CQI-FOR-NAVOTAS-CITY-HOSPITAL-PPT- with suggestions.pptx

sample CQI step by step process

1. CONTINUOUS QUALITY IMPROVEMENT in the Hospital Continuous Quality Improvement in the Hospital Philippine Society for Quality in Healthcare (1) Spica Acoba , (2) Ronald Macapinlac , (3) Arlene Mandal, (4) Jejomar Quiros , (5) Christian Manuel Ramos and (6) Roan Salafranca

2. ORGANIZATIONAL PROFILE Continuous Quality Improvement in the Hospital The Navotas City Hospital (NCH) was recognized by the Department of Health (DOH) as one of the Top 15 Level 1 hospitals in the country.

3. ORGANIZATIONAL PROFILE Continuous Quality Improvement in the Hospital It is a primary hospital that commenced its operations last June 16, 2015, with a fifty (50) bed capacity offering medical services to patients such as Obstetrics and Gynecology, Pediatrics, Internal Medicine, Surgery, Family Medicine, Ophthalmology, Dental and Hemodialysis. A gatekeeping mechanism has been implemented to maximize the utilization of resources and to avoid overcrowding at the hospital, where physicians at the health centers identify patients who warrant specialty consultations, identify complicated cases, and manage the referral system through the Service Delivery Network for further management.

4. PROJECT ABSTRACT Continuous Quality Improvement in the Hospital Medication errors rank as the most frequent and avoidable source of patient harm. They can manifest at various points in the healthcare process, ranging from prescribing to actual drug administration. Given the gravity of this issue, regulatory bodies have introduced guidelines to reduce the occurrence of these incidents (Tariq, 2024). Hence, m edication errors remain a significant concern in healthcare, with serious implications for patient safety. This project aims to address the lack of standardized medication administration practices, which contribute to medication errors in Navotas City Hospital. Through the implementation of Continuous Quality Improvement (CQI) methodologies, including process mapping, root cause analysis, and staff training, the proponents seek to identify and rectify gaps in medication administration protocols. By improving standardization and adherence to medication best practices and protocols which aim to reduce medication errors, enhance patient safety, and improve overall quality of care. Key words: Medication errors, medication nurse, root cause analysis, adherence

5. The following terms were used operationally: Continuous Quality Improvement - refers to a strategic approach to providing the best health care possible. It is a preventive strategy that uses constant innovation to improve work processes and systems by reducing time–consuming, low–value activities.   Complex Medication Regimen - refers to medication regimen complexity (MRC) which includes various aspects of a patient’s medication regimen, including the number of medications prescribed, their dosage forms, dosing frequencies, and usage instructions.   Drug administration - involves the application of a drug on a body surface or the introduction of the drug into a body space to produce systemic or local effects   Drug dose - refers to the amount of medication at any one time prescribed by a medical doctor and administered by a registered nurse. LIST OF TERMINOLOGY USED

6. Intravenous Medication - this means they're sent directly into your vein using a needle or tube. The term “intravenous” means “into the vein.”   Medication error - is defined as any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer.   Medication nurse - someone who assesses patients, develops and documents nursing care and discharge plans, and prepares and administers medications and interventions. Safe medication practices - refer to medication safety which is defined as the freedom from accidental injury due to medical care or medication errors committed by a registered nurse. Standard Operating Procedures - refers to drug protocols or written guidelines that provide directions on how the right and accurate drug administration be carried out. LIST OF TERMINOLOGY USED

7. STEP 1 IDENTIFICATION AND PRIORITIZATION Continuous Quality Improvement in the Hospital Philippine Society for Quality in Healthcare

8. 8 STEP 1: PROBLEM IDENTIFICATION AND PRIORITIZATION WORKSHOP INSTRUCTIONS LIST OF PROBLEMS Prolonged hospitalizations (Long hospital stay) Fast turnover of nurses (resignation) (CAUSE – new nurses – less training – high rate of errors) Wear and tear of m achines (CAUSE – delayed services) Limited budget in the preventive maintenance of machines Recurrent errors in medication administration (SPECIFY WHICH MEDICATION ERROR – ADMINISTRATION/PREPARATION) Recurrent needle prick incidents Recurrent healthcare associated infections (SPECIFY - ???) Ineffective and inefficient Handoffs (CAUSE – delayed services – poor patient satisfaction) Recurrence of Fall 4 USING THE BRAINSTORMING TECHNIQUE, NOMINATE PERCEIVED PROBLEMS IN THE WORKPLACE. Continuous Quality Improvement in the Hospital

