Quality Improvement in Healthcare System: Analytical Essay on Importance of Hand Hygiene

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1.0 Introduction

Barone (2019) define quality management (QM) as “the act of overseeing all activities and tasks needed to maintain desired level of excellence”. Association for Project Management (2019), further explains that QM consist of four elements which are quality planning, quality assurance, quality control and quality improvement. The focus in this discussion is on quality improvement (QI). QI is a systemic approach by employees in an organization to analyse the process for continuous improvement in the quality of the product and sustained.

The dynamic approach of the healthcare industry in prioritising quality improvement is a valuable initiative in advocating the safety of the customers receiving treatment. The Institute of Medicine (IOM) committee on Quality of Health in America revealed a finding done in 1999 entitled “To Err is Human: Building a Safer Health System” that the number of death due to medical error in American hospitals yearly is between 44000 and 98000 and over one million injuries (Wakefield, 2000; Stelfox, Palmisani, Scurlock, Orav, & Bates, 2006). These numbers are alarming as the rate of death is high compared to high risk industries such as the aviation industry. Following this report, it became an eye opener for researches to conduct research and published article pertaining to safety in healthcare and triggers the health industry to improve quality and focus on patient safety.

Today, many healthcare organisations are competing to be certified under various accreditation bodies to ensure the treatment and high quality service rendered to the community are safe and of excellent quality. This indirectly boosts their business income and gain the trust from their customers who are particular with high quality standards. The organizations are being audited by various reputable accreditation bodies such as Malaysian Society for Quality in Health (MSQH), International Organization for Standardization (ISO) or Joint Commission International (JCI).

2.0 Quality improvement in healthcare system

According to the United States (US) Department of Health and Human Services Health Resources and Services Administration [HRSA] (2011), quality improvement (QI) “consists of systematic and continuous actions that lead to measurable improvement in health care services and the health status of targeted patient groups”. In Malaysia, quality improvement in the healthcare sector has been the top most priority in the public and private sector. The initiative on continuous QI of the healthcare in the public sector is also supported by the Ministry of Health. Health Minister, Dr Dzulkefly Ahmad announced that the ministry is looking into improving the quality of the health care at public sector by implementing six measures which highlight on upgrading the facilities, improving waiting time as well as alliance between public hospital and local universities. Last but not least is to collaborate specialist and non-specialist hospital to reach out to the public living in the rural area (Bernama, 2018).

Hidayah (2015) reported in the Malaysian Medical Gazettes on the seven strategies taken by the Ministry of Health (MOH) in Malaysia on patient safety. The initial stage was establishing specific organizational structure such as Patient Safety Council. The next step is to maintain good networking and collaborations with organization such as World Health Organization (WHO) and International Safety for Quality in Healthcare (ISQUA). Followed by producing policies and guideline in the aspect of patient safety, ongoing training to healthcare staff and public to increase the awareness on safety. The subsequent step is to implement a national monitoring system on patient safety, which is Malaysian Patient Safety Goal as a portal for the public as well as private sectors to send their respective data annually as a form of benchmarking nationwide. The next strategy is to conduct research pertaining to patient safety and translate the findings into national policy such as the Lab Critical Value Programme and finally to have programmes on patient safety which is the 13 Malaysian Patient Safety Goals which was launched in 2013 as shown in Figure 1.

Figure 1: 13 Malaysian Patient Safety Goals. Source: https://slideplayer.com/slide/7931695/

QI programs are essential in healthcare setting in improving outcomes for patient in term of safety, reduce mortality, upgrade the efficiency of staff performance and reduce wastage due to failures in the existing process (Serino, 2019). For example, the MSQH fifth edition has around 24 standards that an organization needs to comply according to the services available in the organization. Overall, the QI programs should focus on patient-centered, safety, effectiveness, efficient, equitable and timely (The Scottish Government, 2010). The working committee of Quality Management System (QMS) in the organization the author works is led by the Quality Department that works diligently to guide the clinical and non-clinical department on continuous quality improvement program according to the hospital’s vision and mission. The team provides continuous training and education in QI, safety and risk management programs.

