Page 11 - Buletin Quality 2018
P. 11

Lean Healthcare Initiatives Implementation in Hospital Pulau Pinang
       General Medical Ward
             General Medical Ward of HPP is the busiest ward in the hospital with 48 beds despite                            10% reduction or
       it is originally designed for 35 beds. The objectives of this project are:                            Percentage Reduction   more each year     10.8% reduction
            •  To reduce BOR to <100% (baseline 35 beds/ward)                                                in the Number of Falls   (based on the   Monthly         Achieved
            •  >80% of patients will be discharge within 4 hours from discharge decision    9    To reduce Patient   (adults)    previous years data
                                                                                                                               as a baseline)
                                                                                                      Fall
       Implemented Measures:                                                                                                 10% reduction or

                                                                                                             Percentage Reduction   more each year   Monthly   14.3% increment
                                                                                                             in the Number of Falls
                                                                                                                              (based on the
                                                                                                             (pediatric patients)   previous years data      Not achieved
                                                                                                                              as a baseline)
                                                                                                                                                       Jan-Mac = 0.5%
                                                                                                  To reduce the
                                                                                                  incidence of                                         Apr - Jun = 0.5%
                                                                                            10    healthcare      Incident Rate of  ≤ 3%    Quarterly    Jul -Sep = 0.5%
                                                                                                  associated   Pressure Ulcers                         Oct-Dec = 0.6%
                                                                                                  Pressure Ulcers
                                                                                                                                                       **All achieved
                                                                                                   To reduce
                                                                                                 Catheter Related        Rate of CRBSI   < 5 per 1000   < 5 per 1000 catheter
                                                                                            11    Blood Stream   (Number of CRBSI per   catheter-days    Monthly           days - Achieved


                                                                                                Infections (CRBSI)   1000 catheter-days)
                                                                                                  in the ICU
        Introduction of visual viewing board       Creation of new discharge lounge
                                                                                                   To reduce
                                                                                                       Ventilator   Rate of VAP (Number                 < 10 per 1000
                                                                                            12         Associated   of VAP per 1000   < 10 per 1000   Monthly    ventilator days
                                                                                                                              ventilator days
       Emergency & Trauma Department (ETD)                                                       Pneumonia (VAP)   ventilator days)                          Achieved
             Patient  attendance  at  the  ETD  is  approximately  360 - 380  patients  daily   with  an   in the ICU
       approximate of 150,000 patients annually. Around 86% are triaged as non-critical but only   To implement an   Implementation of A
       47 % of these patients are discharged within 2 hours. Hence, the objective of this project is   Incident Reporting   Facility-Wide Incident
       to increase the proportion of Green Zone patients discharged within 2 hours to >80%.   13   and Learning   Reporting System   System implemented   Yearly   Yes


                                                                                                   System     (Including RCA) or
                                                                                                              Other Methods to
       Implemented Measures:                                                                                  Investigate Incidents





           Upgrade QMS system   Creation of new Primary Triage   Extend LIS to Green Zone & Installation
                                    counter                of network printers

       Conclusion
             Lean healthcare initiative is an effective way of improving work processes at Medical
       Ward and ETD but its implementation is difficult as there are many enablers and barriers to
       adoption. While the plan to extend Lean Healthcare Initiatives to subspecialty medical wards
       is carried out, a comprehensive policy which focuses on rectifying human resource issues                       MPSG Committee Meeting: 25  January & 17  August 2017
                                                                                                                            th
                                                                                                                                        th
       and underutilization of discharge lounge is required.

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