country profile on: patient safety issues and efforts: malaysia

COUNTRY PROFILE ON: PATIENT SAFETY ISSUES AND EFFORTS: MALAYSIA presented by:

Dr. Kalsom bt. Maskon Deputy-Director Medical Development Division Ministry of Health Malaysia 1

A. A BRIEF DESCRIPTION OF THE MALAYSIAN HEALTHCARE SYSTEM

2

MINISTRY MINISTRY OF OF HEALTH HEALTH MALAYSIA MALAYSIA

The Malaysian health care system By: Dr. Kalsom Maskon Deputy Director Section on Quality in Healthcare Medical Development Division MOH, Malaysia 3

Malaysia MALAYSIA

4

MALAYSIA

PERLIS

THAILAND

KEDAH P.PINANG W.P.LABUAN PERAK

KELANTAN

SABAH

TERENGGANU

BRUNEI SOUTH CHINA SEA PAHANG

SELANGOR W.P. KUALA LUMPUR

N.SEMBILAN SA RAWAK MELAKA

JOHOR

SINGAPORE

INDONESIA

INDONESIA

5

Country Profile * Malaysia occupies a central position within Southeast Asia including two land masses separated by the South China Sea * Multi - ethnic population (Malay, Chinese, Indian, Others) •Estimated population :25million (2003) :32 mill (2020) * Relatively young population * Population average growth rate 2.5%

6

Socio-Economic Indicators (2003) Per capita income : RM 14,098 (3710 USD) Economic growth : 5.5% Inflation rate : 2.0% Unemployment rate : 3.1% Dependency ratio : 58.5% Urban population : 62% * Population served with : 87% (rural) safe water supply 98% (urban) * Population with : 98.4% (rural) adequate sanitary latrines: 100%(urban) * 1999 data

7

Population trend by age group 25 20

4.3%

3.7%

15 10 MILLION

6.8%

5 0

1990

2000

2020

0-14

6.75

7.89

8.93

15-64

10.56

13.77

20.87

65+

0.67

0.99

2.19 8

Health Care Provision PUBLIC SECTOR *Ministry of Health (MOH) : Major provider *Ministry of Education *Ministry of Defense *Ministry of Housing and Local Government *Ministry of Home Affairs *Ministry of Human Resource PRIVATE SECTOR TRADITIONAL/COMPLEMENTARY MEDICINE NON-GOVERNMENTAL ORGANIZATIONS.

9

National Referral System, MOH, Malaysia

National Referral Centres Regional Hospital/State Hospital

INSTITUTIONAL CARE

Hospitals with Specialists in Districts

Ambulatory Care Centres

Hospitals without Specialists in Districts Health Clinics 1 : 20,000 population Rural/Community Clinics 1 : 4,000 population

PRIMARY HEALTH CARE

10

RURAL PRIMARY EALTHCARE Community Clinic Community Clinic

(2,000 - 4,000)

Health Clinic

Community Clinic

Community Clinic Coverage : 15,000 - 20,000 population

11

Health facilities MOH &Private MOH FACILITIES

Public Health Health Clinics Community Clinic Mobile Teams

PRIVATE FACILITIES 845 1,924 204

MOH HOSPITALS Hospitals 118 (Acute Beds) (34,089) Medical Institutions 6 ( Chronic Beds) 5,456)

Private clinics : > 5,000

PRIVATE HOSPITAL Hospitals : 219 Beds :10,405

12

B. PRINCIPAL PROBLEMS RELATED TO PATIENT SAFETY IN MALAYSIA presented by: Dr. PAA Mohamed Nazir bin Abdul Rahman Principal Assistant Director Section on Quality in Healthcare Medical Development Division Ministry of Health Malaysia 13

Malaysia’s Experience So far, no major magnitude and finesse of :

studies of the methodological

The Harvard Study of Medical Practice or The Quality in Australian Healthcare Study 14

Malaysia’s Experience Problems concerning safety in: Public Sector hospitals: addressed by various Quality Improvement activities in MOH Private sector: Individual hospital’s interest, “Benchmarking study” conducted in 19 hospitals in private sector in 2002 15

Malaysia’s Experience Public sector problems related to patient safety involve : surgical-related disciplines certain“incidents”

e.g. preventable adverse events

hospital-acquired infection

16

Malaysia’s Experience Data on specific problems related to patient safety: will be presented together with a description of the various Quality Improvement activities that target patient safety ……. in the next section 17

C.

