1. Manila Doctors Hospital Department of Otorhinolaryngology Department of Otorhinolaryngology Continual Improvement Program MBFI Hall August 3, 2010

2. Introduction Manila Doctors Hospital Department 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

3. History Manila Doctors Hospital Department 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

4. Title Manila Doctors Hospital Department of Otorhinolaryngology Prolonged Hospital Stay of ORL-CSR patients undergoing the top 3 elective ORL surgical cases in MDH

5. Manila Doctors Hospital Department of Otorhinolaryngology  Problem identification and prioritization  Root cause analysis (Ishikawa diagram)  3 root causes identification (PARETO diagram)

6. Problem Identification Manila Doctors Hospital Department of Otorhinolaryngology Gaps and areas of improvement identified from: 1.Authorized functions 2.Corporate objectives 3.JCI standards 4.Department Annual Reports 5.Department Census 6.Customer Satisfaction Surveys

7. Problem Identification and Prioritization Manila Doctors Hospital Department of Otorhinolaryngology Specific gaps and areas of improvement: 1.Increased in the length of stay of patients: 1 st 2.There is a delay in the patient’s pre-op and post-op management in terms of clearance and follow-up: 2 nd 3.There is a need for pilot study improving quality service: 3 rd

8. Area of Improvement Manila Doctors Hospital Department 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

9. Statement of the Problem Manila Doctors Hospital Department of Otorhinolaryngology Prolonged Hospital stay of ORL-CSR patients undergoing the top 3 elective ORL surgical cases in MDH

10. Understanding the Present System Manila Doctors Hospital Department of Otorhinolaryngology  Records of previous MDH ORL-CSR admission from January- December 2009 reviewed: -total specific OR procedures -average length of stay(admission-discharge)

11. Understanding the Present System Manila Doctors Hospital Department of Otorhinolaryngology Table 1.Total number of specific procedures done in January to December 2009 Procedure JANJAN FEBFEB MARMAR APRAPR MAYMAY JUNJUN JULJUL A U G SEPSEP OCTOCT NOVNOV DECDEC TOTALTOTAL % Distribution Thyroidectomy -21-1--3-32-1216.2 FESS 111111---31-1013.5 Tonsillectomy -122-21--1--912.1 Foreign body removal -1--1--1-2-168.1 Cheiloplasty-1-----19----2027

12. Understanding the Present System Manila Doctors Hospital Department of Otorhinolaryngology Total number of specific procedures done in January to December 2009 Procedure JANJAN FEBFEB MARMAR APRAPR MAYMAY JUNJUN JULJUL A U G SEPSEP OCTOCT NOVNOV DECDEC TOTALTOTAL % Distribution Tympano- mastoidecto my -------2-2--45.4 Medical management -1-1----221-79.5 Hemiglossect omy -----1------11.4 Excision Ranula -----11-----22.7 Excision Cyst -----1-----122.7 TOTAL2744362252134274100%

13. Understanding the Present System Manila Doctors Hospital Department of Otorhinolaryngology Table2. Average Length of Stay of ORL-CSR Patients per procedure in January-December 2009 Procedure JANJAN FEBFEB MARMAR APRAPR MAYMAY JUNJUN JULJUL A U G SEPSEP OCTOCT NOVNOV DECDEC AVE L O S Thyroidectomy-3.5444--7.5--3.5-4.4 FESS3344442--3.63-3.4 Tonsillectomy-53.5 -32--2--4 Direct laryngoscopy 3-----------3 Foreign body removal -3--2--1-2-52.6 Cheiloplasty-3-3---3----3

14. Understanding the Present System Manila Doctors Hospital Department of Otorhinolaryngology Average Length of Stay of ORL-CSR Patients per procedure in January-December 2009 Procedure JANJAN FEBFEB MARMAR APRAPR MAYMAY JUNJUN JULJUL A U G SEPSEP OCTOCT NOVNOV DECDEC AVE L O S Tympano- mastoidectomy -------5-5--5 Medical management -3-1-9--32--3.6 Hemiglossecto my -----10------ Excision Ranula -----44-----4 Excision Cyst-----3-----22.5

15. FLOWCHART OF KEY TASKS Manila Doctors Hospital Department of Otorhinolaryngology

16. Understanding the Present System Manila Doctors Hospital Department 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 Final Clearance Co-management SURGICAL MEDICAL Post-Op Management ACTUAL SURGERY PLAN Pre-operative Conference/ Consultant Staff consensus Co-management

