Bengkel nia hcm (lec 1)

BENGKEL NIA/KPI BENGKEL NIA/KPI HOSPITAL CHANGKAT HOSPITAL CHANGKAT

MELINTANGMELINTANG

Pengenalan kepada KPI/ NIAPengenalan kepada KPI/ NIADr Lee Oi WahDr Lee Oi Wah

Pengarah HCMPengarah HCM

MALAYSIA VISION FOR HEALTH1.1. Healthy nationHealthy nation with enhancedwith enhanced qualityquality of of lifelife2.2. health system that is :health system that is :

equitable, affordable, efficient, equitable, affordable, efficient, technologically appropriate, adaptabletechnologically appropriate, adaptable consumer friendlyconsumer friendly

3.3. emphasis on : quality & innovation ,emphasis on : quality & innovation , health promotion health promotion respect for human dignity respect for human dignity

4.4. Promotes : individual responsibility Promotes : individual responsibility community participation community participation

DEFINITION OF QADEFINITION OF QA

““Securing Securing optimum achievable resultoptimum achievable result for for each patient,each patient,avoidance of iatrogenicavoidance of iatrogenic complications complicationsand giving attention and giving attention to the to the patientpatientand and family needsfamily needsin a mannerin a mannerthat is that is cost effectivecost effectiveand reasonably and reasonably documenteddocumented

Adapted from ThomsonAdapted from Thomson

Facil i t ies and services are of Facil i t ies and services are of high quality if they are:high quality if they are:

1.1. SafeSafe2.2. Timely ( and appropriate )Timely ( and appropriate )3.3. EffectiveEffective4.4. Equitably accessedEquitably accessed5.5. EfficientEff icient6.6. Patient focus ( Consumer-Patient focus ( Consumer-

centered and centered and consumer-friendlyconsumer-friendly))

Apparent failure due to standards Apparent failure due to standards vs product mismatchvs product mismatch

Failure to conform to Failure to conform to specificationsspecifications

Poor designPoor design Design cannot be implementedDesign cannot be implemented Design not capable of producing Design not capable of producing

desired resultsdesired results Circumstances beyond controlCircumstances beyond control Weak leadershipWeak leadership

1. 1. Not punitive:-Not punitive:- emphasis is on identifying solutions to emphasis is on identifying solutions to

SYSTEMS problem and not to WHO is SYSTEMS problem and not to WHO is responsible for the problemresponsible for the problem

2. 2. Helps ensure optimal Utilisation of Helps ensure optimal Utilisation of ResourcesResources

3. 3. A means of defining performanceA means of defining performance;; comparisons with pre-set standards comparisons with pre-set standards

or Benchmark with similar areas in or Benchmark with similar areas in same organisation or other same organisation or other organizationorganization4. 4. Allows objective confirmation and Allows objective confirmation and

documentation of performance in documentation of performance in measurable unitsmeasurable units

5. 5. Serves to identify and help justify need for Serves to identify and help justify need for additional resources and facilities.additional resources and facilities.

Who’s fault is this ?

To ensure that :To ensure that : our limited resources are optimally our limited resources are optimally utilisedutilised quality of care continues to improvequality of care continues to improve

QuantifiableQuantifiable measurements and measurements and agreed to beforehandagreed to beforehand

Reflect the critical success Reflect the critical success factors of an organizationfactors of an organization

Help an organization define and Help an organization define and measure progress toward measure progress toward organizational goals. organizational goals.

Quick way of seeing the actual performance of Quick way of seeing the actual performance of a goal or strategic objective.a goal or strategic objective.

Decisions can be made much quicker when Decisions can be made much quicker when there are accurate and visible measures to back there are accurate and visible measures to back them up.them up.

Allow management to see department Allow management to see department performance in one place.performance in one place.

A team can work together to aA team can work together to a common set of common set of measurable goalsmeasurable goals

Give everyone in the organization a clear picture

of what is important, of what they need to make

happen.

