3, 2010.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649eff5503460f94c1576b/html5/thumbnails/7.jpg)
Problem Identification and PrioritizationProblem Identification and Prioritization
Manila Doctors HospitalDepartment of Otorhinolaryngology
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
![Page 8: Manila Doctors Hospital Department of Otorhinolaryngology Department of Otorhinolaryngology Continual Improvement Program MBFI Hall August 3, 2010.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649eff5503460f94c1576b/html5/thumbnails/8.jpg)
Area of ImprovementArea of Improvement
Manila Doctors HospitalDepartment of Otorhinolaryngology
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
![Page 9: Manila Doctors Hospital Department of Otorhinolaryngology Department of Otorhinolaryngology Continual Improvement Program MBFI Hall August 3, 2010.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649eff5503460f94c1576b/html5/thumbnails/9.jpg)
Statement of the ProblemStatement of the Problem
Manila Doctors HospitalDepartment of Otorhinolaryngology
Prolonged Hospital stay of ORL-CSR patients undergoing the top 3 elective ORL surgical cases in MDH
![Page 10: Manila Doctors Hospital Department of Otorhinolaryngology Department of Otorhinolaryngology Continual Improvement Program MBFI Hall August 3, 2010.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649eff5503460f94c1576b/html5/thumbnails/10.jpg)
Understanding the Present SystemUnderstanding the Present System
Manila Doctors HospitalDepartment of Otorhinolaryngology
Records of previous MDH ORL-CSR admission from January-December 2009 reviewed:
-total specific OR procedures-average length of stay(admission-discharge)
![Page 11: Manila Doctors Hospital Department of Otorhinolaryngology Department of Otorhinolaryngology Continual Improvement Program MBFI Hall August 3, 2010.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649eff5503460f94c1576b/html5/thumbnails/11.jpg)
Understanding the Present SystemUnderstanding the Present System
Manila Doctors HospitalDepartment of Otorhinolaryngology
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
![Page 12: Manila Doctors Hospital Department of Otorhinolaryngology Department of Otorhinolaryngology Continual Improvement Program MBFI Hall August 3, 2010.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649eff5503460f94c1576b/html5/thumbnails/12.jpg)
Understanding the Present SystemUnderstanding the Present System
Manila Doctors HospitalDepartment of Otorhinolaryngology
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%
![Page 13: Manila Doctors Hospital Department of Otorhinolaryngology Department of Otorhinolaryngology Continual Improvement Program MBFI Hall August 3, 2010.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649eff5503460f94c1576b/html5/thumbnails/13.jpg)
Understanding the Present SystemUnderstanding the Present System
Manila Doctors HospitalDepartment of Otorhinolaryngology
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
![Page 14: Manila Doctors Hospital Department of Otorhinolaryngology Department of Otorhinolaryngology Continual Improvement Program MBFI Hall August 3, 2010.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649eff5503460f94c1576b/html5/thumbnails/14.jpg)
Understanding the Present SystemUnderstanding the Present System
Manila Doctors HospitalDepartment of Otorhinolaryngology
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
![Page 15: Manila Doctors Hospital Department of Otorhinolaryngology Department of Otorhinolaryngology Continual Improvement Program MBFI Hall August 3, 2010.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649eff5503460f94c1576b/html5/thumbnails/15.jpg)
FLOWCHART OF KEY TASKSFLOWCHART OF KEY TASKS
Manila Doctors HospitalDepartment of Otorhinolaryngology
![Page 16: Manila Doctors Hospital Department of Otorhinolaryngology Department of Otorhinolaryngology Continual Improvement Program MBFI Hall August 3, 2010.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649eff5503460f94c1576b/html5/thumbnails/16.jpg)
Understanding the Present SystemUnderstanding the Present System
Manila Doctors HospitalDepartment of Otorhinolaryngology
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
![Page 17: Manila Doctors Hospital Department of Otorhinolaryngology Department of Otorhinolaryngology Continual Improvement Program MBFI Hall August 3, 2010.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649eff5503460f94c1576b/html5/thumbnails/17.jpg)