17. Improving the system the Present System Manila Doctors Hospital Department 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 Final Cleara nce Co-management SURGICAL MEDICAL Post-Op Management ACTUAL SURGERY PLAN Pre-operative Conference/ Consultant Staff consensus Co-management Checklists /Clinical pathways Checklists /Clinical pathways finalized Checklists /Clinical pathways

18. ANALYSIS OF THE PROBLEM Manila Doctors Hospital Department of Otorhinolaryngology

19. Analysis of the Problem Manila Doctors Hospital Department of Otorhinolaryngology Probable root causes were identified using the fishbone and prioritized using the Pareto diagram

20. Analysis of the Problem Manila Doctors Hospital Department of Otorhinolaryngology MATERIALMANENVIRONMENT 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 OR by patient Availability of complete set of materials/equipment Recruiting/proper identification of a good surgical candidate 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 No management review of CSR patient management No structured collaborative effort to address delay in 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

21. Analysis of the Problem Manila Doctors Hospital Department of Otorhinolaryngology Diagram 4. A Pareto Diagram of Probable Root Causes % Frequency 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)

22. SUMMARY OF MAJOR ROOT CAUSES Manila Doctors Hospital Department of Otorhinolaryngology

23. Summary of Major Root Causes Manila Doctors Hospital Department of Otorhinolaryngology ManLeaders 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 admission No 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 clearance No communication plan Education issue Inadequate information regarding the patient’s projected expenses/ estimated OR costs Need to emphasize PCSO/Philhealth subsidies to alleviate burden of high expenses and encourage patients to avail benefits

24. Summary of Major Root Causes Manila Doctors Hospital Department 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 requirements Lack of funds for important diagnostic examinations Difficulty obtaining PCSO/Philhealth subsidies (several requirements/ inaccessibility of office)

25. Summary of Major Root Causes Manila Doctors Hospital Department of Otorhinolaryngology Methods Recruiting/proper identification of a good surgical candidate System for admitting and discharging patients established, reviewed, implemented, monitored, and modified Census tracking of length of stay however not emphasized Residents do not have list of estimated costs for OR for patients Length of stay of patients not reviewed by resident staff in endorsement rounds No management review of CSR patient management No continual improvement being made No evaluation tool to elicit CSR patient feedback No structured collaborative effort to address delay in discharge of ORL-CSR patients Materials Delay in securing materials from implant companies Delay 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

26. SELECTION OF THE BEST ALTERNATIVE SOLUTION Manila Doctors Hospital Department of Otorhinolaryngology

27. Abstract Manila Doctors Hospital Department 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

28. Selection of the Best Alternative Solution Manila Doctors Hospital Department of Otorhinolaryngology ROOT CAUSE SOLUTION ADVANTAG E DISADVA N TAGE Criteria COST EFFECTIVE BREAKTHROUGH OPPORTUNITY 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 810 Table3. Multiple Criteria Assessment

29. Selection of the Best Alternative Solution Manila Doctors Hospital Department of Otorhinolaryngology ROOT CAUSE SOLUTION ADVANTA GE DISADV AN TAGE Criteria COST EFFECTIVE BREAKTHROUGH OPPORTUNITY 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 residents b. 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 8989 10 9

30. Selection of the Best Alternative Solution Manila Doctors Hospital Department of Otorhinolaryngology ROOT CAUSE SOLUTION ADVAN TAGE DIS ADVAN TAGE Criteria COST EFFECTIVE BREAK- THROUGH OPPORTUNIY 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 Census b. Incorporate in Monthly of Census c. 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 8989

31. Selection of the Best Alternative Solution Manila Doctors Hospital Department of Otorhinolaryngology ROOT CAUSE SOLUTION ADVAN TAGE DIS ADVAN TAGE Criteria COST EFFECTIVE BREAK- THROUGH OPPORTUNIY 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 9999

32. Selection of the Best Alternative Solution Manila Doctors Hospital Department of Otorhinolaryngology ROOT CAUSE SOLUTION ADVAN TAGE DIS ADVA N TAGE Criteria COST EFFECTIVE BREAK- THROUGH OPPORTUNIY 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 810