The implementation of Key Performance Indicators The implementation of Key Performance Indicators (KPIs) in the Ministry of Health has been (KPIs) in the Ministry of Health has been recommended in the recommended in the “Pekeliling Kemajuan “Pekeliling Kemajuan Pentadbiran AwamPentadbiran Awam” (PKPA) 2/2005. ” (PKPA) 2/2005.

These indicators can be used to These indicators can be used to assess the overall assess the overall performance performance of the services provided by Clinical of the services provided by Clinical Departments in the MOH.Departments in the MOH.

The KPIs are The KPIs are not intended to replace not intended to replace the currently the currently running Quality Improvement activities. running Quality Improvement activities.

It should be regarded as a It should be regarded as a supplement supplement to these to these activities which concentrate on the clinical aspects of activities which concentrate on the clinical aspects of qualityquality

State Health State Health Departments (Medical) Departments (Medical) are:are:

Clinical Governance in Clinical Governance in Service Delivery Service Delivery

Resource Resource Management Management

PERFORMANCE

Aspect of Performance: Clinical Governance Aspect of Performance:

Resource : Resource Management

Dimension: Patient-CentredServices Care

Dimension: Clinical /Technical (Effectiveness)

Dimension: Clinical Risk Management

Dimension: Staff Health

Dimension: Human Resource

Dimension: Financial Management

ASPECT OF PERFORMANCE : CLINICAL GOVERNANCEASPECT OF PERFORMANCE : CLINICAL GOVERNANCEDimension Dimension : : PATIENT-CENTRED SERVICES PATIENT-CENTRED SERVICES (i)(i) Percentage of Hospitals Which Investigated ALL Written Percentage of Hospitals Which Investigated ALL Written

Complaints Complaints Standard : 100% of all hospitalsStandard : 100% of all hospitals

(ii)(ii) Percentage of Hospitals in the State Achieving the Clinic Percentage of Hospitals in the State Achieving the Clinic Waiting Time Target Waiting Time Target at 3 at 3 Selected ClinicsSelected Clinics

Standard : All (100%) relevant hospitals Standard : All (100%) relevant hospitals to achieve standard to achieve standard at 3 Selected Clinicsat 3 Selected Clinics

Dimension :Dimension : CLINICAL / TECHNICAL (EFFECTIVENESS) CLINICAL / TECHNICAL (EFFECTIVENESS) (iii)(iii) Hospital Accreditation / ISO Hospital Accreditation / ISO CertificationCertification

Percentage of Hospitals with a CURRENT Hospital Percentage of Hospitals with a CURRENT Hospital Accreditation Accreditation OROR ISO status ISO status

Standard : Standard : >> 70% of hospitals in the State 70% of hospitals in the State in the yearin the year

(iv)(iv) Quality Assurance Programme (QAP)Quality Assurance Programme (QAP)National Indicator (NIA) PerformanceNational Indicator (NIA) Performance

Standard: All hospitals to achieve : NIA Standard: All hospitals to achieve : NIA indicator Standards Attained in at least indicator Standards Attained in at least ((>>) 80%) 80% of the NIA Indicators that Are of the NIA Indicators that Are Relevant to the Hospital (every 6 Relevant to the Hospital (every 6 months)months)

Dimension :Dimension : CLINICAL RISK MANAGEMENT CLINICAL RISK MANAGEMENT

(v)(v)Percentage of hospitals with Specialist Services Achieving Percentage of hospitals with Specialist Services Achieving Targeted MRSA Rates Targeted MRSA Rates

Standard: 100% must achieve the Standard: 100% must achieve the standard set of < 0.4%standard set of < 0.4%

Dimension :Dimension : STAFF HEALTH STAFF HEALTH (vi)(vi) Percentage of Hospitals Attaining Set Standards for Routine Percentage of Hospitals Attaining Set Standards for Routine