ANALYSIS OF THE PROBLEMANALYSIS OF THE PROBLEM
Manila Doctors HospitalDepartment of Otorhinolaryngology
![Page 18: Manila Doctors Hospital Department of Otorhinolaryngology Department of Otorhinolaryngology Continual Improvement Program MBFI Hall August 3, 2010.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649eff5503460f94c1576b/html5/thumbnails/18.jpg)
Analysis of the ProblemAnalysis of the Problem
Manila Doctors HospitalDepartment of Otorhinolaryngology
Probable root causes were identified using the fishbone and prioritized using the Pareto diagram
![Page 19: Manila Doctors Hospital Department of Otorhinolaryngology Department of Otorhinolaryngology Continual Improvement Program MBFI Hall August 3, 2010.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649eff5503460f94c1576b/html5/thumbnails/19.jpg)
Analysis of the ProblemAnalysis of the Problem
Manila Doctors HospitalDepartment of Otorhinolaryngology
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
![Page 20: Manila Doctors Hospital Department of Otorhinolaryngology Department of Otorhinolaryngology Continual Improvement Program MBFI Hall August 3, 2010.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649eff5503460f94c1576b/html5/thumbnails/20.jpg)
Analysis of the ProblemAnalysis of the Problem
Manila Doctors HospitalDepartment of Otorhinolaryngology
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)
![Page 21: Manila Doctors Hospital Department of Otorhinolaryngology Department of Otorhinolaryngology Continual Improvement Program MBFI Hall August 3, 2010.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649eff5503460f94c1576b/html5/thumbnails/21.jpg)
SUMMARY OF MAJOR ROOT CAUSESSUMMARY OF MAJOR ROOT CAUSES
Manila Doctors HospitalDepartment of Otorhinolaryngology
![Page 22: Manila Doctors Hospital Department of Otorhinolaryngology Department of Otorhinolaryngology Continual Improvement Program MBFI Hall August 3, 2010.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649eff5503460f94c1576b/html5/thumbnails/22.jpg)
Summary of Major Root CausesSummary of Major Root Causes
Manila Doctors HospitalDepartment of Otorhinolaryngology
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
![Page 23: Manila Doctors Hospital Department of Otorhinolaryngology Department of Otorhinolaryngology Continual Improvement Program MBFI Hall August 3, 2010.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649eff5503460f94c1576b/html5/thumbnails/23.jpg)
Summary of Major Root CausesSummary of Major Root Causes
Manila Doctors HospitalDepartment of Otorhinolaryngology
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)
![Page 24: Manila Doctors Hospital Department of Otorhinolaryngology Department of Otorhinolaryngology Continual Improvement Program MBFI Hall August 3, 2010.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649eff5503460f94c1576b/html5/thumbnails/24.jpg)
Summary of Major Root CausesSummary of Major Root Causes
Manila Doctors HospitalDepartment of Otorhinolaryngology
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
![Page 25: Manila Doctors Hospital Department of Otorhinolaryngology Department of Otorhinolaryngology Continual Improvement Program MBFI Hall August 3, 2010.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649eff5503460f94c1576b/html5/thumbnails/25.jpg)
SELECTION OF THE BEST ALTERNATIVE SELECTION OF THE BEST ALTERNATIVE SOLUTIONSOLUTION
Manila Doctors HospitalDepartment of Otorhinolaryngology
![Page 26: Manila Doctors Hospital Department of Otorhinolaryngology Department of Otorhinolaryngology Continual Improvement Program MBFI Hall August 3, 2010.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649eff5503460f94c1576b/html5/thumbnails/26.jpg)
AbstractAbstract
Manila Doctors HospitalDepartment of Otorhinolaryngology
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
![Page 27: Manila Doctors Hospital Department of Otorhinolaryngology Department of Otorhinolaryngology Continual Improvement Program MBFI Hall August 3, 2010.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649eff5503460f94c1576b/html5/thumbnails/27.jpg)
Selection of the Best Alternative SolutionSelection of the Best Alternative Solution
Manila Doctors HospitalDepartment of Otorhinolaryngology
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