33. Selection of the Best Alternative Solution Manila Doctors Hospital Department of Otorhinolaryngology ROOT CAUSE SOLUTION ADVAN TAGE DIS ADVA N TAGE Criteria COST EFFECTIVE BREAK- THROUGH OPPORTUNIY ACCEPT- ABILITY MATERIALS Provide a list of needed materials for specific procedures Patient/Re- sidents will be guided and reminded 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 810 ENVIRON- MENT Provide reserved beds for ORL patients only PCSO/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 9898

34. Selection of the Best Alternative Solution Manila Doctors Hospital Department of Otorhinolaryngology  Solution chosen and used as intervention: Comprehensive Holistic System approach in the Patient Flow for elective ORL surgeries

35. Selection of the Best Alternative Solution Manila Doctors Hospital Department 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 patients  Check 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

36. Selection of the Best Alternative Solution Manila Doctors Hospital Department 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 Education al, mentoring, coaching strategy  Coach residents for the prompt discharge of patients with specific surgical problems using written guidelines for their discharge

37. SOLUTION IMPLEMENTATION Manila Doctors Hospital Department of Otorhinolaryngology

38. Objectives Manila Doctors Hospital Department 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.

39. 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 Comprehensive Holistic System Approach for ORL-CSR patients

40. Solution Implementation Manila Doctors Hospital Department of Otorhinolaryngology Admission and Discharge Checklists formulated and approved by ORL Chairman 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

41. Solution Implementation Manila Doctors Hospital Department 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

42. Solution Implementation Manila Doctors Hospital Department of Otorhinolaryngology Checklists Clinical pathways

43. Understanding the Present System Manila Doctors Hospital Department 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 Final Clearance Co-management SURGICAL MEDICAL Post-Op Management ACTUAL SURGERY PLAN Pre-operative Conference/ Consultant Staff consensus Co-management

44. Improving the system the Present System Manila Doctors Hospital Department 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 Final Cleara nce Co-management SURGICAL MEDICAL Post-Op Management ACTUAL SURGERY PLAN Pre-operative Conference/ Consultant Staff consensus Co-management Checklists /Clinical pathways Checklists /Clinical pathways finalized Checklists /Clinical pathways

45. EVALUATION Manila Doctors Hospital Department of Otorhinolaryngology

46. EVALUATION Manila Doctors Hospital Department 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

47. Evaluation Manila Doctors Hospital Department of Otorhinolaryngology Table 4. Average Length of Stay of ORL-CSR Patients per procedure in March-May 2010 ProcedureMARCHAPRILMAY Average LOS in days FESS 332.52.8 Tonsillectomy 3-2.752.8 Thyroidectomy --4.5

48. Evaluation Manila Doctors Hospital Department of Otorhinolaryngology Table 4. Average Length of Stay of ORL-CSR Patients per procedure in March-May 2010 ProcedureMARCHAPRILMAY Average LOS in days FESS 332.52.8 Tonsillectomy 3-2.752.8 Thyroidectomy --4.5 Wide excision of oral cavity mass w/ RND --14 Cheiloplasty --33 Tympano- mastoidectomy 2233.5 Medical management 2422.6 Maxillectomy 4--4 Parotidectomy --44

49. Evaluation Manila Doctors Hospital Department of Otorhinolaryngology Table 5. Total number of specific procedures done in March to May 2010 ProcedureMARCHAPRILMAYTOTAL Percent Distribution (%) FESS123615.7 Tonsillectomy1-3410.5 Thyroidectomy--225.2 Wide excision of oral cavity mass w/ RND --112.6 Cheiloplasty/palato plasty --16 42 Tympano- mastoidectomy 11138 Medical management 11138 Maxillectomy1-125.2 Parotidectomy--112.6 TOTAL542938100%

50. Evaluation Manila Doctors Hospital Department of Otorhinolaryngology Table 5. Total number of specific procedures done in March to May 2010 ProcedureMARCHAPRILMAYTOTAL Percent Distribution (%) FESS123615.7 Tonsillectomy1-3410.5 Thyroidectomy--225.2 Others32212668.6 TOTAL542938100%

51. Evaluation Manila Doctors Hospital Department 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 Procedure20092010 FESS42.8 Tonsillectomy3.52.8 Thyroidectomy44.5 Wide excision of oral cavity mass w/ RND -14 Cheiloplasty33 Tympano- mastoidectomy -3.5 Medical management12.6 Maxillectomy-4 Parotidectomy-4 Foreign body removal2-

