Cambodia Situation on Patient Safety

Dr. Sok PoDeputy Director Hospital Services DepartmentIn Charge of Quality ImprovementMinistry of Health

THAILAND LOA PDR

Pailin

Battambang

Banteay MeanChey

Udor Meanchey

Siem Reap

Pursat

Kg. Chhang

Sihanouk Ville KampotKep

KandalKg. Speu

Kg. Cham

Svey Rieng

Prey Veng

Kratie Mondul Kiri

RattanakiriSteung Treng

Kg. Thom

Preah Vihear

Takeo

Koh KongGulf of THAILAND

VIETNAM

GEOGRAPHY

- Location : South-east Asia

- Surface area : 181,035Km2

- Border : Vietnam, Laos, Thailand

- Administration : 25 Provinces/Cities

- Capital : Phnom Penh

- Language : Khmer

- Religion : Buddhism 90%

- Climate : Tropical climate (Rainy/Dry Season)

GEOGRAPHY

- Location : South-east Asia

- Surface area : 181,035Km2

- Border : Vietnam, Laos, Thailand

- Administration : 25 Provinces/Cities

- Capital : Phnom Penh

- Language : Khmer

- Religion : Buddhism 90%

- Climate : Tropical climate (Rainy/Dry Season)

GEO- SOCIO DEMOGRAPHY OF THE KINGDOM OF GEO- SOCIO DEMOGRAPHY OF THE KINGDOM OF CAMBODIACAMBODIA

Overview of Government Health Care System

• Ministry of Health• University Health Science• Nat’l. programs• Nat’l. hospitals• Nat’l. Institute for PH…

• Provincial Health Dept.

• Regional Training Centers:

(4 Kg. Cham, Battambang,

Steung Traeng & Kampot )

Central Level

Provincial Level

Operational District (OD): A Referral hospital and

HCs

The OD is the most peripheral and sub-unit within the health system closest to the population which consist of health centers and

a referral hospital.

Policy and National Initiative to Improve Patient Safety

Accreditation for health care facilities in 2015

QI roadmap

National Policy for Quality in Health

• Oct 2005• Six strategies:

1. Empowering consumer2. Institutional Management3. Clinical Practice4. Professional Development5. Management Development6. Institutionalization of Quality

Road map for Quality Improvement, Oct 2006

Planning

Environment QA office QI working group Working group Hosp Reform Group HTA core group HR (MoH) Med Co NIPH, HRG

Regulation and licensing (private sector) Basic safety PHDs Performance management (public sector) Competence

Enabling legislation Agency Accreditation (public and private facilities) Excellence

National quality policy 2005

Health care financing Human resource management Professional self-regulation Decentralization of management

Six strategies

1 Empowering consumers

2 Institutional management

3 Clinical practice

4 Professional development

5 Management development

6 Institutionalization of quality (MoH)

Patients’ charter MoH

Management standards

Clinical standards

Training, CME

Training, CPD

International principles and frameworks eg EBM, AGREE, ISQua

Plus

CPA, URC tool

Health Sector Strategic plan Institutional development plan

Clinical governance

Information

ST

AN

DA

RD

S

A road map for organisational standards Cambodia, October 2006

Health Strategic Plan 2008-2015Chapter 1, Policy Direction no.5:

“Reinforce health legislation, professional ethics and code of conduct, and strengthen regulatory mechanisms, including for the production and distribution of pharmaceuticals, drug quality control, cosmetics, food safety and hygiene, to protect providers and consumers’ rights and their health.

Health Strategic Plan 2008-2015Chapter 1, Policy Direction no.6:“Improve quality in service

delivery and management through establishment of and compliance with the national protocols, clinical practice guidelines and quality standards, in particular establishment of accreditation systems.”

Master Plan for Quality Improvement in Health 2010-2015

Activities

Monitor client satisfaction in public health service through regular client surveys; and improved communication and coordination between health facilities and Health Centre Management Committees (HCMC), VHSGs, Health Equity Fund implementers, health insurance agencies or HI committee and Commune Councils.