9. 9 LIST OF PROBLEMS PROBLEM OR CAUSE? Prolonged Hospitalizations (long hospital stays) CAUSE Fast turnover of nurses (resignation) PROBLEM (CAUSE) Wear and tear of m achines PROBLEM (CAUSE) Limited budget in the preventive maintenance of machines PROBLEM Recurrent error in medication administration (administration/preparation) PROBLEM Recurrent needle prick incidents PROBLEM Recurrent healthcare associated infections (specify ???) PROBLEM Ineffective and inefficient Handoffs CAUSE Recurrence of Fall PROBLEM 5 INSTRUCTIONS: TRIM DOWN THE LIST OF PERCEIVED PROBLEMS BY GROUPING TOGETHER SIMILAR IDEAS. ALL CAUSES MUST BE ELIMINATED BUT NOTE THE CAUSES FOR STEP#3. CAUSE - Factor contributing to occurrence of problem PROBLEM - Effect/End-result cause/s. STEP 1: PROBLEM IDENTIFICATION AND PRIORITIZATION Continuous Quality Improvement in the Hospital

10. 10 INSTRUCTIONS: 3. CLASSIFY THE CONTROLLABILITY OF THE PROBLEMS. NOTE: Controllable – the process is fully owned by the team members themselves; the boundaries of the process are within the circle’s responsibility; circle members are the one performing the activities within the process. Uncontrollable – beyond the team’s control Interface - involvement of the other section or unit or department in the process LIST OF PROBLEMS I C U Fast turnover of nurses (resignation) (INTERFACE – CAUSE) / Wear and tear of m achines / Limited budget in the preventive maintenance of machines / Recurrent error in medication administration (Administration / preparation) / Recurrent needle prick incidents / Recurrent healthcare associated infections (specify) / Recurrence of Fall / STEP 1: PROBLEM IDENTIFICATION AND PRIORITIZATION Continuous Quality Improvement in the Hospital

11. 11 LIST OF CONTROLLABLE PROBLEMS INITIAL DATA COLLECTED Fast turnover of nurses (resignation) (if this will still be considered as a problem not a cause – inclusive date – can we reconsider data from January to December 2023) From December 2023 to May 2024 , there were 19 out of the 50 resignation of nurses Recurrent error in medication administration From January to December 2023 , there are 5 cases of medication error reported Recurrent needle prick incidents From January to December 2023, there were 8 needle prick incidents Recurrence of Fall (any data from January – December 2023) From January to June 2024, there are 4 cases of fall reported INSTRUCTIONS: 4. VERIFY EXISTENCE OF THE PROBLEM. STEP 1: PROBLEM IDENTIFICATION AND PRIORITIZATION Continuous Quality Improvement in the Hospital

12. INSTRUCTIONS: 5. CLASSIFY PROBLEMS ACCORDING TO ITS SIGNIFICANCE. LIST OF CONTROLLABLE PROBLEMS Initial data collected Significance Action taken Fast turnover of nurses (resignation) From December 2023 to May 2024 , there were 19 out of the 50 resignation of nurses Significant Go Recurrent error in medication administration From January to December 2023 , there are 5 cases of medication error reported Significant Go Recurrent needle prick incidents From January to December 2023, there were 8 needle prick incidents Significant Go Recurrence of Fall From January to June 2024 , there are 4 cases of fall reported Significant Go NOTE: Simple concern – are 5S related issues; problems with obvious or ready solution; the extent of problem is relatively small against its target performance. STEP 1: PROBLEM IDENTIFICATION AND PRIORITIZATION Continuous Quality Improvement in the Hospital

13. 13 INSTRUCTIONS: PRIORITIZE PROBLEMS THROUGH DATA-BASED CONSENSUS. USE PRIORITIZATION TOOL. SIGNIFICANT PROBLEMS CRITERIA TOTAL Frequency Importance Feasibility Fast turnover of nurses (resignation) 3 2 2 7 Recurrent error in medication administration 3 5 4 12 Recurrent needle prick incidents 3 4 3 10 Recurrence of Fall 3 3 3 9 STEP 1: PROBLEM IDENTIFICATION AND PRIORITIZATION Continuous Quality Improvement in the Hospital SCORES OF 2 AND 4 NOT INDICATED IN LEGEND

14. 14 PRIORITY PROBLEM Lack of standardized dosage calculation and administration leading to errors (dosage) (not presented in previous tables – statement of “lack of standardized dosage calculation and administration”) No standard procedure on medication administration (not presented in previous tables – statement of “no standard procedure”) TENTATIVE PROBLEM STATEMENT Based on the data gathered for January to June 202 3 , there are five cases (0.03 % ) of dosage administration error out of the 16,615 patients who received the same intravenous medication in Navotas City Hospital. (inclusive dates does not correspond to tables 1-4) STEP 1: PROBLEM IDENTIFICATION AND PRIORITIZATION Continuous Quality Improvement in the Hospital

