The Culture to Cultivate: A Quality Initiative for the

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Hospital Culture & Its Impact on Quality Care

The Culture to Cultivate: A Quality Initiative for the National Healthcare – A Study on Hospital Culture & Its Impact on Quality CareKidney Hospital & Lifeline Medical Institutions 63&64, Waryam Nagar, Cool Road, Jalandhar-144001, Punjab

Key words: Quality of Care, Quality of Improvement Strategies, Right culture, Retaining, Devising, Quality Drivers, Internal Processes, Customer Satisfaction

ABSTRACT

Hospitals across the country are searching for ways to improve quality of care and promote effective quality improvement strategies. This research study, by members of the Management of Kidney Hospital & Lifeline Medical Institutions, identifies and describes the key factors that contributed to the success of Kidney Hospital’s journey towards excellence. Essential elements of a successful strategy, according to the study, include developing the right culture, attracting and retaining the right people, devising and updating the right in-house processes, and giving staff the right tools to do the job. Through information gleaned from site visits and in-depth interviews with these high-performing staffs, the study assesses quality drivers, internal processes, and challenges, and offers guidance and actions steps to help hospitals move in the right direction.

Introduction – Our HospitalKidney Hospital & Lifeline Medical Institutions Super specialty Hospital, which has super specialties like Urology, Andrology, Nephrology, Transplant Surgery, Gastroenterology, Hepatology, Pancreatology, Gastrointestinal Surgery, and specialties like General Medicine, General Surgery and Pulmonary & Chest Medicine.

The hospital was established in the year 1990. Kidney Hospital & Lifeline Medical Institutions is driven by the vision of creating “quality healthcare services by continually upgrading & improving the medical care by entailing the finest medical skills combined with compassionate patient care”.

Our Vision“Quality Healthcare by compassionate medical professionals, accessible & affordable to all”. The underlying intent is to make Kidney Hospital & Lifeline Medical Institutions as the benchmark for quality healthcare in this region.

Our MissionTo evolve as a benchmark in quality healthcare available to one & all. ²

To be the Centre of excellence for research & academics. ²

To cultivate an environment of trust, honesty, mutual respect, equality & ethics. ²

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Kidney Hospital & Lifeline Medical Institutions

Our Quality PolicyWe are committed to render quality health care services by continually upgrading our skills and resources for the satisfaction of our patients and their relatives.

Our Quality ObjectivesBest quality patient-care. ²

Judicious use of drugs and appropriate interventions. ²

Compliance with the highest standard of medical ethics. ²

Continual improvement of skills and keeping abreast of latest developments. ²

To carry out all processes for the first time, on time and every time. ²

Executive SummaryHospitals across the country are searching for ways to improve quality of care and promote effective quality improvement (QI) strategies. The findings from this study offer guidance and action steps to help hospitals move in the right direction. To promote greater use of practices and policies that enhance quality and QI in hospitals, this research study identifies and describes the key ingredients that have contributed to the success of our high-performing hospital. Through site visits and in-depth interviews with each of these top performers, we assessed specific internal factors and external pressures that drive quality. Additionally, we considered supportive tools and processes, challenges the hospital face, and lessons they offer other hospitals.

Objectives1. Developing the right culture for quality to flourish.2. Attracting and retaining the right people to promote quality.3. Devising and updating the right in-house processes for quality improvement.4. Giving staff the right tools to do the job.

MethodologyKidney Hospital & Lifeline Medical Institutions developed a three-stage methodology to perform this study.

First, we used two data sources to identify top-performing Departments based on both health outcomes and Patient & Employee Satisfaction.

Second, we conducted in-depth site visits to these departments to learn how they are achieving good results.

Third, we interviewed more typical patients and their attendants around the hospital to determine the extent to which they are satisfied with our culture.

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The Four Core Values We Follow

1. Instil a Supportive Culture and PoliciesKidney Hospital & Lifeline Medical Institutions have a striking degree of motivation and commitment to ensuring high-quality care and fulfilling the Quality Improvement mission.

