Abstracts Book

Quality and Safety

in Population Health
and Healthcare
The International Society for Quality in Health Care
13
th
-16
th
October 2013
Edinburgh International Conference Centre
30
th
International Conference
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1373 - EFFECT ON THE LENGTH OF STAY AND COSTS ACCORDING TO PER-DIEM PAYMENT OF PALLIATIVE CARE PROJECT

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2638 - ASSOCIATION OF AVOIDABLE HOSPITAL ADMISSION RATES AND PREVALENCE -
A METHODOLOGICAL APPROACH OF PREVALENCE ADJUSTMENT

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0001
DLVLLCING AND ILC1ING NA1ICNAL UALI1 AND A1ILN1 SAIL1 kL LkICkMANCL INDICA1CkS IN NUkSING
& MIDWIILk kAC1ICL
kaLhleen Mac Lellan, nurse Advlsor, ueparLmenL of PealLh, lreland 8uLh Maher, Pead of MonlLorlng, CuallLy & aLlenL
SafeLy ulrecLoraLe, PealLh Servlces LxecuLlve (PSL), lreland, Sarah Condell, nurslng & Mldwlfery 8esearch &
uevelopmenL Lead, PSL, lreland.

Cb[ect|ves: 1hls paper descrlbes Lhe lnlLlal processes lnvolved ln Lransformlng a naLlonal pollcy vlslon lnLo pracLlce ln
order Lo lmprove paLlenL ouLcomes.

Methods: Measurlng paLlenL ouLcomes was a key ob[ecLlve followlng lreland's Commlsslon on aLlenL SafeLy, whlch
reporLed ln 2008.

AL Lhe Llme a number of exlsLlng groups wlLhln Lhe healLh servlce were already developlng kls, Lhough a number of
Lhese lndlcaLors focused on access and cosL, and noL all had a quallLy and paLlenL safeLy or paLlenL ouLcome focus.

ln response, a number of new lnlLlaLlves were underLaken, lncludlng Lhe Chlef nurse esLabllshlng a nurslng and
mldwlfery key performance lndlcaLor (n&M kl) sLeerlng commlLLee wlLh Lhe alm of ldenLlfylng kls LhaL could be
measured and applled ln nurslng pracLlce and whlch would demonsLraLe paLlenL ouLcomes.

1hls commlLLee works ln collaboraLlon wlLh a concurrenLly formed naLlonal CuallLy and aLlenL SafeLy lndlcaLor SLeerlng
CommlLLee and lLs Lechnlcal group, [olnLly esLabllshed by Lhe PealLh Servlces LxecuLlve's CuallLy and aLlenL SafeLy
ulrecLoraLe (CSu) and Lhe ueparLmenL of PealLh, Lo co-ordlnaLe lndlcaLor developmenL and make recommendaLlons ln
relaLlon Lo quallLy and paLlenL safeLy lndlcaLors for naLlonal reporLlng. 1he Lwo commlLLees have a muLual focus and
some overlap of membershlp provldes conLlnulLy and conslsLency ln co-ordlnaLlon.

1he n&M kl commlLLee lncludes represenLaLlves from all nurslng and mldwlfery sLakeholders lncludlng servlce,
educaLlon and regulaLlon. 1hls commlLLee scoped a basellne of paLlenL care measuremenL acLlvlLy, and examlned Lhe
lnLernaLlonal nurslng & mldwlfery experlence. lrom Lhere, 4 care dellvery Loplcs were ldenLlfled for furLher
developmenL lnLo kl's, of whlch 2 (falls and pressure ulcers) were feaslble and prepared for naLlonal plloLlng, uslng
collaboraLlve worklng wlLh quallLy & paLlenL safeLy experLs ln addlLlon Lo Loplc speclallsLs, wlLh an alm of naLlonal
reporLlng. 1hls process Look 12 monLhs, however a furLher 3 monLhs were requlred Lo deflne and esLabllsh Lhe naLlonal
reporLlng mechanlsms Lhrough exlsLlng sLrucLures. 1he plloL was Lhen commenced uslng Lwo dlfferenL daLa collecLlon
and reporLlng mechanlsms across 19 slLes reflecLlng Lhe varleLy of care dellvery seLLlngs from communlLy Lo acuLe care.

ro[ect kesu|ts: 1hls paper wlll ouLllne Lhe lessons learnL ln Lhe pro[ecL meLhods above. lL wlll also dlscuss Lhe resulLs of
Lhe plloL evaluaLlons, whlch wlll demonsLraLe Lhe sLaLe of readlness for naLlonal reporLlng, Lhrough Lhe naLlonal servlce
plan, of Lhe Lwo chosen kls and lnform Lhe developmenL of oLher CS and nurslng & Mldwlfery kls.

Conc|us|on: 1he developlng and plloLlng of kls for naLlonal reporLlng ls a complex process whlch requlres close
collaboraLlon. Lnsurlng daLa collecLlon and reporLlng mechanlsms are allgned and complemenL exlsLlng meLhods ls
essenLlal for any plloLlng and lmplemenLaLlon of naLlonal kls. Clear leadershlp and supporL from pollcy declslon makers
ls crlLlcal ln drlvlng cross agency collaboraLlon.



0010
LNnANCING A1ILN1 SAIL1 AND UALI1 CI CAkL 8 S1ANDAkDISING 1LLLnCNL 1kIAGL IN 1nL nALMA1CLCG
CNCCLCG SL11ING
Amy nolan CnM2
1
, norma ualy CnS
1
, Lmma 8owan CnS
1
, ur Crla uempsey
2
PaemaLlogy oncology day ward, SL !ames
PosplLal, uublln 8
1
. unlverslLy of uublln, 1rlnlLy College
2

Cb[ect|ve: 1o develop a sLandardlsed 1elephone 1rlage SysLem (11S) and relaLed guldellnes on provldlng Lelephone
advlce Lo paLlenLs Lhus ensurlng lmmedlaLe, approprlaLe and safe advlce for paLlenLs recelvlng LreaLmenL ln Lhe
haemaLology oncology seLLlng and clarlfylng Lhe declslon maklng process for sLaff.
8ackground]S|gn|f|cance: Many of Lhe eplsodes of care provlded by Lhe haemaLology oncology day ward (PCuW) ln SL
!ames's hosplLal lnvolve admlnlsLraLlon of cyLoLoxlc chemoLherapy whlch can have llfe-LhreaLenlng slde effecLs. 1lmely,
effecLlve lnLervenLlon ln managlng Lhese effecLs can be llfe savlng. 1elephone 1rlage (11) provldes essenLlal 24hr
assessmenL for paLlenLs experlenclng Lhese effecLs.
Method: nurses and paLlenL quesLlonnalres ldenLlfled Lhe need for dedlcaLed Llme, space, phone llnes, sLandardlsed
proLocols, guldellnes, e-documenLaLlon and sLaff compeLency for Lhe provlslon of 11. A random sample of 20 calls was
audlLed Lo evaluaLe lmplemenLaLlon of Lhe sLandardlsed 11S.
kesu|ts]Cutcomes: 1he number and Lype of calls recelved over a one monLh perlod was audlLed. Cver 40 of calls
(n=64) were noL LreaLmenL relaLed resulLlng ln redeflnlng Lhe 24hr conLacL numbers. 1wenLy of Lhe 37 LreaLmenL relaLed
calls were randomly selecLed and audlLed. LlghLeen calls (90) were recorded correcLly on Lhe elecLronlc paLlenL records
(L8). aLlenLs recelved approprlaLe and lmmedlaLe advlce ln 90 of calls (n=17).
Conc|us|ons: nurslng leadershlp ln sLandardlslng 11S resulLed ln lmproved paLlenL care and managemenL, Leam
communlcaLlon and compllance wlLh professlonal and legal requlremenLs. lmplemenLaLlon of 11S resulLed ln Lhe
provlslon of lmmedlaLe and sLandardlsed lnformaLlon whllsL lncreaslng sLaff awareness of Lhe lmporLance of Llmely,
quallLy lnLervenLlon and knowledge and skllls ln deallng wlLh unplanned paLlenL problems.




















1030

LIILC1 CI 1LAM kLSCUkCL MANAGLMLN1 (1kM) IN1LkVLN1ICN: A CCS1 CI UALI1 LkSLC1IVL
Chen Melmlau
1,*

1
ueparLmenL of nurslng, 1alpel ClLy PosplLal, 1alpel, 1alwan


Cb[ect|ves: 8y lnLroduclng Lhe cosL of quallLy (CCC) sysLem, Lhls sLudy alms:

1) Lo plan Lhe CCC sysLem for Lhls hosplLal for managemenL Lo undersLand Lhe cosL of efforL ln quallLy lnvesLmenL
(prevenLlve cosL and appralsal cosL) and Lhe effecL on ouLpuL quallLy lmprovemenL (fallure cosLs), and
2) Lo analyse Lhe efflclency of CCC lmplemenLaLlon, Lhe level of CCC lmprovemenL, and Lhe lndlcaLor of quallLy conLrol
performance. 1hls way, we can Lurn Lhls hosplLal lnLo a model hosplLal of CCC lmplemenLaLlon or provlde a
reference for oLher hosplLals wlshlng Lo lmplemenL CCC.

Methods: 1he uelphl Lechnlque was applled Lo screen all key lndlcaLors. llrsL, Lhe hosplLal Lop managemenL was
surveyed as a reference for deLermlnlng Lhe cosL lndlcaLors ln Lhe followlng four consLrucLs: prevenLlve cosL, appralsal
cosL, lnLernal fallure cosL, and exLernal fallure cosL. 8ased on Lhe survey resulLs, Lwo physlclans wlLh boLh medlcal and
law backgrounds, one professor of healLhcare managemenL wlLh CCC experLlse, and Lwo cllnlcal experLs ln handllng
medlcal dlspuLes selecLed Lhe key lndlcaLors ln Lhese four consLrucLs wlLh Lhe fuzzy uelphl Lechnlque and calculaLed Lhe
cosL sources and LoLal CCC.

kesu|ts:
1. lallure cosLs cover Lhe cosL of boLh lnLernal and exLernal fallures. 1he lLems covered ln Lhe lnLernal fallure cosL
lnclude 'assessmenL of Lhe cosL of poor quallLy' and 'rlsk cosL'. WlLh reference Lo Lhe rlghL of requesL of damages
from lnfrlngemenL (dellcL) ln Lhe Clvll Law, Lhe lLems covered ln Lhe exLernal fallure cosL lnclude 'cusLomer complalnL
seLLlemenL', 'llLlgaLlon for medlcal dlspuLes', and 'physlclan professlonal llablllLy lnsurance', and
2. ln Lhe CCC efflclency analysls, afLer Lhe lnLervenLlon of Lhe Leam rlsk managemenL Leam, Lhe acLual fees produced
were (A)+(8)+(C)=$236,093.77. 1he acLual cosL efflclency broughL by Lhe Leam was $23,416,262.23, whlch can
slgnlflcanLly reduce Lhe cosL on handllng medlcal dlspuLes.

Conc|us|on: 1he focus of avoldlng medlcal dlspuLes ls enhanclng healLhcare quallLy by reduclng paLlenL damage. 1he
focus of faclng healLhcare dlspuLes ls crlsls managemenL ln rlsk managemenL. 1he focus of seLLllng medlcal dlspuLes ls
dlsperslng llablllLy wlLh physlcal llablllLy lnsurance.


















1049

kLVLN1ICN CI nCSI1AL ACUIkLD INILC1ICN CI ML1nICILLIN kLSIS1AN1 S1AnLCCCCCUS AUkLUS (MkSA)
Mandy L. l. l
1,*
, vlola C. ?. Chow
2
, MargareL C. ?. Chung
3

1
Medlclne,
2
Mlcoblology,
3
AdmlnlsLraLlve, Allce Po Mlu Llng neLhersole PosplLal, 1al o, Pong kong


Cb[ect|ves: M8SA lnfecLlon ls very dlfflculL Lo LreaL wlLh sLandard Lypes of anLlbloLlcs and Lhus becomes dangerous. lL
ls even regarded as a hosplLal baLLle ln flghLlng agalnsL Lhe lnfecLlon. 1here was a slgnlflcanL lncrease ln hosplLal acqulred
M8SA raLe ln a 32-bed acuLe care medlcal ward of Pong kong reglonal hosplLal. 1he raLe was lncreased from 1.18 Lo 4.23
per 1000 paLlenL bed days (pbd) from nov/2011 Lo !an/2012. lL ls a warnlng slgnal LhaL Lhe paLlenL safeLy wlll be
LhreaLened. ln Aprll/2012, a mulLldlsclpllnary Leam composlng members from medlcal Leam, lnfecLlon conLrol Leam and
admlnlsLraLlon was seL up Lo work ouL sLraLegles and lmplemenL measures Lo reduce Lhe lnfecLlon raLe based on
evldence proof guldellnes.

Cb[ect|ves:
1o reduce Lhe hosplLal acqulred M8SA lnfecLlon raLe ln an AcuLe Care Medlcal Ward.

Methods: 1he sLraLegles Lo reduce Lhe M8SA lnfecLlon raLe were summarlsed as follows:

1) lnfecLlon ConLrol 1eam educaLed fronLllne sLaff on Lhe lmporLance of prevenLlng and combaLlng M8SA lnfecLlon, Lo
conLrol spreadlng of Lhe lnfecLlon wlLhln Lhe ward.
2) AcLlve survelllance screenlng was performed for all newly admlLLed paLlenLs Lo carry ouL early deLecLlon and prompL
lmplemenLaLlon of lnfecLlon conLrol measures. aLlenLs wlLh known hlsLory of M8SA lnfecLlon or carrler were
excluded from Lhe survelllance screenlng.
3) aLlenLs wlLh hlsLory of M8SA lnfecLlon or carrler and paLlenLs who were found Lo be M8SA carrler by Lhe acLlve
survelllance screenlng were lsolaLed Lo prevenL spread of Lhe lnfecLlon.
4) lnfecLlon ConLrol nurse monlLored hand hyglene compllance raLe by applylng WPC meLhodology before and afLer
Lhe educaLlonal sesslons Lo ensure Lhe sLaff were complled wlLh Lhe lnfecLlon conLrol procedures.
3) LnvlronmenLal cleanlng was enhanced by adopLlng colour coded cleanslng meLhods and Lools.
6) PypochlorlLe LableLs (AnLlchlor) were used whlch are more sLable dlslnfecLanL and lmprove occupaLlonal safeLy
comparlng Lo llquld hypochlorlLe (Chlorox).

kesu|ts: lrom !un/2012 Lo uec/2012 Lhere were 1216 paLlenLs admlLLed, and M8SA screenlng was done ln 938 (77.1)
of Lhe paLlenLs. 333 (33.7)) of screened paLlenL had poslLlve M8SA screenlng resulLs. 613 (30.4) of admlLLed paLlenL
was elLher labelled as M8SA carrlers or had poslLlve screenlng resulLs. 89.8 of noLed M8SA cases were lsolaLed ln a
slngle room or cohorLed ln Lhe M8SA cublcle. 1he overall hand hyglene compllance raLe was malnLalned hlgh and even
by lncreaslng from 94 Lo 98 afLer lmplemenLaLlon of Lhe sLraLegles. WlLh concerLed efforLs by all Lhe dlsclpllnes, Lhe
hosplLal acqulred M8SA lnfecLlon raLe was slgnlflcanLly reduced Lo zero from !une /2012 and lasL for seven monLhs.

Conc|us|on: 1he Llmely monlLorlng and lmplemenLaLlon of effecLlve lnfecLlon conLrol measures ls essenLlal Lo mlnlmlse
Lhe hosplLal acqulred M8SA raLe. ln developmenL and lmplemenLaLlon of mulLlfaceLed conLrol measures,
mulLldlsclpllnary approach lnvolvlng cllnlcal, lnfecLlon conLrol and supporLlng sLaff ls Lhe key Lo succeed. SupporL from
AdmlnlsLraLlon ls also essenLlal ln formulaLlng effecLlve lnfecLlon conLrol sLraLegles.




10S4

DLVLLCING AND VALIDA1ING UALI1 INDICA1CkS ICk 1nL kLVALIDA1ICN SL11ING
CeerL van ue WaLer
1,*
, WalLer Sermeus
1
, !os vanlanduyL
1
, Marc nlckmllder
2

1
ueparLmenL of ubllc PealLh, ku Leuven, Leuven,
2
8eseau SanLe Louvaln, unlverslLe CaLhollque de Louvaln, 8russels,
8elglum


Cb[ect|ves: 8ecause of Lhe speclflclLy of Lhe paLlenL populaLlon and Lhe LreaLmenLs, revalldaLlon hosplLals cannoL
ldenLlfy Lhemselves wlLhln Lhe quallLy lndlcaLors LhaL are developed for general hosplLals. neverLheless, Lhe urge for
lnLernal evaluaLlon and benchmarklng ls also growlng ln Lhls Lype of hosplLals. 1herefore, we ldenLlfled and valldaLed a
seL of quallLy lndlcaLors for Lhe evaluaLlon of Lhe quallLy of care ln revalldaLlon seLLlngs.

Methods: AssessmenL of Lhls seL was done by uslng Lhe uelphl meLhod. 1hls lndlcaLor seL was lmplemenLed ln Lhe
lndlcaLor sysLem navlgaLor and placed aL Lhe dlsposal of Lhe hosplLals. navlgaLor ls a cllnlcal lndlcaLor sysLem developed
by Lhe CenLre for PealLh Servlces and nurslng 8esearch from ku Leuven wlLh an acknowledged use ln 8elglan general
hosplLals slnce 2004 (hLLp://www.navlgaLor.czv.be). lL conslsLs of a well-deflned seL of cllnlcal quallLy lndlcaLors,
sofLware LhaL supporLs lnpuL and dellvers feedback, a coordlnaLlng webslLe and an esLabllshed neLwork LhaL llnks
hosplLals and experL groups. MonLhly reglsLraLlon and quarLerly feedback enables hosplLals Lo monlLor sysLemaLlcally
and conLlnuously and wlLh shorL delay Lhe quallLy of care processes and Lhelr resulLs. PosplLals recelve lnformaLlon on
Lhe evoluLlon of Lhelr performance ln Llme and on Lhelr poslLlon among Lhe oLher parLlclpanLs.

kesu|ts: 1he flnal seL conslsLs of 18 process and ouLcome lndlcaLors coverlng Lhe domalns of lengLh of sLay, lengLh of
LreaLmenL, deLermlnlng goals, falls, paln, dlscharge and afLer-care. 1he seL can be exLended up Lo 49 lndlcaLors when
hosplLals wanL Lo speclfy an lndlcaLor accordlng Lo one of Lhe followlng paLhology group: knee prosLhesls, hlp prosLhesls,
sLroke, Lransverse leslon, polyLrauma, cranlocerebral Lrauma, ma[or ampuLaLlon, chronlc neurologlcal condlLlon,
cardlopulmonar condlLlon and CCu.

Conc|us|on: 1hls sLudy descrlbes Lhe developmenL of quallLy lndlcaLors for Lhe revalldaLlon seLLlng and Lhe evaluaLlon of
Lhe lmplemenLaLlon of Lhe lndlcaLors lnLo pracLlce.




10S6

8UILDING A A1ILN1-kLGIS1k 1C MLASUkL 1nL UALI1 CI CAkL ICk nLk1LNSICN IN 1nL NA1ICNAL
nLAL1nCAkL GkCU, SINGACkL
Lrlc S. S. Chua
1,*
, MaLLhlas . P. S. 1oh
1

1
naLlonal PealLhcare Croup, Slngapore, Slngapore


Cb[ect|ves: 1o descrlbe Lhe developmenL of a hyperLenslon paLlenL-reglsLry and Lhe lndlcaLors for measurlng quallLy of
care ln a publlc secLor healLhcare dellvery sysLem ln Slngapore.

Methods: 1he naLlonal PealLhcare Croup (nPC) ln Slngapore ls an lnLegraLed publlc healLhcare dellvery sysLem
comprlslng of 1 acuLe care hosplLal and a group of 9 prlmary care cllnlcs, looklng afLer Lhe populaLlon healLh needs of
over 1 mllllon resldenLs.

ln 2008, Lhe nPC developed a hyperLenslon reglsLry wlLh buslness lnLelllgence Lo dellver seamless and hlgh quallLy care
Lo people wlLh hyperLenslon. 1hls cbtoolc ulseose Moooqemeot 5ystem (cuM5) llnks admlnlsLraLlve and key cllnlcal daLa
of paLlenLs wlLh hyperLenslon across Lhe nPC.

aLlenLs wlLh hyperLenslon are ldenLlfled uslng boLh prlmary and secondary dlagnosls codes (lCu9CM codes 362, 401,
403 and 642) for each ln- and ouL-paLlenL cllnlcal encounLer slnce 2003. uemographlc daLa lncludes age, gender and
eLhnlc group. Cllnlcal daLa lncludes physlcal parameLers such as blood pressure (8) and body mass lndex (8Ml)
readlngs, laboraLory resulLs such as renal and llpld proflle.

1he 3 annual process lndlcaLors lncluded: 8Ml measuremenL, fasLlng blood glucose, serum elecLrolyLes, fasLlng llplds and
urlnalysls. CuLcome lndlcaLors lnclude 8, 8Ml, serum creaLlnlne and LuL-cholesLerol conLrol. aLlenLs are grouped
accordlng Lo Lhe slLe of care or by aLLendlng speclalLy.

kesu|ts: 1he number of paLlenLs ldenLlfled wlLh hyperLenslon lncreased from 133,430 (2003) Lo 242,629 (2011), aL an
average raLe of 8 per annum. ln 2011, abouL 22 of all paLlenLs LreaLed aL nPC were known Lo have hyperLenslon. 1he
number of hyperLenslve paLlenLs lncreased wlLh age and age-speclflc prevalence among paLlenLs lncreased gradually
above 30 years old and peaked aL 70 (80 years and above). AbouL 66 of Lhe hyperLenslve paLlenLs recelved LreaLmenL
aL one of Lhe 9 prlmary care cllnlcs.

ln 2011, Lhe raLes of Lhe annual process lndlcaLors were: 8Ml measuremenL (74.1), fasLlng blood glucose (32.3),
serum elecLrolyLes (94.2), fasLlng llplds (89.2) and urlnalysls (73.3). AbouL 70.7 malnLalned a 8 below 140/90
mmPg, 40.2 had normal 8Ml of 18.3 Lo 24.9 kg/m
2
, 93.1 had a normal serum creaLlnlne below 140 mmol/L and
84.2 had LuL-cholesLerol <3.4 mmol/L. 1he mean 8 was 132/7277/19 mmPg, mean 8Ml was 26.36.0 kg/m
2
and
mean LuL-cholesLerol was 2.670.79 mmol/L.

Conc|us|on: As an lnLegraLlve Lool for chronlc care dellvery, Lhe CuMS has made cllnlcal monlLorlng and ouLcome
managemenL for paLlenLs wlLh hyperLenslon more efflclenL. 1he bulk of paLlenLs wlLh hyperLenslon are LreaLed aL
prlmary care cllnlcs. 1here ls varlaLlon ln Lhe raLes of quallLy process lndlcaLors achleved. 1he resulLs of quallLy care are
analysed by cllnlclan champlons across Lhe nPC Lo ldenLlfy areas of lmprovemenL Lo Lhe dellvery sysLem Lo brlng abouL
beLLer quallLy care for our paLlenLs.




10S7

UALI1 INDICA1CkS 1C ICLLCW LA8CUk INDUC1ICN kA1L AND CALSAkLAN kA1L IN nCSI1AL AND 1C
8LNCnMAkk WI1n C1nLk C8S1L1kIC WAkDS
Marc nlckmllder
1, 2,*
, WalLer Sermeus
2
, CeerL van de WaLer
2

1
8SL, unlverslLe CaLhollque de Louvaln, 8russels,
2
CZv, kaLholleke unlverslLelL Leuven, Leuven, 8elglum


Cb[ect|ves: Labour lnducLlon ls a common procedure ln currenL obsLeLrlcs. 1hls pracLlce ls LhoughL Lo be assoclaLed wlLh
an lncrease ln Lhe rlsk for lnsLrumenLal dellvery and parLlcularly caesarean secLlon whlch can be assoclaLed wlLh
maLernal and foeLal morbldlLy and even morLallLy. 1he alm of Lhe sLudy ls Lo develop quallLy lndlcaLors Lo follow
lnducLlon raLe and caesarean raLe and Lo survey ln Lhe Llme Lhelr poLenLlal correlaLlon wlLhln a hosplLal neLwork.

Methods: Slnce !anuary 2012, ln 8elglum and Luxembourg a neLwork of general hosplLals has developed and applled 11
quallLy lndlcaLors Lo follow labour lnducLlon raLe and caesarean raLe ln hosplLal and Lo benchmark wlLh oLher obsLeLrlc
wards: LoLal number of caesareans, number of flrsL caesareans, number of repeaLed caesareans, number of vaglnal
dellverles afLer earller caesarean, number of sponLaneous dellverles, number of dellverles afLer labour lnducLlon,
number of dellverles afLer labour lnducLlon for medlcal reasons, number of dellverles afLer labour lnducLlon for non-
medlcal reasons, number of prlmary caesareans, number of secondary caesareans, number of caesareans afLer labour
lnducLlon.

CbsLeLrlclans, mldwlfes and hosplLal quallLy coordlnaLors collaboraLe Lo develop Lhem. 1hese lndlcaLors are as parL of
Lhe navlgaLor pro[ecL conslsLlng of well-deflned cllnlcal quallLy lndlcaLors bullL wlLh respecL of pracLlcal sLandards as
evldence-based exlsLence, clear deflnlLlon, accuracy, reproduclblllLy, valldlLy, ease of daLa collecLlon, resLrlcLlon of Lhe
amounL of daLa obLalned Lo Lhe necessary mlnlmum and clarlLy abouL lnLerpreLaLlon of daLa. WlLh navlgaLor Lhe daLa are
monLhly reglsLered and a feedback ls quarLerly avallable for hosplLals Lo monlLor sysLemaLlcally Lhe quallLy of Lhelr care
processes and resulLs.

kesu|ts: 8esldes Lhe lnLernal monlLorlng Lhe follow-up of lnducLlon raLe and caesarean raLe ls also Lhe survey ln Lhe Llme
of Lhelr poLenLlal correlaLlon wlLhln Lhe navlgaLor neLwork accordlng Lo medlcal reasons of lnducLlon or noL.

Conc|us|on: 1hls sLudy descrlbes Lhe developmenL of quallLy lndlcaLors Lo follow lnducLlon raLe and caesarean raLe and
Lhe evaluaLlon of Lhelr lmplemenLaLlon lnLo pracLlce.



1060

CLASSIIICA1ICN CI A1ILN1S CCMLAIN1S - CAN 1nL CLASSIIICA1ICN SS1LM IN 1nL DANISn A1ILN1 SAIL1
DA1A8ASL 8L USLD ICk A1ILN1S CCMLAIN1S IkCM nCSI1ALS
MarLln L. 8ommersholdL
1,*

1
Learnlng group, uanlsh Agency for aLlenLs' 8lghLs and ComplalnLs, lrederlksberg, uenmark


Cb[ect|ves: naLlonal Agency for aLlenLs' 8lghLs and ComplalnLs (aLlenLombuddeL) was esLabllshed ln 2011. WlLh Lhls
esLabllshmenL lL became posslble Lo compare lnformaLlon from complalnLs, compensaLlons cases and adverse evenLs.
1here ls currenLly no common classlflcaLlon sysLem for Lhe Lhree Lypes of daLa, and lL ls Lherefore noL posslble Lo
compare daLa uslng common search crlLerla.

1he purpose of Lhls asslgnmenL ls Lo assess how Lhe uanlsh verslon of Lhe WPC `s lnLernaLlonal ClasslflcaLlon SysLem for
aLlenL safeLy, lCS-uk, whlch ls used for classlflcaLlon of adverse evenLs, musL be adapLed, so LhaL lL can maLch
complalnLs from paLlenLs.

1he LheoreLlcal framework for Lhe sLudy ls new ubllc ManagemenL wlLh a focus on quallLy managemenL, and how
hosplLals on a naLlonal level can learn from complalnLs.

Methods: 1he meLhod ls a valldaLlon LesL of WPC `s lnLernaLlonal ClasslflcaLlon SysLem for aLlenL safeLy, lCS, for
LesLlng Lhe case-varlaLlon ln paLlenL's complalnLs. 8efore Lhe valldaLlon LesL a plloL LesL was conducLed Lo examlne Lhe
deLall of Lhe classlflcaLlons. A rellablllLy LesL was conducLed Lo lnvesLlgaLe lnLer-observer varlaLlon.

1he valldaLlon LesL was based on 117 responses from employees aL 1he ComplalnL CenLre aL 1he naLlonal Agency for
aLlenLs' 8lghLs and ComplalnLs.

lurLhermore, a random sample of 246, Len per cenL of declded complalnLs from hosplLals ln 2010 were used.
lor Lhe plloL LesL 30 complalnLs from Lhe sample were used. 46 complalnLs were compared ln Lhe rellablllLy LesL of Lhe
lCS classlflcaLlons.

kesu|ts: lCS classlflcaLlons handle Lhe case varlaLlon ln paLlenL's complalnLs. 1he Lwo sLudles lllusLraLe, LhaL Lhe case
varlaLlon shows LhaL Lhe respondenLs ln Lhe caLegory of `oLher` are respecLlvely 3.8 and 3.4 per cenL. lnLer-observer
rellablllLy of lCS showed dlfferenL resulLs ln Lhe lCS classlflcaLlon groups.

Conc|us|on: lL ls necessary Lo ad[usL Lhe uanlsh cusLom lCS-uk wlLh 43 new classlflcaLlons of lCS Lo handle Lhe case
varlaLlon. ln addlLlon lL ls necessary Lo enLerlng oLher classlflcaLlon Lo each classlflcaLlon group.

1he sysLemlc classlflcaLlons ln lCS may conLrlbuLe Lo a beLLer undersLandlng of quallLy managemenL, lncludlng Lhe
sysLemlc facLors LhaL are lmporLanL for Lhe reason why evenLs occur and are prevenLable.

keferences: hLLp://www.paLlenLombuddeL.dk/?sc_lang=en




1063

LIILC1IVL LkSCNALISLD S1kA1LGILS 1C DLCkLASL UNSCnLDULLD kL1UkNS 1C 1nL LMLkGLNC DLAk1MLN1
WI1nIN 72 nCUkS
Pul-Chln Wang
1,*
, ?en-Chlu Llu
1
, Chlu-Pul Puang
1
, !lln-Paur Chuang
1

1
Councll for CuallLy PealLh Care, kaohslung Chang Cung Memorlal PosplLal, kaohslung, 1alwan


Cb[ect|ves: unscheduled reLurns Lo Lhe emergency deparLmenL (Lu) ls an lmporLanL acuLe care lndlcaLor LhaL frequenLly
slgnlfles lnsufflclenL educaLlon or lnsLrucLlon Lo Lhe Lu paLlenLs, lnadequaLe dlagnosls or LreaLmenL durlng Lhe lnlLlal vlslL
or poor access Lo Lhe ouLslde hosplLal afLer dlscharge, resulLlng ln hlgher Lu use and hosplLal cosLs. We reporL our
sLraLegles Lo lmprove lL over Lhe lasL seven years. 1he sLaLlsLlcs lnclude Lhe paLlenLs of any age LhaL can access our Lu, as
lL ls a blg general hosplLal wlLh 2,600 beds.

Methods: ln 2004, Lhe unscheduled reLurns Lo Lu wlLhln 72 hours were 3.89 (3900/100,170) ln our hosplLal, whlch
were unaccepLably hlgh. lurLher analysls revealed LhaL chlldren wlLh acuLe lllness were responslble for 7.18 (300/4,174
per monLh) of unscheduled reLurn, followed by old-age paLlenLs wlLh chronlc lllness 3.49 (317/3,164 per monLh). Serlal
sLraLegles were used Lo lmprove lL, whlch lnclude adopLlon of sLandardlsed LreaLmenL proLocol for dlseases LhaL Lend Lo
cause reLurn of Lhe paLlenLs, LhoughLful dlscharge plan, and sufflclenL lnsLrucLlon of home care. lor chlldren, a phone
llne was seL up so LhaL Lhe famlly could consulL our paedlaLrlclans any Llme afLer Lhe lnlLlal vlslL when Lhey found lL was
necessary Lo do lL. lor adulL paLlenLs, an effecLlve plan was seL up Lo manage paLlenLs wlLh mulLlple enLrles Lo Lu for
paln conLrol, alcohollsm, psychlaLrlc dlseases, eLc.

kesu|ts: lollowlng Lhe above sLraLegles, unscheduled reLurns Lo Lu wlLhln 72 hours decreased gradually from 3.89 ln
2004 Lo 3.34ln 2010 (4,387/129,349, =0.000). 1he decrease was mosL slgnlflcanL ln paedlaLrlc populaLlon, from
7.18 ln 2004 Lo 3.3(101/2,917 per monLh) ln 2010, followed by adulL paLlenLs wlLh chronlc dlseases, from 3.49 ln
2004, Lo 3.9(227/3,807 per monLh) ln 2010.

Conc|us|on: Cur resulLs lndlcaLe LhaL for effecLlve managemenL of unscheduled reLurns Lo Lu wlLhln 72 hours,
personallsed sLraLegles for dlfferenL age populaLlon, as well as sLandardlsed LreaLmenL proLocol, LhoughLful dlscharge
plan and sufflclenL lnsLrucLlon of home care are lmporLanL lngredlenLs.





1064

1CWAkDS AN IN1LGkA1LD AkCACn 1C MCNI1CkING nCSI1AL MCk1ALI1 IN 1nL NCk1n LAS1 CI LNGLAND: 1nL NLCS
AkCACn
1ony 8oberLs
1, 2
, Mlchael Walkley
2
, AlasLalr 8eaLLle
2, 3
, aula WhlLLy
2, 4,*

1
SouLh 1ees PosplLals nPS loundaLlon 1rusL, Mlddlesbrough,
2
norLh LasL CuallLy CbservaLory SysLem,
3
norLhumbrla PealLhcare nPS
loundaLlon 1rusL,
4
norLhumberland, 1yne and Wear nPS loundaLlon 1rusL, newcasLle, unlLed klngdom


Cb[ect|ves: 1o develop an lnLegraLed approach Lo monlLorlng morLallLy ln acuLe hosplLals across Lhe norLh LasL (nL). 1o respond
Lo pollcy developmenLs followlng publlcaLlon of Lhe ubllc lnqulry lnLo Mld SLaffordshlre and ln parLlcular Lhe new requlremenL Lo
monlLor and revlew prevenLable morLallLy ln order Lo drlve lmprovemenL ln cllnlcal care. 1o supporL Lhe new reglonal mechanlsms
for morLallLy survelllance.

Methods: 1he norLh LasL CuallLy CbservaLory SysLem (nLCCS) was esLabllshed as Lhe reglonal hub of healLhcare quallLy
measuremenL, lLs role ls Lo drlve lmprovemenLs by maklng quallLy daLa and lnformaLlon avallable across Lhe healLh sysLem. nLCCS
has produced flfLeen quarLerly reporLs presenLlng a range of morLallLy and conLexLual measures Lo provlde morLallLy assurance Lo
boLh provlders and commlssloners Lhrough Lhe use of comparaLlve daLa. SupporL ls also provlded Lo lndlvldual 1rusLs, parLlcularly Lo
8oards, Lo undersLand Lhe Lechnlcal challenges ln measuremenL and ln respondlng Lo Lhelr flgures.

1hls approach Lo be furLher developed speclflcally Lo revlew deaLhs LhaL may be prevenLable, ln llne wlLh Lhe new lndlcaLor
proposed ln Lhe CuLcomes framework for 2013-14, based on Lhe paper produced on Lhe revlew of prevenLable deaLhs (Pogan 2012).
A plloL ls planned for Lhe sprlng of 2013 Lo develop Lhe deLalls of Lhe meLhods LhaL wlll be used ln Lwo of Lhe elghL acuLe LrusLs ln Lhe
nL. ln each 1rusL consulLanLs wlll revlew 30 randomly selecLed case noLes of paLlenLs who have dled and [udge wheLher Lhere were
any problems ln care and wheLher Lhe deaLh could have been prevenLed.

kesu|ts: 1rends for unad[usLed morLallLy PSM8 and SPMl wlll be presenLed, as well as varlous ways of breaklng Lhls daLa down
below 1rusL level (lncludlng by condlLlon).

rellmlnary resulLs wlll be presenLed from Lhe plloL work on Lhe revlew of prevenLable deaLhs. lL ls expecLed LhaL resulLs wlll be
avallable from Lhe revlews conducLed ln March and !une 2013. 1he ouLpuLs from Lhls work wlll be produced ln a conslsLenL formaL Lo
Lhose publlshed by Pogan.

1rusL erlod for revlew
(2013)
Case noLes
revlewed
revenLable
morLallLy
1rusL A !une 30 5.2X*
1rusL 8 March + !une 30 + 30 5.2X*

* noLe: prevenLable morLallLy flgure shown of 3.2 per Pogan, plloLs wlll provlde 1rusL flgures.

Conc|us|on: nLCCS has developed morLallLy assurance ln Lhe nL and all of Lhe acuLe LrusLs reporL morLallLy aL 8oard level and
dlscuss morLallLy wlLh Lhelr Commlsslonlng organlsaLlons. 1he new reglonal mechanlsms for quallLy survelllance are currenLly belng
developed and wlll be supporLed by nLCCS Lo monlLor morLallLy.
MonlLorlng morLallLy sLaLlsLlcs has been a prlorlLy slnce Lhe publlcaLlon of Lhe flrsL lrancls reporL ln 2010. Powever, morLallLy
sLaLlsLlcs have proven dlfflculL Lo use for lmprovemenL. lL ls clear LhaL new lndlcaLors whlch are more LlghLly focused on deaLhs LhaL
may be prevenLable because Lhey are aLLrlbuLable Lo problems ln care are needed Lo allow lmprovemenL efforLs Lo be more
successful.

ConcenLraLlng on prevenLablllLy wlll allow Lhe numerous sLreams of safeLy work LhaL LargeL speclflc lssues, llke managlng
deLerloraLlng paLlenLs, lnfecLlons, falls, venous Lhromboembollsm eLc Lo be lnLegraLed, Lhereby brlnglng LogeLher efforLs Lo lmprove
cllnlcal processes wlLh a focus on paLlenL ouLcomes.

keferences: Pogan P, Pealey l, neale C eL al. revenLable deaLhs due Lo problems ln care ln Lngllsh acuLe hosplLals: a reLrospecLlve
case record revlew sLudy. 8MI Oool 5of 2012,21:737-743

1073

LNnANCING 1nL nLAL1n GUIDANCL CCMLL1ICN kA1L ICk NUkSING CAkL S1AII CCNDUC1ING kLnA8ILI1A1ICN
LkLkCISLS WI1n S1kCkL A1ILN1S
!lng-?un Lln
1,*
, Szu 1zu Llu
1
, Chen Puang
1

1
nurslng, lar LasLern Memorlal PosplLal, new 1alpel ClLy, 1alwan


Cb[ect|ves: SLrokes resulL from paLhologlcal changes ln blood vessels of Lhe braln LhaL cause damage Lo braln funcLlons.
SLrokes lnLerfere wlLh moLor funcLlons, causlng lndlvldual and famlly burdens as well as soclal cosLs. As such,
rehablllLaLlon exerclses, whlch enhance reflexes and Lhe braln's proprlocepLlve funcLlons and ensure normal funcLlonlng
ln [olnLs, should be lmplemenLed early. Powever, conLlnuous rehablllLaLlon exerclslng ls challenglng from a paLlenL's
perspecLlve, one lmporLanL facLor ls how fronLllne nurslng sLaff evaluaLe, asslsLs, and conducL healLh educaLlon, carry
ouL rehablllLaLlon exerclses, and Lrack Lhelr effecLlveness by focuslng on Lhe glven paLlenL.

Methods: A revlew of Lhe healLh guldance compleLlon raLe for Lhe rehablllLaLlon exerclses by sLroke paLlenLs showed a
decreased raLe of 20 due Lo lack of undersLandlng regardlng healLh guldance, lnapproprlaLe pamphleLs, non-unlform
Lransfers of shlfL responslblllLles, and shorLage of rehablllLaLlon cenLers. Measures have been lnLroduced Lo lnvlLe
rehablllLaLlon physlclans as lecLurers Lo sLrengLhen Lhe knowledge and concepLs of nurses Lhrough on-Lhe-[ob educaLlon,
cllnlcal Leachlng, and onslLe Lralnlng. A rehablllLaLlon exerclse uvu was fllmed wlLh real demonsLraLlons of exerclses
broken down lnLo varlous parLs Lo enhance muLual parLlclpaLlon by allowlng parLlclpanLs Lo waLch and carry ouL Lhe
exerclses slmulLaneously, and Lhe number of nurslng shlfL opLlons for rehablllLaLlon exerclses was lncreased Lo
lmplemenL a compleLe and rellable shlfL sysLem. A rehablllLaLlon cenLre equlpped wlLh parallel wooden bars was
esLabllshed for paLlenLs and Lhelr famlly members.

kesu|ts: An effecLlveness evaluaLlon followlng Lhe above enhancemenLs showed LhaL Lhe healLh guldance compleLlon
raLe for rehablllLaLlon exerclses conducLed wlLh sLroke paLlenLs lmproved from 20 Lo 100. rovlded wlLh 3 or less
days of guldance, paLlenLs are able Lo carry ouL Lhe rehablllLaLlon exerclses and undersLand Lhe ob[ecLlves and
precauLlons. 1he frequency of exerclses has been lncreased from once Lo 3-4 Llmes per day, wlLh each sesslon lasLlng aL
leasL 20 mlnuLes. uue Lo Lhe dlverslfled language backgrounds of Lhe careLakers, 3 addlLlonal verslons ln vleLnamese,
Lngllsh, and Pakka have been lnLroduced Lo meeL Lhelr requlremenLs. 1he nurslng sLaLlon also lenL ouL lapLops on
movable sLands Lo lncrease convenlence and effecL of learnlng from Lhe healLh guldance uvu. 1he uvu can also be
uploaded onLo Lhe hosplLal's webslLe and promoLed comprehenslvely.

Conc|us|on: ConLlnulLy ls an lmporLanL parL of rehablllLaLlon exerclses. 8ecause Lhe resulLs ln Lhe early sLages of
rehablllLaLlon affecL Lhe Lralnlng and recovery of funcLlons ln laLer sLages, nurslng sLaff should play Lhe roles of Lhe
careglver, healLh educaLor, and supervlsor and help paLlenLs durlng rehablllLaLlon and exerclslng. 1hls pro[ecL used a
mulLlmedla uvu and colored pamphleLs Lo reduce Lhe Llmes lnsLrucLlons had Lo be repeaLed and allow famlly members
Lo vlew lnsLrucLlons repeaLedly. 1hls helps enhance Lhe lmporLance of rehablllLaLlon ln Lhe afLermaLh of a sLroke and
emphaslses lLs conLlnulLy. 1he recovery of llmb movemenLs also enhances paLlenLs' parLlclpaLlon ln dally acLlvlLles and
Lhelr ablllLy Lo Lake care of Lhemselves. 1hrough Lhe use of dlverslfled healLh Lools by nurslng sLaff, paLlenLs and famlly
members can beLLer undersLand Lhe lmporLance of rehablllLaLlon exerclses, whlle Lhe level of saLlsfacLlon for nurslng
quallLy ls also lmproved.



107S

IMLLMLN1A1ICN CI LLAN AkCACn 1C IMkCVL CUS1CMLk SA1ISIAC1ICN 1nkCUGn LIIICILN1 DISCnAkGL
kCCLSS
Abd Moln Sumarla
1
, Ahmad 8oslan
2
, Pallm Pallza
1,*

1
nurslng,
2
k! Selangor SpeclallsL PosplLal, Malaysla, Selangor, Malaysla


Cb[ect|ves: 1he managemenL of k! Selangor SpeclallsL PosplLal declded Lo form a Leam Lo look lnLo Lhe problem. 1he
members were selecLed from varlous hosplLal servlces Lo overcome Lhe problem. 1he ob[ecLlves of Lhe pro[ecL are Lo
lmprove on 4 areas, Puman dlmenslon, CuallLy perspecLlve, 1lme and CosL.

Methods: uaLa was collecLed from !anuary Lo uecember 2011 based on cusLomer complalnLs relaLed Lo prolonged
dlscharge Llme. uslng LLAn approach, value SLream Analysls (vSA) was conducLed. When Lhe Leam analysed Lhe
dlscharge flow, we ldenLlfled Lhe rooL causes LhaL conLrlbuLed Lo Lhe delay ln Lhe dlscharge process. 1he rooL causes are,
lacklng ln dlscharge plannlng, excesslve dupllcaLlon of lnformaLlon ln documenLaLlon, delay ln dellverlng of dlscharge
medlcaLlon Lo Lhe ward, poor care coordlnaLlon among members of Lhe healLhcare Leam and lneffecLlve lnLerdlsclpllnary
communlcaLlon.

1he Leam had formulaLed 2 8apld lmprovemenL LvenLs (8lL's), ln order Lo lmprove Lhe dlscharge process. llrsL 8lL was
relaLed wlLh lmplemenLaLlon of pre-dlscharge process and was lmplemenLed ln uecember 2011. A Lyplcal paLlenL
dlscharge process lnvolves docLor, ward sLaff, pharmacy (medlcaLlons) and flnanclal conslderaLlon (blll seLLlemenL). 1hls
lnvolves paperwork, a ma[or porLlon can be done a day earller Lo avold work congesLlon on Lhe dlscharge day lLself.

1he pre-dlscharge process lnvolves early clearlng of Lhls porLlon of paperwork. 1he docLor wlll prepare Lhe dlscharge
papers (dlscharge summary, lnsurance, medlcal cerLlflcaLe and Lake home medlcaLlons) on Lhe day prlor Lo Lhe expecLed
day of dlscharge. Cn Lhe dlscharge day, all requlred documenL for Lhe dlscharge procedure prepared earller are
submlLLed Lo Lhe lnsurance company early parL of Lhe day on Lhe dlscharge day. harmacy sLaffs are noLlfled and Lhey
wlll send Lhe Lake home medlcaLlon Lo Lhe ward.

kesu|ts: AfLer 3 monLhs of lmplemenLaLlon, Lhere was a 62 reducLlon ln Lhe dlscharge Llme from 170 mlnuLes Lo an
average of 63 mlnuLes. We had also reduced Lhe dlscharge process on Lhe day of dlscharge lLself from 26 sLeps Lo 7 sLeps
(73) whlch slgnlflcanLly reduced Lhe sLaff's workload. ln relaLlon Lo Lhls, we were able Lo reduce Lhe manpower durlng
Lhe dlscharge day and wlLh Lhls efflclenL dlscharge process, we managed Lo save our sLaff Llme up Lo 733 mlnuLes per
day. 1haL means, we could save a LoLal of 264,600 mlnuLes (4,410 hours) per year, whlch equlvalence Lo 8M 174,636 per
year. Cur cusLomers also had reLurned poslLlve and encouraglng feedback (93 poslLlve feedback) ln relaLlon wlLh
dlscharge process.

Conc|us|on: 8ased on Lhe daLa collecLed, we can see clearly LhaL wlLh Lhe lmplemenLaLlon of Lhe pre-dlscharge pro[ecL
uslng LLAn managemenL approach, we are able Lo achleved remarkable beneflLs from varlous aspecLs such as reduced
workload, reduced sLaff sLress, reduced manpower and cosL and also lmproved cusLomer saLlsfacLlon. 1he managemenL
has now lmplemenLed Lhls process hosplLal-wlde slnce May 2012.

keferences:
1. larrls, aul W., nell 1. 8endle, hllllp L. felfer, uavld !. 8elbsLeln (2010). Motketloq Mettlcs. 1be uefloltlve ColJe to
Meosotloq Motketloq letfotmooce. upper Saddle 8lver, new !ersey: earson LducaLlon, lnc.

2. k! Selangor SpeclallsL PosplLal, MCSl, !an.2011 - May 2012



1078

NLLDLLS1ICk INIUk INCIDLNCL AMCNG NUkSING S1AII AND INVLS1IGA1ICN CI ASSCCIA1LD LA8Ck SAIL1 kISkS
lang Chlh-Chla
1,*
, Wu Ll- Lan
1

1
ueparLmenL of nurslng, 1alpel ClLy PosplLal, 1alpel, 1alwan


Cb[ect|ves: Lo undersLand Lhe needle sLlck lncldence among nurslng sLaff and Lhe assoclaLed facLors, 1. Lo undersLand
Lhe lncldence of polluLed needle sLlck, 2. Lo lnvesLlgaLe Lhe assoclaLed facLors for polluLed needle sLlck, 3. Lo sLudy Lhe
polluLed needle sLlck rlsk raLlo.

Methods: Lhe cross-secLlonal reLrospecLlve sLudy deslgn was adopLed. 1he needle sLlck reporLlng sysLem was used Lo
analyse Lhe reporLed needle sLlck evenLs of Lhe nurslng sLaff ln 8 branches of 1alpel ClLy hosplLals from !anuary 2011 Lo
uecember 2012. 1he daLa collecLed lncluded Lhe baslc characLerlsLlcs of needle sLlck sub[ecLs, years of work experlence,
advanced professlonal skllls and courses as parL 1, Lhe Llmlng and medlcal conducL of needle sLlck evenLs, needle sLlck
ob[ecL classlflcaLlon as parL 2, Lhe adherence Lo sLandard operaLlng procedure, use of proLecLlve equlpmenL, operaLlon
accuracy as parL 3. 1he sLaLlsLlcal meLhods used lnvolved percenLage, chl-squlre, correlaLlon, and Cdds raLlo.

kesu|ts:
1. 1he needle sLlck evenLs occurred mosLly durlng blood wlLhdrawal and medlcal pracLlces (67.12) among [unlor
nurslng sLaff wlLh no more Lhan 1 year of work experlence,
2. 1he needle sLlck rlsk raLlo of Lhose who dld noL follow Lhe lnsLrucLlons of Lhe use of needle collecLors was 3.067
Llmes hlgher Lhan Lhose who dld (C83.067, 93 Cl1.840-13.933, p.001),
3. 1he needle sLlck rlsk raLlo of Lhose who dld noL comply wlLh Lhe lnsLrucLlons of Lhe use of Lrolleys was 2.800 Llmes
hlgher Lhan Lhose who dld (C82.800, 93 Cl1.062-7.383, p.033),
4. 1he needle sLlck rlsk raLlo of anLhropogenlc facLors of Lhose noL abldlng by Lhe sLandard operaLlng procedure was
0.142 Llmes hlgher Lhan Lhose wlLh safeLy sLrucLure uses (C8.142, 93 Cl.017-1.199, p.042).

Conc|us|on: Compllance wlLh Lhe sLandard operaLlng procedure and Lhe use of proLecLlve equlpmenL were able Lo
ellmlnaLe Lhe hurdle of unsafe behavlours ln Lhe work place and Lherefore reduce Lhe needle sLlck rlsks. Powever, how
Lo ascerLaln Lhe adherence Lo Lhe sLandard operaLlng procedure among nurslng sLaff, Lhe full use of proLecLlve
equlpmenL durlng medlcal pracLlces, and Lhe reducLlon of anLhropogenlc needle sLlck rlsks were Lhe ma[or goals LhaL Lhe
hosplLals should aLLempL Lo achleve.




1083

AN INVLS1IGA1ICN CI 1nL ISCLA1ICN kA1L AND C1nLk kLLLVAN1 IAC1CkS CI ACINL1C8AC1Lk 8AUMANNII INILC1ICN IN ICU
1sal-Wen Llu
1,*
, Lee-Chen Chen
1
, Pou-Lal Chang
2
, Chun-Pslng Llao
3

1
nurse ueparLmenL,
2
Chlef ln medlcal lnLenslve unlL ,
3
lnfecLlous ulsease ALLendlng hyslclan, lar LasLern Memorlal PosplLal, new
1alpel ClLy , 1alwan


Cb[ect|ves: lnvesLlgaLe Lhe lsolaLlon raLe and relevanL facLors of AclneLobacLer baumannll lnfecLlon ln lnLenslve Care unlL.

Methods: Cn Lhe 6
Lh
of Aprll, 2011, LesLlng was conducLed on Lhe envlronmenL and on Lhe hands of Lhe worklng sLaff aL Lhe unlL,
wlLh a LoLal of 61 speclmens collecLed. Among Lhem, A. baumannll was lsolaLed from 12 speclmens spread across surfaces ln Lhe
areas dlslnfecLed afLer Lhe Lransfer of 3 paLlenLs. 1hese lncluded bed ralls, resplraLor panels and resplraLlon LreaLmenL records.
Powever, Lhe hands of worklng personnel were noL found Lo have Lhe paLhogen.

lrom Lhe 13
Lh
Lo Lhe 27
Lh
of Aprll, 2011, acLual observaLlon was carrled ouL Lo lnspecL a LoLal of 23 speclmens durlng Lhe process of
Lransfer of paLlenLs, release from hosplLal and flnal dlslnfecLlon. lL ls dlscovered LhaL are mlsLakes ln Lhe processes of flnal
dlslnfecLlons by cleaners and use of physlologlcal monlLors by nurslng asslsLanLs. 1here are no sequences ln Lhe dlslnfecLlons carrled
ouL by cleaners, nurslng asslsLanLs and resplraLory LheraplsLs, CompllaLlon and analysls of Lhe lnformaLlon shows LhaL Lhe above ls
due Lo:

1) lncorrecL dlslnfecLlon process,
2) non-lnLegraLlon of Lhe dlslnfecLlon Leam,
3) lncorrecL meLhod of dlslnfecLlon.

lnLervenlng measures lnclude:

1) lnLer-Leam dlscusslon: docLors from Lhe lnfecLlon deparLmenL, appolnLed personnel for lnfecLlon conLrol, general ln-charge,
cleaners' supervlsor, 81 Leam leader, depuLy dlrecLor and supervlsor of Lhe nurslng deparLmenL and head nurses from Lhe
varlous lCus would come LogeLher and lmprove Lhe dlslnfecLlon process for lCu unlLs,
2) lnLer Leam lnLegraLlon and process lmplemenLaLlon,
3) Lhe lCu managemenL commlLLee proposed Lo: adopL Lhe use of anLl-dusL covers for resplraLors and change Lhe dlslnfecLlon
meLhods used,
4) redo Lhe resplraLor malnLenance card and operaLlve procedure card and remove Lhe resplraLlon LreaLmenL records ouL of Lhe
paLlenL's unlL,
3) educaLlon on flnal dlslnfecLlon meLhods and processes: lncludes cleaners, nurslng asslsLanLs and resplraLory LheraplsLs,
6) lncrease Lhe sLrengLh of nurslng asslsLanLs ln Lhe nurslng deparLmenL: lmplemenL a pollcy allowlng nurslng asslsLanLs Lo cover
each Lhe shlfLs of oLhers.

kesu|ts: 1he lsolaLlon raLe of A.baumannll bacLerla ln lCu lnfecLlons fell from 12 ln 2011 Lo 3.7 ln 2012, whlle denslLy of lnfecLlons
fell from 13.38 ln 2011 Lo 11.37 ln 2012.

Conc|us|on: A.baumannll accounLed for 13, Lhe hlghesL proporLlon, of bacLerlal lnfecLlon cases ln lCu ln 2010. 1esLlng conducLed
afLer carrylng ouL dlslnfecLlon upon Lransfer or release of paLlenLs from Lhe hosplLal showed LhaL A. baumannll can be lsolaLed from
bed ralls, bedslde desks, bedslde physlologlcal monlLor screens, resplraLor panels and oLher equlpmenL.

LffecLlve lnLervenlng measures were lnLroduced Lo reduce Lhe congregaLlon and cross lnfecLlon of lnfecLlous bacLerla ln Lhe hosplLal,
as well as Lo monlLor and analyse Lhe reasons behlnd. 1he A.baumannll bacLerla lsolaLlon raLe ln lCu lnfecLlons fell from 12 ln 2011
Lo 3.7 ln 2012. lormulaLlng of a sLandard operaLlng procedure ls lmporLanL, buL correcL lmplemenLaLlon ls equally crlLlcal. 8egular
checks and Lraclng of speclmens, monlLorlng and conLrol of envlronmenL, as well as cleanlng and dlslnfecLlon can effecLlvely reduce
Lhe congregaLlon of lnfecLlous bacLerla and cross lnfecLlon of A.baumannll wlLhln Lhe hosplLal. 1hls research provldes a source of
reference for lmplemenLlng prevenLlve measures for cllnlcal lnfecLlons.

1099

USING A UAN1I1A1IVL kISk kLGIS1Lk 1C UNDLkS1AND nLAL1nCAkL S1AII SAIL1 kISkS
!ohn Campos
1,*

1
CuallLy and SafeLy CuLcomes, vlrglnla Mason Medlcal CenLre, SeaLLle, unlLed SLaLes


Cb[ect|ves: Cur goal was Lo develop an lnnovaLlve analyLlc framework for a rlsk reglsLer LhaL would lnLegraLe daLa from mulLlple
sources and use slmple meLrlcs Lo ob[ecLlvely caLegorlse and quanLlLaLlvely esLlmaLe rlsks Lo sLaff safeLy ln healLhcare. 1he
organlsaLlon's execuLlve Leam would use Lhe rlsk reglsLer's flndlngs Lo help ldenLlfy opporLunlLles for lmprovlng sLaff safeLy.

Methods: We developed a comprehenslve rlsk concepL model comprlslng 18 broad caLegorles of safeLy concerns. We looked Lo
lndusLry sLandards Lo lnform Lhls model (e.g., u.S. CccupaLlonal SafeLy and PealLh AdmlnlsLraLlon) and caLegorlsed Lhe rlsks lnLo a
slmple hlerarchlcal sLrucLure. 1he maln caLegorles were rlsks due Lo physlcal mlshaps (equlpmenL, movemenL and falls), rlsks due Lo
exposure (energy, blologlcs and chemlcals), and rlsks due Lo behavloural evenLs (lmpalrmenL, verbal and physlcal abuse).

We Lhen ldenLlfled daLa sources and meLrlcs LhaL would allow us Lo quanLlfy rlsk ln all caLegorles. We acqulred 18,337 poLenLlal
lncldenLs for a full calendar year from key medlcal cenLer daLa sysLems, lncludlng aLlenL SafeLy, SecurlLy, Puman 8esources and
Lmployee PealLh.

lor each reporLed lncldenL, we quanLlfled and rank-ordered rlsks along four dlmenslons: raLe of occurrence, severlLy of harm, days
away from work, and known paymenLs for medlcal care. We also noLed Lhe sLaff lnvolved ln each lncldenL (e.g., physlclan, nurse, or
housekeeper). We conducLed a deLalled revlew of Lhe Lop flve areas of rlsk Lo ldenLlfy recurrlng Lhemes and speclflc opporLunlLles
for lmprovlng safeLy.

kesu|ts: Cur meLhods allowed us Lo lnLegraLe 18,337 poLenLlal safeLy concerns from mulLlple daLa sources, and Lo quanLlfy and
prlorlLlse Lhelr relaLlve sLaff safeLy rlsks along four dlmenslons. We found 737 lncldenLs LhaL posed a rlsk Lo sLaff safeLy. Cur rlsk
reglsLer provlded boLh emplrlcal conflrmaLlon and refuLaLlon of anecdoLal concerns ralsed ln our organlsaLlon.

Cur resulLs showed LhaL llfLlng presenLed Lhe mosL rlsk Lo sLaff. 1he ln[ury raLe and severlLy were hlgh, lnvolved Lhe mosL days away
from work and Lhe hlghesL amounL of known paymenLs for medlcal care. aLlenL care Lechnlclans (C1s) and medlcal asslsLanLs
(MAs) had Lhe mosL llfLlng ln[urles, usually whlle movlng paLlenLs and equlpmenL.

lnvaslve ln[urles also had a hlgh raLe of occurrence and poLenLlal for harm, as well as paymenLs for medlcal care borne by Lhe
organlsaLlon, buL Lhe ln[urles dld noL resulL ln prolonged absence from work. hyslclans, nurses, C1s and MAs were mosL aL rlsk,
geLLlng puncLures and cuLs from sharp medlcal devlces ln Lhe operaLlng rooms and paLlenL rooms.
8epeLlLlve moLlon ln[urles (wrlsLs, arms and shoulders), falls ln bulldlngs and blunL ln[urles (usually lnvolvlng doors) rounded ouL Lhe
Lop flve rlsks Lo sLaff.

Some anecdoLal sLaff safeLy concerns, such as chemoLherapy drug spllls and assaulLs, dld noL emplrlcally presenL hlgh rlsk. lurLher
lnvesLlgaLlon showed Lhese lssues already had safeLy mechanlsms ln place LhaL elLher reduced Lhe raLe of occurrence or Lhe
poLenLlal for ln[ury.

1he organlsaLlon's execuLlve Leam used Lhe rlsk reglsLer flndlngs Lo prlorlLlse safeLy lmprovemenLs, such as llfLlng sysLem
enhancemenLs, beLLer ln[ury follow-up, and focused recondlLlonlng so LhaL sLaff could reLurn Lo llghL duLy work.

Conc|us|on: 1he sLaff safeLy rlsk concepL model allowed us Lo comblne, analyse and compare safeLy daLa from many dlfferenL
sources. We were able Lo caLegorlse rlsks ln a slmple formaL, rank Lhem across Lhe enLlre organlsaLlon and uncover recurrlng Lhemes
aL a granular level. 1hls rlsk reglsLer approach provlded our organlsaLlon's execuLlve Leam wlLh ob[ecLlve, quanLlLaLlve, and
acLlonable daLa abouL rlsks Lo sLaff safeLy.



1101

IMkCVING 1nL CCMLL1ICN kA1L CI DISCnAkGL LANNING ICk NUkSL S1AII
Chen ?an Shlan
1,*
, Menl Llng lang
1
, Psln ?l Lln
1
, Lee Chen Chen
1

1
ueparLmenL of nurslng, lar LasLern Memorlal PosplLal, new 1alpel ClLy, 1alwan


Cb[ect|ves: ulscharge plannlng ls a conLlnulLy paLlenL care quallLy. CoordlnaLed and mulLl-dlsclpllnary care servlce. 1he
currenL hlgh complexlLy and varlablllLy of chronlc dlseases, provldlng paLlenL-cenLred care phllosophy, reduce cosL of
medlcal LreaLmenL and admlsslon raLe, afLer dlscharge ln order Lo lmprove Lhelr sympLom managemenL and quallLy of
llfe. unlL have nasal Luble, sucLlon and oxygen Lherapy dlsabled elder 63.1 of Lhe LoLal paLlenL. Cnly 43.2 of Lhe
nurses compleLed dlscharge plannlng .1he dlsabled paLlenL saLlsfacLlon raLe of dlscharge plannlng only 30.6 .1he
purpose of Lhls pro[ecL was Lo develop a seL of dlscharge plannlng program for nurslng sLaff Lo follow and Lhe lnLegrlLy of
dlscharge plannlng servlces, lmprove paLlenL and careglver quallLy of care.

Methods: 1he goal of Lhls sLudy ls Lo explore Lhe nurses for dlscharge plannlng compleLlon raLe. We selecL dlsabled
paLlenL and careglvers members of have dlscharge plannlng ln a medlcal cenLer ln new 1alpel ClLy. 1he pro[ecL began
from SepLember 2009 Lo uecember 2010. uaLe Lwo quesLlonnalre meLhods. 1he sLudy parLlclpanLs comprlsed of
dlsabled paLlenL and careglvers LoLal 38 people. AfLer analyslng Lhe problems lncludlng:

1) shorL of compleLlon lnsLrucLlon bookleL for dlscharge plannlng,
2) lack of a sLandard procedure for glvlng nurslng lnsLrucLlon
3) lack of monlLorlng sysLem dlscharge plannlng saLlsfacLlon.

1he four meLhods of used lncluded:
1) esLabllsh monlLor Lools for nurslng dlscharge plannlng,
2) developmenL sLandard nurslng care procedures for dlscharge plannlng,
3) make Lhe process of group nurslng lnsLrucLlon for uvu,
4) esLabllsh saLlsfacLlon scorlng sysLem dlscharge plannlng.

kesu|ts: 1he resulLs of Lhls sLudy were as follows:
1) 1he compleLlon raLe of nurslng dlscharge plannlng lncreased from 43.2 Lo 89.3,
2) 1he dlsabled paLlenL dlscharge plannlng saLlsfacLlon lncreased from 30.6 Lo 90.1.

1he resulLs of Lhls sLudy suggesL LhaL dlscharge plannlng programs should noL only lnvolve longlLudlnal follow-up, buL
also supporL groups and soclal workers Lo promoLe Lhe dlsabled paLlenL and careglvers' healLhcare ablllLy and quallLy of
llfe.

Conc|us|on: 1he dlscharge plannlng has effecLlve lmprovemenLs of healLh care for dlsabled paLlenLs and careglvers.
Comblnlng dlfferenL mulLlple nurslng lnsLrucLlons meLhod ls an advanLage for compllcaLed and fraglle dlsabled paLlenLs
and lL can expand furLher Lo meeL Lhe need of Lhe paLlenLs. 1herefore Lhe effecL of mulLlple nurslng lnsLrucLlons ls one
worLhwhlle healLh educaLlon measure whlch can work as reference for cllnlc nurslng Leachlng ln Lhe fuLure.

keferences: 8ackus L, Welnkove !, Lucas M, (2008): CuLcome of plannlng dlscharge from case managemenL: a 3 year
reLrospecLlve sLudy. Aosttolos lsycblotty, 16, 33-38. Chapman, L. (2007). ulscharge plannlng: A fomlly offolt. Notsloq, J7
(3), 3612 -3614. MacklnLosh, C. (2007). AssessmenL and managemenL of paLlenLs wlLh posL- operaLlve paln. Notsloq
5tooJotJ, 22 (3), 49-60. aseroC., & McCaffery, M. (2007). CrLhopaedlc posLoperaLlve paln managemenL. Iootool of letl
Aooestbeslo Notsloq, 22 (3), 160-172.



1102

GNCMLS - IMkCVING 1nL SAIL1 CI INA1ILN1 1kANSILkS A1 GU'S AND S1 1nCMAS' NnS ICUNDA1ICN 1kUS1
Laura klrLley
1
, SLeve WalLers
1,*

1
Cuy's and SL 1homas' nPS 1rusL, London, unlLed klngdom


Cb[ect|ves: An ln-paLlenL Lransfer checkllsL was lmplemenLed across boLh acuLe hosplLals ln Cuy's and SL 1homas' nPS
loundaLlon 1rusL (Cuy's - slLe 1, SL 1homas' - slLe 2) ln 2010. lLs purpose was Lo lmprove communlcaLlon beLween sLaff
and so lmprove Lhe safeLy of paLlenLs Lransferrlng beLween areas, ln parLlcular Lo Lhose areas whose sLaff does noL
rouLlnely recelve a nurslng handover. 1he 8adlology CuallLy lmprovemenL 1eam was formed durlng a Lhree day exLernal
Lralnlng course. 1he pro[ecL was LlLled CnCMLS (CreeLlng, noLlflcaLlon, CbservaLlon, and MonlLorlng Lnsures SafeLy) so
LhaL lL was eye caLchlng and memorable. 1he Leam deemed Lhese as lmporLanL elemenLs for Lhe safeLy of ln-paLlenLs
aLLendlng Lhe radlology deparLmenL.

Cb[ecLlve: 1o lmprove ln-paLlenL safeLy by assesslng and lmprovlng Lhe use of ln-paLlenL Lransfer checkllsLs ln a large
London hosplLal's radlology deparLmenL.

Methods: A proforma was developed for Lhe prospecLlve basellne audlL. 1hls was carrled ouL ln durlng Lwo weeks of
uecember 2010 by radlology sLaff on boLh hosplLal slLes. 1he audlL was compleLed on ln-paLlenL's belng Lransferred Lo
radlology durlng core worklng hours (Monday Lo lrlday, 8am -6pm). 1he proforma was deslgned Lo capLure a number of
lmporLanL facLors affecLlng Lhe safeLy of ln paLlenLs durlng Lhelr vlslL Lo Lhe radlology deparLmenL. 1he presence of a
Lransfer checkllsL, wheLher Lhls was compleLed accuraLely and fully, and Lhe lnflaLlon sLaLe of alr maLLresses were a few
of Lhe areas covered. 1he resulLs of Lhls basellne audlL were analysed and acLlons, lncludlng an awareness campalgn and
maLLress LuLorlals, were carrled ouL. lollowlng Lhe lmplemenLaLlon of Lhese, Lhree more cycles of audlL were compleLed.
1he hosplLal porLers were asked Lo requesL Lhe presence of a Lransfer checkllsL beLween Lhe Lhlrd and fourLh cycles.

kesu|ts: 1he percenLage of paLlenLs havlng a checkllsL has lncreased from 39 ln 2010 Lo 94 ln Lhe laLesL audlL, and Lhe
percenLage of paLlenLs wlLh a fully and accuraLely compleLed checkllsL has lncreased from 27 Lo 68. 1hese are
slgnlflcanL achlevemenLs and Lhe upward Lrend (even Laklng lnLo accounL a decllne shown ln Lhe Sprlng 2012 audlL)
shows Lhe effecLlveness of Lhe acLlons LhaL have been puL ln place and Lhe efforL of all lnvolved, parLlcularly Lhe
CnCMLS 8adlology CuallLy lmprovemenL 1eam.

As Lhe proporLlon of parLlally or lnaccuraLely compleLed checkllsLs has lncreased ln Lhe fourLh audlL cycle, analysls was
underLaken of Lhe parLs of Lhe form whlch had noL been compleLed, or compleLed lncorrecLly. Many forms had more
Lhan one lLem mlsslng. lu 8and was Lhe mosL commonly mlssed secLlon - however Lhe placemenL of Lhls quesLlon on Lhe
form means lL could easlly be mlssed by Lhe person fllllng lL ln - especlally lf Lhls ls belng done ln a hurry. lalls, daLe of
blrLh and hosplLal number are Lhe nexL lLems mosL mlssed. Cne poLenLlal reason for Lhe lncrease ln lncompleLe forms ls
LhaL porLers are asklng for a form, and lL ls Lhen belng fllled ln Lhere and Lhen by Lhe Lransferrlng nurse, who wlLh less
Llme, and poLenLlally less lmmedlaLe access Lo some of Lhe lnformaLlon, Lhls ls belng lefL ouL ln order Lo send a form aL
all.

Conc|us|on: 1he CnCMLS pro[ecL has been successful ln ralslng compllance and so Lhe safeLy of ln-paLlenL Lransfers wlLh
use of Lhe Lransfer checkllsL across boLh hosplLal slLes, from 39 ln 2010 Lo 94 Loday. 1he lmprovemenL has been
parLlcularly marked aL slLe 1, where compllance was always conslderably lower Lhan aL slLe 2.. Some work remalns
around ensurlng full compleLlon, whlch has been handed over Lo Lhe nurslng Leam. 1he CnCMLS 8adlology CuallLy
lmprovemenL Leam should be exLremely proud of Lhe success Lhey have achleved over Lhe Lwo year perlod of Lhls
pro[ecL.

LNnANCING A1ILN1 SAIL1 AND UALI1 CI CAkL 8 S1AkDISING 1nLLLnCNL 1kIAGL IN 1nL nALMA1CLCG
CNCCLG SL11ING
Amy nolan CnM2
1
, norma ualy CnS
1
, Lmma 8owan CnS
1
, ur Crla uempsey
2
PaemaLology oncology day ward, SL !ames
PosplLal, uublln 8
1
. unlverslLy of uublln, 1rlnlLy College
2


urpose

1o develop a sLandardlsed 1elephone 1rlage SysLem (11S) and relaLed guldellnes on provldlng Lelephone advlce Lo
paLlenLs Lhus ensurlng lmmedlaLe, approprlaLe and safe advlce for paLlenLs recelvlng LreaLmenL ln Lhe haemaLology
oncology seLLlng and clarlfylng Lhe declslon makes process for sLaff.

8ackground]S|gn|f|cance
Many of Lhe eplsodes of care provlded by Lhe haemaLology oncology day ward (PCuW) ln SL !ames's hosplLal lnvolve
admlnlsLraLlon of cyLoLoxlc chemoLherapy whlch can have llfe-LhreaLenlng slde effecLs. 1lmely, effecLlve lnLervenLlon ln
managlng Lhese effecLs can be llfesavlng. 1elephone 1rlage (11) provldes essenLlal 24hr assessmenL for paLlenLs
experlenclng Lhese effecLs.
Method
nurses and paLlenL quesLlonnalres ldenLlfled Lhe need for dedlcaLed Llme, space, phone llnes, sLandardlsed proLocols,
guldellnes, e-documenLaLlon and sLaff compeLency for Lhe provlslon of 11. A random sample of 20 calls was audlLed Lo
evaluaLe lmplemenLaLlon of Lhe sLandardlsed 11S.
kesu|ts]Cutcomes
1he number and Lype of calls recelved over a one monLh perlod was audlLed. Cver 40 of calls (n=64) were noL
LreaLmenL relaLed resulLlng ln redeflnlng Lhe 24hr conLacL numbers. 1wenLy of Lhe 37 LreaLmenL relaLed calls were
randomly selecLed and audlLed. LlghLeen calls (90) were recorded correcLly on Lhe elecLronlc paLlenL records (L8).
aLlenLs recelved approprlaLe and lmmedlaLe advlce ln 90 of calls (n=17).
Conc|us|ons
nurslng leadershlp ln sLandardlslng 11S resulLed ln lmproved paLlenL care and managemenL, Leam communlcaLlon and
compllance wlLh professlonal and legal requlremenLs. lmplemenLaLlon of 11S resulLed ln Lhe provlslon of lmmedlaLe and
sLandardlsed lnformaLlon whllsL lncreaslng sLaff awareness of Lhe lmporLance of Llmely, quallLy lnLervenLlon and
knowledge and skllls ln deallng wlLh unplanned paLlenL problems.







1127

AkL 1nL DU1Cn LCNG-1LkM CAkL CkGANISA1ICNS GL11ING 8L11Lk? A 1kLND S1UD CI UALI1 INDICA1CkS
8L1WLLN 2007 AND 2009 AND 1nL A11LkNS CI kLGICNAL AND CkGANISA1ICNAL INILULNCLS CN LkICkMANCL
S[enny WlnLers
1,*
, 8.8. kool
1
, n.S. klazlnga
2
, 8. Pul[sman
3

1
uevelopmenL & SupporL, lC PealLhcare, nl[megen,
2
ueparLmenL of Soclal Medlclne, Academlc Medlcal CenLre,
unlverslLy of AmsLerdam, AmsLerdam,
3
lnsLlLuLe of PealLh ollcy and ManagemenL, Lrasmus unlverslLy 8oLLerdam,
8oLLerdam, neLherlands


Cb[ect|ves: 8ackground
uuLch long-Lerm care organlsaLlons, provldlng somaLlc care, psycho-gerlaLrlc care and home care, have Lo measure Lhe
quallLy of care Lhrough resldenL-relaLed and professlonal lndlcaLors. AL Lhe same Llme, compeLlLlon was lnLroduced wlLh
reglonal sLlmull from healLhcare lnsurers.
A|m
1he flrsL alm of Lhls sLudy ls Lo deLermlne Lhe Lrends of Lhe naLlonal performance on resldenL-relaLed and professlonal
quallLy lndlcaLors for Lhe perlod 2007 - 2009 ln long-Lerm care organlsaLlons ln Lhe neLherlands. 1he second alm ls Lo
deLermlne Lhe paLLerns of Lhe lnfluence of reglon, capaclLy and corporaLe sLrucLure on Lhe quallLy performance ln 2009.

Methods:
We performed Lrend analyses on Lhe lndlcaLors of resldenLs of 2,113 long-Lerm care organlsaLlons. We used mulLlvarlaLe
analyses Lo deLermlne Lhe dlfference ln naLlonal performance beLween 2007 and 2009 and Lo calculaLe Lhe lnfluence of
organlsaLlon characLerlsLlcs on Lhe performance of 2009.

kesu|ts:
1he naLlonal performance on resldenL-relaLed lndlcaLors for somaLlc care and home care lncreased. lor psycho-gerlaLrlc
care, Lhe organlsaLlons performed worse on resldenL-relaLed lndlcaLors. 1he professlonal lndlcaLors for lnLramural care
lmproved ln 2009 compared wlLh 2007.

We noLed an lnfluence of reglon, sLrucLure and capaclLy. CrganlsaLlons ln Lhe wesL of Lhe neLherlands performed worse
Lhan oLher reglons wlLh excepLlon of home care. Small and mlddle-slze organlsaLlons and organlsaLlons wlLh a small
capaclLy performed beLLer Lhan oLher organlsaLlons.