Medical Check-ups for Staff aged Over 40 years Medical Check-ups for Staff aged Over 40 years Standard : Standard : At least 70 % (At least 70 % (>> 70%) 70%)of of eligible staff have had a medical check-eligible staff have had a medical check-up in the yearup in the year

ASPECT OF PERFORMANCE : RESOURCE MANAGEMENTASPECT OF PERFORMANCE : RESOURCE MANAGEMENTDimension :Dimension : Human ResourceHuman Resource

(vii)(vii) Percentage of Hospitals Attaining Set standards Percentage of Hospitals Attaining Set standards for Medical Officers Attending Training Courses for Medical Officers Attending Training Courses (MTLS / ACS / PALS) (MTLS / ACS / PALS)

All hospitals to achieve at least All hospitals to achieve at least ((>>)70%)70% Doctors in ED and Doctors in ED and Anesthesia trained in any of the Anesthesia trained in any of the three coursesthree courses

(viii)(viii) Percentage of Hospitals Attaining Set Standards Percentage of Hospitals Attaining Set Standards

for Paramedics Attending BLS Training Coursesfor Paramedics Attending BLS Training Courses

All hospitals have achieved the All hospitals have achieved the target of at least target of at least ((>>) 70%) 70% of their of their Paramedic personnel IN ACUTE Paramedic personnel IN ACUTE CARE areas trained in BLSCARE areas trained in BLS

The NIA for the Patient Care Services QAP The NIA for the Patient Care Services QAP (Quality Assurance Programme) began in 1985. (Quality Assurance Programme) began in 1985.

The goal is to ensure that, within the constraints of The goal is to ensure that, within the constraints of the MOH available resources, the patient, family the MOH available resources, the patient, family and the community obtained the and the community obtained the "optimum "optimum achievable benefit”achievable benefit” from its services, in terms of the from its services, in terms of the advancement of the health and welfare of advancement of the health and welfare of individuals and the community as well as the individuals and the community as well as the Malaysian population. Malaysian population.

** MOH set & provides:MOH set & provides: -- a a standardstandard for each for each indicatorindicator

-- monitoring format for data collection , monitoring format for data collection , analysis & reportinganalysis & reporting

-- protocols & format for protocols & format for SIQSIQ investigation. investigation.

* Hospital has to carry out remedial actions* Hospital has to carry out remedial actions& relook of its effectiveness.& relook of its effectiveness.

NIANIA

Defining standards and establishing Defining standards and establishing systemssystems

to produce the desired attributes / standards to produce the desired attributes / standards of health care services as efficiently as of health care services as efficiently as possible (Models of Good Care / Practice) for possible (Models of Good Care / Practice) for targeted areas of concerntargeted areas of concern

Measuring the Quality of servicesMeasuring the Quality of services (and (and comparing between observed standards comparing between observed standards against set standards)against set standards)

Implementing Remedial measuresImplementing Remedial measures (Change (Change management) to further improve quality (by management) to further improve quality (by meeting or exceeding previously-set meeting or exceeding previously-set standards)standards)

(a) Measure quality

(b) Detect shortfalls?

Yes

No

(c) Investigate reasons for

shortfall

(d) Devise strategies for improvement

(e) Implement strategies

IDENTIFY AREAS OF CONCERN

Figure 2:The National Indicator Approach (Problem-solving) Process

Problem Problem PrioritisationPrioritisation

Problem Problem AnalysisAnalysis

Quality Quality Assurance Assurance

StudyStudy

Identification of Identification of Remedial ActionsRemedial Actions

Implementation of Implementation of Remedial ActionsRemedial Actions

Re-evaluation of the Re-evaluation of the ProblemProblem

Problem Problem identificationidentification

Quality Quality Assurance Assurance

CycleCycle

LIST OF KPI/NIALIST OF KPI/NIAPercentage of Customers Dissatisfied with the Hospital’s Percentage of Customers Dissatisfied with the Hospital’s ServicesServices

