TALK 4

IDENTIFICATION AREA OF CONCERN AND
OPPORTUNITY FOR IMPROVEMENT AND
PRIORITIZATION

DR ZAHARIMAH ABDUL KADIR
HTJS

LOOK AT YOUR OWN SERVICE

• Who are your customer/clients served
- types of customers/clients

• Conditions/situation encountered/managed
• Activities performed to serve clients
• Range of personnel involved
• Site where service is provided
• Time when service is provided

IDENTIFY IMPORTANT ASPECT OF CARE

• Greatest impact on quality of the service
• Occurs frequently or affect a large number of

clients
• Serious consequence if care/service is not

provided correctly
• High risk or problem-prone aspects of care

CORE BUSINESS

• In-patient care
Admission
Investigation
Treatment
Surgical intervention
Counseling
Pysioteraphy
Discharge

CORE BUSINESS

• Out-patient Specialist care
 Registration
Consultation
Investigation
Medication prescription
Referral
Follow up

AREAS OF CONCERN/
OPPORTUNITY FOR IMPROVEMENT

Related to:
 Morbidity
 Mortality
 Disability
 Complications
 Adverse reactions
 Wide and unnecessary variations in practice
 Unnecessary hospitalization
 High risk areas/potential medico-legal

LIST OF OPPORTUNITY FOR
IMPROVEMENT/PROBLEMS

i. Identify a process to improve.
Process: a series of tasks that provide a
product or a service.

ii. Identify the process owner
Process owner: the lowest ranking person that
can authorize a change to a process.

LIST OF OPPORTUNITY FOR
IMPROVEMENT/PROBLEMS

iii. Select a process for improvement: Criteria
• Felt to be important by staff, clients or

administration
• Within your control and authority to change
• Benefits of improvement will be greater or equal

to the cost and effort to improve it
• Potential for value/impact
• Data is relatively easy to obtain

SOURCE OF FEEDBACK

• Patient’s complaints
• satisfaction survey
• Clinical/ technical audits
• Issues raised at meetings/informal discussion
• Findings during morbidity/mortality meetings
• Medical records audit
• Brainstorming session
• KPI SIQs report
• Incident reporting/mishaps
• Public concerns/media

AREAS OF CONCERN/
OPPORTUNITY FOR IMPROVEMENT

• Elective surgery cancellation
• Notification of communicable disease
• Medication error
• Long waiting time at Specialist out-patient

clinic
• Near miss for blood transfusion
• Congestion of medical ward
• Delay in obtaining lab result
• Improper keeping of bio-medical equipment

METHODS FOR SELECTING A PROCESS

• Brainstorming
• Surveys: administration, clients, staff
• Studies
• Prioritization
• Voting
• Multiple voting/nominal group
• Decision matrix

PROBLEM PRIORITIZATION

• IMPORTANT PROBLEM

1

• WITHIN OUR CONTROL

2

• BENEFITS OVERCOME THE

3 COST AND EFFOTS TO SOLVE IT



SMART CRITERIA

SERIOUSNESS

Might cause morbidity,
permanent disability and
mortality

Causing stress to patients and
family

Impact on patient, staff,
community and organization’s
image

SERIOUSNESS

• Serious adverse effects of invasive intubation
and mechanical ventilation on babies (upper
airway injury, retinopathy of prematurity,
intraventricular heamorrhage) increase risk of
mortality and long term morbidity

• It also increase parental dissatisfaction/anxiety,
nursing care, procedures, costs and length of
stay

SERIOUSNESS

• Benign disease of the upper GI and lower GI like
polyps, benign ulcers and inflammatory lesions
which if diagnosed later may lead to patients
presenting to ETD with complication of the
disease like colon-toxic megacolon, perforated
gastric ulcer, variceal bleed, bleeding ulcer and
carcinoma.

• Average waiting time from the symptoms to
referral till endoscopy was 6-8 months

• These complications may lead to mortality and
morbidity with prolonged hospital stay and
increased health cost.

MEASURABLE

Process clearly defined: starting and ending
points

Indicators identifiable with
problems

Data collected to quantify extent of
problem

MEASURABLE

• Intubation rate of babies < 24 hours of life (%) =

Number of intubated babies x
< 24 hours in delivery room or NICU/SCN
100
Number of babies being resuscitated
with PPV in delivery room

MEASURABLE

• Waiting time is measurable
The waiting time for endoscope is the time from
decision for scope by the Medical Officer till the
time of the endoscope is done

APPROPRIATE

Related to Objective Improvements
core consistent initiative within

business with our control
organization

al goals

APPROPRIATE

• Neopuff is practiced in many centers as
recommended by Australian and New
Zealand Resuscitation Councils

• Open access give chance for healthcare
providers including MO, Family physician and
GI endoscopist to be able to scope earlier,
diagnose and treat the lesion earlier

• Benefit the patients :Early diagnosis leads to
early treatment

REMEDIABLE

Resource Solutions Within the
and are capacity of
expertise possible the group
available

REMEDIABLE

• Intubation rate can be reduced by using early
CPAP intervention with Neopuff

• 37% of 104 infants in the early residual
functional capacity intervention (Neopuff) group
intubated within 72 hours of age vs 51% of 103
(self-inflating bag)

• Intubation rate of babies <34 weeks reduced
significantly from 63.6% (before application of
early CPAP) to 23.8% (after application of early
CPAP)

REMEDIABLE

• Identification of high risk patient using validated
criteria

• The changes in work process is not affecting
many areas of care and personnel

• Reduce the process of referral

TIMELINESS

No current operational, financial
or political issues which might
affect the success of the project

Socially, ethically
acceptable

The whole cycle does not
take very long

TIMELINESS

• Self inflating bag has been used for decades
• Accumulating evidence since 2001 support the

use of Neopuff
• 30 bedded NICU will be operational in WCC
• The issue of delay in diagnosis is seriously

affecting the prognosis therefore it needs to be
addressed immediately

RANKING BY SCORE
1= LOW, 2 = MEDIUM, 3 = HIGH

Problem S M A R T Score

OPPORTUNITY STATEMENT

• There is a need to • There is a need to
provide early reduce intubation rate
endoscopy services in order to prevent
for early detection of muiltiorgan
upper GI cancers complications
associated with
mechanical
ventilation, decrease
length of stay,
improve patient’s care
and parental
satisfaction as well as
for economic reason

Rephrase the opportunity for improvement into QA problem
format

Open access Endoscopy Service
Reduces Waiting Time and Increases
Gastrointestinal Cancer Detection

Reducing intubation rate by using
early CPAP intervention with Neopuff

»Thank you