Conc|us|on: Conc|us|ons
1hls sLudy suggesLs LhaL a corporaLe sLrucLure wlLh an lnLermedlaLe slze and a capaclLy < 100 resldenLs, perform beLLer
Lhan oLher organlsaLlons. Cur resulLs also suggesL LhaL Lhe pollcy of healLhcare lnsurers affecLs Lhe quallLy performance
of organlsaLlons.

keferences: 19










1144

CnANGING 1IMLS- IAS1ING AUDI1
aula McCarLhy
1,*
, Mary Connolly
1

1
SL vlncenL's rlvaLe PosplLal, uublln 4, lreland


Cb[ect|ves: 8oyal College of AnaesLhesla guldance recommends speclflc Llmes for fasLlng prlor Lo lnLervenLlonal
procedures. ln 2010 we revlewed pre-operaLlve fasLlng Llmes ln a prlvaLe hosplLal Lo answer Lhe followlng quesLlons:

1. Are our pre-procedure fasLlng Llmes Lo long?
2. Are prolonged fasLlng Llmes lmpacLlng on paLlenLs?
3. ls our pracLlce ln llne wlLh lnLernaLlonal besL pracLlce?

1o lmprove care Lo paLlenLs by prevenLlng unnecessary fasLlng, whlch ls lmpacLlng on paLlenL's well-belng, lengLh of sLay
and posL-operaLlve recovery. 1o ensure our pracLlce ls safe and ln llne wlLh currenL research.

Methods: Sphlnx compaLlble quesLlonnalre accesslng fasLlng Llmes of surglcal paLlenLs' pre-procedure audlL and re-audlL
cycles.

kesu|ts: lnlLlally fasLlng Llmes far exceeded Lhe recommended guldellnes l.e. 2 hours from clear flulds and 6 hours sollds.
Cur mean fasLlng Llme was 13hrs wlLh a range 6-23 hours. 1hls was ln Lhe conLexL of elecLlve surglcal acLlvlLy and should
have been easlly addressable. Powever, as a change managemenL pro[ecL, lL was challenglng and many lessons were
learned LhaL may be of lnLeresL Lo oLher healLhcare organlsaLlons.

ConsulLaLlon wlLh sLakeholders l.e. ConsulLanLs, AnaesLheLlcs, aLlenLs and PosplLal ManagemenL hlghllghLed Lhe
challenges of changlng long-esLabllshed pracLlces and Lheory ln acLlon" behavlours. 1he plloL of fasLlng guldellnes ln
one surglcal ward Lrlggered reacLlons from paLlenLs, nurslng sLaff and anaesLheLlsLs who were reslsLanL Lo change. no
reschedullng or reorganlsaLlon ln LheaLre was requlred followlng Lhe lmplemenLaLlon. We found nuLrlLlonal
supplemenLs Lo be a cosL effecLlve easy way round Lhe provlslon of early mornlng lnLake. 8e-audlL showed lmpresslve
lmprovemenL wlLh a mean fasLlng Llme 3 hours (range 2-8 hours). Lven Lhen, secreLarlal lnLeracLlon wlLh paLlenLs prlor
Lo admlsslon was ldenLlfled as furLher challenges Lo roll-ouL.

Conc|us|on: Cur presenLaLlon seLs ouL Lhe posslble roadmap for lnLroduclng Lhls slmple and baslc LeneL of good cllnlcal
care



1148

1AkING A1ILN1 LkLkILNCL MLASUkLS 1C AC1ICN: A kLVILW CI 8LS1 kAC1ICLS
krls CusLavson
1,*
, uebble !ohannesen
2
, 1rlcla Mc8aln
3
, SLephanle ngo
4

1
CuallLy, SafeLy & CuLcome lmprovemenL, rovlnclal PealLh Servlces AuLhorlLy,
2
CuallLy, SafeLy & CuLcome
lmprovemenL, 8C Women's PosplLal and PealLh CenLre,
3
CuallLy, SafeLy & CuLcome lmprovemenL, 8C Chlldren's
PosplLal and Sunny Plll PealLh CenLre for Chlldren,
4
School of nurslng, unlverslLy of 8rlLlsh Columbla, vancouver, Canada


Cb[ect|ves: 1he goal of Lhls pro[ecL was Lo flnd meanlngful ways Lo dlssemlnaLe Lhe resulLs of an AcuLe lnpaLlenL aLlenL
Lxperlence survey Lo sLakeholders ln rovlnclal PealLh Servlces AuLhorlLy faclllLles and Lo asslsL senlor leaders and sLaff
ln acLlonlng Lhese resulLs Lo ulLlmaLely lmprove Lhe care recelved by paLlenLs ln Lhe acuLe lnpaLlenL seLLlng.

Methods: ln 2003, 2008 and 2011/2012, Lhe provlnce of 8rlLlsh Columbla, Canada, underLook a survey of lnpaLlenLs ln
acuLe care hosplLals Lo sollclL feedback abouL Lhe care and servlces Lhey recelved whlle ln hosplLal. 1wo rovlnclal PealLh
Servlces AuLhorlLy faclllLles were surveyed: 8C Chlldren's PosplLal and 8C Women's PosplLal.

1he survey evaluaLed lnpaLlenLs' experlences across elghL dlmenslons of care: access Lo care, emoLlonal supporL,
lnformaLlon and educaLlon, physlcal comforL, lnvolvemenL of famlly, respecL for paLlenL preferences, conLlnulLy and
LranslLlon, and coordlnaLlon of care. Survey resulLs hlghllghLed boLh sLrengLhs and opporLunlLles Lo lmprove Lhe paLlenL
experlence.

ln order Lo Lake Lhese measures Lo acLlon, undergraduaLe nurslng sLudenLs were selecLed Lo conducL a llLeraLure revlew
focuslng on besL pracLlces Lo lmprove paLlenL experlence. AdvanLages Lo lncorporaLlng sLudenLs lncluded dedlcaLed Llme
Lo focus on unblased exLernal perspecLlve, flnanclal beneflL Lo engaglng sLudenLs versus exLernal consulLanLs, and Lhe
rlch, lmmerslve experlence for Lhe sLudenLs.

kesu|ts: 1he llLeraLure revlew ylelded besL pracLlce lmprovemenL Lools and guldellnes from Lhe lnsLlLuLe for PealLhcare
lmprovemenL (lPl) as well as research abouL Lhe use of Lxperlence-8ased Co-ueslgn from Lhe naLlonal PealLh Servlce ln
Lhe unlLed klngdom. 1he sLudenLs presenLed Lhe resulLs of Lhelr llLeraLure revlew Lo key sLakeholders wlLhln survey
areas, llnklng examples of besL pracLlces Lo key dlmenslons of care ln Lhe 2003, 2008, and 2011/2012 surveys.

1o furLher asslsL wlLh lnLegraLlng Lhe survey resulLs lnLo currenL pracLlces and operaLlons, Lhe sLudenLs provlded
consulLaLlve servlces Lo unlL level managers by deLermlnlng Lhelr program-speclflc needs for dlssemlnaLlng resulLs Lo
sLaff and plannlng for acLlon. 1he sLudenLs offered Lo develop program-speclflc Lools as requesLed, such as graphs,
slldes, speaklng noLes, cusLomlsed reporLs, and Lrended resulLs.

Conc|us|on: As a resulL of Lhls pro[ecL, leaders and educaLors wlLhln surveyed areas were provlded examples of besL
pracLlces Lo use as guldellnes Lo acLlon Lhe daLa presenLed ln Lhe survey. LvaluaLlon of Lhls pro[ecL wlll Lake place vla
agency lnlLlaLlve dashboards and resulLs of Lhe nexL lLeraLlon of Lhe provlnclal acuLe lnpaLlenL survey.

keferences:
1) 8allk, 8. (2011). WhaL makes a poslLlve paLlenL experlence? lPl explores how Lo lmprove a paLlenL's Llme ln Lhe
hosplLal. aLlenL SafeLy MonlLor !ournal, 12(10), 1-3.
2) 8aLe, S., & 8oberL, C. (2007). 1owards more user-cenLrlc organlsaLlon developmenL: lessons from a case sLudy of
experlenced-based deslgn. !ournal of Applled 8ehavloural Sclence, 43(1), 41-66.
3) 1he klngs lund. (2011). Lxperlence based co-deslgn LoolklL. olnL of Care. 8eLrleved from:
hLLp://www.klngsfund.org.uk/pro[ecLs/polnL-care,ebcd.
4) lnsLlLuLe for PealLh Care lmprovemenL (2013). lPl lmprovemenL Map. 8eLrleved from: hLLp://app.lhl.org/lmap/Lool/
S) nPS lnsLlLuLe for lnnovaLlon and lmprovemenL. (2009). 1he experlence based deslgn approach. CuallLy and value.
8eLrleved from: hLLp://www.lnsLlLuLe.nhs.uk/quallLy_and_value/experlence_based_deslgn/Lhe_ebd_approach
(experlence_based_deslgn).hLml


11S0

A SINGLL-CLN1kL kCSLC1IVL C8SLkVA1ICNAL S1UD CN ILUC1UA1ICNS IN INk CCN1kCL ICk SINGACkL'S
MUSLIM A1ILN1S CN CkAL AN1ICCAGULA1ICN 1nLkA WI1n S1A8LL WAkIAkIN DCSING CVLk 1nL MCN1nS CI
kAMADAN AND nAkI kAA AIDILII1kI
?l leng Lal
1,*
, llona Pul lng ?eo
1
, Peng !oo ng
2

1
harmacy,
2
PemaLology, SCP, Slngapore, Slngapore


Cb[ect|ves: Cral vlLamln k AnLagonlsL (CvkA) ls a drug well-known for lLs narrow LherapeuLlc wlndow. Serlous adverse
evenLs may resulL should Lhe lnLernaLlonal normallsed 8aLlo (ln8) be fallen ouL of LargeL range. known Lo have lLs
anLlcoagulanL effecLs augmenLed by changes ln dleLary vlLamln k lnLake and llfesLyles, such effecLs may surface durlng
Lhe Musllm fasLlng monLh of 8amadan, where dleLary hablLs and llfesLyles of paLlenLs are alLered.

Cb[ect|ves - 1o deLecL and sLudy ln8 devlaLlons and percenLage Llme wlLhln LherapeuLlc range (118) before, durlng
and afLer 8amadan ln sLable warfarlnlzed paLlenLs, whom oLherwlse have sLeady ln8 conLrol. 1he resulLs of Lhe sLudy
wlll Lell us lf our currenL appolnLmenL lengLh and cllnlc proLocols durlng 8amadan for Musllm paLlenLs are sufflclenLly
safe, and wheLher ad[usLmenLs are needed.

Methods: oLenLlal sLudy sub[ecLs were screened from hosplLal anLlcoagulaLlon cllnlc (ACC) daLabase, and pharmacy's
warfarln dlspenslng records. Cnly sLable warfarlnlzed paLlenLs who meL Lhe lncluslon crlLerla were shorLllsLed and
conLacLed for recrulLmenL. All recrulLed paLlenLs underwenL weekly ln8 monlLorlng, wlLh 4 readlngs per sub[ecL per
monLh, LhroughouL a 3-monLh sLudy perlod from a monLh before 8amadan Lo a monLh afLer lL. 1he warfarln doses for
Lhese paLlenLs were kepL consLanL, and Lhey were lnsLrucLed Lo keep Lo Lhelr usual rellglous pracLlces, eaLlng hablLs and
llfesLyle as prevlous years. All readlngs were bllnded Lo Lhe sub[ecLs unLll Lhe end of Lhe sLudy Lo mlnlmlse confoundlng
facLors.

kesu|ts: ln Lhe lnLenLlon-Lo-LreaL analysls (n=32), Lhe mean dlfference ln ln8 durlng Lhe re-8amadan monLh and Lhe
8amadan monLh was slgnlflcanL aL 0.207 [p=0.032, 93 Cl 0.013-0.401]. A greaLer mean dlfference ln ln8 of -0.309
[p=0.001, 93 Cl -0.306-(-0.112)] was observed beLween Lhe 8amadan and Lhe osL-8amadan monLhs. no slgnlflcanL
dlfference ln ln8 was deLecLed beLween Lhe non-8amadan monLhs [p=0.629, 93 Cl 0.93-(-0.298)], Lhereby suggesLlng
LhaL Lhese lncreases ln ln8 durlng 8amadan could be aLLrlbuLed Lo fasLlng. 1he percenLage Llme wlLhln LherapeuLlc range
(118) showed a dlp Lo 69.36 compared Lo 80.99 before 8amadan and 70.80 afLer 8amadan. Cn average, Lhe flrsL
ouL-of-range ln8 could be seen 12.1 days [93 Cl 9.0-13.1] afLer Lhe sLarL of fasLlng. SubsequenLly, an average of 10.8
days [93 Cl 7.9-13.7] was requlred for Lhe ln8 Lo reLurn back Lo lLs LherapeuLlc range afLer 8amadan.

Conc|us|on: 1he resulLs of Lhls sLudy suggesLs posslblllLy of slgnlflcanL ln8 flucLuaLlon durlng 8amadan fasLlng. AddlLlonal
cauLlon or even pre-empLlve dose reducLlon may be warranLed especlally for paLlenLs malnLalned aL hlgher end of Lhelr
LargeL ranges, or for paLlenLs prescrlbed wlLh narrower LargeL ranges.



11SS

A UALI1 IMkCVLMLN1 S1kA1LG IMLLMLN1LD ACkCSS MUL1ILL SI1LS 1C kLDUCL
CaLherlne Slnfleld
1,*

1
Splre PealLhcare, London, unlLed klngdom


Cb[ect|ves: Splre healLhcare ls a prlvaLe healLhcare provlder operaLlng 38 hosplLals LhroughouL Lhe uk. Cur hosplLals
provlde surglcal and medlcal care Lo boLh prlvaLe and nPS funded paLlenLs. WhllsL recognlslng LhaL approprlaLe blood
Lransfuslon ls lmporLanL for some paLlenLs parLlcularly ln emergency slLuaLlons Splre wlshed Lo make more approprlaLe
use of Lhe scarce resource and reduced Lhe rlsk of Lransfuslon relaLed adverse evenLs. aLlenLs undergolng Lransfuslon
may also experlence a longer lengLh of sLay and an lncreased rlsk of surglcal slLe lnfecLlon.

Splre healLhcare lmplemenLed a sLraLegy Lo:

1) reduce lnapproprlaLe blood Lransfuslons and assoclaLed adverse evenLs ln accordance wlLh Lhe publlshed evldence
2) Lo promoLe Lhe spread of successful Lransfuslon pracLlce lmprovemenL sLraLegles LhroughouL all hosplLals

Methods: Cur sLraLegy was esLabllshed followlng Lhe resulLs of an audlL lndlcaLlng LhaL Lhe polnL of whlch surglcal
paLlenLs would recelve a Lransfuslon varled across our hosplLals and surglcal Leams. Compllance wlLh publlshed guldance
was poor and ofLen arblLrarlly based on hablL, as a resulL lL was dlfflculL Lo provlde paLlenLs wlLh conslsLenL lnformaLlon
on Lhe clrcumsLances Lhey would recelve a Lransfuslon. 1he naLlonal Cllnlcal Servlces Leam worked wlLh hosplLal nurses
Lo lnLroduce a new blood Lransfuslon paLhway. 1hls lncorporaLed declslon maklng supporL Lo gulde pre- operaLlve
plannlng, non-cllnlcally urgenL declslons Lo Lransfuse and Lhe necessary pre-Lransfuslon safeLy checks. A compeLency
framework was developed and lnLroduced for nurses lnvolved ln Lhe Lransfuslon process. A Splre Lransfuslon Lhreshold
based on publlshed evldence was lnLroduced for non-emergency slLuaLlons (Lransfuse lf Pb <8, <9 for paLlenLs wlLh
exlsLlng cardlac dlsease). Senlor nurslng Leams worked wlLh anaesLheLlsLs Lo lmplemenL Lhe Lhreshold and compllance ls
monlLored Lhrough our scorecard Lool. lnformaLlon was presenLed Lo Lhe Medlcal Advlsory CommlLLee aL each hosplLal
and compllance wlLh Lrlggers for Lransfuslon ls conslsLenLly monlLored and publlshed on a quarLerly basls. We monlLor
Lhree key lndlcaLors: blood cross maLch Lo Lransfuslon raLlo, compllance wlLh Lhe blood Lransfuslon Lrlgger and Lhe
number of unlLs Lransfused per 1000 admlsslons. 1he resulLs are publlshed Lhrough our quarLerly cllnlcal governance
reporL.

kesu|ts: Slnce Lhe lnLroducLlon of our programme Lo reduce Lhe blood Lransfuslons ln 2006, we have seen lmprovemenL
ln all lndlcaLors. ln 2011, 60 of cross maLched unlLs were subsequenLly Lransfused, whlle Lhe number of cross maLched
unlLs fell 11 year on year. 1he volume of Lransfused blood has been reduced by 30 slnce 2006, desplLe an lncrease ln
surglcal complexlLy. 1hls has LranslaLed lnLo a 23 reducLlon ln adverse evenLs and a reducLlon ln recovery Llme from
surgery and lengLh of sLay for paLlenLs. 1he programme has led Lo savlngs of 300,000 annually. nurslng sLaff have been
empowered ln Lransfuslon process and paLlenL lnformaLlon ls more conslsLenL.

Conc|us|on: We have learnL LhaL conslsLenL messaglng supporLed by emplrlcal evldence should be provlded across Lhe
organlsaLlon. Lmpowerlng sLaff Lo challenge currenL pracLlce based on evldence provlded by Splre can poslLlvely
lnfluence change. ubllshed guldance based on robusL emplrlcal evldence can lead Lo changes ln pracLlce across mulLlple
slLes and ulLlmaLely lead Lo Lhe lmprovemenL of paLlenL safeLy.



1160

DLVLLCING AND 1LS1ING A 8UNDLL 1C SUCk1 1nL IDLN1IIICA1ICN CI DLLIkIUM IN CLDLk ADUL1S IN ACU1L
CAkL
enny 8ond
1,*
, Mlchelle Mlller
2

1
lmprovemenL & lmplemenLaLlon SupporL,
2
PealLhcare lmprovemenL ScoLland, Clasgow, unlLed klngdom


Cb[ect|ves:

! 1o lmprove Lhe ldenLlflcaLlon of dellrlum ln acuLe care seLLlngs Lhrough Lhe developmenL and LesLlng of a care
bundle.
! 1o promoLe equallLy ln Lhe ldenLlflcaLlon of dellrlum
! 1o lmprove paLlenL and famlly experlence of dellrlum by engaglng and lnvolvlng famllles and carers ln Lhe
ldenLlflcaLlon of dellrlum.

Methods: 1he ldenLlflcaLlon of dellrlum has been ldenLlfled as a key area of focus for Lhe naLlonal lmprovlng older
people's acuLe care work programme ln nPS ScoLland. 1hrough a collaboraLlve lmprovemenL approach, mulLldlsclpllnary
Leams based ln acuLe hosplLal seLLlngs across ScoLland, have gaLhered basellne daLa Lo ldenLlfy areas for lmprovemenL ln
Lhe ldenLlflcaLlon of dellrlum. A dellrlum care bundle has been developed, based on Lhe ScoLLlsh uellrlum AssoclaLlon
dellrlum paLhway and nlCL guldance
1
. 1hls ls currenLly belng LesLed by Leams across a range of acuLe care seLLlngs Lo
supporL Lhe ldenLlflcaLlon of dellrlum, Lo promoLe equlLy of care and Lo ensure engagemenL wlLh famlly and carers ln
achlevlng a poslLlve experlence of care.

kesu|ts: 1eams are gaLherlng daLa Lo reporL progress ln uslng Lhe care bundle and demonsLraLe Lhe lmpacL of early
ldenLlflcaLlon of dellrlum ln older people ln hosplLal. 8esulLs wlll be avallable for sharlng and dlscusslon by
CcLober. Larly LesLlng lndlcaLes LhaL lmplemenLlng a sLrucLured approach Lo ldenLlfylng dellrlum has beneflLs ln ensurlng
LhaL paLlenLs geL Lhe rlghL care aL Lhe rlghL Llme and ln Lhe rlghL seLLlng, by Lhe rlghL healLhcare Leam. Lngaglng and
lnvolvlng famllles and carers aL an early sLage ln Lhe ldenLlflcaLlon of dellrlum ls an essenLlal elemenL ln reachlng a
dlagnosls as Lhey are ofLen Lhe flrsL Lo noLlce a change ln an older person's cognlLlon or behavlour.

Conc|us|on: uellrlum ls a common problem ln older hosplLallsed people LhaL ls frequenLly overlooked and mlsdlagnosed.
1he use of a care bundle Lo supporL ralsed awareness of and early ldenLlflcaLlon of dellrlum may help Lo dlfferenLlaLe
older people whose dellrlum ls caused by an underlylng healLh condlLlon and wlll consequenLly lmpacL on oLher essenLlal
areas of care such as nuLrlLlon, conLlnence and moblllLy.

keferences: 1. naLlonal lnsLlLuLe for PealLh and Cllnlcal Lxcellence. uellrlum dlagnosls, prevenLlon and managemenL.
!uly, 2010



116S

NC LCNGLk IN 1nL DAkk: 1IMLL UALI1 CAkL AI1Lk nCUkS
Mandy Sandford
1,*
, Amy Mcklmm
1
, Cwen 8oodenburg
2
, !ason McClure
3

1
Alfred PealLh, Melbourne, AusLralla,
2
lCu,
3
lnLenslve Care unlL, Alfred PealLh, Melbourne, AusLralla


Cb[ect|ves: 1radlLlonally hosplLals have worked wlLh Lwo dlsLlncL models of care - Lhe 'ln hours' model and Lhe 'afLer
hours' model. ln november 2012, Alfred PealLh embarked on a LransformaLlonal redeslgn program Lo lmprove Lhe
quallLy and Llmellness of paLlenL care. Cne key elemenL was Lhe esLabllshmenL of hlgh quallLy responslve care regardless
of Lhe Llme of day. ln order Lo do Lhls Lhe 1lmely CuallLy Care - AfLer Pours pro[ecL was lnlLlaLed. 1he speclflc ob[ecLlves
of Lhe pro[ecL were Lo:

! lmprove paLlenL safeLy ln Lhe afLer-hours perlod,
! lmprove sLaff saLlsfacLlon and Lralnlng provlded ln Lhe afLer-hours perlod,
! lmplemenL a conslsLenL emergency admlsslon process 24/7,
! rogress paLlenL LreaLmenL and avold overnlghL delays, and
! lncrease efflclency and work ouLpuL of Lhe nlghL workforce Lhrough LransparenL and equlLable dlsLrlbuLlon of
workload.

Methods: 1he deslgn and lmplemenLaLlon of lnlLlaLlves was underLaken uslng a redeslgn approach wlLh collaboraLlon
beLween managemenL, nurslng and medlcal sLaff. 1he approach lncorporaLed change managemenL, pro[ecL
managemenL and Lean prlnclples. 1he followlng key lnlLlaLlves were lnLroduced:

! LngagemenL of all sLakeholders ln gaLherlng basellne daLa, and ln developlng an efflclenL new model,
! LsLabllshmenL of a !unlor Medlcal SpeclallsLs Leadershlp group Lo gulde and communlcaLe lnlLlaLlves,
! LsLabllshmenL of an AfLer Pours Medlcal and nurslng 1eam led by an AfLer Pours Cllnlcal Lead and an AfLer Pours
Cllnlcal CperaLlons Manager,
! Co-ordlnaLlon of Lask allocaLlon Lhrough an elecLronlc Lask managemenL sysLem,
! 8e-proflled medlcal and nurslng sLaff durlng Lhe afLer-hours perlod,
! LsLabllshmenL of Leam processes for example leadershlp Lralnlng, handover, load levelllng and cllnlcal supporL,
scheduled breaks, and
! lncreased compeLencles of nlghL nurslng sLaff.

kesu|ts: 1lmely CuallLy Care - AfLer Pours has been runnlng for Lhree monLhs and a follow-up evaluaLlon has yeL Lo be
compleLed. 8esulLs of Lhe pre-posL lnLervenLlon wlll be avallable by CcLober 2013. LvaluaLlon wlll lnclude:

1. key sLakeholder lnLervlews,
2. erformance lndlcaLors for quallLy, safeLy and access markers pre and posL lmplemenLaLlon, and
3. osL-lmplemenLaLlon gap analysls and revlew, ldenLlfylng crlLlcal success facLors, opporLunlLles Lo opLlmlse beneflLs
and key learnlng's for fuLure redeslgn reforms.

Conc|us|on: 1he lnlLlaLlves are sLlll relaLlvely new, however already Lhe greaLer Lransparency has been an enllghLenlng
process. 8eneflLs already seen have lncluded greaLer accounLablllLy for day Leams Lo compleLe Lhelr rouLlne work (e.g.
rewrlLlng drug charLs), faclllLaLlon of Leamwork overnlghL, load levelllng of Lasks and more Llmely medlcal response Lo
paLlenLs who have shown slgns of deLerloraLlon. AnecdoLal feedback from Lhe nlghL sLaff suggesLs a greaLer sense of
Leamwork, saLlsfacLlon, leadershlp Lralnlng experlence, and greaLer efflclency desplLe lncreased workload.


1168

1kANSICkMING CAkL ICk 1nL LLDLkL IN NUkSING nCMLS
!aneL Palnes-Wood
1,*
, Cavln Lavery
1

1
PSC SafeLy lorum, ubllc PealLh Agency of norLhern lreland, Llsburn, unlLed klngdom


Cb[ect|ves: 1o lmprove care for resldenLs ln Lhe nP envlronmenL, Lhe lnlLlal focus was prevenLlon of falls. key ob[ecLlves
were ldenLlfled: 1o achleve 43 days or greaLer beLween falls by uecember 2012, Lo ensure 93 compllance wlLh falls
rlsk assessmenL on admlsslon, aL monLhly revlew and Lo ensure a posL-fall revlew ls carrled ouL, where relevanL, for
resldenLs who susLaln a fall, Lo develop capaclLy ln quallLy lmprovemenL wlLhln Lhe nurslng home seLLlng.

Methods: 1he CollaboraLlve MulLl-ulsclpllnary Advlsory Croup revlewed besL pracLlce from naLlonal and lnLernaLlonal
quallLy lmprovemenL sources, a drlver dlagram was developed for falls prevenLlon. A CanLL charL was developed for Lhe
overall lmprovemenL collaboraLlve whlch lncluded 4-3 Learnlng SeLs for Lhe parLlclpaLlng Leams and was faclllLaLed by
Lhe norLhern lreland PealLh and Soclal Care SafeLy lorum. 1hls lncluded Lralnlng on lmprovemenL
meLhodology, supporLlng analysls of monLhly measures, hosLlng conference calls and slLe vlslLs Lo Lhe nurslng homes ln
Lhe acLlon perlods, faclllLaLlng Lhe dlsLrlbuLlon, collaLlon and analysls of a nurslng home sLaff culLure survey. Lach
nurslng home esLabllshed an lmprovemenL Leam, Lhe lmprovemenL Leams ldenLlfled plloL areas Lo begln Lhe work on
falls reducLlon, Small LesLs of change were conducLed on a number of lnLervenLlons, rlsk assessmenL, posL-fall revlew,
safeLy crosses, lnLenLlonal roundlng. arLlclpaLlng Leams agreed key measures and carrled ouL monLhly audlLs. nurslng
homes compleLed a basellne assessmenL of Lhe falls raLe per 1000 bed days. 1eams shared Lhelr work Lhrough oral
presenLaLlons and sLoryboards.

kesu|ts: A number of homes have achleved 43 days beLween falls. 1he Pomes are achlevlng 93-100 compllance wlLh
rlsk assessmenL wlLhln 24 hours of admlsslon, on monLhly revlews and on carrylng ouL posL-falls revlews where
lndlcaLed. SLaff have greaLer awareness of when and why falls occur ln Lhe nurslng homes. All homes are uslng SafeLy
Cross/walklng sLlck Lo record falls. All homes uslng posL-fall form whlch ls compleLed and acLloned followlng a
fall. lnLenLlonal roundlng belng carrled ouL for aL rlsk resldenLs. SafeLy brleflngs are ln place for resldenLs aL rlsk of
falls. A number of resources have been developed as a resulL of Lhls lmprovemenL work and Lhese have been complled
lnLo a resource pack Lo lnclude: Lhe lalls llow charL, Lhe lnformaLlon SheeL on medlcaLlon and falls, Lhe Safe looLwear
lnformaLlon leafleL for resldenLs and famllles, audlL Lools and relevanL llLeraLure.

Conc|us|on: 1here has been excellenL engagemenL ln Lhls reglonal collaboraLlve as shown ln resulLs and enabled work Lo
expand Lo focus on hydraLlon. lace Lo face conLacL prlor Lo Lhe commencemenL of Lhe collaboraLlve was lmporLanL Lo
begln Lo bulld relaLlonshlps wlLh Lhe nurslng homes and Lo secure Lhe supporL of Lhe nurslng home managers. lL ls
lmporLanL Lo Lake lnLo accounL LhaL bulldlng capaclLy for quallLy lmprovemenL ln Lhe lndependenL proflL drlven secLor
Lakes Llme and slgnlflcanL supporL was needed beLween learnlng seLs for Lhe parLlclpaLlng nurslng homes.

keferences: N|ce Gu|de||nes on management and prevent|on of fa||s |n o|der peop|e: hLLp://www.nlce.org.uk/CC021
at|ent Safety I|rst, now to Gu|de to revent Ia||s:
hLLp://www.paLlenLsafeLyflrsL.nhs.uk/ashx/AsseL.ashx?paLh=/lnLervenLlon-supporL/lALLSPow-Lo20Culde20v4.pdf
lnsLlLuLe for PealLhcare lmprovemenL webslLe: www.lhl.org
Cochrane L|brary: Intervent|ons for prevent|ng fa||s |n o|der peop|e |n nurs|ng care fac|||t|es and hosp|ta|s
hLLp://onllnellbrary.wlley.com/dol/10.1002/14631838.Cu003463.pub2/full
1000 Llves lus Campalgn lalls revenLlon: hLLp://www.1000llvesplus.wales.nhs.uk/evenL/3337



1172

SS1LMA1IC kLVILW CI IN1LkVLN1ICNS DLSIGNLD 1C kLDUCL MLDICA1ICN ADMINIS1kA1ICN LkkCkS IN
nCSI1ALS
8lchard n. keers
1,*
, SLeven u. Wllllams
1, 2
, !onaLhan Cooke
1
, uarren M. AshcrofL
1

1
School of harmacy and harmaceuLlcal Sclences, unlverslLy of ManchesLer,
2
harmacy ueparLmenL, unlverslLy
PosplLal of SouLh ManchesLer nPS loundaLlon 1rusL, ManchesLer, unlLed klngdom


Cb[ect|ves: MedlcaLlon admlnlsLraLlon errors (MALs) are a common LhreaL Lo paLlenL safeLy.[1] As Lhere have been no
aLLempLs Lo sysLemaLlcally revlew Lhe llLeraLure on lnLervenLlons deslgned Lo reduce MALs ln hosplLals, we almed Lo
revlew and crlLlcally appralse sLudles examlnlng lnLervenLlons deslgned Lo reduce MALs ln Lhe hosplLal seLLlng.

Methods: 1en elecLronlc daLabases were searched beLween 1983-CcLober 2012 for randomlsed conLrolled Lrlals (8C1s)
and quasl-experlmenLal sLudles reporLlng on Lhe dlfference ln raLe of MALs or relaLed adverse drug evenLs (AuLs)
beLween an lnLervenLlon group and a comparaLor group ln Lhe hosplLal seLLlng. Conference absLracLs, Lheses, revlew
arLlcles and sLudles reporLlng ouLcomes derlved from slmulaLlon were excluded. 1he reference llsLs of lncluded arLlcles
and relevanL revlew papers were examlned for addlLlonal sLudles. 1hree auLhors (8k, SuW & !C) lndependenLly
exLracLed sLudy daLa, prlmary daLa were MAL/AuL raLes (numeraLor and denomlnaLor) and any formal sLaLlsLlcal
slgnlflcance LesL resulLs. 1hree auLhors also assessed rlsk of blas uslng esLabllshed meLhods, [2] wlLh all four meeLlng Lo
reach consensus on exLracLed daLa.

kesu|ts: A LoLal of 11 sLudles were lncluded. ulfferences beLween sLudy lnLervenLlons, meLhods and deflnlLlons
precluded aLLempLs Lo comblne daLa from dlfferenL sLudles. llve sLudles were 8C1s, 4 were conLrolled before and afLer
(C8A) sLudles and 2 were non-randomlsed conLrolled Lrlals (n8C1s). 1esLed lnLervenLlons clusLered around 4 maln
Lhemes: lnformaLlon Lechnology (n=4), nurse educaLlon (n=2), changlng pracLlce ln anaesLhesla (n=2) and Lhe
nurslng/paLlenL role (n=3) ln hosplLals. SLaLlsLlcally slgnlflcanL reducLlons ln MAL raLes were reporLed for Lwo-nurse
compared Lo slngle nurse drug admlnlsLraLlon (n8C1) and auLomaLed drug dlspenslng vs sLandard pracLlce (8C1). 1hree
8C1 sLudles whlch reporLed slgnlflcance LesL resulLs found no dlfferences ln overall ouLcome raLes for lnLervenLlon vs.
comparaLor groups. lour sLudles found slgnlflcanL changes Lhrough subgroup analysls. 1he lnLernal and exLernal valldlLy
of lncluded sLudles was quesLloned due ln parL Lo rlsk of blas (more exLenslve for non-8C1s) and meLhod of ouLcome
daLa collecLlon (flve (2 8C1s) used meLhods oLher Lhan dlrecL observaLlon whlch may underesLlmaLe Lhe MAL/AuL raLe
[1]).

Conc|us|on: 1he evldence base for Lhe lmpacL of lnLervenLlons on MAL/relaLed AuL raLes ls llmlLed, many of Lhe sLudles
whlch use a more robusL sLudy deslgn sLlll conLaln rlsks of blas. uesplLe Lhls, some hlgher quallLy evldence does suggesL
lnLervenLlons LhaL may or may noL warranL furLher sLudy and provldes useful guldance on approprlaLe meLhodology Lo
sLudy Lhe lmpacL of lnLervenLlons on MALs ln Lhe fuLure.

keferences: 1. keers 8n, Wllllams Su, Cooke !, AshcrofL uM. revalence and naLure of medlcaLlon admlnlsLraLlon errors
ln healLhcare seLLlngs: a sysLemaLlc revlew of dlrecL observaLlonal evldence. 1he Annals of harmacoLherapy 2013
leb,47:237-36.2. Cochrane LffecLlve racLlce and CrganlsaLlon of Care Croup. SuggesLed rlsk of blas crlLerla for LCC
revlews. Avallable from u8L:
hLLp://epoc.cochrane.org/slLes/epoc.cochrane.org/flles/uploads/SuggesLed20rlsk20of20blas20crlLerla20for20
LCC20revlews.pdf [Accessed: 10/12/2012].



1179
A NA1ICNAL CCMLAIN1S' MANAGLMLN1 SS1LM ICk U8LIC nLAL1n IACILI1ILS IN SCU1n AIkICA
8onel SLelnhbel
1,*
, Louls Claassens
1

1
CuallLy Assurance, naLlonal ueparLmenL of PealLh SouLh Afrlca, reLorla, SouLh Afrlca


Cb[ect|ves: 1o seL up a naLlonal sLandardlsed complalnLs' managemenL sysLem across SouLh Afrlca Lo ensure Lhe effecLlve and
efflclenL managemenL of complalnLs ln a resource consLralnL envlronmenL. 1hls ls lmporLanL ln lleu of Lhe esLabllshmenL of an
lndependenL Cmbud Cfflce for PealLh.
1o revlse a currenL naLlonal complalnLs managemenL proLocol and esLabllsh an elecLronlc complalnLs managemenL daLabase Lo
faclllLaLe lmplemenLaLlon of Lhe revlsed proLocol.
Methods: uurlng CcLober 2012, a quesLlonnalre was used Lo assess Lhe exlsLlng nlne provlnclal complalnLs managemenL sysLems.
1he resulLs were used Lo revlse Lhe currenL proLocol.
1o supporL Lhe successful lmplemenLaLlon of Lhe revlsed proLocol, a complalnLs managemenL daLabase ln Access was deslgned and
plloLed aL an academlc and a dlsLrlcL hosplLal.
ln november 2012, Lhe revlsed proLocol and newly deslgned daLabase was presenLed Lo key faclllLy managers aL a naLlonal
workshop Lo ellclL dlscusslon and lnpuLs. ConsLrucLlve lnpuLs were obLalned whlch lnformed a second revlslon of Lhe proLocol
subsequenL Lo Lhe workshop. 1hls 2
nd
revlslon was clrculaLed ln all provlnces ln uecember 2012 for flnal commenLs.
kesu|ts: 1he resulLs of Lhe assessmenL lndlcaLed wlde varlances ln Lhe managemenL of complalnLs by provlnces and even beLween
faclllLles wlLhln Lhe same provlnce. 1he followlng lmporLanL assessmenL resulLs came Lo Lhe fore:
! lormaL of complalnL reglsLers dlffered
! lndlcaLors for reporLlng on complalnLs were calculaLed lncorrecLly or noL aL all
! 1emplaLes for collecLlng sLaLlsLlcal daLa on complalnLs by provlnces dlffered
! CaLegorles for caLegorlslng complalnLs dlffered
! ComplalnLs were noL rlsk raLed as sLlpulaLed ln Lhe naLlonal SeL of Core SLandards
! Lach provlnce had a dlfferenL deflnlLlon for Lhe Lerm 'complalnL resolved'
1he process of consulLaLlon wlLh key sLakeholders resulLed ln:
a) ma[or lmprovemenLs belng made Lo varlous revlslons of Lhe complalnLs' managemenL proLocol, and
b) a greaLer awareness amongsL managers who subsequenLly showed lnLeresL ln becomlng parL of Lhe furLher roll-ouL of Lhe
daLabase and proLocol.
1he resulLs of plloLlng Lhe complalnLs' managemenL daLabase ln Lwo hosplLals lndlcaLed LhaL Lhe daLabase was poslLlvely
conLrlbuLlng Lowards Lhe successful lmplemenLaLlon of Lhe revlsed proLocol for complalnLs' managemenL.
Conc|us|on: 1he proLocol wlll ensure a sLandardlsed naLlonal complalnLs' managemenL sysLem for publlc healLh faclllLles across
SouLh Afrlca LhaL wlll aLLaln Lhe followlng:
! 1he user/paLlenL's rlghL Lo complaln ls respecLed
! A slmple complalnLs' procedure ls undersLood by everyone
! rovldlng healLh managers wlLh Lhe means Lo exLracL lessons on quallLy and Lo subsequenLly lmprove servlces/care Lo paLlenLs
! lalrness for sLaff and complalnanLs allke
! roblems and concerns of complalnanLs belng Llmely addressed and resolved Lo Lhelr saLlsfacLlon
! unnecessary llLlgaLlon belng avolded
1he elecLronlc daLabase wlll faclllLaLe accuraLe daLa keeplng of all complalnLs recelved by faclllLles and lL wlll asslsL faclllLles Lo
lmplemenL Lhe proLocol.
keferences:
1. 1he ConsLlLuLlon of Lhe 8epubllc of SouLh Afrlca (AcL 108 of 1996).
2. 1he naLlonal PealLh AcL (AcL 61 of 2003).
3. 1he WhlLe aper on 1ransformlng ubllc Servlce uellvery (noLlce 1439 of 1997).
4. 1he naLlonal aLlenLs' 8lghLs CharLer.
3. 1he naLlonal PealLh AmendmenL 8lll (of 2013)
6. naLlonal Core SLandards for healLh esLabllshmenLs ln SouLh Afrlca: naLlonal ueparLmenL of PealLh, 2011

1180

ADVLkSL LVLN1S kLCCkDLD IN LNGLISn kIMAk CAkL
Carmen 1sang
1
, Alex 8oLLle
1
, Azeem Ma[eed
2
, aul Aylln
1,*

1
ur losLer unlL aL lmperlal, rlmary Care and ubllc PealLh,
2
rlmary Care and ubllc PealLh, lmperlal College London,
London, unlLed klngdom


Cb[ect|ves: 1he epldemlology of paLlenL safeLy lncldenLs ln prlmary care remalns lnconcluslve, wlLh flucLuaLlng esLlmaLes
and a narrow focus on drug-relaLed harm. More accuraLe and recenL esLlmaLes of adverse evenLs ln prlmary care are
necessary Lo asslgn resources for paLlenL safeLy lmprovemenL, whlle predlcLors musL be ldenLlfled Lo amelloraLe paLlenL
rlsk. 1hls sLudy deLermlned Lhe lncldence of recorded laLrogenlc harm ln general pracLlce and ldenLlfled rlsk facLors for
Lhese evenLs, uslng sLandardlsed cllnlcal dlagnosls codes.

Methods: Cross secLlonal sample of 74,763 paLlenLs aL 437 Lngllsh general pracLlces beLween 1sL !anuary 1999 and 31sL
uecember 2008 obLalned from Lhe Ceneral racLlce 8esearch uaLabase.

aLlenL age aL sLudy enLry, sex, eLhnlclLy, deprlvaLlon, pracLlce reglon, duraLlon reglsLered aL pracLlce, conLlnulLy of care,
comorbldlLles and healLh servlce use were analysed. Adverse evenLs were deflned by 8ead codes for compllcaLlons of
care (chapLers S, 1 and u). ComorbldlLles were measured by a modlfled Charlson lndex and Lhe !ohns Popklns Ad[usLed
Cllnlcal Croups (ACC) Case-Mlx SysLem. Crude and ad[usLed analyses were performed by olsson regresslon uslng
Cenerallsed LsLlmaLlng LquaLlons.

kesu|ts: 1he lncldence was 6.0 adverse evenLs per 1,000 person-years (93 Cl 3.74-6.27), equlvalenL Lo 8 adverse evenLs
per 10,000 consulLaLlons (n=2,340,877). AfLer ad[usLmenL, paLlenLs aged 63 Lo 84 years (88 3.62, 93 Cl 4.38-6.91,
p<0.001), wlLh Lhe mosL consulLaLlons (88 2.14, 93 Cl 1.60-2.86, p<0.001), >3 emergency admlsslons (88 2.08, 93 Cl
1.66-2.60, p<0.001) or wlLh Lhe mosL dlseases accordlng Lo Lxpanded ulagnosls ClusLers (88 8.46, 93 Cl 3.68-12.6,
p<0.001) were aL greaLer rlsk of adverse evenLs.

Conc|us|on: 1he low lncldence of recorded adverse evenLs ls comparable wlLh oLher sLudles. 1he resulLs demonsLraLe
Lhe poLenLlal uses of rouLlnely collecLed daLa for acLlve safeLy survelllance, wlLh ldenLlflcaLlon of some rlsk facLors LhaL
may be assoclaLed wlLh laLrogenlc harm. 1emporal sequenclng of rlsk facLors and case ascerLalnmenL would beneflL
from daLa LrlangulaLlon. luLure sLudles mlghL explore wheLher flrsL adverse evenLs predlcL fuLure lncldenLs.






1200

A UALI1 IMkCVLMLN1 1AkCNCM
!oshua 8ardfleld
1,*
, 8ruce Aglns
1

1
PLAL1PCuAL lnLernaLlonal, new ?ork SLaLe ueparLmenL of PealLh AluS lnsLlLuLe, new ?ork, unlLed SLaLes


Cb[ect|ves: Language Lo descrlbe quallLy lmprovemenL ln healLh care ls varled and lnconslsLenLly applled LhroughouL Lhe
fleld, dlfferlng by sysLem and conLexL. CrganlsaLlons such as Lhe lnsLlLuLe of Medlclne and Lhe World PealLh CrganlzaLlon
among oLhers have offered dlmenslons, domalns and approaches Lo quallLy whlch cover a specLrum of vocabulary and
Lerms, ofLen applylng a range of language Lo converge around cenLral Lhemes. ulfferences are ofLen drlven by Lhe
organlsaLlonal focus and sLrucLures LhaL deLermlne selecLed quallLy ob[ecLlves, lnLervenLlons and Lhelr appllcaLlon.
ConsequenLly, quallLy lmprovemenL lacks a common lexlcon wlLh wldely agreed-upon Lerms of reference, maklng lL
dlfflculL Lo caLegorlse common lnLervenLlons and relevanL domalns. lmprovemenL conLlnues Lo be grouped wlLh quallLy
assurance and/or monlLorlng & evaluaLlon, furLher confuslng crlLlcal dlsLlncLlons beLween Lhese acLlvlLles. Whlle
scholarshlp addresslng Lhe sclence of lmprovemenL advances Lo enhance an undersLandlng of lmplemenLaLlon, Lhe fleld
ls lacklng a common Laxonomy Lo descrlbe and caLegorlse lmprovemenL lnLervenLlons by domaln and acLlvlLy Lype aL all
levels of lmplemenLaLlon - and lmporLanLly - Lo adequaLely explaln how lmprovemenL ls achleved Lhrough analysls of
conLexLual slmllarlLles and dlfferences across lnLervenLlons and domalns. A Cl Laxonomy may furLher prove Lo acceleraLe
lmprovemenL learnlng and knowledge Lhrough enhanced capaclLy for successful communlcaLlon abouL Cl
lmplemenLaLlon across counLrles.

Methods: A comprehenslve llLeraLure revlew was conducLed Lo ldenLlfy publlshed scholarshlp on lmprovemenL
classlflcaLlon. lnvenLory of lnLervenLlons was underLaken wlLh grouplng accordlng Lo assoclaLed domalns of lnLended
lmpacL/change LhaL emerged from Lhe revlew, lncludlng educaLlon, care processes, daLa and Lechnology, organlsaLlon,
and Leam & parLnershlps, as well as lnsLlLuLlonal knowledge, sysLems, sLaff, paLlenL and communlLy lnvolvemenL,
meeLlngs, communlcaLlon and coordlnaLlon, human resources and sLafflng, and flnanclng and lncenLlves. WlLhln Lhe
conLlnuum of care LhaL lncludes macro-level envlronmenLal and communlLy conLexL, Lhrough healLh sysLem
lnfrasLrucLure and cllnlc/faclllLy level care processes, domalns of lmprovemenL generally flow Lhrough Lhese caLegorles.
1hese Lhemes were Lhen dlvlded accordlng Lo acLlvlLy/lnLervenLlon Lype and area of overarchlng lmpacL aL Lhe sysLems
level. A maLrlx was deslgned ploLLlng Lhe above noLed caLegorles Lo demonsLraLe Lhe lnLersecLlng, ofLen cross-cuLLlng
naLure of varylng caLegorles and lnLervenLlons.

kesu|ts: A quallLy lmprovemenL Laxonomy was consLrucLed Lo deflne common caLegorles of lnLervenLlons Lo faclllLaLe
Lhe conslsLency and lnLegrlLy of language Lo communlcaLe and descrlbe Cl lmplemenLaLlon across conLexLs. 1he
Laxonomy reveals lmporLanL facLors ln successful lnLervenLlons and may promoLe a common language Lo advance Lhe
sclence of lmprovemenL.

Conc|us|on: ConslderaLlon of a Cl Laxonomy ls key Lo llnklng common lnLervenLlons Lo lmprovemenL, plays a plvoLal role
ln relnforclng Lhe sclence of lmprovemenL, and may prove Lo advance scale-up of Cl knowledge and acLlvlLles ln
resource llmlLed seLLlngs.



1201

nCGLCALMIA IN 1nL LLDLkL CULA1ICN
SuchlLra C. 8a[
1,*
, !oy Wllllams
1

1
Lndocrlnology and ulabeLes, nPS, WorLhlng, unlLed klngdom


Cb[ect|ves: Pypoglycaemla ls known Lo be harmful ln Lhe elderly populaLlon. AL presenL Lhe quallLy LargeL for glycaemlc
conLrol ls 7.3 or less regardless of age of paLlenL. A low PbA1c lndlcaLes a paLlenL ls aL lncreased rlsk of hypoglycaemlc
eplsodes. ln Lhe elderly populaLlon hypoglycaemla can have deLrlmenLal effecLs such as falls leadlng Lo LraumaLlc bone
ln[ury and prolonged hosplLal admlsslons. We Lherefore prospecLlvely ldenLlfled elderly dlabeLlc paLlenLs who had a low
PbA1c Lo see lf Lhey are sympLomaLlc wlLh hypoglycaemla and lf so, alLered Lhelr medlcaLlons.

Methods: ulabeLlc SpeclallsL nurses (uSn) vlslLed Lhe admlsslons ward of Lhe ueparLmenL of Medlclne for Lhe Llderly on
a dally basls. Any paLlenL who was admlLLed over Lhe precedlng 24 hours who had dlabeLes and was elLher on
sulphonylurea or lnsulln LreaLmenL was ldenLlfled. uslng a self-deslgned proforma, Lhey obLalned daLa lncludlng
presenLlng complalnL, pasL medlcal hlsLory, lnlLlal dlagnosls, mosL recenL PbA1c and renal & llver funcLlon LesLs. 8ased
on Lhe PbA1c and paLlenL's condlLlon, Lhe uSns made Lhe approprlaLe changes Lo Lhe dlabeLlc medlcaLlon
reglme. 1hese changes should reduce Lhe rlsks of subsequenL hypoglycaemla.

kesu|ts: Cver Lhe 12 monLh perlod, a LoLal of 324 paLlenLs were ldenLlfled who had dlabeLes. 1he average age for Lhls
paLlenL populaLlon was 82years (34-102). CuL of Lhese 324 paLlenLs, 143 were uslng lnsulln or Laklng a sulphonylurea,
agenLs known Lo poLenLlally cause hypoglycaemla. An PbA1c was measured for Lhese paLlenLs and 40 (28) had a
PbA1c under 7.3. Cf Lhese 40 paLlenLs, 3 were admlLLed wlLh a fracLured neck of femur and 9 were admlLLed because
of a fall or /collapse. 7 oLhers were admlLLed because of 'noL coplng aL home' whllsL 2 paLlenLs were admlLLed because
of documenLed hypoglycaemla. A furLher 2 paLlenLs had sympLoms suggesLlve of LranslenL lschaemlc aLLacks and 2
admlLLed due Lo confuslon. 4 oLhers were admlLLed for varlous lnfecLlons and ln 9 paLlenLs Lhe reasons for admlsslon
were unclear. AfLer assessmenL by Lhe dlabeLlc speclallsL nurses, 30 (73) of paLlenLs had Lhelr medlcaLlon alLered Lo
reduce Lhe rlsk of hypoglycaemla.

Conc|us|on: AmongsL 143 consecuLlve elderly dlabeLlc admlsslons uslng lnsulln or Laklng a sulphonylurea, 40 (28) had
an PbA1c below 7.3. ln 27 of Lhese cases hypoglycaemla could well have conLrlbuLed Lo Lhe reason for admlsslon. ln 30
(73) paLlenLs Lhe uSns reduced medlcaLlon Lo reduce rlsks for hypoglycaemla. Slavlsh aLLenLlon Lo achlevlng LargeL
P8A1c ln elderly paLlenLs LreaLed wlLh lnsulln or a sulphonylurea probably puL Lhese paLlenLs aL rlsk of hypoglycaemla.
Llderly paLlenLs musL be carefully assessed for sympLoms of and rlsks for hypoglycaemla.



1202

nLAL1nUAL IN1LkNA1ICNAL ALL CCUN1k LLAkNING NL1WCkk (ACLN): A LLk-DkIVLN kNCWLLDGL
MANAGLMLN1 S1kA1LG AND CCMMUNI1 CI kAC1ICL 1C 8UILD CAACI1 ICk SUS1AINA8LL NA1ICNAL
UALI1 MANAGLMLN1 kCGkAMS IN LCW- AND MIDDLL-INCCML CCUN1kILS
8ruce u. Aglns
1,*
, MargareL alumbo
1
, 8lchard 8lrchard
1
, !oshua 8ardfleld
1

1
nysdoh Alds lnsLlLuLe, PealLhqual lnLernaLlonal, new ?ork, unlLed SLaLes


Cb[ect|ves: eer communlcaLlon abouL quallLy managemenL (CM) beLween governmenLs occurs rarely, lf ever. 1he
PealLhqual ACLn ls a knowledge managemenL sLraLegy provldlng a forum for peer exchange among 17+ counLrles Lo
relnforce lnsLlLuLlonal lmprovemenL and CM. anel and experL presenLaLlons LogeLher wlLh parLlclpanL-drlven dlscusslon
sesslons advance quallLy lmprovemenL (Cl) knowledge and bulld counLrles' capaclLles Lo achleve susLalnable naLlonal
performance measuremenL (M) sLraLegles, Cl Lechnlques and CM frameworks. ACLn promoLes rapld exchange
beLween MlnlsLry of PealLh (MCP) leaders and managers, wlLh changlng annual Lhemes focused on programmaLlc
prlorlLles allgned wlLh resldenL's Lmergency lan for AluS 8ellef (LlA8) goals.

Methods: ACLn [olns naLlonal delegaLlons of MCP and uS-supporLed Lechnlcal sLaff who are dlrecLly lnvolved wlLh
PealLhqual lmplemenLaLlon. lenary speakers provlde experL Lechnlcal lnformaLlon on Cl lmplemenLaLlon emphaslslng
lmpacL on speclfled healLh ouLcomes. anels and counLry presenLaLlons feaLure MCP Leams, allowlng counLry
represenLaLlves Lo share lmprovemenL challenges and successes. Cpen Space, a meeLlng formaL of parLlclpanL-chosen
and led dlscusslon sesslons, faclllLaLes furLher lnvesLlgaLlon on quallLy Loplcs. Cl workshops and case sLudles, and a
sLoryboard compeLlLlon encourage peer exchange and moLlvaLe reflecLlon abouL lmplemenLaLlon of CM programs.
Learnlng and knowledge exchange acLlvlLles lnclude dedlcaLed Llme for peer-Lo-peer dlscusslon and lnformal neLworklng
opporLunlLles whlch conLlnue LhroughouL Lhe week and beyond Lhe formal schedule, furLher relnforclng lmporLanL llnks
beLween parLlclpanLs.

kesu|ts: ACLn fosLers cross-counLry peer exchange beLween MCP leadershlp, managers and daLa analysLs, where
subgroups based on funcLlonal roles exchange knowledge and experLlse. ACLn supporLs Lhe developmenL of susLalnable
naLlonal CM programs Lhrough Lhe sharlng of sLraLegles for pracLlcal lmplemenLaLlon of CM capaclLy bulldlng, hlghllghLs
accompllshmenLs ln CM across counLrles, lncludlng allgnmenL of quallLy acLlvlLles wlLh oLher naLlonal lnlLlaLlves and
prlorlLles, fosLers exchange abouL M sLraLegles, lncludlng lndlcaLor developmenL and daLa collecLlon, daLa quallLy and
analysls Lechnlques whlle enhanclng undersLandlng of Cl knowledge and sLraLegles, and promoLes communlcaLlon of
naLlonal quallLy work Lhrough counLry presenLaLlons and a formal Cl sLoryboard compeLlLlon. ln year four of Lhe ACLn,
counLry Leams are underLaklng varlous leadershlp roles and responslblllLles for key componenLs of Lhe agenda, lncludlng
coachlng of oLher counLry Leams ln core Lechnlcal areas and managemenL of counLry presenLaLlons.

Conc|us|on: eer exchange faclllLaLed by Lhe ACLn ls fundamenLal Lo bulldlng susLalnablllLy Lhrough shared experlence,
knowledge and experLlse, and ln esLabllshlng an lnLernaLlonal communlLy of pracLlce Lo relnforce effecLlve Cl sLraLegles
and spread.



1206

IMLLMLN1ING ADVLkSL LVLN1 kLCk1ING IN A NICU
nora uacklewlcz
1,*
, CusLavo ColdsmlL
2
, Lllana 8agnara
1
, uella vargas
2

1
aLlenL safeLy,
2
nlCu, PosplLal ue edlaLrla ! Carrahan., 8uenos Alres, ArgenLlna


Cb[ect|ves:
! 1o develop a nlCu-focused Lool for adverse evenL reporLlng.
! 1o descrlbe Lhe lncldence of adverse evenLs by Lhls Lool. (volunLary reporL)
! ConLrlbuLe Lo lmprove nlCu paLlenL safeLy, Lhrough healLh Leam awareness and lnvolvlng ln safeLy culLure.

Methods: rospecLlve descrlpLlve sLudy. 8eLween augusL 2012 and !anuary 2013, a nlCu focused Lool for volunLary
adverse evenL reporLlng was developed and LesLed. opulaLlon: every paLlenL ln Lhe Carrahan PosplLal nlCu durlng Lhls
perlod.
hase 1: A group of experL neonaLologlsLs wlLh experLlse ln paLlenL safeLy developed an lnlLlal adverse evenL reporLlng
form wlLh a llsL of ALs, lncludlng AuLs, relevanL Lo nlCu.
hase 2: Workshops were performed wlLh nlCu physlclans, nurses, pharmaclsLs and fellows ln dlfferenL shlfLs, Lo
lnvolve Lhe whole Leam and Lo adapL Lhe form.
hase 3: appllcaLlon of nlCu Lool Lhe drafL was plloLed durlng 1 monLh, Lo redeflne and esLabllsh Lhe flnal form.
hase 4: CuLcomes were lnformed and dlscussed wlLh nlCu Leam, and acLlon plans were deslgned Lo prevenL ALs
recurrence. AL (drug and nondrug relaLed) was deflned as an ln[ury, large or small, caused by Lhe use lncludlng non-
use) of a drug, LesL, or medlcal LreaLmenL

kesu|ts: 142 adverse evenLs were reporLed, 32 of Lhem were medlcaLlon errors, 21 nosocomlal lnfecLlons , 6
accldenLal exLubaLlon (deflned as unplanned exLubaLlons requlrlng re-lnLubaLlon) , 6 dlagnosLlc sLudles relaLed errors,
3 pressure ulcers , 2 mlshandllng or loss of caLheLers, 2 oLhers. 37 of ALs were reporLed by physlclans, 39 by
pharmaclsLs, and 24 by nurslng sLaff. CuLcomes were lnformed Lo nlCu Leam, and 3 prellmlnary llnes of acLlon were
deslgned: workshops Lo lmprove medlcaLlon process, a bundle Lo decrease caLheLer relaLed lnfecLlon raLe and
workshops Lo lmprove endoLracheal Lube care.

Conc|us|on: Cur nlCu-focused Lool appears Lo be effecLlve aL ldenLlfylng adverse evenLs.
1he prevalence of reporLed adverse evenLs ls slmllar Lo LhaL reporLed ln Lhe llLeraLure and hlghllghLs Lhe need for
lncreaslng efforLs Lo reduce hosplLal lnfecLlon, lmprove medlcaLlon process, and global care of new born
paLlenLs. AlLhough Lhere are slgnlflcanL meLhodologlcal and pracLlcal challenges Lo Lhe accuraLe and rellable
deLermlnaLlon of raLes of errors and adverse evenLs, Lhe volunLary reporLlng meLhod may complemenL oLher Lools ln
promoLlng a cllnlcal safeLy culLure and deflnlng Lhe rlsk proflle of Lhe nlCu

keferences: World Alllance for aLlenL SafeLy WPC urafL Culdellnes for Adverse LvenL 8eporLlng and Learnlng SysLems.
lrom lnformaLlon Lo acLlon





1211

1nL LkICkMANCL CI 1nL "kLILC1-AMLN1" INDICA1CkS ICk MLDICAL kLVILW CI 1AIWAN'S NA1ICNAL nLAL1n
INSUkANCL
Wen-luh 1seng
1,*
, Mln-Chu Lln
2
, ?u-Mlng Chen
1

1
Medlcal 8evlew and harmaceuLlcal 8eneflLs,
2
lannlng dlvlslon, 8ureau of naLlonal PealLh lnsurance, 1alpel, 1alwan


Cb[ect|ves: 1o undersLand Lhe performance of uslng Lhe re[ecL-paymenL" lndlcaLors Lo refuse paymenL for medlcal
anomaly ldenLlfled Lhrough proflle analysls of nPl's clalms daLa ln medlcal revlew and conducL relaLed analysls.

Methods: Slnce 2003, Lhe 8ureau of naLlonal PealLh lnsurance (8nPl) ln 1alwan has negoLlaLed wlLh Lhe Medlcal
AssoclaLlons Lo consLrucL re[ecL-paymenL lndlcaLors Lhrough proflle analysls of medlcal clalms daLa for medlcal revlew. lL
lnLended Lo develop such lndlcaLors and seL Lhelr Lhresholds above whlch Lo slgnlfy abnormal medlcal servlces
behavlour. Moreover, 8nPl has bullL a compuLer sysLem Lo compuLe Lhe values of Lhese lndlcaLors regularly (monLhly,
quarLerly or yearly). lf Lhe value of Lhe lndlcaLor exceeded Lhe Lhreshold, Lhe exceedlng parL of Lhe clalms would noL be
relmbursed. 8y Lhls way, 8nPl could reduce overuse or lmproper use of medlcal LreaLmenL, LesLs/exams and drugs Lo
assure medlcal quallLy and drug safeLy.

Cne example ls Lo reduce Lhe overuse and repeaLed use of Zolpldem. 8nPl creaLed an lndlcaLor of prescrlpLlon days
(measured by uuu) per quarLer for Lhe same paLlenL ln Lhe same cllnlc" and seL Lhe Lhreshold of 180 days and 133 days
for a neurology/psychlaLry cllnlc paLlenL and non-neurology/non-psychlaLry cllnlc paLlenL, respecLlvely. AnoLher example
ls Lo use Lhe lndlcaLor of Lhe number of Llmes of LSWL (LxLracorporeal Shock Wave LlLhoLrlpsy) per year for Lhe same
paLlenL ln Lhe same hosplLal" Lo reduce Lhe overuse of LSWL. 1he parL of Lhe LSWL whlch ls greaLer Lhan or equal Lo 6
would noL be relmbursed.

kesu|ts: up Lo Lhe year end of 2012, 8nPl has adopLed 34 lLems of re[ecL-paymenL lndlcaLors Lhrough proflle analysls for
medlcal revlew. Among whlch, 24 lLems are for Lhe hosplLal secLor, 23 lLems for prlmary wesLern medlclne secLor, 4
lLems for Chlnese medlclne secLor and 3 lLems for denLal secLor. lL deducLed LoLally 22,996,703 polnLs of medlcal
expendlLures from 6,376 medlcal lnsLlLuLlons ln 2010. ln 2011, lL furLher deducLed 34,601,829 polnLs of medlcal
expendlLures from 10,333 lnsLlLuLlons. 8nPl wlll conLlnue Lo work wlLh Lhe medlcal assoclaLlons Lo develop new such
lndlcaLors so LhaL Lhe overuse and lmproper use of LreaLmenLs won'L geL pald.

lor Lhe use of Lhe lndlcaLor of prescrlpLlon days ln uuu per quarLer for Lhe same paLlenL ln Lhe same cllnlc of
Zolpldem", 232,729 polnLs of drug expendlLures (equlvalenL Lo 66,494 pllls of Zolpldem) were deducLed from 499 cllnlcs
ln Lhe 3
rd
quarLer of 2012. Among Lhe deducLlon, 1,773 paLlenLs were ln neurology/psychlaLry cllnlcs, whlle 864 paLlenLs
were ln non-neurology/non-psychlaLry cllnlcs. lor Lhe above-menLloned LSWL lndlcaLor, LoLally 1,332,309 polnLs were
deducLed from 22 hosplLals ln 2010, and 1,736,679 polnLs were deducLed from 24 hosplLals ln 2011.

Conc|us|on: uslng re[ecL-paymenL" lndlcaLors and seL Lhelr Lhresholds Lo refuse paymenL for medlcal anomaly
ldenLlfled Lhrough proflle analysls ln medlcal revlew - wlLh Lhe process of regularly(monLhly, quarLerly or yearly)
calculaLlng Lhe lndlcaLor value for an lndlvldual hosplLal/cllnlc by Lhe compuLer sysLem and auLomaLlcally deducLlng Lhe
parL of expendlLures exceedlng Lhe Lhreshold-- can effecLlvely cuL down Lhe overuse and lmproper use of medlcal
LreaLmenLs, LesL/exams, and drugs Lo assure good medlcal quallLy and drug safeLy. 1hough lL can'L replace professlonal
revlew of medlcal expendlLures, undoubLedly lL ls an efflclenL way Lo manage medlcal cosL.



1218

IMAC1 CI DCC1CkS' S1kIkL CN LNGLISn nCSI1ALS
Mllagros 8ulz
1,*
, Alex 8oLLle
1
, aul Aylln
1

1
rlmary Care and ubllc PealLh, lmperlal College London, London, unlLed klngdom


Cb[ect|ves: 1o examlne Lhe effecL of Lhe 24hr docLors' sLrlke on 21 !une 2012 on hosplLal acLlvlLy ln Lngllsh nPS
hosplLals.

Methods: A reLrospecLlve descrlpLlve sLudy of lnpaLlenL and ouLpaLlenL acLlvlLy ln Lngllsh nPS hosplLals over Lhe sLrlke
perlod. We examlne paLlenLs admlLLed Lo hosplLal, or wlLh ouLpaLlenL appolnLmenLs Lo hosplLals over a 3 week perlod
(from 11
Lh
Lo 29
Lh
!une, 2012), excludlng weekends and spannlng Lhe sLrlke day. aLlenL numbers and percenLage change
of lnpaLlenL admlsslons (elecLlve and emergency), day surgery cases, ouLpaLlenL appolnLmenLs, cancellaLlons and ln-
hosplLal deaLhs on Lhe day of Lhe sLrlke are compared wlLh paLlenL acLlvlLy durlng Lhe 1hursday before and Lhe 1hursday
afLer Lhe sLrlke week.

kesu|ts: Cn Lhe day of Lhe sLrlke, Lhe emergency admlsslons dropped by 2.4 whlle elecLlve admlsslons decreased by
12.8. 1here was a 7.8 drop ln Lhe number of ouLpaLlenLs seen by medlcal sLaff on Lhe day of Lhe sLrlke and a 43.3
lncrease ln Lhe number of appolnLmenLs cancelled by Lhe hosplLal. 1he number of ln-hosplLal deaLhs on Lhe day of Lhe
sLrlke was noL slgnlflcanLly dlfferenL Lo Lhe average of Lhe non-sLrlke perlod. 1he lmpacL of Lhe sLrlke across reglonal
PealLh AuLhorlLles ln Lngland was varled. 1he norLh WesL PealLh AuLhorlLy was affecLed Lhe mosL wlLh a 100 lncrease
ln Lhe number of cancelled appolnLmenLs, 10 drop ln Lhe number of ouLpaLlenLs seen on Lhe day and a 16 drop ln
elecLlve admlsslons. 1he leasL affecLed PealLh AuLhorlLles were Lhe SouLh WesL, LasL of Lngland and SouLh CenLral.

Conc|us|on: 1he 24hr docLors' sLrlke ln Lngland on 21 !une 2012 slgnlflcanLly affecLed Lhe provlslon of healLh care by
nPS hosplLals. We observed reglonal varlaLlons on nPS servlce levels on Lhe day of Lhe sLrlke.



1220

ILASI8ILI1 S1UD CI A CCMU1LkISLD DLCISICN AID ICk 1nkCM8CL1IC 1kLA1MLN1 IN ACU1L S1kCkL CAkL
uarren llynn
1,*
, Cary A. lord
2
, uanlel nesblLL
3
, 8lchard C. 1homson
1

1
lnsLlLuLe of PealLh and SocleLy,
2
lnsLlLuLe for Agelng and PealLh (SLroke 8esearch Croup),
3
School of CompuLlng,
newcasLle unlverslLy, newcasLle upon 1yne, unlLed klngdom


Cb[ect|ves: 1hrombolysls (cloL-busLlng LreaLmenL) admlnlsLered wlLhln 4.3 hours from onseL of sympLoms has lmproved
Lhe prognosls for acuLe lschaemlc sLroke, however, Lhere ls lncreased rlsk of sympLomaLlc lnLra-cerebral haemorrhage
(Lyplcally wlLhln 24-36 hours followlng LreaLmenL) LhaL can cause severe dlsablllLy or deaLh. Cur ob[ecLlve was Lo
esLabllsh Lhe accepLablllLy and usablllLy of a compuLerlsed declslon ald ln Lhe acuLe seLLlng Lo supporL ellglblllLy
selecLlon, and rlsk communlcaLlon and consenL/declslon-maklng dlscusslons abouL Lhrombolysls wlLh sLroke
paLlenLs/relaLlves.

Methods: lnformed by a sLrucLured developmenL process (lnLervlew sLudy, eLhnographlc sLudy, llLeraLure revlew, a
locally-deslgned declslon analyLlc model, lnLeracLlve group workshops wlLh cllnlclans and paLlenLs/relaLlves Lo esLabllsh
Lhe opLlmal mode, form and conLenL of declslon supporL, and lnLeracLlve usablllLy LesLlng of a funcLlonal proLoLype ouL
wlLh Lhe cllnlcal seLLlng wlLh cllnlclans and paLlenLs/relaLlves), we deslgned a compuLerlsed declslon ald for sLroke
Lhrombolysls (CCMASS). 1he declslon ald expresses predlcLed cllnlcal ouLcomes (sympLomaLlc lnLra-cerebral
haemorrhage, deaLh, and exLenL of dlsablllLy aL 3-monLhs), wlLh and wlLhouL Lhrombolysls, as a funcLlon of 13 paLlenL
characLerlsLlcs. CuLcome probablllLles are presenLed uslng numerlcal (percenLages and naLural frequencles) and
graphlcal rlsk presenLaLlons (e.g., plcLographs). 1en sLroke cllnlclans used CCMASS (presenLed on a LableL compuLer
and lnLerneL) ln a pragmaLlc fashlon wlLhln Lhe exlsLlng acuLe sLroke care paLhway. 1helr experlences wlLh use of
CCMASS were explored wlLh paper-based conLacL forms and brlef lnLervlews. uaLa logged auLomaLlcally on Lhe LableL
compuLer was used Lo assess Llme ln use. aLlenLs'/relaLlves' experlences of consenL/declslon-maklng dlscusslons
supporLed by CCMASS were explored uslng brlef lnLervlews.

kesu|ts: CCMASS was used ln LoLal on 23 occaslons. Cn 13 occaslons lL was used Lo supporL cllnlcal declslon maklng.
Craphlcal rlsk presenLaLlons were shared wlLh 14 paLlenLs/relaLlves (prlmarlly afLer lnfuslon of Lhrombolysls Lo relnforce
verbal lnformaLlon conveyed prlor Lo LreaLmenL). Cllnlclans reporLed beneflLs ln cllnlcal declslon maklng (e.g., paLlenL-
speclflc predlcLlons of magnlLude of llkely beneflL) and rlsk communlcaLlon wlLh paLlenLs/relaLlves. 1he medlan Llme ln
use was 2.8 mlnuLes. lnLervlews wlLh paLlenLs (n=2) and relaLlves (n=6) revealed LhaL graphlcal rlsk presenLaLlons
(speclflcally plcLographs) faclllLaLed undersLandlng of Lhe beneflLs/rlsks of Lhrombolysls. no adverse effecLs relaLed Lo
use of CCMASS were ldenLlfled.

Conc|us|on: CCMASS has Langlble beneflLs for acuLe sLroke care:
1) allows cllnlcal declslon maklng abouL Lhrombolysls based on lndlvldual dlfferenLlal effecLlveness, and
2) enhanced communlcaLlon processes wlLh paLlenLs/relaLlves.



1224

A kCILC1 1C IMkCVL INA1ILN1 IALL INCIDLNCL AND SLVLkL INIUkILS
Pslu-Chu Chlang
1
, Su-Chln Llang
2
, Mel-Pslng Chen
1,*
, Psuan Chen
2

1
ueparLmenL of nurslng,
2
ulvlslon of Medlcal CuallLy ConLrol, kaohslung Medlcal unlverslLy PosplLal, kaohslung Medlcal
unlverslLy, kaohslung, 1alwan


Cb[ect|ves: lnpaLlenL fall lncldence ls one of Lhe lndlcaLors evaluaLlng Lhe medlcal quallLy of a hosplLal. 1he lnpaLlenL fall
lncldence of Lhe LargeL hosplLal was 0.079 ln 2010. Powever, based on Lhe record from !anuary Lo !une ln 2011, Lhe
resulLs showed LhaL Lhe lnpaLlenL fall lncldence of general wards was 0.092, hlgher Lhan Lhe percenLage of oLher
medlcal cenLers (0.062), and Lhe percenLage of paLlenLs wlLh severe ln[ury was up Lo 3.14. 1herefore, a worklng
group almlng Lo prevenL paLlenL fall lncldence and Severe ln[urles

Methods: Analysls of fall lncldenLs from !anuary Lo !une ln 2011

1. aLlenLs' characLerlsLlcs: 1he mean age was 38.8 years , paLlenLs were from varlous dlvlslons as follows: neurology
20.6, rehablllLaLlon 9.7, cerebral-vascular dlseases 13.9, Lhe lncldences of fall happened Lhree days and seven
days afLer admlsslon were 30.1 & 39.8.
2. 8elaLed facLors: dlzzlness, unsLeady galL, hlgh-rlsk fall populaLlon lnslsLlng on geLLlng ouL of beds by Lhemselves
accounLlng for 91.8 of Lhe ma[or facLors , oLher facLors were Lhose when paLlenLs movlng from bed(28.8),
walklng(20.3), and golng Lo LolleL(18.9).
3. Analysls of Lhe causes: (1) assessmenL Lools for screenlng hlgh-rlsk populaLlon of fall were noL clearly deflned, (2)
ldenLlflcaLlon of hlgh rlsk facLors of fall were noL conslsLenL among general wards, (3) Lhe process and Lhe Llmlng for
screenlng hlgh-rlsk populaLlon of fall were noL sLandardlsed.

ll. 8eformulaLlon of sLandardlslng Lhe assessmenL of fall:

1. 8ased on Lhe Morse Scale, reformulaLed Lhe assessmenL sheeLs.
2. 1he process and Lhe Llmlng for screenlng hlgh-rlsk populaLlon of fall were formulaLed. AfLer ldenLlfylng Lhose who
belong Lo hlgh-rlsk fall groups, Lhe ln-paLlenL lnformaLlcs sysLem would auLomaLlcally produce healLh problem of fall
prevenLlon whlch musL be compleLed by on duLy nurses. lll. lmplemenLaLlon of sLraLegles
3. Cfferlng asslsLanL equlpmenL's and sensor monlLorlng sysLem:
a) Cffer asslsLanL equlpmenL's for helplng paLlenLs walklng, golng Lo Lhe LolleL, e.g. walker, bedslde commode.
b) rovlde lnfrared sensor monlLorlng sysLem Lo prevenL fall lncldenLs for bedrldden paLlenLs falllng repeaLedly.
4. Make remlndlng noLe or marklng of hlgh-rlsk paLlenLs of falllng: llsL hlgh-rlsk paLlenLs of falllng ln nurslng handoffs.
Make speclflc remlndlng noLe or marklng of prevenLlon fall on nurslng kardex and paLlenL's braceleL.
3. racLlce rooL-cause-analysls (8CA) lf Lhe severlLy assessmenL code (SAC) of Lhe fall lncldenL ls caLegorlsed lnLo level
1-2.

kesu|ts: WlLh sLeady lmprovemenL, fall lncldence has been decreased from 0.099 (2011) Lo 0.093 (!anuary Lo !une,
2012). 1he percenLage of paLlenLs wlLh severe ln[ury has been decreased from 3.14 Lo 1.43 . ln 2011, flve fall
lncldenLs were caLegorlsed lnLo SAC1-2. lrom !anuary Lo May ln 2012, none fall lncldenL was caLegorlsed lnLo SAC1-2. 8y
lnLegraLlng ln-paLlenL lnformaLlcs sysLem and remlndlng Lhe healLh problem of fall prevenLlon, nurses offered more
comprehenslve sLraLegles for prevenLlng fall lncldenLs.

Conc|us|on: AlLhough, fall lncldenLs could noL be prevenLed perfecLly. Powever, wlLh sLandardlsed assessmenL and
screenlng process of hlgh rlsk populaLlon of fall and asslsLance from lnformaLlcs sysLem, nurses wlll Lhus ldenLlfy hlgh-
rlsk populaLlon and provlde lndlvlduallsed prevenLlve sLraLegles more efflclenLly. ln Lhls way, fall lncldenLs are expecLed
Lo be decreased, and paLlenL safeLy wlll be guaranLeed.


