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Clipboard Issue 62& 63 Issue 62 & 63 April-September 2012

Clipboard A Quarterly Update on Management Issues from the Administrators Section of the Christian Medical Association of India Dear Members, Greetings from the Administrators Section of CMAI!

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he National Conference of the Administrators’ Section was held in Guwahati from 11 to 13 October 2012 at Don Bosco Institute which is located on the banks of the river Brahmaputra. The beauty of God's creation provided the perfect ambience for the Conference. A lot of learning experiences were there. I will cover them in the forthcoming issues of Clipboard. In 1999, a book entitled “To Err Is Human - Building a Safer Health System” was published by Institute of Medicine in the US. This book gave a jolt to the people of America as it pointed that there were about 98,000 deaths due to medical errors in 1997. Since then, awareness began spreading regarding patient safety. WHO has taken up the matter seriously and has provided a lot of useful information. In India too a number of organisations including NABH have sought to highlight the need for patient safety.

In this edition of Clipboard I am presenting the following articles pertaining to patient safety. 1. Patient Safety – Hospital Administrators Role 2. IAPO Policy Statement on Health Literacy for Patient Safety 3. Key Facts About Patient Safety – NPSF 4. 10 Facts About Patient Safety – World Health Organization (WHO) 5. What Pilots can Teach Hospitals about Patient Safety - a New York Times Report. Please send in your comments and suggestions.

Stephen Victor Secretary, Administrators' Section stephen.victor@cmai.org

Biblespeak Jesus Heals the Inner Condition

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ark 2: 3-5: Then they came to Him, bringing a paralytic who was carried by four men. When Jesus saw their faith, He said to the paralytic, “Son, your sins are forgiven you.” The friends lower this paralytic through the ceiling; he is placed

before Jesus. Externally, he was paralysed but his inner condition is that he could not forgive himself. Not only could he not forgive himself, he thought even God could not forgive him. It is in this context that Jesus said, ‘My son, your sins are forgiven.’ Today we have so many psychosomatic problems; the spirit within is not well. External wellness means nothing if the spirit within is not well. This is what Jesus addressed in the life of the paralytic.

Rev Dr Roger Gaikwad General Secretary of the National Council of Churches in India (NCCI)

To err is human, to cover up is unforgivable, and to fail to learn is inexcusable. Sir Liam Donaldson speaking at the launch of the World Alliance for Patient Safety

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Clipboard Issue 62 & 63

Patient Safety – Hospital Administrators Role

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Stephen Victor – Secretary, Administrators Section

he Medical fraternity is abuzz with a lot of discussion on patient safety. Workshops, seminars, consultations etc have been held across the globe including India but in practice very little is being done to ensure that healthcare is delivered with utmost care avoiding human or systemic errors. While our doctors and nurses have been well educated in the cardinal principles of patient safety they have little or no time to implement safe practices. Hence the onus falls on the Hospital Administrator to overcome this major hurdle and take concerted efforts to see that patient safety is ensured. This article gives practical tips to Hospital Administrators to make the necessary interventions that would keep the patients safer.

Set systems in order Health professionals aim to deliver safe, high-quality healthcare while minimising the chance of a medical error occurring. Occasionally, however, all human beings can, and do, make mistakes. The current thinking on medical error is that it is often not, or not solely, the fault of individual health professionals, but rather due to a variety of reasons, and occurs mainly as a result of deficiencies in the health systems themselves. For example, a study in the USA found that 75% of adverse drug events are attributable to system failures. Most errors result from problems with procedures and work processes rather than bad or incompetent people. An error

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may result from increasing specialisation and fragmentation of healthcare which impact on the continuity of care for a patient; higher than average patient to nurse ratios; and manufacturing errors (e.g. mislabeling of medicines).

Follow health literacy principles A good health literacy programme includes giving a clear and understandable message, with relevant and tailored content, culturally and linguistically appropriate format, listener involvement and pilot testing on key audiences. This should also be applied to all new recruits as well as to older employees as a refresher course.

Use the services of an interdisciplinary monitoring group The NABH document talks about this under “Responsibility of Management ROM.5” Leaders ensure that patient safety aspects and risk management issues are an integral part of patient care and hospital management a) The organization has an interdisciplinary group assigned to oversee the hospital wide safety programme. b) The scope of the programme is defined to include adverse events ranging from “no harm” to “sentinel events”. c) Management ensures implementation of systems for internal and external reporting of system and process failures.

d) Management provides resources for proactive risk assessment and risk reduction activities

Facilitate hand washing In order to ensure that proper hand washing takes place firstly provide clean water which is available round the clock. Make available enough number of wash basins with soap dispensers and tissues. There should be a system in place to ensure that liquid soap and tissues are replaced before they are over. Locate the washbasins at strategic locations for that they could be easily accessed.

