Tawam Hospital in Affiliation with Johns Hopkins International

Innovative Approaches in JCIA Training

About Tawam Hospital

• 477-bed tertiary hospital in Al Ain

• Highly specialized and well trained doctors and nurses.

• In affiliation with Johns Hopkins Medicine from 2006

• JCI accredited since 2006 and reaccredited in 2009.

• Recognized as Baby Friendly Hospital.

• An educational hospital and training center for faculty of medicine and health sciences- UAE University

Mission Vision & Values

• Mission: To provide a continuum of quality health care which meets the needs and expectations of the UAE population and the surrounding GCC countries. Vision: Tawam Hospital believes in treating all Patients, Visitors and Employees with Respect, Dignity and Equality, guided by UAE laws and respect for patients' rights. Values: Tawam Hospital will provide high quality, affordable medical services delivered in a friendly, safe and caring environment which meets JCIA Standards of Care.

Team Members

• Dr. Mahyar Sadeghi , Chair Dental Center

• Azhar Atlal , Pharmacist

• Dr. Manjula Duhan, Dentist

• Sumaya Al Meqbali, Senior Quality Officer

• Margaret A. Lambert, Senior Risk Officer

• Judy Warren, Infection Control Nurse

• Bachar Mamich, Clerk and Graphic Designer

• Patient Safety Team

• Janelle Quijano, Medication Safety Officer

• Team leader: Mervat Mansour, Section Head , Quality

Challenge

A big challenge of educating non interested staff on important and new topics in a short period of time

How was the Innovative Approach created?

• Intrinsically motivated multidisciplinary team

– Pharmacist , dentist , nurse , 2 quality officers and graphic designer

• Given both the tools and the incentives to produce creative work

11/27/2011 6

Innovation Development- Preparation

Understanding the problem: • Low number of attendants for Joint Commission International

Accreditation lectures

• Ineffective traditional lecturing approaches (dissatisfied attendants )

• JCIA Mock Survey results: Areas of concern:

• Incomplete documentation

• Environmental risks

• Incomplete Medication Prescriptions

– Many newly introduced concepts (sentinel events, Patient Safety Goals, new PPGs )

• Under reporting of incidents

• Loads of new information

11/27/2011 7

4 Phases of Idea Creation ‘ (Wallas, The Art of Thought)

– Preparation

– Incubation

– Illumination

– Verification

4 Phases of Idea Development (Wallas, The Art of Thought)

– Preparation

– Incubation

– Illumination

– Verification

Innovation Development – Preparation &

Information Gathering

• Explored different practices used in other hospitals as Sheikh Khalifa Medial City , Rashid Hospital and Johns Hopkins /USA

• Studied attendants feedback from previous training sessions

• Mock survey results areas of concern

• Literature reviews for best practices

• Identified stakeholders interests

11/27/2011 10

Innovation Development -

Incubation: • Several meetings were held

• Idea generation techniques used

• Active search, research

• Brainstorm

• Critique

• Role Playing

• Sketching

• Attributes listing

11/27/2011 11

Free flow of ideas without deliberate concentration. The attributes wanted:

• Violate previous approaches, assumptions, and conventions

• Grasp attendants attention

• Memorable

• Respects adult learning experiences and help them correlate

Illumination

• A flash of light and joy overwhelmed when innovative ideas have been generated as:

• Lecture- Hall wide snake and ladder game

• Tropical zoo with hanging fruits of knowledge

• House of horror

• Sport games and fun

• Role play as a JCIA assessor for environmental risks and document review

11/27/2011 13

Verification/Evaluation of Ideas

• Anonymous voting

• Cost benefit analysis

• Criteria Weighting Technique

• Objectives Hierarchy

• Prioritization matrix

– Impact

– Ease of implementation

– Attraction

– # of objectives met

– Innovation

Idea Impact

Attraction

Ease of Implementation

Objectives met

Innovation

A

B

11/27/2011 14

Strengths/Weakness of the Approaches Used

Tool Strengths Weaknesses

Brainstorming of Mind Showering

Allows a large volume of ideas to be generated in a short period of time. Also strives to ensure all parties are involved No ideas are discounted initially (later evaluation and filtering undertaken)

while suspension of judgment and going for quantity is necessary for creative thinking, this is not sufficient Brainstorming sessions naively assume that no prior preparation is needed

Forced field analysis

List pro's and con's. List actions and reactions. List strengths and weaknesses. Compare ideal situations and reality. In negotiation, compare the perceptions of opposing parties.