< 8% of hospital’s in-patients < 8% of hospital’s in-patients and out-patientsand out-patients

““Waiting Time to Consult Doctor / Specialist (T1)” at Selected Waiting Time to Consult Doctor / Specialist (T1)” at Selected Clinics in the Hospital Meets with the Set StandardsClinics in the Hospital Meets with the Set Standards

<<90 minutes for at least 90% 90 minutes for at least 90% of patients for General OPD, of patients for General OPD, MO F/up Clinics and Visiting MO F/up Clinics and Visiting Specialist ClinicsSpecialist Clinics

EITHER Hospital Accreditation OR ISO Certification EITHER Hospital Accreditation OR ISO Certification Achieved Accreditation / ISO Achieved Accreditation / ISO and/or Sustained Accreditation and/or Sustained Accreditation / ISO status)/ ISO status)

Quality Assurance Programme (QAP)Quality Assurance Programme (QAP)National Indicator (NIA) Performance of HospitalNational Indicator (NIA) Performance of Hospital

Hospital meets standards in at Hospital meets standards in at least 80% of the relevant NIA least 80% of the relevant NIA indicators for the hospitalindicators for the hospital

INDICATORINDICATOR STANDARD SETSTANDARD SET

6-monthly Average Rate of MRSA in the Hospital6-monthly Average Rate of MRSA in the Hospital < 0.4%< 0.4%

Percentage of Staff Over 40 who had Undergone Routine Percentage of Staff Over 40 who had Undergone Routine Medical Check-ups Medical Check-ups

At least 70 % of their eligible At least 70 % of their eligible staff have had a medical staff have had a medical check-up in the yearcheck-up in the year

Percentage of Personnel Trained in Basic Life Support (BLS) in a Percentage of Personnel Trained in Basic Life Support (BLS) in a YearYear

60% of clinical personnel 60% of clinical personnel (paramedics) in acute care (paramedics) in acute care areasareas))

Percentage of Medical Officers in Percentage of Medical Officers in ED and AnesthesiaED and Anesthesia Who Who Attended MTLS / ALS/ PALS Training Courses in a YearAttended MTLS / ALS/ PALS Training Courses in a Year

60% to be trained60% to be trained

Hospitals Attains Set standards for: “Audit Queries Responded To Hospitals Attains Set standards for: “Audit Queries Responded To and Action Taken by the Hospitals that have been Audited” and Action Taken by the Hospitals that have been Audited”

100% of audit queries 100% of audit queries responded to and action responded to and action takentaken


Acute Coronary Syndrome Case Fatality RateAcute Coronary Syndrome Case Fatality Rate Should not exceed 20% Should not exceed 20% ((<< 20%)20%)

Percentage of Asthma patients Discharged with an Asthma Percentage of Asthma patients Discharged with an Asthma Discharge Plan Document Discharge Plan Document

Not less than 75% Not less than 75%

Percentage of Patients with Ischemic Stroke treated with Anti-Percentage of Patients with Ischemic Stroke treated with Anti-platelet therapy within 48 hoursplatelet therapy within 48 hours

>> 80% 80%

Mild Head Injury Case Fatality Rate Mild Head Injury Case Fatality Rate Not > 5 % Not > 5 %

Percentage of Acute ST Elevation Myocardial Infarction Percentage of Acute ST Elevation Myocardial Infarction

(STEMI) Patients Receiving Thrombolytic Therapy within (STEMI) Patients Receiving Thrombolytic Therapy within

30 Minutes of Presentation at the Emergency 30 Minutes of Presentation at the Emergency

DepartmentDepartment

>> 70% 70%

Dispatch and Ambulance Preparedness for Primary ResponseDispatch and Ambulance Preparedness for Primary Response > 90% with dispatch time of > 90% with dispatch time of

