Quality Management in Philippine Nursing Practice:

How are we doing it?Maria Isabelita C. Rogado, RN, MAN, DNScSecretary, World Federation of Critical Care NursesPresident, Critical Care Nurses Association of the Philippines, Inc.

The Philippines consists of 7,107

islands population of about 100

million people tropical maritime

climate and is usually hot and humid

175 individual languages

Filipino and English are the official languages

The World Health Organization's ranking of the world's health systems. Source: WHO World Health Report, 2000

Rank Country 1 France 2 Italy 3 San Marino 4 Andorra 5 Malta 6 Singapore 7 Spain 8 Oman 9 Austria 10 Japan 11 Norway 12 Portugal 13 Monaco 14 Greece 15 Iceland 16 Luxembourg 17 Netherlands 18 United Kingdom 19 Ireland 20 Switzerland 21 Belgium 22 Colombia 23 Sweden 24 Cyprus 25 Germany 26 Saudi Arabia 27 United Arab Emirates 28 Israel 29 Morocco 30 Canada 31 Finland 32 Australia 33 Chile 34 Denmark 35 Dominica 36 Costa Rica 37 United States of America 38 Slovenia 39 Cuba 40 Brunei 41 New Zealand 42 Bahrain 43 Croatia 44 Qatar 45 Kuwait 46 Barbados 47 Thailand 48 Czech Republic 49 Malaysia 50 Poland 51 Dominican Republic 52 Tunisia 53 Jamaica 54 Venezuela 55 Albania 56 Seychelles 57 Paraguay 58 South Korea 59 Senegal 60 Philippines 61 Mexico 62 Slovakia 63 Egypt 64 Kazakhstan 65 Uruguay 66 Hungary 67 Trinidad and Tobago 68 Saint Lucia 69 Belize 70 Turkey 71 Nicaragua 72 Belarus 73 Lithuania 74 Saint Vincent and the Grenadines 75 Argentina 76 Sri Lanka 77 Estonia 78 Guatemala 79 Ukraine 80 Solomon Islands 81 Algeria 82 Palau 83 Jordan 84 Mauritius 85 Grenada 86 Antigua and Barbuda 87 Libya 88 Bangladesh 89 Macedonia 90 Bosnia-Herzegovina 91 Lebanon 92 Indonesia 93 Iran 94 Bahamas 95 Panama 96 Fiji 97 Benin 98 Nauru 99 Romania 100 Saint Kitts and Nevis 101 Moldova 102 Bulgaria 103 Iraq 104 Armenia 105 Latvia 106 Yugoslavia 107 Cook Islands 108 Syria 109 Azerbaijan 110 Suriname 111 Ecuador 112 India 113 Cape Verde 114 Georgia 115 El Salvador 116 Tonga 117 Uzbekistan 118 Comoros 119 Samoa 120 Yemen 121 Niue 122 Pakistan 123 Micronesia 124 Bhutan 125 Brazil 126 Bolivia 127 Vanuatu 128 Guyana 129 Peru 130 Russia 131 Honduras 132 Burkina Faso 133 Sao Tome and Principe 134 Sudan 135 Ghana 136 Tuvalu 137 Ivory Coast 138 Haiti 139 Gabon 140 Kenya 141 Marshall Islands 142 Kiribati 143 Burundi 144 China 145 Mongolia 146 Gambia 147 Maldives 148 Papua New Guinea 149 Uganda 150 Nepal 151 Kyrgystan 152 Togo 153 Turkmenistan 154 Tajikistan 155 Zimbabwe 156 Tanzania 157 Djibouti 158 Eritrea 159 Madagascar 160 Vietnam 161 Guinea 162 Mauritania 163 Mali 164 Cameroon 165 Laos 166 Congo 167 North Korea 168 Namibia 169 Botswana 170 Niger 171 Equatorial Guinea 172 Rwanda 173 Afghanistan 174 Cambodia 175 South Africa 176 Guinea-Bissau 177 Swaziland 178 Chad 179 Somalia 180 Ethiopia 181 Angola 182 Zambia 183 Lesotho 184 Mozambique 185 Malawi 186 Liberia 187 Nigeria 188 Democratic Republic of the Congo 189 Central African Republic 190 Myanmar

#60 PhilippinesOut of 190 countries

What is the status of care in the Philippines?

Do we meet the standards of quality care?

Are the standards of quality care defined?