Subjective, not quantitative Difficulty of change is not identified

Criteria Weighting Technique

Offers numerical criteria with which to prioritize. Mathematical process (this is a weakness for some.) Objective; may be best in situations where this is competition among the issues. Allows group to weight criteria differently.

Can become a prolonged and complicated exercise

People Involvement

• How was the stakeholder buy-in acquired?

– Cross representation from different disciplines

– Stakeholders analysis : needs and expectations

– Sketch drawing of the creative ideas

– Open discussion

– Forced field analysis

– Plan and budget approval

Who Sponsored The Project?

• Minimal costs of the sports games < AED 500

• Department Performance Innovation

How Concept was Developed Into A Detailed Plan

• Objectives highlighted and made visible to all.

• Decision tree was depicted

• General theme of “sports day” or fun city

• All possible formats for each topic to be presented were considered with the educational topic owner

• Framework drawn , staff flow sketched

Process

• How was the feasibility of the solution evaluated?

– Sketch of the workflow

– Simulation

– Role playing

– Breakdown of work activities determine staffing, time and resources needed

Risk Assessment

• FMEA , possible failures were identified and counter measures taken to prevent:

– Low attendance Strong marketing plan , prizes, word of the mouth , idea supporters

– Crowdedness timed attendance , proper staffing, U-shape flow, clear instructions

– Physicians resistance : Adult learning techniques and variety of approaches

• Discussion with the senior management

• Piloting on a small number of staff

• Team walk through

Implementation

• The training program included 4 parts:

• Clinic Simulation Room and Role Play

• Document Review

• Sports club

• Room of Horror

Role Play & Simulation Room

A simulation room of “A Dental Clinic “ was prepared with all

possible environmental and medication risks.

Playing the role of a JCIA surveyor, the staff has to assess 36

different environmental aspects and safety practices using a

printed checklist for compliance with JCIA requirements.

Department of Performance Innovation

Observation Compliant Non

compliant

Environment of Care

1 No electric hazards could be identified

2 There is no potential risk of injury for patient or staff

3 Eye wash is available to use when needed

4 Instrument Cabinet is used only for instruments

5 Sharp boxes are correctly utilized , and locked

6 Fire exit is clear and safe to use

7Extinguishers are available / ready to use when needed (After you finish the

tour , check extinguishers in the waiting area)

Infection Control

8 Red bags are used for medical wastes

9 Black bags are used for non medical, non hazardous wastes

11 Contaminated instruments are properly stored

12 Suction equipments and water lines are flushed through

13 Used single use disposable consumables are disposed properly

14 The patient's room is clean ;body fluid spills are properly cleaned

15 Personal protection equipments, as gloves, are available to use when needed

16 Personal protection equipment, gloves and gowns are available to use when needed

Medication Safety

17 Medications are stored in their specified cabinet/drawer

18Medications used for external use are stored separately from those

for internal use

19 Dental drug box is appropriate

20 Dangerous abbreviations are not used in the medication prescriptions

21 As needed "PRN" prescriptions are written correctly.

Assessment of Patient

22 Patient is identified correctly

23 "Medical History Form: is filled properly

24 "Medical History Form " is complete

25 Patient pain is assessed and reassessed when needed

Care of Patient /PFR

26 Patients file/information is kept confidential

27 General Consent Form is properly filled

28 Specific Consent Form is properly filled

29 Time out is documented before procedures

30 Treatment Plan is properly filled

31 Name and signature are written for each entry

32 Referral Form is properly filled

33 X- ray is verified for the name and Health Card Number

Patient and Family Education ( PFE)