QI in healthcare defines safety events as practices that does not comply with the policies and procedure for example inserting a central line without adhering to the CVL care bundle checklist such as omitting hand hygiene prior to inserting the line. On the other hand, serious safety events are the errors that occur that can lead to harm and mortality. For example patient was transfused with a mismatched blood due to skipping a step of checking with the second nurse can lead to detrimental effect (Ministry of Health Malaysia [MOH], 2013). Near-miss event is one that almost cause harm to patient but was prevented due to the fast respond of another colleague in preventing it from happening. All this incident including near missed incident should be reported in the accident and incident (AI) for analysis and discussed in the risk management meeting to identify the preventive measure in preventing this incident from recurring. The necessary performance indicators such as the rate of compliance on hand hygiene is submitted to the relevant accreditation body to evaluate whether the changes implemented brings improvement in the organization. The implementation of hand hygiene measures focus on reducing infection to patient and staff (MSQH, 2017).

Safety of the healthcare worker and patient is paramount. There are incidents of patient or relatives who fell from a broken chair that can lead to injuries. It is necessary for the safety officer to implement measures for the head of department of the unit to identify the chairs with problem and condemn it. The Safety Officer at the author’s organization created a chair policy and data on percentage of workplace hazard is submitted monthly to MSQH via Quality Department (MSQH, 2017). The Institute of Healthcare Improvement (IHI) states that the outcome are measured to identify areas that the process could upgrade their care, identify the difference of care and show the evidence based practice that works on the interventions which is patient specific and differentiate the effectiveness of the many treatments and procedures (Tinker, 2018).

The buffer system created by carbon dioxide consists of the following three molecules in equilibrium: CO2, H2CO3-, and HCO3-. When H+ is high, HCO3- buffers the low pH. When OH- is high, H2CO3 buffers the high pH. In respiratory acidosis, the slight increase in bicarbonate serves as a buffer for the increase in H+ ions, which helps minimize the drop in pH. The increase in hydrogen ions inevitably causes the decrease in pH, which is the mechanism behind respiratory acidosis.

3.0 Strategies to improve the quality of care and patient safety

The author, the Head Nurse of a Surgical Unit received a report from the Quality Department that the compliance of hand hygiene in the surgical unit for the year 2018 is only 50 percent which is below the national standard of above 75 percent. Hand hygiene is the simplest and cost effective action in reducing health care-associated infection (HCAI) globally. World Health Organization [WHO] (2009) launched the “Clean Care is Safer Care” as the first Global Patient Safety Challenge which is collaborated in the 2nd KPI of Malaysian Patient Safety Goal. The practice of hand hygiene should be promoted as the best practice in reducing HCAI and improving patient safety.

The author was motivated and committed to provide good leadership in advocating and improving the compliance on hand hygiene among the staffs in the surgical unit. The QI tools that will be used is the Model for Improvement by the Institute for Healthcare Improvement (IHI) which is the plan, do, check and act cycle (PDCA) (Chen, Xie, & Liang, 2015).The author initiated by having a meeting with the all the staffs to impart the data on the hand hygiene compliance rate. All staffs are to brain storm on identifying the purpose of the non-compliance and measures to improve the compliance on hand hygiene. In the meeting, a QI subcommittee which include the link nurse was formed to identify the problem and the corrective action planned. The leader and the subcommittee identified the causes by secretly observing the practices of Hand Hygiene among the staffs according to the 5 Moments of Hand Hygiene. A root cause analysis (RCA) was done by using the cause and effect diagram which is the fishbone diagram developed by Dr Kaoru Ishikawa in 1968 (Neyestani, 2017) as shown in figure two.