52. Evaluation Manila Doctors Hospital Department 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 Procedure20092010 FESS42.8 Tonsillectomy3.52.8 Thyroidectomy44.5 Table 7. Total number of specific procedures done in March to May 2009 vs March to May 2010 Procedure20092010 FESS36 Tonsillectomy44 Thyroidectomy22 Subtotal912

53. Evaluation Manila Doctors Hospital Department 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

54. Evaluation Manila Doctors Hospital Department 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 Procedure20092010 FESS42.8 Tonsillectomy3.52.8 Thyroidectomy44.5 Table 7. Total number of specific procedures done in March to May 2009 vs March to May 2010 Procedure20092010 FESS36 Tonsillectomy44 Thyroidectomy22

55. Evaluation Manila Doctors Hospital Department of Otorhinolaryngology Diagram 5. Benign vs. Malignant Tumor Distribution among CSR Patients who underwent Elective Thyroidectomy on 2009 and 2010

56. Manila Doctors Hospital Department 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

57. Evaluation Manila Doctors Hospital Department of Otorhinolaryngology Table 7. Total number of specific procedures done in March to May 2009 vs March to May 2010 Procedure20092010 FESS3 6 Tonsillectomy4 4 Thyroidectomy2 2 Wide excision of oral cavity mass w/ RND - 1 Cheiloplasty- 16 Tympano- mastoidectomy - 3 Medical management1 3 Maxillectomy- 2 Parotidectomy- 1 Foreign body removal1 - TOTAL11 38

58. Evaluation Manila Doctors Hospital Department of Otorhinolaryngology Table 7. Total number of specific procedures done in March to May 2009 vs March to May 2010 Procedure20092010 FESS36 Tonsillectomy44 Thyroidectomy22

59. Evaluation Manila Doctors Hospital Department of Otorhinolaryngology Table 8. Comparison between the Average Length of Stay (days) of Private and CSR Patients who underwent the Top 3 elective cases in March-May 2009 CASESPRIVATECSR FESS4.94 Tonsillectomy2.33.5 Thyroidectomy2.94

60. Evaluation Manila Doctors Hospital Department of Otorhinolaryngology Table 8. Comparison between the Average Length of Stay (days) of Private and CSR Patients who underwent the Top 3 elective cases in March-May 2009 CASESPRIVATECSR FESS4.94 Tonsillectomy2.33.5 Thyroidectomy2.94

61. Evaluation Manila Doctors Hospital Department of Otorhinolaryngology Table 9. Comparison between the Average Length of Stay(days) of Private and CSR Patients who underwent the Top 3 elective cases in March-May 2010 CASESPRIVATECSR FESS42.8 Tonsillectomy2.52.8 Thyroidectomy34.5

62. Evaluation Manila Doctors Hospital Department of Otorhinolaryngology Table 9. Comparison between the Average Length of Stay(days) of Private and CSR Patients who underwent the Top 3 elective cases in March-May 2010 CASESPRIVATECSR FESS42.8 Tonsillectomy2.52.8 Thyroidectomy34.5

63. Evaluation Manila Doctors Hospital Department 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) CASES20092010 FESSPhp 2360Php 1652 ThyroidectomyPhp 2360Php 2655 TonsillectomyPhp 2065Php 1652 There were slight decreases in the estimated cost of hospital stay

64. Evaluation Manila Doctors Hospital Department of Otorhinolaryngology Table 11. Quality of care indicators for the Top 3 cases in 2009 and 2010 CASES20092010 FESS No post-op bleeding Thyroidectomy No hematomas, No hypocalcemia, No hoarseness No hematomas, No hypocalcemia, No hoarseness Tonsillectomy No post tonsil bleeds Quality of care indicators unaffected with the use of the intervention.

65. STANDARDIZATION Manila Doctors Hospital Department of Otorhinolaryngology

66. Standardization Manila Doctors Hospital Department 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)

67. SELF-EVALUATION AND FUTURE PLANNING Manila Doctors Hospital Department of Otorhinolaryngology

68. Self-evaluation and future planning Manila Doctors Hospital Department 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.

69. 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 Comprehensive Holistic System Approach for ORL-CSR patients

70. Self-evaluation and future planning Manila Doctors Hospital Department 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

71. Self-evaluation and future planning Manila Doctors Hospital Department 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

72. THANK YOU Manila Doctors Hospital Department of Otorhinolaryngology