Quality Beyond AccreditationQuality Beyond AccreditationProfessor Anupam Sibal

Group Medical Director

Apollo Hospitals Group

Senior Consultant

Pediatric Gastroenterologist and Hepatologist

CertificationCertification

ISO 9001:2008

ISO 22870:2006

ISO 14001

Accreditation

Benefits of accreditationBenefits of accreditation

E t bli h ll b ti l d hi th t t i f ll iEstablishes collaborative leadership that strives for excellence in quality and patient safety

Ensures a safe and efficient work environment

Stimulates continuous improvement in clinical care processes

Builds a culture open to learning from adverse events and safety concerns

Improves public trust

What really mattersWhat really matters

Desired clinical outcomes – clinical excellenceNo adverse or unanticipated event – patient safetyp p yValue for money – operational excellence or “efficiency”Care culture – service excellence

Effi iEfficiency

“Avoiding waste, including waste of

i t li id d ”equipment, supplies, ideas and energy”

Institute of Medicine

“Highest Value Hospital” recognitionHighest Value Hospital recognition – Leapfrog Group

Incorporates quality and cost

Perform exceptionally well in clinical processes

and outcomes and resource use

Achieving Efficiency: Lessons from Four Top-Performing Hospitals July 2011 The Commonwealth FundHospitals, July 2011 - The Commonwealth Fund

4 of the 13 Leapfrog Group’s “Highest Value4 of the 13 Leapfrog Group s Highest Value

Hospitals” in 2008

Fairview Southdale Hospital, Minnesota

North Mississippi Medical Center MississippiNorth Mississippi Medical Center, Mississippi

Park Nicollet Methodist Hospital, Minnesota

Providence St. Vincent Medical Centre, Oregan

Efficiency follows excellence

“We don’t have goals for efficiency. It’s a byproduct of

Efficiency follows excellence

g y yp

our success in focusing on what’s right for the patient

and excellence in quality of care (It is)a trailingand excellence in quality of care…….(It is)a trailing

indicator”

Dennis Noonan

Former CFO, Providence St Vincent Medical Centre

Examples of Improvements initiated

Improving patient flow to serve more patients

Integrated care plans to improve post dischargeIntegrated care plans to improve post discharge

outcomes and continuity of care

Computerized test results in the Emergency

Building the CultureBuilding the Culture

“Our management has always sought ways ofOur management has always sought ways of

supporting staff. The philosophy behind shared

i l h b i h i d igovernance is to let the brightest minds sit

together, and get out of their way”

Martie MooreCNO, Providence St Vincent medical Center

Building the CultureBuilding the Culture

An example:An example:Employees to submit at least two improvement ideas

each year Submitted directly to decision makers Employees get “points” for approved ideasAs high as 37% of the ideas approved

Building the CultureBuilding the CultureExamples:Self governance model – each staff member

represented on a clinical or operational councilA l b t d t t ti litAnnual bonuses to departments meeting quality

and cost goalsRegular discussion between Medical directors and egu a d scuss o bet ee ed ca d ecto s a d

physicians identified as “outliers”

Staff relationships and roles matter p

Examples:Service lines with clinical and administrative leadersStaff huddles before start of a surgery to reduce

operating room delaysoperating room delaysBed huddles twice a day which focus on discharge

timing, potential bottlenecks

Staff relationships and roles matter

Examples:

p

Need based “loaning” of staff from other unitsSharing of patient information with patient’s family

d it h i iand community physicianPreserving nurse patient ratiosL f t ffi i il f h i i h dLoss of staffing privileges for physicians who do

not show respect to nurses

Technology as a toolTechnology as a tool

Examples:Electronic health records (EHR) shared between

t ti t d i ti t tti t idoutpatient and inpatient settings to avoid duplication of tests

Clinical decision support systems integrated intoClinical decision support systems integrated into EHR