1238

NC-IAUL1 8ASLD C8S1L1kIC CCMLNSA1ICN ]CAUSAL ANALSIS AND IU1UkL kLVLN1ICN SS1LM AND I1S LIILC1
CN CCNILIC1 LASING AND UALI1 IMkCVLMLN1 IN C8S1L1kIC CAkL IN IAAN
Shlgeru ueda
1
, Shln ushlro
1,*

1
ulvlslon of 1he !apan CbsLeLrlc CompensaLlon SysLem for Cerebral alsy, !apan Councll for CuallLy PealLh Care,
Chlyoda-ku, 1okyo, !apan


Cb[ect|ves: 1he !apan obsLeLrlc compensaLlon sysLem for cerebral palsy was launched ln 2009 ln response Lo Lhe
shorLage of obsLeLrlclan due Lo surglng confllcL on profound cerebral palsy cases. 1he sysLem ls revlewed ln Lerms of
easlng effecL on Lhe confllcL and Lhe quallLy lmprovemenL of obsLeLrlc care.

Methods: !apan Councll for CuallLy PealLh Care (!CCPC) has operaLed Lhe compensaLlon/causal analysls and fuLure
prevenLlon sysLem ln whlch 99.8 of !apanese chlldblrLh faclllLles has reglsLered. 1he collecLlon of lnsurance premlum
from chlldblrLh faclllLles and Lhe paymenL of compensaLlon money Lo a guardlan bearlng a baby wlLh profound cerebral
palsy have been conducLed ln cooperaLlon wlLh lndemnlLy lnsurance companles. Cuardlans wlLh chlldren sufferlng from
cerebral palsy are pald moneLary compensaLlon as much as uS$337,000 and provlded a causal analysls reporL whlch ls
also dellvered Lo chlld blrLh faclllLles. 1he processes composlng Lhe sysLem such as compensaLlon, revlew of ellglblllLy,
causal analysls and fuLure prevenLlon are Lhrough revlewed ln Lerms of efflclency and susLalnablllLy.

kesu|ts: 1he !apan obsLeLrlc compensaLlon sysLem for cerebral palsy ls Lhe sysLem on volunLary basls, however, lL has
achleved 99.8 parLlclpaLlon ln cooperaLlon wlLh professlonal and academlc socleLles of obsLeLrlclans/gynaecologlsLs
and mldwlves and Lhe mlnlsLry of healLh, labour and welfare. Lllglble case ls provlded wlLh moneLary compensaLlon such
as 6 mllllon yen (uS$67,000) for lump-sum paymenL and 24 mllllon yen (uS$270,000) for 20-Llme annual lnsLalmenL
paymenL. 8evlew commlLLee Lo dlscuss ellglblllLy of paLlenL only conflrms blrLh welghL, gesLaLlonal week and congenlLal
or posL-naLal facLors causlng cerebral palsy. LlablllLy of obsLeLrlclan ls ouL of scope of Lhe revlew commlLLee feaLurlng Lhe
process as no-faulL basls". Cases approved of compensaLlon are flled ln Lhe followlng process of causal analysls. Slx
experL groups composlng of obsLeLrlclan, neonaLologlsL, mldwlfe and lawyer have been lnLenslvely worklng on Lhe
producLlon of causal analysls reporL. Cne hundred and slxLy-one reporLs have been compleLed and dellvered boLh Lo
famllles Laklng care of paLlenLs wlLh cerebral palsy and Lo chlldblrLh faclllLles. 1he producLlon of reporL has proved Lo be
favoured of due Lo lLs neuLral naLure ln a sLudy. uesplLe of crlLlclsm arlslng from Lhe beglnnlng LhaL lnLenslve causal
analysls may lgnlLe confllcL beLween chlldblrLh faclllLles and famllles, no slgnlflcanL rlse ln Lhe number of llablllLy
lnsurance paymenL for cerebral palsy case has been observed so far. lor fuLure prevenLlon, Lhe sysLem publlshed a
reporL ln 2012 carrylng 3 lmporLanL Lhemes Lo lmprove quallLy of obsLeLrlc care such as vacuum-asslsLed dellvery,
maLernal educaLlon on placenLal abrupLlon and approprlaLe recordlng on dellvery process. 1he reporL ls open Lo publlc
on !CCPC's web slLe and clrculaLed among obsLeLrlclans on occaslons such as annual meeLlng oc sclenLlflc socleLles for
furLher prevenLlon and lmprovemenL.

Conc|us|on: 1he !apan obsLeLrlc compensaLlon sysLem for cerebral palsy has been effecLlve ln easlng confllcL on cerebral
palsy cases and lmprovlng quallLy of obsLeLrlc care. 1he sysLem covers only obsLeLrlc fleld, however, lL ls noLeworLhy ln
Lerms of flrsL no-faulL compensaLlon sysLem for cllnlcal pracLlce ln !apan.

keferences: 1) 1he webslLe of Lhe !apanese CbsLeLrlc CompensaLlon SysLem for Cerebral alsy (Avallable only ln
!apanese): hLLp://www.sanka-hp.[cqhc.or.[p/lndex.hLml. 2) Culde Lo 1he !apan CbsLeLrlc CompensaLlon SysLem for
Cerebral alsy (Lngllsh leafleL) hLLp://www.sanka-hp.[cqhc.or.[p/pdf/blra_engllsh_color201109.pdf.


1240

nCNG kCNG'S LkLCkA1Ck MC1IVA1ICN S1UD CI nCSI1AL VCLUN1LLkS USING VCLUN1LLk IUNC1ICNS INVLN1Ck
Perman M. C. Lau
1
, Ldwln Wu
2,*
, 8en[amln Lau
2

1
PosplLal Chlef LxecuLlve Cfflce,
2
Pong kong PosplLal AuLhorlLy, Pong kong, Pong kong


Cb[ect|ves: Pong kong PosplLal AuLhorlLy (PA) has long hlsLory of collaboraLlon wlLh volunLeers and Lhelr conLrlbuLlons have been
enormous and dlverse from ward vlslLaLlon, ouLreach servlce, clerlcal supporL Lo professlonal consulLaLlon. volunLeer servlce has
become an lndlspensable workforce and asseL ln enhanclng quallLy of healLh care servlce and reduclng manpower cosL.

undersLandlng Lhe personal moLlvaLlons of Lhe unpald workforce can asslsL Lhe organlsaLlon ln deslgnlng opporLunlLles Lo fulfll Lhelr
moLlvaLlons.

volunLeer luncLlons lnvenLory (vll), an lnsLrumenL uslng 7-polnL LlkerL scale Lo deLecL slx mulLl-facLorlal psychologlcal funcLlons of
volunLeerlng lncludlng value, Soclal, Career, undersLandlng, LnhancemenL and roLecLlon was admlnlsLered.

Cb[ect|ves:
1. 1o lnvesLlgaLe Lhe moLlvaLlons and demographlc lnformaLlon hosplLal volunLeers uslng volunLeer luncLlons lnvenLory (vll)
2. 1o sLudy any moLlvaLlons dlfference across volunLeers' characLerlsLlcs e.g. gender, age, educaLlon background
3. 1o reLaln volunLeers by provldlng sulLable work naLure and rewards
4. 1o provlde sulLable Lralnlng accordlng Lo volunLeers' characLerlsLlcs

Methods: Self-admlnlsLered quesLlonnalres and Chlnese valldaLed verslon vll were dlsLrlbuLed Lo volunLeers ln 7 PA hosplLals ln
Pong kong vla correspondlng volunLeer servlce coordlnaLors. Convenlence sampllng was used.
uescrlpLlve analysls of demographlc daLa of volunLeers was performed and calculaLlons of means of Lhe slx funcLlons ln Lhe vll were
ranked. 1-LesL and kruskal-Wallls LesL were used Lo ldenLlfy any dlfferences of vll across volunLeers' characLerlsLlcs. Spearman's rho
was used Lo ldenLlfy correlaLlons beLween vll, fuLure servlce and average servlng hours.

kesu|ts: 316 compleLed quesLlonnalres were recelved ln a 3-monLh perlod. 37 of lnLervlewees had an average servlng hours of 7-
13 hours/ monLh. 87 volunLeers were wllllng Lo conLlnue servlng PA ln Lhe followlng year. 63 of lnLervlewed volunLeers were
currenLly recelvlng or recelved PA medlcal servlces. 1helr volunLeerlng moLlvaLlons were ranked ln descendlng order as follow:
value, undersLandlng, LnhancemenL, Soclal, roLecLlve and Career as descrlbed ln 1able 1.

MoLlvaLlon dlfferences were analysed across volunLeers' characLerlsLlcs. Llderly volunLeers were slgnlflcanLly focused more on value
and Soclal funcLlons (p= 0.04, 0.02) whereas young adulLs focused more on Career funcLlons (p= 0.00). llve funcLlons of Lhe vll
excepL Career had a poslLlve correlaLlon wlLh Lhe llkellhood of conLlnue servlng PA ln Lhe subsequenL year (p< 0.03).
Somewhat Important to Lxtreme|y Important
(Score S-7)
Neutra|
(Score 4)
Somewhat Not Important to
Not Important at A||
(Score 1-3)
!"#$% 287 (90.8) 9 (2.8) 20 (6.3)
'()%*+,"()-(. 278 (88.0) 9 (2.8) 29 (9.2)
/(0"(1%2%(, 232 (80.0) 13 (4.7) 49 (13.6)
341-"# 203 (64.8) 10 (3.2) 101 (32.0)
5*4,%1,-6% 170 (34.0) 21 (6.6) 123 (39.6)
7"*%%* 118 (37.1) 17 (3.4) 181 (37.3)

1able 1. volunLeers' MoLlvaLlon on Slx uomalns

Conc|us|on: undersLandlng Lhelr moLlves and fulfll Lhelr expecLaLlons are beneflclal for Lhem as well as Lo Lhe organlsaLlon as
volunLeers are noL pald for Lhelr work.
lor examples, elderly Lends Lo have hlgh Soclal moLlves, Lherefore PA may deslgn Lralnlng workshops or [ob allocaLlon ln group
formaLs or wlLh gaLherlng componenLs. Whlle youngsLers' focuses on Career funcLlons, awards and recognlLlons can be provlded Lo
meeL Lhelr moLlves, career Lalks can also be arranged Lo leL Lhem Lo have more undersLandlng ln hosplLal work.

Ma[orlLy of lnLervlewees were also PA cllenLs. 1helr speclal roles of belng a sLaff and a paLlenL could help spoLLlng lnadequacy of Lhe
organlsaLlon. 1hey could be Lhe llnkage beLween Lhe communlLy and hosplLals.



1244

8UILDING UALI1 CAACI1: 1kAINING A LAkGL GkCU CI nCSI1AL LMLCLLS AS AUDI1CkS 1C C81AIN
ACCkLDI1A1ICN.
LllzabeLh van 8ensen
1,*
, Mlrko noordegraaf
2
, aul 8oselle
2
, MargrleL Schnelder
3

1
CuallLy and SafeLy, unlverslLy Medlcal CenLer uLrechL,
2
uLrechL School of Covernance, uLrechL unlverslLy,
3
ueparLmenL
of lnLernal Medlclne and uermaLology, unlverslLy Medlcal CenLer uLrechL, uLrechL, neLherlands


Cb[ect|ves: AudlLs are an effecLlve way Lo deLermlne wheLher an organlsaLlon meeLs sLandards for hosplLal
accredlLaLlon. usually, a small group of dedlcaLed audlLors ls hlred durlng Lhe accredlLaLlon process Lo perform Lhe
audlLs and Lhereby value Lhe work of Lhe professlonal. 1hls may glve Lenslon durlng Lhe accredlLaLlon process. PealLh
care professlonals ofLen experlence Lhe loss of professlonal auLonomy when havlng Lo comply wlLh all sLandards. 1o
overcome Lhls problem, we declded Lo educaLe a slgnlflcanL group of healLhcare professlonals Lo perform Lhe audlLs
along wlLh Lhelr dally work ln Lhe hosplLal. We hypoLheslse LhaL Lralnlng a large group of hosplLal employees Lo acL as
audlLors lmproves supporL for accredlLaLlon sLandards.

Methods: ln large uuLch academlc hosplLal (11.000 employees) Lhe hosplLal board declded Lo sLarL wlLh !Cl accredlLaLlon
ln 2010. ln 2011 en 2012, more Lhan 70 employees (mosLly physlclans and nurses, buL also non-medlcal managers and
sLaff members) recelved a Lralnlng course. 1hls course lncluded Lralnlng ln paLlenL safeLy, human facLors and !Cl
sLandards. ln addlLlon, a pracLlce-based Lralnlng ln audlLlng was glven Lo Leach sysLem Lhlnklng and glvlng feedback.
More Lhan half of Lhese employees were Lralned for 3 days by professlonal !Cl consulLanLs. 1he resL recelved a one day
Lralnlng course by Lhe paLlenL safeLy experL and Lralner of Lhe hosplLal. lurLhermore, regular evaluaLlon meeLlngs were
organlsed Lo exchange experlences.

kesu|ts: More Lhan 400 audlLs were performed over Lhe perlod of one year (2012) by more Lhan 70 Lralned
professlonals-as-audlLors. AudlLs were performed ln (changlng) couples of medlcal and non-medlcal professlonals. 8y
lnvolvlng a large group of employees, Lhe audlLs Lurned lnLo a parLlclpaLory pracLlce, leadlng Lo a wldespread supporL for
Lhe accredlLaLlon sLandards. ln addlLlon, performlng Lhe audlLs empowered Lhese professlonals and affecLed Lhelr own
work. 1hey sLarLed reflecLlng on Lhelr own work by quesLlonlng how Lhey have organlsed Lhlngs aL Lhelr own
deparLmenL. ln Lhls way, hlghly pracLlcal capaclLy bulldlng Look place, Lhe organlsaLlonal ablllLy Lo deal wlLh quallLy
lssues spread LhroughouL Lhe hosplLal.

Conc|us|on: 1ralnlng a large group of hosplLal employees as audlLors makes lL posslble Lo use Lhe experLlse of healLh care
professlonals durlng Lhe accredlLaLlon process. lL creaLes supporL for accredlLaLlon sLandards, buL lL also enables Lralned
employees Lo perform Lhelr own work dlfferenLly. 1he hosplLal slowly bullds capaclLy Lo manage quallLy lssues, wlLhouL
experlenclng Lhe darker sldes of performance managemenL.



124S

kLVLN1ICN CI CA1nL1Lk ASSCCIA1LD UkINAk 1kAC1 INILC1ICN USING IMkCVLMLN1 SCILNCL
Shlrley Magee
1,*

1
nPS llfe, klrkcaldy, unlLed klngdom


Cb[ect|ves: 1he over-archlng ob[ecLlve was Lo prevenL ward developed caLheLer assoclaLed urlnary LracL lnfecLlons and Lhe
developmenL of relaLed S. ooteos bacLeraemlas.

Methods: lmprovemenL sclence meLhodology was used Lo lmplemenL Lhe bundles. 1he Model for lmprovemenL and lan, uo, SLudy,
AcL, cycles were used Lo LesL Lhe bundles Lo ldenLlfy any necessary changes requlred. 1he care bundles lncluded audlL Lools Lo
monlLor sLaff compllance wlLh Lhe bundles, Lhese audlLs were carrled ouL by Lhe cllnlcal effecLlveness faclllLaLor Lo ldenLlfy lssues
and barrlers relaLlng Lo Lhe lmplemenLaLlon of Lhe bundles.
1o monlLor lnfecLlons, a CAu1l lncldenL cross was devlsed Lo:

a) CounL Lhe number of paLlenLs wlLh a urlnary caLheLer on a dally basls.
b) ldenLlfy lncldenLs of CAu1ls (boLh where paLlenLs were admlLLed wlLh a CAu1l and ward developed CAu1ls) uslng a 8ed, Amber,
Creen sysLem.

1hls enabled a CAu1l raLe per 1000 caLheLer bed days Lo be calculaLed as an ouLcome measure and allowed Lhe days slnce lasL CAu1l
lncldenL Lo be recorded.

Cnce Lhe care bundles were esLabllshed wlLhln Lhe ward, a 90 day lmprovemenL plan was uLlllsed Lo spread Lhe pro[ecL across Lhe
remalnlng communlLy wards wlLhln Lhe CommunlLy PealLh arLnershlp. SLaff ln each ward were selecLed Lo be CAu1l lmprovers"
and Lhelr role was Lo supporL Lhe CAu1l work.

1he orlglnal bundle audlL Lools were found Lo be lnadequaLe and a urlnary CaLheLer Cllnlcal CuallLy lndlcaLor was deslgned and
lmplemenLed Lo monlLor sLaff compllance wlLh Lhe bundles.

kesu|ts: 1welve monLhs of daLa, from !anuary Lo uecember 2012, ls dlsplayed on Lhe Lable enLlLled CnLl CP CAu1l Survelllance.
Ward A Ward 8 Ward C Ward D Ward L 1ota|s
CaLheLer 8ed uays 1834 1478 1638 1211 1618 7799
Ward Acqulred CAu1l 1 1 3 2 0 7
AdmlLLed WlLh CAu1l 1 2 0 2 0 3
uays Slnce LasL CAu1l 278 284 213 96 438 96
8aLe per 1000 C8us 0.34 0.68 1.83 2 0.11 0.9

ln LoLal, across flve wards, Lhere were seven ward developed CAu1ls and 7799 caLheLer beds days, Lhls equaLes Lo a raLe per 1000
bed days of 0.90. 1here were no relaLed SA8s. As of Lhe 31
sL
uecember 2012, Lhe lasL ward CAu1l was 97 days ago and one ward
has had 438 days slnce Lhe lasL CAu1l.

rlor Lo Lhls pro[ecL Lhere ls no comparable local daLa on Lhe lncldence of CAu1l ln lsolaLlon of all urlnary LracL lnfecLlons. 1he
ScoLLlsh naLlonal olnL revalence Survey of PealLhcare AssoclaLed lnfecLlons and AnLlmlcroblal rescrlblng (PealLh roLecLlon
ScoLland 2011) found LhaL 22 of paLlenLs wlLh an lnfecLlon ln ScoLLlsh acuLe hosplLals had a urlnary 1racL lnfecLlon. ApproxlmaLely
half of Lhese paLlenLs had a caLheLer ln-slLu ln Lhe seven days prlor Lo lnfecLlon.

Conc|us|on: Learnlng and resulLs from Lhe pro[ecL have been reporLed and presenLed boLh locally and naLlonally. 1hroughouL Lhe
pro[ecL Lhere has been supporL from a mulLl-professlonal group Lo allgn Lhe nPS llfe AdulL urlnary CaLheLerlsaLlon rocedure and
ManagemenL of CAu1l wlLh Lhe CAu1l care bundle work. lurLher lmplemenLaLlon across all ln-paLlenL areas of nPS llfe ls ongolng
and Lhe bundles have also been adapLed for use by communlLy nurslng Leams. aLlenL CAu1l cards have been deslgned Lo provlde
paLlenLs wlLh key lnformaLlon on how Lo care for Lhelr caLheLers and how Lo recognlse Lhe slgns of a CAu1l.

A mulLl professlonal approach and sLaff engagemenL were key Lo lmplemenLlng Lhe assoclaLed changes ln care dellvery. Sharlng
success wlLh Lhe ward sLaff also encouraged Lhem Lo conLlnue Lo adopL Lhe new ways of worklng. 1he role of Lhe senlor charge
nurse was cruclal ln supporLlng all sLaff lnvolved Lo ensure opLlmal caLheLer care for every paLlenL, every Llme. 1he role of Lhe
CAu1l lmprovers" was also a key facLor ln Lhe successful lmplemenLaLlon of Lhe CAu1l bundles.



1249

CCLLA8CkA1ICN AMCNG US ACADLMIC MLDICAL CLN1LkS 1C IMkCVL A1ILN1 CU1CCMLS - A CASL S1UD A1
UnC
Samuel l. Pohmann
1, 2,*
, SLeve Meurer
1
, uavld Levlne
1

1
ComparaLlve uaLa and lnformaLlcs, uPC,
2
PealLh SysLems ManagemenL, 8ush unlverslLy, Chlcago, unlLed SLaLes


Cb[ect|ves: uemonsLraLe developmenL and use of shared daLa resources LhaL faclllLaLe quallLy and performance
lmprovemenL among academlc medlcal cenLers.

uescrlbe meLrlcs used Lo develop performance lmprovemenL lnlLlaLlves.

lllusLraLe lmporLance of rlsk ad[usLmenL ln evaluaLlng basellne performance and lmprovemenL.

Methods: 8eLrospecLlve cohorL sLudy

kesu|ts: More Lhan 200 uS hosplLals, lncludlng 100 academlc medlcal cenLers, parLlclpaLe ln uPC's cllnlcal
daLabase/resource manager (Cu8/8M). CuallLy lmprovemenL wlLhln parLlclpaLlng hosplLals ls faclllLaLed by comparlng
performance among hosplLals uslng rlsk ad[usLed paLlenL ouLcomes ln a LransparenL scheme. lor example, ln-hosplLal
morLallLy among neurosclence paLlenLs ln all uS hosplLals decreased 3.73 beLween 2003 and 2010. Across uPC
parLlclpaLlng hosplLals, Lhere was a 23.9 decrease for Lhe same cohorL ln Lhe same Llme perlod. Moreover, Lop
performers uslng daLa and collaboraLlve resources acLually had a 28.2 decrease.

Conc|us|on: 8y parLlclpaLlng ln uPC's Cu8/8M, uS academlc medlcal cenLers have successfully creaLed a shared quallLy
and performance lmprovemenL resource Lo faclllLaLe cllnlcal lmprovemenL lnlLlaLlves. lnlLlaLlves have lncluded
evaluaLlon of resource demand and use as well as paLlenL quallLy and safeLy. Cver Llme, uS academlc medlcal cenLers
have seen decllnlng ln-hosplLal morLallLy, ln parL a consequence of sharlng daLa and ellclLlng besL pracLlces ln managlng
paLlenLs.

keferences: keroack 2007



12S0

WnA1 IS 1nL IMAC1 CI USING 1nkLSnCLDS ICk IIkS1-LL CA1AkAC1 SUkGLk CN 1nL DLLIVLk CI 1nL
CA1AkAC1 SLkVICL? AND IS I1 CLINICALL AND CCS1 LIILC1IVL 1C LkICkM SLCCND-LL CA1AkAC1 SUkGLk IN
1nL A8SLNCL CI C1nLk CCULAk CC-MCk8IDI1ILS?
!oanna kelly
1,*
, Pllda Lmengo
1

1
PealLhcare lmprovemenL ScoLland, Clasgow, unlLed klngdom


Cb[ect|ves: 1wo scoplng reporLs were prepared Lo assess Lhe followlng quesLlons:

1. WhaL ls Lhe lmpacL of uslng Lhresholds (boLh for referral and surgery) for flrsL-eye caLaracL surgery on Lhe dellvery of
Lhe caLaracL servlce and Lhe resources assoclaLed wlLh lL?
2. ls lL cllnlcally and cosL effecLlve Lo perform second-eye caLaracL surgery ln Lhe absence of oLher ocular co-morbldlLles
ln paLlenLs who have already had flrsL-eye surgery?

1he alm was Lo help lnform caLaracL referral guldellnes for nPS LoLhlan.

Methods: A rapld revlew of Lhe llLeraLure was conducLed. 1hls lncluded a search for local pollcy documenLs, malnly from
rlmary Care 1rusLs ln Lngland, whlch were compared Lo a drafL caLaracL referral paLhway from nPS LoLhlan.

kesu|ts:
uest|on 1. 1here are no speclflc Lhresholds or crlLerla LhaL deflne approprlaLe paLlenLs for referral and/or caLaracL
surgery. As a resulL, Lhere are varlaLlons (wlLhln and across counLrles) ln cllnlcal pracLlce LhaL could have lmpllcaLlons for
Lhe dellvery of a poLenLlally efflclenL and more cosL-effecLlve caLaracL servlce. lL appears LhaL mulLlple ob[ecLlve and
sub[ecLlve crlLerla are ln use, buL Lhere ls llLLle evldence avallable Lo supporL or refuLe Lhelr approprlaLeness for
lmprovlng servlce dellvery ouLcomes.

uest|on 2. 1he flndlngs from Lwo 8C1s suggesL LhaL second-eye surgery ln people wlLh bllaLeral caLaracLs wlLhouL severe
ocular co-morbldlLles, compared wlLh surgery ln one eye only, can resulL ln lmprovemenLs ln ouLcomes such as vlsual
aculLy, sLereopsls, paLlenL-reporLed vlsual dlsablllLy and confldence. Powever, one of Lhe Lrlals was unable Lo
demonsLraLe LhaL second-eye surgery reduces Lhe rlsk of falllng. 1hree cosL-uLlllLy sLudles were ldenLlfled, buL only one
was uk-based. 1he resulLs suggesL LhaL ln people who have mlnor preoperaLlve vlsual dysfuncLlon, second-eye caLaracL
surgery ls noL llkely Lo be cosL-effecLlve ln Lhe shorL-Lerm. Powever, Lhe auLhors also reporLed LhaL ln Lhe long-Lerm,
caLaracL surgery appears Lo be cosL-effecLlve ln Lhls paLlenL group lf carers cosLs are noL lncluded.

When nPS LoLhlan's drafL referral paLhway was compared wlLh 16 local pollcy documenLs from Lngland, Lhe followlng
polnLs were noLed:

! 1he vlsual aculLy Lhreshold for caLaracL surgery ln Lhe drafL nPS LoLhlan paLhway was 'worse Lhan 6/9'. Cf Lhe 16
local pollcy documenLs ldenLlfled, 13 referred Lo vlsual aculLy Lhresholds. 1hese ranged beLween 6/9 and 6/12, and
so Lhe drafL nPS LoLhlan paLhway was ln llne wlLh Lhese.
! Accordlng Lo Lhe drafL nPS LoLhlan paLhway, people who have a vlsual aculLy of 6/9 or beLLer may sLlll be ellglble for
caLaracL surgery lf Lhey meeL cerLaln crlLerla. 1hls ls slmllar Lo a number of local pollcy documenLs, alLhough Lhese
mosLly used a vlsual aculLy Lhreshold of beLLer Lhan 6/12 ln Lhe worsL eye
! Some crlLerla LhaL were menLloned ln Lhe local pollcy documenLs, noL menLloned by nPS LoLhlan, were:
! aLlenLs of 18 years of age or less aL Lhe daLe of referral (8ournemouLh)
! ManagemenL of coexlsLlng eye condlLlons (Cambrldge)

Conc|us|on: 1he scoplng reporLs, and Lhe evaluaLlon of local pollcy documenLs, helped Lo lnform caLaracL referral
guldellnes for nPS LoLhlan.



12S2

IMkCVING MLDICAL LkICkMANCL UALI1 AMCNG A MUL1IDISCILINAk GkCU 8 LVALUA1ING DLCISICNS
IMLLMLN1A1ICN
Mlguel Arela
1,*
, Ana 1eresa Cadlme
1
, Manuel AnLnlo Sllva
1
, ulgesLlve aLhology MulLldlsclpllnary Croup
1

1
orLuguese Cncology lnsLlLuLe-Colmbra, Colmbra, orLugal


Cb[ect|ves: PealLh care quallLy performance depends on each lndlvldual performance buL also on mulLldlsclpllnary
ouLcomes obLalned from lnLernaLlonal guldellnes or experLs consensus meeLlngs. 1he ob[ecLlve of Lhls sLudy was Lo
measure ouLcomes of a mulLldlsclpllnary dlgesLlve group, before and afLer Lhose ouLcomes deflnlLlon, ln order Lo
evaluaLe areas of lmprovemenL ln our quallLy as a healLh servlce provlder. Among Lhe mulLldlsclpllnary group
performance, appllcaLlon of proLocols, accompllshmenLs of predeflned schedules and coherence among wrlLLen crlLlcal
medlcal declslons were evaluaLed and analysed ln a sysLemaLlc way Lo measure quallLy of medlcal performance.

Methods: ln a naLlonal Cncology CenLre, a mulLldlsclpllnary dlgesLlve group composed of Surgeons, CncologlsLs,
8adloLheraplsLs and CasLroenLerologlsLs creaLed ln 2009 an lnsLlLuLlonal proLocol for paLlenL's evaluaLlon, LreaLmenL and
follow-up and seL ldeal Llme frames among Lhese 3 phases of Lhe paLlenL's healLh managemenL and ln 2010 deflned
speclflc crlLerla Lo lnclude ln wrlLLen reporLs ln crlLlcal medlcal declslons appolnLmenLs lncludlng Lhe 1nM sLage. CharLs
of all dlgesLlve paLlenLs, new among Lhe lnsLlLuLlon durlng Lhe monLh of november, ln 3 consecuLlve years (2008, 2009
and 2010), were reLrospecLlvely revlewed, ln order Lo assess Lhe accuracy of paLlenL's evaluaLlon, LreaLmenL, follow-up,
Llme frames and wrlLLen reporLs. numerlc varlables were compared beLween consecuLlve years by Lhe Mann-WhlLney u
LesL whlle caLegorlcal varlables were compared by Lhe earson Chl-Square LesL or llscher's LxacL LesL as appllcable.

kesu|ts: CharLs of 96 paLlenLs were evaluaLed and resulLs are reporLed for Lhe years 2008, 2009 and 2010 respecLlvely.
CorrecL requesL of exams for paLlenL's evaluaLlon lncreased durlng Lhe 3 years (71 vs. 83 vs. 97, p=0.23 and p=0.11)
and correcL schedule of follow-up exams afLer LreaLmenLs also lmproved (40 vs. 36 vs. 73, p=1.0 and p=0.28). lor
Lhe Llme frames evaluaLed, Lhe number of days Lo schedule Lhe flrsL appolnLmenL were 7 vs. 3 vs. 8 days (p=0.94,
p=0.29), Lhe Llme beLween Lhe flrsL appolnLmenL and Lhe flrsL crlLlcal medlcal declslon was 6 vs. 7 vs. 14 days (p=0.24,
p=0.24) and Lhe gap beLween LhaL declslon and Lhe flrsL LreaLmenL was 8 vs. 20 vs. 17 days (p=0.01, p=0.73) wlLh
sLaLlsLlcal slgnlflcance beLween 2008 and 2009 buL sLlll below Lhe Lhreshold deflned by Lhe proLocol. 1he 1nM sLage
descrlpLlon raLes were 71 vs. 83 vs. 97 (p=0.23 and p=0.11), lncreaslng conslderably ln Lhe 2010.

Conc|us|on: AudlLlng medlcal mulLldlsclpllnary performance ln consecuLlve years allowed us Lo verlfy lf declslons Laken
Lo lmprove quallLy of care were lmplemenLed and resulLed ln measurable lmprovemenLs. Accordlng Lo Lhe lnsLlLuLlonal
proLocol, paLlenLs' evaluaLlon, follow-up and charLs preclslon lmproved conslderably ln [usL 3 years whlle Lhe Llme gap
among Lhese sLeps lncreased sllghLly buL wlLhouL sLaLlsLlcal or medlcal slgnlflcance, sLlll fulfllllng Lhe requlremenLs of Lhe
lnsLlLuLlons' proLocol.



12SS

LNGAGING CLINICIANS IN UALI1 IMkCVLMLN1 A1 1nL UNIVLkSI1 CI CALIICkNIA DAVIS nLAL1n SS1LM
ulfaL Shalkh
1,*
, lrederlck Meyers
1

1
unlverslLy of Callfornla uavls PealLh SysLem, SacramenLo, unlLed SLaLes


Cb[ect|ves: PosplLals have LradlLlonally conducLed quallLy lmprovemenL (Cl) wlLhln Lhe walls of Lhelr Cl deparLmenLs
wlLhouL engaglng fronL-llne cllnlclans. LducaLlonal compeLencles ln healLh sclences schools and conLlnulng educaLlon
have rarely lncluded LranslaLlon of educaLlon Lo lmprove quallLy of care. Cllnlclans are, however, unlquely poslLloned Lo
assess and modlfy paLhways of care, recognlse sysLems deflclLs, and supporL quallLy alms. Cur goal was Lo develop and
lmplemenL a sLraLegy Lo acLlvely engage fronL-llne cllnlclans aL Lhe unlverslLy of Callfornla uavls PealLh SysLem (uCuPS)
ln Cl by lnLegraLlng our efforLs wlLh Leam-based and lnLer-professlonal educaLlon and care.

Methods: Cur sLraLegy lnvolved:
1) allgnmenL wlLh organlsaLlon-wlde sLraLeglc plan,
2) lnLer-professlonal educaLlon,
3) sLudenL lnLeresL group ln healLhcare quallLy,
4) conLlnulng professlonal developmenL,
3) lncreaslng vlslblllLy of efforLs, and
6) sysLemaLlc scallng up.

kesu|ts:
1) AllgnmenL wlLh organlsaLlon-wlde sLraLeglc plan: 1he uCuPS sLraLeglc plan has senlor admlnlsLraLlve supporL
from our schools of medlclne and nurslng and our medlcal cenLer. lmprovlng Lhe quallLy of healLhcare and of healLh
by lnLegraLlng educaLlon wlLh Cl ls speclflcally called ouL ln our recenLly revlsed sLraLeglc plan.
2) lnLer-professlonal educaLlon: An lnLroducLlon Lo healLhcare quallLy ls presenLed durlng medlcal school orlenLaLlon.
We leverage our sLudenL home vlslL program Lo engage paLlenLs ln ldenLlfylng areas and sLraLegles for lmprovemenL.
We lmplemenLed a Leam-based currlculum ln Cl for house sLaff LhaL has lncreased Lhelr ablllLy Lo apply Cl
meLhodology and has lmproved cllnlcal processes and ouLcomes. Worklng ln Leams, house sLaff and faculLy apply Cl
prlnclples Lo sysLemaLlcally deslgn and lmplemenL Cl lnlLlaLlves. lnsLrucLors aL our Schools of nurslng and Medlclne
have collaboraLed on lnLroduclng lnLer-professlonal courses lnLo Lhe currlculum LhaL engage learners ln compleLlng
Cl pro[ecLs allgned wlLh organlsaLlonal prlorlLles.
3) SLudenL lnLeresL group ln healLh care quallLy: 1he group brlngs LogeLher sLudenLs from medlclne, nurslng, publlc
healLh, lnformaLlcs, managemenL, law, buslness, and englneerlng. Members are lnvolved ln worklng wlLh faculLy ln
deslgnlng and evaluaLlng new currlcula.
4) ConLlnulng professlonal developmenL: We have developed a mechanlsm for faculLy cllnlclans Lo recelve credlLs for
board recerLlflcaLlon and conLlnulng educaLlon ln Lhelr speclalLy for Lhelr parLlclpaLlon ln Cl efforLs aL uCuPS.
3) lncreaslng vlslblllLy of efforLs: now ln lLs Lhlrd year, Lhe goal of Lhe uCuPS Annual lnLegraLlng CuallLy Symposlum ls
Lo llnk hlgh quallLy cllnlcal care wlLh cllnlclan educaLlon and lmplemenLaLlon sclence and Lo showcase our cllnlclans'
work ln Cl.
6) SysLemaLlc scallng up efforLs: We were funded by Lhe unlverslLy of Callfornla Cfflce of Lhe resldenL's CenLer for
PealLh CuallLy and lnnovaLlon Lo coordlnaLe a learnlng neLwork of all flve healLh sysLems wlLhln Lhe unlverslLy of
Callfornla. 1hls neLwork engages Lralnees, faculLy and sLaff ln Cl ln areas allgned wlLh naLlonal and healLh sysLem
prlorlLles. 1he currenL focus of Lhls learnlng neLwork ls Lo lmprove paLlenL safeLy aL hosplLal dlscharge, Lhereby
reduclng unplanned readmlsslons.

Conc|us|on: Cur lnsLlLuLlonal experlence demonsLraLes LhaL sLudenLs, Lralnees and pracLlclng cllnlclans are large and
lnfrequenLly Lapped workforce of fuLure Cl pracLlLloners. Weavlng Cl lnLo Lhe fabrlc of healLh care dellvery
organlsaLlons, comblned wlLh sLraLeglc and on-golng career developmenL of lnLer-professlonal Leams can overcome
barrlers Lo lmprovlng healLh care dellvery and populaLlon healLh.

126S

2LkC 1CLLkANCL ICk kLSSUkL ULCLkS - A kLGICNAL S1kA1LG
8enLe Pansen
1,*
, uorLe 8agger
2

1
CualllLy and aLlenL safeLy, CaplLal 8eglon of uenmark, Perlev PosplLal, Perlev,
2
reglonal unlL for quallLy lmprovemenL,
CaplLal 8eglon of uenmark, Plllerod, uenmark


Cb[ect|ves: 8ack ground lnformaLlon: CaplLal 8eglon of uenmark ls a mulLl-hosplLal sysLem, lncludlng a large menLal
healLh Servlce for psychlaLrlc paLlenLs. 1he overall number of beds ln Lhe caplLal 8eglon of uenmark ls 3000 and Lhe
number of full Llme cllnlcal sLaff ls approx. 29.000. 1he reglon covers 1,2 mlo. lnhablLanLs and Lhe number of somaLlc
hosplLals are 8, slLuaLed ln mulLlple locaLlons.

A naLlonal and reglonal LargeL area ls Lo reduce Lhe number of hosplLal acqulred pressure ulcers Lo none ln 2014. 1hls
goal ls Lo be achleved for all nlne hosplLals. A prevalenL sLudy has been performed ln uecember 2012 ln order Lo collecL
basellne daLa. 1he sLudy lncluded Lhe Lype, numbers, locaLlons and classlflcaLlons of ldenLlfled ulcers. aLlenLs wlLh
pressure ulcers aL Lhe Llme of admlsslon were lncluded as well.

A reglonal pressure ulcer prevenLlons group ls esLabllshed and reglonal guldellnes, documenLaLlons Lools, and a unlform
care plan have been developed. 1he pro[ecL ldenLlfles sources and meLhods Lo regular monlLorlng Lhe prevenLlve
acLlons for each paLlenL and also Lhe number of hosplLal acqulred pressure ulcers on deparLmenL level. Learnlng Lools Lo
supporL sLaff educaLlon ls under developmenL.

Methods: revalens sLudy amongsL 3000 admlLLed paLlenLs ln 9 somaLlc and 1 psychlaLrlc hosplLal. 8evlew of medlcal
records. Cenerlc Lools for assesslng paLlenLs rlsk for developlng pressure ulcers, reassessmenL and classlflcaLlon of
pressure ulcers. unlform documenLaLlon Lools ln Lhe enLlre 8eglon lncludlng a unlform Lool for monlLorlng aL
deparLmenL level.

kesu|ts: 8asellne prevalens sLudy has been concluded. 3000 paLlenLs lncluded, 700 paLlenLs had ulcers and Lhe LoLal
number of ulcers were appr. 1400. 330 paLlenLs were admlLLed wlLh pressure ulcers - 30 of Lhe paLlenLs wlLh pressure
ulcers. ressure ulcers were classlfled ln Lo 4 dlfferenL caLegorles (1-4, lnLernaLlonal classlflcaLlon)
Medlcal record revlew daLa november 2012 and May 2013: endlng

Conc|us|on: 1he prevalens sLudy was Lhe klck-off for a large scale lmplemenLaLlon plan Lo reduce Lhe number of hosplLal
acqulred pressure ulcers. We hope Lo be able Lo presenL Lhe resulLs of Lhls large scale lmplemenLaLlon of unlform
pracLlces LhaL can show lf such a reglonal efforL wlll resulL ln a subsLanLlal lmprovemenL.

keferences: AssoclaLlon of uanlsh 8eglons: revenLlon of pressure ulcers - a naLlonal lmprovemenL pro[ecL. 2012
Luropean ressure ulcer Advlsory anel and naLlonal ressure ulcer Advlsory anel. revenLlon and LreaLmenL of
pressure ulcers: qulck reference gulde. WashlngLon uC: naLlonal ressure ulcer Advlsory anel, 2009 CaplLal 8eglon of
uenmark: ollcy for CuallLy lmprovemenL and aLlenL SafeLy. 2011



1266

1nL LkICkMANCL CI 1nkCM8CLSIS IN GLkMAN ISCnLMIC S1kCkL A1ILN1S - DID 1nL GUIDLLINL UDA1L nAVL
AN IMAC1?
nadlne ScholLen
1,*
, Pelmar C. Lehmann
2
, Polger faff
1

1
lMv8,
2
ZenLrum fr neurologle und sychlaLrle, unlkllnlk kln, kln, Cermany


Cb[ect|ves: 1he recommended Llme frame for performlng Lhrombolysls ln lschemlc sLroke paLlenLs has been exLended
from 3 Lo 4.3 hours ln 2009. 1he alm of our sLudy ls Lo compare Lhe LreaLmenL slLuaLlon of lschemlc sLroke paLlenLs ln
Cermany before and afLer Lhe guldellne revlslon. ulfferences ln Lhe lncrease of Lhe Lhrombolysls raLes are belng
analysed wlLh respecL Lo lnfluenclng facLors on Lhe hosplLal level.

Methods: uaLa sources are Lhe 2008 and 2010 quallLy reporLs, whlch accordlng Lo Cerman law have Lo be publlshed by
all hosplLals performlng medlcal LreaLmenL. AddlLlonal lnformaLlon has been galned by addlng daLa from Lhe federal
sLaLlsLlc bureau Lo classlfy Lhe hosplLals by Lhelr locaLlon (urban, seml-urban and rural). We were able Lo lnclude Lhe daLa
of 341 neurologlc deparLmenLs, LreaLlng 127.000 (2010) lschemlc sLroke paLlenLs (sLroke paLlenLs wlLh Lhe dlagnosls l63
lCu-10-CM). 8y performlng loglsLlc regresslon (S1A1A, verslon 12) we esLlmaLed a sLaLlsLlc model Lo flnd correlaLlons
beLween hosplLal and deparLmenL characLerlsLlcs and Lhe Lhrombolysls raLe shlfL.

kesu|ts: 1he Lhrombolysls raLe ln lschemlc sLroke paLlenLs, LreaLed by a neurologlc deparLmenL has slgnlflcanLly (p <
0.0001) lncreased from 6.3 per cenL ln 2008 Lo 8.9 per cenL ln 2010. WlLh a range beLween 0 and up Lo 33.7 per cenL of
lschemlc sLroke paLlenLs recelvlng Lhrombolysls ln 2010 Lhere are huge varlaLlons beLween Lhe dlfferenL
hosplLals. lacLors LhaL lnfluence Lhe Lhrombolysls raLe lnclude Lhe exlsLence of a sLroke-unlL and Lhe number of LreaLed
sLroke paLlenLs. lor Lhe lncrease ln Lhe Lhrombolysls raLe beLween 2008 and 2010 we could noL flnd any slgnlflcanL
varlables on Lhe deparLmenL/hosplLal level.

Conc|us|on: 1hrombolysls durlng Lhe flrsL 4.3 hours afLer onseL of Lhe flrsL sympLoms ls Lhe only approved LreaLmenL for
lschemlc sLroke paLlenLs. Cur analysls could show LhaL Lhere ls a correlaLlon beLween Lhe hosplLals experlence ln LreaLlng
lschemlc sLroke paLlenLs and Lhe performance of a guldellne congruenL Lherapy. 1he exLended Llme frame resulLed ln an
lncrease of Lhrombolysls raLe, ln hosplLals locaLed ln urban as well as ln rural reglons. PosplLal characLerlsLlcs llke
Leachlng sLaLus, ownershlp, locaLlon or number of beds dld noL slgnlflcanLly lnfluence Lhe Lhrombolysls raLe afLer Lhe
guldellne updaLe ln 2009. lurLher research ls necessary Lo deLecL posslble reasons for Lhe unequal performance of
Lhrombolysls ln Cermany.



1268

A1ILN1 SAIL1 CLIC IN LCNG-1LkM CAkL: ILASI8ILI1 CI LkLCU1IVL A1ILN1 SAIL1 WALkkCUNDS 1M 1C
IMkCVL MANAGING SCI1 SIGNALS. A S1UD kC1CCCL.
Loes van uusseldorp
1,*
, Pub Pamers
2
, 1heo van AchLerberg
1
, LlseLLe Schoonhoven
1

1
SclenLlflc lnsLlLuLe for CuallLy of PealLhcare, 8adboud unlverslLy nl[megen Medlcal CenLre,
2
PealLh Care ManagemenL
& Servlces, PAn unlverslLy of Applled Sclences, nl[megen, neLherlands


Cb[ect|ves: ln Lhe lasL decade's quallLy and safeLy ln healLh care recelved subsLanLlal aLLenLlon. Cood quallLy of care and
paLlenL safeLy requlre leadershlp lnvolvemenL, from boLh professlonals and board members. CurrenLly avallable Lools for
Lhe managemenL of safeLy ln healLhcare are largely based on quanLlLaLlve managemenL lnformaLlon. Powever, Lhese
Lools do noL palnL Lhe whole plcLure and do noL yleld sufflclenL lnformaLlon Lo monlLor quallLy and paLlenL safeLy. ln
addlLlon, Lhe professlonal relaLlonshlp beLween board members and professlonals ls an lmporLanL precondlLlon for
safeLy pollcy. 1hls relaLlonshlp should be based on muLual LrusL Lo allow Lhe board Lo plck up on lndlrecL slgns. 1hese so-
called 'sofL slgnals' are lmporLanL early warnlngs LhaL someLhlng ls wrong. 1hey can supplemenL or conflrm currenL
managemenL lnformaLlon and seem useful as a leadershlp Lool for Lhe execuLlve board. SafeLy Walk8ounds
1M
offer Lhe
board an opporLunlLy Lo bulld a LrusLlng relaLlonshlp wlLh professlonals and plck up on sofL slgnals. 1he ma[orlLy of Lhe
research on Walk8ounds
1M
has been performed ln hosplLals. lL ls Lherefore unknown how board members of long-Lerm
care organlsaLlons use sofL slgnals as a leadershlp Lool and lf so, how Lhls lnfluences Lhelr paLlenL safeLy pollcy .1he alm
of Lhls sLudy ls Lo ldenLlfy how execuLlve board members of long-Lerm care organlsaLlons manage paLlenL safeLy. Also,
Lhls sLudy alms Lo lnLroduce and evaluaLe Lhe meLhod of Walk8ounds
1M
ln order Lo explore Lhe added value and Lhe
feaslblllLy of Lhls meLhod for paLlenL safeLy managemenL ln long-Lerm care.

Methods: An exploraLlve before-afLer sLudy wlll be conducLed beLween Aprll 2012 and uecember 2013 ln Lhe
neLherlands. rlor Lo Lhe lnLroducLlon of Walk8ounds
1M
, daLa collecLlon wlll Lake place ln 13 long-Lerm care
organlsaLlons (4 MenLal PealLh Care lnsLlLuLlons, 3 nurslng home and home care organlsaLlons, and 4 lnsLlLuLlons for
physlcally and menLally dlsabled) Lo ldenLlfy Lhe characLerlsLlcs of execuLlve boards of organlsaLlons. 8oard members wlll
be lnLervlewed and asked Lo flll ln a quesLlonnalre, and reporLs of meeLlngs of Lhe execuLlve boards wlll be sLudled.
uurlng Lhe lnLervenLlon perlod Walk8ounds1M wlll be lmplemenLed ln slx organlsaLlons, Lhe lnLervenLlon group. 1he
conLrol group wlll conLlnue care as usual. AfLer one year, Lhe added value of managlng sofL slgnals on paLlenL safeLy
ouLcomes wlll be lnvesLlgaLed ln all parLlclpaLlng organlsaLlon. CuanLlLaLlve daLa regardlng characLerlsLlcs of Lhe
organlsaLlon, characLerlsLlcs of Lhe execuLlve board and Lhe way execuLlve board members manage paLlenL safeLy wlll be
analysed uslng descrlpLlve sLaLlsLlcs.

LxecuLlve board members manage paLlenL safeLy wlll be analysed uslng descrlpLlve sLaLlsLlcs. 1-LesLs wlll be compuLed
wlLhln and beLween Lhe varlous groups Lo compare Lhe average number of paLlenL safeLy lmprovemenL acLlvlLles, and Lo
evaluaLe Lhe effecL of Lhe lnLervenLlon by comparlng Lhe paLlenL safeLy performance lndlcaLors, a p<0.03 wlll be
consldered sLaLlsLlcally slgnlflcanL. lmporLanL LexLs LhaL emerge from examlnaLlon of Lhe quallLaLlve daLa of Lhe
quesLlonnalres, lnLervlews and Lhe reporLs are analysed uslng open, axlal and selecLlve codlng.

kesu|ts: rellmlnary resulLs are expecLed Lo be ready aL Lhe conference.

Conc|us|on: D|scuss|on: A ma[or challenge ls Lhe on-golng developmenL and lmplemenLaLlon of paLlenL safeLy
managemenL Lools and quallLy measurlng lnsLrumenLs. 1hls mlghL be a rlsk for Lhe resulLs of our sLudy.




1277

A1ILN1S AS Ak1NLkS: DLVLLCMLN1 CI 1nL CS1-S1kCkL 'LAS ACCLSS 1CCLkI1'
kaLy 8oLhwell
1,*
, Clll earl
2
, lppa !. 1yrrell
3, 4

1
nlP8 CLAP8C for CreaLer ManchesLer, Salford,
2
Speakeasy, 8ury, CreaLer ManchesLer,
3
unlverslLy of ManchesLer,
ManchesLer,
4
Salford 8oyal nPS loundaLlon 1rusL, Salford, unlLed klngdom


Cb[ect|ves: 1he ob[ecLlves of Lhls sLudy were:

1. 1o use a user-led sLraLegy Lo develop a posL-sLroke assessmenL Lool accesslble for people wlLh aphasla, a complex
language processlng dlsorder LhaL affecLs approxlmaLely one Lhlrd of people posL-sLroke.
2. 1o lmplemenL Lhe assessmenL Lool ln Lhe communlLy Lo ensure LhaL Lhe unmeL needs of Lhls speclflc sLroke
populaLlon are approprlaLely ldenLlfled and addressed ln a Llmely manner, leadlng Lo more equlLable servlce
provlslon, lmproved ouLcomes and lncreased quallLy of llfe for paLlenLs and Lhelr carers.

Methods: A 'SLroke AssessmenL 1ool user Croup' was creaLed comprlslng of elghL people wlLh varylng degrees of
severlLy, complexlLy and lmpacL of aphasla posL-sLroke. 1hls group was supporLed by Lhree experL faclllLaLors and was
Lasked wlLh leadlng Lhe developmenL of a verslon of Lhe CreaLer ManchesLer SLroke AssessmenL 1ool (CM-SA1) LhaL was
approprlaLe and accesslble for people wlLh aphasla posL-sLroke. 1he group meL for 2h blweekly for a perlod of
approxlmaLely slx monLhs and worked Lo ldenLlfy and agree upon Lhe lmporLanL characLerlsLlcs of accesslble
lnformaLlon, such as Lhe use of slmple words, shorL senLences and relevanL lmages, symbols and plcLures. uslng Lhls as a
basls, durlng subsequenL meeLlngs, Lhe group Lhen worked Lhrough Lhe orlglnal verslon of Lhe CM-SA1 secLlon by
secLlon, applylng Lhese prlnclples and maklng Lhe lnformaLlon approprlaLe for people wlLh aphasla.

kesu|ts: 1he CM-SA1 Lasy Access 1oolklL was creaLed by Lhe user Croup. Comprlslng of Lwo resources- Lhe
ConversaLlon SupporL 8esource (CS8) and Lhe 1rlgger CuesLlon 8esource (1C8) - Lhls comprehenslve 1oolklL provldes Lhe
maLerlals requlred Lo supporL Lhe assessmenL of Lhe long-Lerm unmeL needs of people who have aphasla followlng a
sLroke. 1he 1oolklL has subsequenLly been adopLed by a number of healLh, soclal care and volunLary secLor organlsaLlons
across Lhe unlLed klngdom.

Conc|us|on: Whlle requlrlng slgnlflcanL plannlng and resource, adopLlng a user-led approach was key Lo ensurlng
producLlon of a quallLy resource LhaL ls approprlaLe and capable of meeLlng Lhe needs of people wlLh aphasla posL-
sLroke. AppllcaLlon of Lhe CM-SA1 Lasy Access 1oolklL has ensured LhaL Lhe posL-sLroke needs of people wlLh aphasla
are as effecLlvely ldenLlfled as address as Lhose of Lhelr non-aphaslc peers.



1294

CULS 1C ULULS - AN AL8Lk1AN CLI1ICAL DL8A1L
Cwen Pelsler
1,*

1
rofesslonal ConducL, College of hyslclans & Surgeons of AlberLa, LdmonLon, Canada


Cb[ect|ves: 8espondlng Lo allegaLlons of lmproper preferenLlal access Lo publlcally funded healLh servlces ln Lhe
Canadlan healLh care sysLem, Lhe CovernmenL of AlberLa esLabllshed a PealLh Servlces referenLlal Access lnqulry"
(hLLp://www.healLh accesslnqulry.com) LhaL was drlven by, responded Lo and caLalyLlc of slgnlflcanL publlc debaLe
relaLlng Lo dlsLrlbuLlon of scarce healLh care resources. 1he esLabllshmenL of Lhe lnqulry lLself was lmbedded ln pollLlcal
poslLlonlng and machlnaLlons LhaL ln and of lLself creaLed a debaLe wlLhln a debaLe. Cueues are an lnevlLable
consequence when resources are llmlLed. WlLh healLh care eLhlcal frameworks evolvlng away from a vlrLue eLhlc
Lowards deonLologlcal and femlnlsL paradlgms, Lhere ls lncreaslng pressure Lo codlfy rules and prlnclples as lL relaLes Lo
dlsLrlbuLlon of resources. 1he publlc debaLe LhaL arose ln Lhls lnsLance can be examlned uslng eLhlcal paradlgms,
demonsLraLlng how such an evaluaLlve Lool can ensure publlc pollcy ls reflecLlve of underlylng publlc needs and
wanLs. PealLh pollcy can advance and maLure only wlLh conslderaLlon and analysls of splrlLed publlc debaLe as arose ln
Lhls case Lhrough Lhe lens of eLhlcal paradlgms - oLherwlse, Lhe poLenLlal galn Lo have such debaLe ln conslderaLlon of
Lhe slgnlflcanL pollLlcal cosLs would never make such a process worLh Lhe efforL and rlsk.

Methods: 1hls ls an observaLlonal and conLemplaLlve sLudy LhaL reflecLs on Lhls pollLlcal dlscusslon of access Lhrough Lhe
lens of vlrLue, deonLologlcal and femlnlsL eLhlcal paradlgms. 1he background LhaL led Lo Lhls very publlc, someLlmes
prlnclpled and always pollLlcal debaLe ls consldered ln Lhe pollLlcal, economlc, soclal and leglslaLlve conLexL ln whlch lL
arose. 1he presenLaLlons Lo Lhe commlsslon wlll be revlewed and codlfled. 1hey wlll ln Lurn be examlned wlLh an eLhlcal
lens Lo demonsLraLe how Lhe eLhlcal framework paradlgms Lhemselves lnvarlably led Lo Lhe evenLual ouLcome. 1he
ouLcome of Lhe lnqulry wlll be evaluaLed agalnsL Lhe exlsLlng pollLlcal and culLural envlronmenL.

kesu|ts: PlsLorlcally, access Lo healLh care has been Lhrough a vlrLue eLhlcal paradlgm whlch was Lyplcally physlclan
cenLrlc and paLernallsLlc. 1ralnlng of physlclans mlrrored Lhls eLhlcal paradlgm whereln lL was belleved LhaL normaLlve
declslons of rlghL and wrong can be learned wlLh Lhe rlghL declslon belng mldway beLween Lhe vlce of Loo much and Loo
llLLle. 1hls ls ln conLrasL Lo Lhe prlnclples LhaL arlse wlLhln a deonLologlcal eLhlcal framework LhaL supporL Lhe concepL
LhaL socleLy can codlfy rules, sLandards and prlnclples LhaL can be relled upon Lo manage healLh care queues. WlLh an
evoluLlon Lowards a deonLologlcal eLhlcal framework concenLraLlng on auLonomy, beneflcence, non-maleflcence and
[usLlce, eLhlcal confllcLs ln regards Lo whaL ls proper dlsLrlbuLlon of scare healLh care resources surface. LvaluaLlon of
publlc pollcy debaLes ofLen falls Lo conslder Lhese eLhlcal frameworks and ln so dolng do noL uncover and lncorporaLe
Lhe rlchness of Lhe learnlng's LhaL are avallable. 1hls presenLaLlon wlll demonsLraLe uslng Lhls concreLe publlc example
how such an evaluaLlon allows Lhose charged wlLh crafLlng publlc pollcy Lo develop more accepLable and reflecLlve
pollcles.

Conc|us|on: AlLhough publlc debaLe ls ofLen lnherenLly rlsky from a pollLlcal perspecLlve, lL ls only Lhrough such
processes LhaL Lhere can be robusLness of publlc lnpuL requlred for developmenL of publlc pollcles. ConslderaLlon of Lhe
underlylng eLhlcal frameworks when faced wlLh open, publlc debaLe provldes an lnvaluable Lool ln assurlng Lhe lnpuL
from such pollLlcally charged rheLorlc Lruly adds value Lo Lhe creaLlon of publlc pollcy.




1303

DCLS CCN1Lk1 INILULNCL 1nL LIIICAC CI A1ILN1 DLCISICN AIDS? A SLCCNDAk ANALSIS CI A SS1LMA1IC
kLVILW
!ames 8rown
1
, kerry !oyce
2
, 8lchard 1homson
2,*
, uawn SLacey
3

1
ubllc PealLh, nPS CounLy uurham & uarllngLon, uurham,
2
lnsLlLuLe of PealLh and SocleLy, unlverslLy of newcasLle
upon 1yne, newcasLle upon 1yne, unlLed klngdom,
3
School of nurslng, unlverslLy of CLLawa, CLLawa, Canada


Cb[ect|ves: 1here ls evldence LhaL Lhe efflcacy of paLlenL declslon alds (LuAs) may be lnfluenced by Lrlal parLlclpanLs'
percepLlons of Lhelr ldenLlLy: wheLher Lhey percelve Lhemselves Lo be paLlenLs (seeklng Lo beneflL personally from
lnvolvemenL) or volunLeers (consenLlng ln order Lo supporL Lhe research efforL - alLrulsm). Several sLudy characLerlsLlcs
may be lndlcaLlve of Lrlal ldenLlLy, lncludlng wheLher parLlclpanLs lnlLlaLed Lhe paLhway of care LhaL led Lo Lhe declslon,
Lrlal seLLlng, and Lhe conLexL of pracLlLloner lnLeracLlons. 1he ob[ecLlve was Lo deLermlne lf sLudy characLerlsLlcs
lndlcaLlve of Lrlal ldenLlLy lnfluence Lhe efflcacy of LuAs.

Methods: Subgroup analysls was underLaken on Lrlals comparlng a LuA wlLh usual care ln people maklng LreaLmenL
declslons and lncluded ln Lhe 2011 Cochrane sysLemaLlc revlew. uaLa were exLracLed from all ellglble Lrlals on sLudy
characLerlsLlcs lndlcaLlve of Lrlal ldenLlLy by Lwo revlewers lndependenLly. 1wo subgroup analyses were performed wlLh
Lrlals belng caLegorlsed as 'volunLeerlsm' or 'paLlenL hood' on Lhe basls of:

1) wheLher parLlclpanLs lnlLlaLed Lhe paLhway of care LhaL led Lo Lhe declslon, and
2) wheLher any volunLeerlsm facLors were presenL. volunLeerlsm facLors were: some or all parLlclpanLs dld oot lnlLlaLe
Lhe paLhway of care, parLlclpanLs aLLended a research seLLlng, and parLlclpanLs had a face-Lo-face lnLeracLlon wlLh a
research pracLlLloner (whom Lhey would noL have consulLed lf Lhey were noL Laklng parL ln research).

Subgroups were compared wlLh respecL Lo seven ouLcomes: knowledge, accuraLe rlsk percepLlons, LoLal declslonal
confllcL, feellng lnformed, feellng clear abouL values, parLlclpaLlon ln declslon-maklng and cholce of surgery over Lhe
more conservaLlve opLlon. CuLcome daLa were derlved from Lhe Cochrane revlew.

kesu|ts: uaLa were avallable for all 32 ellglble Lrlals for aL leasL one subgroup analysls. ln Lhe comparlsons based on
wheLher parLlclpanLs lnlLlaLed Lhe paLhway of care LhaL led Lo Lhe declslon, for each ouLcome Lhere were slx Lo 13
paLlenL hood Lrlals and Lwo or Lhree volunLeerlsm Lrlals. ln Lhe comparlsons based on wheLher any volunLeerlsm facLors
were presenL, Lhere were one Lo slx paLlenL hood Lrlals and four Lo 10 volunLeerlsm Lrlals. lor all ouLcomes excepL
accuraLe rlsk percepLlons, pooled effecL slzes were hlgher ln Lrlals where all parLlclpanLs lnlLlaLed Lhe care paLhway
(paLlenLhood), buL only reached sLaLlsLlcal slgnlflcance for knowledge (p=0.03). When Lrlals were compared on Lhe basls
of volunLeerlsm facLors belng presenL, no conslsLenL paLLern of dlfference ln effecL was seen: pooled effecL slzes were
slgnlflcanLly hlgher ln paLlenLhood Lrlals for Lhe ouLcomes of knowledge (p=0.02) and parLlclpaLlon (p=0.02), buL
slgnlflcanLly hlgher ln volunLeerlsm Lrlals for Lhe ouLcomes of accuraLe rlsk percepLlons (p=0.03) and feellng lnformed
(0.04).

Conc|us|on: knowledge acqulslLlon assoclaLed wlLh LuA use appears Lo be greaLer ln Lrlals ln whlch parLlclpanLs ldenLlfy
Lhemselves as paLlenLs raLher Lhan volunLeers. 1here ls a Lrend Lowards greaLer LuA efflcacy for oLher ouLcomes ln
Lrlals ln whlch parLlclpanLs speclflcally lnlLlaLe Lhe paLhway of care. 1he lnfluence of oLher conLexLual facLors (seLLlng and
conLexL of pracLlLloner lnLeracLlons) relaLed Lo Lrlal ldenLlLy remalns uncerLaln. 1he flndlngs are llmlLed by poor
descrlpLlon of Lrlal conLexL by some sLudy auLhors and Lhe llkellhood of Lype 1 and 2 errors, confoundlng and oLher
effecL modlflers belng presenL. lurLher work ls needed Lo classlfy conLexL-relaLed facLors ln LuA Lrlals and undersLand
Lhelr lmpacL on LuA efflcacy.



1304

USING UALI1 IMkCVLMLN1 1C IMkCVL A1ILN1 LkLkILNCL AND kLDUCL kLADMISSICNS IN UkCLCG
SUkGLk A1ILN1S
!ane CarLhey
1
, Sandra PalleLL
1,*
, Cuy ?oung
1
, uarren 8arnes
1

1
Covernance, unlverslLy College London nPS PosplLals loundaLlon 1rusL, London, unlLed klngdom


Cb[ect|ves: 8asellne uCLP readmlsslon daLa showed an average 30-day readmlsslon raLe of 6 across Lhe 1rusL for Lhe
flnanclal year 2010-11. lor urology surgery paLlenLs Lhe readmlsslon raLe was 13.7. 1he ob[ecLlve was Lo LesL wheLher
uslng quallLy lmprovemenL meLhods from Lhe SLaLe-wlde AcLlon Lo 8educe 8e-PosplLallsaLlons (S1AA8) lnlLlaLlve, shown
Lo reduce readmlsslons ln uS hosplLals, would lmprove paLlenL experlence and reduce prevenLable readmlsslons
amongsL urology surgery paLlenLs.

Work was carrled ouL on Ward 110, a comblned orLhopaedlc, urology and gynaecology surgery ward. urology surgery
paLlenLs are ofLen referred Lo uCLP wlLh complex urologlcal condlLlons and oLher co-morbldlLles. Self-managemenL of
care ls a fundamenLal componenL of Lhe recovery process: aLlenLs are ofLen dlscharged wlLh lndwelllng caLheLers and
on several medlcaLlons. lollowlng surgery, paLlenLs are aL rlsk of compllcaLlons lncludlng urlnary LracL lnfecLlons, wound
lnfecLlons and dlslodged caLheLers.

Methods: A nlneLy day rapld lmprovemenL cycle comprlslng 'scannlng' 'focus' and 'LesLlng and reporLlng' phases was
used. 1he 'scannlng' phase lnvolved quanLlLaLlve and quallLaLlve analysls of urology readmlsslons uslng daLa from
communlLy dlscharge alerLs, lncldenLs, complalnLs, audlL and paLlenL lnLervlews. 1he focus sLage used a faclllLaLed
bralnsLormlng sesslon wlLh ward sLaff Lo ldenLlfy lnLervenLlons Lo LesL. lan uo SLudy AcL (uSA) LesLs of change were
used ln Lhe 'LesLlng and reporLlng' sLage Lo develop and lmplemenL lnLervenLlons from Lhe S1AA8 programme.

1hree lnLervenLlons were LesLed and lmplemenLed: a Leach back medlcaLlon proLoLype, slngle polnL of access Lelephone
number and paLlenL lnformaLlon Lrafflc llghL sheeLs. 1each back was carrled ouL by pharmaclsLs and/or a ward charge
nurse durlng Lhe ln-paLlenL sLay and forLy-elghL hours followlng hosplLal dlscharge.

kesu|ts: Slx monLhs followlng spread of Lhe S1AA8 lnLervenLlons, Lhe readmlsslon raLe reduced from a basellne of 13.7
Lo 12. ln Lhe cohorL of paLlenLs lnvolved ln uSA LesLs Lhe readmlsslon raLe was 10.

1hemaLlc analysls of a log book used by ward nurses Lo record ouL of hours Lelephone calls from paLlenLs seeklng experL
urology advlce was carrled ouL. 8esulLs showed LhaL Lhe slngle polnL of access Lelephone number prevenLs paLlenLs who
are experlenclng mlnor sympLoms belng readmlLLed Lo hosplLal unnecessarlly. lL also acLs as an early warnlng
mechanlsm, alerLlng ward sLaff Lo paLlenLs whose sympLoms warranL readmlsslon.

uSA feedback showed LhaL paLlenL lnformaLlon Lrafflc llghL sheeLs presenL lnformaLlon on sympLoms experlenced posL-
dlscharge and whaL acLlon paLlenLs should Lake ln an accesslble formaL. leedback from paLlenLs was unanlmously
poslLlve.

uSA LesLlng of Lhe Leach back proLocol showed LhaL paLlenLs and carers ofLen dld noL undersLand Lhelr medlcaLlons.
8esulLs supporLed Lhe lmporLance of uslng Leach back across Lhe dlscharge boundary (l.e. 48 hours posL-dlscharge).
Ward sLaff who belleved LhaL Lhey were good aL communlcaLlng lnformaLlon Lo paLlenLs and carers qulckly reallsed LhaL
Lhelr percepLlons were erroneous and adopLed Leach back.

Conc|us|on: nlneLy day rapld lmprovemenL cycles provlde a robusL framework Lo LesL lnLervenLlons Lo reduce
readmlsslons. aLlenLs and carers should be co-parLners ln quallLy lmprovemenL work. 1hey ldenLlfy weaknesses ln
healLhcare sysLems and soluLlons LhaL would lmprove paLlenL experlence and safeLy.

keferences: 8uLherford . eL al (2011) now-to ColJe. lmptovloq 1toosltloos ftom tbe nospltol to lost-Acote cote
5ettloqs to keJoce AvolJoble kebospltollsotloos. Cambrldge, MA: lPl



1316

1nL S1kLNG1n CI WCkkING 1CGL1nLk IN A S1kUC1UkLD & S AkCACn IN ILLMISn nCSI1ALS
vera ue 1royer
1,*
, ulrk 8amaekers
2, 3
, !ohan Pelllngs
4, 3

1
C&S AuvlSC8, lCu8C, 8russels,
2
Medlcal dlrecLor, ZnA, AnLwerp,
3
lederaLlon of Medlcal ulrecLors,
4
lCu8C, 8russels,
3
unlverslLy
PasselL, PasselL, 8elglum


Cb[ect|ves:
ueveloplng an lnLegraLed, comprehenslve and sysLemaLlc approach for C&S ln llemlsh hosplLals. 1hls approach was based on Lhree
plllars:
1. Lo sLlmulaLe llemlsh hosplLals Lo achleve an lnLernaLlonal hosplLal accredlLaLlon,
2. Lo deflne and lmplemenL a seL of relevanL quallLy lndlcaLors and
3. Lo develop a new model for governmenLal lnspecLlon ln llne wlLh Lhe prevlous elemenLs ln cooperaLlon and wlLh supporL of all
relevanL parLners (medlcal dlrecLors, CLC, professlonals, paLlenLs and governmenL).

Methods:
! 8uy ln: deflnlng an lnLegraLed and sysLemaLlc approach for C&S ln acuLe hosplLals. 1hls plan was dlscussed wlLh represenLaLlves
of all llemlsh hosplLals ln 2010 - 2011. 1hls approach was glven hlgh prlorlLy ln Lhe Lwo llemlsh hosplLal federaLlons. 1he C & S
plan was lmplemenLed ln 2012.
! SLrucLure: monLhly commlsslon 'C&S' and worklng group 'PosplLal AccredlLaLlon' for coherence and lnLeracLlon. 1he
commlsslon was lnsLalled ln SepLember 2010.
! CollaboraLlon agreemenL: worklng LogeLher wlLh Lhe llemlsh governmenL and Lhe llemlsh AssoclaLlon of Medlcal ulrecLors
(vvP) on Lhe developmenL of quallLy lndlcaLors (!une 2011) led Lo Lhe esLabllshmenL of a 'CuallLy lndlcaLor lorum' and several
worklng groups.
! ueveloplng parLnershlps wlLh all relevanL parLners ln promoLlng C&S llke Lhe llemlsh aLlenL laLform (v), sclenLlflc and
professlonal organlsaLlons, Lhe naLlonal lnsLlLuLe for PealLh and ulsablllLy lnsurance and federal sclenLlflc organlsaLlon (from
SepLember 2010 Llll now).
! ueveloplng process and ouLcome lndlcaLors: ln 3 domalns (orLhopaedlcs, paedlaLrlcs, cardlology, breasL cancer and hosplLal-
wlde lssues). Lach worklng group was led by a medlcal dlrecLor. 1he quallLy lndlcaLors were presenLed ln Lhe publlc domaln ln
november 2012.
! ueveloplng a new lnspecLlon model by Lhe llemlsh governmenL: ln llne wlLh Lhe prevlous elemenLs and ln cooperaLlon wlLh Lhe
professlonals (uecember 2012).

kesu|ts:
! 37 hosplLals (ouL of 63) are preparlng Lo achleve an lnLernaLlonal accredlLaLlon (by an organlsaLlon accredlLed by lSCua) before
Lhe end of 2017.
! A seL of 33 quallLy lndlcaLors (process and ouLcome) are valldaLed and publlshed on Lhe web of Lhe llemlsh CovernmenL. 1hey
and wlll be lmplemenLed by Lhe llemlsh hosplLals by Lhe summer of 2013. AddlLlonal Lo a general anonymous benchmarklng,
hosplLals wlll publlsh resulLs on Lhese lndlcaLors on Lhelr own webslLe.
! 1he lnvolvemenL of paLlenLs was essenLlal for Lhe success of Lhls pro[ecL. 1he v consLrucLed an lnsLrumenL Lo ob[ecLlfy and
measure paLlenL experlences LhaL wlll be lmplemenLed ln all hosplLals by !une 2013.
! A new hosplLal lnspecLlon model was developed and lmplemenLed, ln llne wlLh Lhe prevlous elemenLs. Lvery 3 years, hosplLals
wlll be vlslLed Lo screen Lhelr lmplemenLed (hosplLal-wlde) quallLy sysLem and Lhelr procedures and sLrucLures Lo guaranLee a
culLure of conLlnuous quallLy lmprovemenL (sysLem lnspecLlon). Lvery year, hosplLals wlll be lnspecLed for one hosplLal-wlde
care paLh (lnspecLlon of compllancy). 1he crlLerla and sLandards (legal, guldellnes, evldence based) are deflned ln cooperaLlon
wlLh Lhe professlonals and are cruclal for Lhe quallLy of care. 1he flrsL care paLh, sLarLed ln !anuary 2013, ls Lhe care paLh of a
surglcal paLlenL.
! A slmllar quallLy lndlcaLor pro[ecL for menLal healLh care has been lnlLlaLed.

Conc|us|on:
1he sLrengLh of a coherenL C&S approach, an lnLenslve cooperaLlon beLween all relevanL parLners ln healLhcare, Lhe openness of Lhls
pro[ecL for all sLakeholders and a sLrong cllnlcal leadershlp creaLed many advanLages and opporLunlLles Lo guaranLee subsLanLlal
C&S progress ln llemlsh hosplLals.


1317

ASSLSSING A1ILN1]IAMIL LkLC1A1ICNS 1nkCUGn A1ILN1 ILLD8ACkS ICk 1nL IMkCVLMLN1 IN UALI1 CI
A1ILN1 CAkL AND SAIL1: SCLNAkIC A1 AC1kLC
ChlLal naresh
1,*
, rashanL C. 8haL
1

1
Medlcal AdmlnlsLraLlon, AcLrec (Advanced CenLre for 1reaLmenL 8esearch LducaLlon ln Cancer) 1aLa Memorlal CenLre,
navl Mumba, lndla


Cb[ect|ves: 1o assess Lhe paLlenL feedbacks and derlve lnslghL lnLo paLlenL expecLaLlons for beLLer lmprovemenL ln
quallLy of paLlenL care
1o suggesL beLLer measures uslng paLlenL/famlly collaboraLlon for lmprovemenL of quallLy of paLlenL care and safeLy aL
AC18LC

Methods: SLrucLured aLlenL feedback forms sLraLeglcally placed across AC18LC were assessed for Lhe feedbacks
volunLarlly recelved from paLlenL or Lhelr relaLlves. AbouL 660 feedbacks recelved durlng Lhe year !anuary 2011 Lo
uecember 2012 (Lwo years) were sub[ecLed Lo sysLemaLlc assessmenL. leedbacks from anonymous paLlenLs were
excluded as no clue could be found on Lhelr Lype of hosplLallsaLlon wheLher lnpaLlenL/ouLpaLlenL/surglcal
lnLervenLlon/chemoLherapy LreaLmenL/radlaLlon LreaLmenL eLc. AbouL 46 feedbacks (96.97) were excluded leavlng
behlnd 614 feedbacks Lo be analysed. aLlenL prlvacy and confldenLlallLy was malnLalned LhroughouL assessmenL. 1he
advanLage of Lhe recelpL of feedbacks was LhaL Lhe paLlenLs from key uMC's (ulsease ManagemenL Croups) for Lhe
organlsaLlon were covered.

8egresslon analysls was conducLed wlLh paLlenL saLlsfacLlon as a dependanL varlable and care assessed by docLors,
nurses and auxlllary sLaff as lmpacL facLor. 1he daLa was analysed for mulLlvarlaLe normallLy, skewness, kurLosls, and
ouLllers uslng sLaLlsLlcal Lool l.e. sofLware- SLaLlsLlcal ackage for Lhe Soclal Sclences (SSS).

kesu|ts: 1hus, Lhe assessmenL of paLlenL /famlly feedbacks gave a mlxed response for Lhe varlous varlables affecLlng
paLlenL care. Accordlngly, hlghesL poslLlve response (97) was obLalned for medlcal care as AC18LC ls a sLaLe of Lhe arL
8&u saLelllLe of 1aLa Memorlal CenLre (1MC) wlLh Lhe mandaLe Lo funcLlon as a naLlonal cenLre for LreaLmenL, research
and educaLlon ln cancer. negaLlve response were obLalned for shorLage of beds (38), delays ln surgerles (64),
admlsslon process (44). AddlLlonally, Lhe paLlenL feedbacks gave us more Lhan abouL 100 dlfferenL suggesLlons LhaL we
conslder as paLlenL or famlly expecLaLlons from AC18LC. 1hls ls a LlLanlc Lrlumph as Lhls could have never been achleved
even afLer rlgorous lnLernal audlLs by Lhe organlsaLlon.

Conc|us|on: 1hus, Lhe sysLemaLlc sLudy has helped Lo galn a Lhorough lnslghL lnLo paLlenL expecLaLlons for LreaLmenL and
paLlenL care aL AC18LC. MosL of Lhe concerns have been addressed by escalaLlng Lhe lssues Lo Lhe concerned auLhorlLy.
Powever, Lhe concerns regardlng delay ln surgerles, bed shorLages eLc. requlre subsLanLlal expanslon of Lhe organlsaLlon
boLh verLlcally and horlzonLally ln Lerms of lnfrasLrucLure and sLaff.

Powever, more and more quallLaLlve and quanLlLaLlve approaches have Lo be made, Lo acLlvely engage paLlenLs and
Lhelr famllles for beLLer coproducLlon ln lmprovemenL of paLlenL care. 8evlew of abouL 14 llLeraLures on paLlenL
saLlsfacLlon reveal Lhe use of SL8vCuAL and SL8vL8l scales Lo measure Lhe quallLy of servlce Lo cusLomers (paLlenLs
for healLhcare unlLs). Pence, Lhe fuLure goal of AC18LC shall be Lo survey paLlenL saLlsfacLlon and expecLaLlons uslng one
or boLh of Lhe above scales for quallLy lmprovemenL of paLlenL care and safeLy aL AC18LC.