15. 15 PRIORITY PROBLEM Lack of standardized dosage calculation and administration leading to errors (dosage) (not presented in previous tables – statement of “lack of standardized dosage calculation and administration”) No standard procedure on medication administration (not presented in previous tables – statement of “no standard procedure”) TENTATIVE PROBLEM STATEMENT Based on the data gathered for January to December 202 3 , there are five cases (0.03 % ) of dosage administration error out of the 16,615 patients who received the same intravenous medication in Navotas City Hospital STEP 1: PROBLEM IDENTIFICATION AND PRIORITIZATION Continuous Quality Improvement in the Hospital

16. STEP 2 UNDERSTANDING THE PRESENT SYSTEM Continuous Quality Improvement in the Hospital Philippine Society for Quality in Healthcare

17. CURRENT PROCESS FLOW FOR MEDICATION ADMINISTRATION PERSON RESPONSIBLE FLOW CHART DESCRIPTION START RECEIVES MEDICATION ORDER CALCULATE THE DOSE IS THE DOSAGE CORRECT? YES NO Document the medication MEDICATION NURSE MEDICATION NURSE MEDICATION NURSE CHECKS AND RECEIVES DOCTOR’S ORDER CALCULATE THE DOSE BASED ON THE MEDICATION CARDS Administer the medication RECHECKED THE DOSE BASED ON THE MEDICATION CARDS ADMINISTER AND DOCUMENT THE DOSE BASED ON THE MEDICATION CARDS

18. PERSON RESPONSIBLE FLOW CHART PREPARES MEDICATION, ENSURE PROCEDURE IS HYGIENIC DESCRIPTION LABEL PREPARED DRUG CHECK PATIENT’S IDENTIFICATION ADMINISTER MEDICATION DOCUMENT ADMINISTRATION END MEDICATION NURSE MEDICATION NURSE MEDICATION NURSE MEDICATION NURSE MEDICATION NURSE ORDERS TO PHARMACY, RECEIVES AND PREPARES MEDICINES READS MEDICATION ORDER IN THE CHART CHECK THE PATIENT’S IDENTIFICATION BY ASKING HIS/HER NAME AND/ OR PATIENT’S TAG GIVES MEDICATION TO THE PATIENT SIGNS THE MEDICATION SHEET CURRENT PROCESS FLOW FOR MEDICATION ADMINISTRATION

19. 2.2 VALIDATE THE EXISTENCE OF THE PROBLEM DATA COLLECTION PLAN DATA TO BE COLLECTED DATA SOURCE AND LOCATION HOW WILL DATA BE COLLECTED WHO WILL COLLECT DATA WHEN WILL DATA BE COLLECTED TOOLS FOR DATA PRESENTATION Number of reported medication error Details of medication errors in patient files Number of reported medication error on administration / preparation (suggestion) Incident report of the involved staff / department at (do we have to indicate a specific nursing unit po, e.g. ICU, Medical Ward, etc.) Review the Incident report submitted by the staff Analyze pharmacy records and ward medication charts for discrepancies Incidence Reports : Safety Officer and Quality Assurance Team Continuously with periodic review (Jan-Dec 2023 or ung date po na nagconduct na tayo ngaun July-Sept 2024) Bar, line and pie charts to show frequency and types of errors Incident Report/ Patients Records (remove) NOTE: IDENTIFY THE DATA NEEDED; SPECIFY ASSIGNMENT OF MEMBERS AND SET DEADLINES; AGREE ON THE METHODS TO USE FOR COLLECTING DATA; SUMMARIZE DATA USING QC TOOLS; INTERPRET AND EXPLAIN INFORMATION. STEP 2: UNDERSTANDING THE PRESENT SYSTEM Continuous Quality Improvement in the Hospital

20. 3. a) FINALIZE THE PROBLEM STATEMENT. NOTE : ELEMENTS OF EFFECTIVE PROBLEM STATEMENT: SHOULD CONTAIN THE FOLLOWING : WHAT, WHERE, EXTENT, WHEN FINAL PROBLEM STATEMENT: Based on the data gathered from January 1 - June 30, 202 3 (January-December 2023) there are five (0.03%) dosage administration error (“dosage administration error – not consistent with previous statements) out of the 16,615 patients who received the same intravenous (intravenous was not mention on previous slides) medication in Navotas City Hospital STEP 2: UNDERSTANDING THE PRESENT SYSTEM Continuous Quality Improvement in the Hospital

21. 3. b) FORMULATE THE OBJECTIVE STATEMENT. NOT E: ELEMENTS OF EFFECTIVE OBJECTIVE STATEMENT: SHOULD CONTAIN THE FOLLOWING : S- SPECIFIC, M- MEASURABLE, A- ATTAINABLE, C- CHALLENGING, T- TIME- BOUND (SMACT). TENTATIVE OBJECTIVE STATEMENT: To reduce the number of medication administration errors by 100% from five ( 5 ) to none (0) by the end of December 2024. STEP 2: UNDERSTANDING THE PRESENT SYSTEM Continuous Quality Improvement in the Hospital