Technology as a toolTechnology as a tool

Examples:Examples:Wireless technology that connects technicians in

ambulances to the emergency, transmits ECGsg y,Real time data collection for quality indicatorsElectronic bed boards / bed tracking systemsg y

Standardize processes and suppliesStandardize processes and supplies

The goal is to help “steer physicians towards

efficiency by using surrogate measures, using their

language and breaking it down into pieces they

understand and can manage”g

Mark Williams

North Mississippi Health Services

Standardize processes and suppliesStandardize processes and supplies

Clinical pathwaysClinical pathwaysClinical practice guidelinesStandard Operating ProceduresStandard Operating ProceduresBulk purchasesBar code scanning for tracking suppliesBar code scanning for tracking supplies

Quality Improvement Tools and Q y pStrategies

“If you keep looking at the data, and you have a

competitive spirit you keep getting better”competitive spirit, you keep getting better

St h B tti tStephen BattistaQuality Improvement DirectorFairview Southdale Hospital

Quality Improvement Tools and Q y pStrategiesKaizen Method, Lean, PDCAImportant that clinical and operations staff outside

the quality department are trainedthe quality department are trained

Benchmark performance against internal goals andBenchmark performance against internal goals and external benchmarks using dashboards

Dashboards incorporate quality and efficiency related indicators

Continuous quest for excellenceJCI accredited Apollo hospitals

Continuous quest for excellence

Delhi (first JCI accredited hospital in India)

ChennaiHyderabad (first JCI accredited stroke

program in the world)LudhianaDhaka BangaloreKolkata

Clinical excellence at ApollopBest clinicians

Clinical practice guidelines

Clinical pathways

Grand rounds

Apollo clinical excellence forum

A ll M di i J lApollo Medicine Journal

Research promotion

Apollo Gold Medals

Clinical excellence dashboard – ACE @ 25Clinical excellence dashboard – ACE @ 25

RACE

Mortality review

Clinical performance indicators for individual consultantsp

Departmental reviews

ACE @ 25ACE @ 25

Clinical balanced scorecard

25 parameters assessed against international25 parameters assessed against international

bench marks

Apollo Light House

CABG mortality rateCABG mortality rateBenchmark: 0.60%

Numerator: Number of in-hospital deaths after CABG

Denominator: Total number of CABG conducted

Indicator Benchmark Range ScoreIndicator Benchmark Range Score

CABG mortality rate 0.60% ≤0.80 4

Cleveland Clinic 0.81-1.20 3

1.21-1.60 22

1.61-2.00 1

>2.00 0

ACE @ 25

Parameters scored as a percentage

ACE @ 25

p g

Maximum score attainable 100

Over all hospital cumulative scores 50 - 75Over all hospital cumulative scores

> 75

50 75

< 50

ALOS post liver transplantALOS post liver transplantBenchmark: 14 days

Numerator: Total number of inpatients days post liver transplant to date of discharge of liver transplant patients

Denominator: Total number of liver transplants performed

Indicator Benchmark Range ScoreIndicator Benchmark Range Score

ALOS post liver transplant 14 days Cleveland Clinic ≤14.00

4

14.01-16.003

216.01-18.00 2

18.01-20.001

>20.000

Patient safetyy

Infection control

Medication safety

Surgical SafetySurgical Safety

Patient falls prevention

Communication safety

Facility safetyFacility safety

Apollo quality programApollo quality program

Clinical handoversClinical handovers

Surgical safety

International patient safety goals

Medication errors

Apollo quality programMonitoring Parameter Scoring

Clinical Handovers

Percentage compliance to completion of In house transfer1

Percentage compliance to completion of In house transfer form before patient transfer >90% 80-90% <80%

2Percentage compliance to use of nursing handover form for patient handover >90% 80-90% <80%

Percentage compliance to use of physician handover form3

Percentage compliance to use of physician handover form for patient handover >90% 80-90% <80%