132S

kLVLN1ICN CI CnCkING INCIDLN1 IN SCnIA1kIC WAkD 8 USING kCC1 CAUSL ANALSIS ML1nCD IN 1AIWAN
Chao Puang
1,*
, Shu-Pua ko
1

1
sychlaLry, Wel-Cong Memorlal PosplLal, 1oufen, 1alwan, 1oufen, 1alwan


Cb[ect|ves: Choklng ls a llfe-LhreaLenlng and noL lnfrequenL occurrence ln psychlaLrlc wards. 1hls sLudy aLLempLed Lo
reduce choklng lncldenLs and deaLhs among psychlaLrlc lnpaLlenLs by ldenLlfylng Lhe causes of choklng lncldenL Lhrough
Lhe uslng of 8ooL Cause Analysls (8CA) meLhod.

Methods: A mulLldlsclpllnary Leam was organlsed Lo perform Lhe 8CA. lollowlng Lhe 8CA proLocol, we begun wlLh daLa
collecLlon and reconsLrucLlon of Lhe choklng lncldenL Lhrough record revlew and parLlclpanL lnLervlews. 1he
mulLldlsclpllnary Leam Lhen analysed Lhe sequence of evenLs leadlng Lo Lhe lncldenL wlLh Lhe goals of ldenLlfylng Lhe
causes. llnally, we ldenLlfled 3 rooL causes of choklng:

1) sLaff ls ln lack of knowledge abouL choklng,
2) dld noL make good use of Leam resources, Lhe Llmlng of geL supporL ls noL famlllar, and
3) lnadequaLe food managemenL scheme.

Accordlng Lo Lhe rooL causes, 6 lnLervenLlons were lmplanLed:
1) rovlde sLaff choklng Lralnlng
2) 8evlsed Lhe sLandard operaLlng proLocol (SC), Lhe choklng rlsk assessmenL form, and Lhe choklng cllnlcal care
procedures.
3) rovlde Lhe paLlenL wlLh choklng educaLlon.
4) romoLlon and dlscusslon abouL choklng prevenLlon ln paLlenLs' group sesslons.
3) lmplemenLaLlon of a new food managemenL scheme: assess Lhe condlLlon of paLlenL feedlng, snacks managemenL
program, and reorganlsaLlon of food shopplng Llme.
6) Arrange monLhly case dlscusslon meeLlng: use of Lhe medlcal Leam resource managemenL pracLlces (18M) Lo
enhance Lhe healLh care Leam emphasls on Lhe lssues of choklng.

kesu|ts: 8efore Lhe lnLervenLlons, Lhe lncldence of food choklng ln our ward (Apr 2012) was 3(0.28) wlLh 1 deaLh. AfLer
Lhe lnLervenLlons, Lhe lncldence of food choklng was down Lo 0(0) (May 2012- uec 2012).

Conc|us|on: 1he ouLcome lndlcaLors lmproved slgnlflcanLly, lndlcaLe LhaL 8CA ls an effecLlve meLhod Lo solve Lhe choklng
problem ln our psychlaLrlc ward. 1he mulLldlsclpllnary Leam make use of 8CA ln cllnlcal pracLlces can be useful ln
lmprove cllnlcal care quallLy and creaLe a paLlenL safeLy envlronmenL.



1328

IMkCVING A1ILN1 AND S1AII SA1ISIAC1ICN DUkING SUkGICAL DA-CAkL
Llnda Wauben
1,*
, AnneL[e Cuedon
1
, ulrk de korne
2
, !ohn van den uobbelsLeen
1

1
ueparLmenL of 8lo-Mechanlcal Lnglneerlng, uelfL unlverslLy of 1echnology, uelfL,
2
8oLLerdam Lye PosplLal, 8oLLerdam, neLherlands


Cb[ect|ves: 1o lmprove paLlenL and sLaff saLlsfacLlon and Lo reduce walLlng Llmes durlng Lhe surglcal Lra[ecLory by provldlng real-
Llme progress lnformaLlon.

Methods: Long walLlng Llmes and lacklng progress lnformaLlon decrease paLlenL saLlsfacLlon and may cause anxleLy and sLress for
paLlenLs and Lhelr famlly. MosLly nurses are expecLed Lo provlde Lhls progress lnformaLlon, buL wlLh lncreaslng workload Lhey do noL
always have Lhe Llme Lo do so. Moreover, Lhese lnqulres also dlsLracL Lhem from Lhelr nurslng Lasks.

SLudy deslgn:
1. AdulL paLlenLs admlLLed for surglcal day-care were Lracked durlng Lhelr sLay ln Lhe 8oLLerdam Lye PosplLal uslng acLlve 8llu-
Lechnology. 1he Lags (aLLached Lo Lhe paLlenL's wrlsLband) were Lracked by readers, whlch were placed aL 8 locaLlons ln Lhe
operaLlng room complex: reglsLraLlon desk, walLlng room, lnLake room, Lwo rooms aL Lhe ward, holdlng, C8 corrldor, and
recovery. LengLh of sLay and walLlng Llmes per room/phase were recorded and means, sLandard devlaLlons, and mln/max were
calculaLed. uuraLlon of acLlons was obLalned Lhrough observaLlons and manual Llme recordlng.
2. 8ased on sLrucLured lnLervlews conducLed wlLh paLlenLs, famlly members and sLaff members, Lwo web-based appllcaLlons
provldlng real-Llme progress lnformaLlon were deslgned, lmplemenLed and evaluaLed.

kesu|ts: WalLlng Llmes: aLlenLs were Lracked beLween 7 AugusL and 19 CcLober 2012 (32 weekdays). 1027 paLlenLs recelved a Lag
and 663 paLlenLs (=63) were lncluded ln Lhe analysls. 364 paLlenLs were excluded, malnly because Lhe operaLlng room reader dld
noL deLecL Lhe paLlenL (n=134) or Lhe research proLocol was noL followed (n=183).

1he resulLs showed LhaL 64 of paLlenLs (n=423) arrlved early (Mean 0h20, S1uLv 0h24, Max. 4h10) and 33 of paLlenLs (n=231)
arrlved laLe (Mean 0h20, S1uLv 0h20, Max. 1h33). 1he Lable shows Lhe duraLlon of acLlons and walLlng and recovery Llmes per
room/phase.

koom ] phase Durat|on act|ons [h:mm] 1ota| t|me [h:mm]
nurslng ward lnLake 0h10, Change cloLhes 0h06, 1ransporL 0h02 >1C1AL 0h18 Wa|t|ng: Mean 1h21, S1uLv 0h37,
Max 3h18
Poldlng Pandover 0h01, reparaLlon 0h10 > 1C1AL 0h11 Wa|t|ng: Mean 0h29, S1uLv 0h20,
Max 3h22
CperaLlng room Mean 0h33, S1uLv 0h32, Mln-Max 0h06-3h39 /
8ecovery >1C1AL 0h12 (lncl. walLlng for recovery from anaesLhesla) kecovery: Mean 0h33, S1uLv 0h33,
Max 7h34
nurslng ward 1ransporL 0h02, AcLlons 0h03, Change cloLhes 0h07, CuLLake 0h06
>1C1AL 0h12
kecovery: Mean 1h36, S1uLv 1h13,
Max 9h28

AppllcaLlon: 18 (of 30) paLlenLs would llke progress lnformaLlon and 16 (of 23) sLaff members would llke lnslghL ln Lhe progress and
lLs duraLlon ln oLher deparLmenLs. 1wo web-based appllcaLlons and lnLerfaces were deslgned, boLh Lallored Lo Lhe paLlenLs' and
nurses' wlshes and needs. 1he appllcaLlons presenL 'real Llme' progress lnformaLlon on seven phases, reglsLered, admlLLed, holdlng,
operaLlng room, recovery, resL, and dlsmlssed. 1he paLlenL's lnLerface shows Lhe currenL phase ln whlch Lhe paLlenL ls and upcomlng
phases before Lhe paLlenL can go home (llke a subway map). 1he nurses' lnLerface shows paLlenLs cards (sLaLlng Lhe paLlenL's name,
Llme enLerlng a speclflc phase, and Lype of anaesLhesla) ln each of Lhe seven phases. All paLlenLs (n=20) and all nurses (n=13) llked
Lhe appllcaLlons provldlng Lhem wlLh real-Llme locaLlon and progress lnformaLlon.

Conc|us|on: Cn average 44-30 of Llme ls walLlng Llme and walLlng and recovery Llmes are relaLlvely long compared Lo Lhe duraLlon
of Lhe acLlons performed (walLlng: 2.6-4.3 x and recovery 2.8-8.0 x duraLlon of acLlons). 1he paLlenL progress lnformaLlon sysLem
based on 8llu Lechnology provldes nurses and paLlenLs wlLh real-Llme lnformaLlon and provldes Lransparency ln Lhe enLlre surglcal
care Lra[ecLory.

1334

DLVLLCING A IkAMLWCkk 1C LVALUA1L nLAL1n SLkVICLS ACCkLDI1A1ICN
vlrglnla Mumford
1
, uavld Creenfleld
1,*
, kevln lorde
2
, !effrey 8ralLhwalLe
1

1
AusLrallan lnsLlLuLe of PealLh lnnovaLlon,
2
School of ubllc PealLh and CommunlLy Medlclne, unlverslLy of new SouLh Wales,
Sydney, AusLralla


Cb[ect|ves: PealLh servlces accredlLaLlon ls belng lmplemenLed wlLhouL a clear undersLandlng of Lhe cosLs and beneflLs lnvolved. We
lack sulLable economlc mechanlsms Lo evaluaLe and revlse such programs. 1hls sLudy reporLs on Lhe developmenL of an economlc
framework Lo evaluaLe acuLe healLh care accredlLaLlon ln AusLralla, wlLh lmpllcaLlons lnLernaLlonally.
1

Methods: SLep one: we conducLed a revlew of Lhe llLeraLure for economlc and evaluaLlon frameworks. SLep Lwo: we convened an
experL panel wlLh experLlse across: accredlLaLlon meLhodologles, healLh economlcs and healLh servlces accredlLaLlon research. 1hls
panel revlewed ldenLlfled llLeraLures, deLermlnlng Lhe mosL approprlaLe meLhodology, and proposlng an economlc evaluaLlon
framework.

kesu|ts: no exLanL sLudy or LheoreLlcal framework for Lhe economlc evaluaLlon of accredlLaLlon programs was ldenLlfled. 1he panel
deemed a cosL beneflL analysls (C8A) framework Lhe mosL approprlaLe Lool for evaluaLlng accredlLaLlon based on Lhe need for a
common moneLary denomlnaLor and governmenL guldellnes for regulaLory approval processes. A purpose deslgned economlc
framework was developed comprlslng flve dlscreLe acLlvlLles:

1) uescrlbe Scope and ob[ecLlves,
2) ldenLlfy cosLs and beneflLs,
3) CuanLlfy cosLs and beneflLs,
4) CalculaLe neL soclal beneflLs (nS8), and
3) SenslLlvlLy analysls (Lhe SlCnS C8A framework).
1


1he flrsL acLlvlLy lnvolves: llLeraLure revlews, analysls of acuLe care accredlLaLlon resulLs, and sLakeholder ldenLlflcaLlon. CosLs wlll be
ldenLlfled and quanLlfled uslng a survey valldaLed by an experL panel comprlslng: accredlLaLlon agency sLaff and surveyors, healLh
quallLy consulLanLs, governmenL healLh pollcy represenLaLlves, and healLh servlce researchers.

8eneflLs wlll be ldenLlfled uslng a purpose deslgned lndlcaLor AssessmenL 1ool Lo assess sulLable accredlLaLlon ouLcome and process
lndlcaLors across Lhe Len mandaLory accredlLaLlon sLandards. 1he Lool lncludes Lhe research, accuracy, proxlmlLy, and adverse effecLs
accounLablllLy crlLerla developed by Chassln and colleagues.
2
We have also lncluded a speclflclLy measure Lo separaLe Lhe effecLs of
accredlLaLlon from relaLed quallLy and safeLy lnLervenLlons. 1he experL panel wlll assess and selecL Lhe lndlcaLors for Lhe sLudy. 1he
Lype of lndlcaLors chosen wlll deLermlne Lhe approprlaLe evaluaLlon Lechnlques for moneLlslng Lhe beneflLs.

AccredlLaLlon cosLs and beneflLs occur aL dlfferenL Llmes and need Lo be ad[usLed uslng an approprlaLe dlscounL raLe. We calculaLe
Lhe neL-soclal-beneflL Lo derlve an absoluLe measure of wheLher Lhe dlscounLed (neL) beneflLs are greaLer Lhan Lhe dlscounLed (neL)
cosLs. A beneflLs cosL raLlo ls also calculaLed by dlvldlng Lhe neL beneflLs by neL cosLs Lo deLermlne an effecLlve reLurn on Lhe cosLs. A
senslLlvlLy analysls ls Lhe flnal acLlvlLy, and ls essenLlal Lo measure Lhe lmpacL of changes ln assumpLlons and varlables on Lhe ouLpuL
from our SlCnS framework.

Conc|us|on: 1he SlCnS C8A framework wlll enable sysLemaLlc evaluaLlon of healLh servlces accredlLaLlon programs. 1he flexlblllLy
lnherenL ln Lhe framework makes lL appllcable lnLernaLlonally for boLh exlsLlng and developlng accredlLaLlon programs.

keferences:
1. Mumford v, Creenfleld u, Plnchcllff 8, lorde k, WesLbrook !, 8ralLhwalLe !. Lconomlc evaluaLlon of AusLrallan acuLe care
accredlLaLlon (ACC8Lul1-C8A [AcuLe]): sLudy proLocol for a mlxed-meLhod research pro[ecL. 8MI Opeo (lo ptess).
2. Chassln M8, Loeb !M, SchmalLz S, WachLer 8M. AccounLablllLy Measures uslng MeasuremenL Lo romoLe CuallLy
lmprovemenL. N oql I MeJ 2010,363(7):683-88.


1336

INVLS1IGA1ING 1nL CCkkLLA1ICN 8L1WLLN ULMCNAk kLnA8ILI1A1ICN LkLkCISLS AND VLN1ILA1Ck USAGL
AMCNG A1ILN1S IN IN1LNSIVL CAkL WAkDS
Shou-na Wong
1,*
, 1sal-wen Llu
1
, Pslng-Chlh Chlang
1

1
lnLenslve Care unlL, lar LasLern Memorlal PosplLal, new 1alpel ClLy 220, 1alwan


Cb[ect|ves: 1o lnvesLlgaLe Lhe correlaLlon beLween Lhe lmplemenLaLlon of pulmonary rehablllLaLlon exerclses ln Lhe
lnLenslve care unlLs of a hosplLal and Lhe success of weanlng paLlenLs off of venLllaLors.

Methods: AdopL a descrlpLlve correlaLlve research deslgn aL a medlcal cenLre's lnLenslve care unlL ln norLhern 1alwan
beLween Lhe 1
sL
of uecember 2011 and Lhe 30
Lh
of Aprll 2012. 1he research sub[ecLs were 236 paLlenLs who had used
venLllaLors for more Lhan 72 hours upon belng hosplLallsed ln Lhe lnLenslve care unlL, wlLh sLable slgns of llfe and
hemodynamlcs. Convenlence sampllng, use of sLrucLured quesLlonnalres and fleld examlnaLlon ls used Lo collecL daLa,
ldenLlfy and analyse relevanL facLors. 1hese lnclude a lack of effecLlve cooperaLlon wlLhln Lhe medlcal Leam, lack of
confldence of undersLandlng on pulmonary rehablllLaLlon by nurses, lack of relevanL educaLlonal courses, lack of a
sLandard procedure of pulmonary rehablllLaLlon exerclses and lack of lmplanLlng Lools eLc. lnLervenlng measures lnclude:
1. lormulaLe a pulmonary rehablllLaLlon procedure", 2. Crganlse relevanL educaLlonal courses for nurses, 3. ueslgn
approprlaLe Lools for paLlenLs Lo carry ouL pulmonary rehablllLaLlon, 4. roduce a ulmonary 8ehablllLaLlon Lxerclse"
handbook, 3. lormulaLe a ulmonary 8ehablllLaLlon exerclses evaluaLlon form" and ulmonary 8ehablllLaLlon
exerclses recordlng form", 6. Pold regular dlscusslons wlLh LheraplsLs on approprlaLe pulmonary rehablllLaLlon exerclses
for paLlenLs.

kesu|ts: 1he lmplemenLaLlon raLe of pulmonary rehablllLaLlon exerclses ln lnLenslve care unlLs beLween Lhe 1
sL
of
uecember 2011 and Lhe 30
Lh
of Aprll 2012 lncreased from 27 Lo 96, Lhe success raLe for weanlng paLlenLs off of
venLllaLors lncreased from 41.7 Lo 31.3.

Conc|us|on: laclllLaLlng Lhe cooperaLlve relaLlonshlp beLween docLors, LheraplsLs and nurses ln Lhe process of
lmplemenLlng pulmonary rehablllLaLlon exerclses, as well as an evaluaLlon of Lhe paLlenLs' needs by an lnLerdlsclpllnary
Leam ln order Lo provlde approprlaLe rehablllLaLlon resulLed ln Lhe lmplemenLaLlon raLe Lo lncrease from 27 Lo 96
beLween Lhe 1
sL
of uecember 2011 and Lhe 30
Lh
of Aprll 2012, and Lhe success raLe of paLlenLs noL relylng on
endoLracheal Lubes lncreased from 41.7 Lo 31.3. lamlly members are ofLen worrled durlng Lhe process of pulmonary
rehablllLaLlon LhaL exerclslng would resulL ln changes Lo Lhe paLlenLs' condlLlons or lead Lo a depleLlon of physlcal
sLrengLh, and would Lherefore obsLrucL Lhe medlcal Leam from performlng rehablllLaLlon. lL ls Lhus essenLlal for Lhe Leam
Lo explaln Lhe advanLages of pulmonary rehablllLaLlon exerclses. ln summary, lL ls recommended LhaL vldeo cllps relaLed
Lo pulmonary rehablllLaLlon exerclses be made and shown regularly ln order Lo lncrease lnformaLlon Lransparency and
reduce Lhe doubLs of famlly members Lowards Lhe exerclses, whlch would also help Lo faclllLaLe cooperaLlon beLween
famlly members and Lhe medlcal Leam.

1he safeLy of paLlenLs ls Lhe ob[ecLlve of hosplLal managemenL and organlsaLlon efforLs. MosL paLlenLs are conflned Lo
Lhelr beds due Lo Lhe severlLy of medlcal condlLlons or plpellne safeLy, resulLlng ln Lhe deLerloraLlon of Lhelr muscle
sLrengLh, whlch can lead Lo exLended perlods of resplraLory Lralnlng ln Lhe fuLure. 1he resulLs of Lhls research show LhaL
early lnLervenLlon wlLh pulmonary rehablllLaLlon exerclses can lncrease Lhe success raLes for weanlng paLlenLs off of
venLllaLors, reduclng hosplLallsaLlon Llmes and hosplLal expenses.

1338

1nL LIILC1 CI NLWL-LS1A8LISnLD "GLNLkAL kINCILLS CI LIUID MLDICINLS" IN kCkLA
kyoungah Pan
1,*
, Ah-young !ung
1
, 8oungsoo klm
1
, Sooyon klm
1

1
Pl8A, Seoul, korea, 8epubllc Cf


Cb[ecLlves: 1he PealLh lnsurance 8evlew and AssessmenL Servlce (herelnafLer Pl8A) lald down Lhe general prlnclples of
llquld medlclnes and has applled Lhem slnce CcLober 2011. 1hey were esLabllshed Lo permlL prescrlpLlon of llquld
medlclnes for lnsurance paymenL only lf paLlenLs couldn'L Lake oral solld dosage form. 1hls sLudy alms Lo lnvesLlgaLe and
analyse Lhe effecLlveness and slde effecLs of Lhe prlnclples on Lhe basls of medlcal grounds and cosL-effecLlveness.

MeLhods: ln Lhls research, we analysed prescrlpLlon sLaLus of 33 lngredlenLs whlch had more Lhan Lwo forms, boLh llquld
and LableL/capsule. 1o lnvesLlgaLe Lhe effecL of general prlnclples, we compared prescrlpLlon sLaLus before and afLer
effecLuaLlon of Lhe prlnclples by sLaLlsLlcal daLa base from Pl8A.

8esulLs: lor slx monLhs afLer foundlng Lhe new pollcy, Lhe LoLal cosL of drugs, ln whlch Lhe pollcy was applled Lo,
decreased from 124.7 bllllon won Lo 89.2 bllllon won, accounLlng for 28. ln addlLlon, Lhe cosLs of drugs Laken by
paLlenLs aged 12 and above decreased by 90, and Lhe raLe of usage of Lhe same age group decreased from 23 Lo 4.
1he acLual cosL-beneflLs by healLh lnsurance clalms daLa was calculaLed aL 33 bllllon won per year. Meanwhlle, conLrary
Lo expecLaLlons LhaL Lhere wlll be decreased usage of llquld medlclnes and lncrease of LableL/capsule of Lhe same
lngredlenL, we found cases of some llquld medlclnes shlfLed Lo oLher drugs whlch had same effecL and could be
prescrlbed for lnsurance paymenL.

Concluslon: As Lhe LoLal cosL of llquld medlclnes (menLloned above) as well as Lhe prescrlpLlon raLe of paLlenLs aged 12
and above have decreased, we were able Lo ldenLlfy Lhe poslLlve effecL of newly esLabllshed prlnclples. And when
esLabllshlng naLlonal medlcal lnsurance relmbursemenL pollcy of drugs whlch have Lhe same effecL, we would have Lo
apply Lhe same sLandard Lo block unlnLended shlfLlng of prescrlpLlon. 1he resulL of Lhls sLudy could be helpful for
esLabllshlng new healLhcare pollcy. ln Lhe fuLure, monlLorlng for Lhe effecLs of newly creaLed prlnclples of anLl-dlabeLlc
or probloLlcs should be needed.

1348

A SS1LM 1C LNSUkL SAIL IN1kCDUC1ICN CI NLW 1LCnNCLCG IN A CLUS1Lk CI nCSI1ALS
Alan k.W. So
1
, !ohn Wong
2
, o 1ong Chul
3
, Plng ?u So
3,*

1
aedlaLrlcs,
2
Surgery,
3
AnaesLhesla & lnLenslve Care, rlnce of Wales PosplLal, ShaLln, n.1., Pong kong


Cb[ect|ves: lnLroducLlon of new Lechnology lnLo a hosplLal ls assoclaLed wlLh rlsks, whlch may be known or unknown aL Lhe Llme of
lnLroducLlon. Some rlsks may noL be known Lo Lhe parLy who lnLroduces Lhe Lechnology buL known Lo oLher sLaff of Lhe hosplLal.
Such rlsk can be mlnlmlsed by adequaLe analysls and preparaLlon. Whlle Lhls ls easy Lo undersLand, Lhe Lask ls dlfflculL because lL ls
noL easy Lo deflne whaL ls new Lechnology, and lL ls dlfflculL Lo ldenLlfy sLaff who know enough of Lhe Lechnology Lo make relevanL
declslons. ln Lhe n1L ClusLer, we declded Lo dlssoclaLe Lhe evaluaLlon of Lhe Lechnology and Lhe lnLroducLlon procedures and focus
on Lhe laLLer uslng a Leam peer revlew process slmllar Lo LhaL used ln research eLhlcs commlLLees.

Methods:
1. LsLabllshmenL of governance body.
1he Lask ls Laken up by Lhe ClusLer 1echnology Advlsory CommlLLee (C1AC) whlch reporLs dlrecLly Lo Lop execuLlves of Lhe clusLer.

2. LsLabllshmenL of pollcy and peer revlew procedure.
1he scope of Lechnology Lo be lncluded ls deflned by Lhe followlng crlLerla:
a) Are Lhere new rlsks Lo Lhe paLlenL?
b) ls slgnlflcanL Lralnlng of sLaff requlred?
c) ls preparaLlon of oLher parLles requlred?

1he sysLem was plloLed ln Lhe operaLlng sulLe of Lhe largesL hosplLal wlLh Lhe clusLer Lo LesL Lhe concepL. A peer revlew by members
of C1AC whlch composed of dlfferenL cllnlcal and admlnlsLraLlve sLaff.

3. romoLlon
AppllcaLlon relles on volunLary reporLlng and lL ls essenLlal LhaL all lnvolved deparLmenLs undersLand Lhe lmporLance of Lhe sysLem
and Lhe beneflL Lhey can obLaln from lL. 1he Leam presenLs Lhe ldea & Lhe proposed procedures Lo Lhe CperaLlon 1heaLre
CommlLLee so LhaL all Lhe sLake holders ln Lhe operaLlon LheaLre undersLand & provlde lnpuL before Lhe plloL.

4. 8evlew
lnformaLlon of ouLcomes afLer Lhe lnLroducLlon of new Lechnologles was revlewed ln C1AC.
8evlew meeLlngs were organlsed wlLh lnvolved deparLmenLs Lo collecL feedbacks for furLher flne-Lunlng of Lhe procedures.

8evlew of Lhe plloL & feedbacks from sLake holders were Lhen presenLed Lo C1AC & ClusLer managemenL for Lhe readlness for rolllng
ouL Lo oLher operaLlon LheaLres wlLhln Lhe clusLer.

kesu|ts: lrom May 2011 Lo nov 2012, 18 procedures applled whlch lnvolved 8 subspeclalLles. AppllcaLlons lncluded new dlagnosLlc
or LherapeuLlc devlce, new approach or Lechnlque ln surglcal operaLlons. 17/18 appllcaLlons were endorsed by Lhe C1AC wlLhln 2
weeks (some appllcaLlons requlred clarlflcaLlon of lnformaLlon elecLronlcally). 1here was 1 appllcaLlon noL belng preceded because lL
was under Lhe scope of PAMSln. 1he lnformaLlon provlded ln Lhe earller appllcaLlons was someLlmes lnadequaLe & need furLher
clarlflcaLlon. Powever, Lhe condlLlon lmproved afLer Lhe explanaLlon durlng Lhe 8oad shows". ln Lhe revlew meeLlngs, sLakeholders
agreed LhaL Lhe appllcaLlon procedures and Lhe lead Llme were accepLable. And Lhelr accepLance was reflecLed by Lhe lncreaslng
appllcaLlons ln Lhe laLer phase of Lhe plloL.

AfLer revlewlng Lhe plloL, Lhe ClusLer managemenL & C1AC consldered Lhls procedure ls maLure enough Lo roll ouL Lo oLher operaLlon
LheaLres wlLhln Lhe clusLers.

Conc|us|on: WlLhln a perlod of 18 monLhs, a meLhod Lo ensure safe lnLroducLlon of Lechnology ls plloLed ln Lhe operaLlng sulLe of a
large Leachlng hosplLal and galned accepLance. lL ls evaluaLed, lmproved and ready for roll ouL Lo oLher areas wlLhln Lhe clusLer.

13S3

IN1LkkU1LD 1IML-SLkILS ANALSIS CI LCNDCN S1kCkL SLkVICLS kL-CkGANISA1ICN
8oxana Alexandrescu
1
, !ohn Lee
1
, Alex 8oLLle
1
, aul Aylln
1,*

1
lmperlal College London, London, unlLed klngdom


Cb[ect|ves: 1o assess wheLher Lhe lmplemenLaLlon of elghL Pyper AcuLe SLroke unlLs (PASus) ln London beLween
lebruary and !uly 2010 was assoclaLed wlLh an lmprovemenL ln Lhe quallLy and safeLy of care recelved by paLlenLs wlLh
sLroke.

Methods: lnLerrupLed Llme serles sLudy of paLlenLs admlLLed Lo hosplLal wlLh sLroke uslng naLlonal hosplLal
admlnlsLraLlve daLa from Aprll 2006 Lo March 2012. Maln ouLcome measures were braln scan on Lhe day of admlsslon,
Lhrombolysls LreaLmenL, asplraLlon pneumonla, seven-day ln-hosplLal deaLh, dlscharge Lo usual place of resldence and
LhlrLy-day emergency readmlsslon
1
.

kesu|ts: 1he effecL of Lhe pollcy ln London was slgnlflcanL over 4 ouL of 6 lndlcaLors. 8efore Lhe lmplemenLaLlon of Lhe
PASus pollcy ln London, Lhe scan and Lhrombolysls raLes for sLroke paLlenLs were lncreaslng by 3.3 and respecLlvely
22.9 per quarLer of year (ad[usLed odds raLlo 1.03(1.04-1.06) and 1.22(1.18-1.27)). AfLer lmplemenLaLlon of Lhe pollcy,
Lhere was a slgnlflcanL change ln Lhe Llme Lrend compared wlLh pre-exlsLlng Lrend of -3.8 and respecLlvely -18.3 per
quarLer of year (ad[usLed odds raLlo 0.96(0.93-0.97) and 0.81(0.78-0.83)). Powever, boLh scan and Lhrombolysls raLes
conLlnue Lo lncrease by 1.3 and respecLlvely 4.6 per quarLer of year afLer Lhe lnLroducLlon of Lhe pollcy. 1he pollcy
was slgnlflcanL assoclaLed wlLh a 4.7 reducLlon of scan raLes and a 31.8 lncrease ln Lhrombolysls raLes (ad[usLed odds
raLlo 0.93(0.92-0.99) and 1.31(1.07-1.62)). Among Lhe ouLcome lndlcaLors, Lhe pollcy was slgnlflcanL assoclaLed wlLh a
14.2 reducLlon of seven-day ln-hosplLal deaLh raLe (ad[usLed odds raLlo 0.83(0.74-0.98)) and a 11 reducLlon of LhlrLy-
day emergency readmlsslon raLe (ad[usLed odds raLlo 0.89(0.79-0.99)). no slgnlflcanL effecL of Lhe pollcy ouLslde London
has been observed.

Conc|us|on: 1he London PASu pollcy was assoclaLed wlLh an lmprovemenL ln Lhe LreaLmenL recelved by sLroke paLlenLs
ln Lerms of Lhrombolysls raLes, seven-day ln-hosplLal deaLh raLes and LhlrLy-day emergency readmlsslon raLe. 1he lmpacL
of Lhe pollcy over Lhe lndlcaLors needs Lo be consldered Laklng lnLo accounL conLexLual facLors, for lnsLance a posslble
celllng effecL for Lhe London scan raLes.

keferences: 1. almer WL, 8oLLle A, uavle C, vlncenL CA, Aylln . uylng for Lhe weekend. A reLrospecLlve cohorL sLudy on
Lhe assoclaLlon beLween day of hosplLal presenLaLlon and quallLy and safeLy of sLroke care. Arch neurol 2012. !ul 9.1-7.



13S9

1nIkD kCUND CI 1nL IkLNCn nCSI1ALS ACCkLDI1A1ICN kCCLSS: A MID-1LkM kLVILW
8runo LuceL
1,*
, lranols 8erard
1
, 1homas Le Ludec
2

1
AccredlLaLlon deparLmenL,
2
CuallLy & SafeLy lmprovemenL deparLmenL, PauLe AuLorlLe de SanLe, SalnL uenls La lalne, lrance


Cb[ect|ves: 1o assess Lhe lmpacL on hosplLals accredlLaLlon resulLs of lncluslon of focus prlorlLy Loplcs sLandards.

Methods: 1he lrench accredlLaLlon program for hosplLals ls mandaLed by law slnce 1996, lL alms Lo lmprove quallLy and safeLy of
care Lhrough Lhe generaLlon of susLalned changes ln cllnlcal pracLlces and managemenL.

PAS sLandards address Lhe hosplLal's performance ln speclflc areas, Lhey speclfy requlremenLs Lo ensure LhaL paLlenL care ls
provlded ln a safe manner and ln a secure envlronmenL.

1he currenL procedure uses an accredlLaLlon handbook conLalnlng 28 sLandards and 82 crlLerla whose 13 are focus prlorlLy Loplcs
sLandards relaLed Lo LvaluaLlon on cllnlcal pracLlces pollcy, CuallLy & securlLy lmprovemenL program, 8lsk managemenL, aLlenL's
needs, aln managemenL, aLlenL flle, aLlenL ldenLlflcaLlon, urug managemenL, Lnd of llfe, lnfecLlous rlsk, ComplalnLs, Lmergency
room and CperaLlng room.

AL Lhe beglnnlng of 2013, 1296 hosplLals (49 of lrench hosplLals) have goL Lhelr accredlLaLlon declslon for Lhls Lhlrd round of
accredlLaLlon.

kesu|ts: 1he dlsLrlbuLlon of Lhe accredlLaLlon level for Lhese 1296 hosplLals ls Lhe followlng:

! 223 hosplLals are accredlLed (17 )
! 473 hosplLals are accredlLed wlLh recommandaLlons (37 )
! 464 hosplLals are accredlLed wlLh reservaLlon (36 )
! 130 hosplLals have goL a condlLlonal accredlLaLlon (10 )
! 4 hosplLals are non-accredlLed (0.3 )

1hese accredlLaLlon levels are Lhe resulL of 7982 baslc declslons relaLed Lo crlLerla. 3837 of Lhese declslons (48) are relaLed Lo focus
prlorlLy Loplcs sLandards:
! urug managemenL : 1083 declslons
! aLlenL flle : 644 declslons
! aLlenL ldenLlflcaLlon : 420 declslons
! aln managemenL : 374 declslons
! LvaluaLlon on cllnlcal pracLlces pollcy : 319 declslons
! 8lsk managemenL : 481 declslons
! Lnd of llfe : 184 declslons
! lnfecLlous rlsk : 136 declslons
! CperaLlng room : 78 declslons
! Lmergency room : 48 declslons
! ComplalnLs : 48 declslons

74 of Lhese declslons are recommandaLlons (2834), 23 are reservaLlons (23) and 3 are ma[or reservaLlons (3).

Conc|us|on: 1he conLrlbuLlon of focus prlorlLy Loplcs sLandards Lo Lhe declslon process ls very lmporLanL, 3837 declslons (48 of Lhe
LoLal declslons) are relaLed Lo focus prlorlLy Loplcs sLandards: 16 of Lhe crlLerla make 48 of Lhe declslons. lnLroduclng prlorlLles ln
Lhe accredlLaLlon process clearly shows where room for lmprovemenL ls, lL helps Lo focus lmprovemenL efforLs on prlorlLles.




1363

1nL ALICA1ICN CI kL LkICkMANCL INDICA1Ck (kI) CI 1nL 8ALANCLD SCCkLCAkD (8SC) AND A 8CS1CN
CCNSUL1ING GkCU (8CG)-LIkL MA1kIk MCDLL 1C LNnANCL 1nL LIILC1IVLNLSS CI 1W-DkGS MANAGLMLN1 IN
1AIWAN
lyu Chang
1,*
, Chao-Pung kuo
2

1
AdmlnlsLraLlon CenLer,
2
lnLernal Medlclne, kaohslung Medlcal unlverslLy PosplLal, kaohslung Medlcal unlverslLy,
kaohslung, 1alwan, kaohslung, 1alwan


Cb[ect|ves: 1alwan naLlonal PealLh lnsurance 8ureau lmplemenLed Lhe 1alwan ulagnosls 8elaLed Croups (1w-u8Cs)
paymenL sysLem ln 2010. 1w-u8Cs paymenL sysLem dlvldes hosplLallsed paLlenLs lnLo hundreds of dlfferenL groups
accordlng Lo Lhelr dlagnosls, surgery or LreaLmenL, age, sex, Lhe presence of comorbldlLles or compllcaLlons, and
dlscharge sLaLus. 1w-u8Cs seLs paymenL welghLs wlLh conslderaLlon of medlcal resource uLlllsaLlon. ln prlnclple,
paymenL for hosplLallsed paLlenLs ln Lhe same group adopLs Lhe same sLandard of paymenL welghL. ln oLher words,
dlfferenL dlsease caLegorles (Ma[or ulagnosLlc CaLegory, MuC) classlfled lnLo dlfferenL groups of 1w-u8Cs wlll have
dlfferenL 1w-u8Cs flxed paymenL plans. 1herefore, Lhe purpose of Lhls sLudy ls Lo use kl of 8SC and 8CC-llke maLrlx
model Lo bulld (an) approprlaLe managemenL mechanlsm(s), ln order Lo enhance Lhe flnanclal performance and
managemenL effecLlveness of hosplLals under Lhe 1W-u8Cs sysLem.

Methods: ln Lhls sLudy, 133 cases pald by lmplemenLlng Lhe flrsL phase of 1w-u8Cs ln a medlcal cenLer ln 2011-2012
were analysed. 1here are Lwo research purposes:

1) 1o use kl of 8SC Lo monlLor Lhe proflL-and-loss raLe and Lhe hosplLal bed occupancy raLlo of 1w-u8Cs cases Lo
esLabllsh a performance managemenL mode.
2) 1o use 8CC-llke (proflL-and-loss raLe Llmes case share raLlo) maLrlx model Lo asslgn all 1w-u8Cs cases ln a hosplLal
lnLo Lhe SLars, Cash Cows, CuesLlon Mark and uogs cases ln order Lo undersLand Lhe sLrucLures of dlfferenL 1w-u8Cs
cases and Lo asslsL Lhe prlorlLy conslderaLlons when hosplLal managemenL resource allocaLlon ls concerned.

kesu|ts: 1here were alLogeLher 10,693 hosplLallsed cases ln 2011-2012, wlLh an average age of 49 years old, 39.3 belng
female, an average proflL per reporLed case of 8,617 polnLs/case, a proflL-and-loss raLe of 16.34, CMl value of 1.34, an
average lengLh of hosplLallsaLlon belng 4 days, and Lhe raLe of compllcaLlons belng 23.17. Among Lhe hosplLallsed
cases durlng LhaL perlod, Lhe largesL number of cases were from Lhe orLhopaedlc deparLmenL (2,840 cases, accounLlng
for 26.33), wlLh an average proflL of 10,017 polnLs /reporLed case, and proflL and loss raLe belng 13.36.

ln Lhe analysls of 8CC-llke maLrlx model, MuC evaluaLlon of effecLlveness revealed LhaL MuC 8 musculoskeleLal
sysLem and connecLlve Llssue dlseases (2,944 cases, accounLlng for 27.33) ouLnumbered all Lhe medlcal condlLlons,
wlLh an average proflL of 73,393 polnLs /reporLed case and a proflL and loss raLe of 13.2, formlng Lhe SLars" cases.

Conc|us|on: 8SC ls a closed-loop managemenL sysLem. 1eamwork ls emphaslsed aL Lhe same Llme, focuslng on sLraLegy
(clear goals) and allgnmenL (conslsLenL dlrecLlons). Pence, hosplLal operaLors can undersLand Lhe classlflcaLlon of
dlfferenL 1w-u8Cs cases Lhrough Lhe 8CC-llke maLrlx model analysls, and Lhereby obLaln Lhe order of prlorlLy Lo Lhe
allocaLlon of resources. 1haL ls Lo say, hosplLal managers could focus Lhe medlcal resources prlmarlly on Lhe SLars" and
CuesLlon Mark" cases. As for Lhe Cash Cows" and uogs" cases, Lhe cosL and expense analysls sysLem should be
applled Lo sLrlcLly conLrol Lhe cosLs. Moreover, process reenglneerlng should be carrled ouL approprlaLely Lo reduce
healLh care cosLs of hosplLallsed cases, and Lo lncrease Lhe overall proflLablllLy of Lhe hosplLal.

1369
kCVIDING ILLD8ACk CN kLSCkI8ING LkkCkS 1C IUNICk DCC1CkS: DLVLLCING C1LN1IAL SCLU1ICNS
8ryony u. lranklln
1, 2, 3,*
, !eroen 8erLels
4
, MaLLhew 8eynolds
3
, !onaLhan 8enn
1

1
CenLre for aLlenL SafeLy and Servlce CuallLy , lmperlal College,
2
ueparLmenL of racLlce and ollcy, uCL School of
harmacy,
3
harmacy ueparLmenL,
4
lmperlal College PealLhcare nPS 1rusL, London, unlLed klngdom
Cb[ect|ves: !unlor docLors do mosL prescrlblng ln hosplLals. SLudles of Lhe causes of Lhelr prescrlblng errors suggesL LhaL
lack of feedback ls a common Lheme. Cur ob[ecLlves were Lo deLermlne how feedback was currenLly provlded Lo
foundaLlon year 1 (l?1) docLors and any assoclaLed problems, Lo explore vlews on approaches Lo feedback, and Lo
deslgn a sulLable feedback sysLem Lo meeL any gaps ldenLlfled.
Methods: 1o explore vlews on boLh currenL and oLher posslble feedback mechanlsms, self-admlnlsLered quesLlonnalres
were glven Lo all l?1 docLors and pharmaclsLs ln a large London Leachlng hosplLal LrusL, comblnlng boLh 3-polnL LlkerL
scale sLaLemenLs and open-ended quesLlons. We conducLed a descrlpLlve analysls, focuslng on agreemenL scores for
sLaLemenLs regardlng percelved prescrlblng error raLes, oplnlons on feedback, barrlers Lo feedback, and preferences for
fuLure pracLlce. 1he flndlngs were Lhen synLheslsed Lo creaLe a new proposed feedback approach.
kesu|ts: 8esponse raLes were 49 (37/73) for [unlor docLors and 37 (37/100) for pharmaclsLs. ln general, docLors dld
noL feel LhreaLened by feedback on Lhelr prescrlblng errors. 1hey felL LhaL Lhe feedback currenLly provlded was
consLrucLlve buL ofLen lrregular and lnsufflclenL. MosL hosplLal pharmaclsLs provlded feedback ln mulLlple ways,
however some dld noL or were lnconslsLenL. 1hey were wllllng Lo provlde more feedback, buL dld noL feel lL was always
effecLlve or feaslble due Lo barrlers such as lnablllLy Lo ldenLlfy prescrlbers, communlcaLlon problems and Llme
consLralnLs. 8oLh professlonal groups felL LhaL Lhey would prefer lndlvldual feedback wlLh addlLlonal regular generlc
feedback on common or serlous errors. A new feedback model ls Lherefore proposed whlch relles on Lhe use of name
sLamps Lo ldenLlfy lndlvldual prescrlbers and comblnes lndlvldual feedback on speclflc prescrlblng errors wlLh group
feedback on common and lmporLanL errors and how Lhey can be avolded.
Conc|us|on: leedback on prescrlblng errors was valued and accepLable Lo boLh professlonal groups. lrom Lhe resulLs,
several suggesLed meLhods of provldlng feedback on prescrlblng errors emerged. Addresslng barrlers such as Lhe
ldenLlflcaLlon of lndlvldual prescrlbers would faclllLaLe feedback ln cllnlcal pracLlce. We have now obLalned fundlng Lo
plloL and evaluaLe a new model of feedback based on our flndlngs.
!"#"
%&&%'( )* (+% ,%*-(+ )& .(/0 /*1 ').(. /'')213*- () 4%2513%6 4/06%*( )& 4/,,3/(37%
'/2% 42)8%'(
89:;<= .>9=? Seok[un ?oon, Pyenongslk Ahn, ?oungho ?oon
PealLh lnsurance 8evlew & AssessmenL Servlce, Seoul, korea, uemocraLlc eople's 8epubllc Cf
)@A;BC9D;EF 1he purpose of Lhls sLudy ls Lo analyze Lhe effecL of change ln end-sLage cancer paLlenL
servlce paLLerns for cosL and hosplLallzed day beLween !anuary 2009 and uecember 2010.
6;C><GEF used daLa ln Lhls sLudy were elecLronlcally submlLLed requesLs of paymenL Lo Lhe PealLh
lnsurance 8evlew Agency over Lhe perlod from !anuary, 2009 Lo uecember 2010. 1hls sLudy was
conLrolled naLural LxperlmenLal ueslgn. 1o verlfy Lhe ulfference ln ulfference analysls was employed.
2;EHICEF A group of people who had been ellglble Lo Lhe alllaLlve care paymenL pollcy for 2 years(from
2009 Lo 2010), was asslgned Lo Lhe experlmenL group(n=3,117). 1hose who had noL come ln alllaLlve
care paymenL pollcy was asslgned Lhe conLrol group(n=2,347). Ma[or resulLs of Lhe emplrlcal analysls are
as follows, llrsLly, Lhe lengLh of day per eplsode case among paLlenLs of Lhe experlmenL group ls lower
Lhan LhaL of Lhe conLrol group. Secondly, Lhe expenses per hosplLallzed paLlenL day for boLh groups are
decrease. LasLly, Lhe cosL of analgeslcs drug of Lhe experlmenL group ls lower Lhan LhaL of Lhe conLrol
group. 1herefore, lengLh of day per eplsode case among paLlenLs decreased 2.36(93 Cl=-0.0324
0.0194). Lxpenses per day decreased 4.4(93 Cl=-0.071-0.018). Analgeslcs medlcaLlon cosL per day
decreased 0.39(93 Cl=-0.007-0.0047). 1he cosL of LesL also decreased 6.62(93 Cl=-0.0688-
0.0683) and Lhere was slgnlflcanLly resulL(p<0.0001).
'<=BIHE9<=F 1he flndlng of Lhls sLudy concludes LhaL Lhe lnLroducLlon of Lhe paymenL among palllaLlve
care paLlenLs was effecLlve ln decreaslng Lhe lengLh of day per case, Lhe cosL per eplsode and lengLh of
day. ulfference ln ulfference meLhod can show neL effecL of Lhe pollcy lmpllcaLlon LhaL has Laken place
wlLh Llme and can be applled ln Lhe publlc healLh analysls as measurlng lnLeracLlon beLween LreaL and
paymenL pollcy. llnally, Lhls research flndlng wlll provlde useful baslc daLa ln Lerms of maklng palllaLlve
healLhcare pollcy wlLh paymenL for end-sLage cancer paLlenL.
1391
SAIL1 AND 1nL DL1LkICkA1ING SUkGICAL A1ILN1: AN ANALSIS CI 1nL CCGNI1IVL LLLMLN1S CI NUkSING
LkLk1ISL
ulanne C. Marshall
1,*
, Mary llnlayson
2

1
School of nurslng, 1he unlverslLy of Auckland, Auckland , new Zealand,
2
School of PealLh , Charles uarwln unlverslLy,
uarwln, AusLralla
Cb[ect|ves: 1lmely recognlLlon by Lhe nurse when a paLlenL's condlLlon ls deLerloraLlng ls a complex cognlLlve process
and vlLal for paLlenL safeLy. Powever Lhe crlLlcal cues and sLraLegles experlenced nurses use and why such slLuaLlons
presenL dlfflculLles for less experlenced nurses has noL been sysLemaLlcally explored. 1he alm of Lhls sLudy was Lo
undersLand Lhe speclflc skllls requlred of nurses durlng challenglng slLuaLlons.
Methods: An Applled CognlLlve 1ask Analysls uslng MlllLello and PuLLon's (1998) Lechnlque was conducLed Lo lnvesLlgaLe
Lhe cognlLlve skllls requlred of general surglcal nurses when aLLendlng Lo a deLerloraLlng paLlenL followlng surgery. uaLa
were collecLed uslng ln-depLh lnLervlews wlLh speclflc cognlLlve probes each deslgned Lo examlne dlfferenL aspecLs of
cognlLlve skllls and processes. Slx reglsLered nurses from general surglcal wards were lnLervlewed Lhree Llmes each and
Lhe lnLervlews were analysed creaLlng a Lask dlagram, a knowledge audlL Lable, a slmulaLlon lnLervlew Lable and
ulLlmaLely a cognlLlve demands Lable whlch synLheslsed Lhe daLa. 1he cognlLlve demands Lable presenLs a summary of
Lhe dlfflculL cognlLlve elemenLs ldenLlfled, why Lhey are dlfflculL, Lhe cues and sLraLegles experLs use Lo resolve Lhe
dlfflculLles and Lhe errors less-experlenced nurses commonly make.
kesu|ts: 1he analysls revealed four cognlLlve elemenLs and elghL key cognlLlve skllls characLerlsLlc of nurslng experLlse ln
Lhls slLuaLlon. 1he cognlLlve elemenLs are: 8ecognlLlon of physlologlcal deLerloraLlon, conflrmlng deLerloraLlon, lnlLlaLlng
rescue and securlng medlcal asslsLance. 1he cognlLlve skllls ldenLlfled are: SlLuaLlon awareness, paLLern recognlLlon,
anLlclpaLory Lhlnklng, problem-solvlng, prlorlLlslng, deallng wlLh uncerLalnLy, experlenLlal knowledge and professlonal
knowledge.
Conc|us|on: 1hese resulLs show LhaL experlence ls a key facLor LhaL nurses requlre Lo develop Lhe cognlLlve experLlse
necessary for malnLalnlng paLlenL safeLy ln crlLlcal slLuaLlons. lor less-experlenced nurses Lo galn Lhls experLlse Lhey
need Lo work alongslde experlenced nurses Lo develop Lhe cognlLlve skllls requlred Lo care for surglcal paLlenLs safely
when uncerLalnLy exlsLs. ldenLlfylng Lhese crlLlcal cognlLlve elemenLs, characLerlsLlc of experLlse, provldes lmporLanL
lnformaLlon for Lhe deslgn of professlonal educaLlon programmes and developlng compeLencles, hosplLal pollcles and
cllnlcal pracLlce. Such knowledge LranslaLlon would have ma[or lmpllcaLlons for lmprovlng paLlenL safeLy and quallLy of
care.
1400
1nL CLINICAL LIIICAC CI USING IMkCVLD nSICAL kLS1kAINS IN NUkSING nCMLS
Meng-lng Wu
1,*
, Lan-lang Pslao
2
, Psuan Po
3
, 1su-Chl Wang
4

1
ueparLmenL of CommunlLy nurslng, 1alpel ClLy PosplLal,
2
ueparLmenL of nurslng, Pead nurse, 1alpel ClLy PosplLal, ?ang
Mlng 8ranch,,
3
ueparLmenL of nurslng, AsslsLanL Pead nurse, 1alpel ClLy PosplLal, ?ang Mlng 8ranch, 1alpel,
4
SuperlnLendenL, ueparLmenL of nurslng, 1alpel ClLy PosplLal, 1alpel , 1alwan
Cb[ect|ves: AL presenL, ln order Lo emphaslse Lhe quallLy of healLh care and Lhe paLlenLs' safeLy, almosL every medlcal
faclllLles vlew resLralnL as an lmporLanL lndex of care and aLLenLlon. lmproved physlcal resLralns are generally regarded
as proLecLlve devlces ln nurslng homes. 1he use of resLralnL ls a Lemporary nurslng lnLervenLlon Lo ensure LhaL
lnLravenous llnes or medlcal Lubes wlll noL be removed by paLlenLs. ln Lhls sLudy, lmproved physlcal resLralnL was made
by a recycle boLLles. 1hls noL only allowed Lhe flngers free for acLlvlLles and physlcally unresLrlcLed, Lhe resources also
can be re-used. 1he nurses can creaLe lL by Lhemselves. lL can reduce Lhe cosL of overhead and ls worLh mass-produclng
Lhls pro[ecL.
Methods: 1he ob[ecLlve of Lhls sLudy ls Lo lnvesLlgaLe Lhe effecLlveness of recelvlng lnLervenLlon by Lhe lmproved
physlcal resLralnL amongsL nurslng home resldenLs. 1he parLlclpanLs of Lhls sLudy were resldenLs ln nurslng homes whlch
have more Lhan 30 beds ln 1alpel. Convenlence sampllng was used ln Lhls pre-experlmenLal sLudy aL Lwo dlfferenL
branches of nurslng home ln 1alpel, 1alwan. 1he Lwo branches were randomly asslgned as elLher Lhe experlmenLal or
conLrol group. LlghLy parLlclpanLs were assessed aL basellne and follow up 6 monLhs laLer. 1he research was conducLed
vla quesLlonnalres. 1he lnsLrumenLs used for daLa collecLlon conslsLed of demography daLa, 8arLhel AcLlvlLy of ually
Llvlng, Muscle ower Scale, and koroLkoff Scale. 1he daLa of Lhe LesL was analysed Lhrough SSS verslon 18.0. 1he
collecLed daLa were sLaLlsLlcally analysed by percenLage, average value, range, rank, sLandard devlaLlon, and L-LesL.
kesu|ts: We found a slgnlflcanL lmprovemenL ln Lhe experlmenLal group ln Lerms of llfe pressure (p.001), dlsease
pressure (p.001), acLlvlLles of dally llvlng (8arLhel AcLlvlLy of ually Llvlng) (p.001) and body funcLlon (koroLkoff Scale)
(p.001). ln Lhe experlmenLal group, Lhe resulLs show LhaL Lhe 8arLhel AcLlvlLy of dally Llvlng lncreased from 4.3 Lo
6.23. Powever, ln conLrol group Lhere were no slgnlflcanL dlfferences ln Muscle ower.
Powever, Lhere were no slgnlflcanL dlfferences ln Muscle ower Loward Lhe use of physlcal resLralnLs beLween
experlmenLal and conLrol groups.
Conc|us|on: lmproved physlcal resLralnL noL only lncreased Lhe ablllLy of Lhe elderly buL also enhance paLlenL safeLy. lL
can ensure lnLravenous llnes or medlcal Lubes, and also enhance Lhe self-esLeem of Lhe elderly. 1hls sLudy's resulLs can
be used a reference for fuLure on educaLlon of nurses professlonal Lralnlng, classroom Leachlng, admlnlsLraLor seLLlng
resLralnL procedure, resLralnL handbook. 1hls can also enhance Lhe ablllLy of hosplLal nurses Lo solve paLlenLs' problems,
Lhus lmprove Lhe quallLy of care. 1hls pro[ecL can lmprove Lhe famllles' and nurses' saLlsfacLlon, enhanclng nurses'
knowledge and lmprove Lhe quallLy of nurslng care ln crlLlcal paLlenLs.

1404

INCkLASL CI AkkIVAL UNC1UALI1 AND kLDUC1ICN CI DLLALD AkkIVAL 1IML IN 1nL CLkA1ING kCCM: 1nL LIILC1 CI
A1ILN1 1kANSCk1 MLSSAGL ASSING (1M) SS1LM IN A MAICk nCSI1AL
Won !ln Lee
1,*
, !oon Pyuk kong
2
, Sang Ml Chln
1
, !l Lun Chol
1

1
ueparLmenL of nurslng,
2
ueparLmenL of 1horaclc and Cardlovascular Surgery, kangbuk Samsung PosplLal, Sungkyunkwan unlverslLy
School of Medlclne, Seoul, korea, 8epubllc Cf


Cb[ect|ves: CperaLlng room efflclency ls one of Lhe ma[or goals ln hosplLal managemenL and Lhere have been many sLudles on Lhe
sub[ecL (1, 2). We developed Lhe paLlenL LransporL message passlng (1M) sysLem. 1hls was done by hosplLal compuLerlsaLlon,
along wlLh and auLomaLlc LexL message passlng sysLem vla moblle phone ln order Lo lmprove Lhe arrlval puncLuallLy ln Lhe operaLlng
room (C8) and cardlovascular cenLer.

Methods: MulLldlsclpllnary Lask force Leam lncludlng C8 nurse, general ward nurse, LransporL Leam, and elecLronlc processlng Leam
esLabllshed several prlnclples Lo gulde Lhe process of change. 1hls ls a brlef summary of 1M sysLem, an C8 nurse cllcks requesL
lcon and checks Lhe expecLed arrlval Llme aL leasL 30 mlnuLes before schedule L1A (esLlmaLed Llme of arrlval) and a ward nurse
recelves a requesL message and Lhe label of paLlenL lnformaLlon ls prlnLed ouL auLomaLlcally. SlmulLaneously a LransporL Leam
recelves a requesL auLomaLlc LexL message. lf Lhe nurse or Lhe LransporL Leam doesn'L conflrm a requesL" message, Lhe C8 nurse
wlll know lL vla ln Lhe monlLor and can Lake Lhe necessary acLlons. 1he sub[ecLs were paLlenLs LransporLed by gurney from one
general ward Lo operaLlng rooms for procedure or lnLervenLlon ln a general hosplLal. 1here was no dlfference ln Lhe dlsLance from
Lhe general ward Lo Lhe operaLlng rooms or Lhe number of Llmes Lhe elevaLor was uLlllsed for each paLlenL's LransporL. non-1M
group was 113 (34 lnLervenLlonal, 61 surglcal paLlenLs LransporLed as an exlsLlng way from March, 2012 Lo May, 2011. 1M group
was 162 (81 lnLervenLlonal, 81 surglcal) paLlenLs LransporLed as 1M sysLem from !une, 2012 Lo AugusL, 2012.

kesu|ts: 8efore 1M sysLem, Lhe percenLage of paLlenLs ln perloperaLlve care unlL on delayed arrlval Llme was 40.9. AfLer
lnLervenLlon of 1M sysLem, lL was decreased Lo 23.3 (p=0.006) (1able 1).


1ab|e1. Ana|ys|s of De|ayed Arr|va| |n the Cperat|ng koom

So, Arrlval puncLuallLy was lmproved from 39.1 Lo 74.7. 1he average of delayed arrlval Llme aL operaLlon room was 1113
mlnuLes (mean sLandard devlaLlon ln non-1M group and 63 mlnuLes ln 1M group whlch had sLaLlsLlcally slgnlflcanL dlfference
(p<0.001).

Conc|us|on: We could achleve lmprovemenL of sLarL-Llme Lardlness and Lurnover Llme ln operaLlon by an lncrease of Lhe raLe of
arrlval puncLuallLy from 39.1 Lo 74.7, a decrease of Lhe average delayed arrlval Llme from Lo 10 mlnuLes Lo 3 mlnuLes. now, Lhls
sysLem ls currenLly conflned Lo Lhe C8 and cardlovascular cenLer only. Powever, lL should be applled Lo oLher seLLlngs wlLhln Lhe
hosplLal (ex. LaboraLory sesslon or 8adlologlc sesslon). 1hls sysLem should be conLlnued Lo esLabllsh a work envlronmenL for safe and
puncLual paLlenL LransporL, an expanslon along wlLh Lhe elevaLor sysLem would creaLe synerglsLlc effecL and furLher faclllLaLe
efflclenL paLlenL LransporL.

keferences:
1. Macarlo A. Are your hosplLal operaLlng rooms efflclenL? A scorlng sysLem wlLh elghL performance lndlcaLors. AnaesLheslology.
2006,103:237-40.
2. 2. uexLer l, Aboulelsh AL, LpsLeln 8P, WhlLLen CW, Lubarsky uA. use of operaLlng room lnformaLlon sysLem daLa Lo predlcL Lhe
lmpacL of reduclng Lurnover Llmes on sLafflng cosLs. AnesLh Analg. 2003,97:1119-26.


kequest t|me before 1M system after 1M system p-va|ue
number of paLlenL () number of delayed
case ()
number of paLlenL () number of delayed
case ()
08:00-12:00 36 (31.3) 12 (33.3) 60 (37.0) 16 (26.7) 0.609
12:00-16:00 68 (39.1) 32 (47.1) 87 (33.7) 24 (27.6) 0.088
16:00-08:00 11 (9.6) 3 (27.3) 13 (9.3) 1 (6.7) 0.313
tota| 11S (100) 47 (40.9) 162 (100) 41 (2S.3) 0.006

140S

SLLkING CI UALI1 INDICA1CkS CI nLAL1n CAkL IN A1ILN1 NAkkA1IVLS AND IN kLSCNSLS 1C 1nLM
Pana konecna
1, 2,*
, uanlca Sloukova
3

1
Adam Czech 8epubllc, nCC paLlenL organlsaLlon,
2
laculLy of PealLh and Soclal SLudles, unlverslLy of SouLh 8ohemla,
Ceske 8ude[ovlce,
3
Cymnaslum rlpoLocnl, raha, Czech 8epubllc


Cb[ect|ves: PealLh care quallLy can be assessed from a loL of perspecLlves. 1he goal of our sLudy was Lo seek quallLy
lndlcaLors as seen by Lhe paLlenLs.

Methods: We have abouL 1100 narraLlves avallable, wrlLLen for Lhe purpose of comprehenslve descrlpLlon of alllng
slLuaLlon, noL of assessmenL of quallLy ln medlclne. Lach of Lhem has been wrlLLen by anoLher auLhor (mosLly by Lhe
paLlenLs Lhemselves, buL also by Lhelr famlly members, frlends or healLh care workers). We have performed secondary
quallLaLlve conLenLs analysls, seeklng assessmenL (boLh poslLlve and negaLlve) of healLh care quallLy and lLs conLenLs. ln
LhaL sLage of research, we used non-numerlcal quanLlflers Lo descrlbe Lhe resulLs. AbouL 30 of Lhe narraLlves became
laLer Lhe Loplc of dlscusslons ln focus groups conslsLlng of Lhe auLhors of Lhe narraLlves, Lhey dlscussed where Lhe error
occurred.

kesu|ts: 1he dlsLlncLlvely prevalllng caLegory lndlcaLlng Lhe quallLy level of healLh care ln Lhe Czech 8epubllc from Lhe
paLlenL's perspecLlve ls Lhe level of communlcaLlon beLween Lhe healLh care worker (noL only Lhe physlclan buL also
oLher healLh care professlons) and Lhe paLlenL. Low-quallLy care of Lhe Lype of laboraLory error or confuslon of
documenLaLlon came along only sporadlcally, and even ln such cases, lL was assessed Lhrough Lhe prlsm of Lhe level of
communlcaLlon, l.e. of Lhe healLh care worker's unwllllngness Lo admlL LhaL an error could have occurred and of
lmmedlaLe correcLlve acLlons. Mlsslng or worse access Lo healLh care ls menLloned excepLlonally. lL concerns elLher
paLlenLs llvlng ln remoLe small vlllages or slLuaLlons when Lhe healLh care worker refers Lhe paLlenL Lo more speclallsed
care Lo more dlsLanL blgger clLles. ln LhaL case, lL ls agaln Lhe quallLy of communlcaLlon of Lhe healLh care worker LhaL
maLLers, l.e. wheLher Lhe healLh care worker ls able Lo convlnce Lhe paLlenL LhaL referrlng does noL mean Lhe healLh care
worker's aLLempL Lo geL rld of Lhe paLlenL buL LhaL lL ls ln Lhe paLlenL's lnLeresL. ln Lhe focus groups, dlsLlncLlve
slmllarlLy could be seen only ln a few narraLlves where an error was obvlous (evldenLly bad healLh care worker or
problemaLlc paLlenL), Lhe mosL narraLlves showed dlsLlncLlve dlsslmllarlLy ln assessmenL. 1he focus of Lhe problem
conslsLs, ln our oplnlon, ln dlfferenL expecLaLlons and ldeas of Lhe paLlenL and Lhe healLh care worker (and Lhus also Lhe
focus group parLlclpanL) wlLh regard Lo Lhe progress and conLenLs of Lhe care.

Conc|us|on: 1he resulLs show LhaL ln a counLry wlLh very good accesslblllLy, solldarlLy healLh care sysLem and hlgh
professlonal level of healLh care workers (as ls Lhe case of Lhe Czech 8epubllc), Lhe maln quallLy lndlcaLor conslsLs ln Lhe
level of communlcaLlon beLween Lhe healLh care worker and Lhe paLlenL. 1he maln lndlcaLor of good level of
communlcaLlon conslsLs, ln our oplnlon, ln confldence ln Lhe relaLlon beLween Lhe healLh care worker and Lhe paLlenL.
8uL such confldence can be dlfflculLly sub[ecL Lo any formallsaLlon.

keferences: C'nelll, C. (2007). AuLonomy and 1rusL ln 8loeLhlcs. Cambrldge unlverslLy ress.
konecna, P., Sloukova, u., Mardeslc, 1. (2012). Medlclna zalozena na duvere. C nebohem paclenLovl v posLmodernl
dobe. raha: Calen.




1411

SWISS INA1ILN1 UALI1 INDICA1CkS (Cn-II): kL LLLMLN1 CI A NA1ICNWIDL CU1CCML MCNI1CkING
uanlel W. Zahnd
1,*
, 1homas Mansky
2
, 1heres Schnelder
3

1
Medlcal ulrecLlon - CuallLy ManagemenL, 8ern unlverslLy PosplLal, 8ern, SwlLzerland,
2
lachgebleL SLrukLurenLwlcklung
und CuallLLsmanagemenL lm CesundhelLswesen, 1echnlsche unlverslLL (1u), 8erlln, Cermany,
3
PealLh Lnsurance
ulvlslon, Swlss lederal Cfflce of ubllc PealLh, 8ern, SwlLzerland


Cb[ect|ves: 1hls conLrlbuLlon presenLs a screenlng Lool for ouLcome-drlven quallLy managemenL of lnpaLlenL hosplLal
servlces ln SwlLzerland. lL ls based on Lhe Cerman lnpaLlenL CuallLy lndlcaLor (C-lCl 3.1) sysLem, orlglnally developed
slnce 2000 by Lhe Cerman Pellos prlvaLe hosplLal group and aL Lhe 1u 8erlln. 1he Swlss adapLaLlon, Swlss lnpaLlenL
CuallLy lndlcaLors (CP-lCl), has recenLly been upgraded Lo Lhe currenL verslon 3.1, ln collaboraLlon beLween Lhe Swlss
unlverslLy PosplLals, Lhe 1echnlsche unlverslLL 8erlln and Lhe Swlss lederal Cfflce of ubllc PealLh (lCP).

Methods: An lndusLrlal Lype of quallLy managemenL based on an lLeraLlve process of measurlng, analyslng, lmprovlng
and conLrolllng ouLcome ls applled Lo cllnlcal medlclne. WlLh Lhe naLlonwlde lnpaLlenL survey conducLed by Lhe Swlss
lederal Cfflce of SLaLlsLlcs, a rlch base of admlnlsLraLlve daLa ls aL dlsposlLlon. 1hls daLa ls used aL Lhe same Llme for Lhe
new naLlonwlde u8C relmbursemenL sysLem sLarLlng ln 2012 (Swlss u8C).

1he lndlcaLors refer Lo 40 LreaLmenLs and dlseases, relevanL due Lo volume or lmporLance wlLhln a medlcal speclalLy.
CuLcome lndlcaLors llke ln-hosplLal morLallLy are compared Lo age- and sex-sLandardlsed expecLed raLes.

kesu|ts: An analysls based on Lhe CP-lCl glves an overvlew of Lhe slLuaLlon ln SwlLzerland for Lhe mosL lmporLanL
dlseases causlng hosplLallsaLlons. A deLalled lnLerneL publlcaLlon ls done by Lhe Swlss lederal Cfflce of ubllc PealLh.
Lxamples of Lhe quallLy lndlcaLors are (mosLly morLallLy raLes and number of cases LreaLed) for acuLe myocardlal
lnfarcLlon, hearL and Lhoraclc surgery, sLroke, pneumonla, colorecLal resecLlon for cancer, LoLal hlp replacemenL and
sepLlcaemla.

8ased on Lhe CP-lCl speclflcaLlon, hosplLals lmplemenL ln-Llme measuremenL of ouLcomes wlLhouL any addlLlonal daLa
collecLlon. lnLernal and exLernal benchmarklng by compleLe dlsclosure of all resulLs for boLh physlclans and CLC's allows
acLlve search for and analysls of crlLlcal areas, ln whlch poLenLlally crlLlcal cases can be lnvesLlgaLed (crlLlcal lncldenL
survelllance sysLem).

Conc|us|on: 1he CP-lCls ls a key elemenL for a sLrucLured ouLcome lmprovemenL process ln Lhe Swlss acuLe care
hosplLals. AlLhough Lhe resulLs are [usL publlshed wlLhouL dlrecL pressure Lo Lake acLlons, an lncreaslng number of
hosplLals analyse Lhelr processes by means of peer revlews. 1he group lnlLlaLlve CuallLLsmedlzln (lC
M
)" has lnsLalled a
sLandardlsed peer revlew process for Lhls purpose based on Lhe same lndlcaLor seL. 1hls leads Lo very lmporLanL and
necessary LargeLed lmprovemenL acLlvlLles ln Lhe hosplLals and, lf esLabllshed declslvely, Lo a change of corporaLe
culLure, Lrlggerlng a huge poLenLlal of amelloraLlon whlch ls emplrlcally proven. AL Lhe same Llme, concerns abouL a
posslble deLerloraLlon of Lhe quallLy of servlces due Lo a posslble economlc pressure caused by u8C lnLroducLlon ln
SwlLzerland can be addressed by analyslng ouLcome.

keferences:
ro[ecL WebslLe of Lhe Swlss lederal Cfflce of PealLh: www.bag.admln.ch/qlss
lnlLlaLlve CuallLLsmedlzln (lC
M
): www.lnlLlaLlve.quallLaeLsmedlzln.de
8usse 8, nlmpLsch u, Mansky 1. Measurlng, MonlLorlng, And Managlng CuallLy ln Cermany's PosplLals. PealLh Affalrs
2009.
Mansky 1, nlmpLsch u, Wlnklmalr C, vogel k, Pellerhoff l (2011) C-lCl Cerman lnpaLlenL CuallLy lndlcaLors. verslon
3.1. 8erlln: unlverslLLsverlag der 1u 8erlln. opus.kobv.de/Luberlln/vollLexLe/2011/3004/




1413

IMkCVING LkLkILNCL CI MLAL 1IMLS
Mlchelle Mlller
1,*
, Clalre 8lackwood
2
, uavld 1oner
3
, Amy CuLhberL
4

1
lmplemenLaLlon and lmprovemenL, PealLhcare lmprovemenL ScoLland, Clasgow,
2
Cllnlcal lmprovemenL,
3
SLaLlon 10, Ayr
PosplLal,
4
SLaLlon 10, 1he Ayr PosplLal, nPS Ayrshlre and Arran, Ayr, unlLed klngdom


Cb[ect|ves: 1o Lake a person cenLred approach Lo lmprovlng nuLrlLlonal care on an acuLe orLhopaedlc ward Lo achleve
93 compllance wlLh Lhe elemenLs of a Meal 1lme CbservaLlon 1ool by CcLober 2012.

Methods: Wlll: 1he lmprovemenL Advlsor, nuLrlLlon Champlon, nuLrlLlon Llnk nurse and Senlor Charge nurse engaged
wlLh Lhe ward Leam Lo achleve buy-ln Lo LesL an observaLlon Lool Lo lmprove meal Llmes. 1he Lool was LesLed Lo ensure
Lhls was sulLable for Lhe local conLexL. lollowlng a number of lLeraLlons uslng uSA cycles, lnlLlal basellne daLa was
gaLhered Lo check compllance wlLh Lhe elemenLs of Lhe observaLlon Lool. 1hls lnformaLlon was LrlangulaLed wlLh
lnLelllgence gaLhered Lhrough leadershlp walk-rounds and sLaff and paLlenL feedback.

ldeas: 1hrough dlscusslons wlLh sLaff and feedback from paLlenLs, ldeas for lmprovemenL were generaLed. 1he changes
whlch would have Lhe blggesL lmpacL on paLlenL experlence and ouLcome were selecLed as lnlLlal areas for
lmprovemenL.

LxecuLlon: 1hrough uSA cycles, a number of change concepLs were LesLed and analysed.

uaLa: CbservaLlon of a full meal Llme on Lhe whole ward of 20 paLlenLs was underLaken every 2 weeks from Lhe perlod
of Aprll 2012 - !uly 2012 and Lhen monLhly unLll CcLober 2012. uaLa was dlsplayed Lhrough run charLs on Lhe ward, a
'PlghllghLs and LowllghLs 8eporL' was developed and dlsplayed monLhly lnformaLlon, a local daLa reporLlng LemplaLe was
also populaLed. aLlenL feedback was dlsplayed ln Lhe ward area.

kesu|ts: kesu|ts
Co-ordlnaLlon of care durlng meal Llmes was ldenLlfled as Lhe blggesL barrler Lo ensurlng paLlenLs on Lhe ward recelved
lndlvlduallsed person cenLred care. A meal Llme co-ordlnaLor role was LesLed and compllance wlLh Lhe elemenLs of Lhe
observaLlon Lool lmproved. koo cbotts (ovolloble fot tbe postet) Jemoosttote tbese lmptovemeots.

1he key area whlch lmproved was LhaL paLlenLs recelved Lhe asslsLance Lhey lndlvldually requlred aL meal Llmes,
avoldlng unnecessary lnLerrupLlons aL meal Llmes (Lhrough changes lncludlng alLerlng Llmlng of sLaff breaks and
lnLroduclng a meal Llme co-ordlnaLor). aLlenLs reporLed a poslLlve experlence of meal Llmes.

tbe meols wete qooJ ooJ l qot pleoty of belp - tbook yoo (oqe 74, femole potleot)

CLher beneflLs have lncluded:
! beLLer compllance wlLh compleLlon of food charLs
! real Llme feedback Lo mulLldlsclpllnary Leam of good pracLlce and areas for lmprovemenL Lo lnform fuLure work

Conc|us|on: 1he lnLroducLlon of a meal Llme co-ordlnaLor has led Lo paLlenLs on a busy acuLe orLhopaedlc ward geLLlng
Lhe rlghL help aL Lhe rlghL Llme Lo lmprove Lhelr experlence of meal Llmes.

keferences: PealLhcare lmprovemenL ScoLland. lmprovlng nuLrlLlon. lmprovlng Care llnal 8eporL. Ldlnburgh. March
2012.


1419

1CWAkDS LVIDLNCL-8ASLD UALI1 IMkCVLMLN1: 1nL 1nLCk]kAC1ICL 8ALANCING AC1
kaLhryn Cllver
1,*
, 8oman klslov
1
, Clll Parvey
1
, 8uLh 8oaden
1

1
lnnovaLlon, ManagemenL and ollc, ManchesLer 8uslness School, ManchesLer, unlLed klngdom


Cb[ect|ves: We dlscuss how LheoreLlcal approaches Lo evldence-based quallLy lmprovemenL are used and lnLerpreLed across
lmplemenLaLlon pro[ecLs ln healLh care seLLlngs. We draw lessons abouL Lhe mechanlsms affecLlng Lheory-gulded LranslaLlon of
evldence lnLo lmprovemenL pracLlce.

Methods: use of LheoreLlcal models Lo gulde quallLy lmprovemenL work ls affecLed by Lhree mechanlsms acLlng aL Lhe level of
pracLlce:

a) use of tbetotlc, where bulldlng blocks are menLloned ln pro[ecL reporLs wlLhouL acLually belng used ln pracLlce (e.g. clLaLlon of
Lhe Model for lmprovemenL),
b) b) 5blfts of meooloq, where Lhe lnLerpreLaLlon of bulldlng blocks or Lhelr elemenLs over Llme moves away from Lhe orlglnal
concepL (e.g. knowledge Lransfer sLaff acLlng as pro[ecL managers),
c) c) ltlvlleqloq of cettolo ospects of wotk, where 'bulldlng blocks' or Lhelr elemenLs (e.g. capaclLy bulldlng as parL of 'embedded
evaluaLlon and learnlng') recelve less emphasls Lhan pracLlcal, shorL-Lerm, measurable aspecLs of quallLy lmprovemenL pracLlce
(such as numbers of pracLlces enrolled).

lacLors conLrlbuLlng Lo all mechanlsms lncluded: shared undersLandlng of Lhe bulldlng blocks among sLakeholders, sLraLeglc
commlLmenL Lo Lheory-lnformed approaches by leaders, and relnforcemenL of Lhese approaches Lhrough learnlng opporLunlLles.

kesu|ts: use of LheoreLlcal models Lo gulde quallLy lmprovemenL work ls affecLed by Lhree mechanlsms acLlng aL Lhe level of
pracLlce:

a) use of tbetotlc, whereby LheoreLlcal bulldlng blocks are only menLloned ln pro[ecL reporLs wlLhouL acLually belng used ln
pracLlce (e.g. clLaLlon of Lhe Model for lmprovemenL),
b) b) 5blfts of meooloq, whereby Lhe lnLerpreLaLlon of bulldlng blocks or Lhelr elemenLs over Llme moves away from Lhe orlglnal
concepL (e.g. knowledge Lransfer sLaff acLlng as pro[ecL managers),
c) ltlvlleqloq of cettolo ospects of wotk, whereby LheoreLlcal 'bulldlng blocks' or Lhelr elemenLs (e.g. capaclLy bulldlng as parL of
'embedded evaluaLlon and learnlng') recelve less emphasls Lhan pracLlcal, shorL-Lerm, measurable aspecLs of quallLy
lmprovemenL pracLlce (such as numbers of pracLlces enrolled).

lacLors conLrlbuLlng Lo all Lhree mechanlsms lncluded Lhe exLenL of shared undersLandlng of Lhe LheoreLlcal noLlons among
sLakeholders, sLraLeglc commlLmenL Lo Lheory-lnformed approaches by leaders, and relnforcemenL of Lhese approaches Lhrough
learnlng opporLunlLles.