Equipment/Product

Reminders

Inadequate number Empty hand soap Lack of poster

Of hand rub dispenser/paper towel

Compliance on hand hygiene

Poor location of hand rub

Lack of knowledge Lack of training

Indifference attitude No penalties for

Forgetfulness non-compliance

Lack of role model

Management

Human factor

Figure 2: Fish bone diagram on lack of hand hygiene compliance

The goal is to achieve 80 percent compliance on 5 Moments of Hand Hygiene by the nursing staff of Surgical Ward A. The World Health Organization [WHO] (2012) action plan was used as a guide to improve the compliance on hand hygiene. The second step is to look at system change by seeking the Infection Control Nurse (ICN) opinion on staff with allergic skin due to hand rub. The staff was encouraged to wash hand and soap or other option of hand rub product was given to the staff to assess for any signs of allergic. The staff with allergic skin is also advised to moisturize their hands in between completion of nursing care and to avoid using hot water to wash the hand (World Health Organization [WHO], 2009). The ICN advice to place the hand rub bottles at point of care for example at each bedside and on procedure trollies. The assistant nurse is assigned and whoever that notice the hand rub bottle is empty to replace it immediately. The cleaners are to check regularly the hand soap and paper towel dispenser and replenish accordingly.

The author and the subcommittee act as the champion to promote hand hygiene in the wards. The ICN is invited to give training on hand hygiene and emphasize the ward staffs on the importance of hand hygiene to reduce risk of Healthcare Associated Infection (HCAI). The 5 moment’s video will be shown to give a better understanding on the indication of the nurses to perform hand hygiene especially when performing aseptic procedures such as administration of medication via the parenteral route. The author and the link nurse would teach on hand hygiene step and randomly pick the staff to perform hand hygiene competency to assess the technique of washing hand to ensure optimal cleaning of the staff’s hand. The hand hygiene washing technique poster is placed on the wall above the sink as a continuous reminder (Liu, Zhang, Cheng, & Sun, 2016). The image on 5 Moments of Hand Hygiene is put as the computer screen saver and posters are placed at the patient care area and treatment room as a reminder to the nursing staff to adhere to hand hygiene. A hand hygiene corner is set up with the image of staffs acting as the ambassador of hand hygiene to motivate the staff to perform hand hygiene and to cultivate a culture of hand hygiene among the staffs. The staffs are encouraged to contribute their talent in drawing posters on hand hygiene to gain their interest in hand hygiene, promote hand hygiene culture and reward them with a token of appreciation.

Weekly meeting will be done to provide feedback to the staffs on the compliance observation done by the subcommittee and the head nurse. The moments such as before patient contact that the nurses missed to perform hand hygiene will be emphasized for improvement and sustained at high level. The head nurse and the QIA subcommittee will perform monthly hand hygiene audit according to the 5 moments of Hand Hygiene. Staffs who were found noncompliance despite given training and frequent reminders will be given counseling for the first time and verbal warning if it is the second time. The third time of violation on noncompliance in hand hygiene will affect the staff’s year end appraisal as patient safety is being ignored. Although in terms of QI, the focus is in improving the system and not blaming Lillis (2015) explained in her article that there are some study agree that some of disciplinary action is needed to stress the importance of hand hygiene.

The step by step cycle from planning right up to act gives a systematic approach in guiding the author and the team to do the necessary measures to improve compliance on hand hygiene. Implementation of the PDCA cycle, has improved the knowledge of the staff on the importance of hand hygiene, leading to increase compliance on hand hygiene. The practice of hand hygiene has been a culture in the surgical ward. The data obtained after 3 months showed the compliance of 84 percent, exceeding the target set.

4.0 Conclusion

In conclusion, QI is essential in the healthcare setting to improve the healthcare industry standard in ensuring excellence service being rendered to the public. The six main focus of QI programs are patient-centered, safety, effectiveness, efficient, equitable and timely. Quality service is for the benefit of all people including us to have trust that when we come to seek treatment in an organization, necessary standards that adhere to the legislation practice are in place to prevent harm. The activation of AI gives a direction for analysis on the incident that occur of actual incident and near missed to identify the hazard and eliminate it to prevent untoward incident to the staff and patient. As a leader, it is important to be dynamic, have an open mind and dedicated to continuously support the QI programme and work as a team to implement measures in line with the organization’s vision and mission.