22. STEP 3 ANALYSIS OF ROOT CAUSES Continuous Quality Improvement in the Hospital Philippine Society for Quality in Healthcare

23. BALLOON TREE TEMPLATE Based on the data gathered January 1 - June 30, 2024 there are five (0.03%) dosage administration errors out of the 16,615 patients who received the same intravenous medication in Navotas City Hospital. ineffective handoff communication during shift changes Long shifts without break, overwork and high patient load Multiple distractions (phone calls etc ) during critical tasks Ineffective handoff communication during shaft change La ck of standardized communication/ endorsement protocols High turnover rates and inadequate staffing level staff nurses are used to old ways in endorsement such as “same meds lang” Wrong preparation of medication lack of knowledge/ skills Newly passed the board exam or has not practice for a time Continuous Quality Improvement in the Hospital Lack of double -checking system for high risk medication No SOP for Medication Administration / actual experience No demo return demo training prior to deployment to area complex medical regimen with multiple medications of similar names or appearances No existing training protocol for new and existing staff multitasking during medication administration Incomplete staffing due to absences

24. BALLOON TREE TEMPLATE Based on the data gathered January 1 – December 30, 2024 there are five (0.03%) dosage administration errors out of the 16,615 patients who received the same intravenous medication in Navotas City Hospital. Unclear endorsement statement – eg “Same meds lang yan ” Over worked staff Long shifts without break La ck of standardized communication/ endorsement protocols Incomplete staffing due to absences No verification procedures Wrong preparation of medication lack of competency skills Newly board passer or has not practice for a time Continuous Quality Improvement in the Hospital Lack of double -checking system for high risk medication / actual experience No deployment orientation or demonstration activities complex medical regimen with multiple medications of similar names or appearances No existing training protocol for new and existing staff Inadequate staffing level / personnel High patient load High turnover or attrition rates Multiple distractions (phone calls etc ) during critical tasks multitasking during medication administration Unclear SOP for Medication Administration

25. Continuous Quality Improvement in the Hospital INSTRUCTIONS: 1. IDENTIFY PROBABLE CAUSES. STEP 3: ANALYSIS OF THE ROOT CAUSES MEDICATION ERROR PEOPLE METHOD ENVIRONMENT NOT E: NOMINATE PROBABLE CAUSES OF THE PROBLEM USING THE FISHBONE DIAGRAM; SUB-CAUSES SHOULD REACH AT LEAST 5 TH “WHY” LEVEL; RELATIONSHIP BETWEEN CAUSES AND EFFECTS MUST BE CLEARLY UNDERSTOOD. no counter checking of the right medication and dosage Long shifts without break, overwork and high patient load x Incomplete staffing due to absences No SOP for medication administration No structured hand off of patients Lack of knowledge and skills multitasking during medication administration staff nurses are used to old ways in endorsement ( e.g “same meds lang”) multiple distractions (e.g. phone calls) Wrong Preparation of Medication ineffective handoff communication during shift changes PROCESS No training protocol

26. MEDICATION ERROR STAFF-RELATED No counter checking METHOD materials Complex Medical Regimen Wrong Preparation of Medication 5 No Standard Procedure 1 26 Continuous Quality Improvement in the Hospital No Standard Communication Protocol 2 No training protocol lack of knowledge and skills high patient load/ long shifts Resignation no proper endorsement, no proper handoff 34 33 Limited actual hospital exposure/ actual experienced Burnout, Fatigue Insufficient Training prior deployment No structured hand off of patients Incomplete staffing due to absences

27. Based on the data gathered January 1 – December 30, 2024 there are five (0.03%) dosage administration errors out of the 16,615 patients who received the same intravenous medication in Navotas City Hospital. PEOPLE / STAFF-RELATED Lack of double -checking system for high-risk medication METHOD / PROCESS TRAINING No existing training protocol for new and existing staff lack of competency skills 2 No / Unclear SOP for Medication Administration 1 27 Continuous Quality Improvement in the Hospital Lack of standardized communication/ endorsement protocols 4 high patient load Incomplete staffing due to absences no proper endorsement, no proper handoff 33 35 Over worked staff complex medical regimen with multiple medications of similar names or appearances Long shifts without break Wrong preparation of medication Unclear endorsement statement – eg “Same meds lang yan” A A B B Inadequate staffing level / personnel High turnover or attrition rates Newly board passer or has not practice for a time Newly board passer or has not practice for a time C Multiple distractions (phone calls, etc.) during critical tasks multitasking during medication administration C