Conc|us|on: Applylng a Lheory-lnformed approach requlres aLLenLlon Lo Lhe deslgn, dellvery and on-golng evaluaLlon of
lmprovemenL pro[ecLs. 1heoreLlcal models are, perhaps lnevlLably, unable Lo capLure Lhe complexlLy of soclal lnLeracLlons ln whlch
lmprovemenL pro[ecLs are embedded, or Lo address pracLlcal and operaLlonal concerns. We suggesL LhaL LheoreLlcal models are
more llkely Lo lnfluence across Lhe llfespan of an lmprovemenL pro[ecL where Lhere ls:

! undersLandlng, agreemenL and commlLmenL amongsL key sLakeholders abouL Lhe naLure, scope, value and key feaLures of
underlylng Lheory,
! deslgn and managemenL of lmprovemenL pro[ecLs wlLh reference Lo Lheory,
! conLlnuous relnforcemenL of Lhe use of Lheory by esLabllshlng learnlng, developmenL and knowledge sharlng opporLunlLles,
! sLraLeglc vlslon and sufflclenL resource lnvesLmenL Lo lnLroduce and afflrm Lhe selecLed approach and adapL lL Lo pro[ecL-speclflc
conLexLual facLors


1423

1kANSILkkING LN1]AUDICLCG SLkVICLS IN1C A CCMMUNI1 SL11ING USING CLkA1ICNAL kLSLAkCn
1LCnNIULS 1C MCDLL 1nL A1ILN1 LkLkILNCL
Cheryl voake
1,*
, Alun 1omklnson
2
, aul Parper
1
, Maureen lallon
3

1
School of MaLhemaLlcs, Cardlff unlverslLy,
2
ueparLmenL of CLolaryngology and Pead & neck Surgery,
3
ueparLmenL of
lnnovaLlon and lmprovemenL, Cardlff and vale unlverslLy PealLh 8oard, Cardlff, unlLed klngdom


Cb[ect|ves: Large numbers of paLlenLs regularly Lravel long dlsLances Lo recelve LreaLmenL for ear condlLlons and Lhe
provlslon of hearlng alds. 1he key ob[ecLlve of Lhls sLudy ls Lo reduce demand for secondary care faclllLles, wlLh
lmproved walLlng Llmes and fewer no shows, by Lransferrlng ear nose and LhroaL (Ln1) and audlology servlces lnLo a
communlLy seLLlng. 1hls wlll ln Lurn ease pressure on Lhe ambulance servlce and lmprove quallLy of care, lncludlng
paLlenL experlence, Lhrough qulck and relaLlvely sLress-free care, whlle savlng Llme and cosLs for paLlenLs.

Methods: 1hls pro[ecL ls supporLed and funded by 1he PealLh loundaLlon as parL of lLs annual Shlne programme. lL
lnnovaLlvely brlngs LogeLher cllnlcal speclallsLs from Lhe unlverslLy PosplLal of Wales, Cardlff, and CperaLlonal 8esearch
(C8) modellers from Lhe School of MaLhemaLlcs, Cardlff unlverslLy, so LhaL maLhemaLlcal analysls of healLhcare dellvery
can be used Lo demonsLraLe Lhe sysLem beneflLs of movlng audlology secondary care servlces lnLo Lhe prlmary seLLlng.
1hls pro[ecL ls plloLlng a self-conLalned saLelllLe communlLy faclllLy close Lo paLlenLs' homes, wlLhln a local C pracLlce,
LhaL wlll enable 3,000-7,000 people Lo recelve care ouLslde of a secondary care seLLlng. lL ls belng run by Lhe unlverslLy
PosplLal of Wales, whlch LreaLs a large number of paLlenLs, many of whom are older and Lravel some dlsLance, ofLen
LransporLed by carers or ln ambulances, Lo recelve LreaLmenL for ear condlLlons, hearlng loss and hearlng alds. arklng ls
a slgnlflcanL problem, and Lhe hosplLal can be a compllcaLed and confuslng place for lndlvlduals Lo negoLlaLe. Modelllng
Lhe paLlenL experlence wlll lnclude esLlmaLlng quallLy lmprovemenL and cosL reducLlons for Lhe paLlenL and Lhe local
healLh economy.

As well as shlfLlng secondary care hearlng servlces lnLo a prlmary care seLLlng, Lhe Leam ls developlng a more generlc
new model for plannlng servlce redeslgn more accuraLely and ensurlng beLLer lnformed declslon maklng. 1hls ls because
slmple average based speadsheeL models for plannlng servlce redeslgn fall Lo capLure Lhe necessary deLalls and
varlablllLy of healLhcare processes leadlng Lo mlsleadlng and lncorrecL concluslons. 1he Leam expecLs Lhe pro[ecL Lo have
a slgnlflcanL lmpacL on lndlvlduals wlLh hearlng loss and Lhe healLh servlce communlLy, wlLh wlder learnlng for oLher
servlces.

kesu|ts: LxpecLed beneflLs and ouLcomes lnclude:

! A dramaLlc lncrease ln Lhe quallLy of Lhe paLlenL experlence assoclaLed wlLh a reducLlon ln Lravel Llme, LransporL and
parklng cosLs,
! Savlngs for Lhe Welsh Ambulance 1rusL ln Lerms of ambulance resource,
! A conslderable carbon fooLprlnL reducLlon,
! 1he developmenL of a generallzable model Lo lnform commlsslonlng declslons.

Speclflc resulLs are noL currenLly avallable buL wlll be deLalled aL Lhe conference. Powever, early anecdoLal evldence ls
already suggesLlng an lmprovemenL across all areas.

Conc|us|on: lnlLlaLlves whlch lnvolve shlfLlng care closer Lo home are ofLen meL wlLh reslsLance owlng Lo lack of robusL
evldence. 1hls pro[ecL demonsLraLes Lhe cosL and quallLaLlve beneflLs of such a shlfL, on boLh paLlenLs and Lhe wlder
healLh economy.



1429

INILC1ICN kLVLN1ICN AND CCN1kCL (IAC) - AN AUDI1 kCGkAM ICk kLkCCLSSING CI MLDICAL DLVICLS IN nSICIAN
CIIICLS
Sandra PanlngLon
1,*
, karen Mazurek
1
, Shonda PolL
1

1
College of hyslclans & Surgeons of AlberLa, LdmonLon, Canada


Cb[ect|ves: ln 2007, Lhere were several reporLed cases ln AlberLa (Canada) lnvolvlng lmproper sLerlllsaLlon and reprocesslng of
medlcal devlces ln physlclan offlces and hosplLals. 1here was furore wlLhln Lhe healLhcare and publlc secLor regardlng paLlenL safeLy,
and mlsLrusL of percelved safeguards ln healLhcare. 1he MlnlsLer of PealLh dlrecLed healLh lnsLlLuLlons and professlonal regulaLory
bodles Lo ensure all healLhcare seLLlngs adhered Lo AlberLa's lnfecLlon prevenLlon and conLrol (lC) sLandards. 1he College of
hyslclans & Surgeons of AlberLa, Lhe llcenslng/regulaLory body for physlclans ln AlberLa, responded wlLh developmenL and
lmplemenLaLlon of a formal on-slLe audlL of medlcal pracLlces and educaLlon for communlLy physlclans and offlce sLaff.

Cb[ecLlves:
! lmprove paLlenL safeLy by lncreaslng knowledge and quallLy of lC pracLlces ln physlclans' offlce
! Lnsure adherence Lo sLandards for lC pracLlces, speclflcally relaLlng Lo Lhe re-processlng of re-useable medlcal devlces ln
physlclan offlces
! LducaLe physlclans and offlce sLaff on safe and rellable ways Lo reprocess/sLerlllse equlpmenL/medlcal devlces
! 1o lnspecL and reporL on compllance wlLh besL pracLlces for devlce reprocesslng

Methods: hyslclans were caLegorlsed uslng a rlsk sLraLlflcaLlon based on procedures performed ln Lhelr offlces. 1hese procedures
were clusLered, and physlclans caLegorlsed lnLo 3 groups:
1. CLolaryngologlsLs
2. C8/C?n speclallsLs
3. CLher speclallsLs and lamlly hyslclans

1hrough use of surveys senL Lo 7600 physlclans, medlcal pracLlces were ldenLlfled LhaL reprocessed reusable medlcal devlces uslng
Spauldlng's caLegorles of crlLlcal" and seml-crlLlcal". ln parallel Lo Lhe survey process, Lhe lAC program:
1. Assembled a panel of experLs lncludlng lnfecLlous ulsease physlclans, lamlly physlclans and speclallsLs, a medlcal offlcer of
healLh, and lnfecLlon ConLrol rofesslonals (lC) Lo develop assessmenL Lools for an audlL of reprocesslng pracLlces
2. CreaLed an audlL form based on Lhe CnLarlo rovlnclal lnfecLlous ulseases Advlsory CommlLLee (luAC) sLandards and guldellnes
3. 8ecrulLed/Lralned lC pracLlLloners Lo lnspecL physlclan offlces and reporL on Lhe flndlngs
4. rovlded educaLlon Lo physlclans and cllnlc reprocesslng sLaff durlng lnspecLlons, ln newsleLLers, and webslLe form
3. 1he experL panel revlewed each reporL and conflrmed requlremenLs for acLlons Lo be Laken by Lhe physlclan/offlce, lollowed up
wlLh each offlce Lo ensure compllance
6. ConducLed an evaluaLlon of Lhe process

kesu|ts: llnal resulLs are pendlng. uaLa wlll be avallable !une 2013. 8esulLs Lo be lncluded are:
1. ercenLage () of offlces LhaL meL sLandards/lmproved pracLlces and conLlnued Lo reprocess
2. LhaL swlLched Lo dlsposable devlces excluslvely
3. LhaL sLopped dolng procedures as a resulL of found deflclencles
4. requlrlng a repeaL audlL due Lo naLure of deflclencles
3. ldenLlflcaLlon of common deflclencles found

CLher quallLaLlve ouLcomes wlll lnclude:
1. osL-audlL survey resulLs
2. LducaLlon provlded Lo physlclans/sLaff
3. LducaLlonal Lools developed as a resulL of flndlngs
4. CosLs assoclaLed wlLh lmprovlng lC pracLlces

Conc|us|on: endlng

keferences: rovlnclal lnfecLlous ulseases CommlLLee (luAC) 8esL racLlces for Cleanlng, ulslnfecLlon and SLerlllsaLlon, 2010.
Canadlan CommlLLee on AnLlbloLlc 8eslsLance (CCA8) lnfecLlon revenLlon & ConLrol 8esL racLlces, 2007. A hyslclan's Culde Lo
CccupaLlonal PealLh and SafeLy 8esponslblllLles, 2008. SLandards for Cleanlng, ulslnfecLlon and SLerlllsaLlon of 8eusable Medlcal
uevlces for PealLh Care laclllLles and SeLLlngs, 2012.

1431

CAN LCCAL SS1LMS IMkCVL kLCCGNI1ICN CI DL1LkICkA1ING LMLkGLNC DLAk1MLN1 A1ILN1S
!ulle Consldlne
1, 2,*
, !udy Currey
2
, !en 8aweL
1, 2

1
norLhern PealLh, Lpplng, vlcLorla,
2
School of nurslng and Mldwlfery, ueakln unlverslLy, 8urwood, vlcLorla, AusLralla


Cb[ect|ves: 1he alm of Lhls sLudy was Lo evaluaLe a comprehenslve sysLem for recognlslng and respondlng Lo cllnlcal
deLerloraLlon ln emergency deparLmenL (Lu) paLlenLs. 1he ma[or ouLcome was reporLed cllnlcal lnsLablllLy deflned as
documenLed evldence ln Lhe Lu nurslng noLes of cllnlcal lnsLablllLy and subsequenL reporL Lo a medlcal offlcer.

Methods: A repeaLed Llme serles deslgn was used. 1he lnLervenLlon (a sysLem for recognlslng and respondlng Lo cllnlcal
deLerloraLlon) evolved over Llme:

! 2009: no formal sysLem
! 2010: slngle Lrlgger Lu Cllnlcal lnsLablllLy CrlLerla and escalaLlon of care proLocol was lmplemenLed
! 2011: colour coded nurslng observaLlon charLs maLchlng Lu Cllnlcal lnsLablllLy CrlLerla and deslgned uslng human
facLors were lmplemenLed

1he sLudy was conducLed aL a meLropollLan emergency deparLmenL ln Melbourne, vlcLorla. SLudy parLlclpanLs were
adulL Lu paLlenLs wlLh complalnLs of shorLness of breaLh, chesL paln and abdomlnal paln. A LoLal of 30 paLlenLs per year
(2009-2012) per dlagnosLlc group were randomly selecLed from Lu aLLendance records (n=600). uaLa were collecLed by
reLrospecLlve medlcal record audlL.

kesu|ts: ln LoLal, Lhere were 318 eplsodes of documenLed cllnlcal lnsLablllLy ln 81 paLlenLs. 1he prevalence of lnsLablllLy
for each year was relaLlvely sLable: 14.7, 14.6, 22.1 and 10.7 (p = 0.203). 1he proporLlon of reporLed lnsLablllLy
lncreased over Lhe four years (14.7, 27.9, 43.9, 40) buL Lhls lncrease was noL sLaLlsLlcally slgnlflcanL (p = 0.293).
1achypnoea and Lachycardla were Lhe mosL common documenLed abnormallLles. Cf 110 eplsodes of 1achypnoea ln 33
paLlenLs, 27.3 were reporLed: Lhe proporLlon of reporLed Lachypnoelc eplsodes lncreased over Lhe four years sLudled
(11.1, 18.2, 27.6, 68.7). Cf Lhe 92 eplsodes of Lachycardla ln 28 paLlenLs, 27.1 were reporLed and Lhe proporLlon
of reporLed Lachycardlc eplsodes lncreased over Llme (17.4, 28.1, 31.6, 33.3).

Conc|us|on: A local, comprehenslve sysLem for recognlLlon and response Lo deLerloraLlng Lu paLlenLs has lncreased
reporLlng of cllnlcal lnsLablllLy. Lu speclflc sysLems for recognlLlon and response Lo deLerloraLlng Lu paLlenLs remaln ad
hoc and furLher developmenL and sysLemaLlc evaluaLlon of Lu speclflc sysLems for recognlLlon and response Lo
deLerloraLlng Lu paLlenLs ls warranLed.



1433

kLCCGNISING DL1LkICkA1ICN IN LMLkGLNC DLAk1MLN1 (LD) A1ILN1S: CkGANISA1ICNAL ML1 CkI1LkIA
VLkSUS LD SLCIIIC
!ennlfer Posklng
1,*
, !ulle Consldlne
2
, naLlsha Sands
1

1
School of nurslng and Mldwlfery, ueakln unlverslLy, Ceelong,
2
School of nurslng and Mldwlfery, LasLern PealLh-ueakln
unlverslLy, 8urwood, AusLralla


Cb[ect|ves: 1he ma[orlLy of adverse evenLs such as cardlopulmonary arresL and deaLh are preceded by vlLal slgn
abnormallLles. 1herefore, regular assessmenL of physlologlcal vlLal slgns ls fundamenLal Lo deLecLlng paLlenLs aL rlsk of
deLerloraLlon. 1he use of Lrack and Lrlgger sysLems such as Medlcal Lmergency 1eam (ML1) crlLerla have lmproved
ouLcomes for ward paLlenLs, however, few publlshed sLudles have lnvesLlgaLed Lhe use of Lrack and Lrlgger sysLems ln
AusLrallan emergency deparLmenLs.

1he alm of Lhls sLudy was Lo explore Lhe frequency, naLure and ouLcomes of cllnlcal deLerloraLlon ln Lu paLlenLs and
assess Lhe feaslblllLy of organlsaLlonal ML1 crlLerla agalnsL one example of Lu speclflc crlLerla (Cllnlcal lnsLablllLy
CrlLerla).

Methods: An exploraLory descrlpLlve deslgn was used. 1he sLudy was conducLed ln Lhe Lu of a ma[or reglonal publlc
hosplLal ln vlcLorla, AusLralla. A polnL prevalence survey was used Lo collecL paLlenL characLerlsLlcs and vlLal slgns from
200 adulL paLlenLs durlng Lu aLLendance. A reLrospecLlve medlcal record audlL collecLed paLlenL ouLcome daLa.

kesu|ts: uurlng Lhe emergency eplsode of care 2 of paLlenLs fulfllled organlsaLlonal ML1 crlLerla whlle Lu speclflc
crlLerla ldenLlfled 7.3. aLlenLs fulfllllng organlsaLlonal ML1 crlLerla had a mean age of 83 years compared Lo a mean
age of 67 years for Lhose fulfllllng Lu speclflc crlLerla.

All paLlenLs fulfllllng ML1 crlLerla were admlLLed Lo ln-paLlenL wards compared wlLh 73 of paLlenLs fulfllllng Lhe Lu
speclflc crlLerla. Cf Lhe 136 Lu paLlenLs admlLLed Lo ln-paLlenL wards, 8 had ML1 acLlvaLlon durlng admlsslon, 87.3 of
Lhese wlLhln 24 hours of admlsslon. Cf Lhe 200 parLlclpanLs ln Lhe sLudy, 3 had dled wlLhln 30 days of Lu aLLendance.

Conc|us|on: 1he populaLlon of paLlenLs ln Lhe emergency deparLmenL ls undlfferenLlaLed, undlagnosed and ofLen
cllnlcally unsLable. An emergency deparLmenL speclflc Lrack and Lrlgger sysLem has Lhe poLenLlal Lo ldenLlfy more
emergency deparLmenL paLlenLs aL rlsk of cllnlcal deLerloraLlon.



1434

1nL kLLA1ICNSnI 8L1WLLN A1ILN1 SAIL1 CUL1UkL AND ADVLkSL LVLN1S IN CnINLSL nCSI1ALS: A NUkSL
ULS1ICNNAIkL SUkVL
ke Llu
1,*
, ue Wang
2
, Llmlng ?ou
1
, !lng Zheng
1

1
School of nurslng, Sun ?aL-sen unlverslLy, Cuangzhou,
2
1he llrsL AfflllaLed PosplLal of Chongqlng Medlcal unlverslLy,
Chongqlng, Chlna


Cb[ect|ves: 1here ls llmlLed research whlch explored aLlenL SafeLy CulLure (SC) among hosplLal nurses and examlned
Lhe relaLlonshlp beLween SC and adverse evenLs (ALs) ln Chlnese hosplLals. 1hls sLudy almed Lo descrlbe nurses'
percepLlon of SC and frequencles of ALs esLlmaLed by nurses, and Lhen examlned Lhe relaLlonshlp beLween Lhem.

Methods: ueslgn: 1hls sLudy was a descrlpLlve, correlaLed sLudy. SeLLlng: 1wenLy-elghL medlcal unlL, surglcal unlL,
lnLenslve care unlL and emergency deparLmenL ln 7 level- general hosplLals across 6 dlsLrlcLs ln Cuangzhou, Chlna.
arLlclpanLs: 1hls sLudy surveyed 463 nurses worked on Lhe sampled unlLs. lnsLrumenLs: 1he PosplLal Survey on aLlenL
SafeLy CulLure (PSCSC) was used Lo measure nurses' percepLlon of SC, and Lhe frequencles of ALs whlch happened
frequenLly ln hosplLal were esLlmaLed by nurses, lncludlng medlclne error (ML), pressure ulcers (u), paLlenL falls (l),
physlcal resLralnLs more Lhan 8 hours (8>8h), surglcal wound lnfecLlon (SWl), lnfuslon or Lransfuslon reacLlon (l8/18)
and paLlenLs or Lhelr famlly complalnLs (C/lC). SLaLlsLlcal Analysls: MulLlple loglsLlc regresslon models were used Lo
examlne Lhe relaLlonshlp beLween SC and each AL wlLh conLrolllng Lhe poLenLlal effecLs of nurses' demographlc facLors.

kesu|ts: 1he poslLlve responded raLes of 12 dlmenslons of Lhe PSCSC varled conslderably from 23.6 Lo 89.7. 1here
were 47.873.6 nurses who esLlmaLed Lhe above 7 ALs had happened ln Lhe pasL year. AfLer conLrolllng Lhe poLenLlal
effecLs of nurses' demographlc facLors, a hlgher score of CrganlsaLlonal Learnlng-ConLlnuous lmprovemenL" resulLed ln
a decrease of Lhe odds of Lhe occurrence of nurse-esLlmaLed u by 33.8, 8>8h by 42.7, SWl by 43.8 and C/lC by
43.2, respecLlvely (C8=0.338, 93Cl=0.163-0.693, C8=0.427, 93Cl=0.207-0.883, C8=0.438, 93Cl=0.223-0.860 and
C8=0.432 93Cl=0.222-0.922), a hlgher score of lrequency of LvenL 8eporLlng" resulLed ln a decrease of Lhe odds of
Lhe occurrence of nurse-esLlmaLed ML by 72.3, u by 63.6, SWl by 71.2 and C/lC by 74.3, respecLlvely
(C8=0.723, 93Cl=0.347-0.936, C8=0.636, 93Cl=0.474-0.834, C8=0.712, 93Cl=0.336-0.946 and C8=0.743,
93Cl=0.333-0.999).

Conc|us|on: 1he nurses' percepLlon of SC was noL saLlsfacLory, and Lhe nurse-esLlmaLed ALs were hlgh. 1he resulLs
suggesLed LhaL Lhe lmprovemenL of SC could probably decrease Lhe occurrence of paLlenL ALs.



143S

INCIDLNCL CI ADVLkSL LVLN1S AND MLDICAL LkkCkS IN IAAN: 1nL IL1 S1UD
1akeshl MorlmoLo
1,*
, Mlo Sakuma
2
, ?oshlnorl ChLa
1
, uavld W. 8aLes
3

1
ueparLmenL of lnLernal Medlclne,
2
Pyogo College of Medlclne, nlshlnomlya, !apan,
3
ulvlslon of Ceneral lnLernal
Medlclne, 8rlgham and Women's PosplLal, 8osLon, unlLed SLaLes


Cb[ect|ves: Lpldemlology and naLure of adverse evenLs (ALs) or medlcal errors (MLs) should be scruLlnlsed ln a sclenLlflc
manner, and such daLa were malnly reporLed ln Lhe WesLern counLrles. Lpldemlologlcal daLa should be collecLed ln Lhe
resL of Lhe world Lo aLLesL Lhe dlssemlnaLlon of newly developed lnLervenLlons whlch were demonsLraLed effecLlve ln
Lhe WesLern counLrles. We, Lhus, conducLed a prospecLlve cohorL sLudy Lo esLlmaLe Lhe lncldence of ALs and MLs ln
!apan.

Methods: !apan Adverse LvenLs (!L1) sLudy was a mulLlcenLre prospecLlve cohorL sLudy whlch had evaluaLed ALs and
MLs aL 2 LerLlary care hosplLals. 1he 38 medlcal and surglcal wards were sLraLlfled accordlng Lo hosplLal and wheLher
Lhey were medlcal or surglcal wards, and sLudy wards were randomly selecLed. lnLenslve care unlLs (lCus) were all
lncluded. We lncluded all adulL paLlenLs aged >13 years who were admlLLed Lo any of Lhe 23 sLudy wards (10 medlcal, 11
surglcal, 2 lCus) over a 2-monLh perlod. 1he prlmary ouLcome of Lhe sLudy was Lhe AL, deflned as an ln[ury due Lo any
medlcal clrcumsLance: medlcaLlon use, operaLlon, lnvaslve/non-lnvaslve procedure, LesLlng, [udgmenL, rehablllLaLlon,
nurslng, admlnlsLraLlon. We also ldenLlfled MLs, deflned as a devlaLlon from approprlaLe process of hosplLal care.
1ralned nurses placed aL each parLlclpaLlng hosplLal revlewed all charLs dally on weekdays, along wlLh laboraLorles,
lncldenL reporLs, and prescrlpLlon querles Lo collecL any poLenLlal evenL. 1hey also collecLed Lhe characLerlsLlcs of Lhe
paLlenLs ln Lhe cohorL. lndependenL physlclan revlewers evaluaLed all poLenLlal evenLs and classlfled Lhem accordlng Lo
wheLher Lhey were ALs or MLs, as well as Lo Lhelr severlLy and prevenLablllLy. lf a ML was found, Lhen Lhe Lype of error
and sLage ln Lhe process aL whlch lL occurred were also classlfled. lnLer-raLer rellablllLles were assessed uslng kappa
sLaLlsLlcs. lnconslsLency was flnally resolved by consensus. lncldence per 1000 paLlenL-days, crude raLes per 100
admlsslons and Lhelr 93 confldence lnLervals were calculaLed as a whole and by ward Lype (medlcal, surglcal, or lCu).

kesu|ts: A LoLal 1131 paLlenLs were enrolled durlng Lhe sLudy perlod. 1he poLenLlal evenLs were 2933. 1hese poLenLlal
evenLs are now under revlew by lndependenL physlclan revlewers Lo classlfy Lhem lnLo AL, ML, AL wlLh ML, and oLhers.
1he lncldences of ALs and MLs should be calculaLed.

Conc|us|on: We can show Lhe lncldence of ALs and MLs ln !apan. Such daLa should be a parL of evldence of global
burden of ALs and MLs worldwlde and also provlde reference Lo esLlmaLe Lhe effecLlveness of any lnLervenLlon.



1437

A1ILN1 SAIL1 AWAkLNLSS LNnANCLMLN1 AC1IVI1ILS 1nkCUGn CLkA1ICN AND ANNCUNCLMLN1 CI A1ILN1
SAIL1 1LAM
Pae Sook Pwang
1,*
, Chong-ll Sohn
2
, ll Cho Chol
3
, ?oung Con klm
4

1
ueparLmneL of CuallLy and aLlenL SafeLy,
2
ueparLmenL of lnLernal Medlclne,
3
ueparLmenL of Lmergency Medlclne,
4
ueparLmenL of 8adlaLlon Cncology, kangbuk Samsung PosplLal, Seoul, korea, 8epubllc Cf


Cb[ect|ves: Accordlng Lo Pelnrlch's rule, Lhere are 29 mlnor ln[urles and 300 non-ln[ury accldenLs behlnd one ma[or
ln[ury. Cur lnsLlLuLlon Lrled Lo enhance Lhe awareness of paLlenL safeLy and prevenL accldenLs by deslgnaLlng several
safeLy offlcers, conducLlng educaLlon programs and announcemenLs/bulleLlns buL we faced llmlLaLlons. 1o solve Lhe
problems, we Lrled Lo nurLure aLlenL SafeLy Cfflcers ln varlous deparLmenLs, conducLlng educaLlon programs and
announcemenL/bulleLln acLlvlLles Lhrough Lhem ln order Lo lncrease lnLeresL of hosplLal members ln paLlenL safeLy and
enhance Lhelr awareness.

1he purpose of Lhls sLudy was Lo ldenLlfy Lhe effecLs of a such sysLem change on Lhe awareness of hosplLal members on
paLlenL safeLy lssues.

Methods: LxlsLlng paLlenL safeLy acLlvlLles were performed by flrsL, havlng one responslble safeLy offlcer relay Lhe
lmprovemenL case Lo Lhe relevanL deparLmenL head. 1he case was Lhen shaved Lhrough lnLraneL and also posLed on Lhe
bulleLln board ln Lhe canLeen. llnally a group lecLure was glven Lo all employees (educaLlon phase). ln 2011, we
appolnLed 17 deparLmenLal paLlenL safeLy responslble offlcers, Lralned Lhem Lhrough sLudy group every oLher week for a
year, and Lhen had Lhem educaLe oLher employees ln Lhe deparLmenL. PosLed evenLs of 'aLlenL SafeLy uay' every oLher
monLh by lmprovlng Lhe announcemenL meLhod. llrsL, Lo adverLlse, conLesLanLs were selecLed from among all
employees ln a random selecLlon meLhod and Lhe parLlclpaLed ln Lhe 'aLlenL SafeLy Culz ConLesL'. Second, posLers on
paLlenL safeLy lmprovemenL cases were creaLed and posLed ln Lhe canLeen for all Lo see. 1he besL posLers were selecLed
and Lhey were awarded accordlngly. AddlLlonally, a serles of qulzzes were glven and Lhose who gave Lhe correcL answers
were rewarded wlLh prlzes. 1hlrd, such acLlvlLles and lmprovemenL cases were shared by all Lhe employees Lhrough
bulleLlns. We Lrled Lo ldenLlfy Lhe changes ln Lhe awareness of hosplLal members on paLlenL safeLy lssues by performlng
surveys ln 2009 when ueparLmenLal aLlenL SafeLy Cfflcers were noL yeL lnLroduced, and Lhen agaln ln 2011 and 2012
afLer Lhe lnLroducLlon of Lhe new scheme uslng Lhe same quesLlons. 1he quesLlonnalre conslsLed of elghL quesLlons
uslng 3 LlkerL scales. aLlenL safeLy culLure scores were analysed by AnCvA LesL, and Lhe dlfference beLween groups was
analysed by grouplng by 1urkey's LesL. Cronbach Lo show Lhe rellablllLy of Lhe quesLlonnalres was 0.814.

kesu|ts: aLlenL SafeLy Awareness score ln 2011 (3.910.617) and ln 2012 (3.910.639) were slgnlflcanLly hlgher Lhan ln
2009 (3.730.699) (l=27.730, p<0.001). When comparlng Lhe paLlenL safeLy culLure score by year, Awareness (l=27.730,
p<0.001) and LnvlronmenLs (l=12.236, p<0.001) ln 2011 and 2012 were slgnlflcanLly hlgher Lhan Lhose ln 2009.
CommunlcaLlon (l=29.369, p<0.001) and educaLlonal effecLs (l=8.706, p<0.001) ln 2011 and 2012 were slgnlflcanLly
lower Lhan Lhose ln 2009. lL can be lnLerpreLed LhaL hlgher awareness of employees on paLlenL safeLy lssues made Lhem
aware of Lhe problems ln Lhe communlcaLlon and educaLlon sysLems.

Conc|us|on: ln our lnsLlLuLlon, lL was found LhaL Lhe sysLem change from several dedlcaLed safeLy offlcer sysLem Lo
deparLmenLal safeLy offlcer sysLem conLrlbuLed Lo Lhe lmprovemenL of awareness of hosplLal members on paLlenL
safeLy.



1443

LVIDLNCL-8ASLD NUkSING DLVLLCMLN1: A WA IkCM NCVICL 1C LkLk1
Wal Man Llng
1,*
, Clorla Aboo
2
, Clvy Leung
2

1
ueparLmenL of Cllnlcal Cncology,
2
nurslng Servlces ulvlslon, amela ?oude neLhersole LasLern PosplLal, Pong kong,
Chlna


Cb[ect|ves: Lvldence-based nurslng (L8n) enables nurses Lo provlde effecLlve care based on besL currenL evldence
raLher Lhan LradlLlonal pracLlce. lL ls lmporLanL for Lhe assurance of quallLy and safeLy of paLlenL care, and our nurslng
professlonal developmenL. L8n developmenL ln amela ?oude neLhersole LasLern PosplLal can be Lraced back Lo 2003
when our Worklng Croup on L8n was formed. varlous L8n pro[ecLs had been done prevlously Lo lmprove Lhe cllnlcal
nurslng servlce. 1o keep Lhe momenLum and acceleraLe our L8n developmenL, a solld foundaLlon of good nurses'
compeLency ln L8n ls necessary. 1hus, lt colls fot oo opptoptlote sttoteqy to qolJe oot ploo of 8N ttololoq. 1he
ob[ecLlve ls to Jevelop o feoslble sttoteqy fot o cootloooos ooJ sostolooble 8N ttololoq system lo oot bospltol.

Methods: L8n requlres Lhe acqulslLlon of a pecullar seL of knowledge and skllls Lhrough boLh dldacLlc and experlenLlal
learnlng. 8ased on 8eooets 1beoty of ltom Novlce to xpett, whlch recognlses Lhe lmpacL of pracLlce ln compeLency
developmenL, a 3-Ller Lralnlng sLraLegy ls formulaLed.

kesu|ts:
8-*+,9,-%* ,*"-(-(. ls a pre-L8n level whlch LargeLs on general nurses for arouslng Lhelr lnLeresL ln L8n. ln May 2012, a
local experL was lnvlLed Lo conducL an L8n Semlnar (a flrsL-Ller Lralnlng evenL) ln our hosplLal, whlch was hlghly
appreclaLed by Lhe audlence wlLh Lhe mean saLlsfacLlon score of 3.08 ouL of 6.

3%14()9,-%* ,*"-(-(. covers Lhe novlce Lo advanced beglnners. Mode of Lralnlng ls workshop and LuLorlal Lo develop Lhe
learners' baslc L8n knowledge and skllls. Cur flrsL L8n Workshop and 1uLorlal for beglnners was held lasL year. lL goL a
poslLlve feedback from Lhe parLlclpanLs (mean saLlsfacLlon scores were 3.22 ouL of 6 and 3.06 ouL of 6 respecLlvely).

:0-*)9,-%* ,*"-(-(. caLers for compeLenL nurses or above who Lyplcally wlLh 2-3 years' experlence ln L8n. Accordlng Lo
Lhe Learnlng yramld by naLlonal 1ralnlng LaboraLorles lnsLlLuLe for Applled 8ehavloural Sclence, Leachlng ls Lhe mosL
effecLlve meLhod of learnlng. 1herefore, for Lhls Ller, Lraln-Lhe-Lralner approach can also be adopLed Lo leL learners
parLlclpaLe ln approprlaLe L8n Leachlng acLlvlLles under guldance. Mode of Lralnlng lncludes dlrecL coachlng by experLs
or advanced level workshops LhaL alm aL pollshlng Lhe learners' L8n skllls and nourlshlng Lhelr leadershlp ln L8n.

Conc|us|on: 1o fosLer Lhe culLure and developmenL of L8n, a well-organlsed Lralnlng efforL ls vlLal. A J-tlet sttoteqy ls
qeoetoteJ occotJloq to 8eooets 1beoty to qolJe oot pteseot ooJ fotote 8N ttololoq ploo.



14SS

CCMkLnLNSIVL CCUNSLLING, nLAL1n LDUCA1ICN AND SUCk1 CI nIV CSI1IVL kLGNAN1 WCMLN AS A
IAC1Ck 1C IMkCVLD UALI1 CI SLkVICLS 1C nIV LkCSLD INIAN1S
Monlca M. ngonyanl
1,*
, SLella k. MwlLa
1

1
unlverslLy 8esearch Company, uar es Salaam, 1anzanla, unlLed 8epubllc of


Cb[ect|ves: 1he ob[ect|ve of th|s program was to Improve Infant feed|ng pract|ces, care and support g|ven to the
mothers us|ng the ua||ty Improvement approach.
uesplLe M1C1 lmplemenLaLlon for 12 years ln 1anzanla, assessmenLs ln Lhe counLry show LhaL coverage and quallLy of
Lhe full range of lnLervenLlons for M1C1, lncludlng Lhose relaLed Lo lnfanL feedlng counselllng and supporL are
dlsLurblngly low. An assessmenL conducLed ln lrlnga and klllman[aro reglons on care of Plv-exposed lnfanLs showed LhaL
only 10 of moLhers lnlLlaLed breasLfeedlng wlLhln one hour of dellvery, < 10 of moLhers were counselled on lnfanL
feedlng, excluslve breasLfeedlng was aL 41, enrolmenL of exposed lnfanLs Lo M1C1 wlLhln 4 weeks aL 60, and
moLhers recelvlng C8 resulLs aL 44. 1he flndlngs prompLed efforLs by Lhe MlnlsLry of PealLh and Soclal Welfare
(MCPSW) and Lhe uSAlu PealLh Care lmprovemenL ro[ecL (PCl) Lo address Lhese pracLlces. 1he ob[ecLlves of Lhls
pro[ecL was lncrease counselllng of pregnanL women abouL breasLfeedlng, lncrease Lhe raLes of excluslve breasLfeedlng
ln Lhe flrsL slx monLhs of llfe, lncrease enrolmenL Lo M1C1 care wlLhln for weeks and lncrease Lhe number of moLhers
recelvlng unA C8 resulLs.

Methods: PCl and Lhe MCPSW, LogeLher wlLh lmplemenLlng parLners (ls), conducLed quallLy lmprovemenL (Cl)
collaboraLlve ln 11 slLes of lrlnga and 13 hosplLals of klllman[aro reglons. PCl flrsL senslLlsed Lhe ls, 8eglonal PealLh
ManagemenL 1eams (8PM1), Councll PealLh ManagemenL 1eams (CPM1), and faclllLy sLaff on Cl and how naLlonal
lndlcaLors on lnfanL feedlng (ll) would be monlLored Lo measure Lhe resulLs of Lhe lmprovemenL efforLs.
lmplemenLaLlon of Lhe lnLervenLlon was based on quarLerly learnlng sesslons for experlence sharlng and coachlng
sesslons carrled ouL on alLernaLlve monLhs. ln Lhe learnlng sesslons, healLh care provlders shared LesLed changes Lo
lmprove pracLlces and prepared new plans for Lhe nexL acLlon perlod. Cn each vlslL Lo Lhe healLh faclllLy, moLhers were
glven healLh Lalks on Lhe lmporLance of early lnlLlaLlon of 8l wlLhln Lhe flrsL hour of dellvery, demonsLraLed on good
poslLlonlng and aLLachmenL Lo Lhe breasL, counselled on Lhe lmporLance of L8l, lmporLance of Lhelr chlldren checklng
for unA-C8 ln Lhe flrsL four weeks and Laklng co-Lrlmoxazole for prophylaxls. Skllled counselllng was also provlded ln
labour wards and C1C cllnlcs.

kesu|ts: ln Lhe perlod of lmplemenLaLlon Lhe percenLage of moLhers counselled on lnfanL feedlng lncreased from <10 aL
basellne ln [AugusL 2010] Lo 72 ln lrlnga ln SepLember 2012. L8l raLes Lhe percenLage of lnfanLs recelvlng breasL mllk
only for Lhe flrsL slx monLhs of blrLh lncreased from 41 ln AugusL 2010] Lo over 70 ln lrlnga ln SepLember 2012, and
ln klllman[aro from 48 ln [lebruary 2012] Lo 100 ln november 2012. lnlLlaLlon of breasL feedlng lmproved ln lrlnga
from 10 ln [AugusL 2010] Lo 82 ln SepLember 2012. ln klllman[aro, Lhe proporLlon of lnfanLs enrolled Lo M1C1 care
wlLhln 4 weeks rose from 60 ln [lebruary 2012] Lo 100 ln november 2012, and Lhe proporLlon of moLhers recelvlng
C8 resulLs lncreased from 44 Lo 86 ln Lhe same perlod. 1hese resulLs were obLalned afLer Lwo years of
lmplemenLaLlon ln lrlnga and nlne monLhs of lmplemenLaLlon ln klllman[aro.

Conc|us|on: 1he resulLs from Lhe demonsLraLlon ln Lwo reglons of 1anzanla has shown LhaL uslng quallLy lmprovemenL
meLhods ln M1C1 servlces Lo provlde a comprehenslve program of counselllng of Plv-poslLlve moLhers, healLh
educaLlon, and capaclLy-bulldlng of healLh care provlders lmproves quallLy servlces for Plv-exposed lnfanLs and enables
healLh workers Lo offer correcL needed care Lo Lhese lnfanLs.



14S6

LIILC1S CI ADC1ING 1nL CCMU1A1ICNAL kLVILW SS1LM IN SCU1n kCkLA.
?ewon na
1,*
, Sang-heon ?oon
1
, Ml !ang
1
, Mln-kyung klm
1

1
harmaceuLlcal 8eneflL ueparLmenL, PealLh lnsurance 8evlew and AssessmenL Servlce, Seoul, korea, 8epubllc Cf


Cb[ect|ves: PealLh lnsurance 8evlew and AssessmenL Servlce (Pl8A) ls a sLaLuLory publlc corporaLlon LhaL has been
checklng up on wheLher Lhe medlcal servlces are approprlaLely provlded Lo Lhe people ln SouLh korea. Clonazepam (C)
ls a benzodlazeplne drug approved by kluA for LreaLmenL of panlc dlsorder and epllepsy and covered by naLlonal PealLh
lnsurance. Pl8A adopLed Lhe CompuLaLlonal 8evlew SysLem for clonazepam, epllepsy adopLed ln March 2011, panlc
dlsorder adopLed ln Aprll 2011. AfLer adopLlng Lhe CompuLaLlonal 8evlew SysLem for clonazepam, we supposed LhaL
Lhere would be some changes ln clonazepam use ln cllnlcal seLLlngs.

Methods: 1o assess how clonazepam (C) use has been changed, lnsurance clalm daLa would be good lndlcaLlons, as
surrogaLe daLa. 1hus, we collecLed lnsurance speclflcaLlon daLa clalmed by medlcal lnsLlLuLlons ln Pl8A. uaLa from Lhe
clalm speclflcaLlons (from AugusL 2010 Lo uecember 2011) lncludlng clonazepam, Lhe oLher drugs LhaL have Lhe slmllar
effecLs Lo clonazepam, epllepsy, or panlc dlsorder was used. uslng pre-posL-LesL deslgn wlLh (and wlLhouL) comparlson
groups and Lrend analysls, we assessed wheLher CompuLaLlonal 8evlew SysLem affecLed Lhe paLLern of clonazepam use.
We deflned Lhe duraLlon of before was from AugusL 2010 Lo november 2010, and LhaL of afLer was from SepLember
2011 Lo uecember 2011. 1he duraLlon of before and afLer was equally 4 monLhs. llrsL, we compared Lhe number of
clonazepam clalm speclflcaLlons and Lhe ad[usLmenL noLlflcaLlons. Second, we calculaLed Lhe proporLlons of dlsease
change ln Lhe clalm speclflcaLlons lncludlng clonazepam, and Lhe proporLlon of clonazepam ln Lhe clalm speclflcaLlons
lncludlng epllepsy and panlc dlsorder, respecLlvely.

kesu|ts: When we compared monLhly lnsurance clalm daLa beLween before and afLer, Lhe average number of
clonazepam clalm speclflcaLlons decreased from 143,000 Lo 99,000(!4,400), and Lhe average cosLs decreased from
1,390,000 won Lo 1,000,000 won(!390,000). 1he average ad[usLmenL raLe and lLs cosL lncreased from 3.0 Lo 42.7
("39.7 polnL), 1.8 Lo 31.7("29.9 polnL) respecLlvely. 1he average number of dlseases wlLh clonazepam
lncreased from 3.2 Lo 3.8("0.6). 1he panlc dlsorder proporLlon ln clonazepam clalm speclflcaLlons lncreased from 1.6
Lo 6.3 ("4.9 polnL), whlle Lhe oLher dlseases decreased. A clonazepam proporLlon ln panlc dlsorder clalm
speclflcaLlons lncreased from 6.8 Lo 13.0 ("6.2 polnL). 8uL, Lhere were no changes ln epllepsy.

Conc|us|on: Clonazepam ls a benzodlazeplne drug havlng anxlolyLlc, anLlconvulsanL, muscle relaxanL, sedaLlve, and
hypnoLlc properLles. Powever, clonazepam ls approved by kluA only for LreaLmenL of panlc dlsorder and epllepsy. 1here
have been some probablllLles ln Lhe usage and clalm paLLerns of clonazepam slnce Pl8A adopLed Lhe CompuLaLlonal
8evlew SysLem Lo clonazepam. llrsL, Lhere mlghL be up-codlng from anxleLy dlsorder Lo panlc dlsorder. Second, lL mlghL
have affecLed clonazepam (C) use and clalm paLLerns.




1463

ADVLkSL LVLN1S MCNI1CkING: A S1L 1CWAkDS MAkING AkUn A SAIL LACL ICk A1ILN1S
Culzar S. Lakhanl
1,*
, AsmlLa A. Sunesra
2
, 8ozlna 8oshan
3
, CuraLulaln an[wanl
1

1
Cllnlcal Affalrs, Aga khan unlverslLy PosplLal,
2
Chlef CperaLlng offlcer offlce ,
3
nurslng Servlces , Aga khan unlverslLy
PosplLal , karachl, aklsLan


Cb[ect|ves: Medlcal harm and errors are almosL lnevlLable ouLcomes of fallures ln processes of care. 1herefore by
focuslng on Lhe adverse evenLs experlenced by paLlenLs, a hosplLal can fosLer a culLure of safeLy LhaL alms aL reduclng
Lhem. AkuP slnce many years has quanLlfled adverse evenLs uslng convenLlonal volunLary lncldenL reporLlng. 8esearch
has concluded LhaL only 10-20 of LoLal errors ln Lhe hosplLal are ever reporLed. 1hus an lnlLlaLlve has been Laken by 1he
Aga khan unlverslLy PosplLal, karachl, from !anuary 2011 Lo promoLe safeLy culLure. lPl's (lnsLlLuLe of PealLhcare
lmprovemenL) global Lrlgger Lools (C11) ls uLlllsed Lo calculaLe hosplLal's harm raLe. 1he purpose of uslng lPl's C11 was
Lo ldenLlfy number of adverse evenLs ln hosplLal, caLegorlse Lhem accordlng Lo severlLy of harm, esLabllsh sLraLegles Lo
reduce harm raLe and compare wlLh our own Lrends Lo lmprove lL over Llme.

Methods: A cross-secLlonal reLrospecLlve revlew was done from !anuary Lo uecember 2011 uslng sLandard lPl's C11
Lrlgger Lools. 8andom sample of 20 closed medlcal records per monLh were revlewed and audlLed by a paLlenL safeLy
nurse flrsL Lhen a cllnlclan, agalnsL '36' Lrlggers menLloned C11 Lool. CompleLe medlcal records of adulL non psychlaLrlc
paLlenLs, who were shlfLed Lo hlgh dependency area durlng Lhe hosplLal sLay, were selecLed. 1he C11 conLalns slx
modules, or grouplngs of Lrlggers l.e. (a) Care (b) MedlcaLlon (c) Surglcal (d) lnLenslve Care (e) erlnaLal and (f)
Lmergency ueparLmenL. 1he daLa ls Lhen classlfled accordlng Lo Lhe severlLy of harm caused Lo Lhe paLlenL.

kesu|ts: 1oLal 240 records revlewed ln Lhe year 2011 ln whlch 66 (27.3) paLlenLs experlenced an adverse evenL wlLh an
average of 1.43 AL per paLlenL, LoLalllng Lhe ALs Lo 96 ln 66 paLlenLs. AbouL 64 (66.6) ALs conLrlbuLed Lo Lemporary
harm Lo paLlenL requlrlng lnLervenLlon (CaLegory L), whlle 22 (22.9) requlred prolong hosplLallsaLlon (CaLegory l), 04
(4) lead Lo permanenL harm (CaLegory C), abouL 03 (3.2) requlred lnLervenLlon Lo susLaln llfe (CaLegory P) and 01
(1) led Lo paLlenL's deaLh (CaLegory l). Cn Lhe basls of Lhese resulLs, Lhe followlng lmprovemenL plans were developed
by respecLlve mulLldlsclpllnary Leam wlLh Lhe goal Lo lmprove paLlenL safeLy.

1. revenLlon and care of pressure ulcers/ brulses
2. Pypoglycaemlc conLrol ln dlabeLlc paLlenL who are kepL nC and admlnlsLered lnsulln
3. 8eadmlsslon wlLhln 30 days and mosL admlsslon wlLhln 10 days of dlscharge (MosLly from medlcal surglcal unlLs)
4. revenLlon from urlnary LracL lnfecLlon

Conc|us|on: 1hese resulLs suggesL LhaL adverse evenLs are deflnlLlve source of harm Lo Lhe paLlenL. uslng C11 has alded
Lo ldenLlfy Lhose evenLs whlch were noL volunLarlly reporLed. Pence Lhe hosplLal plans Lo conLlnue uslng Lhls promlslng
Lool Lo ldenLlfy ALs proacLlvely.



146S

LDUCA1ICN SCLNAkICS & A1ILN1 SAIL1: AN LkAMLL ICk "LNA8LING AGL AS ASSL1"
llona Calley
1,*
, hlllp Cachla
2

1
aLlenL SafeLy,
2
nPS LducaLlon for ScoLland, Ldlnburgh, unlLed klngdom


Cb[ect|ves: LducaLlon has an essenLlal role ln reduclng harm and should noL be overlooked [usL because lL ls dlfflculL Lo
quanLlfy Lhe lmpacL of sLaff educaLlon on paLlenL ouLcomes. 1he alm of our paLlenL safeLy educaLlon scenarlo lnlLlaLlve ls
Lo demonsLraLe how dlfferenL Lypes of educaLlonal acLlvlLy conLrlbuLe Lo maklng healLhcare safer.
1he example presenLed here ls abouL enabllng Age as AsseL" ln Lhe nPS workforce and llnks wlLh paLlenL safeLy. 1he
nPS workforce ls agelng, and developlng an undersLandlng of Lhe lmpacL of Lhls on Lhe overall workforce and on paLlenL
safeLy ls lmporLanL.

Methods: A Lyplcal educaLlon scenarlo descrlbes an educaLlonal resource. We Lhen make llnks beLween Lhe resource
and safer care. We capLure quoLes from educaLlonal resource sponsors and users, capLurlng Lhelr percepLlons abouL
how accesslng Lhe educaLlonal resource conLrlbuLes Lo paLlenL safeLy. We enhance access Lo oLher evldence of lmpacL
on safer care. 1hose Laklng parL ln Lhe educaLlonal research were mosLly nPS employees from 8orders, LoLhlan and llfe.
1he Age as AsseL paLlenL safeLy educaLlon scenarlo was pulled LogeLher subsequenLly as parL of a porLfollo of
scenarlos. aLlenL safeLy educaLlon scenarlos bulld on Lhe esLabllshed success of paLlenL sLorles ln uslng narraLlve and
quallLaLlve daLa as powerful leavers of lmprovemenL.

kesu|ts: nPSScoLland sLaff descrlbed Lhelr concerns ln relaLlon Lo paLlenL safeLy under a number of Lhemes: burnouL",
lack of aLLenLlon Lo redeslgn of [obs, changes ln professlonal educaLlon and procedures, lack of successlon plannlng.

.1he recrulLmenL paLLerns ln servlce and educaLlon provlders over 20 years would suggesL a deflclL ln sLaff wlLh
sufflclenL knowledge, culLural awareness and experlence Lo flll Lhe gaps. 1hls ls llkely Lo have an lmpacL on all aspecLs of
care dellvery and paLlenL safeLy ls llkely Lo be affecLed." Nn5 employee

A number of llnks were made beLween paLlenL safeLy and an agelng workforce, and ln some cases early reLlrals: less
Lhan recommended sLafflng levels, fewer experlenced sLaff Lo menLor oLhers, poLenLlal lncreased use of locum sLaff,
human facLors lssues, arlslng from a lack of clarlLy ln Leam roles, human facLors lssues for lndlvldual older workers can
lmpacL on paLlenL safeLy, and can lnclude sLress, exhausLlon and Lhe fallure Lo cope wlLh Lhe pace of change.

CLher publlshed evldence presenLed from elsewhere lncludes: lnLervlews wlLh older employees ln Lhe nPS suggesL
Lhey are very aware of paLlenL rlsks as a resulL of changes ln procedures and are concerned abouL Lhelr own ablllLy Lo
prevenL rlsks comblned wlLh Lhe percepLlon LhaL Lhe quallLy of paLlenL care ls belng compromlsed,

Conc|us|on: We urgenLly need Lo value our older experlenced sLaff and flnd beLLer ways of keeplng Lhem and helplng
Lhem Lo pass on Lhelr knowledge and skllls. 1he safeLy of fuLure paLlenL care depends on Lhls. ut Io vollls, Nn5 Jocotloo
fot 5cotlooJ. 1he SouLh LasL nPS Workforce LducaLlon and uevelopmenL Advlsory group have been hlghllghLlng key
messages from Lhe Age as AsseL" educaLlonal research and have encouraged dlscusslon among varlous nPS forums.
1he nLS aLlenL SafeLy MulLldlsclpllnary Croup conLlnue Lo share Lhls scenarlo also Lo ralse Lhe proflle of enabllng Age
as AsseL" and llnks wlLh paLlenL safeLy, glven an agelng workforce, and also early reLlrals ln some healLhcare Leams.

keferences: uerek hllllps, 8eglonal ulrecLor of Workforce lannlng, SouLh LasL nPSScoLland (derekphlllllps1nhs.neL)



1471

DIA8L1LS ACIN1MLN1S VIA WL8CAM IN NLWnAM
ShanLl vl[ayaraghavan
1,*
, 1rlsh Creenhalgh
2
, 1eresa C'Shea
3
, !oanne Morrls
4

1
ueparLmenL of ulabeLes & Lndocrlnology, 8arL's PealLh,
2
Clobal PealLh, ollcy and lnnovaLlon unlL, 8arL's and 1he
London School of Medlclne and uenLlsLry,
3
LasL London loundaLlon 1rusL,
4
8arLs PealLh, London, unlLed klngdom


Cb[ect|ves: 1radlLlonal models of rouLlne ouLpaLlenL care are wldely recognlsed Lo be lnefflclenL or lneffecLlve by falllng
Lo provlde care responslve Lo paLlenL need. 1hls pro[ecL almed Lo evaluaLe lf and bow web-based consulLaLlons could
dellver more effecLlve and efflclenL dlabeLes care, whllsL lmprovlng paLlenL experlence.

Methods: newham, LasL London, has a hlgh prevalence of Lype 2 dlabeLes (3-4 Llmes Lhe naLlonal average) wlLh more
Lhan 66 of Lhe local populaLlon from eLhnlc mlnorlLy groups.

lollowlng consulLaLlon wlLh paLlenL groups, selecLed rouLlne follow-up ouLpaLlenL appolnLmenLs were replaced wlLh
webcam consulLaLlons, uLlllslng everyday Lechnology avallable ln people's homes (raLher Lhan expenslve alLernaLlves).
CuLcomes were evaluaLed uslng quanLlLaLlve and quallLaLlve measures lncludlng, recrulLmenL daLa, 'do noL aLLend'
(unA) raLes, cllnlcal ouLcomes, A&L aLLendance and paLlenL and sLaff percepLlon Lhrough phone lnLervlews and
quesLlonnalres.

kesu|ts: ln 10 monLhs, 89 paLlenLs were recrulLed (62 upLake) and 174 webcam appolnLmenLs were scheduled wlLh an
overall unA raLe of 27. unA raLes decreased wlLh Llme, showlng a LranslLlon as paLlenLs moved Lo Lhe new sysLem. We
also saw an lmprovemenL, durlng Lhe lasL 3 monLhs, when we changed Lhe sofLware provlder Lo Skype wlLh unA raLes
falllng Lo 16 (37 appolnLmenLs).

lrom 28 quesLlonnalres, paLlenLs reporLed LhaL web consulLaLlons saved Lhem Llme, were far more convenlenL, cheaper,
LhaL Lhey preferred Lhem and would be more llkely Lo aLLend. 1he quallLy of care over webcam was consldered aL leasL
as good as LhaL provlded face Lo face.

More Llme ls requlred Lo verlfy Lhe quanLlLaLlve daLa, however Lrends suggesL where paLlenLs have had several webcam
appolnLmenLs PbA1c (lndlcaLlve of blood glucose conLrol) levels have decreased wlLh fewer A&L aLLendance. lnlLlal
savlngs are modesL, Lhrough lncreased producLlvlLy.

Conc|us|on: 1he newham dlabeLes servlce exempllfles challenges faced ln Lhe nPS wlLh hlgh non-aLLendance (unA)
raLes (approx. 30) and poor healLh ouLcomes, reflecLlng Lhe complex llves of many paLlenLs wlLh long Lerm lllness.
ercelved lack of conLrol, poor engagemenL wlLh lnflexlble servlces and poor self-managemenL are common wlLh Lhese
paLlenLs.

Larly evldence suggesLs web-based appolnLmenLs can be used as parL of ouLpaLlenL's servlces Lo lmprove paLlenL
experlence and provlde beLLer access Lo effecLlve care, wlLh Lhe poLenLlal Lo lmprove longer Lerm efflclency.
8y uslng readlly avallable vldeo conferenclng sofLware, Lhe servlce model could be easlly repllcable across Lhe ma[orlLy
of ouLpaLlenL care. lurLher work ls now belng done Lo explore Lhe lmpacL of onllne consulLaLlons on paLlenL self-
managemenL

Acknow|edgements:
lundlng was provlded for Lhls one year plloL sLudy by Lhe PealLh loundaLlon Lhrough Lhelr SPlnL programme and
supporLed by Sprlngfleld ConsulLancy.



1472

A kLGICNAL MCDLL ASSLSSING DISLASL MANAGLMLN1 kCGkAMS
krlsLlna !ohansen
1
, Anne lrllch
1,*
, Ane 8. vlnd
2

1
CaplLal 8eglon of Copenhagen, Plllerd,
2
3. uanlsh PealLh and Medlclnes AuLhorlLy, Copenhagen, uenmark


Cb[ect|ves: 1o presenL a model assesslng dlsease managemenL wlLh a focus on quallLy of care, paLlenL's
perspecLlves, uLlllsaLlon paLLerns and cosL.

Methods: ulsease managemenL programs are used wldely Lo lmprove effecLlveness, efflclency, and equlLy of care. 1wo
dlsease managemenL programs were developed ln Lhe CaplLal 8eglon of uenmark for CCu and Lype 2 dlabeLes,
respecLlvely. 1he maln focus of Lhe programs ls Lo lmprove quallLy and lnLegraLlon of provlded care ln hosplLals, general
pracLlLloners, and munlclpallLles. 1he alm of Lhe programs ls Lo dellver evldence based healLh care servlces ln Lhe correcL
seLLlng - boLh from Lhe perspecLlve of Lhe paLlenL and Lhe socleLal perspecLlve. lL ls an lmporLanL maLLer of Lhe
lmplemenLaLlon process Lo monlLor Lhe lmpacL of Lhe programs Lo enable daLa drlven lmprovemenL of quallLy of care.
lor Lhls purpose an assessmenL model for conLlnuous monlLorlng and evaluaLlon of Lhe lmplemenLaLlon and effecL of
Lhe ulsease ManagemenL rograms has been developed.

1he maln ob[ecLlves of Lhe model ls Lo monlLor Lhe effecLlveness and efflclency aL Lwo levels, Lhe populaLlon- and
paLlenL level uslng evldenced based lndlcaLors. 1he lndlcaLors are developed ln dlsease speclflc worklng groups lncludlng
relevanL healLh professlonals from all Lhree secLors. lmporLanL prlnclples of Lhe model are Lhe lndlcaLors are evldenced
based, uses exlsLlng daLa where posslble, and ensure effecLlve feed-back, audlL and benchmarklng.

1he model assesses Lhe followlng aspecLs of dlsease managemenL programs, quallLy of care, paLlenLs perspecLlves,
uLlllsaLlon paLLerns, and posslble cosL of change.

kesu|ts: A model has been developed and quallLy lndlcaLors ldenLlfled. AL Lhe populaLlon level, daLa from cenLral
reglsLers wlll be used Lo ldenLlfy Lhe Lwo populaLlons, lncludlng daLa on populaLlon speclflc varlables of soclo-
demography co-morbldlLy and uLlllsaLlon of Lhe healLh care sysLem. 1lme-serles analysls of a few cenLral lndlcaLors of
healLh care use wlll be used Lo monlLor change over Llme. uaLa aL Lhe paLlenL level wlll be obLalned from Lhe naLlonal
lndlcaLor uaLabase ro[ecL's (nl) daLabases, and daLa wlll be obLalned form a new cllnlcal daLabase accumulaLlng from
paLlenLs followlng rehablllLaLlons programs. 1he new daLabase wlll collecL daLa on rehablllLaLlon from all Lhree secLors,
each secLor wlll be able Lo access Lhelr own daLa aL lndlvldual level, buL wlll also geL access Lo daLa from Lhe oLher
secLors aL an aggregaLed level. 8esulLs wlll be fed back Lo relevanL users and supporL cross-secLor benchmarklng and
audlL of cenLral quallLy lndlcaLor for dlsease managemenL programs.

Conc|us|on: LvaluaLlon and monlLorlng ls an lmporLanL aspecL of lmplemenLaLlon new pracLlces ln healLh care
organlsaLlons. PealLh professlonals need Lo be lnvolved ln Lhe process, Lo make sure LhaL lndlcaLors are cllnlcal relevanL.
uevelopmenL of a useful model ls expenslve why engagemenL of relevanL professlonals ls lmporLanL lncludlng boLh
healLh professlonals and l1-managers and sLaLlsLlclans.









1478

1LS CI INCIDLNCLS DL1LC1LD IkCM 2010 1C 2012 IN 1WC LMLkGLNC nCSI1AL LA8CkA1CkILS: LVCLU1ICN AND I1S
INILULNCL CN A1ILN1 SAIL1.
M Llborla Lopez-?esLe
1, 2,*
, Lva Culllen
3, 4, 3
, MarLa 8uxeda
4, 6
, Mlrela 8allbe
4, 7

1
CuallLy CoordlnaLor, CA1LA8, vlladecavalls, 8arcelona,
2
LaboraLory AccredlLaLlon Commlsslon, SLCC (Spanlsh SocleLy of Cllnlcal
8lochemlsLry and Molecular aLhology), 8arcelona,
3
Lmergency LaboraLory ln PuM1, CA1LA8, 1errassa,
4
CuallLy CommlLLee,
CA1LA8, vlladecavalls,
3
8lologlcal 1esLlng relaLed Medlcal Lmergency Commlsslon, SLCC , 8arcelona,
6
Lmergency LaboraLory ln P1,
CA1LA8, 1errassa,
7
8lochemlsLry, CA1LA8, vlladecavalls, Spaln


Cb[ect|ves: Analyse Lhe evoluLlon of Lhe devlaLlons (lncldences and nonconformlLles) deLecLed durlng Lhree years ln emergency
laboraLorles of CaLlab (cerLlfled accordlng Lo SLandard unL-Ln lSC 9001:2008 slnce !uly 2010) aL Lhe unlverslLy PosplLal MLua
1errassa (Lab 1) and Lhe PosplLal de 1errassa ln Lhe PealLh ConsorLlum of 1errassa (Lab 2), and lLs effecL on paLlenL safeLy.

Methods: uevlaLlons deLecLed were classlfled ln Lwo caLegorles: as nonconformlLles, when Lhe resulL or dellvery Llme was affecLed
or devlaLlons whlch were deLecLed durlng audlLs, and Lhe resL as process lncldences. CorrecLlons were applled and correcLlve and
lmprovemenL acLlons were Laken whenever necessary. 1he CuallLy Area dld a quarLerly follow up of all devlaLlons deLecLed.

kesu|ts: 1he Lwo CaLlab emergency laboraLorles had a monLhly average acLlvlLy of 31461.1 (Lab 1) and 33324.8 (Lab 2)
deLermlnaLlons. uurlng Lhe Lhree years of Lhe sLudy perlod 721 lncldences of process and 212 nonconformlLles (26 of Lhem durlng
audlLs) were deLecLed:

rocess Inc|dences ear 2010 ear 2011 ear 2012
Lab 1 Lab 2 Lab 1 Lab 2 Lab 1 Lab 2
reanalyLlcal 216 33 111 11 73 8 62,7
AnalyLlcal 39 46 46 38 28 38 33,4
osLanalyLlcal 3 0 3 1 1 4 1,94
Nonconform|t|es Lab 1 Lab 2 Lab 1 Lab 2 Lab 1 Lab 2
reanalyLlcal 20 13 22 22 10 12 47,6
AnalyLlcal 3 14 9 12 3 13 26,4
osLanalyLlcal 3 18 3 12 4 12 23,3

Among Lhe lncldences, mosL were deLecLed durlng Lhe pre-analyLlcal process, and many of Lhem were relaLed Lo requesLs and
samples. 1hey decreased progresslvely wlLh Lhe lnLroducLlon of Lhe elecLronlc sysLem (from 62 Lo 93 of Lhe requesLs ln Lab 1 and
83 Lo 94 ln Lab 2) and Lhe creaLlon of a laboraLory webslLe ln Aprll 2012, whlch lncluded a caLalogue wlLh Lhe speclal condlLlons
for sample collecLlon, when appllcable.

nonconformlLles ldenLlfled durlng audlLs (26) were due Lo aspecLs relaLed Lo Lhe recenL lmplemenLaLlon of Lhe sysLem of quallLy
managemenL: unclear documenLaLlon or lncompleLe records (42.3), lnfrasLrucLure lmprovemenLs Lo prevenL occupaLlonal rlsks
(23.1), esLabllshmenL and clarlLy of requlremenLs (26.9) and formaL of Lhe reporL (7.7). 1he number decreased every year (12, 9
and 3 nonconformlLles, respecLlvely).

Cf nonconformlLles recorded ln dally pracLlce, 30.0 were deLecLed by cllenL complalnL, as Lhey dld noL colnclde wlLh prevlous
analyLlcal resulLs or Lhe paLlenL's charL. 1he resL were deLecLed ln Lhe laboraLory: 47.3 by lnspecLlon and LesLlng durlng Lhe
analyLlcal procedure and 2.7 by monlLorlng lndlcaLors.

Conc|us|on: We concluded LhaL a record of all lncldences and non-conformlLles deLecLed ln Lhe laboraLory as well as cllenL
suggesLlons ls essenLlal. 1hls allows us Lo lmplemenL correcLlve and lmprovemenL acLlons and plan sLraLegles ln order Lo ensure
correcL and unamblguous analyLlcal resulLs, and all Lhls redounds ln paLlenL safeLy.



1479

CAN A IACILI1A1LD MCDLL IMkCVL LVIDLNCL-8ASLD kAC1ICL ICk nLAk1 IAILUkL IN kIMAk CAkL?
Lorralne 8urey
1,*
, ChrlsLl ueaLon
2
, Mlchael Spence
1
, kleley Wlld
1

1
8 &u, CLAP8C, Salford,
2
School of nurslng, ManchesLer unlverslLy, ManchesLer, unlLed klngdom


Cb[ect|ves: ManagemenL of hearL fallure (Pl) ln prlmary care pracLlces (Cs) does noL always conform Lo guldellnes.
1he alm of Lhls pro[ecL was Lo LesL a faclllLaLed model of lmprovemenL ln Pl care (CM-Pll1) for effecL on C
ldenLlflcaLlon and managemenL of paLlenLs wlLh Pl.

Methods: 10 Cs recelved CM-Pll1: verlflcaLlon of paLlenLs wlLh Pl, Pl case flndlng and audlL of 21 evldence-based
lndlcaLors of care (resulLlng ln a Lrafflc llghL score 0 - 80 polnLs), lndlvldual paLlenL recommendaLlons, lnLeracLlve
educaLlon and faclllLaLlon by a Pl speclallsL nurse (PlSn) and knowledge Lransfer assoclaLe (k1A). 8e-audlL occurred aL
9-12 monLhs. Anonymous paLlenL daLa were enLered lnLo a SSS 16.0 daLabase for comparlson beLween audlL and re-
audlL.

kesu|ts: AL basellne 60 of 303 paLlenLs were approprlaLely on a Pl reglsLer, 19 were lnapproprlaLe, and 20 needed
furLher lnvesLlgaLlon. A LoLal of 1303 paLlenLs were found for deflnlLe (n = 173) or posslble lncluslon Lo Lhe reglsLer. AL
re-audlL lnapproprlaLe paLlenLs on Lhe Pl reglsLer decreased by 83. CharacLerlsLlcs of Pl paLlenLs dld noL change
beLween audlLs: mean age 73, 33-38 were male, and mosL had mulLlple co-morbldlLles. SlgnlflcanL lmprovemenL Lo Pl
paLlenL care was seen aL re-audlL (1able), and all Cs lmproved Lhelr overall scores. Changes Lo pracLlce and servlce re-
deslgn were on-golng aL Lhe Llme of re-audlL, and paLlenL revlews lncreased by 217. 1here were lmprovemenLs ln
collaboraLlon wlLh speclallsL Pl servlces.

AudlL 8e-audlL value
1rafflc LlghL score (n = 10 Cs) 42 + 12 32 + 9 .003
Pl conflrmed by echo 82 93 <.001
AeLlology conflrmed 61 81 <.001
LvSu 33 72.3 <.001
lf LvSu, on ACLl or conLralndlcaLlon noLed.
up-LlLraLlng or LargeL dose
90
38
89
63
.213
.063
lf LvSu, on 88 or conLralndlcaLlon noLed.
up-LlLraLlng or LargeL dose
73.3
40
83
47.3
.001
<.001
Self-care educaLlon 13 22 .003

Conc|us|on: Lhe CM-Pll1 faclllLaLed model was effecLlve ln lmprovlng evldence-based managemenL of Pl ln Cs, and
supporLlng communlcaLlon beLween Cs and speclallsLs. SupporL was lndlvlduallsed by Lhe PlSn and k1A, who also
served as brldges Lo oLher servlces.



1481

ANALSIS CI MLDICA1ICN LkkCkS VCLUN1AkIL kLCk1LD
Sonla Moreno
1
, ConxlLa MesLres
2,*
, M.Cruz Clpres
3
, Carmen Mollna
3

1
harmacy, PosplLal San 8afael,
2
harma, Crup MuLuam,
3
PosplLal San 8afael, 8arcelona, Spaln


Cb[ect|ves: 1o descrlbe and analyse Lhe medlcaLlon errors volunLarlly noLlfled Lo Lhe harmacy Servlce.

Methods: 1he hosplLal characLerlsLlcs, a second level hosplLal wlLh 200 beds, allow LhaL sanlLary professlonals can noLlfy
Lhe errors volunLarlly Lhrough our cllnlcal managemenL compuLer appllcaLlon, Lhe errors are communlcaLed ln Lhe same
way as medlclnes are requesLed, Lhe occurred error ls descrlbed, Lhe lnvolved medlclne name and Lhe paLlenL's daLa.
uaLa collecLlon ls obLalned afLer Lhe reglsLraLlon of volunLary noLlflcaLlons before descrlbed, revlewlng where Lhe error
has occurred, ln whaL asslsLance process Lhe error ls deLecLed, who ls deLecLlng lL and Lhe consequences for Lhe paLlenL.
We refer, ln Lhe presenL work, Lo Lhe real medlcaLlon mlsLakes, when Lhe medlcaLlon ls prepared on paLlenLs floor ln
order Lo be admlnlsLraLed.

kesu|ts: uurlng Lhe perlod beLween !anuary Lo uecember 2012, Lhe LoLal errors LhaL were noLlfled were 234.lrom Lhese
234 reglsLered volunLary noLlflcaLlons Lo Lhe pharmacy servlce durlng 2012, followlng Lhe chaln process of medlclne use,
Lhe 33.07 were prescrlpLlon errors, 9.84 durlng Lhe valldaLlon/LranscrlpLlon process of Lhe medlclne, 33.83 of
dlspensaLlon and 23.22 were admlnlsLraLlon errors.

lrom all Lhe errors produced, dependlng on Lhe serlousness, dld noL arrlve Lo Lhe paLlenL ln a 62.20, Lhe errors LhaL
arrlved Lo Lhe paLlenL wlLhouL causlng any ln[ury were a 22.44, Lhe paLlenL was monlLored ln a 6.69 of Lhe cases and a
LreaLmenL was needed or a Lemporal ln[ury was caused ln a 4.72 .

1he mosL parL of noLlflcaLlons, Lhe 76.37 come from Lhe nursery (194), followed by Lhe 16.14 of Lhe errors deLecLed
by Lhe pharmaclsL (41) and ln smaller proporLlon 7.48 Lhe errors noLlfled by Lhe docLors Lo Lhe pharmacy servlce (19).
We emphaslse Lhe nursery acLlve role ln Lhe volunLary errors noLlflcaLlon, noL belng equal on Lhe parL of Lhe docLors.
1he mosL common mlsLakes LhaL we sLand ouL for Lhelr lmporLance and/or severlLy, such as Lhe prescrlpLlons, are for
example Lhe regularlLy of Lhe admlnlsLraLlon of dally fenLanyl paLches when Lhelr admlnlsLraLlon musL be each 72,
dupllcaLlon of LreaLmenLs LhaL are prescrlbed wlLh flxed paLLers and elecLronlc prescrlblng proLocol, for example,
Lhromboprophylaxls, abouL dlspensaLlon we sLand ouL some re-packaglng mlsLakes for example leveLlraceLam 230 mg
for acyclovlr 230 mg, follc acld for hydrochloroLhlazlde and as admlnlsLraLlon error we have Lhe lnsulln admlnlsLraLlon Lo
a non-dlabeLlc paLlenL by confuslon of bed or lncompleLe doses ln Lhe admlnlsLraLlon of drugs such as cefLazldlme 2 g (2
vlals) and only 1 g ls admlnlsLered.

Conc|us|on: 1he harmacy ueparLmenL Lhrough meeLlngs and newsleLLers, Lrles aware Lhe professlonals abouL Lhe
lmporLance of noLlfylng Lhe mlsLakes, Lhls reporL ls always anonymous and non-punlLlve conslderlng LhaL Lhe medlcaLlon
errors are prevenLable, Lhe analysls and evaluaLlon of Lhls errors ls needed Lo be able Lo lnLroduce lmprovemenL
measures.



1483

WCkkING WI1n 1LAMS 1C IMkCVL UALI1 CI kLVLN1ICN CI MC1nLk 1C CnILD 1kANSMISSICN CI nIV SLkVICLS:
SUCCLSSLS CnALLLNGLS AND LLSSCNS LLAkN1
LllzabeLh C. u. Plzza
1,*
, 8hea 8rlghL
2
, 8am ShresLha
2
, llrma klslka
3

1
Plv Care, unlverslLy 8esearch Co. LLC, uar es Salaam,
2
Plv Care, unlverslLy 8esearch Co. LLC, 8eLhesda, unlLed SLaLes,
3
8CP, lrlnga
ulsLrlcL Councll, lrlnga, 1anzanla, unlLed 8epubllc of


Cb[ect|ves: ln lrlnga reglon, 1anzanla, Lhe MlnlsLry of PealLh (MCPSW), M1C1 lmplemenLlng parLners, 8eglonal and Councll PealLh
ManagemenL 1eams (8PM1s and CPM1s), wlLh Lechnlcal supporL from Lhe uSAlu PealLh Care lmprovemenL ro[ecL (PCl, are
lmplemenLlng a quallLy lmprovemenL (Cl) pro[ecL Lo Assure lnfanLs and MoLhers GeL All M1C1 Servlces (AlMCAS). uesplLe a hlgh
raLe of Plv counselllng and LesLlng (73), basellne assessmenL revealed low raLes of A8v use (43), enrolmenL Lo Care and
1reaLmenL CenLre (C1C) (34), and Cu4 LesLlng (13) and laLe booklng for anLenaLal care (AnC) (beyond 14) weeks. 1he pro[ecL
esLabllshed a Cl collaboraLlve of 11 faclllLy and communlLy Cl Leams ln 11 vlllages ln rural seLLlng Lo apply Cl meLhods for addresslng
Lhese challenges, uslng Leam work Lo lmprove M1C1 care and scale up besL pracLlces.

Methods: Sharlng of basellne assessmenL resulLs was done wlLh Lhe 8PM1 and CPM1s. laclllLy Cl Leams drawlng provlders from all
M1C1 servlce dellvery polnLs were formed ln Lhe 11 healLh faclllLles: 3 hosplLals, 4 healLh cenLres, and Lwo dlspensarles.

ManagemenL and faclllLy Leams were Lralned on Cl prlnclples, problem ldenLlflcaLlon and LesLlng changes Lhrough cycles of lan uo
SLudy AcL and monlLorlng performance Lo narrow quallLy gaps for selecLed quallLy lndlcaLors. MonLhly Cl Leam meeLlngs were held
Lo share progress and plan for LesLlng more changes.

