Action research, a.o. 21

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Southwestern University Cebu City Graduate School of Health Science, Management and Pedagogies HINUNANGAN COMMUNITY HOSPITAL’S IMPLEMENTATION AND COMPLIANCE WITH ADMINISTRATIVE ORDER NO. 2008-0021 I. Introduction / Problem Identification Safety, for both personnel and service consumers, is a concern and a priority for hospitals as institutions of health care. Standards guide and, maintain the quality of health care service to give justice to the utility of health benefits as a public service especially in government hospitals. In order for these standards to be set, regulations must be formulated and implemented as to the fact that the success of an organization lies on the proper implementation and compliance of its policies. The administration, according to Tan and Beltran (2009), “is the policy making body and as such sets the policy for the organization.” Policies are plans reduced to statements or instructions that direct organizations in their decision making. Thus policies direct individual behavior toward the organization’s mission and define broad limits and desired outcomes of commonly recurring situations while learning some discretion and initiative to those who must carry out that policy (Marquis and Huston, 2009). Together, the administrators and managers work for the accomplishment of the organization’s goals and objectives. August 28, 2010, a visit was made for the purpose of data gathering at Hinunangan Community Hospital. And as to the researcher’s observation and experience on other hospital settings, the researcher’s concern was caught on the presence of and the continued use of equipment containing elemental mercury. Thus, this study intends to delve on the Hospital’s implementation and compliance to phase-out mercurial equipment use in response to the 6 point agenda to a mercury free Philippines. Page | 1

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Transcript of Action research, a.o. 21

Page 1: Action research, a.o. 21

Southwestern UniversityCebu City

Graduate School of Health Science, Management and Pedagogies

HINUNANGAN COMMUNITY HOSPITAL’S IMPLEMENTATION AND COMPLIANCE WITH ADMINISTRATIVE

ORDER NO. 2008-0021

I. Introduction / Problem Identification

Safety, for both personnel and service consumers, is a concern and a priority for hospitals as institutions of health care. Standards guide and, maintain the quality of health care service to give justice to the utility of health benefits as a public service especially in government hospitals. In order for these standards to be set, regulations must be formulated and implemented as to the fact that the success of an organization lies on the proper implementation and compliance of its policies.

The administration, according to Tan and Beltran (2009), “is the policy making body and as such sets the policy for the organization.” Policies are plans reduced to statements or instructions that direct organizations in their decision making. Thus policies direct individual behavior toward the organization’s mission and define broad limits and desired outcomes of commonly recurring situations while learning some discretion and initiative to those who must carry out that policy (Marquis and Huston, 2009). Together, the administrators and managers work for the accomplishment of the organization’s goals and objectives.

August 28, 2010, a visit was made for the purpose of data gathering at Hinunangan Community Hospital. And as to the researcher’s observation and experience on other hospital settings, the researcher’s concern was caught on the presence of and the continued use of equipment containing elemental mercury. Thus, this study intends to delve on the Hospital’s implementation and compliance to phase-out mercurial equipment use in response to the 6 point agenda to a mercury free Philippines.

Health Secretary Esperanza Cabral in a meeting with environmental health group, Health Care Without Harm-Southeast Asia (HCWH-SEA) identified measures to ensure that the public will be safe from mercury such as no longer giving permits to medical devices distributors to sell mercurial equipment and to promote and disseminate AO 21, implemented in September 2008, to the local government units (LGUs) who are managing the barangay health units, rural health units, city heath and municipal, district and provincial hospitals. To further strengthen this, Cabral signed the Green Health Covenant which calls for the health sector and other individuals to call on their candidates to support mercury phase-out in the country and other green health care agenda such as proper heath care waste management leading to zero waste, chemical safety in health care and a health care responsive to climate change. The Green Health Covenant now has more than 900 signatures from health care facilities in Regions 1, 2, 4A and online signatories (http://www.medicinenet.com/mercury_poisoning/article.htm#general).

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It was known that Administrative Order 2008–0021 or Mercury Phase-out in all of Philippine health care facilities, signed and approved by Francisco T. Duque III, MD, MSc, reached the hospital administration which contains the following probations:

Recognizing the unnecessary risk posed by the continued use of mercury containing products in the healthcare system, the DOH hereby orders that:1. All hospitals shall immediately discontinue the distribution of mercury thermometers to patients

through the distribution of hospital admission/discharge kits.2. All hospitals shall follow the guidelines for the gradual phase-out of mercury in health care facilities

described in this document in the timeline specified.3. All new Health Care Facilities applying for a License to Operate shall submit an inventory of all

mercury-containing devices that will be used in their facilities and a corresponding mercury elimination program.

4. All other Health Care Facilities other than hospital shall make a Mercury Minimization Program based on the guidelines set by this administrative order.