28. INSTRUCTIONS: 3. VALIDATE PROBABLE ROOT CAUSES. IDENTIFY CONTROLLABILITY OF THE VERIFIED ROOT CAUSES. NOT E: COLLECT DATA FOR EACH ROOT CAUSES IDENTIFIED AND DRAW CONCLUSION FOR EACH ROOT CAUSE; CLASSIFY EACH ROOT CAUSE IF IT IS W/N CONTROL, BEYOND CONTROL OR INTERFACE. PROBABLE ROOT CAUSES VALIDATION METHOD FINDINGS CONTROLLABILITY CONCLUSION No / unclear SOP for Medication Administration Actual Observation; Documents review There are no SOPs found on medication administration With 16,615 times of medication administration, 58 times issues and concerns were noted regarding medication administration protocols. controllable True cause No existing training protocol for new and existing staff Documents Review Based on the data gathered, five (5) employees have limited hospital exposure prior to employment Uncontrollable (Controllable) True cause Lack of Human Resources (High turnover or attrition rates) Documents review (Employee Turnover and Number of Hired Employees) There are ten (10) vacant positions for nurses uncontrollable True cause Lack of standard communication / endorsement protocols Actual Observation; Documents review There are no SOPs found on communication/endorsement Out of the 1,095 endorsements conducted, it has been noted that there 28 instances of miscommunications. controllable True cause Complex medical regimen with multiple medications of similar names or appearances (this is under probable root cause 1 – regarding SOP on Medication Administration) Incomplete staffing due to absences Documents Review Review attendance sheets or records Based on the data gathered, five (5) patients on Complex Medical Regimen (baka pwede pong maglagay nalang ng number dito ) There 20 out of 1,095 shifts were different units have episode of staff absences Uncontrollable Uncontrollable Not a True Cause True cause STEP 3: ANALYSIS OF THE ROOT CAUSES Continuous Quality Improvement in the Hospital

29. INSTRUCTIONS: CREATE A PARETO CHART CAUSES Frequency Percentage total Cumulative % No SOP for Medication Administration 10 (0) 50% 50% Lack of standard communication / endorsement protocols 5 (0) 25% 75% Lack of Human Resources 3 (10) 15% 90% Inadequate Patient Assessment (not indicated in table 3) 2 10% 100% TOTAL 20  100%   STEP 1. ARRANGE FACTORS FROM HIGHEST TO LOWEST. STEP 2. COMPUTE THE PERCENTAGE OF EACH DATA ITEM Ex: 20 / 50 x 100 = 40 % STEP 3. COMPUTE FOR THE CUMULATIVE PERCENTAGE Ex: 0 + 40% = 40% 40% + 20% = 60% STEP 4. DRAW THE PARETO DIAGRAM STEP 5. INTERPRET THE RESULTS AND IDENTIFY THE “VITAL FEW” CAUSES (80-20 RULE). STEP 6: PUT THE TITLE ON THE DIAGRAM. EX: STEP 3: ANALYSIS OF THE ROOT CAUSES Continuous Quality Improvement in the Hospital

30. INSTRUCTIONS: CREATE A PARETO CHART CAUSES Frequency Percentage total Cumulative % No / unclear SOP for Medication Administration 58 47.9% 48.0% Lack of standard communication / endorsement protocols 28 23.1% 71.1% Incomplete staffing due to absences 20 16.5% 87.6% High turnover or attrition rates 10 8.3% 95.9% No existing training protocol for new and existing staff 5 4.1% 100% TOTAL 121  100%   STEP 1. ARRANGE FACTORS FROM HIGHEST TO LOWEST. STEP 2. COMPUTE THE PERCENTAGE OF EACH DATA ITEM Ex: 20 / 50 x 100 = 40 % STEP 3. COMPUTE FOR THE CUMULATIVE PERCENTAGE Ex: 0 + 40% = 40% 40% + 20% = 60% STEP 4. DRAW THE PARETO DIAGRAM STEP 5. INTERPRET THE RESULTS AND IDENTIFY THE “VITAL FEW” CAUSES (80-20 RULE). STEP 6: PUT THE TITLE ON THE DIAGRAM. EX: STEP 3: ANALYSIS OF THE ROOT CAUSES Continuous Quality Improvement in the Hospital

31. PARETO DIAGRAM: MEDICATION ERROR Continuous Quality Improvement in the Hospital 75% 50% 90% 100% Inadequate Patient Asse…..