![Page 28: Manila Doctors Hospital Department of Otorhinolaryngology Department of Otorhinolaryngology Continual Improvement Program MBFI Hall August 3, 2010.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649eff5503460f94c1576b/html5/thumbnails/28.jpg)
Selection of the Best Alternative SolutionSelection of the Best Alternative Solution
Manila Doctors HospitalDepartment of Otorhinolaryngology
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
![Page 29: Manila Doctors Hospital Department of Otorhinolaryngology Department of Otorhinolaryngology Continual Improvement Program MBFI Hall August 3, 2010.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649eff5503460f94c1576b/html5/thumbnails/29.jpg)
Selection of the Best Alternative SolutionSelection of the Best Alternative Solution
Manila Doctors HospitalDepartment of Otorhinolaryngology
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
![Page 30: Manila Doctors Hospital Department of Otorhinolaryngology Department of Otorhinolaryngology Continual Improvement Program MBFI Hall August 3, 2010.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649eff5503460f94c1576b/html5/thumbnails/30.jpg)
Selection of the Best Alternative SolutionSelection of the Best Alternative Solution
Manila Doctors HospitalDepartment of Otorhinolaryngology
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
![Page 31: Manila Doctors Hospital Department of Otorhinolaryngology Department of Otorhinolaryngology Continual Improvement Program MBFI Hall August 3, 2010.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649eff5503460f94c1576b/html5/thumbnails/31.jpg)
Selection of the Best Alternative SolutionSelection of the Best Alternative Solution
Manila Doctors HospitalDepartment of Otorhinolaryngology
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
![Page 32: Manila Doctors Hospital Department of Otorhinolaryngology Department of Otorhinolaryngology Continual Improvement Program MBFI Hall August 3, 2010.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649eff5503460f94c1576b/html5/thumbnails/32.jpg)
Selection of the Best Alternative SolutionSelection of the Best Alternative Solution
Manila Doctors HospitalDepartment of Otorhinolaryngology
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
![Page 33: Manila Doctors Hospital Department of Otorhinolaryngology Department of Otorhinolaryngology Continual Improvement Program MBFI Hall August 3, 2010.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649eff5503460f94c1576b/html5/thumbnails/33.jpg)
Selection of the Best Alternative SolutionSelection of the Best Alternative Solution
Manila Doctors HospitalDepartment of Otorhinolaryngology
Solution chosen and used as intervention:Comprehensive Holistic System approach in the Patient Flow for elective ORL surgeries
![Page 34: Manila Doctors Hospital Department of Otorhinolaryngology Department of Otorhinolaryngology Continual Improvement Program MBFI Hall August 3, 2010.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649eff5503460f94c1576b/html5/thumbnails/34.jpg)
Selection of the Best Alternative SolutionSelection of the Best Alternative Solution
Manila Doctors HospitalDepartment of Otorhinolaryngology
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
![Page 35: Manila Doctors Hospital Department of Otorhinolaryngology Department of Otorhinolaryngology Continual Improvement Program MBFI Hall August 3, 2010.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649eff5503460f94c1576b/html5/thumbnails/35.jpg)
Selection of the Best Alternative SolutionSelection of the Best Alternative Solution
Manila Doctors HospitalDepartment of Otorhinolaryngology
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
![Page 36: Manila Doctors Hospital Department of Otorhinolaryngology Department of Otorhinolaryngology Continual Improvement Program MBFI Hall August 3, 2010.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649eff5503460f94c1576b/html5/thumbnails/36.jpg)
SOLUTION IMPLEMENTATIONSOLUTION IMPLEMENTATION
Manila Doctors HospitalDepartment of Otorhinolaryngology
![Page 37: Manila Doctors Hospital Department of Otorhinolaryngology Department of Otorhinolaryngology Continual Improvement Program MBFI Hall August 3, 2010.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649eff5503460f94c1576b/html5/thumbnails/37.jpg)
ObjectivesObjectives
Manila Doctors HospitalDepartment of Otorhinolaryngology
(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.