This commitment is reflected in and nurtured by the active leadership and personal involvement on the part of the Director, CEO and other top managers, through an explicit quality-related mission and aggressive quality-related targets; standing and ad-hoc quality committees; regular reporting of performance indicators with accountability for improved results; and the promotion of a safe environment for reporting errors.

2. Attract and Retain the Right PeopleHigh-quality physicians, nurses, managers, and ancillary staff are critical to producing high-quality outcomes and effective quality improvement. Top-performing departments stressed the need for selective hiring, credentialing, and re-credentialing. Successful recruitment and retention of nursing staff was tied to an absolute respect for and empowerment of nurses—who must be treated as full partners in patient care and given opportunities for advancement. All are expected to be good team players, able to participate in multi-disciplinary teams for both QI and patient care management.

3. Develop Effective In-house ProcessesQI department of Kidney Hospital & Lifeline Medical Institutions are adequately staffed, have credibility with physicians, and are trained to facilitate the problem-solving process. Deficiencies in outcomes are not hidden or ignored, but instead are used to inspire an iterative process of discovery followed by corrective actions and accountability. Effective problem-solving leads to the development of evidence-based protocols and critical paths, and enhanced efficiencies such as reduced turn-around time for test results and reduced errors related to standardization of supplies and procedures.

Another important process involved team-based care management. A key to success involves making sure physicians and other caregivers accept the case manager’s or team leader’s role in coordinating and facilitating care.

4. Provide the Right Tools to Do the Right JobKidney Hospital & Lifeline Medical Institution also give their physicians, nurses, and other staff the tools and support they need to practice high-quality medicine on a daily basis and to identify and investigate quality problems when they do surface.

It also includes access to guidelines and protocols, and support to physicians in developing a consensus around their own evidence-based best practices so they have tools they are actually willing to use. Other tools involve external training, peer networking, and conferences.

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Our Journey Towards Our Culture & Our Culture Towards Excellence

Our Culture1. Prayer – The Beginning of the Care (Culture of Dedication)

Hospital prayer

Kidney Hospital & Lifeline Medical Institutions believe that Without the Blessings of God, Nothing will be possible. Here, in each shift the entire staff of the hospital before starting their duty will gather together at the designated place and will pray to god in the form of a prayer song and dedicate themselves to the God for making them capable to treat the patient, the community and to serve the hospital better. Initially the participation for the prayer were only from the staff side but later on the patients and attendants started to join with staff for the prayer. Now we enjoy a home feeling in the hospital atmosphere.

2. In-charge’s Department Introduction & Hierarchy (Culture of Obedience)

Incharge explaining the department hierarchy to the supervisor

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Once somebody visits any department of the hospital, the staffs that are present after the self-introduction will start to explain the hierarchy of the department which is already displayed outside the departments. Soon after presenting the hierarchy the department incharge takes the over and start to present the entire department. The advantage of this culture is that if anybody comes from outside they become aware that whom to contact in case of any issues or to lodge a complaint. The other thing is that the entire staff of the department is well aware that whom they are responsible and answerable.

3. StaffSelfIntroduction(Cultureofconfidence&help)

Housekeeping staff introducing himself to the Senior Manager

4. Good Morning Sir, Myself Sonu, Housekeeping Department, May I Help You

Here in Kidney Hospital & Lifeline Medical Institution’s every corner you will hear a word “May I Help You”. From Bottom to Top level whenever the staffs meet each other and whenever the staff meet the patient they present themselves to the other and offer help each other. Through this culture we found and developed cooperation among staff and assurance of proper care and concern to the patient and their family members. Our aim behind this culture was to offer the needed service without any request.

5. Staff Working Station Presentation (Culture of awareness)

Staff presenting the working station

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Various SOP’s and Protocols which the staffs are supposed to follow and practice in their respective area are already displayed in the Station itself. Here once the management team takes official round in the hospital or during the individual round by the management team the staffs is supposed to explain the protocols and various SOPs as seen in the picture. We believe that only placing the protocol on the wall will not make staff aware about the Standard operating procedure but continuous explanation and presentation about the SOPs will help them to make these protocols as part of their day today life. These cultures help them to provide their care to the patients without any complaints.

