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

2. PREFACE
Max Super Speciality Hospital, Vaishali is re-accredited for NABH and NABL since 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.

3. What Should Hospital do to stay one step ahead to ensure Quality Beyond Accreditation?
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.
“Your hospital is accredited and yet the quality of service is still poor….”

4. CONCEPT
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.

5. OPERATIONAL EXCELLENCE MEET
User Department
Quality Team
Leaders
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.
DRIVERS OF QUALITY

6. STRUCTURE 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

7. OPERATIONAL EXCELLENCE MEET
OT & ANESTHESIA
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 % inpatients requires surgical intervention.
Huge Capital Investment.

8. REPRESENTATION 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 STATUTORY COMPLIANCES
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)
Total number of Surgeries
Specialty wise – No. of surgeries performed
Theatre Utilization

10. MEASURING METRICS
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.
“When you can measure what you are speaking about and express it in numbers, you know something about it.”

11. DASH BOARD OF OT & ANESTHESIA

13. DOCUMENTATION ACCURACY CONTENT OF INTERNAL AUDIT
Awareness of staff pertaining to various policies and procedures like:
Patient Identification
Vulnerable Patient
High Risk Medications
BMW Management
ER codes etc
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.

14. MORTALITY AND MORBIDITY CASES
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.

15. INCIDENT REPORTED
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

16. IMPROVEMENT

17. SURGICAL CONSENT FORM AUDIT

18. ANESTHESIA CONSENT FORM AUDIT

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.