1. In order to ensure safety and contamination control, steps taken towards mercury elimination in facility must be consistent and predetermined. It is therefore a must to involve the whole facility in a dedicated Mercury Management and Minimization Program, with the goal of:a. Raising awareness on the dangers posed by mercury and mercury-containing devices in all health care

facilities and institutions.b. Developing a clear preference for the use of Alternative to Mercury-containing Devices among health

care personnel.c. In the short term, preventing the further release of mercury to the environment through proper

disposal.2. All Health Care Facilities are hereby tasked to designate a dedicated Mercury Management Team within two months from the issuance of this order. This team should be directly under the Hospital Waste Management Committee.For the first 6 months from their inception, the Mercury Management Team should have:a. Conducted a Mercury Audit of their facility (Refer to Annex "A" Sample Mercury Audit Form). This

should include an assessment of the cost of switching to alternatives to mercury-containing devices.b. Developed and managed a Mercury Minimization Program for their facility (Refer to Annex "B" Sample

Mercury Minimization Program).c. Drafted and implemented a purchasing policy that requires vendors to sign a mercury-content

disclosure agreement (Refer to Annex "C" Sample Vendor Product Mercury-Content Disclosure) covering products intended for purchase. A clear preference for Alternatives to Mercury-containing Devices where applicable should be in effect. Efforts should be made to communicate with suppliers about an eventual mercury-free purchasing policy and to work with staff on finding Alternative to Mercury-containing Devices.

d. Conducted a facility-wide information campaign and employee education on the consequences of continued mercury use. Personnel training on preventing and proper handling of mercury spills should also be accomplished (Refer to Annex "D" How to Handle Mercury Spills).

e. Identified and removed unnecessary practices that promote the use and distribution of mercury-containing medical devices.

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3. Within 24 months from the effectivity of this administrative order, all hospitals should have accomplished the following:a. Fully implemented the Mercury Minimization Program developed for their facility.b. Switched to alternatives from mercury-containing devices.c. Developed and implemented a program of waste segregation and recycling to further reduce the

mercury waste stream in cases where no alternative products exist. For instance, mercury containing batteries and fluorescent light bulbs should be collected and processed for recycling or should be properly stored.

d. Identified a dedicated mercury collection area within the facilitye. Developed proper temporary mercury storage in the facility inaccessible to the public.f. Incorporated a mercury management module in their training program for new personnel.g. Information materials on mercury are displayed and/or available in their facility for the benefit of their

patients and the general public.

This order shall take effect 30 days after publication in the Official Gazette and major newspapers and shall supersede all issuance inconsistent herewith (http://www.cldh.org/dohao212008.html).

In response to this order, the chief of HCH Dr. Leoncio P. Mato issued Hospital Order 2 (Appendix A). On the basis of this memorandum, studies reveal that, highly toxic and volatile, mercury is a natural metal that is fatal if inhaled and absorbed by the skin. Exposure to the liquid metal may lead to tremors, impaired vision and hearing, paralysis, insomnia, emotional instability, developmental deficits during fetal development, and attention deficit and developmental delays during childhood. According to the World Health Organization (WHO), health care facilities are one of the main sources of mercury release into the atmosphere because of emissions from the incineration of medical waste. They are also responsible for mercury pollution in water bodies from the release of untreated waste water, which constitute 5% of all mercury releases in wastewater. In healthcare facilities, mercury can be found in medical equipment such as sphygmomanometers, thermometers, laboratory staining solutions and preservatives, feeding tubes, and gastrointestinal diagnostic equipment. It is also present in fluorescent and ultraviolet lamps (http://www.varsitarian.net/sci_tech/a_mercury_free_philippines).

This study looks on the administrative aspect of the problem and primarily aims to aid the Hinunangan Community Hospital be a mercury free health institution adherence to AO 21, determine precipitating and predisposing factors to the hospital’s failure to comply to the probations of the memorandum on immediate time, improve information communication of administration to personnel or vice versa and to update the hospital with the here and now issues to improve practice standards.

II. Problem Analysis

The researcher collaborated with the members of the hospital administration and lower level managers. Together with their inputs, factors were identified and agreed that the problem is centered to:

Limitation of budget and availability of supply for equipment replacement. Failure to integrate the probations of the memorandum as part of the hospital safety policy. Failure to update knowledge and communicate information to the lower hierarchy personnel.

III. Formulating Hypothesis

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In this study the following hypotheses will be investigated:

The sufficiency and the process of hospital budget request and availability of appropriate equipment for replacement.

The application of evidence/research based practice in the hospital. Methods of information communication utilized by the hospital. Emphasis given to hospital policies particularly to policies related to safety.