6. Patient Presentation by Nursing Staff (Culture of intimacy)

Nursing staff presenting his patient to the Consultant

In Kidney Hospital we promote a culture of Deep Care to the Patients by the dedicated staff. We believe that if staffs are fully dedicated to the patient care, then they will be able to present their patient status and details even without the help of a file or other records. Here all the medical officers and Nursing staff are fully aware about their patients and their conditions. During the rounds of the consultants and the management staff the staffs is able to present the patient without seeing file. The way how the staff present their patient is attached below.

“Good Morning Sir, Myself Sr Renu, May I Help You, Please Come & Let Me Present My Patient, She is Mrs. Kamaljit Kaur, Diagnosis is CKD, She is admitted under Nephrology Department, Patient is stable, Vitals are checked and recorded, Intake and output is maintained, Back Care and Mouth Care done, No bed sore, Pain Scale is Zero, No any fresh complaint”.

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7. Staff Near to the Patient—No centralised Nursing Station (Culture of personal touch & approachability)

Allotted staff sitting on the allotted area

Here we don’t believe in the system of centralised nursing stations or duty stations where the patient or the attendant have to go to the nursing stations or duty stations to call the staff for their care or to remind them or to ask something about their expected care. We believe that as care providers we should be always in the reach of patient and the particular patient shall be the under the close observation of the staff always. Here, the staffs sit on the patient care area only that is in the wards itself and the patient doesn’t want to call, ask or request to the staff for anything as they are already under the close observation.

8. OfficialRoundbytheManagementStaff(Cultureofsupport)

Official round by the management staff

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We believe that if the management sit on the office without any touch with staff and to the patients then the purpose of the management is partial. So here the management has a organised an official round during which they will interact with the staff and each patient personally to assess the care. Through this the implementations of protocols and various standards have a practical background. Once the staffs are well aware about that the management staff will meet each patient personally and will take a personal feedback they offer their best to satisfy the patient. The problems find or arise during this round will provide immediate solution as the decision making authorities are on round.

9. Care Auditor’s Round (Culture of commitment)

Nursing Superindent in the role of care Auditor

Here in Kidney Hospital & Lifeline Medical Institutions our aim is to offer maximum support and care in both physically and psychologically to the patient. We believe that after doing our best also if the patient is not satisfied then that should undergo for a thorough evaluation and we should improve in it. In order to analyse the depth of our care that we offer to the patient we come up with an idea of Care Auditor. Here the care auditor goes to each patient care area and present herself or himself in the following way.

“Good Morning to All, Myself Sr. Renu, Am the Care Auditor of the Hospital, We wish you a speedy recovery from your diseases, and we are dedicated to serve you and we assure you that we will serve you our best. Here is my Colleague Sr. Priya; she is dedicated for the care of you for the next six hours, if you have any kind of problems kindly share with her. Thank You So Much for giving us an opportunity to care you.”

Through this culture the patient feel free to interact with our care auditor as team discussion and we get the proper feedback about our care which helps us to improve further.

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10. Patient Greetings Protocol (Culture of trust)

Staff greeting the Patient during the time of hand over of the duty

At the time of the end of the shift the staff cared the patient for the last six hours goes to the particular patient along with the new shift staff and tell the patient that “ Sir, My duty is over, Thank you for giving me an opportunity to care you. She is Sr. Geeta, now for the next six hours she will be taking care of you”. Then the staff who takes over Greet the Patient saying “Sir, My name is Geeta, Next six hours I will be taking care of you, I wish let my care remove your Pain and bring smile on your face”. We experienced improvement in the trust level of the Patient and a satisfactory smile. We believe through this culture we are able to provide a mental support to the suffering.

11.SafetyCounsellingbytheSecurityOfficer(Cultureofsafety)

Security officer giving safety counselling to the patients

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Disasters occur sudden without any prior information. So it was a question mark how to educate the patient regarding the safety as they come only for one or two days stay in our hospital. From this the idea araised for a safety counselling and become a part of our Culture. Here, two times in a day our security officer visits the Patient Care Areas and educates the patients and attendants regard the safety aspects in the hospital.