Landscape information

Nursing supply and demand issue

Changes in disease patterns

Issues on Patients’ satisfaction

Nursing Shortage:A Supply and Demand Issue

Demand:Patient acuity levels and care needsAgency hiring practices/staffing patternsDemographic trends

Supply:Entry into professionAging and retirementAttrition from jobs and from profession

PHILIPPINE HRH SITUATION

Human resources for health are enormous but unevenly distributed in the country

The Philippines is a major source of health professionals to other countries◦Leading exporter of nurses to the world◦Second major exporter of physicians

Large exodus of nurses and physicians (as nurses) in recent years has been unparalleled in the migration history of the country.

PHILIPPINE HRH SITUATION High unemployment rate for new nurses: lack of

positions for nursing jobsMigration of trained nurses

◦Inward migration to urban centers High employment in urban areas Low employment at rural areas

◦Outward migration abroadHigh training expenses of new nurses for local

employment as replacement to those who migrated abroad

Position Title

Salary Grade

Secondary Hospitals Teaching and Training Tertiary Hospitals

100-beds 150- beds 200-beds 300-beds 400-beds

Nurse I 10 48 36 55 83 106Nurse II 14 74 116 137 175 226Nurse III 16 5 7 12 39 31Nurse IV 18 0 0 2 1 18Nurse V 20 1 1 1 2 4Nurse VI 22 0 0 1 2 2Nurse VII 24 - - - 1 1

Source: DBM, 2007

Plantilla Positions for Hospital Nurses, 2007

Government Position

Professionals Monthly Wage(Basic Pay + Guaranteed / Regular

Cash Allowance in USD)

Doctors 320 Nurses 250General Secondary Educator

400

Pre-elementary Educator 420College / University Educator

680

Accountant Auditor 460Electrical Engineer 660

Source: Bureau of Labor and Employment Statistics, Occupational Survey, 2002

Comparison of Average Monthly Wage Rates of Selected Professions, 2002

Numbers of Nurses (Production)Advanced Beginners in

Most Field of Nursing

Affecting Quality of Care

Distribution of Nurses According to Years of Experience

N = 832

0-1 Year 1-2 Years 2-3 Years 3-4 Years 4-5 Years 5 Years 6-25 Years0

50

100

150

200

250 223

159

191

96

72

16

75

Total Staff nurses

27% 19% 23% 11% 9% 2% 9%

Chong Hua Hospital, Cebu CitySeptember, 2014

15

Globalization, Urbanization,Emerging Threats and Health Systems

Mudslide flooding due to cyclones and typhoons in the Philippines

Health Care Scenarios70% of disease pattern are related to:• Non-communicable disease• Psychiatric Mental Problems•Trauma

Millions die each year, needlessly!(Risk Care Group LLC, December 2005)

One billion people lack access to health care systems

36 million deaths each year are caused by non-communicable disease

Over 7.5M children under the age of 5 die from malnutrition

6.7M people die of infectious diseases (WHO, 2008)

Tuberculosis kills 1.7M each year Malaria causes 225M acute illness and

780,000 deaths annually AIDS/HIV has spread rapidly

◦ 33.4M living with AIDS◦ 2.7M new infections◦ 2M deaths

Now, its EBOLA

Millions die each year, needlessly!(Risk Care Group LLC, December 2005)

Health care scenarioschallenges

the management of Quality care….

19

Are patients satisfied or dissatisfied with health services, given the many advances in medical science, health professions, technology?

20

Why are patients dissatisfied?

“Disease” rather than “illness” or person-focused care—supply driven, rather than customer driven health services

Limited patient voice in treatment decisions Lack of a conducive atmosphere for expression of anxieties,

distress Mechanical care for many patients, those with terminal

illnesses Lack of privacy, protection of dignity; environments not

conducive to recovery Costs too high or unaffordable

(Kathleen Fritsch, WHO)

Findings from interviews with people with chronic conditions

People want: More time with their doctors and nurse Better explanations about their conditions Less unsettling failures in communication Assistance with accessing and coordinating services Assistance with the costs of health care Recognition of their life and culture Acknowledgement of links between mental and

physical health

21

(Kathleen Fritsch, WHO)

The “Perfect Storm” Demographic trends

in the profession Financial pressures

within health care Demand for health

care and demand for nursing services within the health care system

October 2001, NOAA Active Satellite Archive

In this “perfect storm”How can we manage quality care?

Safe: avoiding injuries to patients from the care that is intended to help themEffective: providing services based on scientific evidence to all who could benefit and refraining from providing services to those not likely to benefit – avoiding underuse and overusePatient-centered: providing care that is respectful of and responsive to individual patient preferences, needs and values, and ensuring that patient values guide all clinical decisionsTimely: reducing wait times and potentially harmful delays for both those who receive and give careEfficient: avoiding waste (administrative and operational) particularly waste of equipment, supplies, and human resourcesEquitable: providing care that does not vary in quality because of person characteristics such as age, gender, ethnicity, geographic location and socioeconomic status.