Patient safety initiatives

QUALITY ASSURANCE PROGRAMME

Started in 1985 – indicator approach Presently 20 Quality Improvement activities covering a number of approaches 18

QUALITY ASSURANCE PROGRAMME IN MINISTRY OF HEALTH • Launched in 1985 (with implementation of Patient Care Services QA Programme) • QAP expanded to Ð Public Health Services (1990) Ð Pharmaceutical Services (1990) Ð Dental Services (1992) Ð Engineering Services (1992) Ð Laboratory Services (1992) Ð Training & Manpower Services (1996) Ð Planning Division (1998)

QAP ORGANISATIONAL STRUCTURE

20

The The MOH MOH Steering Steering Committee Committee Programme Programme Level Level QAP QAP Committee Committee State State QAP QAP Steering Steering Committee Committee State State QAP QAP technical technical sub-committee sub-committee Hospital Hospital // District District QAP QAP Committee Committee 21

MEDICAL PROGRAMME QAP: QI Activities That Target Patient Safety

22

MOH Operational Definition of QUALITY (2001)

Facilities and services are of high quality if they are: 1. 2. 3. 4. 5. 6.

SAFE Effective Appropriate Equitably accessed Efficient Patient-centred and consumer-friendly 23

QI ACTIVITIES IN THE MEDICAL CARE PROGRAMME ….. They deal with performance in ……… (a) (b)

Technical aspect Inter-personal aspect of Q

hospital

of Q (Caring)

24

Technical

Quality

Indicator Approach (i) National Indicator Approach (NIA) (ii) Hospital Specific Approach (HSA) (iii) (iv) (v)

Patient Safety Council of Malaysia Incident Reporting Hospital Infection Control 25

Clinical

Review)

(vii) (viii) (ix)

Audit

(Internal

Peer

Perioperative Mortality Review (POMR) Intensive Care Unit audit Nursing audit

26

External Peer Review (x)

Hospital Accreditation Programme

Explicit Process Measurement (xi) Clinical Care Pathways for mgt. of: Acute Myocardial Infarct, Asthma, Head Injury, Eclampsia (in various stages of development) 27

OTHER QUALITY IMPROVEMENT ACTIVITIES IN THE MOH MALAYSIA TARGETING PATIENT SAFETY

MATERNAL MORTALITY REVIEW/ PERINATAL MORTALITY REVIEW CLINICAL PRACTICE GUIDELINES (CPG) INNOVATIONS CREDENTIALING OF MEDICAL STAFF HEALTH TECHNOLOGY ASSESSMENT (HTA)

PATIENT SAFETY IN MALAYSIA

29

Making

Patient Safety a National Agenda

The Hon. Health Minister tabled a Cabinet Note on Patient Safety to Malaysian Cabinet Recommended formation of the Patient Safety Council of Malaysia Approved by Malaysian Cabinet : 29th January 2003 30

Patient Safety Council : Composition Chaired by : Director- General of Health Malaysia

Secretariat : Section on Q in Healthcare, Med. Development Div. MOH Representatives – public and private sector - Universities -professional bodies -consumer groups 31

PSCoM : Terms of reference Advise Hon. Health Minister on : national priority areas and strategies for patient safety and quality improvement in healthcare Gives importance to Clinical Risk Management 32

6

Sub-committees

Data and Information

Consumer Education and Empowerment

Continuing Education Medication Safety Transfusion Safety

Safe Staffing and Quality of Work Life

33

NATIONAL INDICATOR APPROACH (NIA)

34

National Indicator Approach (NIA): Common indicators & standards to measure quality in the various areas of concern INDICATORS : monitored nationally investigated locally to identify shortfalls in Q Action taken for correction. Knowledge gained used to design better systems of care provision 35

NATIONAL INDICATORS TARGETING SAFETY MEDICAL PROGRAMME

36

HOSPITAL-WIDE INDICATORS 1. 2. 3. 4. 5.