32. INSTRUCTIONS: 4. SET FINAL OBJECTIVE STATEMENT NOT E: RE-STATE THE OBJECTIVE; CONTROLLABILITY OF THE REAL CAUSES MUST BE CONSIDERED IN THE OBJECTIVE; SET TARGET PERFORMANCE BASED ON THE TEAM’S CAPABILITY; FOLLOW THE SMACT RULE. FINAL OBJECTIVE STATEMENT: To reduce the percentage of medication administration error from 0.03% to 0% by December 2024 in Navotas City Hospital STEP 3: ANALYSIS OF THE ROOT CAUSES Continuous Quality Improvement in the Hospital

33. 35 INSTRUCTIONS: GENERATE ALTERNATIVE SOLUTIONS FOR EACH REAL ROOT CAUSE. EVALUATE AND SELECT BEST ALTERNATIVE SOLUTIONS. NOT E: BEST ALTERNATIVE SOLUTION MUST SIGNIFICANTLY REDUCE THE ROOT CAUSE IT IS ADDRESSING. TRUE CAUSE ALTERNA TIVE SOLUTION Controllability ADVANTAGES DISADVANTAGES Criteria Total Decision A B C D No standard Procedure on Medication Administration Creation of Policy on Medication Administration Controllable - Proper documentation - Serves as guide - Step-by-step procedure - Difficulty in monitoring - Different interpretation 4 ♦ 3 ♥ 3 ♥ 3 ♥ 13 Go Allow double checking with other health care professional (e.g. doctor, nurse, physician) Controllable - Limit occurrence of negligence - - Time consuming - Requires availability of other personnel in the unit 4 ♦ 3 ♥ 2  3 ♥ 12 No Go Lack of standard communication / endorsement protocols Creation of Policy on Standard Communication Controllable - Proper documentation - Serves as guide for ease and clarity of endorsement - Difficulty in monitoring - Different interpretation to policy 3 ♥ 3 ♥ 2  3 ♥ 11 No Go Create an electronic format of endorsement platform that is accessible within hospital local network Uncontrollable - Easy access of all health care providers to data information of patient - Less error in writing - Use of portable gadget like tablet for endorsement is costly - Difficulty in monitoring of end-users - Possibility of data breach 3 ♥ 3 ♥ 2  2  10 No Go STEP 4: SELECTION OF BEST ALTERNATIVE SOLUTION Continuous Quality Improvement in the Hospital

34. 36 INSTRUCTIONS: GENERATE ALTERNATIVE SOLUTIONS FOR EACH REAL ROOT CAUSE. EVALUATE AND SELECT BEST ALTERNATIVE SOLUTIONS. NOT E: BEST ALTERNATIVE SOLUTION MUST SIGNIFICANTLY REDUCE THE ROOT CAUSE IT IS ADDRESSING. TRUE CAUSE ALTERNATIVE SOLUTION Controllability ADVAN TAGES DISADVANTAGES Criteria Total Decision A B C D Incomplete staffing due to absences Create a pool of relievers that will augment the needs during absences Uncontrollable - Accessibility to available nurses oriented to different nursing units - Difficulty in training staff that is oriented in all nursing units - Additional costs to management if needs hiring additional staff 4 ♦ 3 ♥ 3 ♥ 3 ♥ 13 No Go Allow 12-hour schedule for nurses Controllable - Allows manageable nurse-patient ratio with long duty hours - More offs for staffs, means more staffs are needed to supplement long offs 2  3 ♥ 2  2  9 No Go High turnover or attrition rates Partnership with nursing schools or colleges of nursing uncontrollable - Long term solution - Steady pipeline of talent - Custom training programs - Improved retention through early engagement - Difficulty in implementation - Time-intensive setup - No assurance of job positions - Risk of retention issues 4 ♦ 2  2  1 □ 9 No Go Provide competitive salary incentives and benefits Uncontrollable - High job satisfaction rate - Attracts talents - Boosts morale and motivation - Enhances reputation - Budget allocation and approval from head agency - Increase salary of staff means, increase fees in private services 4 ♦ 3 ♥ 2  2  11 No Go STEP 4: SELECTION OF BEST ALTERNATIVE SOLUTION Continuous Quality Improvement in the Hospital

35. 37 INSTRUCTIONS: GENERATE ALTERNATIVE SOLUTIONS FOR EACH REAL ROOT CAUSE. EVALUATE AND SELECT BEST ALTERNATIVE SOLUTIONS. NOT E: BEST ALTERNATIVE SOLUTION MUST SIGNIFICANTLY REDUCE THE ROOT CAUSE IT IS ADDRESSING. TRUE CAUSE ALTERNATIVE SOLUTION Controllability ADVAN TAGES DISADVANTAGES Criteria Total Decision A B C D No existing training protocol for new and existing staff Assign a buddy system (senior nurse) to each new personnel Controllable - Personalized guidance - Faster integration - Improved confidence - Enhanced patient safety - Potential mismatches - Mentor burnout - Dependency issues - Inconsistent quality of mentoring - Potential bias 2  3 ♥ 2  2  9 No Go Create an intensive and comprehensive training program for new nurses Controllable - Improved patient safety - Enhanced skill development - Standardized procedures - Increased confidence - Time-intensive - Costly implementation - Resistance to change - Varied learning styles 4 ♦ 3 ♥ 3 ♥ 3 ♥ 13 Go STEP 4: SELECTION OF BEST ALTERNATIVE SOLUTION Continuous Quality Improvement in the Hospital