Activities on Patient Safety

Ministry of Health, with technical assistance from WHO, developed the 'Clinical pathway for safe surgical care' (2013)– based on WHO Surgical Safety Checklist– local advisory group (Cambodian surgeons,

anesthetists, nurses and Cambodian Society of Surgery) participated

– Pilot tests (Nov 2012 – Jan 2013)– Rolled out nationwide to all national and

provincial level hospitals with operating theaters (Feb 2013)

• 33 (67.3%) hospitals routinely use clinical pathway

• Provincial hospitals generally showed higher utilization rate compared to national hospitals

National Hospitals

Provincial Hospitals

Total

Number of hospitals visited 6 43 49Number of hospitals currently using the CP 4 (66.7%) 29 (67.4%) 33 (67.3%)

Results

• Routine use of clinical pathway contributes to a decrease in surgical complications

Data from 4 National hospitals Before AfterNumber of cases reviewed 112 117Post-surgical complications Overall complication rate 13 (11.6%) 3 (2.6%) Surgical site infection 1 (0.9%) 1 (0.9%) Fever after surgery 12 (10.7%) 2 (1.7%)

Data from 2 pilot test hospitals

Before(July-Oct, 2012)

During pilot test(Nov2012 – Jan 2013)

After(Mar-Apr 2014)

Number of cases reviewed 100 177 50Post-surgical complications Overall complication rate 20 (20.0%) 4 (2.3%) 1 (2.0%) Surgical site infection 16 (16.0%) 3 (1.7%) 0 (0.0%) Unplanned blood transfusion 2 (2.0%) 0 (0.0%) 0 (0.0%)

Results

• Staff agreed that the clinical pathway:• improved the safety of patients• Improved communication among the surgery team

National Hospitals

Provincial Hospitals Total

Number of staff interviewed 57 192 249

CP is easy to use 53 (93.0%) 173 (90.1%) 226 (90.8%)

CP improves the safety of patients who have operations 57 (100.0%) 173 (90.0%) 230

(92.3%)CP improves communications among the operation team 57 (100.0%) 173 (90.0%) 230

(92.3%)CP should continue to be used in this hospital 57 (100.0%) 173 (90.0%) 230

(92.3%)I experience some difficulties when using the CP 11 (19.3%) 11 (6.4%) 22 (8.8%)

Results

Results• Staff’s reception of clinical pathway is higher in

pilot test hospitals where more intensive staff training was provided

Data from 2 pilot test hospitals BeforeNov-Dec 2012

AfterMar-Apr 2014

Number of staff interviewed 69 20CP is easy to use 64 (92.7%) 20 (100.0%)CP does not take long time to complete 64 (92.7%) 20 (100.0%)CP improves the safety of patients who have operations

68 (98.5%) 20 (100.0%)

CP improves communications among the operation team 68 (98.5%) 20 (100.0%)

CP should continue to be used in this hospital 69 (100%) 20 (100.0%)

“What do you think is the most important factor for sustainable use of the clinical pathway?”

Results

Difficulties faced by hospitals in using the clinical pathway

•Insufficient understanding of the clinical pathway•Lack of cooperation and coordination among staff and teams•Lack of staff (esp. anesthetists) •Lack of commitment from senior staff•Lack of guidance materials and information sources

Recommendations by hospitals for better use of clinical pathway

•On-site staff training on proper usage of the clinical pathway•Refreshment courses for trainers•Monitoring, coaching and follow-up by MoH or other recognized body (e.g. professional societies, universities)•Continuous medical training on patient safety in general

Recommendations by hospitals for better use of clinical pathway

•On-site staff training on proper usage of the clinical pathway•Refreshment courses for trainers•Monitoring, coaching and follow-up by MoH or other recognized body (e.g. professional societies, universities)•Continuous medical training on patient safety in general

18

Activities on Patient Safety

Infection Prevention and Control (IPC)

Policy on Infection ControlNational Strategy Plan for IPC (2011-2015)

19

Activities on Patient Safety Infection Prevention & Control GuidelineIPC Curriculum for training

Challenges• Lack of guidance materials and information sources on Patient Safety• There is no training on patient safety in general• Health care provider fear to report on medical error

25 Oct 2002 E-mail: soksrun@camnet.com.kh 21