(IOM 6 Aims for Improvement in the 21st–century Health Care System)

?

X

Culture of Safety An environment that encourages others to

talk about errors◦ What caused them◦ How to stop them

People should have access to information Providers should have protection to

encourage reporting and prevent mistakes from happening again

Nursing programs about quality are concerned with the quantitative assessment of nursing care as measured by proven standards of nursing practice.

Quality management system motivates nurses to strive for excellence in delivering quality care and to be more open and flexible in experimenting with innovative ways to change outmoded systems.

Total Quality Management

http://currentnursing.com/nursing_management/total_quality_management_health_care.html

“Quality assurance is a judgment concerning the process of care, based on the extent to which that cares contributes to valued outcomes”.

(Donabedian 1982)  “Quality assurance as the monitoring of the activities

of client care to determine the degree of excellence attained to the implementation of the activities”.

(Bull, 1985)  Quality assurance is the defining of nursing

practice through well written nursing standards and the use of those standards as a basis for evaluation on improvement of client care

(Maker 1998)

Concepts of Quality

Quality StoriesCritical Care Nurses Association of the Philippines, Inc.

Improvement Initiative

BEYOND TURNING:Reducing the rate of Hospital-acquired Pressure Ulcer

Aeron Coronado, RNNeurocritical Care Unit & Epilepsy Monitoring UnitSt. Luke’s Medical Center-Quezon City

First story…..

DISCLAIMER: WHO WE ARE

St. Luke’s Medical Center – Quezon cityNeurocritical Care Unit and Epilepsy Monitoring unit

18 Critical Care Nurses, 1 Department Manager and

1 Neurointensivist

Pressure ulcer: Facts and Figures

1 2 37 5 0

Reported pressure ulcer out of the 196

adult patients admitted in 2012

Reported pressure ulcer out of the 124 adult

patients admitted from January to June 2013

Of the 118 adult patients admitted in Neurocritical Care unit from July to December 2013, none of them develop pressure ulcer

New Perspective, New Initiative

It simply goes BEYOND TURNING.

Beyond Turning addresses the challenges and opportunities of pressure ulcer prevention to the nursing workforce.

Six Sigma is a set of techniques and tools for process improvement.

Six Sigma seeks to improve the quality of process outputs by identifying and removing the causes of defects (errors) and minimizing variability in manufacturing and business processes

Getting Started

5 required phases of a Six Sigma projectD - DesignM - MeasureA - Analyze

I - ImproveC - Control

DEFINE MEASURE

Process Improvement: DMAIC Methodology

Process Improvement: DMAIC Methodology

ANALYZE ANALYZE

BEYO

ND

TRU

NIN

GSURPRISING FACTS

Lack of proper knowledge on pressure ulcer is common among nurses.

Skin care issues previously reported as pressure ulcer are not really PU in the strictest sense.

Not all pressure ulcers are preventable

GOAL: Reduction of Hospital-acquired Pressure Ulcer by 50% in 6 months

Spread the Message!

PROCESS IMPROVEMENTORIENTATION

Calling it the Right thing

Calling it the Right thing

Moisture lesion

Intertrigo

Making our campaign visible

Pressure ulcer updates through online courses

Pressure ulcer courses

Huddle on skin care issues

Working closely with Managers

Utilization of Mobile appsFor Pressure ulcer

Family matters

The patient, family and caregivers are key to

prevention, management and treatment of pressure

ulcers. -Agency for Healthcare Research and

Quality, 2012

Partners in CARE

30DAYS

50 DAYS

BEGINHERE

15DAYS

100DAYS AND

COUNTING

Pressure ulcer: Results

*International Guideline: Pressure Ulcer Treatment Technical Report, NPUAP & EPUAP 2009

1 2 37%* 3.57% 2.07%

Incidence rate 7 out of the 196 adult patientsdeveloped pressure ulcer in

2012

5 out of the 241 adult patientsdeveloped pressure ulcer in

2013

Decrease of HAPU in

2013!142%

WHAT IS NEXT?WHERE DO WE GO FROM HERE?

SKIN SAVERS

Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it’s the only thing that ever has-Margaret Mead

IPUP survey orientation

“ The practice of being humble enough to admit that someone else is better at something and being wise enough to try to learn how to match and even surpass them at it.” (DTI, 1992)

Also, you can recolor the entire video or apply a video style easily. Your videos will look great!

MAKING METRICS MEANINGFUL!