Delay in surgery for : very urgent cases Unplanned return to operating theatre Unplanned re-admissions within 48 hours of discharge. Incidence of pressure sores in nonambulatory patients Trauma patients returning to the Emergency department within 24 hours of first consultation. 37

SURGICAL INDICATORS 6.

Incidence of Plaster of Paris cast complication.

7.

Incidence of complications following ritual circumcision

38

ANESTHESIA INDICATORS 8. Occurrence of adverse events during recovery period. 9. Unplanned admission to ICU within 24 hours of surgery.

39

UROLOGY INDICATORS 10.

Morbidity from Percutaneous Nephrolithotripsy (PCNL)

11. Morbidity from Transurethral Resection of Prostate(TURP).

40

DIAGNOSTIC & IMAGING INDICATORS 12. Morbidity associated with Percutaneous needle aspiration cytology/Biopsy of chest and abdomen –pneumothorax 13. Morbidity associated with Percutaneous needle aspiration cytology/Biopsy of chest and abdomen - hemorrhage 41

PHYSIOTHERAPY INDICATORS 14. Burns during delivery of electrotherapeutic modalities and thermal agents.

42

DIETARY INDICATORS

15. Incidence of physical food contamination.

43

NURSING INDICATORS 16. Incidence of Thrombophlebitis in

patients therapy.

receiving

intravenous

44

NOSOCOMIAL / HOSPITAL INFECTION CONTROL

45

Achievements: 'Point Prevalence Survey‘ undertaken nationally since 2003

-

Collection of data on Hospitalacquired infections : MRSA data - 14 State hospitals starting 1 July 2002 ESBL data

since August 2003

46

Results of monitoring (MRSA) (Jan. - December 2003)

14 hospitals

Total MRSA = Total In-patient Admissions = Average National Rate

3 132 87,9116

= 0.35 % 47

Twice-yearly Point Prevalence Surveys : Indicators for Monitoring of Nosocomial infections 5 types of Nosocomial infections surveyed (March, September yearly) (i) (ii)

UTI - symptomatic & asymptomatic Surgical site infections - superficial - deep incisional - organ / space

48

Nosocomial infections … continued

(iii) (iv) (v)

Pneumonia Blood Stream infections Clinical sepsis

49

Point Prevalence Survey in 14 hospitals

Total Nosocomial cases Total Patients

Percentage

March ‘03

Sept. ‘03

731

583

9 407

9 559

7.7%

6.1%

50

Prevalence Survey Pneumonia (24.5% & 26.6%) SSI (21.9% & 21.6%) ”Targeted surveillance” for Ventilatorassociated Pneumonia (VAP) dan SSI : in 2004 Concentrating hospitals

on

ICUs

in

14

State 51

Determining: - Norms for Infection Control Nurse in MOH hospitals ( 1 : 250 occcupied beds)

- every ward to train a 'link nurse' 52

Training & Continuing Education: - Development of “Post-Basic” courses in Infection Control -

“APSIC” course conducted by Malaysian Infection Control Society 2 weeks duration

Awareness Programme & ”Hand Hygiene” dan “Standard Precautions” 1,500 persons trained in all States except Perak & Pulau Pinang

53

PERI-OPERATIVE MORTALITY REVIEW

54

Perioperative Mortality Review: A

national level study to identify:

remediable factors leading to mortality within the length of hospital stay of Patients who had undergone surgery In order to improve the quality of patient care 55

Definition of perioperative mortality: A death occurring within the length of hospital stay of a surgical or gynaecological procedure done under general or regional anaesthesia 56

POMR REPORTING SYSTEM Death Occurs in Wards

Anaesthetic Doctor

Ward Sister- Document biodata & inform doctor

Surgical Doctor

POMR Coordinator (Hospital Matron)

Head of Anaesthesia review Case

POMR Secretariat

Surgical Head Review Case

For Assessment by POMR Committee Prepares Reports/Case summaries & Recommendations