36. 38 CRITERIA A Effectiveness of solution B Probability of success C Ease of implementation D Reasonable cost Overall Disposition: 10 points and above = GO Below 10 points = NO GO CRITERIA FOR SELECTING BEST SOLUTIONS: Formula: A + B + C + D LEGEND: RATING 4 ( ♦) (EXCELLENT) 3 ( ♥ ) (SATISFACTORY) 2 ( ☺ ) (GOOD) 1( □ ) (POOR) Continuous Quality Improvement in the Hospital

37. INSTRUCTIONS: 3. Identify details of the solutions. Draw an action plan by doing Gantt Chart Activity Person In-Charge April May June Creation of SOP on Medication Administration Training Committee of Nursing Department/ Quality Nursing Manager Cascading of SOP Nursing Manager for Training Monitoring of Implementation Head Nurse STEP 4: SELECTION OF BEST ALTERNATIVE SOLUTION Continuous Quality Improvement in the Hospital

38. INSTRUCTIONS: 3. Identify details of the solutions. Draw an action plan by doing Gantt Chart STEP 4: SELECTION OF BEST ALTERNATIVE SOLUTION Continuous Quality Improvement in the Hospital

39. INSTRUCTIONS: 3. Identify details of the solutions. Draw an action plan by doing Gantt Chart STEP 4: SELECTION OF BEST ALTERNATIVE SOLUTION Continuous Quality Improvement in the Hospital

40. 42 INSTRUCTIONS: 4. IDENTIFY POTENTIAL PROBLEMS THAT MAY OCCUR. DRAW PREVENTIVE AND CONTINGENCY PLAN BY USING POTENTIAL PROBLEM ANALYSIS TABLE. POTENTIAL PROBLEM ANALYSIS TRUE CAUSE BEST SOLUTION POTENTIAL PROBLEM MOST LIKELY CAUSE PREVENTIVE ACTION CONTINGENT ACTION PERSON RESPONSIBLE TARGET No standard Procedure on Medication Administration Creation of Policy on Medication Administration Staff not following the revised process Inconsistency/ inefficient staff Mandatory training including demo/ return demo Reinforcement Periodic Competency Evaluation Head Nurse June 1, 2024 STEP 4: SELECTION OF BEST ALTERNATIVE SOLUTION Continuous Quality Improvement in the Hospital

41. STEP 5 SOLUTION IMPLEMENTATION Continuous Quality Improvement in the Hospital Philippine Society for Quality in Healthcare

42. 44 MONITORING PLAN DATA TO BE COLLECTED DATA SOURCE AND LOCATION HOW WILL DATA BE COLLECTED WHO WILL COLLECT DATA WHEN WILL DATA BE COLLECTED TOOLS FOR DATA PRESENATION Total number of patients on oral/ intravenous medication Requisitions slips/ prescription Manual and Electronic System Pharmacy Department Daily Bar Graph Total number of new nurses hired (permanent and contractual) Personnel Selection Board results, Human Resource Management Office Validation from HRMO of filled-up positions HRMO personnel assigned in Personnel Selection From June-July 2024 Bar and line graph STEP 5: SOLUTION IMPLEMENTATION Continuous Quality Improvement in the Hospital

43. STEP 6 EVALUATION OF RESULTS Continuous Quality Improvement in the Hospital Philippine Society for Quality in Healthcare

44. BEFORE No Standard Procedure in Safe Medication Administration AFTER Manual Procedure on Safe Medication Administration START Carry out orders Reads the doctor’s orders. Request medication at Pharmacy Checking and Prepares Medication Receives medicines END Verbal confirmatio n IDENTIFY THE CORRECT MEDICINE AND CALCULATE THE DOSE SAFE MEDICATION PREPARATION (counterchecking) LABEL PREPARED DRUG START Confirm medication order CHECK PATIENTS’ IDENTIFICATION END 46 Continuous Quality Improvement in the Hospital Administration of medication RE-CHECK DRUG PRESCRIPTION/ MEDICATION LABEL ADMINISTER MEDICATION

45. Before: 20 After: 0 100% Reduction Analysis: There were no medication error for the year 2024 . 47 EXAMPLE Continuous Quality Improvement in the Hospital

46. Tangible Benefits Number of Personnel Dedicated Hours Person - Hours 7 Management Committee 3 hours 21 person hours 11 TWG members 16 hours 176 person hours 3 Secretariat 40 hours 120 person hours TOTAL 317 person hours Work Hours dedicated Creation of Manual EXAMPLE Item Quantity Unit Price Printing of Manual 10 areas x Php 200 P 2,000 Snacks during Cascading 80 staff x Php 300 P 24,000 TOTAL P 26,000 Cost of Improvement:

47. Intangible Benefits In the process Circle Level Individual Level Criteria Before Target After A. Knowledge in QCC 2 4 4 B. Interest in QCC 1 4 3 C. Teamwork 2 4 4 D. Ability to solve problems 2 4 4 E. Value of cooperation 3 4 4 F. Communication with other dept. 2 4 3 G. Improve self confidence 2 4 4 H. Acquired new skills 1 4 5 I. Improved leadership 2 4 4 1 2 3 4 5 A B C D E F G H I LEGEND: 5—Excellent 4—Very Good 3—Good 2—Average 1—Fair 49 Continuous Quality Improvement in the Hospital

48. Intangible Benefits Impact to the Organization Develop People Depend on each other Delight Customers Deliver on Commitments 4 D's Other Intangible Effects: More utilized staff More productive time 50 Continuous Quality Improvement in the Hospital

49. STEP 7 STANDARDIZATION/INSTITUTIONALIZATION Continuous Quality Improvement in the Hospital Philippine Society for Quality in Healthcare

50. 52 INSTRUCTION: PREPARE A WRITTEN DOCUMENTATION OF THE NEW SOP BY USING THE 5W AND 1H. WHAT WHEN WHERE WHO WHY HOW What to Standardize Effective Date What Area Person Responsible Objective Monitoring Policy on Medication Administration -Ordering -Requisition -Preparation -Administration June 2024 Ward, ER, OR and DR Chief Nurse/ Quality Manager To reduce the percentage of medication error Actual Observation/ Demo/ Return Demo STEP 7: STANDARDIZATION/INSTITUTIONALIZATION Continuous Quality Improvement in the Hospital

51. STEP 8 SELF-EVALUATION AND FUTURE PLANNING Continuous Quality Improvement in the Hospital Philippine Society for Quality in Healthcare

52. 54 INSTRUCTION: 1. IDENTIFY GOOD AND BAD POINTS IN GOING THRU EACH OF THE PROBLEM SOLVING STEP. USING A RADAR CHART, ASSESS TEAM’S SKILLS IN APPLYING QC TOOLS AND TECHNIQUES THEN PREPARE A TEAM DEVELOPMENT PLAN. 2. MAKE A RADAR CHART ACTIVITIES PERSON RESPONSIBLE SCHEDULE RESOURCES NEEDED Continuous Training Program for Self Development of the Staff Coaching and Mentoring on Medication Administration Issues per department Nursing Training Manager HR Staff Nursing Training Manager Charge or Head Nurses Quarterly Quarterly Quarterly Training Module Training Videos Resource Person Pre-Test/ Post Test Conference Rooms Conference Rooms TEAM DEVELOPMENT PLAN STEP 8: SELF-EVALUATION AND FUTURE PLANNING Continuous Quality Improvement in the Hospital

53. 55 ACTIVITIES PERSON RESPONSIBLE SCHEDULE RESOURCES NEEDED Refresher on Step 3 of QI Methodology Data Gathering CQI Committee Chair/Training CQI Committee Members 4 th Week of Nov 2 nd Week of Dec CQI Training Module Training Materials TEAM DEVELOPMENT PLAN Continuous Quality Improvement in the Hospital

54. 1 2 3 3 2 1 3 2 1 3 2 1 PROB ID/ PRIORITIZATION UNDERSTANDING PRESENT SYSTEM ANALYSIS OF ROO CAUSES FORMULATION OF ALTERNATIVE SOLUTIONS SOLUTION IMPLEMENTATION STANDARDIZATION BRAINSTORMING CHECKSHEET GRAPHS PARETO CHART HISTOGRAM ISHIKAWA DIAGRAM EVALUATION OF RESULTS CONTROL CHART SCATTER DIAGRAM SELF EVALUATION/ FUTURE PLANS KNOWLEDGE ON QI METHODOLOGY AND 7 BASIC QC TOOLS LEVEL 0 – NOT HEARD ABOUT IT LEVEL 1 – CAN DO IT WITH SUPERVISION LEVEL 2 – CAN DO IT ALONE LEVEL 3 – CAN TEACH OTHERS BEFORE AFTER Continuous Quality Improvement in the Hospital

55. 11/9/2020 57 FUTURE PLANS Continuous Quality Improvement in the Hospital 1 . To implement and institutionalize safe medication practices such as the proposed policy on medication administration. To strictly monitor and report medication error incidents through a centralized reporting system accessible to all staff. Quarterly committee review on the implementation of the proposed policy on medication administration. Learning Action Cell (LAC) Sessions per department Strategies for reducing errors include checking at each step of the medication administration process.

56. 11/9/2020 58 Tariq, R. (2024). Medication Dispensing Errors and Prevention from https://www.ncbi.nlm.nih.gov/book/NBK519065 . Lee, J. (2022).Drug administration. https://www.msdmanuals.com/home/drugs/administration-and-kinetics-of-drugs/drug-administration Continuous Quality Improvement in the Hospital REFERENCES

57. Thank you!