“Good Morning to all, I would like to convey you three things regarding safety. 1. Use the electrical appliances safely, 2. Once you step down from the bed please be careful 3. If you find fire and smoke in the hospital, pleas press the fire safety button located in every floor.

12. Swatch Sunday-2010 Onwards (Culture of clean care & safer care)

The staff cleaning premisis during Swatch Sunday

13. Discharge with a Flower (Culture of happiness & self satisfaction)

The staff who cared the patient offering a flower at the time of discharge

We believe that no one in this world will like to get admitted in a hospital due to disease. And the same way the happiest moment for a patient is in his hospital stay will be the moment that the consultants tell “Today is your Discharge”. Here our thinking was make

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the patient to feel that even though they are at hospital; make them feel that they are at their home only. After the care of a patient and made him free from diseases, for a staff it boost up her self-satisfaction by offering a flower with a smiling face and telling him all the best. Patient feels very happy to accept that flower once they are totally happy.

14. Home Care Education Cell (Culture of promoting health)

Inauguration of Home Care Education CellWe believe that every health care institutions main aim is to make the community healthy and keep them away from diseases. We care the patient who is sick but we should educate them how one can be away from diseases. This led us to an idea of establishing a Home Care Education Cell for the Public. Every Wednesday from 10 am to 11.30 am there will be a health education session for the patient attendants and to the public regarding how to be away from diseases and various precautionary measures to be taken not to get diseased. We get the participation beyond our capacity for this programme and good number of requests to conduct these programmes in various villages. Through this culture, we feel Moral satisfaction.

15. Training on Culture & Culture on Training (Culture of learning)

Training session in the orientation room

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Orientation room

In health care set up once we are dealing with life care, a small mistake can harm a life. Usually the word Training itself hard to accept for a staff as they start to feel that they are inferior in practice. We made training as our passion and a part of our day today life. Once in rounds or in charges report if any staff found lacking the skills next day onwards that staff will be on training and after proper training that staff will be back to duty. We have specially designed a Orientation room for the staff where they get idea about all the process and protocols. Now it is been found that the staff comes themselves ahead requesting for training and within one or two hour the requested staff found trained. So ultimately the patient, staff and the hospital is benefitted.

16. Nursing Excellence Week (Culture of improvement & excellence)

Nursing excellence week programme

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Every year 8th December to 13th December we celebrate as Nursing Excellence Week. During this week we evaluate the entire performance of the Year and implement new programmes for the excellence. Here through these programmes we appreciate the staff that performed well in the previous year and takes new challenges for the coming year.

Impacts of Our Culture

1. High Level Patient Satisfaction

DefinitionValued Suggestions and support help to make our hospital a better organization.

Calculated By:Sum of downtime for all critical equipment in hours / Uptime of the equipment

Hospital Services in Form(IPD & OPD)

Hospital Stay, Hospital Environment, Ward Facilities, Toilet cleaning, Food Diet, Attending Doctor and Nurses Services, Hospital Billing, Reception/Enquiry Service, Admission Process, Discharge Process and Overall Rate the Hospital

MONTHS-2014 PLEASANT SATISFACTION UNPLEASANT TOTAL NO. OF FORMS

August 94% 5% 1% 150

September 96% 4% 0% 102

October 98% 2% 0% 138

November 98% 2% 0% 130

December 99% 1% 0% 190

Patient Satisfaction Rates

% of PatientSatisfaction

120 –

100 –

80 –

60 –

40 –

20 –

0 –

94

5 1 4 0 2 0 2 0 1 0

96 98 98 99

Pleasant

Satisfaction

Unpleasant

August September October November December

– – – – – –

2. High Level Employee SatisfactionDefinition Patient Satisfaction is defined in terms of the degree to which the patient’s expectations are

fulfilled. It is an expression of the gap between the expected and perceived characteristics of a service

Calculated By:Score achieved × 100 / Maximum possible score

MONTHS-2014 VERY-SATISFACTION SATISFACTION UNSATISFACTION

July to December 90.9% 7.1% 2%

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Employee Satisfaction Rate

90.9

7.12

% of Satisfaction

Score

Employee SatisfactionRate

Very ...