4

No. of instances (per month) where Clinical Handovers were one of the proximate causes for the adverse clinical events and outcomes <1 1 >1

IPSGs

5 IPSG 1 Tracker score 100% 90-99.9% <90%

6 IPSG 2 Tracker score 100% 90-99.9% <90%

7 IPSG 3 T k 100% 90 99 9% 90%7 IPSG 3 Tracker score 100% 90-99.9% <90%

8 IPSG 4 Tracker score 100% 90-99.9% <90%

9 IPSG 5 Tracker score 100% 90-99.9% <90%

10 IPSG 6 Tracker score 100% 90 99 9% <90%10 IPSG 6 Tracker score 100% 90-99.9% <90%

Surgical Care Improvement

11Percentage of patients receiving antimicrobial prophylaxis one hour before surgery >95% 90-95% <90%

12Percentage of patients excluded from SSI calculation due to lack of follow up for the requisite time frame <20% 20-30% >30%

13 SSI <2.2% 2.21-2.85% >2.86%

14Number of instances of wrong patient, wrong side, wrong procedure surgery None Any

15Compliance to communicating sponge and instrument count to surgeon before skin closure >95% 90-95% <90%

16 Incidents of retained foreign body during surgery None Any

Medication Safety

17 Medication errors per 100 discharges <2.2% 2.21-2.85% >2.86%

18Medication errors due to sound alike look alike drugs as a percentage of total errors <2% 2-4% >4%

Remain focused

The Apollo Standards for Clinical CareThe Apollo Standards for Clinical Care

Apollo Critical Policies Plans 125Apollo Critical Policies, Plans 125and Procedures

Apollo Clinical Excellence @ 25 100Apollo Clinical Excellence @ 25 100Rocket ACE 100Apollo Quality Programme 100Apollo Quality Programme 100Apollo Mortality Review 50Apollo Incident Reporting System 25Apollo Incident Reporting System 25

Operational excellenceOperational excellence

The Apollo WayCost control

The Apollo Way

A new platform at Apollo to offer better patient experience

The Apollo Way

A new platform at Apollo to offer better patient experience through improved services

An operations-improvement programme

Deliver and sustain “Apollo Way benchmark” performance around key operational metrics

Through process improvement and capability building

Cost Control

Centralized purchase of supplies

Cost Control

Centralized purchase of supplies

Central purchase directly from manufacturers

Standardized supplies across the GroupStandardized supplies across the Group

Lean methodology

Service excellenceService excellence

VOCVOC

Performanometer

Apollo TLCApollo TLC

Patient Satisfaction

WEEKLYPERFORMANOMETER

MEDICAL SERVICES TEAM

5.0

4.9

MEDICAL SERVICES TEAM

4.94.8

5.03T1

4

4.84.74.54.6

4.7

MEDICAL

HOSPITAL

4.5

4.4

4.64.57

4 14.24.34.4PHYSIOTHERAPY

LAB SERVICES

6T1

4.24

4.1

4.3

3.83.94.04.1PAIN

RADIOLOGY

PROCEDURE

3.83.94.0

3.53.63.7

PROCEDURE

BLOOD BANK

EMERGENCY

Voice Of Customer is a Customer Feedback Programme being run byIndraprastha Apollo Hospitals.

Each patient is asked for a feedback at the time of discharge on a especially designed feedback form consisting of 40 odd questions.

Each question is marked on scale of 1 to 5.On the basis of Voice Of Customer, the scores of specialties , services and

floors are tracked on a weekly and monthly basis.

3.73.6

“Your attitude, not your aptitude, determines your altitude”determines your altitude”

Zig Zagler

S b 3 & 20 2 li l i iSeptember 13 & 14, 2012 ●Melia Hotel ● Hanoi, Vietnam

Dr. Ravinder UberoiChief Quality Officer, Indraprastha Apollo Hospitals 

druberoi@apollohospitals.com