57

POMR Findings Executive Summary POMR Reports 2nd & 3rd Inadequate pre-operative preparation, assessment and lack of consultation identified as major contributing factors

58

POMR Deaths

85% of deaths occurred during emergency procedures 33% of these deaths were in patients > 60 years old 62% of patients were ASA - IV &V 43% of patients had associated medical illness 59

RECOMMENDATIONS OF THE POMR COMMITTEE

Reorganising the Operating Theatre services to give priority to Emergency cases

Developing protocols and guidelines to manage ill patients

Ensuring appropriate pre-operative consultation and optimisation of patients. -adequate assessment and preparation of patients for surgery. Ensuring greater specialist participation in treating ill cases

60


Ensuring the adequate matching of surgical and anaesthetic skills in carrying out operations

Increasing the number of anaesthetic specialists in the hospitals

Properly-equipped and staffed trauma centres and burns units to manage the growing number of major trauma and burns cases. 61


Increasing the number of Intensive Care Unit beds and creating step-down facilities such as High Dependency Wards (HDW) Ensuring the effective and appropriate utilisation of these beds

62


Complex surgery should only be undertaken if adequate critical care facilities are available Forming retrieval teams to transfer ill and unstable patients from smaller centres to higher levels of care Conducting regular Morbidity and Mortality meetings at the hospitals

63

Products of POMR

POMR Report-biennial POMR Assessors Manual POMR Bulletin- 20th COTDS-computerised OT documentation system Guidelines for emergency cases TAC –technical advisory committee • ICU/HDU beds, burns unit in major hospitals

Opening of two OTs for emergency cases

64

ACHIEVEMENTS : 1. Developments of policies and guidelines. 2. Improvement in OT, ICU and HDU services. 3. Improvement in Training and Supervision. 4. Computerised OT Documentation System. 5. Provide inputs for future development of Surgical, Anaesthetic and Trauma Services, facility development and Human Resource planning for the 8th and 9th Malaysia Plan. 65

Perioperative Mortality Review (POMR) Actions taken as a result of reports) 1.

POLICY : Pediatric “major

surgery” can only be performed by Paediatric Surgeons

2. Special ambulance system to transport neonatal patients 66

Policies and recommendations Established Paediatric ICU in each State or Regionally Public patients needing care not available in Government hospitals can have the care outsourced from private hospitals (out-sourcing of a service) when referred by a Government doctor 67

National Audit on Adult Intensive Care Units (NAICU)

68

National Adult ICU Audit Objectives: To identify remediable factors in the provision of ICU services in Malaysia and hence improve the quality of ICU services

69

National Adult ICU Audit 14 Hospitals involved: all State hospitals (>4 ICU beds) -

data collection using a standard format – “SYNAPSE SOFTWARE” Analisis of ICU data 70

Findings

71

ICU beds by sector (as on August 2003) No. ICU

No. ICU Beds (%)

Average No. Bed

MOH state hospitals

15

142 (27.9)

9.5

MOH district hospitals

24

80 (15.7)

3.3

University / Military hospitals

5

54 (10.6)

10.8

Private hospitals

40

233 (45.8)

5.8

Total

84

509 (100)

6.1

Definition of ICU bed = hemodynamic monitoring plus mechanical ventilation Government ICU beds = 276 (54.2%)

ICU beds = 1.1% of total hospital beds 72

Referrals for ICU admission 1600 1400

Total referrals 8615

1200 1000

4911 (57%) denied admission

800 600 400 200 0 A

B

C

D

E

F

Admitted

G

H

I

J

K

L

M

N

Not Admitted

73

Findings

Severe shortage of ICU beds Performance of ICU comparable with overseas centres High percentage of admissions from operative-emergency patients Disproportionately high mortality in operative elective patients

74

Recommendations

In-depth audit of outcome for major elective surgeries

Urgent need to increase intensive care facilities

75

INCIDENT REPORTING

INCIDENT REPORTING

a system of reporting any unintended occurrences which could have (“near-miss”) or caused harm (“adverse events”) to the patient 31 “incidents” monitored nationally

Root Cause Analysis / Problem analysis conducted at local level

INCIDENTS MONITORED FOR ALL LOCATIONS

1.