IV. Experimentation and Action

Guided with the formulated hypotheses, the researcher developed plan of actions that are expected to address the identified factors contributing to the hospital’s failure to apply the probations of the memorandum probing the prohibition of elemental mercury containing equipment for hospital use. As to the implementation, the following plans were adapted by the hospital:

A wall space immediately visible to all for the purpose of information communication of issues such as safety, researches, trivia, memo and all necessary information that needs dissemination.

A formal request for budget and supply sent to the provincial office. A mandatory review of hospital protocols regarding the proper handling, disposal and

contingency plans for hazardous chemicals in the hospital.

The formation of a committee under the jurisdiction of the nurse administrator that shall be responsible for the following:

Reception and dissemination of necessary information for the hospital Update the hospital to the latest researches and discoveries in the field of health and

other interesting facts. Review hospital policies and submit proposals for amendments or new policies

applicable to inline the hospital’s standards to the national or international standards. Observe and guard hospital policy implementation and compliance of personnel Do benchmarking strategy to upgrade hospital function and status

V. Evaluation

Monitoring on the actions made will be constant from time to time. Solicited feedbacks of affected individuals so far were favorable for the hospital administration.

A common information corner is now seemingly a trivia board for all who are interested. New postings were being put weekly fostered with all the creativity offered. The information campaign supplemented everybody’s knowledge regarding the details of the DOH campaign for a mercury free country. Further discussions were conducted by hospital personnel particularly on precautionary measures for hazardous chemicals.

Initiation of safety alternatives and innovative ways for hospital environment and service is now part of personnel’s initiative. A proposed monthly review seminar for all hospital personnel is now at the hands of the administration for approval. Warnings and labels were put to place and disposal containers were provided.

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A certain committee consisted of nurse volunteers is now organized, responsible to function as providers for the contents of the board.

It is expected that for the next fiscal budget the request together with the list of needed equipment replacements will be granted and ultimately the hospital will be mercury free by the end of the year.

The administration is now on the tract of responding to the campaign of the Department of Health as evidenced by its effort in formulating a program. Due to the fiscal constraints of the community hospital, the administration came up with the Gradual Phase-out Program of mercurial devices in accordance to the mandate of the memorandum, an action helping the hospital to compensate to the call for change.

As of the current time, the hands-on workers of the hospital especially the nurses and the volunteer nurses were instructed not to use mercurial devices as much as possible. For now they are using their personally owned equipment in performing their work but for some inevitable circumstances that the choice is limited to the use of old devices they were allowed provided further that its use will be applied with precautionary measures without compromising quality service.

VI. Conclusions and Recommendations

This study did not eliminate mercurial equipment on the hospital yet it yielded to some positive results on the aspects of hospital safety and communication.

The implementation of new policies is a positive paradigm. It will constantly happen as to the discoveries made from time to time. Safety among all should be a priority of an administration on the basis that its quasi legislative and executive powers and authority to promote change is an organizations pillar. It is strengthened with clear communication paths and results to a productive institution with quality.

The compliance is directly related to the emphasis given, degree of awareness of the affected individuals and the strength of its implementation. The compliance of the implemented rules lies to the clarity of the information communication and to the administration as a believable authority.

Evidence based practice is a safety guide that needs promotion and support to extract the benefits it offers. Initiative and assertiveness of learning it and eventually applying it to practice gives both the hospital and its human resource the chance to be in the standard that encourages wellness as to promotive and preventive care for all.

This study revealed one major contributing factor to the hospital’s failure to implement and ultimately comply with the memorandum on immediate time and this ground would be due to the budget and supply limitation of the hospital. Hinunangan Community Hospital is a primary government hospital which is monetarily dependent to the provincial budget allocation. A factual fact in the Philippine setting is that monetary problems are issues hard to address because the Philippines is a third world country.

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The dependency of government facilities on fiscal matters eventually affects the quality of services if offers compromising the satisfaction of its recipients or beneficiaries. Just like other effects of this political disease, the impact it produces to any resource can be devastating.

To further help the hospitals’ fiscal problem, it is then suggested to initiate an income generating program or a department that would independently generate funds not connected to its health services for the hospital’s personal use or in emergency cases. This is a program suggested to minimize the weight of the budget and supply limitations and delay problem of hospitals like Hinunangan Community Hospital. A program designed not to make the hospital a profit making institution but intends, to a degree, to free the hospital in some aspects from the burden of funding dependence or if not minimize the intensity of the impact of the problem which compromises the hospital’s adaption to change.

This study served as a unit to assess the functionality of an administration and is suggested to be done also to any organization having the motive of gaining strength and stability. This study recommends to workout implementation of other national policies and standards for administrations. Based on the results of this study, it is recommended that a constant evaluative supervision of hospitals under a regulatory body to promote compliance must be initiated

In the near future, more policies are suggested to be a subject variable of alike studies to identify and solve problems leading to a more reliable and effective health care delivery system.

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Appendix A

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