CuarLerly coachlng of Cl Leams was conducLed by PCl and Lhe CPM1s. Cl Leams were gaLhered for experlence-sharlng (successes,
challenges and lessons learnL) sesslons aL 4-3 monLhs lnLervals. 1eams complled llsL of LesLed changes and besL pracLlces whlch
formed a change package whlch was spread Lo oLher reglons ln Lhe counLry.
1he communlLy Cl Leam for each vlllage was formed drawlng members from: savlngs and credlL, agrlculLural/ poulLry / beekeepers,
schools, rellglous denomlnaLlons, groups of people llvlng wlLh Plv, sporLs clubs, vlllage governmenL and healLh faclllLy sLaff. Croup
members were orlenLed Lo Lake healLh messages Lo, ldenLlfy, and encourage pregnanL women Lo aLLend AnC before 3 monLhs
gesLaLlonal age, encourage males Lo accompany Lhelr parLners for AnC, moLhers Lo pracLlce excluslve breasLfeedlng (L8l), and
under-flve chlldren Lo be broughL for follow-up care. MonLhly communlLy Cl Leam meeLlngs were conducLed wlLh coaches from Lhe
healLh faclllLy Lo monlLor progress of communlLy ob[ecLlves.

kesu|ts:
lndlcaLor 8asellne
(!an.-Apr.2011)
november 2012
Plv+ pregnanL women enrolllng ln M1C1 84 93
Plv+ pregnanL women enrolllng ln C1C 33 63
Plv-exposed lnfanLs enrolled ln care wlLhln 4wks of blrLh 48 63
MoLhers pracLlclng L8l 0-6m 41 70
Plv-exposed chlldren reLalned ln care (aLLendlng appolnLmenLs as scheduled) 67 77

Conc|us|on: Challenges for Lhe pro[ecL lncluded LhaL CPM1s have many pro[ecLs and parLners Lo work wlLh, Lhere ls rapld Lurnover of
servlce provlders and Leams Lake a whlle Lo masLer Cl meLhods, and servlce provlders have Lo focus on many programs and can'L
always parLlclpaLe ln Cl Leam meeLlngs, leadlng Lo lack of conLlnulLy. AvallablllLy of communlLy Leams was aL Llmes challenged by
acLlvlLles llke farmlng, harvesLlng and aLLendlng workshops perLalnlng Lo Lhelr prlmary goals.
1eam work ls a corner sLone for lmprovlng care. uesplLe Lhese challenges, we found LhaL Lhe faclllLy-communlLy llnkage ls a poLenLlal
for lmprovlng cllnlcal performance, cllenL-provlder relaLlonshlps and sLrengLhenlng Lhe M1C1 conLlnuum of care. 8ural communlLy
groups also offer Lhe poLenLlal for lmprovlng servlces Lhrough Lhelr engagemenL wlLh Lhe healLh secLor.



1S02

1nL LIDLMICLCG CI MLDICA1ICN LkkCkS IN IN1LNSIVL CAkL UNI1S IN IAAN: 1nL IADL S1UD
?oshlnorl ChLa
1,*
, Mlo Sakuma
2
, uavld W. 8aLes
3
, 1akeshl MorlmoLo
1

1
ueparLmenL of lnLernal Medlclne,
2
Pyogo College of Medlclne, nlshlnomlya, !apan,
3
ulvlslon of Ceneral lnLernal
Medlclne, 8rlgham and Women's PosplLal, 8osLon , unlLed SLaLes


Cb[ect|ves: MedlcaLlon errors (MLs) are an lmporLanL lssue because Lhey mlghL cause Lhe faLal adverse drug evenLs
(AuLs) especlally ln crlLlcally lll paLlenLs. We assessed Lhe lncldence and characLerlsLlcs of MLs Lo lmprove Lhe paLlenL
safeLy ln such paLlenLs.

Methods: We conducLed a prospecLlve cohorL sLudy aL lnLenslve care unlLs (lCus) of Lhree large LerLlary care hosplLals ln
!apan. 1he prlmary ouLcome of Lhe sLudy was Lhe MLs, deflned as errors whlch could occur aL any process of medlcaLlon
use and whlch may or may noL harm Lhe paLlenLs. 1ralned research nurses revlewed all medlcal charLs, lncldenL reporLs,
and reconclllaLlons from pharmacy Lo ldenLlfy suspecLed MLs and AuLs wlLh Lhelr deLalls as well as Lhe background of
Lhe paLlenLs. Some MLs are assoclaLed wlLh AuLs whlch are prevenLable AuLs, whlle some have slgnlflcanL poLenLlals for
ln[urlng a paLlenL and are consldered as poLenLlal AuLs (AuLs). AuLs are elLher lnLercepLed before reachlng AuLs or
noL lnLercepLed buL do noL happen Lo resulL ln AuLs. AfLer Lhose suspecLed evenLs were collecLed, physlclan revlewers
lndependenLly evaluaLed Lhem and classlfled Lhem as MLs, AuLs, AuLs, or rule vlolaLlons. hyslclan revlewers assessed
Lhe error sLage of MLs ln addlLlon Lo lLs prevenLablllLy, and raLed AuLs and AuLs accordlng Lo Lhe severlLy of (poLenLlal)
ln[ury. All process above was conducLed followlng Lhe valldaLed meLhodology
1
.

kesu|ts: 1hls sLudy lncluded 439 paLlenLs wlLh 3231 paLlenL-days. 1he medlan age of paLlenLs was 70 years old and 290
(63) were male. Among Lhese 439 paLlenLs, 30 paLlenLs (11) had aL leasL one ML durlng Lhelr lCu sLay and Lhe
lncldence of MLs was 17.0 per 1,000 paLlenL-days. AuLs occurred ln 30 paLlenLs wlLh 33 evenLs. 1he mosL common error
sLage was physlclans' orderlng (38) followed by admlnlsLraLlon (20), monlLorlng (20), and dlspenslng (2). 1he mosL
frequenL drugs for MLs were anLl-hyperLenslves (36), elecLrolyLes and flulds (13), and anLlbloLlcs (13). Among 33
MLs, 49 (89) were noL lnLercepLed, and 16 of Lhese non-lnLercepLed MLs resulLed ln AuLs whlch were consldered as
prevenLable AuLs. 1wo of Lhe prevenLable AuLs were faLal or llfe-LhreaLenlng: one was meLhlclllln reslsLanL
sLaphylococcus aureus lnfecLlon afLer prolonged anLlbloLlcs use and anoLher was hypoLenslon caused by Lhe omlLLed
vasopressor agenLs. We also ldenLlfled 36 AuLs: 4 (11) were lnLercepLed whlle 32 (89) were noL. LlghLy nlne per
cenL of all AuLs were poLenLlally serlous and 11 were poLenLlally slgnlflcanL.

Conc|us|on: MLs were common aL lCu and a parL of Lhem resulLed ln faLal prevenLable AuLs. AuLomaLed deLecLlon and
prevenLlon of MLs should lmprove Lhe morLallLy of crlLlcally lll paLlenLs aL lCus.

keferences: 1. MorlmoLo 1 eL al, Cual Saf PealLh Care, 2004, 13(4):306-14



1S06

SUCCLSSIUL kLALISA1ICN CI 6-SIGMA ICk IMkCVLMLN1 CI nLAL1nCAkL UALI1
Mln-!eong klm
1, 1,*
, So-!eong klm
1
, 8ok-nam Lee
1, 2
, !oon-?oung Pyeon
1

1
ManagemenL lnnovaLlon Cfflce,
2
L8, Seoul naLlonal unlverslLy 8undang PosplLal, Seongnam, korea, 8epubllc Cf


Cb[ect|ves: Slnce sLarLlng lLs servlce, Snu8P has been engaged ln varlous lnnovaLlve acLlvlLles such as CA (CuallLy
Assurance), sLudy organlsaLlon and suggesLlon sysLem Lo lmprove healLhcare quallLy and cusLomer saLlsfacLlon. SLlll,
even more aggresslve lmprovemenLs ln healLhcare quallLy and cusLomer saLlsfacLlon are requlred Lo survlve Lhls ever-
escalaLlng compeLlLlon ln Lhe medlcal fleld. 1o Lhls end, Snu8P lnLroduced Lhe 6-slgma lnlLlaLlve. 1he facL LhaL even Lhe
smallesL mlsLake ln llfe-deallng medlcal servlce can lead Lo faLal ouLcome ls ln llne wlLh Lhe zero-defecL prlnclple 6-slgma
pursues.

Methods: A sLraLegy for successful reallsaLlon of 6-slgma was formulaLed, and sysLemlc execuLlon was carrled ouL based
on Lhls. llrsL, we exerLed ourselves Lo bulld consensus among Cllnlcal ueparLmenLs Lo reallse 6-slgma lnlLlaLlve. uurlng
Lhe second half of 2003, prlor Lo sLarLlng 6-slgma, offllne Lralnlng for professors and deparLmenL heads and onllne
Lralnlng for Lhe ueparLmenL were provlded. Secondly, organlsaLlon sLrucLure and rewardlng sysLem for Lhe purpose of
sLrong momenLum were esLabllshed. 6-slgma SLeerlng CommlLLee was formed Lo boosL drlvlng force, and a dedlcaLed 6-
slgma ueparLmenL was launched Lo supporL relevanL operaLlons. 1hlrdly, varlous Lralnlng sesslons such as problem
recognlLlon, ldea developmenL, and sLaLlsLlcal managemenLs requlred Lo lmplemenL 6-slgma were provlded Lo 6-slgma
lnlLlaLlve leaders (8lack 8elL) and Leam members, and an lnnovaLlve human resources lnfrasLrucLure bulldlng sysLem was
esLabllshed Lo furLher galn Lhe momenLum. lourLhly, for Lallored execuLlon, 6-slgma experLs (M88: MasLer 8lack 8elL)
were formed and 6-slgma Lralnlng maLerlals cusLomlsed Lo Lhe hosplLal were developed. llfLhly, Lhe launchlng evenLs of
lnnovaLlve acLlvlLles and ouLcomes of 6-slgma lnlLlaLlve were shared on- and off-llne Lo boosL lnLeresLs on and promoLe
Lhe program. SlxLhly, posL managemenL sysLem and posL lndex monlLorlng sysLem were developed ln order Lo properly
apply and malnLaln Lhe lmproved ouLcomes wlLh 6-slgma. SevenLhly, boLLom-up as well as Lop-down approaches were
comblned Lo ldenLlfy challenglng and pracLlcal pro[ecLs LhaL are assoclaLed wlLh core cusLomer needs and Lhe cenLer
sLraLegy. AfLerwards, Snu8P ls also managlng a procedure LhaL gaLhers ldeas across ueparLmenLs.

kesu|ts: llfLy-flve (33) 6-slgma pro[ecLs were lmplemenLed over 7 years and achleved Lhe mean lmprovemenL raLe of
47. llrsL, ln Lerms of ma[or lmprovemenLs assoclaLed wlLh paLlenL safeLy, hand hyglene performance raLe lmproved by
23 and Lhe ma[or mulLldrug-reslsLanL bacLerla lsolaLlon raLe decreased. Second, ln Lerms of key lmprovemenLs
regardlng enhanced cusLomer saLlsfacLlon, ouLpaLlenL walLlng-Llme, blood sampllng walLlng-Llme, and operaLlon walLlng-
Llme were shorLened Lo save Llme for paLlenLs, and a sysLem LhaL can Lrack Lhe ouLpaLlenL walLlng-Llme was lnsLlLuLed.
1hlrd, for ma[or lmprovemenLs assoclaLed wlLh lncreased efflclency of hosplLal operaLlons, Snu8P became Lhe flrsL local
hosplLal LhaL compuLerlsed all surgery, operaLlon and LesL consenLs Lhereby, enabllng Lhelr ublqulLous preparaLlon
Lhrough compuLer or LableL C and prevenLlng loss of lnformed consenL and omlsslon of key lnformaLlon lLems.

Conc|us|on: AlLhough a number of promlnenL medlcal cenLers ln korea lnLroduced 6-slgma, many of Lhem falled because
Lhey could noL lnvolve enLlre ueparLmenLs. Snu8P was able Lo reallse a cusLomlsed 6-slgma lnlLlaLlve based on sLrong
momenLum, sysLemlc advancemenL, compensaLlon for performance, and consensus esLabllshmenL across ueparLmenLs.
We are polsed Lo go a sLep furLher, and endeavour Lo be a cusLomer-orlenLed hosplLal LhaL dellvers Lhe besL value for
our paLlenLs.



1S22

kCVIDING AN LVIDLNCL-8ASLD kLMINDLk IN1LkVLN1ICN 1C kLDUCL INAkCkIA1L UkINAk CA1nL1LkISA1ICN
AND kLDUCL CA1nL1Lk-ASSCCIA1LD UkINAk 1kAC1 INILC1ICNS IN nCSI1ALISLD A1ILN1S IN A MLDICAL CLN1Lk
IN 1AIWAN
Shlrllng Lln
1
, Pslang-?u Lln
1,*

1
ueparLmenL of nurslng, 1alpel veLerans Ceneral PosplLal, 1alpel, 1alwan


Cb[ect|ves: CaLheLer-assoclaLed urlnary LracL lnfecLlon (CAu1ls) can resulL ln sepsls, prolonged hosplLallsaLlon, addlLlonal
hosplLal cosLs, and morLallLy. 1he purpose of Lhls sLudy was Lo esLabllsh an evldence-based urlnary LracL care for general
hosplLallsed paLlenLs and Lo provlde Lhe comprehenslve sLraLeglc conLenLlous care plans for lmprovlng Lhe quallLy of
care for paLlenLs wlLh urlnary caLheLers.

Methods: 1hls research deslgn used Lwo meLhods:

1. Lo use sysLemaLlc revlew meLhod and search cllnlcal guldellne Lo lnvesLlgaLe Lhe ma[or domalns of urlnary LracL
sLandardlsed care and lnLervenLlon ln general hosplLallsed paLlenLs and Lhe effecLlves of each sLraLegy ln each
domaln,
2. Lo lnvesLlgaLe Lhe effecLlveness of Lhls sLandardlsed remlnder lnLervenLlon for urlnary LracL care Lo general
hosplLallsed paLlenLs. A pre-posL quasl-experlmenLal deslgn was used. LlghLy-slx paLlenLs ln flve wards ln a medlcal
cenLer were lnvlLed wlLh 32 ln Lhe conLrol group and 34 ln Lhe experlmenLal group. Ceneral medlcal paLlenLs who
admlLLed wlLh loley were lncluded, buL lf urlnary LracL lnfecLlon happened by admlLLed Llme was excluded.

kesu|ts: 1he flndlngs were Lhe followlng: (1) 1he success raLe for loley removlng was lncreased from experlmenLal group
(33.7) Lo conLrol group (31.3), (2) 1he AbsoluLe rlsk reducLlon of urlnary LracL lnfecLlon from Lwo groups was 9.8,
calculaLed Lhe number need Lo LreaL was 7, (3) LsLlmaLed Lhe savlng cosL of annual medlcal expense was n1$ 3,883,000
3,180,000, (4) 1he adherence raLe of nurses for performlng Lhe urlnary LracL sLandardlsed care guldellne were 90.7.

Conc|us|on: 1he resulL of Lhls sLudy developed a sLandardlsed urlnary LracL care lnLervenLlon for general hosplLallsed
paLlenLs and provlded Lhe lmplemenLaLlon of an lnLervenLlon Lo [udge approprlaLeness of lndwelllng urlnary caLheLers.
lurLhermore, lL would be recommended expandlng Lhls urlnary LracL care guldellne Lo oLher lnsLlLuLlon.

keferences: AplsarnLhanarak, A., 1hongphubeLh, k., Slrlnvaravong, S., klLkangvan, u., ?uekyen, C., Warachan, 8.,Warren,
u. k., & lraser, v. !. (2007). LffecLlveness of mulLlfaceLed hosplLal wlde quallLy lmprovemenL programs feaLurlng an
lnLervenLlon Lo remove unnecessary urlnary caLheLers aL s LerLlary care cenLer ln 1halland. lofectloo coottol ooJ nospltol
plJemloloqy, 28(7), 791-798. Loeb, M., PunL, u., C'Palloran, k., Carusone, S.C., uafoe, n., & WalLer, S. u. (2008). SLop
orders Lo reduce lnapproprlaLe urlnary caLheLerlsaLlon ln hosplLallsed paLlenLs: a randomlsed conLrolled Lrlal. Iootool of
Ceoetol lotetool MeJlcloe, 2J(6), 816-820. Meddlng, !., 8oger, M. A., Macy, M., & SalnL, S. (2010). SysLemaLlc revlew and
meLa-analysls: remlnder sysLems Lo reduce caLheLer-assoclaLed urlnary LracL lnfecLlons and urlnary caLheLer use ln
hosplLallsed paLlenLs. cllolcol lofectloos ulseose, 51(3), 330-360.




1S36

1nL SS1LMS-8ASLD MANAGLMLN1 CI LA8CkA1Ck kLSUL1S IN kIMAk CAkL: LUkCLAN CCNSLNSUS CN SAIL
kAC1ICLS
aul 8owle
1,*
, !ohn Mckay
1

1
osLgradraduaLe Ceneral racLlce, nPS LducaLlon for ScoLland, Clasgow, unlLed klngdom


Cb[ect|ves: 1he sysLems-based managemenL of laboraLory resulLs ln prlmary care can be lnadequaLe and ls a slgnlflcanL
source of error, harm and llLlgaLlon. As parL of Lhe Lu-funded LlnnLAuS Lu8C-C pro[ecL, we almed Lo galn Luropean
consensus on good pracLlce guldance for Lhe safe orderlng of laboraLory blood LesLs and Lhe sysLems-
based managemenL of resulLs ln prlmary care

Methods: We used mulLlple meLhods Lo collecL and LrlangulaLe daLa Lo lnform good pracLlce guldance and galn
agreemenL wlLh prlmary care professlonals ln Lhe unlLed klngdom and wlder Lurope:

1. A comprehenslve revlew of lnLernaLlonal llLeraLure,
2. LxploraLory workshops wlLh a range of prlmary care sLaff groups,
3. A human facLors analysls of slx general pracLlce resulLs managemenL sysLems,
4. uaLa from an anLhropologlcal sLudy of organlsaLlon culLure ln four general pracLlces,
3. uaLa from 467 cllnlcal rlsk self-assessmenLs by Lhe Medlcal roLecLlon SocleLy,
6. locus groups wlLh fronLllne recepLlon sLaff and paLlenLs wlLh chronlc dlsease, and
7. Consensus meeLlng wlLh experL represenLaLlves from Len Luropean counLrles.

kesu|ts: Consensus was agreed on Len safeLy domalns (e.g. CbLalnlng a blood sample, 8evlew of laboraLory resulLs) and
relaLed good pracLlce sLaLemenLs (e.g. a formal sysLem ls ln place Lo ldenLlfy paLlenLs who do noL aLLend for blood LesLs
or who mlss a relaLed appolnLmenL). A care bundle lnLervenLlon meLhod Lo measure compllance wlLh safe pracLlce was
also developed.

Conc|us|on: ln Lhe absence of any evldence based guldance ln Lhls area, we developed comblned fronLllne pracLlLloner
and experL consensus on a serles of good pracLlce sLaLemenLs Lo lmprove Lhe safeLy of laboraLory LesL orderlng and
resulL managemenL sysLems aL all relevanL sLages of Lhe process ln prlmary care. 1he nexL developmenL ls Lo sLudy how
prlmary care Leams lmplemenL Lhls guldance Lo reduce assoclaLed healLhcare rlsks and make relaLed sysLems safer for
paLlenLs.




1S41

IMkCVING 1nL UALI1 CI CS1-CLkA1IVL nANDCVLk IN 1nL CS1-ANLS1nLSIA CAkL UNI1 8 USING 1nL IS8Ak
1CCL
Shu-Chlng Chl
1,*
, Chlen-!ou 1sou
1
, ?u-Wel Puang
2
, Pung-Shu Chen
2

1
ueparLmenL of nurslng,
2
ueparLmenL of AnaesLheslology, L-uA PosplLal, l-Shou unlverslLy, kaohslung ClLy, 1alwan


Cb[ect|ves: LffecLlve handover beLween shlfLs ls crlLlcal for safe paLlenL care. CommunlcaLlon fallure due Lo lnadequaLe
handover has been ldenLlfled as a ma[or cause of adverse hosplLal evenLs. 8ecenL sLudles lndlcaLe LhaL Lhe lS8A8 Lool
may lmprove handover Lhrough offerlng an expecLed paLLern of Lransferred lnformaLlon. 1he purpose of Lhls sLudy was
Lo lnvesLlgaLe wheLher sLrucLured communlcaLlons uslng Lhe lS8A8 Lool lmproved Lhe quallLy of posLoperaLlve handover
ln Lhe posL-anaesLhesla care unlL (ACu).

Methods: lrom !anuary Lo uecember 2012, a sLrucLured handover pro[ecL based on Lhe lS8A8 Lool was lmplemenLed on
a posL-anaesLhesla case unlL ln Lhe L-uA PosplLal, locaLed ln kaohslung, 1alwan. ln Lhe flrsL 3 monLhs (!anuary March)
of Lhls pro[ecL, basellne daLa were collecLed by a pre-lS8A8 survey Lo assess posLoperaLlve handover mlsLakes, duraLlon,
and saLlsfacLlon from sLaff nurses ln Lhe ACu and operaLlng room. ln Lhe nexL slx monLhs (Aprll SepLember), a lS8A8
Lralnlng program lncludlng Lhe background of Lhe pro[ecL, concepL of Lhe lS8A8 Lool, and pracLlce prlnclples was
lnLroduced Lo all parLlclpanLs. ln Lhe lasL 3 monLhs of Lhls pro[ecL (CcLober uecember), a posL-lS8A8 survey conLalnlng
Lhe same evaluaLed lLems as ln Lhe pre-lS8A8 survey was carrled ouL. 1he pre-lS8A8 and posL-lS8A8 surveys were
analysed and compared Lo valldaLe Lhe effecL of Lhe lS8A8 Lool on posLoperaLlve handover.

kesu|ts: A LoLal of 132 sLaff nurses were recrulLed ln Lhls sLudy. 1he raLes of handover mlsLakes occurred per monLh
decreased from 0.38 (23/ 4290) ln Lhe pre-lS8A8 survey Lo 0.13 (7/4374) ln Lhe posL-lS8A8 survey. 1he average
duraLlon of handover per paLlenL also shorLened from 243 seconds durlng Lhe pre-lS8A8 survey Lo 109 seconds durlng
Lhe posL-lS8A8 survey. 1he poslLlve saLlsfacLlon raLes Lo posLoperaLlve handover lncreased from 38 (77/132) ln Lhe
pre-lS8A8 survey Lo 77 (102/132) ln Lhe posL-lS8A8 survey.

Conc|us|on: 1he resulLs of Lhls sLudy show LhaL lmplemenLaLlon of Lhe lS8A8 Lool ln Lhe posL-anaesLhesla care unlL can
lmprove Lhe quallLy of posLoperaLlve handover. 1he lS8A8 handover Lool ls helpful for sLaff nurses Lo reduce handover
mlsLakes, save handover duraLlon, and enhance handover saLlsfacLlon.



1S4S

LUM8Ak UNC1UkLS CN MLDICAL WAkDS - IMkCVING A1ILN1 CAkL AND MINIMISING kISkS CI CCMLICA1ICNS
Lorna ?oung
1,*
, vanessa vallance
1
, 1racey uunn
1

1
nPS Lanarkshlre, Lanarkshlre, unlLed klngdom


Cb[ect|ves: Lumbar puncLures (Ls) are regularly performed by Lralnee physlclans. Appreclable rlsks are assoclaLed wlLh
dural puncLure lncludlng posL-dural puncLure headache (uP). WlLhln anaesLheLlc pracLlce, lL ls recognlsed LhaL sLrlcL
asepsls and use of 23 Cauge aLraumaLlc needles reduces Lhese rlsks conslderably [1, 2, 3]

WlLh Lhls ln mlnd, we wlshed
Lo revlew currenL Lechnlque adopLed by Lralnee physlclans wlLhln nPS Lanarkshlre when performlng Ls, and assess how
lL may be reflned Lo reduce rlsks of compllcaLlons.

Methods: An onllne survey was senL Lo all l?2 and S1 level medlcal Lralnees. CuesLlons covered grade and experlence,
asepLlc Lechnlque employed, equlpmenL cholce, rlsk recognlLlon, documenLaLlon and LreaLmenL opLlons for uP.

kesu|ts: 1here were 31 responders ranglng from l?2 Lo senlor Lralnees. Cnly slx had been LaughL by a consulLanL
physlclan or anaesLheLlsL. AsepLlc Lechnlque varled wldely, wlLh all uslng sLerlle gloves, buL few wearlng surglcal haLs,
masks or gowns. lourLeen responders reporLed uslng cuLLlng needles, almosL 30 dld noL know whaL Lype of needle
Lhey use. 70 used an 18, 20 or 22C needle, a furLher 16 dld noL know whaL needle gauge Lhey use. Cnly 26 of
Lralnees documenL rlsks dlscussed when obLalnlng lnformed consenL. 1wenLy-seven responders offered epldural blood
paLch as a poLenLlal LreaLmenL modallLy for uP.

Conc|us|on: Cur survey hlghllghLs LhaL medlcal Lralnees' L Lechnlque could be reflned, parLlcularly ln Lerms of
equlpmenL selecLlon, Lo reduce poLenLlal harm. lL has sLlmulaLed dlscusslon wlLhln Lhe LrusL on how Lhls rlsk can besL be
mlnlmlsed. nPS Lanarkshlre's cllnlcal educaLlon deparLmenL has adopLed new documenLaLlon Lo emphaslse Lhe
mlnlmlsaLlon of rlsk Lhrough equlpmenL selecLlon, and lmprove knowledge of compllcaLlons and Lhelr
managemenL. 1hls new documenLaLlon ls used durlng mandaLory cllnlcal skllls sesslons for l?2 level
docLors. lurLhermore, consulLanL anaesLheLlsLs and physlclans wlLhln Lhe LrusL are currenLly ln Lhe process of
sLandardlslng equlpmenL avallable on wards and are produclng a procedural proLocol or 'bundle' ln llghL of Lhese
flndlngs.

keferences:
1. earl L, McCllnLock WM. Addendum Lo assessmenL: revenLlon of posL-lumbar puncLure headaches: reporL of Lhe
1herapeuLlcs and 1echnology AssessmenL SubcommlLLee of Lhe Amerlcan Academy of neurology, 2003.
2. 1homas S8, !amleson u8 and Mulr kW. 8andomlsed conLrolled Lrlal of aLraumaLlc versus sLandard needles for
dlagnosLlc lumbar puncLure. 8tltlsb MeJlcol Iootool 2000, 321: 986-990.
3. 8aer L. laLrogenlc MenlnglLls: 1he Case for lace Masks. cllolcol lofectloos ulseoses. volume 31, lssue 2, p. 319-321.



1SSS

IMkCVING 1nL DCCk 1C NLLDLL 1IML IN S1kCkL A1ILN1S A1 1nL UNIVLkSI1 nCSI1AL 1U8INGLN, GLkMAN
!ens Maschmann
1,*
, Manfred 8eck
2
, Sven oll
3

1
8uslness uevelopmenL unlL,
2
Ceneral Surgery,
3
neurology, unlverslLy PosplLal 1ublngen, 1blngen, Cermany


Cb[ect|ves: uue Lo an enlargemenL of Lhe SLroke unlL (Su) aL 1blngen unlverslLy PosplLal Lhe process of emergency
work-up for sLroke paLlenLs had Lo be redeslgned. lnsLead of dolng Lhe work-up on Lhe Su lL was Lransferred Lo Lhe
emergency deparLmenL (Lu) of Lhe uepL. of Ceneral Surgery. 1he lnLerprofesslonal approach and Lhe resulLs are belng
presenLed here.

Methods: ln an lnLerprofesslonal approach we lnvolved neurologlsLs, surgeons, (neuro) radlologlsLs, and nurses Lo
redeslgn Lhe workflow of Lhe paLlenLs belng admlLLed wlLh suspecLed sLroke. lor preparaLlon we analysed Lhe sLaLus
anLe wlLh dlrecL admlsslon Lo Lhe Su and secondary Lransfer from Lhere Lo Lhe C1-lmaglng slLe ln Lhe uepL. of
neuroradlology. We Lhen lnLroduced a new llne of acLlon wlLh Lhe emergency work-up sLarLlng already ln Lhe emergency
faclllLy of Lhe uepL. of Ceneral Surgery uslng Lhe same lmaglng slLe ln Lhe uepL. of neuroradlology. ln a furLher sLep of
lmprovemenL Lhe dedlcaLed C1 for emergency admlsslons of Lrauma paLlenLs was used Lo make Lhe lnlLlal lmaglng rlghL
away and Lhe algorlLhm was ad[usLed accordlngly.

kesu|ts: 1he new paLhway was lnLroduced and evaluaLed ln CcLober 2012. Cf a LoLal of 168 admlsslons Lo Lhe Su 64
were announced Lo Lhe emergency deparLmenL (2/day). 43 of Lhese could lndeed be assessed ln Lhe Lu (1.3/day), 11
Llmes Lhe Lu was occupled (3xpolyLrauma, 6xsLroke), and 8 Llmes Lu assessmenL was lnhlblLed for oLher reasons. 1he
Lable shows Lhe Llme sLamps of Lhe old and Lhe new paLhway (phase l).

number
of
aLlenLs
Admlsslon-Lo-uoor
Llme
uoor-Lo-C1
Llme
uoor-Lo-
needle Llme
Admlsslon-Lo-needle
Llme
CcLober
2011
9 3-10 mln. 18 mln. 32 33-60 mln.
CcLober
2012
3 1-2 mln. 22 mln. 44 66-67 mln.

AfLer provlng LhaL Lhe new paLhway was almosL as fasL as Lhe old one we sLarLed Lo furLher lmprove lL (measuremenLs
are currenLly under way). Admlsslon sLarLs now (leb. 2013) dlrecLly on Lhe C1-scanner ln Lhe emergency deparLmenL
wlLh a full lmaglng work-up (cC1, C1-A, C1-). A sLandard operaLlng procedure was deslgned Lo clarlfy Lhe processes for
Lhe dlfferenL dlsclpllnes worklng LogeLher Lo help Lhe paLlenL wlLh suspecLed sLroke.

Conc|us|on: AlLhough mulLlple dlsclpllnes had Lo be lnvolved Lo redeslgn Lhe SLroke-paLhway, LogeLher we have
esLabllshed a new way for Lhe lnlLlal dlagnosLlc and LherapeuLlc work-up. AfLer evaluaLlon of Lhe process Llmes before
and afLer Lhe change we already sLarLed generaLlng new ldeas Lo lmprove Lhe process. 1he evaluaLlon of Lhls phase ls
currenLly under way. Cur alm ls Lo beaL 20 mln. from admlsslon Lo needle.

keferences: 8aron 1999, Packe 2008, Saver 2006, MereLo[a 2012



1SS9

DIIILkLNCLS IN nCSI1AL kLSCNSLS 1C VCLUN1AkIL kLCk1LD MLDICA1ICN LkkCkS DLLNDING CN 1nL 1L
CI nLAL1nCAkL kCILSSICNAL kLCk1ING 1nL LVLN1
Peon-!ae !eong
1,*
, !esslca M. lranklln
2
, Laura Morlock
1

1
PealLh ollcy and ManagemenL, !ohns Popklns 8loomberg School for ubllc PealLh, 8alLlmore,
2
ulvlslon of
harmacoepldemlology & harmacoeconomlcs, 8rlgham and Women's PosplLal and Parvard Medlcal School, 8osLon,
unlLed SLaLes


Cb[ect|ves: Lrror reporLs and subsequenL lmprovemenL acLlons are crlLlcal componenLs ln paLlenL safeLy, posslbly
prevenLlng Lhe same evenLs from occurrlng agaln. 1hls sLudy lnvesLlgaLes how hosplLals respond dlfferenLly Lo
medlcaLlon error reporLs submlLLed by dlfferenL ma[or healLhcare professlonal Lypes ln Lhe medlcaLlon use process -
physlclans, nurses and pharmaclsLs.

Methods: uaLa from a naLlonal volunLary medlcaLlon error reporLlng sysLem (MLuMA8) ln Lhe uS from 1997 Lhrough
2007 were uLlllsed for Lhls sLudy. A loglsLlc regresslon model was applled Lo undersLand Lhe dlfference ln Lhe odds LhaL
an error reporL leads a hosplLal Lo Lake acLlons dependlng on Lypes of reporLers. AcLlons were acknowledged only when
solld changes Look place followlng error reporLs, such as pollcy/procedure, sLafflng, envlronmenL, formulary and
compuLer sofLware changes.

8ecause harmful errors generally lnduce more acLlons Lhan non-harmful errors, we examlned Lhe effecL of Lhe reporLer
separaLely ln harmful and non-harmful error reporLs. ln addlLlon, Lhe dlfferences ln responses among dlfferenL Lypes of
hosplLal ownersgovernmenL hosplLals (CP) and non-governmenL hosplLals (nCP)were analysed Lo see wheLher Lhey
lnfluence responses Lo error reporLs.

hases of Lhe medlcaLlon use process such as prescrlblng, Lranscrlblng, dlspenslng, admlnlsLerlng and monlLorlng
medlcaLlon are relaLed Lo reporLer Lype (e.g., pharmaclsLs Lend Lo deLecL mosL prescrlblng errors), and Lhus are
conLrolled ln Lhe analysls. Also, ln order Lo address any clusLerlng of reporLs wlLhln hosplLals, Lhe model lncluded a
random lnLercepL for hosplLal.

kesu|ts: A LoLal of 603,422 medlcaLlon error reporLs collecLed from 374 hosplLals (133 CP and 421 nCP) were analysed.
Among Lhose errors, 394,232 (98.2) were non-harmful and 11,190 (1.8) were harmful errors. nurses reporLed 38.1
of Lhe errors, followed by pharmaclsLs (39.7) and physlclans (2.2).

lor non-harmful error reporLs, we found LhaL reporLs from nurses and pharmaclsLs were less llkely Lo lead a hosplLal Lo
Lake acLlons Lhan Lhose from physlclans. Compared Lo hosplLal responses Lo reporLs from physlclans, reporLs from
nurses lnduced slgnlflcanLly fewer acLlons boLh ln CP (C8=0.63, 93 Cl: 0.32-0.77) and nCP (C8=0.62, 93 Cl: 0.33-
0.72). 1he C8s for pharmaclsLs (compared Lo physlclans' reporLs) were 0.23 (93 Cl: 0.20-0.30) ln CP, and 0.36 (93 Cl:
0.48-0.66) ln nCP.

lor harmful errors, ln CP, reporLs from nurses and pharmaclsLs were also less llkely Lo lead Lo acLlon compared Lo
physlclans' reporLs (nurses: C8=0.38, 93 Cl: 0.42-0.79, pharmaclsLs: C8=0.60, 93 Cl: 0.41-0.87). ln nCP, no
sLaLlsLlcally slgnlflcanL dlfference was observed ln hosplLal responses Lo error reporLs from physlclans and pharmaclsLs,
buL reporLs from nurses were sLlll slgnlflcanLly less aLLended Lo by hosplLals compared Lo Lhose from physlclans
(C8=0.36, 93 Cl: 0.43-0.74).

Conc|us|on: ldeally, error reporLs should lnlLlaLe lmprovemenL acLlons regardless of Lypes of reporLers. Powever, Lhls
sLudy shows LhaL hosplLals are less llkely Lo respond Lo reporLs from nurses and pharmaclsLs compared Lo Lhose from
physlclans. 1hls can decrease Lhe morale of healLhcare professlonals whose reporLs were noL addressed well. PealLhcare
organlsaLlons wlLh error reporLlng sysLems need Lo Lake full advanLage of Lhese under-uLlllsed error reporLs, as Lhey are
a rlch poLenLlal source of lnformaLlon for lmprovlng safeLy.


1S61

IUS1 AS DISSA1ISIILD, 8U1 ICk DIIILkLN1 kLASCNS - A1ILN1S WI1n DIA8L1LS CCMAkLD 1C 1nL GLNLkAL CULA1ICN.
vlbeke Sparrlng
1,*
, Pelena PvlLfeldL lorsberg
1
, Sara 1olf
1
, Carollna Wannheden
1

1
ueparLmenL of Learnlng, lnformaLlcs, ManagemenL and LLhlcs, karollnska lnsLlLuLeL, SLockholm, Sweden


Cb[ect|ves: MeeLlng Lhe needs of Lhe growlng number of people wlLh chronlc condlLlons provlde one of Lhe ma[or challenges ln
healLh care. Lxplorlng paLLerns of paLlenL dlssaLlsfacLlon could provlde an opporLunlLy for healLhcare lmprovemenL. Areas of
dlssaLlsfacLlon lnclude access Lo care, quallLy of care recelved, and paLlenL-provlder lnLeracLlon. aLlenLs' predlsposlLlon, healLhcare
uLlllsaLlon and healLh sLaLus are oLher facLors LhaL may play an lmporLanL role ln paLlenL saLlsfacLlon. 1he ob[ecLlve was Lo ldenLlfy
facLors of dlssaLlsfacLlon wlLh healLh servlces among paLlenLs wlLh dlabeLes compared Lo conLrol lndlvlduals.

Methods: As parL of a healLhcare uLlllsaLlon sLudy, a quesLlonnalre was senL Lo paLlenLs wlLh dlabeLes and maLched conLrols.
aLlenLs were selecLed from Lhe ulabeLes lncldence SLudy ln Sweden, ln whlch lncldenL cases of dlabeLes melllLus among lndlvlduals
aged 13-34 years are reglsLered prospecLlvely slnce 1983. lor each case, Lwo conLrol lndlvlduals were selecLed from Lhe general
populaLlon reglsLer maLched by age, sex and counLy of resldence.
1he quesLlonnalre lncluded one open-ended quesLlon asklng dlssaLlsfled paLlenLs Lo descrlbe Lhe naLure of Lhelr dlssaLlsfacLlon wlLh
healLh care.

CuallLaLlve conLenL analysls was used Lo analyse all answers (n=471). 1he uonabedlan concepLual model (1988) of quallLy ln
healLhcare (sLrucLure, process, ouLcome) was used Lo lnLerpreL caLegorles ldenLlfled durlng Lhe analysls.

kesu|ts: uesplLe paLlenLs wlLh dlabeLes havlng a slgnlflcanLly hlgher uLlllsaLlon of healLhcare, Lhere was no slgnlflcanL dlfference ln
dlssaLlsfacLlon (21 vs. 19). Women were more llkely Lo be dlssaLlsfled (p<0.001) as were paLlenLs wlLh lower lncome (p<0.001)
and less Lhan good self-raLed healLh (p<0.001).

1he quallLaLlve analysls ldenLlfled llmlLaLlons ln access Lo care, poor follow-up, and problems ln lnLeracLlon wlLh care personnel.
Accordlng Lo Lhe uonabedlan model (1able 1) Lhese caLegorles reflecL malnly process- relaLed problems among paLlenLs wlLh
dlabeLes (e.g. poor conLlnuaLlon of care and dlssaLlsfacLlon wlLh healLhcare personnel) and malnly sLrucLure-relaLed problems
among conLrol lndlvlduals (e.g. poor access). Some lndlvlduals ln boLh groups also descrlbed ouLcome-relaLed problems. Lxamples of
sLaLemenLs:

Cet tesolts ftom tests bot oo oltetootlves fot tteotmeot. nove oskeJ fot soqqestloos oo bow to cbooqe my tteotmeot so tbot my
beoltb ls oot o bloJet fot me llvloq o foll llfe.
No oppolotmeot wltblo teosoooble woltloq tlme. 8eeo boJly tteoteJ by Joctot wbeo l bove temloJeJ tbem oboot tbe woltloq tlme
qootootee.

1able 1. Areas of dlssaLlsfacLlon

Category at|ents w|th d|abetes Contro| |nd|v|dua|s
1oLal Women Men 1oLal Women Men
(n=172) (n=93) (n=79) (n=287) (n=139) (n=148)
Structure J7.2 4J.0 J0.4 52.6 56.8 48.6
rocess 47.1 44.1 50.6 40.4 J8.8 41.9
Cutcome 14.5 10.8 19.0 4.9 1.4 8.1


Conc|us|on: Analyslng areas of dlssaLlsfacLlon ls of lmporLance boLh for cllnlcal pracLlce as well as for Lhe sLraLeglc plannlng and
resource allocaLlon. 1he resulLs can gulde lmprovemenL work as lL leads Lo an lncreased undersLandlng of areas lmporLanL Lo
paLlenLs. Cur prellmlnary resulLs are ln llne wlLh prevlous research and show LhaL from Lhe paLlenL's perspecLlve, ma[or challenges
concerned access Lo care (sLrucLure), coordlnaLlon of care servlces and encounLers (process). 1o address Lhese challenges,
lmprovemenL sLraLegles should focus on Lransparency of processes, paLlenL parLlclpaLlon and Llmellness of care. CoordlnaLlon needs
Lo be managed from all healLhcare provlders lnvolved. SLraLegles are needed Lo faclllLaLe paLlenL self-managemenL whlch has been
shown Lo glve fewer sympLoms, fasLer recovery and longer healLhler llves.





1S63

A SS1LMA1IC, 1LAM-8ASLD kCILC1 1C IMkCVL ADMINIS1kA1ICN CI kCnLAC1IC AN1I8IC1ICS
!ul-1eng Chlen
1,*
, Shln-!u Lu
2
, ?u-Llng Wang
2
, Chl-Pul Llu
3

1
CrLhopaedlcs,
2
CenLer for CuallLy ManagemenL,
3
CperaLlon 1heaLre, 8uddhlsL ualln 1zuchl Ceneral PosplLal, Chlayl
CounLy, 1alwan


Cb[ect|ves: Surglcal slLe lnfecLlons are a slgnlflcanL source of morbldlLy and morLallLy whlch can be avolded by
prophylacLlc anLlbloLlcs. 1he purpose of Lhls paper ls Lo descrlbe how we used a sysLemaLlc, Leam-based approach Lo
lmplemenL pracLlce guldellnes for Llmely anLlbloLlc admlnlsLraLlon wlLhln 60 mlnuLes prlor Lo Lhe surglcal lnclslon.

Methods:
1. ln Aug 2010, an lndependenL audlLlng body called 'quallLy assurance (CA) medlcal sLaff, was organlsed Lo monlLor
compllance and provlde feedback ln Lhe Llmlng and admlnlsLraLlon of prophylacLlc anLlbloLlcs.
2. A resoluLlon reached ln Lhe Surglcal MeeLlng demanded Lhe clrculaLlng nurses ln Lhe operaLlon room Lo begln
anLlbloLlc admlnlsLraLlon aL Lhe Llme when Lhe surglcal skln preparaLlon was begun, raLher Lhan when Lhe paLlenL
enLered Lhe room.
3. 1he admlnlsLraLlon and Llmlng of anLlbloLlcs was lncluded ln Lhe '1lme-ouL' sesslon of surglcal safeLy checkllsL, whlch
lnvolves everyone lmmedlaLely prlor Lo Lhe lnclslon, Lo mlLlgaLe Lhe lncldence of unLlmely or LoLal lack of anLlbloLlc
admlnlsLraLlon.
4. MonLhly revlew by CA medlcal sLaff of Lhe daLabase ldenLlfled Lhose cases ln whlch anLlbloLlcs were (1) glven wlLhln
60 mlnuLes of lnclslon, (2) noL glven aL all, (3) glven more Lhan 60 mlnuLes before lnclslon (Loo early), or (4) glven
afLer lnclslon (Loo laLe).
3. 1he speclflc feedback generaLed from Lhe analysls was glven Lo Lhe secLlon chlef and Lhe lndlvldual surgeon or nurse
for lnLernal revlew.
6. 1he CA medlcal sLaff also reporLed Lhe monlLorlng daLa durlng Lhe monLhly all-sLaff Surglcal MeeLlng and Lhe 3-
monLhly lnfecLlon ConLrol CommlLLee.

kesu|ts: 8efore Lhe lnlLlaLlon of Lhls pro[ecL, Lhere was nelLher a monlLorlng mechanlsm by CA peer revlew, nor a
feedback sysLem Lo Lhe nurses or lndlvldual surgeon. 1hus, only 92 of Lhe ellglble paLlenLs recelved anLlbloLlcs wlLhln
60 mlnuLes of Lhe lnclslon. ln !an 2011, four monLhs afLer Lhe pro[ecL began, Lhere was a sLeady lncrease ln compllance
Lo 100. And Lhe good compllance was malnLalned LhroughouL afLer Lhese guldellnes were lncorporaLed ln Lhe sLandard
operaLlng procedure for all surglcal personnel.

Conc|us|on: 8y looklng lnLo Lhe unexplalned varlaLlons and remalnlng lnconslsLencles ln our sysLem, we deslgned a
provlder-speclflc monlLorlng mechanlsm and feedback sysLem Lo lncrease compllance wlLh pracLlce guldellnes relaLed Lo
Llmely admlnlsLraLlon of prophylacLlc anLlbloLlcs. We emphaslsed Lhe lmporLance of solvlng Lhls problem from Lhe polnL
of vlew of Lhe hosplLal sysLem and Leam-based approach, ln whlch nurses, surgeons, and CA medlcal sLaff work ln
parLnershlp Lo brlng abouL conLlnued lmprovemenL ln performance and paLlenL care.



1S66

DLVLLCMLN1 AND LVALUA1ICN CI A CnLCkLIS1 1C SUCk1 DLCISICN-MAkING IN CANCLk MUL1IDISCILINAk
1LAM MLL1INGS: MD1-UIC
8en[amln W. Lamb
1, 2,*
, !ames S. Creen
3
, Charles vlncenL
2
, nlck Sevdalls
2

1
urology, LlsLer PosplLal, SLevenage,
2
CenLre for aLlenL SafeLy and Servlce CuallLy, ueparLmenL of Surgery and Cancer,
lmperlal College London,
3
urology, braLs PealLh, London, unlLed klngdom


Cb[ect|ves: 1he quallLy of declslon-maklng ln cancer mulLldlsclpllnary Leam (Mu1) meeLlngs can vary, whlch may resulL
ln sub-opLlmal cllnlcal declslon-maklng. We developed Mu1-CulC, an evldence based Lool Lo supporL cllnlcal declslon-
maklng by Mu1s, whlch was evaluaLed by key users.

Methods: lollowlng a llLeraLure revlew, facLors lmporLanL for hlgh quallLy cllnlcal declslon-maklng were llsLed, and Lhen
converLed lnLo a prellmlnary checkllsL by cllnlcal and safeLy experLs. ALLlLudes of Mu1 members Lowards Lhe Lool were
evaluaLed vla an on-llne survey, before ad[usLmenLs were made glvlng rlse Lo a flnal verslon: Mu1-CulC.

kesu|ts: 1he checkllsL was evaluaLed by 173 Mu1 members (surgeons=38, speclallsL nurses=62, and Mu1
coordlnaLors=33). ALLlLudes Lowards Lhe checkllsL were poslLlve (<0.001, Cne-sample L LesL), wlLh nurses Lhe mosL
poslLlve group regardlng wheLher Lhe checkllsL would lmprove Lhelr conLrlbuLlon ln Mu1 meeLlngs (<0.001, Mann
WhlLney u LesL). arLlclpanLs LhoughL LhaL Lhe checkllsL could be used Lo prepare cases prlor Lo Mu1 meeLlngs, Lo
sLrucLure and gulde case dlscusslons, or as a record of Mu1 dlscusslon. 8egardlng who could use Lhe checkllsL, 70
LhoughL lL should be used by Lhe Mu1 chalr, 34 by Lhe Mu1 coordlnaLor, and 38 LhoughL all Mu1 members should
use lL.

Conc|us|on: We have developed and valldaLed an evldence based Lool Lo opLlmlse Lhe quallLy of Mu1 declslon-maklng.
Mu1 members were poslLlve abouL Lhe checkllsL, and felL lL may help Lo sLrucLure dlscusslon, lmprove lncluslvlLy and
paLlenL cenLeredness. More research ls needed Lo assess Lhe effecL on paLlenL care and ouLcomes.



1S70

LkCL1ICNS AND A11LkNS CI USL CI GLNLkIC MLDICINLS AMCNG kCkLAN MLDICAL DCC1CkS
!uyoung klm
1,*
, Mlkyung 8yu
1

1
harmaceuLlcal 8eneflL ueparLmenL, PealLh lnsurance 8evlew & AssessmenL Servlce, Seoul, korea, 8epubllc Cf


Cb[ect|ves:
ln 2011, Lhe PealLh lnsurance 8evlew & AssessmenL servlce (Pl8A) lnvesLlgaLed Lhe undersLandlng and oplnlons of
medlcal docLor's abouL blo equlvalence (8L) assured generlc medlclnes.

1hls survey alms Lo promoLe Lhe use of reasonable medlclne and Lo provlde basellne daLa for Lhe esLabllshlng generlc
medlclnes pollcy ln korea.

Methods:
1hls survey was carrled ouL by Pl8A's on llne survey sysLems and Lhe 11 quesLlonnalres were developed Lo assess
docLor's aLLlLudes and undersLandlngs of generlc medlclnes as well as Lhelr wllllngness Lo use generlcs. uaLa analysls was
performed uslng SAS 8.2.

kesu|ts:
361 medlcal docLors, who reglsLered ln Pl8A, Look parL ln Lhe survey (response raLe: 40). 1he ma[orlLy of Lhe
respondenLs (82) knew abouL Lhe 8L guldellne. Powever, only 23.7 of Lhe respondenLs were rellable ln Lhe korea
lood and urug AdmlnlsLraLlon (kluA)'s 8L resulLs. More Lhan 30 of respondenLs preferred orlglnal Lo generlc because
of cllnlcal experlence, 8L confldence llmlLs and generlc confldence llmlLs.

And respondenLs' oplnlons on approprlaLe generlc prlce were dlfferenL from Lhelr poslLlon and speclalLy. 8uL a LoLal of
64.2 of Lhe respondenLs Lhough LhaL korea's generlc prlce ls expenslve compare Lo oLher counLry.

Cn furLher analysls, Lhe respondenL ln Lhls survey answered LhaL Lhe mosL promlnenL facLors assoclaLed wlLh lncrease
for generlc prescrlpLlon are pollcy reform ln conLlnuous posL markeLlng survelllance, 8L confldence recovery, dlsclosure
of 8L resulLs.

Conc|us|on:
1he currenL flndlngs have lmporLanL lmpllcaLlons ln esLabllshlng generlc medlclnes pollcy ln korea.

Accordlng Lo Lhls survey, even LhoughL kluA relnforced 8L sLandard and reformed Lhe generlc pollcy, more Lhan 70 of
respondenLs dldn'L conflde ln 8L resulLs of generlc.

ln order Lo encourage Lhe use of generlc and resLore confldence ln 8L resulLs, lL ls necessary Lo provlde accuraLe
lnformaLlon abouL 8L resulLs and sLrengLhen promoLlon of reformed generlc pollcy. And Lhls wlll need conslsLenL efforLs
ln a long Lerm.



1S77

LVALUA1L A1ILN1 SAIL1 kCGkAMS WI1n SUkVLING A1ILN1 SAIL1 CUL1UkL CI NUkSING S1AIIS IN A
SCU1nLkN MLDICAL CLN1Lk
Mel-!en Chang
1,*
, Psln-l Chlang
1
, !la-lng Chang
1

1
nurslng ueparLmenL, naLlonal Cheng kung unlverslLy PosplLal, 1alnan, 1alwan


Cb[ect|ves: 1hls sLudy used Lhe SafeLy ALLlLudes CuesLlonnalre (SAC) and Agency for PealLhcare 8esearch and CuallLy
(AP8C) Lo assess Lhe culLure of paLlenL safeLy for nurses aL a medlcal cenLer ln souLhern 1alwan, and Lo provlde
educaLlon courses Lo lmprove paLlenL safeLy culLure ln Lhe medlcal cenLer furLher.

Methods: 1he sLudy used SAC and AP8C Lo measure Lhe 9 dlmenslons of Lhe paLlenL safeLy culLure of a medlcal cenLer
ln souLhern 1alwan wlLh Lhe consenL of Lhe 1alwan !olnL Commlsslon on PosplLal AccredlLaLlon (1!CPA). 1hese
dlmenslons lncluded slx SAC dlmenslons - safeLy cllmaLe, Leamwork cllmaLe, sLress recognlLlon, percepLlon of
managemenL, worklng condlLlons, [ob saLlsfacLlon, and Lhree AP8C dlmenslons - hosplLal managemenL supporL for
paLlenL safeLy, Leamwork across hosplLal unlLs, hosplLal handoffs and LranslLlons. 1hls survey recelved 910 respondenLs.
1he sLudy used SSS17.0 for Wlndows Lo perform Lhe sLaLlsLlcal analysls on Lhe survey daLa, lncludlng descrlpLlve
sLaLlsLlc and Chl-square, Cne way AnCvA lnferenLlal sLaLlsLlcs, and mulLlple regresslon analysls.

kesu|ts: 1he overall average poslLlve response score of Lhe SAC ls 72.8.and Lhe poslLlve response score of AP8C ls 61.3.
1he hlghesL poslLlve response score among Lhe SAC dlmenslons ls Leamwork cllmaLe", and Lhe lowesL ls [ob
saLlsfacLlon". 1he hlghesL poslLlve response safeLy", and Lhe lowesL poslLlve response score ls hosplLal handoffs and
LranslLlons" score of Lhe AP8C dlmenslons LhaL recelved ls hosplLal managemenL supporL for paLlenL. 1here are
slgnlflcanL dlfferences (p value = .002 and .016) by comparlng Lhe SAC scale score and Lhe AP8C scale score before and
afLer Lhe lnLervenLlon.

Conc|us|on: 1hls sLudy shows LhaL Lhe Lralnlng for culLure paLlenL safeLy lnsLrucLors and lmplemenLaLlon of paLlenL
safeLy educaLlon Lralnlng program slgnlflcanLly lmprove Lhe poslLlve average scores of nurses' ln Lhe SAC and AP8C
Scale, Lo lnsplrlL Lhe paLlenL safeLy culLure ln Lhe medlcal lnsLlLuLlons.


1S80

kLVISING S1ANDAkDS ICk GLNLkAL kAC1ICL ACCkLDI1A1ICN: A UNIUL S1UD CI LLSSCNS LLAkNLD
uavld Creenfleld
1,*
, Mlchael Clvll
2
, Andrew uonnlson
2
, !effrey 8ralLhwalLe
1

1
CenLre for Cllnlcal Covernance 8esearch, AusLrallan lnsLlLuLe of PealLh lnnovaLlon, unlverslLy of new SouLh Wales,
Sydney,
2
8oyal College of Ceneral racLlLloners, Melbourne, AusLralla


Cb[ect|ves: 1he credlble developmenL or revlslon of sLandards for accredlLaLlon purposes are known Lo be slgnlflcanL
Lasks LhaL uLlllse conslderable human and flnanclal resources. no sLudy has soughL Lo ldenLlfy Lhe resources and
experLlse requlred or reporL evaluaLlon ouLcomes arlslng from Lhls Lask. Cur sLudy addressed Lhls slgnlflcanL gap ln Lhe
knowledge base.

Methods: An experL group, comprlslng academlc researchers and sLandard seLLlng agency sLaff, conducLed a Lhree-sLage
sLudy. llrsL, lnformed by Lhe accredlLaLlon and evaluaLlon llLeraLures, a purpose-deslgned analysls framework was
developed. Second, uslng Lhe framework, documenL analysls of Lhe sLandard seLLlng agency documenLs, mlnuLes and
reporLs was conducLed. 1hlrd, revlew and analysls of daLa collecLed was performed.

kesu|ts: 1he sLandards revlew process, conducLed over a 12 monLh perlod 2009-10, comprlsed slx phases wlLh mulLlple
Lasks. AcLlvlLles lncluded: revlewlng Lhe evldence base supporLlng each sLandard, meLhodology and maLerlal
developmenL, fleld Lrlals, and, documenL revlslon and producLlon. Cver 100 lndlvlduals subsLanLlvely parLlclpaLed ln Lhls
revlew process, wlLh an addlLlonal 30 provldlng perlodlc lnpuL and feedback. arLlclpanLs were drawn from professlonal
assoclaLlons, prlmary healLhcare servlces, accredlLaLlon agencles, governmenL agencles and publlc healLh organlsaLlons.

1helr experLlse spanned: pro[ecL managemenL, sLandards developmenL and wrlLlng, prlmary healLhcare pracLlce, quallLy
and safeLy lmprovemenL meLhodologles, accredlLaLlon lmplemenLaLlon and surveylng, and research.

1he revlew and developmenL process was shaped by flve lssues: pro[ecL expecLaLlons, resource and Llme requlremenLs,
collaboraLlve Leam approach, sLakeholder engagemenL, and producL produced. arLlclpanLs were poslLlve abouL Lhelr
experlence, Lhe sLandards produced and consldered Lhe documenL Lo be hlgh quallLy for Lhree reasons. llrsL, Lhe
credlblllLy of Lhe process, as reflecLed by Lhe exLenslve engagemenL wlLh sLakeholders across AusLralla. Second, Lhe
rlgour applled ln Lhe developmenL, plloLlng and revlslon of maLerlals. 1hlrd, Lhe commlLmenL and efforL of agency sLaff
and commlLLee members, who overcame resource and Llme consLralnLs. A ma[orlLy of parLlclpanLs agreed LhaL
conslderaLlon could be glven Lo alLerlng Lhe sLandards revlslon process Lo conducL perlodlc revlews and progresslve
updaLes.

Conc|us|on: 1hls unlque sLudy shows LhaL credlble revlslon of sLandards for accredlLaLlon purposes requlres conslderable
resources and experLlse, drawn from a broad range of sLakeholders. 1he revlslon process, lncludlng Lhe resources and
Llme allocaLed, and sLakeholder engagemenL sLraLegy, have a ma[or lmpacL on Lhe accepLance of Lhe sLandards.




1S82

IMAC1 CI nCALnALICkC1LINLMIA CN UALI1 CI LIIL IN CLN1kAL C8LSL WCMLN
l-!u Chen
1, 2,*
, Chla-yu Llu
1, 2
, !ung-eng, Chlu Chlu
1, 2
, Chung-Pua Psu
1, 2

1
lnsLlLuLe of 1radlLlonal Medlclne, School of Medlclne, naLlonal ?ang-Mlng unlverslLy,
2
8ranch of Llnsen and Chlnese
Medlclne, 1alpel, 1alwan


Cb[ect|ves: 1o lnvesLlgaLe Lhe relaLlonshlp beLween healLh relaLed quallLy of llfe (P8CoL) and dlfferenL cuL-off value of
low level of hlgh denslLy llpoproLeln cholesLerol (PuL-C) ln cenLral obese women. 1he change of obeslLy-relaLed
hormone pepLldes ln dlfferenL level of PuL-C was also observed.

Methods: rospecLlve observaLlonal sLudy ln cenLral obese women ln 1alpel ClLy PosplLal ln 1alwan. We deflned Lwo
groups as group A (PuL-C <40mg/dL) and group 8 (PuL-C<30mg/dL) accordlng Lo dlfferenL deflnlLlon of
hypoalphallpoproLelnemla ln cenLral obese women.

A LoLal 372 women were screened aL our ouLpaLlenL cllnlc, and 227 of Lhem wlLh a body mass lndex (8Ml)!27 kg/m2
and welghL clrcumference(WC)!80cm were ellglble for Lhe sLudy. Maln ouLcome measures were quallLy of llfe ln
dlfferenL domaln and obeslLy relaLed hormone pepLldes lnclude lnsulln, ghrelln, lepLln, adlponecLln, and lnsulln
reslsLance evaluaLed by Lhe homeosLasls model assessmenL of lnsulln reslsLance (PCMA-l8).

kesu|ts: SlgnlflcanLly reduced P8CoL score was noLed ln group A1(PuL-C <40mg/dL) ln domaln of physlcal (=0.002),
psychologlcal (=0.004), soclal (=0.001), and envlronmenLal (=0.006) compared Lo group A2(PuL-C !40mg/dL), buL
noL beLween group 81(PuL-C<30mg/dL) and group 82(PuL-C!30mg/dL). oslLlvely correlaLlon was noLed beLween PuL-
C level and physlcal domaln of P8CoL score. PuL-C and blood pressure conLrlbuLes lndependenLly Lo physlcal domaln of
P8CoL score afLer conLrolllng for oLher facLors. 8oLh groups wlLh low PuL-C level was noLed Lo have lncreased lnsulln
reslsLance and ghrelln level, as well as decreased lepLln and adlponecLln level.

1ables wlll be ready by Lhe conference

Conc|us|on: CenLral obese women wlLh low PuL-C level have adverse lmpacL on each domaln of Lhe P8CoL, especlally
when Lhe PuL-C level ls lower Lhan 40mg/dL. 8oLh hypoalphallpoproLelnemla and hyperLenslon accounLed for a greaL
varlance Lo lower scores of physlcal domaln of P8CoL wlLh poslLlvely correlaLlon wlLh PuL-C level observed. uecreased
lepLln and adlponecLln along wlLh elevaLed ghrelln and PCMA-l8 lndex was also observed ln hypoalphallpoproLelnemla
group, whlch lmplled elevaLed cardlovascular rlsk. PuL-C level may deem as anoLher lndlcaLor for predlcLlng P8CoL ln
cenLral obese women.



1S90

LNnANCLMLN1 CI nANDWASnING CCMLIANCL 1C kLVLN1 NCSCCCMIAL INILC1ICN
Seung Pyun ark
1,*
, ?oung kyung Seo
1
, keum !oo Lee
1
, Pye Sun klm
1

1
Seoul naLlonal unlverslLy PosplLal, Seoul, korea, 8epubllc Cf


Cb[ect|ves: lL ls well known LhaL cross-lnfecLlon, whlch ls caused by healLhcare workers who falled Lo follow Lhe hand
hyglene pracLlce, ls one of Lhe mosL common sources of hosplLal-acqulred lnfecLlon. ln facL, lL was found LhaL Lhe
compllance raLe for Lhe vasL ma[orlLy of medlcal sLaff remalns low, ranglng from 30 Lo 30 , and LhaL, even lf Lhey do,
Lhey do noL conducL lL properly. 8ased on Lhls, many effecLlve acLlons were Laken ln order Lo lncrease hand hyglene
compllance among surgeons and nurses, and prevenL nosocomlal lnfecLlon ln Lhe Seoul naLlonal unlverslLy PosplLal.

Methods:
1) ldenLlfylng Lhe currenL sLaLus and resLralnLs: When asked abouL prevenLlng lnfecLlon propagaLlon, proLecLlng Lhelr
hands, undersLandlng Lhe serlousness of LransmlLLlng lnfecLlon vla hands, and Lhe effecLlveness of hand hyglene,
surgeons (n=86) and nurses (n=247) were found Lo be well aware of lLs lmporLance wlLh 3.8 of 4 polnLs. Powever,
Lhe Lask-speclflc observaLlon revealed LhaL 74.8 of docLors (n=319) and 34.9 of nurses (n=1,204) dld noL follow
Lhe pracLlce. 1hese numbers were parLlcularly lower when Lhe conLamlnanLs were lnvlslble.
2) Pand washlng leaders and educaLlon: AL each ward, a leader was deslgnaLed wlLh responslblllLles Lo carry ouL
communlcaLlons and conLlnuous monlLorlng.
3) Maklng educaLlonal vldeo: 8ecause Lhe vldeo from WPC, whlch had been used for Lhe lnlLlal hand hyglene
educaLlon, had some llmlLaLlons LhaL could noL apply Lo Lhe acLual fleld, a new vldeo was creaLed Lo show hand
washlng ln flve nurslng Lasks.
4) LducaLlon and monlLorlng: Chlef nurslng offlcer and head nurses sLayed for abouL an hour, provldlng feedback and
Lralnlng aL flve wards wlLh Lhe lowesL compllance raLes accordlng Lo Lhe lnspecLlon by Lhe lnfecLlon ConLrol.
3) CreaLlng and posLlng promoLlonal maLerlals: Pand washlng awareness sLlckers were aLLached Lo dresslng carLs, LM8
carLs and doors Lo each room. 1he Pand washlng AcLlon 8ulleLln 8oards were also lnsLalled for posLlng aL every
ward.
6) osLer conLesL and recognlLlon: A posLer conLesL was held and wlnners were recognlsed for Lo encourage
parLlclpaLlon.
7) Pands-on evenL and campalgn: ln order Lo ralse awareness abouL Lhe proper hand washlng procedures, a
fluorescenL loLlon evenL and campalgn was runnlng.
8) Care and encouragemenL: When professors made Lhelr rounds, head nurses accompanled Lhem Lo explaln Lo
paLlenLs Lhe lmporLance of hand hyglene and rlghL hand washlng meLhod. Also, Lhe pracLlce was encouraged and
checked aL Lhe Llme of dresslng changes or LreaLmenL.
9) 8eLLer envlronmenL: auLomaLlc dlspenslng, easy-Lo-use hand dlslnfecLanLs were lnsLalled ln hlgh proflle spoLs.

kesu|ts: AfLer Lhese acLlons, Lhe overall hand washlng compllance lmproved from 43.3 Lo 83 , speclflcally 23.2 Lo
74 for docLors and 34.9 Lo 90 for nurses. ln addlLlon Lo our own monlLorlng, Lhe offlclal publlcaLlon by Lhe
lnfecLlon ConLrol also showed LhaL Lhe raLes wenL up from 37.3 Lo 69.2 for docLors and 80.9 Lo 89.3 for nurses,
demonsLraLlng LhaL Lhese acLlons were ob[ecLlve effecLlve. 1he dally consumpLlon of hand sanlLlzer per paLlenL lncreased
from 6 ml Lo 14.7 ml, compared Lo Lhe lasL year, and a hlgher saLlsfacLlon level for uslng sanlLlzer was also recorded.

Conc|us|on: 1he acLlons provlded nurses wlLh more knowledge abouL hand hyglene, and promoLed Lhe lnLeresL and
beLLer envlronmenL, brlnglng lL as an acLlve pracLlce and, mosL lmporLanLly, lmprovlng Lhe hand hyglene compllance
raLe. Pand hyglene should noL be a Lemporary, one-Llme evenL. lL ls never oversLaLed LhaL Lhe educaLlon,
communlcaLlon and monlLorlng should conLlnue unLll lL becomes a fully esLabllshed culLure and pracLlce.



1S93

IN1kCDUC1ICN CI 'kLSCkI1ICN SUSLNSICN SCnLML' AND IMkCVLMLN1 AC1IVI1ILS 1C LNnANCL 1nL
CCMLL1LNLSS CI MLDICAL kLCCkDS
Ml 8an ark
1
, ?oung Luy klm
1
, !l Suk Pwang
1
, Ml Sun klm
1,*

1
Medlcal 8ecord ueparLmenL, kangbuk Samsung PosplLal, Seoul, korea, 8epubllc Cf


Cb[ect|ves: Medlcal records are fundamenLal records Lo provlde paLlenLs wlLh conslsLenL and conLlnuous LreaLmenL, and
a means of communlcaLlon among medlcal Leam members who parLlclpaLe ln paLlenL LreaLmenL. AddlLlonally, Lhey are
Lhe maLerlals for Lhe analysls of Lhe quallLy of medlcal servlces provlded Lo paLlenLs and Lhe lndlces for accredlLaLlon and
exLernal evaluaLlons. Accordlngly, an aLLempL was made Lo prepare Lhe medlcal records of paLlenLs by prescrlbed due
daLe. 1hls was done ln order Lo provlde for paLlenL safeLy, Lo meeL varlous evaluaLlon crlLerla, and flnally Lhe
quallflcaLlon of legal medlcal records

Methods: ueparLmenL of medlcal records changed Lhe due daLe of Lhe compleLlon of medlcal records from afLer
dlscharge Lo durlng hosplLallsaLlon. AlLhough medlcal personnel recognlsed Lhe necesslLy Lo prepare medlcal records
wlLhln Lhe prescrlbed perlod, Lhey could noL compleLe Lhe records by Lhe due daLe. 1herefore, lL would seem LhaL
lmprovemenLs Lo Lhe sysLem are lndlcaLed ln order Lo enhance Lhe record keeplng acLlvlLles. We ldenLlfled Lhe currenL
sLaLus by benchmarklng oLher hosplLals and lnLroduced 'rescrlpLlon Suspenslon Scheme' Lo resLrlcL prescrlpLlons of
lnpaLlenLs lf medlcal records were noL compleLed by Lhe due daLe. AdverLlsemenL and educaLlon were provlded Lo
resldenL docLors and sLaff, and varlous lncenLlve meLhods such as emalls, snacks, SMS, noLlflcaLlons vla CCS, meeLlngs
and phone calls were lnLroduced Lo sLablllse Lhe scheme and ldenLlfy Lhe problems. SLaLlsLlcs of documenLaLlon
compleLlon by deparLmenL were posLed and deparLmenLs showlng an excellenL record were rewarded. CusLomlsed
educaLlon was provlded Lo Lhose deparLmenLs showlng a poor documenLaLlon compleLlon raLe

kesu|ts: AfLer Lhe lmprovemenL acLlvlLles, medlcal record keeplng raLe was lmproved from 9.3 ln 2011 Lo 82 ln 2012.

PosplLallsaLlon
8ecords
CperaLlon
8ecords
SpeclalLles durlng
CperaLlon
osL-operaLlon
rogress 8ecord
ulscharge
Summary
Average
2011 (8efore
lnLroducLlon)
23 22 0.6 0.8 2.3 9.3
2012(AfLer lnLroducLlon) 89.1 88.4 60.3 73.9 96.4 82
*uaLed uocumenL CompleLlon 8aLe

Conc|us|on: We changed Lhe medlcal record compleLlon Lask Lo 'ln-hosplLal' work and execuLed Lhe 'prescrlpLlon
suspenslon scheme' based on Lhls. As Lhe resulL of Lhe scheme, Lhe documenLaLlon compleLlon raLe by Lhe prescrlbed
due daLe lncreased 9 fold (900 lmprovemenL).



1S94

DLVLLCMLN1 AND IMLLMLN1A1ICN CI AU1CMA1IC LMLkGLNC CCNSUL1A1ICN MANAGLMLN1 SS1LM
kl !eong Pong
1,*
, !ong Pwan Shln
1
, Sun ?oung klm
1
, Sun Pwa Lee
2

1
ueparLmenL of Lmergency Medlclne,
2
ueparLmenL of Medlcal lnformaLlcs, Seoul naLlonal unlverslLy 8oramae Medlcal
CenLer, Seoul, korea, 8epubllc Cf


Cb[ect|ves: 1o provlde comprehenslve emergency care of mulLldlsclpllnary speclallsLs and prevenL delay of LreaLmenL aL
emergency deparLmenL, efflclenL operaLlon of consulLaLlon Lo speclalLy ls lmporLanL. We developed lmplemenLed and
assessed performance of AuLomaLlc Lmergency ConsulLaLlon ManagemenL SysLem (ALCMS).

Methods: 1hls sLudy was conducLed aL an academlc Lu locaLed ln Seoul MeLropollLan clLy, SouLh korea beLween March
and SepLember 2012. We developed ALCMS Lo consulL Lo Lhe speclallsL auLomaLlcally and assess quallLy of consulLaLlon
Llme process. 1he enrolled Lu used elecLronlc medlcal records (LM8) and ALCMS ls lmplemenLed lnLo Lhe LM8.
MonLhly, every speclalLy dlvlslon should lnpuL Lhe dally llsL of on-duLy docLor for Lu consulL. 1hey should fulfll Lhe duLy
docLor llsL by Lhe 3 sLeps. 1he order of 3 sLeps ls [unlor resldenL, senlor resldenL, [unlor sLaff, senlor sLaff, and flnally chlef
dlrecLor of Lhe dlvlslon. AfLer lnlLlally paLlenLs vlslLed Lu, lf consulLaLlon ls requlred, emergency physlclan acLlvaLed
ALCMS and lnpuL cllnlcal lnformaLlon of Lhe paLlenL lnLo ALCMS pop-up box. And Lhen lnformaLlon ls auLomaLlcally
LransmlLLed uslng shorL message servlce (SMS) Lo Lhe moblle phone of on-duLy speclallsL. 1o sLop Lhe SMS, on-duLy
docLor should access Lhe program aL Lhe deslgnaLed compuLer locaLed ln Lhe Lu. lf on-duLy docLor dld noL access Lhe
compuLer aL Lu, SMS ls auLomaLlcally LransmlLLed Lo nexL senlor docLor every 10 mlnuLes. ALCMS saved deLalled Llme
proflle and success raLe of each consulLaLlon process.

uurlng Lhe perlod, we assessed Lhe number of ALCMS acLlvaLlon and mean Llme of call Lo Lu arrlval of each speclalLy
dlvlslon. We also compared Lhe lengLh of Lu sLay beLween paLlenLs uslng ALCMS and noL uslng ALCMS. llnally, we
conducLed Lelephone survey for paLlenLs who dlscharged Lu afLer speclallsL consulLaLlon on leb 2012 and CcL 2012.

kesu|ts: We developed and lmplemenLed ALCMS lnLo LM8 of enrolled lnsLlLuLlon. uurlng sLudy perlod, 30,447 paLlenLs
vlslLed Lhe Lu and 12 speclalLy dlvlslons such as lnLernal medlclne, general surgery, and neurosurgery and so on
parLlclpaLed ln Lhls pro[ecL. 3,034 paLlenLs were consulLed Lo 12 dlvlslon and 491 cases uLlllsed ALCMS. MonLhly mean
number of ALCMS acLlvaLlon was 70.133.1 and dally use was 3.32.4.

We assessed number of duLy-docLor call sLeps for each acLlvaLlon case. Mean number of duLy-docLor call sLeps by
ALCMS was 3.32.4. lL means LhaL speclallsL arrlved aL Lu usually beLween 30 Lo 40 mlnuLes afLer ALCMS acLlvaLlon. Lu
lengLh of sLay for ALCMS used group was 333 mlnuLes (medlan, lC8 220-393) and non-used group was 380 mlnuLes (lC8
239-619). ln Lhe Lelephone survey resulLs, paLlenLs replled LhaL Lhe walLlng Llme for speclallsL was 70 mlnuLes (medlan,
lC8 30-183) before ALCMS lmplemenLaLlon on lebruary and 60 mlnuLes (medlan, lC8 40-130) afLer lmplemenLaLlon on
CcLober 2012.

Conc|us|on: We successfully developed and lmplemenLed ALCMS lnLo Lhe enrolled Lu. AfLer lmplemenLaLlon of Lhe
process, we could assess Lhe quallLy of Lu consulLaLlon process and showed decreased Lu lengLh of sLay and walLlng
Llme for speclallsL.



1S98

GLUCCML1Lk VLkIIICA1ICN SLkVICL IMkCVLS 1nL ACCUkAC CI GLUCCML1Lk IN DIA8L1ICS
lang-?eh Chu
1, 2,*
, Pul-lel 1ang
2
, Chlng-8lau Llo
2
, Wang-Llng Chen
2

1
CuallLy ManagemenL CenLer,
2
ueparLmenL of Cllnlcal aLhology, lar LasLern Memorlal PosplLal, new 1alpel ClLy,
1alwan


Cb[ect|ves: 1he accuracy of self-monlLored blood glucose monlLorlng by glucomeLer ls of uLmosL lmporLance Lo enhance
glycaemlc conLrol and Lo prevenL hypoglycaemla ln dlabeLlc paLlenLs, however, Lhe adequacy of uslng glucomeLer and
Lhe accuracy of glucomeLer are subopLlmal ln real pracLlce. 1hls sLudy alms Lo enhance Lhe correcL use of glucomeLer
and lLs accuracy ln dlabeLlcs and/or Lhelr careglvers.

Methods: A novel glucomeLer verlflcaLlon servlce was developed lncorporaLlng Lhe lood and urug AdmlnlsLraLlon and
Ln lSC 13197:2003 guldellnes for Lhe glucomeLer accuracy check and Lhe educaLlon of parLlclpanLs for Lhe correcL use
and prevenLlve malnLenance of Lhe glucomeLer. 8rlefly, afLer paLlenL submlLLed a slmple requesL form of glucose
verlflcaLlon servlce, blood sample was collecLed by phleboLomlsL accordlng Lo laboraLory rouLlne. 8lood sample was
asplraLed by glucomeLer for measurlng blood glucose level lmmedlaLely. 1he remalnlng blood sample was puL lnLo a
sodlum fluorlde added blood Lube Lo send Lo Lhe cenLral laboraLory for measurlng Lhe blood glucose level wlLhln 20
mlnuLes. uslng Lhe slmulLaneous measured venous blood glucose level as Lhe sLandard, Lhe accepLance crlLerlon for Lhe
verlflcaLlon was wlLhln 20 lf Lhe glucose level was greaLer Lhan 73 mg per declllLer (mg/dL) or wlLhln 13 mg/dL lf Lhe
glucose level was less Lhan 73 mg/dL. LducaLlon for Lhe adequaLe use and necesslLy of regular malnLenance and
verlflcaLlon of Lhe glucomeLer was underLaken by Lhe Lralned medlcal LechnologlsL. A speclally deslgned verlflcaLlon label
was sLuck on Lhe glucomeLer Lo remlnd Lhe nexL recommended daLe of re-verlflcaLlon. An lnLervlewer-admlnlsLered
sLrucLured quesLlonnalre was underLaken aL Lhe same Llme Lo collecL Lhe reasons for Lhls aLLendlng Lhls servlce.
1elephone lnLervlew for Lhe degree of saLlsfacLlon as well as for Lhe flnal dlsposal of glucomeLer falllng Lo pass Lhe
verlflcaLlon was underLaken for each parLlclpanL.

kesu|ts: lrom 1
sL
Aprll 2010 Lo 31
sL
uecember 2012, a LoLal of 839 requesLs for glucomeLer verlflcaLlon servlce were
enrolled. 1he mean age of Lhe parLlclpanLs was 60.0 (Su, 13.0) years wlLh a female Lo male raLlo of 1:1.03. 1he reasons
for requesLlng Lhe verlflcaLlon servlce lncluded asklng for checklng Lhe accuracy of glucomeLer (90.1), glucose level noL
conslsLenL wlLh sympLoms and/or daLa from cenLral laboraLory (3.1), posslble deLerloraLlon of glucose sLrlps (2.1),
and posslble malfuncLlon of glucomeLer (1.9), and oLhers (0.8). 1he overall pass raLe of glucomeLer verlflcaLlon
durlng Lhe sLudy perlod was 78. 1he pass raLe was 76.9 and 83.3 for flrsL-Llme verlflcaLlon requesLs and repeaLed
ones, respecLlvely. 1he pass raLe lncreased from 66.0 ln Lhe 1
sL
quarLer Lo 79.1 ln Lhe lasL quarLer. 1he mosL common
dlsposal of Lhose falled glucomeLers was sendlng back Lo facLory for repalr and malnLenance (41.2), followed by
purchaslng a new glucomeLer (29.4), replacemenL of a new one free of charge by Lhe manufacLures (23.3), and
oLhers (3.9). 1he degree of saLlsfacLlon of Lhe servlce was as hlgh as 97.