Satisfa.

..

Unsatis.

.....

100–90–80–70–60–50–40–30–20–10–0–

3. Less Employee Turnover Rate

Definition

Turnover or Staff turnover or labor turnover is the rate at which an employer gains and losses employees. Simple ways to describe it are “how long employees tend to stay” or the rate of traffic through the revolving door”

Calculated By:Number of employees who left during the year × 100 / Number of employees at the beginning + at the end of the year.

Percentage of Employee Turnover Rate

MONTHS 2013 ATTRITION NO. OF EMPLOYEES PERCENTAGE

September 4 240 1.7%

October 5 241 2.0%

November 5 250 2.0%

December 5 250 2.0%

Employee Turnover

1.7

2 2 2

% of Turnover

Employee Turnover

Septem

ber

Octobe

r

Novembe

r

Decembe

r

2.05–2–

1.95–1.9–

1.85–1.8–

1.75–1.7–

1.65–1.6–

1.55–

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4. High Level of Safety Awareness

DefinitionCalculated ByNo. of employees adhering to safety precautions × 100 divided by No. employees sampled

MONTHS-2014NAME OF THE DEPARTMENTS

NURSING STAFF % ICU % O.T % DIALYSIS % LABORATORY %

August 82 92 93 92 91

September 83 92 94 93 92.4

October 88 92 95 94 93

November 91 98 97 96 95

December 96 98 98 99 97

Safety Precautions

Nursing Staff

ICU

OT

Dialysis

Laboratory

82 8388

92959493 9198 98989997 9796 9695

92 92949392.49292193

120–

100–

80–

60–

40–

20–

0– August September October November December

5. Low Level of Medication Errors

Definition

A Medication error is any preventable event that may cause or lead to inappropriate medication use or harm to patient examples: wrong drug, wrong strength, and wrong patient, wrong route of administration error.

Calculated By:Number of Medication error / Number of Inpatients in that month × 100

MONTHS-2014 ERROR RATE INPATIENTS PERCENTAGE

August 0 1593 0.0%

September 0 1773 0.0%

October 0 1680 0.0%

November 0 1343 0.0%

December 0 1444 0.0%

Total 0 7833 0.0%

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August

Septem

ber

Octobe

r

Novembe

r

Decembe

rTot

al

Medication Error

% of Error

Medication Error1–

0.9–0.8–0.7–0.6–0.5–0.4–0.3–0.2–0.1–

0–0 0 0 0 0 0

6. Decrease in Hospital Acquired Infections

Definition

A hospital-acquired infection is usually one that first appears three days after a patient is admitted to a hospital or other health-care facility. Infections acquired in a hospital are also called Nosocomial Infections.

Calculated ByTotal No of Infections after 48 hrs. × 100 / Total no of Admissions

MONTHS-2014 Infection Admissions PERCENTAGE

August 19 (Phlebitis)

435 4.3%

September 19 (17 Phlebitis and 2 others)

445 4.2%

October 24(23 Phlebitis and 1 others)

412 5.8%

November 19(16 Phlebitis and 3 others)

380 5%

December 30(25 Phlebitis and 5 others)

384 7.8%

August

Septem

ber

Octobe

r

Novembe

r

Decembe

r

Percentage

Months 2013

Hospital AssociatedInfection Rates

Hospital Associated Infection Rates

4.3 4.2

5.85

7.89–

8–

7–

6–

5–

4–

3–

2–

1–

0–

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ConclusionHospitals, to survive, must be transformed into responsive, participative organizations capable of new practices that produce improved results in both quality of care and service at reduced costs. Creating, managing, and changing the culture are critical leadership functions that will enable the hospital to succeed. Strategic planning and effective implementation of planned change will produce the desired culture. Work restructuring, a focus on quality management along with changes in clinical practices, as well as the care and support processes, are all a part of the necessary hospital cultural revolution.

“Happy Hospitals Make Happy Patients”

Documents

The Culture to Cultivate: A Quality Initiative for the