Avoid patient falls Are all beds maintained with proper railings for protection? Hospital beds need periodic inspection to verify whether the railings are stable and perform their functions without fail. Patients who are bulky or those who are prone to epileptic convulsions may apply heavy pressure on the railings when they move towards to edge of the bed. Therefore due care should be taken to keep the railing strong and sturdy. Are your ramps made to the right specification? Improper ramps can lead to patient falls from trolleys/wheel chairs. The following is the correct specification for ramps according to the National Building Code: (a) General : A ramp in a hospital shall not be less than 2.25 mts (7½ ft.) wide in addition to satisfy the fire fighting requirements. (b) Slope : A ramp shall have slope of not more than 1:10. It


Clipboard Issue 62& 63 shall be of non-slippery material. (c) Handrail : A handrail shall be provided on both the sides of the ramp.

Purchase medicines from reliable sources Substandard and even spurious medicines have been put in the market by unscrupulous elements. The hospital administrator’s duty is to carefully choose the genuine supplier of medicines. In many cases the supplier who boasts of his ability to supply medicines at rates much lower than the market price may be selling spurious products. A few years back a survey in SouthEast Asia found that in 38% of

104 anti-malarial drugs for sale in pharmacies did not contain any active ingredients.

Record and analyse medical errors In most cases medical error occur and are immediately covered up and efforts are taken to play down the incident. It rarely gets recorded and properly investigated with the needed documentation. Sweeping such incidents under the carpet is dangerous. Primarily this prevents a proper analysis of the event which allows pinning the reason behind the episode. Secondly the possibility of learning from such an experience so that such events are prevented from recurrence is lost.

The NABH has given guidelines under the follow sections: Continuous Quality Improvement CQI.6 Sentinel events are intensively analysed a) The organisation has defined sentinel events. b) The organisation has established processes for intense analysis of such events. c) Sentinel events are intensively analysed when they occur. d) Actions are taken upon findings of such analysis. The standards call for continuous monitoring of sentinel events and comprehensive corrective action plans leading to building of quality culture at all levels and across all the functions.

Key Facts About Patient Safety – National Patient Safety Foundation (NPSF) What do we mean when we talk about patient safety?

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octors, nurses, and other health professionals dedicate their lives to caring for their patients. But providing healthcare can be complicated. There are often multiple steps involved in a health care visit. A number of different medical staff may take part in the care of a single patient. And patients may be confused by unfamiliar words and technical language. Although hospitals, clinics, and doctor’s offices take many steps to keep their patients safe, medical errors can happen. Often, medical errors (also called adverse events) happen when there

is a single misstep in a chain of activities.

It can also mean the wrong surgery was performed.

Patient Safety Challenges

Wrong-site surgery is rare and preventable, but it does still occur. Between 1995 and 2010, 956 wrong-site incidents were reported to the Joint Commission (the Joint Commission is an organization that reviews and grants accreditation to health care institutions in the US). One study surveyed surgical procedures from 28 hospitals and found the incidence of WSS to be approximately 1 in 112,994 procedures.

Researchers and experts in the field of patient safety have identified a number of ongoing patient safety challenges. Below are descriptions of some of the most common and worrisome issues. 1. Wrong-Site Surgery 2. Medication Errors 3. Health Care-Acquired Infections 4. Falls 5. Readmissions 6. Diagnostic Error 1. Wrong-Site Surgery (WSS) Wrong-site surgery means an operation done on the wrong part of the body or on the wrong person.

2. Medication Errors Medication errors are unfortunately very common. According to the Institute of Medicine’s July 2006 report Preventing Medication

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Clipboard Issue 62 & 63 Errors, medication errors harm an estimated 1.5 million Americans each year, resulting in upward of $3.5 billion in extra medical costs. Medication errors include cases where the wrong medication is given, where the wrong dose of the right medication is given, or when medication is given the wrong way (for example, in pill form rather than liquid) or when it is given at the wrong time. According to WHO estimates 10% of all drugs worldwide have been faked. 20% of drugs sold in India are fake, fear experts. ASSOCHAM estimates that the lethal market is growing at 25% annually. (Times of India 14 May, 2008) 3. Health Care-Acquired Infections A health care-acquired infection (HAI) is an infection a person gets while being treated for a medical condition. HAIs may occur in patients who are treated at a medical facility or in their homes. An infection is considered to be an HAI when it occurs after treatment begins. HAIs are often discovered within 48 hours of admission to a health care facility, but other infections may also be considered HAIs. The three most common types of HAIs are: • Catheter-related bloodstream infections:Catheter-related bloodstream infections, (CRBSIs), are among the most common infections in patients who are admitted to critical care units. These infections occur when bacteria and other germs travel down a “central line” and enter the bloodstream. • Hospital-acquired pneumonia: Hospital-acquired pneumonia (HAP) is an infection