34 Patient and family needs were assessed and addressed

35 Patient and Family Education Record is multidisciplinary

36Name, signature and designation of staff providing the education are

documented

Dear Staff ,

Please read the scenario and enter simulated patient room to discover all compliant

and noncompliant areas with the JCIA requirements; Surprises are hidden… Mark

this sheet then check your observations posted on answer sheet. Scenario:

Part 2 :Document Review

• The simulation room is followed by document review for a medical file that has copy of real progress notes, x rays and medication prescriptions with errors ( details of patients and physician were deleted) = staff identify 10 different errors. Learning by doing.

Part 3 Mini- Sports Club

– The lecture hall was turned into a mini-sports club hall for 3 days: 6 different sport games including basket ball, shooting, Boling , cricket , darts ,etc

– To participate in each game, staff has to answers 4- 6 different questions related to the topic.

Part 3 Mini- Sports Club

– The information were presented in posters , take away leaflets , question & answer quizzes , videotapes broadcasting and JCIA Q&A booklet.

– “ Fishing your prize” after finishing all the games.

Room of Horror

• Underreporting of incidents: fear of blame

• 3 incidents only reported in 3 months

• Room of Horror

– Anonymous reporting of incidents

– Dual objectives: Education about the 28 different types of error that should be reported

– Based on Trianti’s Thoery of constraints

– Analogy: fear of error, ease when reporting it

Trianti’s Theory of Constraints

• Based on Triantis’ Behavioral Modeling Theory, probability of behaving in a particular situation is governed by the following equation:

• Probability of act = [habit + intention *] x [motivation x facilitating condition]

Heinreich’s Ratio1

1 Major injury

29 Minor injuries

300 No-injury

accidents

300

29

1

For each 1 major incident reported , it is expected to have 29 minor injuries and

300 no –injury accidents 2.

2. An Organization With a Memory, A report of an expert group on learning from adverse events in the NHS chaired by the

Chief Medical Officer, The Stationary Office, London 2000

1. Heinreich HW Industrial Accident Prevention, NY And London 1941

Room of Horror

• A small room (1m x 1m ) that has no light

• Covered ceilings with black textile

• Hanged scary masks

• Played scary music and sounds

• Provided a small lantern

• “Do you dare to enter?”

Room of Horror • A2 size check sheet of the common incidents with clear instructions on how

to fill and a message: “By reporting Incidents, you Might Save live “We posted the check sheet in the room.

• At the entrance one staff for instructions

• One staff at a time was allowed to enter.

• In a confidential and exciting way staff reported any accident he/she had experienced in the last 3 months by ticking the incident/s from a list of possible incidents that could happen at the Dental Center.

Results

• Dazzling results

• 85 % of Dental Center staff attended voluntarily

• Happy and satisfied clients -92% overall staff satisfaction with the JCIA Fair

• # of reported incidents increased by 125 times

• Idea replicated at Tawam Hospital JCIA Fair and other satellites

• Substantial increase in documentation compliance

• Reduction in the number of rejected medication prescriptions

Indirect Benefits

• Increased patients and staff safety

• Less medication errors

• Reduction in the number of rejected mediations prescriptions

• More awareness about environmental risks

• A more realistic estimate of the number of incidents

• Memorable experience

• Satisfied staff

Way Forward

• Recognition :

– Party for all staff involved

– Thank you letters

• The idea was replicated in Tawam's JCIA Fair, simulating a patient room

– Patient had pressure ulcer and wound scoring was required from the visitors in addition to identifying all risks in the room

– More topics included

• No intellectual property, everyone is encouraged to replicate

Lessons Learnt

Never get afraid of thinking outside the box.

It is always nice to see life from a different perspective

A Final Thought

Innovation is both art and science… It feeds on big challenges, sharing of information, collaboration , freedom to explore, and endless flow of ideas.

Q & A

Thank you