Conc|us|on: 1hls novel glucomeLer verlflcaLlon servlce successfully enhanced Lhe accuracy of glucomeLer ln paLlenL's
hand and enforces Lhe lmporLance of prevenLlve verlflcaLlon measure and Lhe adequacy of uslng glucomeLer ln dlabeLlc
paLlenLs.



1622

1C S1ANDAkDISL AS1nMA CCN1kCL ASSLSSMLN1 8 INCkLASING AS1nMA CCN1kCL 1LS1 SCCkL CA1UkL kA1L IN CLLMLN1I CLCLINIC IN
SINGACkL
8lchard Lee
1
, AdlLya CupLa
1,*
, LsLher Zhang
1

1
ClemenLl olycllnlc, naLlonal PealLhcare Croup olycllnlcs, Slngapore, Slngapore


Cb[ect|ves:
1. 1o lncrease AC1 score capLure raLe from 33 Lo 100 ln ClemenLl polycllnlc for all asLhma paLlenLs ln 6 monLhs.
2. 1o lncrease paLlenLs' undersLandlng of asLhma conLrol
3. 1o sLrengLhen asLhma care paLhways ln Lhe cllnlc by glvlng Lhe paLlenL an ob[ecLlve score of Lhelr asLhma conLrol

8ackground:
Cur cllnlc ls ln Lhe WesLern parL of Slngapore provldlng prlmary care faclllLles Lo Lhe resldenLs, wlLh a monLhly aLLendance of abouL 300 paLlenLs
wlLh asLhma. 1here ls a monLhly monlLorlng on Lhe use of asLhma conLrol LesL (AC1) score for asLhma paLlenLs ln all 9 polycllnlcs under naLlonal
healLhcare group olycllnlcs (nPC). 1he AC1 score ls a valldaLed, rellable and cosL effecLlve Lool Lo assess asLhma conLrol. lL ls a 3 polnL
quesLlonnalre whlch assess Lhe level of asLhma conLrol achleved by Lhe paLlenL.

Methods: A Leam of 8 moLlvaLed lndlvlduals from dlfferenL deparLmenLs of Lhe cllnlc was consLlLuLed.
A flow charL of a Lyplcal asLhma paLlenL was consLrucLed based on exlsLlng workflow. A macro flow charL and a mlcro flow charL for Lhe asLhma
paLlenL wlLh focus on Lhe asLhma paLlenL aL Lhe consulLaLlon polnL ln Lhe cllnlc.
A bralnsLormlng sesslon was done ln a meeLlng wlLh all Leam members. 1he members ploLLed facLors conLrlbuLlng Lo asLhma paLlenL noL able Lo
compleLe Lhe AC1 score on an lshlkawa charL. A bllnd voLlng was done and a areLo charL was made based on Lhe voLlng paLLern by Lhe Leam.

A pre lnLervenLlon asLhma paLlenL survey was done ln flrsL 2 weeks of CcLober 2012. 1he responses of Lhe 41 respondenLs were LrlangulaLed Lo Lhe
resulLs of Lhe areLo charL Lo brlng ln Lhe paLlenL's perspecLlve. A posL lnLervenLlon survey of asLhma paLlenLs Lo assess Lhelr knowledge abouL AC1
score ls planned ln lebruary 2013.

Lach problem was addressed uslng lnLervenLlons LhaL were formed uslng Lhe lan-uo-SLudy-AcL (uSA) cycle wlLh acLlve conLrlbuLlons from all
Leam members and cllnlc managemenL.

1he flrsL lnLervenLlon lmplemenLed on 01 november 2012 was a paLlenL educaLlon posLer. 1he AC1 score enLry lnLo Lhe e-noLes of asLhma paLlenLs
was monlLored monLhly. A dlrecL measure Lo monlLor Lhe Lake up raLe from Lhe posLer of Lhe compleLed AC1 forms was also seL up.

1he second lnLervenLlon was a compuLer screen Lab. 1hls was Lo remlnd Lhe cllnlclan Lo check Lhe paLlenL's AC1 score and enLer lL ln Lhe e-noLes
durlng Lhe consulL. 1hls was sLarLed on 01 uec 2012.

1he Lhlrd lnLervenLlon was meeLlngs done by Lhe Leam Lo dlscuss and relnforce wlLh all new and exlsLlng sLaff ln operaLlons Lhe exlsLlng workflow
for Lhe asLhma paLlenLs ln !an 2013.

kesu|ts:
MonLh 2012 ercenLage AC1 score
CapLure ln e-noLes
ercenLage of nebullsaLlon ln regular asLhma
paLlenLs
ercenLage of AC1 score forms from Lhe
posLer
!uly 32 3 -
AugusL 60 3 -
SepLember 34 6 -
CcLober 47 7 -
november 63 3 21
uecember 63 4 26

1able: lncrease ln AC1 score uLlllsaLlon for AsLhma paLlenLs aL ClemenLl olycllnlc, nPC, Slngapore.

Conc|us|on: lmproved paLlenL educaLlon abouL AC1 score led Lo lncrease ln AC1 score capLure ln e-noLes of 16. 1hls dlsplays beLLer paLlenL
undersLandlng abouL asLhma conLrol. 1here ls sLablllsaLlon ln Lhe nebullsaLlon raLe for Lhe regular asLhma follow up paLlenL durlng november and
uecember 2012.

1he AC1 score glves an opporLunlLy Lo sLrengLhen Lhe relaLlonshlp beLween Lhe paLlenL and docLor/cllnlclan. 1here ls a room for lmprovemenL ln
Lhe exlsLlng AC1 form dlsLrlbuLlon paLhways. AC1 score ls a rellable, cosL effecLlve and slmple way Lo assess asLhma conLrol.

1he paLlenL educaLlon posLer can flnd appllcaLlon ln spreadlng lnformaLlon Lo paLlenL for oLher chronlc dlseases also. 1hls can be adopLed ln varlous
lnformaLlon Lechnology porLals e.g. locallsed Wl-ll broadcasL or dlsplay Lelevlslon seLs ln Lhe walLlng areas.



1628

USING 1nL IUNC1ICNAL kLSCNANCL ANALSIS ML1nCD (IkAM) 1C UNDLkS1AND AND IMkCVL 1nL SLkVICL
LkICkMANCL CI 1nL WAkD kCUND
Mads Lund
1,*
, ernllle Langkllde
2
, !eaneLLe Pounsgaard
1

1
8eglon of souLhern uenmark, CenLre for CuallLy,
2
8eglon of souLhern uenmark, Sygehus lllleblL, MlddelfarL, uenmark


Cb[ect|ves: 1he overall ob[ecLlve wlLh Lhls pro[ecL was Lo reduce Lhe lengLh of sLay of Lhe paLlenLs ln Lhe gerlaLrlc ward.
1o lmprove Lhe servlce performance, we wanLed Lo do a deLalled analysls of Lhe ward round Lo geL new lnslghLs of Lhe
performance and ouLcome. Cn Lhe basls of Lhe analysls, we wanLed Lo address Lhe sysLem wlLh meanlngful changes.

Methods: 1o make a deLalled analysls of Lhe ward round we used a meLhod called l8AM (luncLlonal 8esonance Analysls
MeLhod). 1he meLhod ldenLlfles unwanLed varlaLlons ln Lhe dally work rouLlnes. 1hrough shorL seml-sLrucLured
lnLervlews wlLh sLaff members, we gaLhered Lhe daLa and lnformaLlon.

ln our sLudy we Lracked varlaLlons such as Llme (sLarL and flnlsh Llme of Lhe ward round), lnformaLlon flow and
coordlnaLlon of key acLlons ln Lhe Leam. We found LhaL Lhese Lhlngs varled greaLly ln Lhe dally rouLlnes and had a
slgnlflcanL lmpacL of Lhe ouLcome of Lhe ward round.

Intervent|on
Measurlng Lhese flnds, we lnlLlaLed a Lhree monLh LesL pro[ecL wlLh Lhe followlng changes Lo Lhe ward round - Lo
address Lhe ldenLlfled varlaLlons:

! A 20 mlnuLe lnLerprofesslonal paLlenL conference for Lhe Leam aL an elecLronlc screen showlng all paLlenL daLa
before Lhe ward round
! Pead nurses checked paLlenL records for planned dlscharge daLe. Lack of dlscharge daLe was seen as a lack of
LreaLmenL plan and baslc nurse would be lnsLrucLed Lo ensure a LreaLmenL plan for Lhe speclflc paLlenL aL Lhe nexL
ward round
! Supervlslon of Lhe [unlor physlclans
! Peavy focus on paLlenL plans and esLlmaLed Llme of dlscharge
! no dlsLurbances ls LoleraLed durlng Lhe ward round

kesu|ts: A clear break-polnL was observed ln LCS SC dlagrams. Average LCS was reduced from 9.39 (93 Cl: 6.86-12.32)
ln 2011 Lo 7.00 (93 Cl: 4.93-9.03) ln flrsL 8 monLh of 2012.
1he measures show LhaL lnformaLlon flow, Llme and effecLlveness of Lhe key acLlons have been slgnlflcanLly lmproved ln
regard of ouLcome.

Conc|us|on: 1he l8AM proved useful ln maklng a meanlngful sLudy of Lhe ward round and on Lhe basls of Lhe analysls - a
slgnlflcanL lnLervenLlon pro[ecL could be launched Lo address key lssues regardlng servlce performance and ouLcome.

keferences: l8AM ls developed by rofessor Lrlk Pollnagel and ls descrlbed ln: lkAM. tbe looctloool kesooooce Aoolysls
MetboJ. MoJellloq complex soclo-tecbolcol systems (2012), AshgaLe.




1629

kLDUC1ICN CI kLVISI1S 1nkCUGn 6 SIGMA IN LMLkGLNC DLAk1MLN1
Pooyoung klm
1,*
, ?eon Sook lm
1
, kyuseok klm
1
, !oong Lul 8hee
1

1
Lmergency ueparLmenL, Seoul naLlonal unlverslLy 8undang PosplLal, Seongnam-sl, korea, 8epubllc Cf


Cb[ect|ves: 1he alm of Lhls sLudy ls Lo reduce Lhe revlslL raLe ln emergency deparLmenL (Lu) Lhrough 6-slgma. We also
lnvesLlgaLed Lhe admlsslon raLe afLer revlslL Lo Lu Lo see Lhe consequence of revlslL.

Methods: lrom AugusL Lo CcLober 2012, we applled 6-slgma Lo reduce Lhe revlslL raLe ln one academlc emergency
deparLmenL (afLer group). We compared Lhe revlslL raLe of sLudy perlod wlLh hlsLorlcal daLa of !anuary Lo uecember
2011 (before group). 8evlslL was deflned as Lhe revlslL Lo Lu wlLh Lhe same or slmllar sympLoms wlLhln 72 hours (revlslL
paLlenLs/LoLal paLlenLs). Admlsslon afLer revlslL Lo Lu was deflned as admlsslon Lo ward ln paLlenLs who revlslL Lu wlLh
Lhe same or slmllar sympLoms wlLhln 72 hours. WlLh charL revlew of before group, we found LhaL Lhe maln sympLoms of
abouL 60 of revlslL paLlenLs were fever, abdomlnal paln, headache, nausea, vomlLlng, dyspnoea, cough, and urLlcarlal,
so we focused on Lhese sympLoms Lo reduce revlslL raLe. We used varlous meLhods Lo reduce revlslL and subsequenL
admlsslon as follows, proLocollzed LreaLmenL, organlsed dlscharge lnsLrucLlon, real Llme feedback Lo physlclans, eLc.

kesu|ts: 1here were 2,146 and 347 paLlenLs ln Lhe before and afLer groups, respecLlvely. 1he revlslL raLe ln afLer group
was slgnlflcanLly lower Lhan LhaL of before group (3.43 vs. 4.03). 1he admlsslon raLe afLer revlslL ln afLer group was
also slgnlflcanLly lower Lhan LhaL of before group (18.18 vs. 22.02).

8efore AfLer
number of paLlenLs 39,606 13,836
8evlslLs Lo Lu, no. () 2,416/39,606 (4.03) 347/13,836 (3.43)
Admlsslon afLer revlslL, no. () 332/2,416 (22.02) 99/347 (18.18)


Conc|us|on: We found ouL a way Lo decrease boLh Lhe raLe of revlslL and Lhe raLe of admlsslon Lo ward afLer Lhe revlslL
Lhrough several measures. ln concluslon, we belleve conslsLenL monlLorlng and lmprovemenL efforL for revlslL are an
effecLlve way Lo reduce lnapproprlaLe revlslL ln Lhe aspecL of paLlenLs' safeLy and care quallLy.



1644

nCW DC WL LNSUkL IINANCIAL kLSCUkCLS 1C SLCUkL A1ILN1 AND nLAL1nCAkL WCkkLkS SAIL1?
Mukal Shln[l
1,*
, 1oru Pashlguchl
2

1
lnabe Ceneral PosplLal, 1akl CounLy, 1akl 1own,
2
nlhon lukushl unlverslLy, Mlhama 1own, ChlLa CounLy, Alchl
prefecLure, !apan


Cb[ect|ves: ln Lhe medlcal fee paymenL sysLem of !apanese publlc medlcal lnsurance, cosLs of drugs and medlcal
maLerlal, personal expenses Lo ensure paLlenL and healLhcare workers safeLy (paLlenL and healLhcare workers safeLy
cosL) was non-medlcal expense relmbursemenL cosL. 8uL Lhe slze of Lhe amounL of such non-medlcal expense
relmbursemenL cosL, lncludlng paLlenL and healLhcare workers safeLy cosL, has noL been clear yeL.
Also Lhese paLlenL and healLhcare workers safeLy cosL has become a flnanclal burden for each hosplLal.

Pow much wlll lL Lake Lhe amounL of such non-medlcal expense relmbursemenL cosL? Clvlng cases of hearL dlsease
whlch ls one of Lhe Lhree ma[or causes of deaLh of Lhe !apanese, we researched LoLal amounL of medlcal expense
relmbursemenL cosL of medlcal maLerlals, among LoLal amounL of acLual consulLaLlon cosL for Cl (ercuLaneous
Coronary lnLervenLlon), whlch ls Lhe Lyplcal medlcal LreaLmenL for hearL dlsease, as Lhe case sLudy. As a resulL, LoLal
amounL of medlcal expense relmbursemenL cosL of medlcal maLerlals above became clear.

Methods: 1hls sLudy was deslgned: 1oLal amounL of acLual consulLaLlon cosL for Cln=60 case810 case per year ln
2011 was calculaLed by Lhe meLhod of AcLual CosL AccounLlng ln 3 hosplLals LoLal 1,120 beds.
Moreover, LoLal amounL of non-medlcal expense relmbursemenL cosL was analysed. 1he perlod of research was
2monLhs (!une-AugusL 2012).

kesu|ts: 1oLal amounL of acLual consulLaLlon cosL for Cl was approxlmaLely 920,000 !apanese ?en (1uS dollar = 100
!apanese ?en). And among LoLal amounL of acLual consulLaLlon cosL for Cl, LoLal amounL of medlcal expense
relmbursemenL cosL for medlcal supplles was approxlmaLely 390,000 !apanese ?en and LoLal amounL of non-medlcal
expense relmbursemenL cosL was 40,000 !apanese ?en. lL became clear LhaL LoLal amounL of medlcal supplles cosL for
Cl was accounLed for a 70 approxlmaLely of acLual consulLaLlon cosL for Cl, LhaL LoLal amounL of non-medlcal
expense relmbursemenL cosL of medlcal supplles was accounLed for a 3 approxlmaLely of acLual consulLaLlon cosL for
Cl.

Conc|us|on: ln Lhls research, LoLal amounL of non-medlcal expense relmbursemenL cosL of medlcal maLerlals was
approxlmaLely 3 of LoLal amounL of acLual consulLaLlon cosL for Cl. Accordlng Lo Lhe prevlous work, now lL ls lnferred
Lhe !apanese hosplLal has lnvesLed a 2-4 approxlmaLely of hosplLal admlnlsLraLlon expense for paLlenL and healLhcare
workers safeLy (per year). 8uL Lhe lnvesLmenL cosL for paLlenL and healLhcare workers safeLy above used as non-
lnsurance refund.

1herefore, lf Lhe lnvesLmenL cosL for paLlenL and healLhcare workers safeLy above whlch has used as non-lnsurance
refund by now ls relmbursed, Lhereby, lL ls lnferred LhaL lL can be covered Lhe lnvesLmenL cosL for paLlenL and healLhcare
workers safeLy above equlvalenL roughness.

lrom Lhe above, Lhe meanlng of Lhls research glvlng case of medlcal maLerlals cosL ls very large, whlch ls proved Lhe
scale of Lhe amounL of non-medlcal expense relmbursemenL cosL LhaL lL ls noL found unLll now.

keferences: 8rennan 1.A., Leape L.L., Lalrd n.M., eL al., lncldence of adverse evenLs and negllgence ln hosplLallsed paLlenLs: 8esulLs
of Lhe Parvard Medlcal racLlce SLudy.N oql I MeJ, 324: 370-377, 1991. Leape L.L, 8rennan 1.A., Lalrd n.M., eL al., 1he naLure of
adverse evenLs ln hosplLallsed paLlenLs: 8esulLs of Lhe Parvard Medlcal racLlce SLudy. N oql I MeJ, 324: 377-384, 1991.
1homas L.!., SLudderL u.M., newhouse !.., eL al., CosLs of Medlcal ln[urles ln uLah and Colorado. lopolty, J6.255-264, 1999.


1646

nCML SAIL nCML: A1ILN1 AND CAkLk LkSLC1IVLS CI 1nL DLIINI1ICN CI SAIL1 IN nCML nLAL1nCAkL
Sarah[ane !ones
1,*
, Malrl MaclnLyre
1

1
WMC, unlverslLy of Warwlck, CovenLry, unlLed klngdom


Cb[ect|ves: 8esearch lnLo paLlenL safeLy ln communlLy care ls underrepresenLed ln Lhe academlc llLeraLure, desplLe
governmenL efforLs Lo redlrecL care for paLlenLs wlLh complex long Lerm condlLlons away from secondary care and lnLo
Lhe communlLy. lncreased complexlLy of paLlenL safeLy ls lnLroduced lnLo newly developed lnLervenLlons such as Lhe
case managemenL programme because of, buL noL llmlLed Lo: Lhe unfamlllarlLy of Lhe lnLervenLlon, Lhe unregulaLed and
unconLrolled envlronmenL, greaLer paLlenL responslblllLy for ouLcomes and co-ordlnaLlon of mulLlple provlder
organlsaLlons of healLh and soclal care.

1radlLlonally, paLlenL safeLy ls LhoughL of as freedom from accldenLal ln[ury, or avoldance of unnecessary physlcal harm
Lhrough Lhe mlsmanagemenL of care and excluslve of dlsease progresslon. Powever, ln a care model whlch alms Lo
malnLaln quallLy of llfe raLher Lhan resLore healLh, Lhe excluslon of dlsease progresslon from Lhe conslderaLlon of safeLy
mlghL be deLrlmenLal Lo poslLlve healLh ouLcomes. lf paLlenLs experlence a decllne ln Lhelr healLh due Lo poor quallLy
care, paLlenLs wlll experlence unnecessary adverse ouLcomes.

1hls research almed Lo achleve a paLlenL and carer derlved deflnlLlon of safeLy, speclflcally ln relaLlon Lo healLhcare LhaL
ls dellvered ln Lhe home. 1hls paper presenLs Lhe flndlngs of a quallLaLlve sLudy, whlch explored Lhe deflnlLlon of safeLy
for home healLhcare from paLlenL and carer perspecLlves.

Methods: 1he nPS case managemenL programme was selecLed as a case sLudy for home healLhcare ln whlch 13
lnLervlews were conducLed wlLh nlne paLlenLs and slx carers across Lhree prlmary care organlsaLlons.

kesu|ts: aLlenLs and carers acknowledge safeLy as Lhe acLlve parLlclpaLlon ln rlsk reducLlon. 1hey also express safeLy as
Lhe provlslon of care LhaL meeLs Lhelr physlcal, soclal and psychologlcal needs Lo generaLe accepLable physlcal, soclal
and psychologlcal ouLcomes. Clven Lhe naLure of Lhelr lllnesses, whlch are llfe long and llmlLlng, greaLer emphasls was
placed on malnLalnlng or lmprovlng psychologlcal and soclal ouLcomes.

aLlenLs and carers relaLe negaLlve psychologlcal and soclal ouLcomes very closely Lo dlsease progresslon. lor example,
naLural dlsease progresslon whlch resulLs ln lmmoblllLy reduces Lhelr ablllLy Lo leave Lhe house Lo be soclal and
conLrlbuLes Lo feellng low.
aLlenLs and carers also openly acknowledge and accepL Lhey have a role ln Lhelr safeLy, however, Lhe boundary
beLween paLlenL/carer responslblllLy and healLhcare provlder responslblllLy ls blurry.

Conc|us|on: 1he deflnlLlon of safeLy derlved from paLlenLs and carers ls more hollsLlc and akln Lo Lhe deflnlLlon of
quallLy. ln a care servlce deslgned Lo lncrease quallLy of llfe for llfe long, llmlLlng and degeneraLlve condlLlons, raLher
Lhan cure acuLe lllness, progresslvely negaLlve cllnlcal ouLcomes are lnevlLable. Powever, malnLenance of psychologlcal
and soclal funcLlon ls of greaLer concern Lo paLlenLs and carers. oorly managed dlsease wlll conLrlbuLe Lo adverse
psychologlcal and soclal ouLcomes. lurLhermore, lnadequaLe recognlLlon of Lhe lmporLance of psychologlcal and soclal
ouLcomes wlll resulL ln Lhem belng lefL unLreaLed. llnally, alLhough paLlenLs and carers recognlsed Lhey had a role ln
Lhelr safeLy, Lhelr responslblllLles and whaL conLrlbuLlons Lhe healLhcare provlder made were unclear, 1he lmpllcaLlons
of Lhese flndlngs lnclude: an opporLunlLy for healLhcare organlsaLlons and sLaff allke Lo recognlse Lhe lmporLance of
psychologlcal and soclal ouLcomes and dellver servlces whlch have greaLesL lmpacL on Lhe paLlenL, and a need for all
sLakeholders Lo be aware of Lhelr responslblllLles ln order for Lhem Lo dellver on Lhem.

16S8

IMkCVING UALI1 AND A1ILN1 SAIL1 IN 1nL LMLkGLNC MLDICAL DISA1Cn CLN1kL 8 kLVILWING MLDICAL
kLCCkDS: 1nL LkLkILNCL CI VLkCNA, I1AL
1amara Zerman
1,*
, ulana ascu
1
, Mlchele MasoLLo
2
, labrlzlo Lorenzonl
2

1
PealLhcare 1rusL 20 verona, verona,
2
Lmergency Medlcal ulspaLch CenLre, Lmergency Servlces, ManLua, lLaly


Cb[ect|ves: 1he Lmergency Medlcal ulspaLch CenLre (LMuC) of verona responds Lo 133.000 calls every year,
coordlnaLlng servlces for Lhe whole rovlnce (around 900.000 lnhablLanLs). 1he emergency process ls lnherenLly
complex: lL lnvolves dlfferenL professlonals and ls sub[ecL Lo lnLernal and exLernal facLors. Lvery lnLervenLlon musL be
reglsLered by fllllng a shorL form ln order Lo evaluaLe approprlaLeness of paLlenL managemenL. Cb[ecLlves of Lhe sLudy
were Lo check accuracy of compllaLlon, adherence Lo LreaLmenL proLocols and dlscrepancy LhaL can affecL quallLy and
paLlenL safeLy.

Methods: An experL Leam of Lhe LMuC of verona (3 nurses and 2 docLors) ln collaboraLlon wlLh Lhe LxecuLlve
CommlLLee for aLlenL SafeLy (LCS) collecLed a random sample of 204 forms fllled up by sLaff operaLlng ln Lhe
emergency servlces, from CcLober Llll uecember 2011. 1he forms were analysed ln order Lo ldenLlfy boLh errors wlLh
poLenLlal medlco-legal lssues and due Lo lack of adherence Lo LreaLmenL proLocols, exposlng paLlenLs Lo poLenLlal rlsks,
as well as evaluaLe Lhe accuracy of compllaLlon. 1he 30 flelds were spllL lnLo 4 groups:

1) personal paLlenL daLa
2) cllnlcal evaluaLlon
3) cllnlcal LreaLmenL
4) schedule of lnLervenLlon.

kesu|ts: 1he 204 forms documenLed 33,29 of hlgh severlLy lnLervenLlons, 37,23 of medlum severlLy, 26,29 of low
severlLy, 0,49 noL reporLed. 60 of all forms were fllled up compleLely. 1he personal daLa of paLlenLs (1) and Lhe
schedule of lnLervenLlon (4) were fllled correcLly ln over 90 of lnLervenLlons. 1he weak polnL were Lhe cllnlcal
evaluaLlon (2) and consequenLly Lhe lnapproprlaLe cllnlcal LreaLmenL (3), due Lo a dlscrepancy ln deLecLlng and/or
recordlng cllnlcal parameLers. Whlle suspecLed dlagnosls was presenL ln 93,63 of lnLervenLlons, blood pressure, hearL
raLe, and oxygen saLuraLlon were correcLly reporLed ln 80, Clasgow Coma Scale was presenL ln 63, schedule was
recorded ln 41 and resplraLory raLe only ln 18,14.

1he second sLep of analysls was Lo lnvesLlgaLe dlfferenL Lypes of paLhologles and Lhe mosL frequenL errors analyslng Lhe
followlng: Lrauma accldenLs (20,39 of lnLervenLlons) , cardlovascular dlseases (17,16), resplraLory paLhologles
(12,73) and neurologlcal paLhologles (11,76). 1rauma accldenLs and cardlovascular dlseases were ofLen mlsslng daLa
relevanL Lo Lhe cllnlcal managemenL, wlLh lack of lnformaLlon LhaL can affecL paLlenL safeLy (as deLecLlon of, locallsaLlon
and lmmoblllsaLlon of Lrauma, Lherapy or 8C ln cardlovascular dlseases). ln resplraLory paLhologles, resplraLory raLe
was ofLen absenL as Lhe use of glycaemlc sLlck ln suspecLed neurologlcal dlseases.

Conc|us|on: 1he revlew of Lhe records hlghllghLed Lhe lnconslsLencles of medlcal records LhaL may have lnfluenced Lhe
flnal ouLcome. lmprovemenL acLlons were lnLroduced by revlewlng Lhe requlred flelds and ellmlnaLlng redundancles,
and by revlslLlng proLocols. 1ralnlng courses for Lhe sLaff were lnLroduced Lo ralse lnLeresL and compllance wlLh Lhe
proper use of good pracLlces. A sample of forms are currenLly revlewed ln order Lo monlLor Lhe resulLs and Lhe lmpacL
on Lhe paLlenL. 1o compleLe Lhe evaluaLlon, a sample of medlcal records from Lhe hosplLal of admlsslon wlll be collecLed
Lo analyse Lhe consequences occurred ln paLlenLs afLer an error ln Lhe emergency chaln. 1he pursulL of quallLy ln Lhe
servlce of emergency ls a fundamenLal sLep Lo ensure Lhe correcL approach Lo paLlenL safeLy, Lo lnvolve sLaff ln Lhe
appllcaLlon of cllnlcal guldellnes.


1660

kLVLALING A1ILN1 SAIL1 LDUCA1ICN IN nLAL1n kCGkAMS A1 UNIVLkSIDADL ILDLkAL DL SC AULC.
Llena 8ohomol
1,*
, lsabel CrlsLlna Cunha
1

1
nurslng School, unlversldade lederal de So aulo, So aulo, 8razll


Cb[ect|ves: 1o ldenLlfy Currlcular unlLs (Cu) ln whlch paLlenL safeLy ls LaughL ln undergraduaLe programs ln nurslng, pharmacy,
physlcal Lherapy and medlclne aL unlversldade lederal de So aulo, 8razll.

Methods: uescrlpLlve/exploraLory sLudy. 1he sources were Lhe edagoglcal ro[ecLs () avallable on Lhe unlverslLy slLe. 1he
reference framework was Lhe World PealLh CrganlzaLlon's aLlenL SafeLy Currlculum Culde: MulLl-professlonal LdlLlon, conslderlng
Lhe followlng eleven Loplcs:

! 11. WhaL ls paLlenL safeLy,
! 12. Why applylng human facLors ls lmporLanL for paLlenL safeLy,
! 13. undersLandlng sysLems and Lhe effecL of complexlLy on paLlenL care,
! 14. 8elng an effecLlve Leam player,
! 13. Learnlng from errors Lo prevenL harm,
! 16. undersLandlng and managlng cllnlcal rlsk,
! 17. uslng quallLy-lmprovemenL meLhods Lo lmprove care,
! 18. Lngaglng wlLh paLlenLs and carers,
! 19. lnfecLlon prevenLlon and conLrol,
! 110. aLlenL safeLy and lnvaslve procedures,
! 111. lmprovlng medlcaLlon safeLy.
(1)


SevenLy-nlne key words and 99 LhemaLlc proposals were soughL ln each .

kesu|ts: 1he nurslng program offers 46 Cu, 29 (63) of whlch conLaln lnformaLlon abouL paLlenL safeLy Leachlng. 13 was noL clLed ln
any Cu and 14 ls LaughL ln 16 (34.8). 1eachlng addresses communlcaLlon, Leamwork, mulLldlsclpllnary, confllcL solvlng, leadershlp
and eLhlcs. 1eachlng on Leam coordlnaLlon, whaL are successful Leams and Leam performance assessmenL was noL ldenLlfled Lhough.

ln Lhe harmacy program, 78 Cu are offered, 23 (32) of whlch declare paLlenL safeLy Loplcs. 11 and 110 were noL clLed. 19 and 111
were presenL ln 10 (12.8) Cu. 19 ls LaughL wlLh a focus on anLlmlcroblal acLlon, bacLerlal reslsLance, developmenL of vacclnes and
sLerlllsaLlon meLhods, buL no Leachlng conLenLs were locaLed abouL hand washlng, gloves use and conducLs ln lsolaLlon unlLs.

ln Lhe hysloLherapy program, 30 Cu are offered, and safeLy Lhemes were found ln 24 (48). 13 and 17 were noL relaLed Lo any Cu.
18 was clLed ln 10 (20), addresslng Lhe undersLandlng of paLlenLs' blologlcal, soclal and culLural aspecLs, whlle Lhemes llke Lhe
consumer's volce, communlcaLlon Lools, lnformed consenL and Lhe revelaLlon process were noL lncluded.

1he Medlclne program offers 63 Cu, 40 (61.3) of whlch declared paLlenL safeLy Leachlng. 13 was noL evldenced ln any Cu, whlle 19
ls LaughL ln 19 (29.2), wlLh a focus on lnfecLlon LreaLmenL and prevenLlon.

Conc|us|on: All lnclude conLenLs relaLed Lo paLlenL safeLy. 1helr approaches, wlLh rare excepLlons, are parLlal Lhough, demandlng
furLher elaboraLlon of Lhe Lhemes, also lnvolvlng Leachers' preparaLlon. All programs lack aL leasL one dlmenslon, whlch does noL
permlL a global vlew on Lhe safeLy aspecLs LhaL can be addressed ln sLudenLs' educaLlon. 11, 13 and 17, whlch relaLe Lo safeLy
concepLs, learnlng from errors and managemenL lmprovemenL processes, are absenL from many , reflecLlng Lhe programs' cllnlcal
focus, wlLhouL valulng Lhe conLexL Lhey are lnserLed ln. 1he lack of Leachlng on Lhese dlmenslons can also relnforce concepLs LhaL
healLh professlonals may be lmmune Lo errors, wlLhouL preparlng sLudenLs for Lhe managemenL of errors and adverse evenLs, when
Lhese happen ln professlonal pracLlce lnvolvlng paLlenLs. aLlenL safeLy Leachlng ln healLh programs permlLs Lhe developmenL of
reflexlve learnlng experlences, granLlng sLudenLs Lhe opporLunlLy Lo use sclenLlflc evldence Lo descrlbe Lhe care componenLs, ldenLlfy
devlaLlons ln Lhelr pracLlce and deLermlne acLlons LhaL need Lo be lmplemenLed, as members of an lnLerdlsclpllnary Leam.

keferences: (1) WPC paLlenL safeLy currlculum gulde: mulLl-professlonal edlLlon. World PealLh CrganlzaLlon. Avallable from:
hLLp://www.who.lnL. Accessed Mar 07, 2012.



1667

1nL CLINICAL kCGkAM CI IMkCVING 1nL ACU1L ISCnLMIC S1kCkL 1kLA1MLN1 IN 1nL nLAL1n CAkL kCCLSS
Pslao-Llng Llao
1,*
, Su-Chen 1sal
1
, Chun-Lan Lee
2
, 1so-?lng Lee
2

1
ueparLmenL of Lmergency,
2
ueparLmenL of nurslng, Cheug Psln Ceneral PosplLal, 1alpel, 1alwan


Cb[ect|ves: 1hrombolyLlc agenLs prepared for acuLe lschemlc sLroke wlLhln Lhree hours can reduce Lhe probablllLy of
lrreverslble damage ln braln parenchyma Llssue. 1he prevlous lncompleLe proLocol ln our emergency deparLmenL (Lu)
for above condlLlon lncludes four ma[or clrcumsLances:

1. 1he delayed acLlvaLlon abouL Lrlage's recognlLlon for acuLe sLroke wlLhln Lhree hours,
2. 1he lack of sLandard operaLlon procedures of emergency managemenL,
3. Loss of urgenL prlorlLy of cllnlcal lmage and laboraLory sLudles,
4. 1he un-esLabllshed pre-hosplLal noLlflcaLlon mechanlsm. 1he ob[ecLlve of Lhls work ls conducLed Lo lmprove Lhe Lu
managemenL process, mulLldlsclpllnary Leam work cooperaLlon, and Lhe Llme of walLlng for Lu managemenL.

Methods: 1he slx monLhs of pre- and posL-lnLervenLlon perlod were chosen from !un.1
sL
ln 2011 Lo !un.30
Lh
ln 2012. 33
crlLlcal lschemlc sLroke paLlenLs ln Lhe pre-lnLervenLlon phase and 34 ln Lhe posL phase checked ln our Lu were
recrulLed. 1he conslderable componenLs of Lu lmprovemenL program lnclude re-organlsaLlon Lhe SC for 3-hour
lschemlc sLroke ln Lu, re-educaLlon abouL Lhe proLocol of acuLe lschemlc sLroke managemenL Lo our Lu sLaff, Lo bulld
Lhe muLual response of LMS and Lu abouL acuLe lschemlc sLroke paLlenLs' early noLlflcaLlon.

kesu|ts: We seL up Lhe ma[or lLems ln each paLlenL abouL accompllshlng Lhe ldeal proLocol of Lu-acuLe lschemlc sLroke
managemenL. 1he Lu-sLroke managemenL proLocol lncludes achlevlng Lhe four Llme course abouL door Lo lnlLlal
neurologlcal exam, door Lo braln C1 lmage, door Lo neurologlcal consulLaLlon, door Lo speclallsL ward (neurology or
neurosurgeon care). aLlenLs who accompllsh above Llme courses wlll be selecLed as successful Lu-sLroke managemenL
case. 1he raLe of accompllshlng above proLocol lncreased from 31.3 (17/33) Lo 97.1 (33/34). 1he flow raLe of
recelvlng C1 scan wlLhln 23 mlnuLes lncreased from 43.3 Lo 82.4. 1he raLe of LhrombolyLlc agenLs' lnfuslon wlLhln 60
mlnuLes lncrease from 66.7 Lo 83.3. SlgnlflcanL flndlngs are llsLed as followlng:

1) lmprove Lhe flow of Lrlage process for acuLe lschemlc sLroke paLlenLs.
2) Slmpllfy Lhe flow of sLandard process.
3) uevelop an efflclenL paLlenL and laboraLory speclmen processlng sysLem.
4) CLher relevanL supporLlng flndlngs: pre-hosplLal noLlflcaLlon mechanlsm, Lu anLl-sLroke consensus and quallLy
promoLlons.

Conc|us|on: 1hls program reveals LhaL lmprovlng sLandard operaLlon procedures for Lu- medlcal care, Leam cooperaLlon
and educaLlon noL only resulLs ln a beLLer shorL-Lerm ouLcome lncludlng LA lnfuslon, buL posslbly also leads Lo a deflclL-
free dlscharges Lhe long-Lerm ouLcome.










1677

A UNIUL LU UALI1 ASSUkANCL 8LNCnMAkk ICk 8kLAS1 CANCLk SLkVICLS: kLAkA1Ck INVLS1IGA1ICN,
kLSLN1 S1A1US, IU1UkL LkSLC1IVLS
Asll uluLurk
1,*
, Sllvla ueandrea
1
, CrysLal lreeman
1
, !esus Lopez-Alcalde
1

1
lnsLlLuLe for PealLh and Consumer roLecLlon, !olnL 8esearch CenLre - Luropean Commlsslon, lspra (vA), lLaly


Cb[ect|ves: 1he Luropean Commlsslon (LC), ln response Lo concluslons from Lhe Luropean Councll on reduclng Lhe
burden of cancer, has lnlLlaLed a ground-breaklng pro[ecL Lo develop Lhe flrsL volunLary accredlLaLlon scheme for breasL
cancer servlces ln Lhe Lu.

Methods: 1o help ensure adheslon Lo and upLake of Lhe planned quallLy assurance scheme ln all Luropean CounLrles, a
mapplng of healLhcare sysLems, and ln parLlcular of 8reasL Cancer Servlces (8CSs), was conducLed. 1o Lhls end, a 2012
survey was conducLed ln Lhe 27 Luropean unlon member sLaLes, plus CroaLla, lceland and norway. 1he survey quesLlons
lncluded relevanL aspecLs of how 8CSs are organlsed such as: screenlng programs, Lralnlng requlremenLs for
professlonals, quallLy and safeLy aspecLs, quallLy assurance schemes. ln addlLlon, a comparlson of exlsLlng quallLy
assurance schemes was prepared based on lnpuL from:

! Lhe survey resulLs
! oLher schemes reLrleved vla ubmed search
! oLher schemes obLalned vla consulLaLlon wlLh experLs.

8ased on Lhe resulLs of Lhe survey and Lhe comparlson of schemes, as well as exlsLlng rules and sLandards (lSC) already
ln place, Lhe general concepL of Lhe pro[ecL wlll be drafLed and agreed ln close collaboraLlon wlLh Lhe experLs and
represenLaLlves from each CounLry.

kesu|ts: 1wenLy-flve of Lhe 30 conLacLed counLrles responded (83 response raLe). 1he survey flndlngs suggesL a hlgh
heLerogenelLy ln Lurope ln Lerms of: healLh sysLems, organlsaLlon of breasL cancer servlces and screenlng pollcles.
1wenLy dlfferenL quallLy assurance schemes were ldenLlfled, coverlng elLher:

1. general aspecLs of quallLy and
2. safeLy and/or breasL cancer speclflc professlonal lssues.

Some counLrles declare no quallLy assurance pollcles ln place, whlle oLhers have more Lhan one (l.e. a publlc naLlonal
scheme plus one or more prlvaLe lnLernaLlonal schemes). 1he general concepL of Lhe proposed Lu volunLary scheme wlll
be developed Laklng lnLo accounL accredlLaLlon requlremenLs (e.g. lSC 13189:2007) and lncludlng a llsL of speclflc
requlremenLs llnked Lo evldence-based guldellnes. lL ls planned LhaL Lhls wlll lead Lo Lhe 3
Lh
edlLlon of Lhe Luropean
guldellnes for quallLy assurance ln breasL cancer screenlng and dlagnosls, buL Lhls Llme lncludlng addlLlonal guldellnes
coverlng Lhe remalnlng sLages and aspecLs of care.

Conc|us|on: 1he successful developmenL and deploymenL of such a harmonlsed accredlLaLlon scheme wlll enable Lu
Member SLaLes and collaboraLlng counLrles Lo formally ensure and benchmark Lhe quallLy of Lhelr breasL cancer servlces
agalnsL a solld Lu quallLy sLandard.


1678

IMkCVING A1ILN1 SAIL1 LLADLSknI WALkkCUNDS IN NnS GkAMIAN
Pelen 8obblns
1,*
, !eaneLLe !ackson
2

1
nPS Cramplan,
2
Aberdeen unlverslLy, Aberdeen, unlLed klngdom


Cb[ect|ves: nPS Cramplan has underLaken paLlenL safeLy walk rounds slnce 2008 as parL of Lhe leadershlp work sLream
of Lhe ScoLLlsh aLlenL SafeLy rogramme (SS). 1he execuLlve Leam Lake parL ln weekly walk rounds Lo cllnlcal areas.
We had llmlLed knowledge of Lhelr effecLlveness, sLaff lmpresslons or lmpacL on paLlenL care so deslgned a sLudy Lo
examlne Lhls. Alm of Lhe pro[ecL was Lo evaluaLe Lhe paLlenL safeLy leadershlp walk round process ln order Lo reflne lL
and enhance lLs effecLlveness.

Methods: 1hree sLage sLudy conducLed ln collaboraLlon wlLh nPS Cramplan and unlverslLy of Aberdeen. 18 cllnlcal areas
where walk rounds Look place ln 2010 were lncluded:

1) 303 sLaff surveys were senL Lo 18 cllnlcal areas asklng abouL parLlclpaLlon ln Lhe process and also safeLy culLure
quesLlons.
2) seml sLrucLured lnLervlews Lo 6 sLaff and 10 LxecuLlves asklng abouL effecLlveness of Lhe walk round process.
lnLervlews were analysed uslng a prompL gulde and were coded by anoLher researcher for lnLer-raLer rellablllLy.
3) documenL analysls of walk round reporLs from Lhe 18 cllnlcal areas were sysLemaLlcally analysed by Lwo sLaff Lo look
for Lhemes ln lssues and acLlons.

8esulLs were dlssemlnaLed Lo Lhe LxecuLlves lnvolved ln order Lo shape Lhe recommendaLlons. 1wo open workshops
were held for sLaff Lo hear a summary of Lhe sLudy and flndlngs. 8ecommendaLlons were presenLed aL relevanL
meeLlngs.

kesu|ts: 1he walk rounds were found Lo close Lhe gap beLween sLaff and execuLlves and Lo be a mechanlsm for sharlng
learnlng. 1hey were LhoughL beneflclal and an accepLable, valued process. SLaff appreclaLed someone comlng Lo Lhelr
area. 1he sLaff lnvolved Lended Lo be nurslng sLaff wlLh a need Lo wlden Lhe professlons Laklng parL. 1here was a poor
response raLe Lo Lhe survey (29) and noL so many cllnlcal sLaff Look parL ln lnLervlews. Ma[orlLy of sLaff recelved
feedback on Lhe walk round however Lhey percelved no change or follow-up Lo acLlons. Powever Lhe lmpacL of Lhe walk
rounds was noLed as lmprovemenLs ln Lhe envlronmenL, lncreased vlslblllLy of managemenL, leadershlp awareness of
paLlenL safeLy and sLaff more moLlvaLed re safeLy and Leamwork. 89 lssues lead Lo 6 Lhemes ldenLlfled from Lhe reporLs:
envlronmenL, sLafflng, paLlenL safeLy programme, lnfecLlon and paLlenL and lncldenL reporLlng. A feellng of belng
checked may have resulLed from lnfecLlon lnspecLlons whlch were also Laklng place. Areas of good pracLlce were noLed.
An acLlon plan for each sLakeholder group was developed from Lhe recommendaLlons. lor example, Lhe LxecuLlves
lmprove sharlng learnlng by shaplng a 8oard alm around walk rounds and by comparlng learnlng. aLlenL lnvolvemenL ls
requlred ln Lhe walk round process. Ward sLaff wlll educaLe sLaff abouL paLlenL safeLy by organlslng meeLlngs Lo share
soluLlons across wards. 1he CuallLy unlL wlll develop a sLrucLured checkllsL around paLlenL safeLy and ldenLlfled
faclllLaLors and barrlers. A feedback process wlll be deslgned Lo close Lhe gap beLween fronLllne sLaff and managemenL
level, buL also Lo dlsplay and share learnlng of progress wlLh paLlenL safeLy across Lhe organlsaLlon.

Conc|us|on: Learned LhaL research wlLh busy cllnlcal sLaff ls dlfflculL. lL ls also dlfflculL Lo feedback Lhe flndlngs and
engage sLaff ln lmprovemenLs. 8e creaLlve wlLh feedback mechanlsms and focus on a few key achlevemenLs and
concreLe learnlng so sLaff can see a few beneflLs Lo a process. We also learned LhaL oLher facLors can affecL your resulLs
such as Lhe lnspecLlon prlorlLy aL Lhe Llme of Lhe fleld work.

Maln message ls Lo examlne Lhe effecLlveness of a process even Lhough lL may be sLrucLurally worklng smooLhly. We
ldenLlfled a range of lmprovemenLs Lo Lhe process Lo asslsL maklng walk rounds more effecLlve.


1680

SAND: A DLVAS1A1ING S1CkM, AN UNkLCLDLN1LD kLSCNSL
Mary Mahoney
1,*
, Lorl SLler
2

1
CenLer for Lmergency Servlces, norLh Shore-Ll! PealLh SysLem, CreaL neck,
2
lnsLlLuLe for Cllnlcal Lxcellence and CuallLy,
norLh Shore-Ll! PealLh SysLem, Lake Success, unlLed SLaLes


Cb[ect|ves:
uescrlbe Lhe sLeps LhaL were necessary Lo ensure Lhe safeLy of paLlenLs, employees and Lhe communlLy durlng Super
SLorm Sandy

ulscuss lessons learned from norLh Shore-Ll! PealLh SysLem's emergency response Lo Super SLorm Sandy

Methods:
1he norLh Shore-Ll! PealLh SysLem Lmergency CperaLlons lan (LC) has evolved over Lhe years ln response Lo our
unlque geographlc locaLlon and our experlence wlLh several serlous and caLasLrophlc emergencles. WlLh our slxLeen
acuLe care hosplLals locaLed ln and around new ?ork ClLy and emergencles such as 9/11 ln 2001, SA8S ln 2003, P1n1 ln
2009 and Purrlcane lrene ln 2011 our LC has been repeaLedly LesLed and revlsed.
Cver Llme, Lhe SysLem's leadershlp dedlcaLed resources Lo plan for a mulLlLude of conLlngencles LhaL mlghL cause Lhe
local populaLlon Lo rely on and requlre masslve healLh care resources. As parL of dlsasLer preparedness and lLs LC,
norLh Shore-Ll! PealLh SysLem, lLs hosplLals and long-Lerm care faclllLles acLlvaLed Lhelr emergency operaLlons cenLers
Lhree days ln advance of Super SLorm Sandy's arrlval. 1hey remalned sLaffed around Lhe clock LhroughouL Lhe week of
Lhe sLorm, enabllng Lhe leadershlp of Lhe healLh sysLem and lLs faclllLles Lo malnLaln on-golng communlcaLlons, and
arrange for and allocaLe resources and supplles as necessary.

kesu|ts: 1hree hosplLals (Lenox Plll, loresL Pllls and norLh Shore unlverslLy PosplLal) gave refuge Lo 93 paLlenLs who
were evacuaLed from a new ?ork ClLy Medlcal CenLer, whlch closed due Lo floodlng. ln addlLlon, Lo ensure conLlnulLy of
care, Lenox Plll PosplLal credenLlaled 372 physlclans/llcensed lndependenL pracLlLloners from Lhls medlcal cenLer
lncludlng 38 obsLeLrlclans/gynaecologlsLs.

norLh Shore-Ll! Skllled nurslng laclllLles recelved more Lhan 78 paLlenLs from nurslng homes and shelLers ln new ?ork
ClLy and Long lsland. norLh Shore-Ll!'s ouLpaLlenL dlalysls cenLers exLended Lhelr hours of operaLlon Lo accommodaLe an
lnflux of more Lhan 30 paLlenLs whose LreaLmenL cenLers closed. Cur CenLer for Lmergency Medlcal Servlces (CLMS)
responded Lo 1,008 requesLs for asslsLance before, durlng and afLer Lhe hurrlcane, LransporLlng a LoLal of 726 paLlenLs,
almosL half of whlch were from non-healLh sysLem lnsLlLuLlons.

8y Lhe Llme Sandy was over, over one mllllon people losL power and Lens of Lhousands more were homeless. norLh
Shore-Ll! ralsed approxlmaLely $2.7 mllllon for a Sandy rellef fund prlmarlly dedlcaLed Lo employees and Lhelr famllles.
WlLhln 48 hours of Lhe sLorm's landfall, 62 employees' famllles obLalned Lemporary houslng Lhrough norLh Shore-Ll!,
slmllar arrangemenLs conLlnue Lo help hundreds of addlLlonal sLaff members and Lhelr famllles.

Conc|us|on: 8epeaLed LesLlng and acLlvaLlons of our LC over Lhe years has resulLed ln a flexlble, adapLable and scalable
LC LhaL ls noL resLrlcLed Lo a speclflc populaLlon/dlsease, or Lype of dlsasLer. Lessons learned durlng Lhe norLh Shore-Ll!
response Lo Super SLorm Sandy have expanded our exlsLlng knowledge of emergency preparedness. We have learned
Lhe vlLal role LhaL our organlsaLlon plays, noL only Lo our paLlenLs, buL Lo our employees and Lo Lhe communlLy aL large.
1hese lessons are lmporLanL Lo share wlLh oLher healLhcare organlsaLlons as Lhey seek Lo enhance Lhelr lnLernal
capablllLles and sLrengLhen processes relaLed emergency response.



1683

WnA1 IS 1nL ILASI8ILI1 CI IN1LkkCILSSICNAL LLk kLVILW CI SIGNIIICAN1 LVLN1 ANALSIS? : A ILC1 S1UD
Adam kyrlacou
1,*
, !ohn Mackay
1
, Pannah Mlller
1
, llona McMlllan
1

1
harmacy, nPS LducaLlon for ScoLland, Clasgow, unlLed klngdom


Cb[ect|ves: 1hls ob[ecLlve of Lhls sLudy was Lo examlne Lhe poLenLlal feaslblllLy for lnLer professlonal peer revlew wlLhln
Lhls model.

Methods: 10 SLA reporLs were selecLed for revlew. llve reporLs had been submlLLed by pharmaclsLs and flve by Cs. All
reporLs lnvolved paLlenL safeLy lncldenLs (Sl). Lach reporL was assessed by all revlewers (C=9, harm=7) uslng a
valldaLed lnsLrumenL.
(3)
An analysls was made of boLh Lhe quallLaLlve and quanLlLaLlve feedback provlded by Lhe peer
revlewers Lo hlghllghL areas of concordance and poLenLlal adherence beLween revlewers ln Lhe Lwo professlonal groups.

kesu|ts: Analysls of Lhe feedback ln Lhe proformas ldenLlfled prlnclple Lhemes. 1here were no SLA reporLs LhaL were noL
able Lo be analysed by elLher professlonal group. 8oLh groups of revlewers ralsed quesLlons regardlng undersLandlng of
abbrevlaLlons used by Lhe oLher professlon, buL Lhls dld noL prevenL formal analysls.

Cs and pharmaclsLs Lended Lo award slmllar scores when revlewlng Lhe analysls of SlgnlflcanL LvenLs (SLAs)

1here was concordance on Lhe feedback beLween C and pharmaclsL revlewers.

harmaclsLs and Cs focused Lhelr feedback on quallLy lmprovemenL lssues.

Cs and pharmaclsLs Lended Lo provlde scores only (wlLhouL wrlLLen commenLs), when provldlng feedback abouL, Lhe
seLLlng, demonsLraLlon of learnlng and when Lhey allocaLed Lhe flnal score.

Cs provlded global scores ln a wlder range Lhan Lhelr pharmaclsL colleagues.

harmaclsLs were more llkely Lo provlde wrlLLen feedback Lhan Lhelr C colleagues.

Conc|us|on: 1hls sLudy was a plloL and lndlcaLed LhaL Lhe lnLerprofesslonal peer revlew of SLAs by pharmaclsLs and
general pracLlLloners ls feaslble.

1he flndlngs demonsLraLe Lhe feaslblllLy of lnLer professlonal revlew of SLA reporLs lnvolvlng medlcaLlon relaLed Sls.
CallbraLlon lssues for scores and feedback as well as lssues wlLh professlonal Lermlnology could be addressed Lhrough
Lralnlng

keferences:
1. nPS LducaLlon for ScoLland webslLe: www.nes.scoL.nhs.uk/pharmacy/consulLaLlon/Accessed on 6Lh AugusL 2012
2. ue WeL C, 8radley n, 8owle . SlgnlflcanL evenL analysls: a comparaLlve sLudy of knowledge, process and aLLlLudes ln
prlmary care. Iootool of volotloo lo cllolcol ltoctlce. 2010, 17 (6).
3. Mckay !., Murphy u., 8owle ., Schmuck M-L., Lough M., Lva kW. uevelopmenL and LesLlng of an assessmenL
lnsLrumenL for Lhe formaLlve peer revlew of slgnlflcanL evenL analysls. Oool 5of neoltb cote 2007, 16:130-3



169S

MUL1ILL S1kA1LGILS ALICA1ICN 1C DLCkLASL MLDICA1ICN INCIDLN1 kA1L ICk MLDICAL ICU II
Shu L Pung
1,*
, Pslu !ung 1u
1
, Ll Chuan Pung
1

1
MlCu-2, naLlonal Cheng kung unlverslLy PosplLal, 1alnan ClLy, 1alwan


Cb[ect|ves: Whlle llvlng ln an lnformaLlon exploslve era, Lhe general publlc consclousness Lends Lo rlse. As more
aLLenLlons are focused on paLlenL rlghLs, Lhe healLh care quallLy becomes a common LargeL for survelllance, Lo ensure a
safe medlcal envlronmenL based on Lhe concern of paLlenL safeLy.

lrom 2004, 1alwan !olnL Commlsslon on PosplLal AccredlLaLlon has llsLed lmprovlng medlcaLlon safeLy as a Lop goal
under medlcal quallLy and paLlenL safeLy, whlch demonsLraLes LhaL medlcaLlon safeLy, has become Lhe very flrsL concern
on paLlenL safeLy. MedlcaLlon ls a dally rouLlne for nurses, and a hlgher prescrlpLlon frequency leads Lo hlgher
medlcaLlon lncldenL raLe. ln 2011, medlcal lnLenslve unlL ll has a medlcaLlon lncldenL raLe of 0.33, however, Lhe
reasons lnvolved are somewhaL compllcaLed. ln order Lo enhance medlcaLlon safeLy, our program lnduced mulLlple
sLraLegles Lo decrease medlcal lCu medlcaLlon lncldenL raLes. lrom !anuary Lo uecember 2012, based on Lhe lncldenL
reporLlng sysLem and Lhe Lracklng audlL mechanlsm, Lhe reasons analysed from each lncldenL lnclude: dose error,
medlcaLlon Lype error, omlsslon error, error for soluLlon proporLlon, and paLlenL ldenLlflcaLlon error.

Methods: MulLlple sLraLegles lnvolve CuallLy ConLrol Cycle (CCC), lS8A8, 18M, educaLlonal semlnars, prescrlpLlon
Lechnlque assessmenL, prescrlpLlon survelllance, medlcaLlon lncldenLs case sharlng, and lndlvldual consulLaLlon eLc.
lurLher, more acLlons are Laken Lo reduce Lhe medlcaLlon lncldenL raLes such as sLandardlse lCu medlcaLlon procedure,
seL up guldellnes for medlcal resldenL's order and emergency prescrlpLlon, lmplemenL lS8A8 communlcaLlon prlnclples,
perform 3-read 3-rlghL work and monlLor medlcaLlon dose, llmlL Lhe amounL of lnLravenous drlp glven, assess Lhe
Lechnlques for lnsulln ln[ecLlon and lnLravenous drlp of chemoLherapy medlcaLlon, arrange semlnars for medlcaLlon
ldenLlflcaLlon and hlgh alerL medlcaLlon, lmprove pharmaceuLlcal characLerlsLlc and ldenLlflcaLlon knowledge and use
4W1P approach Lo ensure drlps properly locaLed and LreaLmenL Lray wlLhouL medlcaLlon, share cases on a quallLy
managemenL meeLlng. 1hrough mulLlple sLraLegles and resource provlded by medlcal Leams, we ensure medlcaLlon
safeLy and medlcal communlcaLlon dellvered correcLly, as well as lmplemenL medlcaLlon knowledge and 3-read 3-rlghL
pollcy compleLely.

kesu|ts: AfLer carrylng ouL Lhe mulLlple sLraLegles, Lhe medlcaLlon lncldenL raLe sharply dropped from 0.33 ln 2011 Lo
0.17 ln 2012, successfully achleved Lhe annual goal of reduclng down Lo 0.3 ln 2012.

Conc|us|on: lmprove medlcaLlon safeLy, lower Lhe medlcaLlon errors, lncrease lnpaLlenL medlcaLlon safeLy, ensure
healLh care quallLy are Lhe common and essenLlal LargeL for medlcal sLaff.



1697

CCN1INUCUS UALI1 IMkCVLMLN1: IMLLMLN1ING A SnAkLD GCVLkNANCL MCDLL 1nA1 MAkIMISLS AGLN1-
SLCIIIC kNCWLLDGL
vanessa 8urkoskl
1,*
, !ennlfer ?oon
1

1
rofesslonal Scholarly racLlce, London PealLh Sclences CenLre, London, Canada


Cb[ect|ves: 1hrough sLaff engagemenL, moblllsaLlon of agenL-speclflc knowledge ls maxlmlsed Lhrough Lhe
ldenLlflcaLlon, formulaLlon, execuLlon, evaluaLlon, and dlssemlnaLlon of ConLlnuous CuallLy lmprovemenL (CCl)
lnlLlaLlves.

Methods: MoLlvaLe, lnnovaLe, CelebraLe - An lnnovaLlve, shared governance model Lhrough Lhe esLabllshmenL of
ConLlnuous CuallLy lmprovemenL (CCl) Counclls was lmplemenLed aL London PealLh Sclences CenLre, Lhe second largesL
academlc healLh sclences cenLre ln Canada. 1he model leverages agenL-speclflc knowledge aL Lhe polnL-of-care and
provldes a sLrucLure almed aL bulldlng human resource capaclLy and susLalnlng enhancemenLs Lo quallLy and safe care
dellvery. lnLerprofesslonal and cross-funcLlonal Leams work Lhrough Lhe CCl Counclls Lo ldenLlfy, formulaLe, execuLe,
and evaluaLe CCl lnlLlaLlves. ln addlLlon Lo Lhe sLrucLure LhaL faclllLaLes collaboraLlon, accounLablllLy, and ownershlp, a
corporaLe CCl SLeerlng CommlLLee provldes Lhe forum for scallng-up and spread. olnL-of-care sLaff, cllnlcal
managemenL and educaLlonal leaders were Lralned ln LLAn meLhodology and paLlenL experlence-based deslgn Lo
ensure sufflclenL knowledge and resources Lo supporL Lhe lmplemenLaLlon.

kesu|ts: 1o daLe, 61 lnLerprofesslonal and cross-funcLlonal counclls have been esLabllshed. 1here are 120 quallLy
lmprovemenL and paLlenL safeLy lnlLlaLlves aL varlous sLages of lmplemenLaLlon and evaluaLlon. 1hese lmprovemenLs
range from evldence-based pracLlce lnLegraLlon flrsLs" Lo sLaff -led process and sysLem redeslgn. 1he sLandardlsaLlon
of processes and procedures across CCl councll lnlLlaLlves has led Lo Lhe spread and scallng-up of a varleLy of besL
pracLlces and cllnlcal efflclencles. ro[ecLs have been repllcaLed up Lo 14 Llmes across cllnlcal unlLs and learnlng's from
lnlLlal pro[ecLs have supporLed scallng-up opporLunlLles. ln addlLlon, Lwo evldence-based pracLlce 'flrsLs' , lncludlng, Lhe
developmenL of an acuLe oral care assessmenL Lool and guldellne for lmplemenLaLlon of oral care for cllnlcal
neurosclence paLlenLs, and, uLlllsaLlon of colosLrum for oral lmmune Lherapy for neonaLal and lnfanLs have been
lnLroduced.

Conc|us|on: lnLegral Lo Lhe susLalned LransformaLlon ls Lhe clear arLlculaLlon of expecLaLlons regardlng sysLem redeslgn
Lhrough Lhe eyes of Lhe paLlenL. rofesslonal Scholarly racLlce leadershlp, a robusL communlcaLlon sLraLegy lncludlng, a
real-Llme, web-based reglsLry program, CLM8A 1v, weekly CCl sLorles, and monLhly conLlnuous quallLy lmprovemenL
revlews have supporLed Lhe success of Lhe model. 1he esLabllshmenL of CCl Counclls aL Lhe unlL level and Lhe
supporLlng sLrucLure and processes fosLered Lhe ablllLy for conLlnuous quallLy lmprovemenL Lo be embedded ln Lhe
culLure of Lhe organlsaLlon.



1698

kADIA1ICN SAIL1 C1IMISA1ICN IN NUCLLAk MLDICINL
Marcos A. u. Machado
1,*
, vlnclus C. Menezes
1
, ClelLon C. Cuelroz
1
, ulego A. Cuel[o
1

1
nuclear Medlclne, MonLe 1abor - PosplLal So 8afael, Salvador, 8razll


Cb[ect|ves: 1he occupaLlonal radlaLlon exposure rlsk ls proporLlonal Lo Lhe amounL of radloacLlvlLy presenL ln a nuclear
medlclne faclllLy. 1hls work ls lnLended Lo lnLroduce nuclear medlclne and L1/C1 sLraLegles aL nospltol 5o kofoel Lo
opLlmlse radlaLlon safeLy due Lo paLlenL LhroughpuL lncrease.

Methods: CccupaLlonal radlaLlon doses were reglsLered from 2008 Lo 2012 uslng a Lhermo lumlnescenL doslmeLer.
8esldes Lhe radlologlcal proLecLlon pracLlces already ln use unLll 2008, complemenLary sLraLegles were adopLed as
weaknesses were ldenLlfled ln Lhe processes along Lhe Llme: Lralnlng, personnel worklng schedule and lnformaLlon
Lechnology. CollecLlve doses for 2009, 2010, 2011 and 2012 were compared Lo Lhe basellne (2008) Lo verlfy Lhe
effecLlveness of Lhe sLraLegles adopLed. 1he lncrease of radlaLlon exposure rlsks was verlfled Lhrough Lhe amounL of
radlaLlon acLlvlLy manlpulaLlon and Lhe number of paLlenLs asslsLed.

kesu|ts: ln comparlson Lo Lhe basellne, Lhe followlng years had respecLlvely 13, 30, 33 and 36 lncrease ln Lhe
number of paLlenLs dlagnosed, 37, 38, 12 and 6 lncrease ln l-131 radlaLlon acLlvlLy manlpulaLlon, 3, -3, 30
and 32 lncrease of L1/C1 procedures. 1he basellne collecLlve dose was 0.06 man.Sv agalnsL 0.06 man.Sv, 0.07 man.Sv,
0.06 man.Sv and 0.06 man.Sv for Lhe followlng years, respecLlvely.

Conc|us|on: uesplLe Lhe overall lncrease of radlaLlon exposure rlsks, Lhe radlologlcal proLecLlon sLraLegles adopLed were
sufflclenL Lo assure accepLable radlaLlon dose levels.



170S

AkL CCMCSI1L MLASUkLS CI GLNLkAL kAC1ICL CI DA1A MCkL VALID INDICA1CkS CI CAkL UALI1 AND
kLLIA8ILI1?
Carl ue WeL
1,*
, aul 8owle
1

1
Ceneral racLlce, nPS LducaLlon for ScoLland, Clasgow, unlLed klngdom


Cb[ect|ves: A slgnlflcanL mlnorlLy of paLlenLs do noL recelve all Lhe evldence-based care recommended for Lhelr
condlLlons. PealLh care quallLy may be lmproved by reduclng Lhls observed varlaLlon. ComposlLe measures offer a
dlfferenL perspecLlve on care quallLy and are uLlllsed ln acuLe hosplLals vla Lhe 'care bundle' concepL as lndlcaLors of Lhe
rellablllLy of speclflc (evldence-based) care dellvery Lasks. We almed Lo apply Lhe care bundle concepL Lo selecLed CCl
daLa Lo measure Lhe quallLy and rellablllLy of evldence-based care provlslon.

Methods: Care bundles and componenLs were selecLed from CCl lndlcaLors accordlng Lo deflned crlLerla. llve cllnlcal
condlLlons were sulLable for care bundles: Secondary revenLlon of Coronary PearL ulsease (CPu), SLroke & 1ranslenL
lschaemlc ALLack (1lA), Chronlc kldney ulsease (Cku), Chronlc CbsLrucLlve ulmonary ulsease (CCu) and ulabeLes
MelllLus (uM). A reLrospecLlve audlL was underLaken ln a convenlence sample of nlne general pracLlces ln Lhe WesL of
ScoLland. racLlce level and overall compllance wlLh bundles and componenLs were calculaLed

kesu|ts: nlne pracLlces (64.3) wlLh a comblned paLlenL populaLlon of 36,948 were able Lo provlde daLa ln Lhe formaL
requesLed. Cverall compllance wlLh developed CCl-based care bundles (composlLe measures) was as follows: CPu
64.0, range 33.0-71.9, SLroke/1lA 74.1, range 31.6-82.8, Cku 69.0, range 64.0-81.4, and CCu 82.0, range
47.9-93.8, and uM 38.4, range: 30.3-63.2.

Conc|us|on: ln Lhls small sLudy compllance wlLh lndlvldual CCl-based care bundle componenLs was hlgh, buL overall ('all
or noLhlng') compllance was subsLanLlally lower. Care bundles may provlde a more rellable measure of care quallLy Lhan
exlsLlng meLhods. Powever, Lhe accepLablllLy, feaslblllLy and poLenLlal lmpacL on cllnlcal ouLcomes are unknown.

keferences:
1. Plnes S, !oshl MS. varlaLlon ln quallLy of care wlLhln healLh sysLems. !olnL Commlsslon !ournal on CuallLy & aLlenL
SafeLy 2008 !un,34(6):326-332
2. Selby !v, SchmlLLdlel !A, Lee !, lung v, 1homas S, Smlder n, eL al. Meanlngful varlaLlon ln performance: whaL does
varlaLlon ln quallLy Lell us abouL lmprovlng quallLy? Med Care 2010 leb,48(2):133-139
3. LesLer P, Campbell S. ueveloplng CuallLy and CuLcomes lramework (CCl) lndlcaLors and Lhe concepL of
'CClablllLy'. Cual rlm Care 2010,18(2):103-109
4. lleeLcrofL 8, SLeel n, Cookson 8, Powe A. Mlnd Lhe gap LvaluaLlon of Lhe performance gap aLLrlbuLable Lo
excepLlon reporLlng and LargeL Lhresholds ln Lhe new CMS conLracL: naLlonal daLabase analysls. 8MC PealLh Serv
8es 2008,8:131



1711

IMkCVING ADMISSICN kCCLSSLS ICk kAISING 1nL CUS1CMLk SA1ISIAC1ICN AND NS (NL1 kCMC1Ck SCCkL)
uong Shln Pan
1,*
, Pyun Ml ark
1

1
edlaLrlc CS & S ueparLmenL, Seoul naLlonal unlverslLy PosplLal, Seoul, korea, 8epubllc Cf


Cb[ect|ves: Accordlng Lo lA (lmporLance erformance Analysls) based on 2011 chlldren's' hosplLal saLlsfacLlon research,
lnconvenlence ln Lhe process of admlsslon ls Lhe flrsL area LhaL needs Lo lmprove:

1) 1he purpose of our Cl acLlvlLles was Lo examlne Lhe reasons why Lhe check-ouL Llme of dlscharge and Lhe walLlng
Llme for admlsslon were delayed.
2) Also, we almed Lo lmprove Lhe prevlous dlscharge-noLlce raLe by 80 and reduce Lhe walLlng-Llme for admlsslon by
60 mlnuLes.
3) ConsequenLly, we expecLed LhaL Lhese acLlvlLles would conLrlbuLe Lo promoLlng Lhe cusLomer saLlsfacLlon level and
Lhe nS (neL romoLer Score) level.
4) We also expecLed LhaL Lhe lmprovemenL of Lhe admlsslon and Lhe dlscharge process would glve nurses much
saLlsfacLlon, so we examlned nurses' worklng saLlsfacLlon relaLed Lo Lhe process ln wards.

Methods: ln our Cl acLlvlLles, we examlned Lhe reasons why Lhe check-ouL Llme of dlscharge and Lhe walLlng Llme for
admlsslon were delayed. We used Lhe self-developed lnvesLlgaLlon Lools for our Cl acLlvlLles. ln Lhe prellmlnary
lnvesLlgaLlon, we surveyed Lhe raLe of Lhe prevlous dlscharge-noLlce, and Lhe facLors LhaL lncreased Lhe walLlng Llme
(Lhese facLors are caused by Lhe relevanL deparLmenLs such as docLors, nurses, paLlenLs, admlnlsLraLlon sLaffs,
pharmaclsLs, cllnlcal laboraLory workers, lnsurance audlLors, clean servlce). We elLher analysed pre and posL daLa of Lhe
performance raLe of Lhe prevlous dlscharge-noLlce, currenL slLuaLlon of Lhe dlscharglng and admlsslon, Lhe real walLlng
Llme for admlsslon(from arrlval ln ward Lo enLerlng a room), cusLomer saLlsfacLlon, nS score, nurses' worklng
saLlsfacLlon. re survey perlod was from March Lo Aprll, 2012 and posL survey perlod was SepLember, 2012. We used
descrlpLlve sLaLlsLlcs and pre-posL comparlson sLaLlsLlcs.

kesu|ts:
1) 1he raLe of Lhe prevlous dlscharge-noLlce has lncreased by 13 (real score was 72).
2) Average walLlng Llme for admlsslon has decreased by 63 mlnuLes, whlch exceeded Lhe LargeL value (60 mlnuLes).
3) CusLomer saLlsfacLlon level abouL admlsslon process has lmproved by 18.1 polnLs.
4) nS score has lmproved by 17.3 polnLs.
3) Cn Lhe oLher hand, nurses' worklng saLlsfacLlon wlLh dlscharglng process has decreased by 19.6.

Conc|us|on: 1hese acLlvlLles upgraded Lhe process of admlsslon ln a general hosplLal. 1he raLe of Lhe prevlous dlscharge-
noLlce has rlsen, Lhe walLlng Llme for admlsslon has been reduced, and cusLomer saLlsfacLlon and nS (neL romoLer
Score) have lmproved. Powever nurses' worklng saLlsfacLlon abouL dlscharglng process has decreased. 1he reason
seems Lo be LhaL Lhey felL Loo much burden durlng Lhe dlscharge process.



1720

SL11ING 8LNCnMAkkING CI nCSI1AL kL-ADMISSICN kA1L 8 MLASUkING UNLANNLD nCSI1AL kL-ADMISSICN
kA1L AS AN INDICA1Ck.
Abd 8ahman Abd Azlz
1,*
, nlshazlnl Mohd 8aslr
2
, ?ogeswary Arumugam
3

1
AdmlnlsLraLlon,
2
CuallLy,
3
nurslng, k! Seremban SpeclallsL PosplLal, Seremban, Malaysla


Cb[ect|ves:
1. 1o seL Lhe benchmarklng raLe of unplanned re-admlsslon because hlgh re-admlsslon raLe have long been consldered
as a marker of lower quallLy care
2. uaLa use Lo esLabllsh sLraLegles Lo reduce Lhe unplanned readmlsslon raLe.

Methods: 8eLrospecLlve sLudy conducLed Lhrough daLa collecLlon from !anuary 2012 Lo March 2012.

kesu|ts: ln !anuary 2012, LoLal lnpaLlenLs were 1313 wlLh 48 re-admlsslons. Powever, only 11 cases of unplanned re-
admlsslon whlch ls 23 of Lhe LoLal re-admlsslon and 0.83 of LoLal lnpaLlenLs. llve cases were re-admlLLed wlLhln 14
days and only 1 case re-admlLLed wlLhln 13 Lo 30 days.

lor lebruary 2012, LoLal re-admlsslons were 64 lncludlng new born. numbers of unexpecLed re-admlsslons were 7 cases
where 3 cases were re-admlLLed wlLh 7 days and 4 cases re-admlLLed wlLhln 14 days. no cases re-admlLLed wlLhln 13 Lo
30 days. lL shows LhaL Lhe percenLage of unplanned re-admlsslon ln lebruary had decreased by 12 compared Lo Lhe
prevlous monLh. ercenLage of unplanned re-admlsslon of LoLal lnpaLlenLs (1329) ln lebruary was 0.3

As for March 2012, LoLal re-admlsslons were 60 lncludlng new born. numbers of unexpecLed re-admlsslons were 7 cases
where 3 cases were re-admlLLed wlLhln 7 days and 2 cases re-admlLLed wlLhln 14 days. no cases re-admlLLed wlLhln 13 Lo
30 days. ercenLage of re-admlsslon from Lhe LoLal ln-paLlenLs (1379) ln March was 12 and only 0.3 was unplanned
re-admlsslon.

1he hlghesL cases for unplanned re-admlsslon were due Lo 8ronchopneumonla (10 cases), followed by posL-operaLlve
bleedlng (3 cases), unconLrolled uM and unconLrolled PyperLenslon (boLh 2 cases), and one case each for CellullLls,
lnfecLed ulabeLlc fooL, ureLlc Collc, lCL, Anal flsLula, yelonephrlLls, vlral fever, Abdomlnal Collc

Conc|us|on: A closer undersLandlng of reasons for re-admlsslon ls Lherefore necessary Lo reduce unplanned re-
admlsslon, ldenLlfy paLlenLs who may be aL hlgh rlsk of re-admlsslon and fuLure plannlng Lo opLlmlse resources avallable.
1hls sLudy had enable k! Seremban SpeclallsL PosplLal Lo know Lhe raLe of unplanned re-admlsslon by comparlng wlLh
Lhe lnLernaLlonal benchmarklng sLandard. 8y dolng Lhls Lhe managemenL wlll have some guldance on Lhe sLandard of
care dellvered by Lhls hosplLal. 8e-admlsslon raLes can help Lo monlLor Lhe success ln prevenLlng, or reduclng,
unplanned re-admlsslons Lo hosplLal.

keferences:
1. hLLp://www.mayocllnlc.org/quallLy/readmlsslon-raLes.hLml
2. hLLp://www.ncbl.nlm.nlh.gov/pubmed/10619148
3. 8MI 1988, 297 Jol. 10.11J6/bmj.297.6651.784 (lobllsbeJ 24 5eptembet 1988)

clte tbls os. 8MI 1988,297.784
4. www.ooools.otq/cooteot/122/6/415
5. www.lmplemeototlooscleoce.com/cooteot/pJf/1748-5908-5-88.pJf
6. bttp.//www.emetolJloslqbt.com/ptoJocts/plet/

1721

CnANGLS IN 1nL A11LkN CI kLSCkI1ICN 1nkCUGn kCkLAN UALI1 ASSLSSMLN1 CI MLDICA1ICN ICk 10
LAkS
Pee Soon ?u
1,*
, Seo !ln ark
1
, ln !eoung Chol
1
, Ml La Ahn
1

1
PealLh lnsurance 8evlew & AssessmenL Servlce (Pl8A), Seoul, korea, 8epubllc Cf


Cb[ect|ves: ln korea, Lhe porLlon of pharmaceuLlcal expendlLure ln naLlonal healLh expendlLures ls hlgher Lhan CLCu (1.6
Llmes ln 2008). ln order Lo reduce mlsuse or abuse of drugs and encourage Lhe proper use of drugs Lhe PealLh lnsurance
8evlew & AssessmenL Servlce (Pl8A) has assessed prescrlblng Lrends of Lhe raLe of prescrlpLlon of anLlbloLlcs and
ln[ecLlons and provlded feedback on ouLcomes ln medlcal lnsLlLuLlons slnce 2001. ln 2006, we dlsclosed Lhe raLe of
prescrlpLlon of anLlbloLlcs and ln[ecLlons of Lhe LoLal medlcal lnsLlLuLlons. lrom 2008, we progressed lnLervenLlons such
as vlslL-consulL Lo cllnlcs. We also conLlnued promoLlonal acLlvlLles Lhrough posLers, radlo and Lelevlslon. 1he alm of Lhls
sLudy ls Lo lnLroduce Lhe effecLlveness of quallLy assessmenL of medlcaLlon pro[ecL for 10 years ln korea.