Medication Error

2.

Adverse

3.

Adverse Transfusion

4.

Transfusion Error

5.

Adverse Outcome of Procedure

6.

AOR Discharges

7.

Equipment- related Incidents

8.

Patient Falls in

: Reaction

Drug

Reaction

Ward

9.

Staff falls in Ward

10.

Needle Stick

11.

Complaints by Patients and / or Relatives

Injury 78

OPERATING THEATRE INCIDENTS

1. Cardiac / respiratory Arrest 2. Wrong Procedure Performed

3. Prolonged Stay in Recovery Room for more than 2 hours

4. Operative Consent Error

5. Incorrect Instrument or Swab Count

6. Elective Surgery Cancelled in OT

7. Reintubation 79

ICU INCIDENTS Accidental Extubation Readmission to ICU within 24 hours of Discharge to Ward Unexpected Death Complications during Stay in ICU LABOUR ROOM INCIDENTS Death of Fetus Weighing > 800grams or > 28 weeks of gestation Poor Apgar Score Injury to Neonate during Delivery 80

PRIVATE HEALTHCARE FACILITIES & SERVICES ACT 1998 - Section 37 REPORTABLE INCIDENTS

Unexplained Deaths of patients

:

Injuries to patients involving: • brain or spinal cord injuries • falls resulting in fractures, dislocations, concussions or lacerations extending beyond the epidermis into deep tissue or which threaten vital structures • life-threatening (or potentially fatal) complications of anesthesia • life-threatening (or potentially fatal) transfusion errors or reactions • 2nd or 3rd degree burns involving > 20 % surface area (adult) or 15 % (child) 81

PRIVATE HEALTHCARE FACILITIES & SERVICES ACT 1998 - REPORTABLE INCIDENTS

: Fires resulting in death or personal

injury

Assault or battery of patients by employees or other persons Malfunction or intentional or accidental misuse of patient care equipment that would have significantly adversely affected a patient or employees of the healthcare premises 82

PRIVATE HEALTHCARE FACILITIES & SERVICES ACT 1998 - REPORTABLE INCIDENTS

Utility system failure that resulted in or : to an “incident” contributed significantly Suicide of a patient Infant abduction or discharge to the wrong family Rape Surgery on the wrong patient or wrong body part Medication error resulting in harm to the patient 83

HOSPITAL ACCREDITATION PROGRAMME

84

DEFINITION OF ACCREDITATION “a self-assessment and external peer review process to accurately assess level of performance in relation to established standards and to implement ways to continuously improve the healthcare system” ISQua definition : Federation Operating Rules 1998 85

MALAYSIAN HOSPITAL ACCREDITATION STANDARDS

Emergency Allied Health Pro. Anaesthetic Critical Care Services CSSU Day Only Surgery Engineering & Building Environmental Food Governing Body/Mgmt.

AREAS OF PRIORITY

Housekeeping Pathology Linen Radiology Medical Records Medical-Surgical Nursing Operating Suite Pharmacy General

Organization and Management. Human Resource Development and Management. Policies and Procedures Facilities and Equipment. 86 Quality Improvement Activities SAFETY

VOLUNTARY REQUEST PREPARATION & STANDARDS INTERPRETATION SELF-EVALUATION BY HOSPITALS AGREEMENT ON SURVEY DATES SURVEYORS’IDENTIFICATION/APPOINTMENT/CONCENSUS SURVEY COORDINATION PRE-SURVEY ASSESSMENT

SURVEY

87

FULL ACCREDITATION Ð 3 YEARS 1 YEAR ACCREDITATION FOCUS SURVEY

+ 2 YEARS AWARD

NON-ACCREDITATION 88

QUALITY IMPROVEMENT IS A NEVER-ENDING JOURNEY, AND NOT A DESTINATION

T TH HA AN NKK YYO OU , U , FFO ORR YYO OU RR U A AT TT TEEN NT TIIO ON N 90