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of the lungs that occurs 48 hours or longer after admission to a hospital. This pneumonia tends to be more serious because patients in the hospital are often sicker and unable to fight off germs than otherwise healthy people. Hospital-acquired pneumonia occurs more often in patients who are using a respirator (machine) to help them breathe. Surgical site infections (SSI): A surgical site infection is an infection that occurs after surgery in the part of the body where the surgery took place. Surgical site infections sometimes only involve the skin. Others are more serious and can involve tissues under the skin, organs, or implanted material (such as knee or hip replacements).

4. Falls Falls are a common cause of injury, both within and outside of health care settings. According to the U.S. Center for Disease Control and Prevention, more than one-third of adults over 65 fall each year. Injuries that result from falls can include bone fractures, excessive bleeding, or even death. Researchers estimate that more than 500,000 falls happen each year in U.S. hospitals, resulting in 150,000 injuries. Patients may be at increased risk of falls if they • have an impaired memory • have muscle weakness • are older than 60 • use a cane or walker to help them walk Medications may also play a role in increasing a person’s risk for a fall. Studies have also shown that elderly patients taking four or more prescription medications are at three time’s greater risk for

falls than are other patients. Hospitals and other health care organisations take steps to prevent falls among their patients. You can help prevent falls by asking your doctor or nurse about your risk and taking steps to reduce your chance of a fall. 5. Readmissions A readmission is when a patient needs to return to the hospital less then 30 days after being discharged. Many factors may lead to hospital readmissions, such as poor quality care or a gap in the transition between different providers and care settings. Readmissions may also occur if patients are discharged from hospitals prematurely, or if they are discharged to inappropriate settings, or if they do not receive adequate information or resources to aid in recovery. Patients can help avoid readmission by making sure they understand their care plan before they are discharged from the hospital. They also need to be sure to follow up on care once they leave the hospital. 6. Diagnostic Errors Diagnostic errors mean a diagnosis that was either “wrong, missed, or unintentionally delayed.” No-fault errors may happen when there are masked or unusual symptoms of a disease, or when a patient has not fully cooperated in care. Diagnostic errors may also result from system-related problems, such as equipment failure or flaws in communication. A wrong diagnosis may also occur when the clinician relies too much on common symptoms, and choosing an obvious answer, without looking further into what may be causing them.


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Policy Statement on Health Literacy for Patient Safety The International Alliance of Patients' Organizations (IAPO) 2. Provide education on patient safety and patient safety issues and the value of involving patients in patient safety initiatives. Hold a workshop on patient safety or a specific patient safety issue. Copy or adapt and distribute the Frequently Asked Questions (FAQs) inserts on patient safety issues

I. Advocate 1.

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dvocate for patient involvement in healthcare policy-making to improve patient safety. It is only with the effective engagement of patients and patient advocates at all levels of healthcare policy decision-making that patients’ needs will be listened to and acted upon. Ask for patient advocates to be on boards of organisations, hospitals, health professional bodies and other decision-making bodies.

2. Advocate on specific patient safety issues to governments, hospitals and health professional organisations. Get patient safety onto the political agenda and address specific patient safety con-

III. Raise awareness Raise awareness of patient safety with the media and the public

cerns – write a letter to your hospital or government explaining your patient safety concerns and outlining the action that you would like them to take. 3. Partner and get involved with other patient safety initiatives – by working together we will be more effective.

II. Educate

1. Add a news item about patient safety to your website or develop a patient safety webpage on your website – aim to keep this updated. 2. Write and distribute a press release to the media highlighting your patient safety concerns and actions you would like to be taken. Available at: www.patientsorganizations. org/healthliteracy suggest the following approach

1. Provide information to patients to help them protect themselves from patient safety incidents. Develop and/or distribute posters and leaflets through your networks, and to hospitals and healthcare settings.

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10 Facts About Patient Safety – World Health Organization (WHO) Patient safety is a serious global

public health issue. In recent years, countries have increasingly recognised the importance of improving patient safety. In 2002, WHO Member States agreed on a World Health Assembly resolution on patient safety.