PRESSURE ULCER PREVENTION:TAKE-HOME LEARNINGS

» KNOWING is one thing. UNDERSTANDING is another thing

» Nothing is great than EVIDENCE-BASE PRACTICE

» Great things come from small beginnings

» Team work divides the task and multiplies the success

» Change is easier when you know where you are going and why it’s worth it.

WE LEARNED THAT…

Big changes can start with very small steps. Small changes tend to snowball.

“It is only a question of how much you want it and how much you are willing to give to

have it.”-NCCU Staff Nurses 07/15/13

“QUALITY STORIES” IN

THE ICUH O L D O N T I G H T:

A PROJECT ON THE CARE OF INTUBATED PATIENTS IN THE ICUs

KATHERINE A. FLORES, RNStaff Nurse – Neuro Critical Care Unit/ Surgical Intensive

Care UnitS

Second story……

UNPLANNED SELF-EXTUBATIONS Reported

incidence ranging from 4.47% to 22.5% of mechanically ventilated

patients (Chang, L. etal, 2009)

INCREASED MORBIDITY AND MORTALITYOccur in 31 to 78% of

cases

Possibly…

Requiring re-

intubation

Complicated by

ArrhythmiasBronchial AspirationDifficulty in Re-intubation

Even DEATH

2011 20120

1

2

3

4

5

6

7

8

9

Unplanned Self-Extubations in SLMC GC ICUs

(Pre-intervention Phase)

UNPLANNED SELF-EXTUBATIONS:

TRENDING THREAT IN PATIENT SAFETY!

2011 Intervention:Routine Restraints

Application

Aug-12

Sep-1

2Oct-

12Nov

-12Dec

-12Jan

-13Fe

b-13

Mar-13

Apr-13

May-13

Jun-13

Jul-13

Aug-13

020406080

100120140160180200

Endotracheal Tube Device Days in the ICUs from August 2012 to

August 2013

Total device days of 1,461 for study inclusion (943 NCCU/ SICU/ MICU cases and 518 CCU cases).

SCOPE: Adult patients intubated with an ET inserted through the mouth and admitted in Adult Critical Care

Units from August 2012 to August 2013

Behavior (Combative, Agitated, Light sedation)Improperly secured endotracheal tube

Poorly/ loosely placed ET tapeInadequate ET tape length

Restraint applicationLoosely placed restraintsInadequate points used

Staffing (2:1 patient-nurse ratio for level IV cases, Junior staff nurses)

Poor Positioning (Bed elevation and position allows patient to lean towards side, enabling the patient to reach endotracheal tube

Positioning and Bed Elevation

Restraints Application

New ET Tape Method

HOLD ON TIGHTTHREE MEASURES OF CARE

October 2012:Initiation of Measures

January 2013:Full Implementation

Aug-12

Sep-1

2Oct-

12Nov-

12Dec-

12Jan

-13Feb

-13Mar-

13Apr-

13

May-13

Jun-13 Jul-

13Aug

-130

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

0

1.4

1.13

0 0

0.85

0 0 0 0 0 0 0

Monthly Analysis: Occurrence Per 100 Device Days of Self-Extubations from Au-

gust 2012 to August 2013

Target threshold of less than 0.56 per 100 device days

Reported incidence rate of 4.47% (or 0.56 per 100 device days) to 22.5%[*Supported by Chang, L. etal in 2009 (Taipei, Taiwan), with citations to the papers of Moons, P. etal. (Belgium) and Yeh, S. etal (Taiwan)]

Target threshold of less than 0.56 per 100 device

days occurrence is achieved by the

project

2011 2012 20130123456789

8

21

Incidences of Self-Extubations in the ICUs from 2011 to 2013

October 2012:Initiation of Measures

Number of unplanned self-extubations in the

ICUs: decrease in trend from 2011 to mid-year of 2013

2nd Week of October 2012• Use of new

ET Tape Method

• Orientation of staff to new ET Tape Method

3rd Week of October 2012• Orientation (to

new hires) of proper patient positioning and bed elevation

• Re-orientation (to senior staff)

December 2012• Procurement

of new restraints

January 2013• Orientation of staff to

new restraints• FULL

IMPLEMENTATION OF MEASURES

IMPROVED PATIENT

SAFETY IN THE ICUs

UNPLANNED SELF-EXTUBATIONS

TRENDING THREAT IN PATIENT SAFETY!

“There's only one corner of the universe you can be certain of improving,

and that's your own self.”- Aldous Huxley

“Without good and careful nursing many must suffer greatly, and

probably perish, that might have been restored to health and

comfort, and become useful to themselves, their families, and the

public, for many years after.” Benjamin Franklin (1751)