1. 1 OPERATIONAL EXCELLENCE MEET: DRIVING QUALITY IMPROVEMENT THROUGH ENGAGING HOSPITAL PROFESSIONALS

2. 2 Max Super Speciality Hospital, Vaishali is re-accredited for NABH and NABL since 2013. We measure, monitor and analyze the required 64 indicators. Conventionally, Quality Managers are the ones driving the culture. Usually, the data capturing from the user’s end is not a regular affair and happens mostly at the time of the External/Internal Audits. PREFACE

3. 3 What Should Hospital do to stay one step ahead to ensure Quality Beyond Accreditation? “Your hospital is accredited and yet the quality of service is still poor….” Elevate bar of quality or excellence either by aiming for another quality certification or establish the concept that aims for the development of organizational culture of quality by engaging end users.

4. 4 The engagement with the Clinical Departments is the most challenging task. In order to bridge the gap, a platform is created for the collaboration of the Clinicians, Administrators and Top Management. Hence the idea of “Operational Excellence Meet” was conceptualized. The ownership of convening such meetings lies jointly with the User Department in association with the Quality Managers. CONCEPT

5. The schedule is devised on regular basis, the meets are convened at pre-defined regular intervals for both Clinical & Non- clinical departments with representation from all relevant stakeholders. 5 DRIVERS OF QUALITY User Department Quality Team Leaders OPERATIONAL EXCELLENCE MEET

6.  Departmental Statistics  Statutory Compliances  Departmental KPIs  Documentation Accuracy and Internal Audit Findings  Mortality and Morbidity – Cat 2 and Cat 3 Deaths  Incidents Reported  Process improvement initiatives/Gaps  Training Compliance  Patient and Consultant’s Feedback  Patient Education Material  Operational Concerns of the Department 6 STRUCTURE

7. 7 OPERATIONAL EXCELLENCE MEET  Most complex unit in the hospital involving innumerous processes and sub- processes.  Involvement of Multiple stakeholders inclusive of Key Surgeons, Anesthetists, Nursing personnel's, Technicians & Administrative staff etc.  Patient Safety is a prime concern.  Approx 50 - 60% inpatients requires surgical intervention.  Huge Capital Investment. OT & ANESTHESIA

8. REPRESENTATION 8  Management: Unit Head  Medical Admin: Medical Superintendent/Additional MS  OT Team: Head – OT & Anesthesia, Anesthetists, Surgeons, CNO, OT Nursing In-charge, OT Technician In-charge, OT Coordinator, Infection Control Nurse and  Medical Quality Team.

9. DEPARTMENTAL STATISTICS  Total number of Surgeries  Specialty wise – No. of surgeries performed  Theatre Utilization  License to operate C-arm  Compliance to Monitoring and proper usage and handling of TLD badges and Lead Aprons.  Display of Adequate Signages as per NBC or AERB etc.  Adherence to MTP Act, BMW Rules, Narcotics Management  Registrations of Doctor’s and Nurses – (Credentialing & Privileging) 9 STATUTORY COMPLIANCES

10. 10 Data is captured on Monthly Basis which gives the user end the thorough knowledge & understanding not only about the processes functional within the department but also of the interlinked Departments. MEASURING METRICS “When you can measure what you are speaking about and express it in numbers, you know something about it.”

11. 11 DASH BOARD OF OT & ANESTHESIA

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13. DOCUMENTATION ACCURACY  Surgical & Anesthesia Informed Consent.  OT Notes – Prior to transfer out of patient from recovery area.  Identification of person writing notes -Name/Signature/Date & Time.  Compliance to Pre-operative checklist.  Drug Order written in CAPITAL LETTERS. Awareness of staff pertaining to various policies and procedures like:  Patient Identification  Vulnerable Patient  High Risk Medications  BMW Management  ER codes etc 13 CONTENT OF INTERNAL AUDIT

14. IHI Toolkit is implemented across the organization and all deaths are peer reviewed and categorized under following heads: Category 1: Terminal condition at the time of admission. Includes patient for palliative care and deaths in the ER for pronouncement. Category 2: Death that occurred possibly due to complicating factors. Death may not be expected at the time of admission but was expected at the time of death. Quality of care may be an issue. Category 3: Case of unexpected death. Death that occurred due to unexpected complications and/or Quality of care given was an issue. 14 MORTALITY AND MORBIDITY CASES

15. Incident reporting is frequently used at our hospital as a voluntary patient safety event reporting systems. Voluntary event reporting is therefore a passive form of surveillance for near misses or unsafe conditions. However, an active participation has been ensured through OEM by engaging staff from various level of patient care. The Top Management has especially empowered the nursing staff to routinely report the untoward incidents. Following incidents are reported but not limited to:  Patient Identification errors  Sample Collection errors  Patient Falls  Delay in Medication Administration  Equipment Failures etc 15 INCIDENT REPORTED

16. IMPROVEMENT 16

17. SURGICAL CONSENT FORM AUDIT 17

18. 18 ANESTHESIA CONSENT FORM AUDIT

19. 19 MEASURING SATISFACTION “WE ARE LISTENING ” There is a mechanism wherein the surgeons/consultant’s feedback are captured and via these structured meetings the red flag issues raised were extensively discussed. The intent to discuss the same is to gain insight of surgeons/consultant’s concerns and reasons for discontent and the ways to handle them effectively in future with an aim to minimize errors and increase operational efficiencies.

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