Fact 1

Estimates show that in developed countries as many as one in 10 patients is harmed while receiving hospital care. The harm can be caused by a range of errors or adverse events.

Fact 2

In developing countries, the probability of patients being harmed in hospitals is higher than in industrialised nations. The risk of health care-associated infection in some developing countries is as much as 20 times higher than in developed countries.

Fact 3

At any given time, 1.4 million people worldwide suffer from infections acquired in hospitals. Hand hygiene is the most essential measure for reducing health care-associated infection and the development of antimicrobial resistance.

At least 50% of medical equipment in developing countries is unusable or only partly usable. Often the equipment is not used due to lack of skills or commodities. As a result, diagnostic procedures or treatments cannot be performed. This leads to substandard or hazardous diagnosis or treatment that can pose a threat to the safety of patients and may result in serious injury or death.

Fact 5

In some countries, the proportion of injections given with syringes or needles reused without sterilisation is as high as 70%. This exposes millions of people to infections. Each year, unsafe injections cause 1.3 million deaths, primarily due to transmission of bloodborne pathogens such as hepatitis B virus, hepatitis C virus and HIV.

Fact 6

Surgery is one of the most complex health interventions to deliver. More than 100 million people require surgical treatment every year for different medical reasons. Problems associated with surgical safety in developed countries account for half of the avoidable adverse events that result in death or disability.

Fact 4 Fact 7

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The economic benefits of improving patient safety are compelling Studies show that additional hospitalisation,litigation costs, infections acquired in hospitals,lost income, disability and medical expenses have cost some countries between US$ 6 billion and US$ 29 billion a year.

Fact8

Industries with a perceived higher risk such as aviation and nuclear plants have a much better safety record than health care. There is a one in 1,000,000 chance of a traveller being harmed while in an aircraft. In comparison, there is a one in 300 chance of a patient being harmed during health care.

Fact 9

Patients' experience and their health are at the heart of the patient safety movement. The World Alliance for Patient Safety is working with 40 champions – who have in the past suffered due to lack of patient safety measures – to help make health care safer worldwide.

Fact 10


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What Pilots Can Teach Hospitals About Patient Safety

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earing scrubs and slouching in their chairs, the emergency room staff members, assembled for a patientsafety seminar, largely ignored the hospital’s chief executive while she made her opening remarks. But the room became still and silent when an airline pilot who used to fly F-14 Tomcats for the Navy took the lectern. Handsome, upright and meticulously dressed, the pilot began by recounting how in 1977, a series of human errors caused two Boeing 747s to collide on a foggy runway in the Canary Islands, killing 583 people. Riveted, a surgeon gripped his pen with both hands as if he might break it, an anesthetist stopped maniacally chewing his gum, and a wide-eyed nurse bit her lip. An attention grabber, yes, but what does an airplane crash have to do with patient safety? A growing number of health care providers are trying to learn from aviation accidents and, more specifically, from what the airlines have done to prevent them. In the last five years, several major hospitals have learnt standard cockpit procedures like communication protocols, checklists and crew briefings to improve patient care, if not save patients’ lives. “We’re where the airline industry was 30 years ago” when a series of fatal mistakes increased scrutiny and provoked change, said Dr Stephen B Smith, chief medical officer at the Nebraska Medical Center in Omaha, the teaching hospital for the University of Nebraska. After the Canary Islands accident, NASA convened a panel to address aviation safety and came up with a program called Cockpit or Crew

Resource Management. The Federal Aviation Administration requires that all pilots for commercial airlines and the military undergo the training. They learn, among other things, to recognize human limitations and the impact of fatigue, to identify and effectively communicate problems, to support and listen to team members, resolve conflicts, develop contingency plans and use all available resources to make decisions. The British medical journal BMJ, The Journal of the American Medical Association and The Journal of Critical Care have also published research suggesting that hospitals that adopt these measures have fewer malpractice suits and postsurgical infections. Patient recovery times tend to be lower, and employee satisfaction is higher. Dr David M Gaba, associate dean of immersive and simulation-based learning at the Stanford University School of Medicine in Palo Alto, Calif says “Both (pilots & physicians) work profile involve hours of boredom punctuated by moments of sheer terror,”. In addition to sometimes having to make life-and-death decisions in seconds, pilots and physicians also tend to be highly skilled, Type A personalities, who rely heavily on technology to do their jobs. The definition of an error in health are, Professor Helmreich professor of psychology at the University of Texas at Austin and director of its Human Factors Research Project said, is “fuzzier” than in aviation, where it is easier to identify a “foul-up” and who was responsible. Health care providers’ fear of litigation and losing their medical licenses also hinders the honest reporting of mistakes. Some institutions, like Johns Hopkins, have

