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“TQA for APS ” Thailand Quality Award for Acute Pain Service

“TQA for APS ” Thailand Quality Award for Acute Pain Service. Vimolluck Sanansilp , M.D. Dept. of Anesthesiology, Faculty of Medicine Siriraj Hospital Mahidol University. Reaching the Gold Standard (HA, JCI): Acute Pain Service. Vimolluck Sanansilp , M.D. Dept. of Anesthesiology,

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“TQA for APS ” Thailand Quality Award for Acute Pain Service

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  1. “TQA for APS” Thailand Quality Award for Acute Pain Service VimolluckSanansilp, M.D. Dept. of Anesthesiology, Faculty of Medicine Siriraj Hospital Mahidol University

  2. Reaching the Gold Standard (HA, JCI):Acute Pain Service VimolluckSanansilp, M.D. Dept. of Anesthesiology, Faculty of Medicine Siriraj Hospital Mahidol University

  3. Reaching the Gold Standards…HA – Hospital Quality Improvement & AccreditationJCI – Joint Commission International Accreditation Standards for Hospitals “According to JCI and HA standards, you should….., ….., ……, and …… .”

  4. Reaching the Gold Standards…HA JCI What? Why? How? ? ? ?

  5. Reaching the Gold Standards…HA JCI What? Why? How? - Oh! I know it well. Anything new? Your response might be… - Yeh! I know some, but I’m not interested in it. (= Why should I care? It’s not for me!!) or - Uhmm! I’m not sure. You can talk about it.

  6. Reaching the Gold Standards…HA JCI What? Why? How? - Oh! How can I do it? When I was assigned to talk… - I’m an Ac Pain Dr., not the expert in this area! - I’ll try my best to learn what it is. and - Uhmm! I’ll share what I’ve learned with you.

  7. Reaching the Gold Standards…HA JCI What? Why? How? and - Uhmm! I’ll share what I’ve learned with you. …for Acute Pain Service…

  8. Reaching the Gold Standards…HAJCI What does HA stdlook like? HA standard has been adapted….to reach Thailand Quality Award (TQA) criteria.

  9. Reaching the Gold Standards…HA You need…idea of TQA …first. HA standard has been adapted….to reach Thailand Quality Award (TQA) criteria.

  10. TQA Criteria for Performance Excellence: System Viewpoints Organizational Profile Environment, Relationships, Strategic situation 2. Strategic Planning 5. Workforce Focus 7. Results 1. Leadership 3. Customer Focus 6. Operations Focus 4. Measurement, Analysis, and Knowledge Management

  11. TQA Criteria for Performance Excellence: System Viewpoints

  12. Hospital Accreditation (HA) Framework

  13. Hospital Accreditation (HA) Framework 13

  14. HA “Quality Improvement & Learning Cycle” Act (A) Plan (P) Study (S) Do (D) Process:“P-D-S-A”

  15. TQA – Scoring System  HA Integration (I) Approach (A) Learning (L) KPI PDSA PDSA Deployment (D) PDSA Process Evaluation:“A-D-L-I”

  16. TQA – Scoring System  HA Integration (I) Harmonize with others Levels (Le) Comparisons (C) KPI Goal Benchmark Trends (T) 3-point Trend Result Evaluation:“Le-T-C-I”

  17. From our practice… back to the standards From standards… go to practice

  18. From our practice… back to the standards I’ll share Siriraj APS’s experience

  19. TQA Criteria for Performance Excellence: System Viewpoints Organizational Profile Environment, Relationships, Strategic situation 2. Strategic Planning 5. Workforce Focus 7. Results 1. Leadership 3. Customer Focus 6. Operations Focus 4. Measurement, Analysis, and Knowledge Management

  20. TQA Criteria for Performance Excellence: System Viewpoints Organizational Profile Environment, Relationships, Strategic situation

  21. We ask ourselves 1. Do my hospital need an Acute Pain Service? 2. What kind of “Organizational profile” do we plan to have?

  22. We ask ourselves Problem = 1. Do my hospital need an Acute Pain Service? What should be Equation of “Problem”: What is x Concern –

  23. We ask ourselves Problem = 1. Do my hospital need an Acute Pain Service? What should be Equation of “Problem”: What should be x Concern –

  24. We ask ourselves Problem = 1. Do my hospital need an Acute Pain Service? What should be Equation of “Problem”: What is x zero –

  25. We ask ourselves 2. What kind of “Organizational profile” do we plan to have?

  26. Acute Pain Service (APS) models 1.Anesthesiologist-based APS 2.Nurse-based, anesthesiologist-supervised APS 3.Nurse-based, surgeon collaborated, anesthesiologist-supervised APS

  27. Acute Pain Service (APS) models 1.Anesthesiologist-based APS -Patient-controlled analgesia (PCA) -Epidural analgesia with opioid and/or LA -IV infusion -Regional blocks Superior pain relief

  28. Acute Pain Service (APS) models Frequent assessment - pain, - treatment efficacy Require special monitoring Documentation High cost Not enough anesthesiologists Need teamwork 1.Anesthesiologist-based APS Superior pain relief