![Page 38: Manila Doctors Hospital Department of Otorhinolaryngology Department of Otorhinolaryngology Continual Improvement Program MBFI Hall August 3, 2010.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649eff5503460f94c1576b/html5/thumbnails/38.jpg)
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
![Page 39: Manila Doctors Hospital Department of Otorhinolaryngology Department of Otorhinolaryngology Continual Improvement Program MBFI Hall August 3, 2010.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649eff5503460f94c1576b/html5/thumbnails/39.jpg)
Solution ImplementationSolution Implementation
Manila Doctors HospitalDepartment of Otorhinolaryngology
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
![Page 40: Manila Doctors Hospital Department of Otorhinolaryngology Department of Otorhinolaryngology Continual Improvement Program MBFI Hall August 3, 2010.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649eff5503460f94c1576b/html5/thumbnails/40.jpg)
Solution ImplementationSolution Implementation
Manila Doctors HospitalDepartment of Otorhinolaryngology
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
![Page 41: Manila Doctors Hospital Department of Otorhinolaryngology Department of Otorhinolaryngology Continual Improvement Program MBFI Hall August 3, 2010.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649eff5503460f94c1576b/html5/thumbnails/41.jpg)
Solution ImplementationSolution Implementation
Manila Doctors HospitalDepartment of Otorhinolaryngology
Checklists
Clinical pathways
![Page 42: Manila Doctors Hospital Department of Otorhinolaryngology Department of Otorhinolaryngology Continual Improvement Program MBFI Hall August 3, 2010.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649eff5503460f94c1576b/html5/thumbnails/42.jpg)
Understanding the Present SystemUnderstanding the Present System
Manila Doctors HospitalDepartment of Otorhinolaryngology
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
![Page 43: Manila Doctors Hospital Department of Otorhinolaryngology Department of Otorhinolaryngology Continual Improvement Program MBFI Hall August 3, 2010.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649eff5503460f94c1576b/html5/thumbnails/43.jpg)
Improving the system the Present SystemImproving the system the Present System
Manila Doctors HospitalDepartment of Otorhinolaryngology
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
Pre-operativeConference/Consultant
Staff consensus
Co-management
Checklists/Clinical pathways
Checklists/Clinical pathways finalized
Checklists/Clinical pathways
![Page 44: Manila Doctors Hospital Department of Otorhinolaryngology Department of Otorhinolaryngology Continual Improvement Program MBFI Hall August 3, 2010.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649eff5503460f94c1576b/html5/thumbnails/44.jpg)
EVALUATIONEVALUATION
Manila Doctors HospitalDepartment of Otorhinolaryngology
![Page 45: Manila Doctors Hospital Department of Otorhinolaryngology Department of Otorhinolaryngology Continual Improvement Program MBFI Hall August 3, 2010.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649eff5503460f94c1576b/html5/thumbnails/45.jpg)
EVALUATIONEVALUATION
Manila Doctors HospitalDepartment of Otorhinolaryngology
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
![Page 46: Manila Doctors Hospital Department of Otorhinolaryngology Department of Otorhinolaryngology Continual Improvement Program MBFI Hall August 3, 2010.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649eff5503460f94c1576b/html5/thumbnails/46.jpg)
EvaluationEvaluation
Manila Doctors HospitalDepartment of Otorhinolaryngology
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
![Page 47: Manila Doctors Hospital Department of Otorhinolaryngology Department of Otorhinolaryngology Continual Improvement Program MBFI Hall August 3, 2010.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649eff5503460f94c1576b/html5/thumbnails/47.jpg)
EvaluationEvaluation
Manila Doctors HospitalDepartment of Otorhinolaryngology
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%
![Page 48: Manila Doctors Hospital Department of Otorhinolaryngology Department of Otorhinolaryngology Continual Improvement Program MBFI Hall August 3, 2010.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649eff5503460f94c1576b/html5/thumbnails/48.jpg)
EvaluationEvaluation
Manila Doctors HospitalDepartment of Otorhinolaryngology
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
![Page 49: Manila Doctors Hospital Department of Otorhinolaryngology Department of Otorhinolaryngology Continual Improvement Program MBFI Hall August 3, 2010.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649eff5503460f94c1576b/html5/thumbnails/49.jpg)
EvaluationEvaluation
Manila Doctors HospitalDepartment of Otorhinolaryngology
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