5 minutes or less5 minutes or less


Inappropriate Triaging (Under-triaging) : Percentage of Inappropriate Triaging (Under-triaging) : Percentage of Category Green Patients Who Should Have Been Triaged as Category Green Patients Who Should Have Been Triaged as Category RedCategory Red

Not > 0.5% Not > 0.5%

InappropriateTriaging (OVER- TRIAGING) :InappropriateTriaging (OVER- TRIAGING) :

Percentage of Cat. Red Patients Who Should Have Percentage of Cat. Red Patients Who Should Have

Been Triaged As Cat. Green Been Triaged As Cat. Green

Not > 0.5% Not > 0.5%

Proportion of Radiographs RejectedProportion of Radiographs Rejected < 5% < 5%

Delivered KT/V in patients on centre haemodialysisDelivered KT/V in patients on centre haemodialysis At least 80% of patients At least 80% of patients should have average should have average prescribed KT/V prescribed KT/V >> 1.2 yearly 1.2 yearly

Effectiveness & Appropriateness ofEffectiveness & Appropriateness ofADL intervention of stroke patientsADL intervention of stroke patients

75% 75% of target group should of target group should obtain a score of 70% MBI obtain a score of 70% MBI after a minimum of 8 after a minimum of 8 treatment sessions treatment sessions in 12 in 12 weeksweeks


Incidence of Physical Contamination of Food Served to PatientsIncidence of Physical Contamination of Food Served to Patients SENTINEL EVENT. SENTINEL EVENT.

Incidence of Thrombophlebitis Among ADULT Incidence of Thrombophlebitis Among ADULT

In-patients Receiving Intravenous TherapyIn-patients Receiving Intravenous Therapy

Timeliness in the Preparation of Medical ReportsTimeliness in the Preparation of Medical Reports

Within 14 daysWithin 14 daysNot less than 95 % of Not less than 95 % of

completed medical reportscompleted medical reports Timeliness of Dispatching Medical Records of Discharged Timeliness of Dispatching Medical Records of Discharged Patients to the Medical Records DepartmentPatients to the Medical Records Department within 72 hrs within 72 hrs

Not less than 95%Not less than 95%

Incidence of Massive Primary Post-partum Haemorrhage (PPH) Incidence of Massive Primary Post-partum Haemorrhage (PPH) Not > 0.5% of total no. of Not > 0.5% of total no. of deliveriesdeliveries

Incidence of Recurrent Eclamptic Fits Occurring after Hospital Incidence of Recurrent Eclamptic Fits Occurring after Hospital AdmissionAdmission

Sentinel Event (No cases) Sentinel Event (No cases)


Death Due to Heart Disease in PregnancyDeath Due to Heart Disease in Pregnancy Sentinel Event (No cases)Sentinel Event (No cases)

Community–acquired Pneumonia Death Rate in previously Community–acquired Pneumonia Death Rate in previously healthy children aged from healthy children aged from >>1 month to 1 month to << 5 years 5 years

<< 2.5% 2.5%

Dengue Hemorrhagic Fever Deaths in Pediatric casesDengue Hemorrhagic Fever Deaths in Pediatric cases Sentinel event (No deaths)Sentinel event (No deaths)

Death due to Acute Gastroenteritis in Paediatric patientsDeath due to Acute Gastroenteritis in Paediatric patients Sentinel event (No deaths)Sentinel event (No deaths)

Number of Paediatric Patients Who are Readmitted to HospitalNumber of Paediatric Patients Who are Readmitted to Hospital

For Acute Exacerbation Of Asthma Within 28 Days Of DischargeFor Acute Exacerbation Of Asthma Within 28 Days Of DischargeSentinel eventSentinel event

(No cases)(No cases)

Defaulter Rate of Psychiatric Patients Attending Defaulter Rate of Psychiatric Patients Attending

Outpatients ClinicOutpatients Clinic Less than 15%Less than 15%

Terima Terima KasihKasih

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