created their own in-house training programs and safety structures based on aviation. “Aviation provided us with the ideas, which we then modified for health care as well as our particular situation,” said Dr. Peter Pronovost, the director of the Center of Innovation in Quality Patient Care at Johns Hopkins. Employees who work at hospitals that have adopted these kinds of aviationbased safety programmes are mostly enthusiastic. Many say they are more confident doing their jobs thanks to posted checklists, which, for example, include reminders to wash their hands, confirm the identity of the patient and check for drug allergies. They appreciate the fact that they are now not only encouraged to speak up if they are concerned about something, but also required to do so. Communication is so much better,” said Shelly Schwedhelm, a nurse and director of perioperative and emergency services at Nebraska Medical Center, which instituted aviation-style safety measures a year ago. We now have debriefings after every surgery, during which we identify what we could do better but also what went right,” she said. “I’m hearing compliments and acknowledgment, which has really boosted morale.” “I’m seeing errors caught virtually every day” in the operating room, said Dr. Timothy Dowd, the chairman of the anesthesiology department at Vassar Brothers, where critical-care staff members underwent aviationbased patient-safety training six months ago. “Even the most curmudgeonly surgeon has to admit this is a better way,” he said. New York Times Report dated October 31, 2006

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Clipboard Issue 62 & 63

LEGAL WATCH

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How can the interests of a small hospital be safeguarded in the matter of payment of compensation? Is there any way to pass this liability? Small hospitals may take a professional insurance policy for a certain period, covering the negligence on the part of medical professionals, paramedical and other staff, from liability in the name of the institution and pay insurance premium every year. This may cover the risk. If the court orders payment of compensation by the hospital in a dispute, the insurance company shall pay the compensation amount in the hospital’s name. There is another way. Presently, a Christian Mission Hospital in Orissa deposits a small premium amount in a separate account every year from its budget. As there is no considerable claim so far, the reserve funds stand at more than Rs.50 lakhs at present. This method can also be followed by other small hospitals. What is the procedure to conduct a case in a consumer forum? A consumer forum/commission is only a quasi-judicial authority. A hospital can file a reply to a complaint and argue the case according to the facts of the case. A doctor, who performed a treatment/ procedure on a patient, can depose before a forum/commission and argue his case on merit. A forum is presided over by a judge with the aid of two lay persons. The law does not compel a doctor/hospital to engage a lawyer before the forum. However, a doctor may engage a lawyer if he feels that he can attend to his work instead of waiting in the court in connection with a case.

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A CMAI publication focussing on issues related to hospital administration

Christian Medical Association of India

Is there any court fee payable by the patient to the consumer forum? Neither the petitioner (patient) nor the opposite party (hospital) is required to pay any court fee to the consumer forum. Only if an award has been passed against the medical professional at the time of appeal, he has to pay/ deposit a certain amount. Briefly describe the consumer forum. There are three types of disputes/ redressal mechanisms exclusively for consumers under the Consumer Protection Act, 1986. They are: a. District Consumer Disputes Redressal Forum (DCDRF) – to settle claims up to Rs.20 lakhs. b. State Consumer Disputes Redressal Commission (SCDRC) – to receive and dispose complaints which involve amounts ranging from Rs.20 lakhs to Rs.1 crore. c. National Consumer Disputes Redressal Commission (NCDRC) – to receive and dispose complaints which involve more than Rs.1 crore. A consumer or an opposite party may make a final appeal before the Supreme Court if he/she is not satisfied with an award passed by the NCDRC in a dispute. Source: Laws on Hospital Administration by Mr D Samuel Abraham

Published by The General Secretary CMAI, Plot no. 2, A-3 Local Shopping Centre, Janakpuri New Delhi 110 058 Tel: (011) 2559 9991/2/3 E-mail: cmai@cmai.org cmaidel@vsnl.com Website: www.cmai.org CMAI Bangalore Office HVS Court, 3rd Floor 21 Cunningham Road Bangalore 560 052 Tel: (080) 2220 5464, 2220 5837 E-mail: cmaiblr@vsnl.com Editorial Committee Dr Bimal Charles Dr Jeyakumar Daniel Mr Innocent Xess Sr Vijaya Mr Samuel NJ David Mr Edward David Dr CAK Yesudian Ms Jaya Philips Editor Mr Stephen Victor Editorial Coordinator Ms Jaya Philips Design & Production Susamma Mathew Printer: Impulsive Creations


Clipboard April - September 2012