![Page 50: Manila Doctors Hospital Department of Otorhinolaryngology Department of Otorhinolaryngology Continual Improvement Program MBFI Hall August 3, 2010.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649eff5503460f94c1576b/html5/thumbnails/50.jpg)
EvaluationEvaluation
Manila Doctors HospitalDepartment of Otorhinolaryngology
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
![Page 51: Manila Doctors Hospital Department of Otorhinolaryngology Department of Otorhinolaryngology Continual Improvement Program MBFI Hall August 3, 2010.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649eff5503460f94c1576b/html5/thumbnails/51.jpg)
EvaluationEvaluation
Manila Doctors HospitalDepartment of Otorhinolaryngology
Diagram 5. Benign vs. Malignant Tumor Distribution among CSR Patients who underwent Elective Thyroidectomy on 2009 and 2010
![Page 52: Manila Doctors Hospital Department of Otorhinolaryngology Department of Otorhinolaryngology Continual Improvement Program MBFI Hall August 3, 2010.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649eff5503460f94c1576b/html5/thumbnails/52.jpg)
Manila Doctors HospitalDepartment of Otorhinolaryngology
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
![Page 53: Manila Doctors Hospital Department of Otorhinolaryngology Department of Otorhinolaryngology Continual Improvement Program MBFI Hall August 3, 2010.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649eff5503460f94c1576b/html5/thumbnails/53.jpg)
EvaluationEvaluation
Manila Doctors HospitalDepartment of Otorhinolaryngology
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
![Page 54: Manila Doctors Hospital Department of Otorhinolaryngology Department of Otorhinolaryngology Continual Improvement Program MBFI Hall August 3, 2010.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649eff5503460f94c1576b/html5/thumbnails/54.jpg)
EvaluationEvaluation
Manila Doctors HospitalDepartment of Otorhinolaryngology
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.
![Page 55: Manila Doctors Hospital Department of Otorhinolaryngology Department of Otorhinolaryngology Continual Improvement Program MBFI Hall August 3, 2010.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649eff5503460f94c1576b/html5/thumbnails/55.jpg)
STANDARDIZATIONSTANDARDIZATION
Manila Doctors HospitalDepartment of Otorhinolaryngology
![Page 56: Manila Doctors Hospital Department of Otorhinolaryngology Department of Otorhinolaryngology Continual Improvement Program MBFI Hall August 3, 2010.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649eff5503460f94c1576b/html5/thumbnails/56.jpg)
StandardizationStandardization
Manila Doctors HospitalDepartment of Otorhinolaryngology
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)
![Page 57: Manila Doctors Hospital Department of Otorhinolaryngology Department of Otorhinolaryngology Continual Improvement Program MBFI Hall August 3, 2010.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649eff5503460f94c1576b/html5/thumbnails/57.jpg)
SELF-EVALUATION AND FUTURE PLANNINGSELF-EVALUATION AND FUTURE PLANNING
Manila Doctors HospitalDepartment of Otorhinolaryngology
![Page 58: Manila Doctors Hospital Department of Otorhinolaryngology Department of Otorhinolaryngology Continual Improvement Program MBFI Hall August 3, 2010.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649eff5503460f94c1576b/html5/thumbnails/58.jpg)
Self-evaluation and future planningSelf-evaluation and future planning
Manila Doctors HospitalDepartment of Otorhinolaryngology
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.
![Page 59: Manila Doctors Hospital Department of Otorhinolaryngology Department of Otorhinolaryngology Continual Improvement Program MBFI Hall August 3, 2010.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649eff5503460f94c1576b/html5/thumbnails/59.jpg)
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
![Page 60: Manila Doctors Hospital Department of Otorhinolaryngology Department of Otorhinolaryngology Continual Improvement Program MBFI Hall August 3, 2010.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649eff5503460f94c1576b/html5/thumbnails/60.jpg)
Self-evaluation and future planningSelf-evaluation and future planning
Manila Doctors HospitalDepartment of Otorhinolaryngology
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
![Page 61: Manila Doctors Hospital Department of Otorhinolaryngology Department of Otorhinolaryngology Continual Improvement Program MBFI Hall August 3, 2010.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649eff5503460f94c1576b/html5/thumbnails/61.jpg)
Self-evaluation and future planningSelf-evaluation and future planning
Manila Doctors HospitalDepartment of Otorhinolaryngology
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
![Page 62: Manila Doctors Hospital Department of Otorhinolaryngology Department of Otorhinolaryngology Continual Improvement Program MBFI Hall August 3, 2010.](https://reader035.fdocuments.in/reader035/viewer/2022062720/56649eff5503460f94c1576b/html5/thumbnails/62.jpg)
THANK YOUTHANK YOU
Manila Doctors HospitalDepartment of Otorhinolaryngology