5.0 Reference

Association for Project Management [APM]. (2019). Association for Project Management.Introduction to Quality management. Retrieved from: https://www.apm.org.uk/body-of-knowledge/delivery/quality-management/
Barone, A. (2019). Investopedia. Quality Management. Retrieved from: https://www.investopedia.com/terms/q/quality-management.asp
Bernama. (2018). New Straits Times. Six measures towards quality healthcare Retrieved from https://www.nst.com.my/news/nation/2018/06/378656/six-measures-towards-quality-healthcare
Chan, D. P. (2013). Orientation Program Duchess of Kent Hospital. Overview of Malaysian Patient Safety Goals. Retrieved from: https://slideplayer.com/slide/7931695/
Chen, C., Xie, X., & Liang, Y. (2015). Retrieved from Application of PDCA Circulation in Improving the Hand Hygiene Compliance of the Medical Staffs in Department of Burn Surgery.Retrieved from: http://www.hougner.com/wp-content/uploads/2016/07/2015-4-4.pdf
Hidayah. (2015). The Malaysian Medical Gazette. Retrieved July 1, 2019, from Patient Safety Must Always Be A Priority- KKM. Retrieved from: https://www.mmgazette.com/patient-safety-must-always-be-a-priority-kkm/
Kurowski, E. M., SchondelmeyeR, A. C., Brown, C., Dandoy, C. E., Hanke, S. J., & Cooley, H. L. (2015). Springer Link. A Practical Guide to Conducting Quality Improvement in the Health Care Setting.Retrieved from: https://link.springer.com/article/10.1007/s40746-015-0027-3
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Liu, Y. H., Zhang, L., Cheng, K., & Sun, X. (2016). Acta Medica Mediterranea. Application Of PDCA Cycle in the Management Of Medical Staff Hand Hygiene in Community Hospitals. Retrieved from: http://www.actamedicamediterranea.com/archive/2016/special-issue-1/application-of-pdca-cycle-in-the-management-of-medical-staff-hand-hygiene-in-community-hospitals/pdf
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Serino, A. (2019). Clear Point Strategy. 5 Examples Of Quality Improvement In Healthcare & Hospitals.Retrieved from: https://www.clearpointstrategy.com/examples-of-quality-improvement-in-healthcare/
Stelfox, H. T., Palmisani, S., Scurlock, C., Orav, E. J., & Bates, D. W. (2006). National Center for Biotechnology Information (NCBI). The “To Err is Human” report and the patient safety literature. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2464859/
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Tinker, A. (2018). Health Catalyst. The Top Seven Healthcare Outcome Measures and Three Measurement Essentials. Retrieved from: https://www.healthcatalyst.com/insights/top-7-healthcare-outcome-measures
U. S. Department of Health and Human Services[HRSA]. (2011). Quality Improvement. Retrieved from: https://www.hrsa.gov/sites/default/files/quality/toolbox/508pdfs/qualityimprovement.pdf
Wakefield, M. (2000). American Psychological Association. doi:https://psycnet.apa.org/doi/10.1037/h0092814
Worcestershire Acute Hospitals NHS . (2018). Quality Improvement Strategy (Version 8) Retrieved from: https://www.worcsacute.nhs.uk/patient-information-and-leaflets/documents/2116-quality-improvement-strategy-2018-2021/file.
World Health Organization [WHO]. (2009). WHO Guidelines on Hand Hygiene in Health Care: A Summary. Retrieved from:https://www.who.int/gpsc/5may/tools/who_guidelines-handhygiene_summary.pdf
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Quality Improvement in Healthcare System: Analytical Essay on Importance of Hand Hygiene

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