Page 28 - Buletin Quality 2018

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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