  29. Acute Pain Service (APS) models 2.Nurse-based,anesthesiologist-supervised APS (1) Aim: every patients undergoing surgery include day-case surgery Simpler & less expensive Routine pain management - not need anesthesiologist --need standard orders, protocols

  30. Acute Pain Service (APS) models 2.Nurse-based,anesthesiologist-supervised APS (2) Main role of anesthesiologists = - in-service training for medical & nursing staff - supervise Acute Pain Nurse - maintain cooperation Acute Pain Nurse - effective liaison between surgeon, anesthesiologist and ward nurse - “trouble shooting” (epidural, PCA) - check pain assessment documentation APS Nurse role is crucial

  31. Acute Pain Service (APS) models 2.Nurse-based,anesthesiologist-supervised APS (3) Ward nurses -Patient education of pain score -Ask patient to grade pain severity & record on specially reserved place on vital sign chart = routine pain scoring = “5th Vital Sign” Neither Acute Pain Nurse nor anesthesiologist guarantees good pain management on wards Ward nurse quality is crucial

  32. Acute Pain Service (APS) models 3.Nurse-based,surgeon collaborated, anesthesiologist-supervised APS  Surgeons have roles in taking care of their patients receiving anesthetic pain control (intraspinal opioid and/or local anesthetics) Surgeon can order PCA/contin. IV infusion& know how to take care these patients Surgeons need to know how to collaborate with nurse ward and APS team

  33. ? Non-standardizedmodel? IMp.r.n. q 6 h + Oral p.r.n. q 6 h -Prescribed by surgeon -Administered by ward nurse -Confusing with “Which med to give first?” Still most commonly used

  34. TQA – Scoring System Integration (I) Harmonize with others Levels (Le) Comparisons (C) KPI Goal Benchmark Trends (T) 3-point Trend Result Evaluation:“Le-T-C-I”

  35. KPI This is what we begin with… Set “Measurable Outputs”  “Results” KPI - reported regularly - every month  Peer review – “problems”

  36. Comparison Level KPI We set our goals…benchmark (q 1 h x4, q 2 h x4, q 4 h x3 ~ 11 times) 1-2. Pain scores 1. PS ≥ 7 x 2 successively < 10% of patients 2. PS ≥ 6 < 20% of patients C (q 4 h x6) < 15% of patients 3. Pain scores ≥ 6 4-6. Side effects from analgesics - once is counted 4. Respiratory depression < 1% of patients 5. Hypotension < 5% of patients 6. Motor weakness < 10% of patients 7-8. Patient outcomes - interviewed 7. Cannot sleep well - pain < 10% of patients 8. Very satisfied - APS service > 90% of patients

  37. Trends KPI 2 Number of Patient with PS ≥ 6 (KPI: < 20%) Record q 1 h x4, q 2 h x4, q 4 h x3 (~ 11 times)

  38. Trends KPI 3 Number of Patient with PS ≥ 6 (KPI: < 15%) Record q 4 h (6 times) C 7

  39. Trends KPI 5 Respiratory depression (KPI: < 1% of patients) 2010 2011 2012

  40. TQA – Scoring System  HA Integration (I) Approach (A) Learning (L) KPI PDSA PDSA Deployment (D) PDSA Process Evaluation:“A-D-L-I”

  41. KPI Process Evaluation:“A-D-L-I”

  42. KPI Key Performance Index Process Evaluation:“A-D-L-I”

  43. Hospital Accreditation (HA) Framework

  44. KPI Key Performance Index ? 1. Leadership A - Vision, gatherer, committee (Hospital  APS), team, plan together; Audits & Research D - Committee meeting regularly; every mo/wk L - Data & Problems presented  solve together I - Join with surgeons’ & ward nurses’ plans including work & research areas

  45. KPI Key Performance Index ? 2. Strategic Management A - 1) SWOT analysis; 2) Plan to convey knowledge to all personnel, pilot project  generalized; 3) IV inj. approval; 4) JCI helps push APS forward D - 1) Training - nurse, residents; 2) CPG; 3) Aiming at the goals needs data to benchmark with others I - 1) Set “KPI” & look for “Benchmark”; 2) Nurses -crucial Role - pain assessment & IV algorithm use 3) Not all surgeons involved - need system to help

  46. CPG – Clinical Guidance…in Siriraj Hospital

  47. KPI Key Performance Index ? 3. Patient Focus A - 1) Specify type of patients in service; 2) Patient’s need heard; 3) survey level of satisfaction - patients, surgeons, nurses D - Analgesic techniques: CEA, PCEA, IV inf., IV-PCA, CPNB, PCRA, IV algorithm, oral a.t.c./p.r.n. L - Know - 1) Suitable tech. for each type of operation;2) Problems; 3) Prevent & solve problems; 4) Epidural techniques revision: dose, cath, taping I - Patients/Family satisfied w information & results

  48. A

  49. A

  50. A For patients_2011 For parents_2012

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