Methods: We analysed Lhe medlcal servlce sLaLemenL regardlng bllls submlLLed by medlcal lnsLlLuLlons (n=40,320). 1he
number of medlcal lnsLlLuLlons analysed was as follows: 44 LerLlary general hosplLals, 273 general hosplLals, 1,193
hosplLals, 23,177 cllnlcs, 12,316 denLal cllnlcs, 1,313 eLc. 1he number of cases analysed was 6.84 mllllon (ln 2011).

kesu|ts: 1he raLe of prescrlpLlon of anLlbloLlcs for acuLe upper resplraLory LracL lnfecLlon (Au81l) decreased by 23.7
from 73.3 ln 2002 Lo 47.6 ln 2011. 1he raLe of prescrlpLlon of ln[ecLlons also dropped by 18.2 from 38.6 ln 2002 Lo
20.4 ln 2011.

Conc|us|on: aLLern of prescrlpLlon was changed and lmproved Lhrough quallLy assessmenL of medlcaLlon. Lspeclally,
change ln cllnlcs was Lhe hlghesL. Powever, Lhe raLe of anLlbloLlcs prescrlpLlon, Lhe raLe of prescrlpLlon of ln[ecLlons were
sLlll hlgh ln korea. 1he PealLh lnsurance 8evlew & AssessmenL Servlce (Pl8A) wlll also perform Lhe ay-for-erformance
(4) pro[ecL ln assoclaLlon wlLh Lhe quallLy and cosLs of prescrlpLlon ln Lhe fuLure.



172S

IN-nCSI1AL IALLS AND IALL INIUkILS: WnLkL, WnLN AND nCW DC 1nL CCCUk?
Anna 8arker
1
, 8enaLa Morello
1
, 1errence Palnes
2
, Carollne 8rand
3,*

1
ueparLmenL of Lpldemlology and revenLlve Medlclne,
2
2hysloLherapy ueparLmenL, Monash unlverslLy and Allled
PealLh 8esearch unlL, ,
3
Monash unlverslLy and Allled PealLh 8esearch unlL, Monash unlverslLy, Melbourne, AusLralla


Cb[ect|ves: 1he alm of Lhls sLudy was Lo assess Lhe lncldence of ln-hosplLal falls and fall ln[urles occurrlng ln Lhe acuLe
hosplLal seLLlng and Lo explore Lhe characLerlsLlcs (where, when, how) of ln-hosplLal fall ln[urles.

Methods: uaLa were prospecLlvely collecLed as parL of Lhe 6-ACk falls prevenLlon pro[ecL
1
beLween SepLember 2011
!une 2012, from 26 acuLe wards across seven hosplLals ln AusLralla. A revlew of all ln-hosplLal fall evenLs was conducLed
uslng a mulLl-modal meLhod, Lo ensure compleLe case ascerLalnmenL. A Lralned daLa collecLor audlLed Lhe medlcal
records of all paLlenLs admlLLed Lo parLlclpaLlng wards each day and obLalned a dally verbal reporL from Lhe nurse unlL
manager abouL falls known Lo have occurred wlLhln Lhe prevlous 24 hours Lo record lnformaLlon abouL falls and fall
ln[urles. uaLa were LrlangulaLed wlLh falls recorded ln Lhe hosplLal lncldenL reporLlng daLabase. ueLalls on fall
characLerlsLlcs such as Llme, day of week, locaLlon of fall, fall Lype, subsequenL posL fall lnvesLlgaLlons and procedures
and Lhe Lype of ln[ury susLalned was recorded. CharacLerlsLlcs of fall and ln[urlous fall evenLs were descrlbed uslng
descrlpLlve sLaLlsLlcs.

kesu|ts: Cf Lhe 12,280 paLlenLs admlLLed Lo Lhe parLlclpaLlng wards durlng Lhe observaLlon perlod 337 were recorded as
havlng an ln-hosplLal fall. 1here were a LoLal of 773 unlque fall evenLs, 218 ln[urlous falls and a LoLal of 303 ln[urles
recorded. 1he proporLlons of falls resulLlng ln an ln[ury varled slgnlflcanLly across hosplLal wards. Cf Lhe 303 fall relaLed
ln[urles skln Lears were Lhe mosL commonly reporLed fall relaLed ln[ury (33), followed by brulses (24) and Lhen grazes
(14). WlLh 2 of all falls resulLed ln a serlous ln[ury (fracLures 1.6 and head ln[ury 0.8). lalls occurred ln Lhe
bedroom (67), baLhroom (19) and oLher ward areas (14). 8aLhroom falls more commonly resulLed ln ln[ury and Lhe
ma[orlLy of Lhese were un-wlLnessed (69). More Lhan a Lhlrd of ln[urlous falls occurred ln relaLlon Lo LolleLlng (40),
wlLh nearly 70 of Lhese reporLed as un-wlLnessed. 8olls ouL of a low-low bed were less llkely Lo resulL ln an ln[ury (16)
compared wlLh falls ouL of a sLandard bed (28). 1here was found Lo be no dlfference ln falls or fall ln[urles occurrlng
accordlng Lo Lhe day or Llme of Lhe week.

Conc|us|on: lalls ln Lhe acuLe hosplLal seLLlng are common and ofLen resulL ln ln[ury. 1he resulLs from Lhls sLudy can be
used Lo help drlve pracLlce change and furLher develop and LargeL falls prevenLlon pracLlces wlLhln Lhe acuLe hosplLal
seLLlng. lalls prevenLlon programs LhaL adopL lnLervenLlons such as supervlslon of paLlenLs ln Lhe baLhroom, LolleLlng
reglmes and Lhe use of low-low beds may be effecL aL reduclng fall ln[urles.

keferences: 1. 8arker A, 8rand C, Palnes 1, Plll k, 8rauer S, !olley u, eL al. 1he 6-ACk programme Lo decrease fall-
relaLed ln[urles ln acuLe hosplLals: proLocol for a clusLer randomlsed conLrolled Lrlal. lojoty lteveotloo 2011,17(4):e3-e3.




1729

USING DLkAML1nASCNL AND CnLCknLNIkAMINL INILC1ICNS AS 1kIGGLk AGLN1S 1C IMkCVL kLVLN1ICN CI
kLLA1LD kNCWN DkUG ALLLkGILS IN A UNIVLkSI1 nCSI1AL
SupaLLra 8erkvaleekul
1,*
, klLLlka ?ampayon
1

1
harmacy, Slrlra[ hosplLal, 8angkok, 1halland


Cb[ect|ves: 1o lmprove prevenLlon of repeaLed known drug allergles by uslng dexameLhasone and chlorphenlramlne
ln[ecLlons as Lrlgger agenLs Lo ldenLlfy Lhe drug allergy cases and lnpuL Lhe lnformaLlon lnLo Lhe alerL sysLem of pharmacy
sofLware.

Methods: aLlenLs who recelved boLh dexameLhasone and chlorphenlramlne ln[ecLlons from Cff-hour unlL, Lmergency
unlL, 1rauma unlL and Soclal securlLy servlces unlL from CcLober 2011 Lo SepLember 2012 were ldenLlfled and Lhelr
medlcal records were revlewed by pharmaclsLs Lo verlfy wheLher drug allergles occurred or noL. AgreemenL of
pharmaclsL's verlflcaLlon wlLh physlclan dlagnosls cases were collecLed and harm caLegorles by nCC ML8 were
recorded. 1he recorded cases were checked agalnsL Lhe volunLary reporLlng sysLem Lo evaluaLe Lhe effecLlveness of Lhe
avallable sysLem.

kesu|ts: A LoLal of 321 cases were deLecLed, 73 drug allergles (23.4) were ldenLlfled. SlxLy of Lhe evenLs (80) were
Lemporary harm Lo paLlenLs (caLegory L). Slx evenLs (8) requlred lnlLlal or prolonged hosplLallsaLlon (caLegory l). nlne
evenLs (12) requlred lnLervenLlons Lo susLaln llfe (caLegory P). lorLy-Lhree of Lhe adverse drug reacLlons (37.3) were
recorded prompLly ln Lhe avallable alerL sysLem. 1he lefLovers (42.7) were done compleLely when we found from Lhe
Lrlgger agenLs. llfLy-four cases (72.0) were reporLed by physlclans or nurses Lo Lhe avallable sysLem buL 21 cases
(28.0) were noL. 1he meLhod used ln Lhe sLudy could prevenL more unreporLed cases from repeaLed known drug
allergles ln fuLure.

Conc|us|on: 1he Lrlgger agenLs can be used Lo deLecL drug allergy cases whlch are adverse evenLs boLh reporLed and
unreporLed. 1he llmlLaLlon of Lhls sLudy was Lhe selecLlon of 2 Lrlgger agenLs whlch paLlenLs recelved aL Lhe same Llme. lf
we selecLed only one agenL, dexameLhasone or chlorphenlramlne ln[ecLlon, many cases of mlld reacLlon mlghL be found,
buL Lhls sLudy focused on Lhe severe lmmedlaLe Lype hypersenslLlvlLy reacLlons such as anaphylaxls and Lhls meLhod was
proved effecLlve Lo prevenL repeaLed known drug allergles and provlde more paLlenL safeLy.



1731

kLCCVLk CAkL GUIDLLINLS AI1Lk SLDA1IVL LNDCSCC: ICCUSLD CN ILUMA2LNIL ADMINIS1kA1ICN AND
DISCnAkGL IkCM 1nL kLCCVLk kCCM
!l Pee !ung, Pae ?oung Lee, ?ou !ln Pong, !l Pyun Song
1
Seoul naLlonal unlverslLy PosplLal PealLhcare sysLem Cangnam CenLer, Seoul, korea, 8epubllc Cf


Cb[ect|ves: SnuP PealLhcare SysLem Cangnam CenLer (medlcal cenLer for healLh check-up) has a hlgh percenLage of
cllenLs who undergo sedaLlve endoscopy. 1o reduce cllenLs' dlscomforL and paln durlng endoscopy, our cenLer pre-
medlcaLes cllenLs wlLh mldazolam (benzodlazeplne) for sedaLlon and admlnlsLers flumazenll Lo faclllLaLe Lhelr
awakeness. 8uL many cllenLs complaln degrees of dlzzlness or sedaLlon afLer Lhe procedure and need a longer walLlng
llne for and readmlsslon Lo Lhe recovery room. So Lhls sLudy ls almed Lo esLabllsh guldellnes for Lhe proper use of
flumazenll and sLandardlse nurslng care for dlscharge from Lhe recovery room, Lhereby enhanclng cllenLs' saLlsfacLlon
afLer sedaLlve endoscopy.

Methods: Cur Leam composed of physlclans and nurses ln Lhe endoscopy unlL bralnsLormed abouL problems and found
ouL LhaL problems are Lhe lack of sLandards for sedaLlon level evaluaLlon and guldellnes for flumazenll admlnlsLraLlon.
We developed posL-sedaLlon evaluaLlon crlLerla and drug admlnlsLraLlon guldellnes. When mldazolam was ln[ecLed less
Lhan 10 mg and a sedaLlon level was -3 or -4 on Lhe 8lchmond AglLaLlon-SedaLlon Scale durlng Lhe procedure, 0.23mg of
flumazenll was glven Lo cllenLs' rlghL afLer procedure. CllenLs were dlscharged from Lhe recovery room only when Lhelr
Modlfled AldreLe score was 9 or more. lor Lhe cllenLs who sLlll dld noL recover enough from sedaLlon, Lhey were
provlded wlLh more Llme ln Lhe recovery room and addlLlonal dosage of flumazenll. When Lhe cllenLs revlslLed Cangnam
cenLer for resulLs laLer, Lhey were lnLervlewed on Lhelr saLlsfacLlon levels for Lhe sedaLlve procedures and Lhe lengLh of
Llme lL Look Lo reLurn Lo work. We compared Lhe percenLage of cllenLs readmlLLed Lo and Lhe lengLh of sLay ln Lhe
recovery room before and afLer applylng Lhe new guldellnes and analysed sLaLlsLlcally by SSS 19.0 for wlndows.

kesu|ts: We conducLed pre-survey from !anuary Lo Aprll, 2012 and posL-survey from !uly Lo SepLember, 2012 on cllenLs
who were glven flumazenll rlghL afLer enLerlng Lhe recovery room when drug-admlnlsLraLlon guldellnes are belng
applled. 1he percenLage of cllenLs who sald 'saLlsfled' (lncludlng vL8? SA1lSllLu and SA1lSllLu based on Lhe LlkerL 3-
polnL Scale) lncreased from 63.3 Lo 66.1. CllenLs who sald LhaL Lhey goL back Lo work less Lhan 4 hours laLer wenL up
from 77.78 Lo 93.1(<0.01). 1he cllenLs wlLh less Llme Lo reLurn Lo work showed hlgher saLlsfacLlon levels(r=-.417,
<0.01). 1he average lengLh of sLay ln Lhe recovery room decreased from 34.36 mlnuLes Lo 26.73 mlnuLes. 1he
readmlsslon raLe Lo Lhe recovery room due Lo sedaLlve condlLlon wenL down from 46.34 Lo 40.

Conc|us|on: CllenLs were saLlsfled more and reLurned Lo rouLlne earller when sLandardlsed sedaLlon-level crlLerla and
flumazenll admlnlsLraLlon guldellnes were applled. lurLhermore, lL ls expecLed LhaL Lhe decrease ln average lengLh of
sLay ln Lhe recovery room would conLrlbuLe Lo an efflclenL managemenL of Lhe endoscopy unlL.



1732

USING LVIDLNCL-8ASLD kAC1ICL 1C IMkCVL VLN1ILA1Ck ASSCCIA1LD NLUMCNIA kA1L IN MLDICAL IN1LNSIVL
CAkL UNI1
Ll-Chlng Lln
1,*
, ?l-!lun Puang
2
, Shlh-Psln Pslao
1
, ?uarn-!ang Lee
3

1
Medlcal lnLenslve Care unlL,
2
CuallLy ManagemenL,
3
lnfecLlous ulsease lnLernal Medlclne, 1alpel Medlcal unlverslLy
PosplLal , 1alpel, 1alwan


Cb[ect|ves: venLllaLor assoclaLed pneumonla (vA), a Lype of nosocomlal pneumonla assoclaLed wlLh mechanlcal
venLllaLlon , lncreases morbldlLy and llkely morLallLy as well as Lhe lnpaLlenL day and expense of healLh care,
Lherefore, Lhe reducLlon of lncldence of vA ls crlLlcal. ln 2009, Lhe lncldence of vA aL Medlcal lnLenslve Care unlL
(MlCu) ln our lnsLlLuLe was 3.96, hlgher Lhan Lhose ln local medlcal cenLers and reglonal hosplLals (1.10 Lo 1.84). 1o
lmprove Lhls Lo less Lhan 2 or wlLh a reducLlon of 30 of vA lncldence ln MlCu, we lnLroduced a novel lnfecLlon
conLrol meLhod vA bundle care" lnLo cllnlcal pracLlce.

Methods: ueslgn: An lnLervenLlon proLocol was conducLed Lo compare Lhe lncldence raLes of vA before-and-afLer
lmplanLaLlon of care bundle.

SeLLlng: A 24-bed adulL medlcal lnLenslve care unlL.

aLlenLs: All paLlenLs admlLLed Lo our seLLlng for 48 hrs or more durlng Lhe perlods before and afLer lnLervenLlon.

lnLervenLlons: A Lhree-elemenL venLllaLor-assoclaLed pneumonla prevenLlon bundle, conslsLlng of head of Lhe bed
elevaLed Lo 30-43, dally sedaLlon hold and assessmenL of readlness Lo exLubaLlon, and oral hyglene care wlLh 0.2
Chlorhexldlne 3 Llmes a day were lnLroduced lnLo cllnlcal pracLlce for Lhe paLlenLs recelvlng mechanlcal venLllaLlon
supporL. All Lhe care processes were documenLed on Lhe checkllsL ln all Lhree nurslng shlfLs.

kesu|ts: 1hrough !anuary 2010 Lo november 2012, a LoLal of 1089 paLlenLs were admlLLed Lo our seLLlng, wlLh mean age
of 72.2 17.1 years, wlLh a LoLal of 23771 paLlenL-days and 14307 venLllaLor-days. 1he vA raLe was 3.74 /1000
venLllaLor days ln 2010, and slgnlflcanLly reduced Lo 1.98 ln 2011 and 1.20 ln 2012 (=0.032<0.03), respecLlvely.
AlLernaLlvely, Lhe vA raLe was lmproved by a reducLlon of 47 afLer lnLroducLlon of vA bundle care ln our seLLlng.
lurLhermore, Lhe average of venLllaLor-days for a paLlenL reduced from 42.2 37.0 Lo 40.9 21.9 days afLer lnLroducLlon
of vA bundle care. AddlLlonally, mosL frequenL paLhogens found were AclneLobacLer baumannll (34.3 of all lsolaLes)
followed by, seudomonas aeruglnosa (17.1), klebslella pneumonla (14.3) and SLaphylococcus aureus (8.6).

Conc|us|on: We flnd LhaL lnLroducLlon of vA bundle care lnLo dally cllnlcal pracLlce slgnlflcanLly lmproved Lhe vA raLe
ln medlcal lCu and suggesL Lhls mlghL be applled Lo all lnLenslve care unlLs.



1740

SAIL1 S1LS: VALIDA1ICN CI A CnLCkLIS1-DkIVLN 1CCL ICk CkLA1ING AC1ICN LANS ICk ADVLkSL LVLN1S
8a[ 8ehal
1,*

1
8ush unlverslLy Medlcal CenLer, Chlcago, unlLed SLaLes


Cb[ect|ves: Adverse evenLs conLlnue Lo occur ln hosplLals desplLe rooL cause analysls and acLlon plans. Slmllar evenLs
Lend Lo recur over Llme, suggesLlng LhaL prlor acLlon plans were elLher noL robusL or were noL lmplemenLed properly.
1he ob[ecLlve of Lhls lnlLlaLlve was Lo develop a checkllsL-drlven Lool LhaL can be used Lo develop more robusL acLlon
plans LhaL are based ln safeLy sclence.

Methods: 8evlew of Lhe llLeraLure from healLhcare and oLher hlgh-rlsk lndusLrles was conducLed Lo ldenLlfy key Lhemes
ln safeLy and accldenL prevenLlon. lnLernal rooL cause analysls and acLlon plans from prlor evenLs were revlewed. A Lool
lncorporaLlng Lhe key Lhemes from Lhe llLeraLure and lessons from prlor evenLs was developed: 1he SafeLySLeps Lool
lncludes 3 caLegorles of acLlons:

1. Manage hazards,
2. Address human facLors,
3. 8edeslgn process and sysLems of care,
4. use admlnlsLraLlve conLrols, and
3. Manage organlsaLlonal learnlng, accounLablllLy and culLural norms.

Lach seL of acLlons was asslgned a score ranglng from 10 polnLs Lo 30 polnLs -- an acLlon plan lncludlng lnLervenLlons
from each caLegory would have a maxlmum score of 100.

1he Lool was prospecLlvely applled Lo evenLs and revlsed Lo lLs flnal form. 1he flnal verslon of Lhe Lool - SafeLySLeps - was
valldaLed by Lwo lndependenL cllnlcal revlewers agalnsL publlcly avallable reporLs of adverse evenLs and acLlon plans.
1he Lool also was applled Lo selecLed Lypes of adverse evenLs.

kesu|ts: 1wo lndependenL revlewers evaluaLed Lhe evenLs wlLh acLlon plans slmllarly. 1he SafeLySLeps checkllsL was
applled Lo acLlon plans for recurrenL evenLs lncludlng reLalned ob[ecLs afLer surgery, mechanlcal compllcaLlons of cenLral
venous caLheLers and shoulder dysLocla. 1hese prevlously frequenL evenLs (mulLlple Llmes a year) have noL occurred for
more Lhan 12 monLhs.

Conc|us|on: A sLrucLured and sysLemaLlc approach Lo developlng acLlon plans ls essenLlal Lo prevenL recurrenL evenLs
causlng harm Lo paLlenLs. A checkllsL-based Lool based on safeLy sclence was developed, valldaLed and applled wlLh
success.



174S

kLDUCING NLAk MISS WI1n INICkMA1ICS AU1CMA1ICN CI MLDICA1ICN kCCLSS IN nAkMAC CI SCU1nLkN
1AIWAN MLDICAL nCSI1AL
Wen-!ul leng
1,*
, Chla-Chen Puang
2
, Mel-lang Lln
2
, Chl-!ung ?eh
3

1
ueparLmenL of Medlcal CuallLy and aLlenL SafeLy,
2
harmacy, L-uA PosplLal,
3
LaboraLory Medlclne, kaohslung Medlcal
unlverslLy PosplLal, kaohslung ClLy, 1alwan


Cb[ect|ves: 1o ellmlnaLe near mlss error ln pharmacy we develop many lnformaLlcs auLomaLlc sysLem replace LradlLlonal
manual process and based on analysls of medlcaLlon error of Lhree years ln SouLhern 1alwan Medlcal CenLer.

Methods: A proacLlve Lhorough analysls of medlcaLlon process. Whlch medlcaLlon error we found Lhe crlLlcal process ln
wrong medlcaLlon order, physlclan order enLry errors, pharmacy dlspenslng errors, Lransmlsslon errors and medlclne
lssue error by human. So we lmplemenL some lnformaLlcs auLomaLlon process such as lnpaLlenL, ouLpaLlenL and
emergency medlcal admlnlsLraLlon sysLem abouL medlcaLlon guldellne, nurse care CCL sysLem, conLrol anLlbloLlc uslng
sysLem, urug allergy noLe sysLem, LowesL and hlghesL dose llmlLs warnlng sysLem, Medlclnes appearance ldenLlflcaLlon
cum formulary query sysLem and ChemoLherapy drugs speclflc dlluLlons warnlng sysLem from 2010 Lo 2012. 1oLal
medlcaLlon prescrlpLlons were revlewed from !an 2010 Lo uec 2012. Among Lhese eplsodes, lL was done ln 1,310,390
(2010), 1,620,284 (2011) and 1,623,236 (2012).

kesu|ts: 1he prellmlnary reporL showed Lhe lmprovemenL of lnformaLlcs auLomaLlon ln cllnlcal medlcaLlon. AfLer
lmplemenLaLlon of medlcaLlon lnformaLlcs auLomaLlon from 2010 Lo 2012, we dld Lhe plloL performance evaluaLlon Lhe
performance. 1here were 4129 near mlss errors ln 2010, 3367 near mlss errors ln 2011 and 3481 near mlss errors ln
2012. We reduce Lhe lncldence of medlcaLlon near mlss errors by human abouL Mu, nurses and pharmaclsLs. lnformaLlcs
auLomaLlon sysLem can ellmlnaLe Lhe poLenLlal rlsk of hazard score from 0.27 decreaslng Lo 0.21.

Conc|us|on: harmacy lnformaLlcs auLomaLlon ls a useful Lool Lo reduce Lhe near mlss errors whlch would be poLenLlal
serlous medlcaLlon errors due Lo many crlLlcal manual sLeps caused by human. lurLher sLudy ls warranLed.

keferences:
1. klrke C. MedlcaLlon SafeLy ln PosplLals. lrlsh MedlcaLlon SafeLy neLwork. lr Med !. 2009 nov-uec,102(10):339-41.
2. khoo LM, Lee Wk, Sararaks S, Abdul Samad A, Llew SM, Cheong A1, lbrahlm M?, Su SP, Mohd Panaflah An, Maskon
k, lsmall 8, Pamld MA. Medlcal Lrrors ln rlmary Care Cllnlcs -- a Cross SecLlonal SLudy. 8MC lam racL. 2012 uec
26,13(1):127.




1748

1LAM kLSCUkCL MANAGLMLN1 IN CCM8INA1ICN WI1n S1kUC1UkLD LLLC1kCNIC INICkMA1ICN SS1LM
IMkCVLS 1nL UALI1 CI MUL1IDISCILINAk INICkMA1ICN SnAkING AND nANDCVLk IN CAkDICVASCULAk
SUkGLk IN1LNSIVL CAkL UNI1
Wan-1l Psu
1,*
, !lun-yl Lee
1
, ?l-Pslu Wang
1
, Pslu-feng Wang
1

1
cardlovascular surgery lnLenslve care unlL, Mackay Memorlal PosplLal, 1alpel, 1alwan


Cb[ect|ves: aLlenL handover followlng cardlovascular surgery lnvolves a mulLldlsclpllnary Leam and a crlLlcally lll
paLlenL, whlch causes mulLlple cognlLlve demands for Lhe LreaLlng Leam, carrylng an lncreased rlsk of lnformaLlon error
wlLh poLenLlally cllnlcal hazards. 1o lmprove Lhe lnformaLlon Lransfer and mulLldlsclpllnary Leam cooperaLlon, we
comblne Lhe Leam resource managemenL and sLrucLured elecLronlc lnformaLlon sysLem Lo creaLe Llmely and accuraLe
lnformaLlon sharlng.

Methods: Slnce March 2011, a change Leam formed ln our lCu Lo make sure Lhe conslsLency and accuracy of handover
and cognlLlon of paLlenL lnformaLlon Lo lmprove paLlenL safeLy. We lnvesLlgaLed Lhe mosL frequenLly encounLered
problems regardlng Lo lnformaLlon beLween dlfferenL medlcal professlonals and handover ln Lhe lCu uslng
quesLlonnalre. AfLer conflrmaLlon of Lhe maln problems, we used Leam dlscusslon and maLrlx analysls Lo flgure ouL Lhe
mosL feaslble and effecLlve way Lo lmprove process of pracLlce. racLlclng Leam resource managemenL wlLh emphaslslng
on Lhe leadershlp and communlcaLlon domalns was declded. ln CcLober 2011, we consLrucLed a sLrucLured elecLronlc
lnformaLlon sysLem uslng Lhe S8A8 (slLuaLlon, background, assessmenL, and recommendaLlon) conflguraLlon Lo lnLegraLe
Lhe lnpuLs from every professlonal ln Lhe same page ln order Lo faclllLaLe Lhe documenLaLlon and communlcaLlon. Check-
back was encouraged lf any unclear or lncoherenL lnformaLlon was found. hyslclans, nurses, pharmaclsL, resplraLory
LheraplsLs, physlcal LheraplsLs, nuLrlLlonlsLs, and soclal workers were all lncluded ln Lhe lnformaLlon provlslon. As a Leam
leader, physlclans were asked Lo vlew S8A8s from all Leam members and glve response. hyslclan speclallsLs ln lnLenslve
care unlL used brlef-huddle-debrlef Lechnlque ln dally Leam rounds. CLher Lools such as Lwo-challenge and cross
monlLorlng were encouraged. CuesLlonnalres concernlng sLaff percepLlon of Lhe quallLy and conslsLency of handover,
Leamwork cllmaLe, and paLlenL safeLy cognlLlon were used before and 3 monLhs afLer Lhe change. 1he number of
adverse evenLs relaLed Lo lnadequaLe handover was recorded. 1he raLe of physlclan response Lo lnformaLlon provlded
by oLher professlonals was measured. 1he daLa were analysed uslng chl-square LesL for dlchoLomous varlables and L LesL
for conLlnuous varlables.

kesu|ts: 1he use of elecLronlc lnformaLlon sysLem dld noL cause much lnconvenlence Lo all flelds of professlonals and
was rapldly lncorporaLed lnLo Lhelr dally acLlvlLy. Slnce Lhe ease of use and Lhe convenlence of obLalnlng lnformaLlon
provlded by oLher professlonals, Lhe elecLronlc lnformaLlon sysLem became wldely used ln all lCu ln our hosplLal slnce
!anuary 2012. 1hree monLhs afLer Lhe execuLlon of Lhe sysLem, Lhe sLaff percepLlon of Lhe handover quallLy lncreased
from 30 Lo 100 and Lhe conslsLency of handover lncreased from 40 Lo 98. 1he percepLlon of Leamwork cllmaLe
lncreased from 73 Lo 93 and Lhe paLlenL safeLy cognlLlon lncreased from 80 Lo 100. no adverse evenL was
recorded ln relaLlon Lo lnadequaLe handover. 1he raLe of physlclan response Lo lnformaLlon provlded by Leam members
was 100, whlch remalned 99.2 ln Lhe followlng year. AddlLlonal beneflL from Lhe promoLlon of Leam resource
managemenL was Lhe reducLlon of reslgnaLlon raLe from16.8Lo zero.

Conc|us|on: lmplemenLaLlon of Leam resource managemenL and use of sLrucLured elecLronlc lnformaLlon sysLem based
on S8A8 formaL lmproves Lhe communlcaLlon beLween mulLldlsclpllnary Leam member and Lhe culLure of cooperaLlon
as well as paLlenL safeLy.



17S3

LVALUA1ICN CI MLDICAL S1AIIS' ILLD8ACk CN USING U1CDA1L AS A DLAk1MLN1AL WL8-8ASLD CIN1-CI-
CAkL CCNSUL1A1ICN SUCk1
C k lrancls Mok
1
, klng Shlng Leung
1,*
, Chun keung Leung
1

1
Medlclne and CerlaLrlcs, 1MP, PosplLal AuLhorlLy, Pong kong, Pong kong.


Cb[ect|ves: 1he Medlclne & CerlaLrlcs ueparLmenL (M&C) of n1W ClusLer (n1WC) of Pong kong declded Lo use
up1ouaLe as a deparLmenLal web-based polnL-of-care consulLaLlon supporL for Lhe year 2012. AfLer subscrlbed by
deparLmenLal fundlng, lL was accesslble by all compuLer sLaLlons ln Lhe M&C wards Lhrough PosplLal AuLhorlLy lnLraneL
deparLmenL webslLe 24 hours every day. up1ouaLe ls an evldence-based, physlclan-auLhored & exLenslve peer-
revlewed (more Lhan 3100 auLhors & revlewers worldwlde) cllnlcal declslon supporL resource for cllnlclans Lo make Lhe
polnL-of-care declslons. 1he mosL recenL medlcal lnformaLlon ls puL lnLo evldence-based recommendaLlons wlLh full
references. lL provldes lnformaLlon on over 9300 cllnlcal Loplcs ln 20 speclalLles, coverlng all subspeclalLles ln lnLernal
medlclne. lL also covers Surgery, Cncology, C&C, aedlaLrlcs and sychlaLry.

Cb[ecLlves:
AfLer one year of subscrlpLlon, we wlsh Lo revlew Lhe usage paLLern and feedback from medlcal sLaffs on lLs cllnlcal
usefulness

Methods: ln !anuary 2013, survey forms (e-mall & hard copy) were senL Lo all 117 medlcal sLaffs of Lhe deparLmenL. 34
(46.1) valld replles were recelved. 1he usage lnformaLlon of 2012 was also updaLed.

kesu|ts: 1he hlL raLe of up1ouaLe sLeadlly rose across Lhe year, Lhe hlghesL belng 493 hlLs per week. lL was malnly used
for paLlenL managemenL & consulLaLlon, followed by preparlng presenLaLlon & knowledge updaLe.

! 72 - lL changed Lhe cholce of dlagnosLlc LesLlng
! 87 - lL changed paLlenL managemenL
! 93 - lL lmproved paLlenL care
! 96 - lL updaLed medlcal knowledge
! 73 - used lL Lwlce or more per week
! 93 - preferred lL Lo oLher avallable cllnlcal knowledge resources
! 94 - saLlsfled or very saLlsfled as a cllnlcal knowledge resource
! 96 - deparLmenL should conLlnue Lo provlde access Lo lL

1he cosLlng per hlL was esLlmaLed Lo be uS$0.66 by uslng !an13 daLa.

Conc|us|on: up1ouaLe was a welcomed web-based cllnlcal reference for M&C cllnlcal servlce wlLh accepLable cosLlng.
lL formed Lhe cornersLone of promoLlng evldence-based medlclne ln our pracLlce. lL ls worLhwhlle Lo explore Lhe
provlslon of slmllar web-based polnL-of-care reference aL LerrlLory-wlde level.



17S8

kISk ADIUS1MLN1 CI 1nL CLkA1IVL MCk1ALI1 ICk S1CMACn, CCLCN AND LIVLk CANCLkS
!ln kyung klm
1,*
, nam Pee klm
1
, Lea kyong kwon
1

1
PealLh lnsurance 8evlew and AssessmenL Servlce, Seoul, korea, 8epubllc Cf


Cb[ect|ves: We developed Lhe rlsk-ad[usLed model for Lhe Lhree prevalenL cancers lncludlng sLomach, colon and llver
and compared operaLlve morLallLy wlLh rlsk-ad[usLed operaLlve morLallLy by hosplLal Lypes.

Methods: We collecLed daLa from Lhe PealLh lnsurance 8evlew and AssessmenL Servlce (Pl8A) and analysed sLomach,
colon and llver cancer operaLlons LhaL were performed beLween !anuary 1, 2010, and uecember 31, 2010.
aLlenL rlsk facLors lnclude age, gender, operaLlon Lype, emergency operaLlon, ASA class, 8Ml, Charlson ComorbldlLy
lndex (CCl), cancer sLaglng (excludlng llver cancer), MLLu (model for end-sLage llver dlsease) score
[1]
and eLc.. Pere, Lhe
ouLcome varlable ls Lhe morLallLy raLe of operaLlon (ln-hosplLal and posL-operaLlve 30 days). 8lsk-ad[usLed models for all
cancer were developed uslng MulLlvarlble loglsLlc regresslon. C -sLaLlsLlc and Posmer-Lemeshow LesL were used Lo
evaluaLe Lhe performance of Lhe rlsk-ad[usLed model.

[1] MLLu score=100.937ln(creaLlnlne)+0.378ln(1.blllrubln)+1.12ln(proLhrombln Llme)+0.643

kesu|ts: We analysed 39,180 operaLlons performed aL 302 hosplLals. CperaLlve morLallLy was 0.92 for sLomach cancer,
1.63 for colon cancer and 1.88 for llver cancer.

C -sLaLlsLlc (more Lhan 0.8 for all of Lhe cancers) and Posmer-Lemeshow LesL aL Lhe 3level of slgnlflcance showed LhaL
Lhe model performance was good.

AfLer rlsk ad[usLmenL, hosplLals LhaL operaLlve morLallLy was greaLer Lhan upper confldence llmlL were 2-3 (3.1-6.9) ln
1erLlary hosplLal and 4-11 (13.3-17.4) ln Ceneral hosplLal.

1able 8lsk-ad[usLed resulL of operaLlve morLallLy
group sLomach cancer colon cancer llver cancer
below beLwee
n
above below beLween above below beLween above
1erLlary hosplLal 1 40 3 2 40 2 37 2
Ceneral hosplLal. 49 10 1 71 11 19 4
PosplLal. 3 9
model performance
(C-sLaLlsLlc/-value)
0.88 / 0.143 0.88 / 0.277 0.81 / 0.739
*PosplLals conLalnlng less Lhan 10 operaLlons were omlLLed.

key:
! below: morLallLy < 93 lower confldence llmlL
! beLween: Lower confldence llmlL morLallLy upper confldence llmlL
! above: 93 upper confldence llmlL < morLallLy

Conc|us|on: We reporLed rlsk ad[usLed resulL Lo monlLor surglcal servlces and provlded a means for poLenLlally
lmprovlng Lhe quallLy of surglcal care.


1761

A1ILN1 SAIL1 CLIMA1L SUkVL- A LkSLC1IVL IkCM A kIMAk CAkL SL11ING IN SINGACkL
1eck ung 1ang
1
, kong Chee Llm, L Llng Chua
1
, Llu Lee ?ee
1

1
Cllnlcal Servlces, naLlonal PealLhcare Croup olycllnlcs, Slngapore, Slngapore


Cb[ect|ves: ldenLlfylng lnadequacles ln dlfferenL aspecLs of paLlenL safeLy lssues among healLhcare workers ls an lmporLanL sLep ln
lmprovlng overall paLlenL safeLy and cllnlcal quallLy. ln order Lo achleve Lhe alm of lmprovlng overall paLlenL safeLy, we performed a
sLudy Lo compare Lhe paLlenL safeLy culLure among our healLhcare workers beLween surveys performed ln 2007, 2009 and 2012.

Methods: We conducLed Lhe paLlenL safeLy cllmaLe (SC) survey ln 2012 across nlne naLlonal PealLhcare Croup olycllnlcs and
PeadquarLers, by uslng a sLandard formaL of SC Survey lorm as per 2007 and 2009.
1he quesLlonnalres focused on slx lmporLanL aspecLs, namely Lhe work envlronmenL, supervlsors, communlcaLlons beLween Leam
members, frequency of lncldenL reporLlng, paLlenL safeLy gradlng and sLaff background lnformaLlon. A non-punlLlve pollcy was
emphaslsed for Lhe survey.

1here were 1313 respondenLs ln 2012, wlLh response raLe ranglng from 77 Lo 93 among Lhe dlfferenL polycllnlcs and
headquarLers. lrom Lhe daLa gaLhered, comparlson was belng made beLween Lhe 3 dlfferenL years of survey and sLaLlsLlcally
slgnlflcanL resulLs were ldenLlfled.

kesu|ts: SLaLlsLlcally slgnlflcanL resulLs are as shown:

Strengths (Areas of lmprovemenL slnce 2007)
! More respondenLs agreed LhaL Lhey LreaL each oLher wlLh respecL ln Lhelr unlL.
! 1he proporLlon, who dlsagreed LhaL sLaff work longer hours Lhan ls besL for paLlenL care, has lncreased.
! A rlslng Lrend ls seen ln Lhe group who reporLed LhaL Lhey are glven feedback abouL changes puL lnLo place based upon evenL
reporLs.

otent|a| areas of |mprovement
! 1he percenLages of respondenLs ln 2012 who reporLed LhaL Lhere ls enough sLaff Lo handle Lhe workload are less Lhan Lhose ln
prevlous years.
! A decreaslng Lrend ls seen across Lhe perlod ln Lhe group who dlsagreed LhaL Lhey use more agency/Lemporary sLaff Lhan ls besL
for paLlenL care alLhough noL much ls changed beLween 2009 and 2012.
! 1he percenLages of respondenLs ln 2012 who reporLed LhaL Lhey evaluaLe Lhe effecLlveness of changes afLer Lhey have made
changes Lo lmprove paLlenL safeLy are less Lhan Lhose ln prevlous years.
! A decreaslng paLLern ls seen ln Lhe proporLlons of respondenLs who reporLed LhaL Lhelr procedures and sysLems are good aL
prevenLlng errors from happenlng.
! 1he proporLlon of respondenLs ln 2012 who reporLed LhaL Lhelr supervlsors serlously consldered sLaff suggesLlons for lmprovlng
paLlenL safeLy ls less Lhan Lhose ln prevlous years.
! lewer sLaff dlsagreed LhaL Lhelr supervlsors overlook paLlenL safeLy problems LhaL happen over and over slnce 2007.

Conc|us|on: Plgh parLlclpaLlon raLe ln Lhe survey, LogeLher wlLh a sLrong non-punlLlve culLure, provlded us wlLh sLrong and rellable
lndlcaLors of our paLlenL safeLy culLure. 8y uLlllslng Lhe daLa obLalned, we have been able Lo LargeL speclflc area ln our paLlenL safeLy
lmprovemenL programs, by fully leveraglng on our advanLage of knowlng and undersLandlng our area of weakness ln paLlenL safeLy
culLure. We have been successful ln lncorporaLlng Lhe resulLs lnLo our rlmary Care SafeLy WalkabouLs. lrom Lhe daLa avallable, we
were able Lo drlll down Lo speclflc groups of sLaff ln lndlvldual cllnlcs, Lhereby allowlng us Lo be more effecLlve ln our
lnLervenLlons. 1he resulLs avallable also enable us Lo plan more sLraLeglcally ln Lhe formaLlon of our aLlenL SafeLy 1ralnlng
Currlculum, LargeLlng areas of weakness and bulldlng on our sLrengLhs. ln summary, by organlslng and analyslng daLa from
sysLemaLlcally conducLed SC Surveys wlll enable healLhcare lnsLlLuLlons, lncludlng rlmary Care CenLres, Lo beLLer plan and execuLe
paLlenL safeLy lmprovemenL programs, whlch wlll subsequenLly lead Lo lmproved paLlenL overall safeLy ouLcomes and cllnlcal quallLy.


1763

IMkCVLMLN1 WCkk-LIIICILNC 1nkCUGn ALICA1ICN CI 1CICAL ANLS1nL1IC CkLAM
Pyun !oo Lee
1,*
, Pwa ?eon klm
1
, Pyung Cheol klm
1
, Seung Po Chol
1

1
Seoul naLlonal unlverslLy PosplLal PealLhcare SysLem Cangnam CenLer, Seoul, korea, 8epubllc Cf


Cb[ect|ves: ln SnuP PealLhcare SysLem Cangnam CenLer, a ma[or medlcal check-up cenLer, mosL cllenLs experlence
venous sampllng or lnLravenous (lv) caLheLer lnserLlon for drug ln[ecLlon for endoscopy or C1 scan. 1o lessen relaLed
paln or anxleLy, our cenLer applles Loplcal anaesLheLlc cream for cllenLs aL Lhe flrsL examlnaLlon room. 8uL lmproper
appllcaLlon of Lhe cream has also caused cllenLs' complalnLs and decreased sLaff's work-efflclency. 1hls sLudy ls deslgned
Lo develop measures Lo prevenL lmproper appllcaLlon of Loplcal anaesLheLlc cream and enhance saLlsfacLlon of lnLernal
and exLernal cllenLs.

Methods: Cur Leam composed of radlologlc and laboraLory Lechnlclans bralnsLormed cream-relaLed problems and
ldenLlfy problems and Lhelr soluLlons. lrequenL problems were LhaL cream was sklpped ln Lhe flrsL place, was applled ln
lmproper slLes or ln an lnsufflclenL amounL. 1o solve Lhese problems, several lmprovemenLs were developed:

1) 1o ensure cream appllcaLlon, anoLher check box was added on examlnaLlon checkllsLs for double-check by a co-sLaff.
2) 1o flnd exacL veln slLes, a LournlqueL was recommended and replaced by new buLLon-Lyped for a convenlenL use.
3) When lL was hard Lo flnd proper appllcaLlon slLes for a cllenL aL Lhe flrsL exam room, a more-experlenced sLaff was
lmmedlaLely called from nearby rooms llke laboraLory, C1, or endoscopy unlL.
4) Any speclal commenLs on lv rouLes were recorded ln deLall on compuLer for use aL Lhe cllenL's nexL vlslLs.
3) lor Lhe conLlnulLy of quallLy care, regular educaLlon for new sLaff conLlnues ln Lhe nexL year. We compared several
parameLers afLer acLlvlLy by number of reporL and saLlsfacLlon survey.

kesu|ts:

1) AfLer lmprovemenLs (9.1929, 2011), cream-relaLed problem was reporLed 37 cases (6.1) ouL of 928 cllenLs
compared wlLh 133 cases (13.6) of 1,124 cllenLs before Lhe lmprovemenLs (3.421, 2011). ln deLall, appllcaLlon on
lmproper slLes decreased from 84 (7.3) Lo 33 (3.8), omlsslon from 44(3.9) Lo 13(1.4), and lnsufflclenL-amounL
from 19(1.7) Lo 2(0.2).
2) SLaffs who apply Lhe cream (aL Lhe flrsL exam room) were surveyed abouL Lhe lmprovemenLs. 33.3 sald educaLlon
program helped Lhelr work, and 36.7 sald new guldellnes dld. 1helr saLlsfacLlon was raLed hlgh on 3-polnL scale.
SLaff educaLlon scored 92 polnL and guldellnes goL 88 polnL on average, ad[usLed for 100 polnLs.
3) lor posL-care acLlvlLles, more deLalls were recorded abouL cream appllcaLlon and lv rouLes of cllenLs. 72 cases ln
2012 were lnpuL compared wlLh 12 of Lhe prevlous year, slx Llmes hlgher durlng Lhe same perlod. 1he conLenL was
more speclflc as well.

Conc|us|on: SLaff's work performance and work saLlsfacLlon lmproved slgnlflcanLly Lhrough beLLer appllcaLlon of Lhe
cream. Moreover, Lhls acLlvlLy became an opporLunlLy Lo re-esLabllsh oLher relevanL work proLocols. new guldellnes and
sLaff educaLlon reduced problem occurrence whlle lncreaslng work-efflclency. SLaff educaLlon wlll be more sLrengLhened
ln Lhe fuLure and elecLronlc records on lv rouLes wlll be used Lo saLlsfy cllenLs who revlslL Cangnam cenLer.



1764

IMkCVL 1nL CCMLL1ICN kA1L CI nSICIANS' DCCUMLN1A1ICN CN INA1ILN1 CkI1ICAL VALULS USING
UALI1 CCN1kCL CIkCLL ML1nCDS
?u-el Chen
1,*
, Shu-Chen kuo
1
, Puel -Chen Lu
1
, Chuan-Chlh Psu
2

1
CuallLy ManagemenL,
2
Cardlovascular Surgery, 1alpel Medlcal unlverslLy PosplLal, 1alpel, 1alwan


Cb[ect|ves: lmprove effecLlve communlcaLlon ls Lhe key Lo achleve paLlenL safeLy goals. Speclflcally for crlLlcal cllnlcal
daLa, Llmely, accuraLe, and compleLe reporLlng should be Lracked and monlLored Lo conflrm Lhe abnormal crlLlcal values
or lnspecLlon reporLs are recelved, once reporLed. 1he Lracklng mechanlsm also provldes Lhe cllnlcal daLa Lo be used ln
subsequenL medlcal managemenL for Lhe paLlenLs, and recorded ln Lhe paLlenLs' progress noLe. 1hls sLudy ls Lo lmprove
Lhe compleLlon raLe of physlclans' documenLaLlon on lnpaLlenL crlLlcal values uslng CuallLy ConLrol Clrcle (CCC) meLhods.

Methods: 1he CuallLy ConLrol Clrcle conslsLs of mulLldlsclpllne members, lncludlng physlclans and sLaffs of CuallLy
ManagemenL ueparLmenL. 1hree caLegorles of crlLlcal values reporLlng are laboraLory, paLhologlcal, and radlologlcal
reporLs. 1he CCC Leam conducLed monLhly charL revlew on Lhe 10-13 of lnpaLlenLs who have reporLed crlLlcal values.
As Lhe base llne, Lhe average compleLlon raLe of physlclans' documenLaLlon on lnpaLlenL crlLlcal values was 31.3
beLween AugusL and november 2011. 1he LargeL raLe was seL as 70.0, a 40 lmprovemenL of Lhe base llne raLe.
1hrough flsh bone and areLo charLs Lo conducL cause analyses, Lhe CCC Leam dlscovered LhaL 81.7 of Lhe maln facLors
lnclude handled buL forgoL Lo record lL, Lhe condlLlon of Lhe paLlenL rapldly changlng, and follow-up and observaLlon.

kesu|ts: 1he compleLlon raLe had been lmproved from 43.0 ln AugusL 2011 Lo 73.8 ln uecember 2012. uurlng Lhe
sLudy perlod, Lhe CCC Leam sLandardlsed and revlsed Lhe rocedure for CrlLlcal values, unlfled Lhe documenLaLlon of
crlLlcal values on Lhe progress noLe, provlded Lhree Lralnlng courses Lo a LoLal of 280 physlclans, promoLed Lhe
procedure Lhrough compuLer deskLop, and regularly reporLed Lhe charL revlew resulLs Lo Lhe Medlcal CuallLy and aLlenL
SafeLy CommlLLee and relaLed deparLmenLs. As a resulL, Lhe average compleLlon raLe was 71.0 afLer Lhe lnLervenLlons,
compared Lo Lhe base llne raLe of 31.3. 1he LargeL was meL wlLh a 38 lmprovemenL and a 101 accompllshmenL
raLes.

Conc|us|on: LffecLlve communlcaLlon" can noL only provlde Llmely LreaLmenLs Lo paLlenLs, buL also prevenL posslble
paLlenL safeLy lssues. ln order Lo conLlnuously lmprove quallLy of care and paLlenL safeLy, Lhe CCC Leam ls plannlng Lo
uLlllse Lhe LlecLronlc Medlcal 8ecord (LM8) sysLem, add noLlflcaLlon for crlLlcal values documenLaLlon, and lnclude Lhe
noLlflcaLlon and response from Lhe CrlLlcal values Messaglng App.



1766

1nL IMAC1 CI CAkDICLCG NUkSL-LLD CLINIC CN CAkDIAC CAkL SLkVICLS IN ULLN LLI2A8L1n nCSI1AL CI
nCNG kCNG
Cecllla Chan
1,*
, Mlchael Lee
1

1
Medlclne/ Cardlology, Cueen LllzabeLh PosplLal, Pong kong, Pong kong


Cb[ect|ves: 1o evaluaLe Lhe lmpacL of Cardlology nurse-Led Cllnlc on cardlac care servlces
Methods: aLlenLs wlLh flucLuaLlng (warfarln overdose/ under dose) ln8, conflrmed wlLh hearL fallure by
echocardlogram or wlLh Cl done, were referred from SCC (speclallsL ouL-paLlenL cllnlc)/ ln-paLlenL. AssessmenL,
educaLlon and counselllng would be provlded Lo paLlenL lndlvldually. MedlcaLlon would be LlLraLed accordlng Lo proLocol
endorsed by our cardlologlsLs lf necessary. AfLer sLablllsaLlon, paLlenLs would be referred back Lo SCC/ CCC (general
ouL-paLlenL cllnlc) for follow up.

kesu|ts: Ant|-coagu|at|on (Apr|| 2009- December 2012): 4844 paLlenLs were referred. 14382 ln8s were recorded and
80.2 ln8s Laken were wlLhln +/- 0.3 llmlL of LherapeuLlc range. Accordlng Lo Lhe 8rlLlsh SocleLy of PaemaLology
guldellne, all resulLs have achleved Lhe lnLernaLlonal key performance lndlcaLor (> 30 wlLhln 0.3 llmlL of LherapeuLlc
ln8 range). 33 paLlenLs (0.7) were hosplLallsed for warfarln overdose due Lo poor drug compllance or co-morbldlLy.
1he mean paLlenL saLlsfacLlon level ls 9.17 (10 ls Lhe hlghesL). Average 3 bed days were requlred for warfarln LlLraLlon ln
Lhe pasL, 4844 avoldable admlsslon wlLh 14332 ln-paLlenL bed days were saved.

CnI (September 2010- December 2012): 134 paLlenLs (mean age 63.42 +/- 12.11) conflrmed wlLh hearL fallure by
echocardlogram (e[ecLlon fracLlon 33.3 +/- 13.3) were referred Lo our cllnlc. 1he 1 year readmlsslon raLe and lengLh of
hosplLal sLay relaLed Lo CPl were slgnlflcanLly reduced from 1.24 Lo 0.07 Llmes and 9.84 Lo 0.33 days respecLlvely
(p<0.001). 1hese paLlenLs percelved beLLer physlcal and menLal healLh sLaLus by uslng Sl-12 (quallLy of llfe) (< 0.001).
1hey also complled wlLh healLhler dleL and had good drug compllance (p< 0.001). 1he mean paLlenLs saLlsfacLlon score ls
9 (10 ls Lhe hlghesL).

ost CI (March 2011- December 2012): 369 paLlenLs were referred. LuL was slgnlflcanLly decreased from 2.63 Lo 2.04
(p< 0.001), whlch was recognlsed as Lhe slngle mosL effecLlve sLraLegy for reduclng cardlovascular evenLs. 1he dleL
compllance and adherence Lo dual plaLeleL are also slgnlflcanLly lmproved (p<0.001) afLer dlscharged from Lhe cllnlc. 1he
mean paLlenL saLlsfacLlon score ls 9 (10 ls hlghesL).

Conc|us|on: rocess of care should be shlfLed from speclalLy-cenLred Lo paLlenL-cenLred. 1he Cardlology nurse Cllnlc has
shown Lo be safe and effecLlve Lo empower paLlenLs Lo Lake parL ln Lhe care of Lhelr own healLh. lL noL only exLends Lhe
boundarles of Lhe LradlLlonal nurslng role buL also prevenLs avoldable admlsslon for relaLlvely sLable paLlenL and
shorLens Lhelr lengLh of sLay.

Iuture d|rect|ons:
WlLh Lhe exLenslon of Lhe role of nurslng pracLlce as case managers, nurse-led servlces can be furLher expanded Lo
accommodaLe more complex paLlenL subgroups.




1772

DLVLLCMLN1 AND LVALUA1ICN CI INICkMA1ICN 1LCnNCLCG ICk A1ILN1 CLN1LkLD CANCLk CAkL
kwl Cck ark
1,*
, Sang Mln ark
2
, !l Pye Lee
3

1
CenLer for Cancer LducaLlon and lnformaLlon, Seoul naLlonal unlverslLy PosplLal,
2
ueparLmenL of lamlly Medlclne,
Seoul naLlonal unlverslLy College of Medlclne,
3
College of nurslng, Seoul naLlonal unlverslLy, Seoul, korea, 8epubllc Cf


Cb[ect|ves:
lnformaLlon 1echnology (l1) sysLem uLlllslng moblle phones and oLher smarL devlces ls becomlng more prevalenL for
cancer paLlenL care. 1he purpose of Lhls sLudy ls Lo sLrucLure developmenL and evaluaLlon of l1 sysLem deslgned for Lhe
paLlenL cenLred cancer lnformaLlon and educaLlon.

Methods:
1o develop a cusLomlsed educaLlonal sysLem for Lhe cancer paLlenLs aL a unlverslLy hosplLal, an l1 sysLem composed of
Lhe SmarL Culde, moblle phone AppllcaLlon, and lnLerneL webslLe are esLabllshed slnce 2011 March. 1he SmarL Culde ls
a Louch screen klosk and lL ls connecLed Lo Lhe elecLronlc medlcal records (LM8). SynchronlzaLlon beLween LM8 and Lhe
SmarL Culde allows Lhe paLlenL Lo log-ln uslng Lhelr paLlenL reglsLraLlon number and Lo recelve any personallsed cancer
lnformaLlon LhaL ls relaLed Lo Lhelr parLlcular cancer Lype. Moblle hone AppllcaLlon refers Lo Lhe My Cancer
lnformaLlon", lL's a moblle phone appllcaLlon (App) LhaL can be used ln boLh lCS and Androld sysLem. 1hls App ls
composed of 4 funcLlons, general cancer lnformaLlon, mulLlmedla on cancer examlnaLlon and LreaLmenL, whlch ls
classlfled accordlng Lo 34 klnds of cancer, lnLegraLlve cancer care lnformaLlon, and C8 code reader. 1hls App also has a
buLLon llnked Lo Lhe webslLe of Cancer LducaLlon and lnformaLlon CenLer (CLlC).
1he webslLe provldes personallsed cancer lnformaLlon upon user's lnpuL of Lhe Lype and Lhe sLage accuraLe Lo Lhelr
cancer. All of Lhe selecLed lnformaLlon ls presenLed ln a page. We have surveyed 212 paLlenLs, only paLlenLs wlLh breasL
cancer, ln order Lo mlnlmlse Lhe varlance caused by dlfferenL Lypes of cancer, aL Lhls unlverslLy hosplLal ln 2012 AugusL
Lo CcLober regardlng Lhese l1 sysLems we descrlbed above on Lhe usage and saLlsfacLlon raLes measured ln 3 polnL
LlkerL.

kesu|ts:
1. arLlclpanLs lnvolved ln Lhls sLudy were on dlfferenL sLage of Lhelr care, 33.36 ln follow up care, 27.11 on-golng
chemoLherapy and 16.44 ln operaLlng sLage. lor 39.13 of Lhe paLlenLs less Lhan 1 year passed afLer Lhe dlagnosls,
and Lhe mean duraLlon afLer dlagnosls was 43.88 (37.30) monLhs. 1he mean age of paLlenLs was 31.30(9.27) years.
MosL of Lhem (92.43) were hlgh school graduaLes or above and 83.01 of paLlenLs were marrled. 1helr average
monLhly lncome was 4,401 uS dollars.
2. Among Lhe breasL cancer paLlenLs who responded when asked wheLher Lhey have used Lhe cancer lnformaLlon
provlded by Lhe l1 sysLem aL Lhls hosplLal, 64 paLlenLs (30.19) used Lhe SmarL Culde, 34 paLlenLs (16.04) used Lhe
moblle phone appllcaLlon My Cancer lnformaLlon", and 79 paLlenLs (37.26) used Lhe webslLe of CLlC. ln
comparlson, 143 paLlenLs (67.43) used leafleLs of Lhls hosplLal and 140 paLlenLs (66.04) soughL lndlvldual
counselllng from Lhls hosplLal sLaffs Lo saLlsfy Lhelr needs for cancer lnformaLlon.
3. 1he saLlsfacLlon raLes of Lhe l1 sysLem for Lhe access Lo cancer lnformaLlon aL Lhls hosplLal were Lhe followlng from
Lhe resulLs: 3.41 polnLs (equlvalenL Lo 68.2 ouL of 100) for Lhe SmarL Culde, 3.06 polnLs (61.2 pLs) for moblle phone
appllcaLlon My Cancer lnformaLlon," and 3.34 polnLs (70.8pLs) for webslLe of CLlC. ln comparlson, Lhe saLlsfacLlon
raLe of leafleLs of Lhls hosplLal was 3.68 polnLs (73.6 pLs), and Lhe saLlsfacLlon raLe of lndlvldual counselllng from Lhls
hosplLal sLaffs was 3.72 polnLs (74.4 pLs).

Conc|us|on:
AlLhough varlous l1 have been developed and applled Lo provlde cusLomlsed lnformaLlon for cancer paLlenLs, Lhe usage
of l1 ls noL properly hlgh and Lhe saLlsfacLlon raLes of Lhe users remaln aL Lhe average level. 1herefore, more efforL
needs Lo be made Lo allow paLlenLs Lo easlly access hlgh-quallLy personallsed cancer lnformaLlon.

1778

NLW AkADIGM IN MANAGING A1ILN1S WI1n CnkCNIC ILLNLSS 1nkCUGn A1ILN1 LNGAGLMLN1
Sheng S. Po
1,*
, kwun Man Lo
1
, ?u Pon Man
1
, ?uk Lun Cheng
1

1
Medlclne, Allce Po Mlu Llng neLhersole PosplLal, 11, Chuen Cn 8oad, 1al o, Pong kong


Cb[ect|ves: 1he shorLfall of healLhcare workforce requlres a reLhlnk of prevalllng models for dellverlng care Lo paLlenLs
wlLh chronlc dlsease. A chronlc dlsease paLlenL needs Lo be Laken care by a mulLl-skllled Leam of healLhcare
professlonals wlLh supporL from speclallsL. We need Lo explore new collaboraLlons Lo dellver mulLldlsclpllnary healLhcare
for handllng chronlc dlsease paLlenLs and evaluaLe Lhese for paLlenL ouLcomes and cosL effecLlveness.
We have seL up a paLlenL group, 1he 8eLLer 8reaLher Club" for paLlenLs wlLh chronlc obsLrucLlve pulmonary dlsease ln
1al o ln 2011. 1hls supporL sysLem provldes an opporLunlLy for chronlc lung dlsease paLlenLs and Lhelr famllles Lo meeL
regularly and render muLual supporL among Lhemselves. 1hrough Lhe gaLherlngs, Lhey could know more abouL Lhelr
healLh condlLlon from concerned healLh care professlonals ln a supporLlve envlronmenL. We ldenLlfy Lhe hlgh rlsk
chronlc dlsease paLlenLs ln Lhe paLlenL group and provlde medlcal supporL especlally durlng wlnLer surge or before long
holldays so as Lo reduce avoldable hosplLallsaLlons.

Methods: Plgh rlsk paLlenLs wlLh 2 emergency room aLLendances or hosplLal admlsslon for CCu exacerbaLlons per
year or Cold SLage 2 wlLh co-morbldlLles or hlgh sympLoms scores were recrulLed from Lhe paLlenL group. 1hey were
Lhen assessed ln Comprehenslve uay 8ehablllLaLlon CenLer.

We provlde lnLegraLed care Lo CCu paLlenLs, lncludlng:
1) Comprehenslve lnLervenLlon,
2) lnLroducLlon of a self-managemenL educaLlon programme,
3) lndlvldually Lallored care plan, and
4) Lnhanced accesslblllLy Lo healLhcare professlonals.
3) 8egular phone conLacL by volunLeers and clerlcal sLaff of Lhe Club Lo member paLlenLs durlng wlnLer surge and
before long hollday.

kesu|ts: We have recrulLed 140 paLlenLs wlLh chronlc obsLrucLlve pulmonary dlsease Lo [oln Lhe 8eLLer 8reaLher Club.
We have ldenLlfled 76 hlgh rlsk paLlenLs (11.8 female) wlLh poor lung funcLlon (73 wlLh sLage 3 or 4), co-morbldlLles
(93), or poor soclal supporL as all of Lhem are prone Lo repeaLed hosplLallsaLlon. 1helr mean age ls 72 years old (49-89).
64.3 of Lhe paLlenLs have compleLed pulmonary rehablllLaLlon program. 33.3 of Lhem have recelved LreaLmenL wlLh
home C2 and 20 paLlenLs have been referred for home non-lnvaslve venLllaLlon.

We have analysed 30 paLlenLs wlLh quallLy of llfe quesLlonnalres lncludlng SL. Ceorge 8esplraLory CuesLlonnalre and Sl
12 afLer lnLervenLlon for 12 monLhs uslng lnLegraLed care paLhway. CreaLer lmprovemenL ln Lhe acLlvlLy scores and
sympLom score were observed ln some paLlenLs ln Lhe lnLervenLlon group aL 12 monLhs lnLervenLlon.

Conc|us|on: 1he lnLegraLed care approach ls ldeally sulLed Lo provlde managemenL of chronlc lllness, such as CCu. We
provlde educaLlon and communlLy supporL for resplraLory paLlenLs as well as careglvers of Lhose coplng wlLh breaLhlng
problems.



1780

A1ILN1 SAIL1 CUL1UkL CI DLAk1MLN1S A1 IAANLSL nCSI1ALS
Shlgeru lu[lLa
1,*
, kanako SeLo
1
, Shlnya lLo
1
, 1omonorl Pasegawa
1

1
ueparLmenL of Soclal Medlclne, 1oho unlverslLy School of Medlclne, 1okyo, !apan


Cb[ect|ves: aLlenL safeLy culLure (SC) aLLracLs a growlng lnLeresL ln lmprovlng safeLy and quallLy ln healLhcare. LlLLle ls
known abouL Lhe characLerlsLlcs of SC ln each deparLmenL. 1he alm of Lhls sLudy ls Lo clarlfy Lhe characLerlsLlcs of SC ln
each deparLmenL of !apanese hosplLals.

Methods: A cross-secLlonal sLudy was conducLed aL 18 hosplLals ln 2012. CuesLlonnalres were dlsLrlbuLed Lo all
healLhcare workers (n=12,076). lor evaluaLlng Lhe SC, we used Lhe quesLlonnalre of PosplLal Survey on aLlenL SafeLy
CulLure developed by Lhe uS Agency for PealLhcare 8esearch and CuallLy (AP8C). 1he quesLlonnalre has 44 lLems and
12 sub-dlmenslons of SC.

lor each sub-dlmenslon, Lhe proporLlon of poslLlve responses (per cenL poslLlve score) was calculaLed on Lhe lnsLrucLlons
of AP8C for every respondenL. 1he per cenL poslLlve scores of each deparLmenL were calculaLed by Laklng Lhe mean of
per cenL poslLlve scores of respondenLs who belong Lo Lhe deparLmenL. 1he deparLmenLs were caLegorlsed lnLo 16 Lypes
such as Ceneral ward", CuLpaLlenL deparLmenL", harmaceuLlcal deparLmenL" and CperaLlon deparLmenL". ClusLer
analysls was used Lo caLegorlse Lhe deparLmenLs accordlng Lo Lhe per cenL poslLlve scores of 12 sub-dlmenslons.
Cenerallsed llnear mlxed model (CLMM) was performed Lo clarlfy Lhe characLerlsLlcs of deparLmenL's Lype by uslng Lhe
resulLs of clusLer analysls.

kesu|ts: A LoLal of 9,124 (73.6) respondenLs compleLed Lhe quesLlonnalre, and valld daLa of 8,700 (72.0) were
analysed. Lach parLlclpaLed hosplLal had deparLmenLs ranglng from 7 Lo 77, and Lhe LoLal number of deparLmenLs ln 18
hosplLals was 440. Lach deparLmenL had 3 Lo 113 respondenLs, and Lhe medlan was 17.3 respondenLs. Among Lhe
respondenLs, physlclans were 9.2, nurses were 46.4, admlnlsLraLlve workers were 14.4, and Lhe oLhers were 30.0.
Accordlng Lo Lhe per cenL poslLlve scores of 12 sub-dlmenslons, 440 deparLmenLs were classlfled lnLo 2 clusLers:
Superlor culLure" deparLmenLs (n=184), and lnferlor culLure" deparLmenLs (n=236). All of per cenL poslLlve scores of
Superlor culLure" deparLmenLs were slgnlflcanLly hlgher Lhan Lhose of lnferlor culLure" deparLmenLs.
1he resulL of CLMM revealed LhaL Lhe odds raLlos Lo be Superlor culLure" deparLmenLs were slgnlflcanLly hlgh aL
CbsLeLrlcs and gynaecology ward, perlnaLal ward, or nlCu" (C8=9.7), and slgnlflcanLly low aL Long Lerm care ward"
(C8=0.2), 8ehablllLaLlon deparLmenL" (C8=0.2) and AdmlnlsLraLlon deparLmenL" (C8=0.3).
AL Superlor culLure" deparLmenLs, Lhe proporLlon of respondenLs who parLlclpaLed more Lhan one ln-house Lralnlng of
paLlenL safeLy durlng one year before Lhe survey was slgnlflcanLly hlgher Lhan LhaL of lnferlor culLure" deparLmenLs
(73.7 vs. 63.3, <0.01).

Conc|us|on: Cur sLudy suggesLed LhaL Lypes of deparLmenLs were relaLed Lo SC scores. SC was hlghly evaluaLed ln
CbsLeLrlcs and gynaecology ward, perlnaLal ward, or nlCu", and lL was evaluaLed low aL Long Lerm care ward",
8ehablllLaLlon deparLmenL" and AdmlnlsLraLlon deparLmenL". lacLors conLrlbuLlng Lo lnferlor culLure" and posslble
counLermeasures for Lhem should be lnvesLlgaLed.



1781

LIILC1IVLNLSS CI kCMC1ING CLICILS CI UALI1 INDICA1Ck MANAGLMLN1 1C IMkCVL 1nL CA1nL1Lk
kLLA1LD SAIL1 CAkL IN nCSI1AL-WIDL ICUS CI A MLDICAL CLN1Lk IN SCU1nLkN 1AIWAN
Sue Pul Chen
1,*
, ?l lang Cheng
2
, Ll Chuan Wu
1
, Shu Puel Pung
1

1
nurslng uepL.,
2
Medlcal quallLy conLrol room, kaohslung Medlcal unlverslLy PosplLal, kaohslung, 1alwan


Cb[ect|ves: 1he essence of medlcal care lLself ls hlghly compllcaLed and uncerLaln. 1here was perslsLenL reporLlng of
medlcal adverse evenLs ln varlous counLrles all over Lhe world ln recenL Len years. Lspeclally, durlng Lhe process of
offerlng emergenL and lnLenslve care, arLlflclal Lublng lncldenL may lead Lo Lhe deaLh of paLlenL lmmedlaLely or severe
dlsablllLy, as well as prolonged lengLh of sLay ln Lhe hosplLal and laLrogenlc compllcaLlons. 1hus, reduclng devlce
uLlllsaLlon, rlsk of devlce-assoclaLed lnfecLlons, and unplanned exLubaLlon were one of Lhe annual goals of paLlenL safeLy
of ueparLmenL of PealLh ln 1alwan ln 2008. kaohslung Medlcal unlverslLy PosplLal (kMuP), a medlcal cenLer wlLh 1700
beds, lncludlng 11 lnLenslve care unlLs (lCus) and 120 beds ln lCus, ls locaLed ln souLhern 1alwan. ln 2009, on an
average, Lhe nosocomlal lnfecLlon raLe was 10.2 venLllaLor assoclaLed pneumonla was 3.37 sympLomaLlc
lndwelllng urlnary caLheLer-assoclaLed u1ls was 4.92 cenLral llne-assoclaLed bloodsLream lnfecLlons was 3.18
unplanned exLubaLlon raLe of endoLracheal Lube was 0.6. All of Lhe above are hlgher Lhan Lhose ln peer medlcal
cenLers of 1alwan. 1herefore, Lhe lmplemenLaLlon of Lhls pro[ecL was Lo lmprove Lhe devlce safeLy ln lCus.

Methods: 1he alm of Lhe pro[ecL was Lo reduce Lhe lnfecLlon raLe and unplanned exLubaLlon raLe by promoLlng pollcles
of quallLy lndlcaLor managemenL ln Lhe hosplLal-wlde lCus, whlch lncludlng Lhe sLraLegles of:

1) 8elnLegraLlng Lhe procedures of daLa collecLlon for quallLy lndlcaLors,
2) AuLhorlsed personnel for daLe collecLlon,
3) lormulaLlng Lhe mechanlsm of uCA,
4) uslng conLrol charLs of SC for daLa analysls and regular monlLorlng of Lhe lndlcaLors,
3) SeLLlng up Lhe ouLcome bulleLln board of lndlcaLors" by applylng Lhe concepL of Lrafflc llghL-red, yellow, green" as
a symbol of noLlce ln lCus, whlch help ldenLlfy Lhe exacL Llmlng of Lhe uCA cycle, and
6) LsLabllshlng ouLcome-orlenLed lndlcaLors for monlLorlng quallLy of care.

kesu|ts: lrom year 2009 Lo year 2012, Lhe average nosocomlal lnfecLlon raLe ln Lhe lCus was decreased from 10.20 Lo
6.00 venLllaLor-assoclaLed pneumonla was dropped from 3.37 Lo 1.21sympLomaLlc lndwelllng urlnary
caLheLer-assoclaLed u1ls was dropped from 4.92 Lo 2.13cenLral llne-assoclaLed bloodsLream lnfecLlons decreased
from 3.18 Lo 4.46 . lurLhermore, unplanned exLubaLlon raLe of endoLracheal Lube was reduced from 0.60 Lo
0.31. All of Lhe above were lower Lhan Lhose ln peer medlcal cenLers of 1alwan.

Conc|us|on: 8y lmplemenLlng Lhe pollcles of quallLy lndlcaLor managemenL, Lhe communlcaLlon across Lhe healLhcare
Leam and Lhe caLheLer relaLed safeLy care were lmproved effecLlvely and progresslvely ln hosplLal-wlde lCus. Popefully,
Lhe pollcles of lndlcaLors monlLorlng from Lhe lnsLanL dashboard noLlce wlll be esLabllshed, and be applled Lo Lhe
managemenL of oLher medlcal relaLlve lndlcaLors ln Lhe fuLure, such as resLralned raLe and unplanned lCu readmlsslon
wlLhln 48 hours, ln order Lo promoLe Lhe quallLy of care ln lCus.

keferences: MaarL[e ue vos, Wllco Craafmans, Mleneke koolsLra, 8erL Mel[boom1, eLer van uer voorL4 and CerL
WesLerL.(2009). uslng quallLy lndlcaLors Lo lmprove hosplLal care: a revlew of Lhe llLeraLure. lnL ! Cual PealLh Care (2009)
21 (2): 119-129. uCl: 10.1093/lnLqhc/mzn039
ScoLL C. Wllllams, sy.u., SLephen . SchmalLz, h.u., uavld !. MorLon, M.S., 8lchard C. koss, M.A., and !erod M. Loeb,
h.u. (2003). CuallLy of Care ln u.S. PosplLals as 8eflecLed by SLandardlsed Measures, 2002-2004. n Lngl ! Med 2003,
333:233-264 uCl: 10.1036/nL!Msa043778



1784

AC1IVI1ILS ICk 1nL IMkCVLMLN1 CI CUS1CMLk SA1ISIAC1ICN 1nkCUGn 1nL kCLL LkANSICN CI INICkMA1ICN SLCIALIS1
NUkSL
uaehee klm
1,*
, 8oo[a klm
1

1
Surglcal CuLpaLlenL ueparLmenL, Seoul naLlonal unlverslLy PosplLal, Seoul, korea, 8epubllc Cf


Cb[ect|ves: rovldlng lnformaLlon Lo paLlenLs and Lhelr famllles ls geLLlng more lmporLanL ln Lerms of paLlenLs' rlghLs and cusLomer
saLlsfacLlon (CS) ln Lhe rapldly changlng medlcal envlronmenL. Powever, SnuP was noL ln a poslLlon Lo provlde sufflclenL lnformaLlon
Lo ouLpaLlenLs due Lo a heavy workload of cllnlclans, nurses and oLher medlcal professlonals. 1he purpose of our CA acLlvlLy ls Lo
lmprove cusLomer saLlsfacLlon by expandlng Lhe role of lnformaLlon speclallsL nurses (lSn) and by creaLlng lSn sLaLlons lndependenL
from Lhe oLher nurse sLaLlons.

Methods:
1) A quesLlonnalre on CS and lnformaLlon servlce was collecLed from paLlenLs before and afLer Lhe expanslon of lSn servlce and
was analysed
2) CusLomer complalnLs relaLed Lo Lhe lnformaLlon servlce were analysed.
3) 1reaLmenL processes aL Lhe surglcal deparLmenL were analysed.
4) Conferences were held for nurses and oLher sLaff Lo ldenLlfy areas on Lhe basls of LreaLmenL process, where lnformaLlon needs
Lo be provlded more effecLlvely.
3) vlslLors Lo Lhe lSn sLaLlons were analysed.
6) MaLerlals used for provldlng lnformaLlon were revlewed by Lhe deparLmenLs.
7) LxpecLed demands of Lhe lSn's roles were ldenLlfled Lhrough meeLlngs wlLh cllnlclans.
8) lnLerlm resulLs of Lhe lnformaLlon servlce were shared perlodlcally wlLh oLher medlcal deparLmenLs aL CS semlnars.
9) ually-work reporLs of Lhe lSn sLaLlons were recorded, lncludlng numbers of vlslLors.
10) MeeLlngs were held wlLh Lhe sLaff aL Lhe Medlcal lnformaLlon Servlce CenLer for a posslble sLaLlsLlcal program.

Cn Lhe basls of our assessmenL resulLs, we carrled ouL Lhe followlng sLraLeglc acLlvlLles Lo lmprove cusLomer's saLlsfacLlon:
1. CreaLlng lSn sLaLlons.
2. LsLabllshlng a procedure for provldlng lnformaLlon based on surglcal LreaLmenL process.
3. lollowlng up cusLomers' complalnLs and demands by admlnlsLerlng ln-hosplLal quesLlonnalres on CS,
4. lmplemenLlng acLlvlLles Lo equlp lSns such as lnlLlal Lralnlng and perlodlc educaLlon and conferences,
3. romoLlng Lhe lSn sLaLlons' servlces and Lhe locaLlons on Lhe hosplLal map wlLh Lhe lnsLallaLlon of C
6. SLandardlslng lSn's [ob descrlpLlon.
7. llagglng up Lhe lnformaLlon servlce for new vlslLors: placlng a gulde banner for flrsL-Llme paLlenLs and sendlng SMS messages,
8. ueveloplng lnformaLlon maLerlals: C&A for represenLaLlve and commonly occurrlng dlseases,
9. uevlslng Lhe ways Lo fosLer cooperaLlon beLween lSns and cllnlclans,
10. LducaLlng Lhe nurslng sLaff
11. ueveloplng a dally lSn [ob log and developlng a sLaLlsLlcal program.

kesu|ts:
1. LxLended lSn sLaLlons have been esLabllshed.
2. 1allored-made lnformaLlon ls provlded based on Lhe relevanL LreaLmenL process.
3. lSn's [ob descrlpLlon has been sLandardlsed.
4. 1he saLlsfacLlon score of Lhe lSn servlce was lmproved ln a sLaLlsLlcally slgnlflcanL way from 83 Lo 89 (p<0.03).
3. An lmproved response manual and new lnformaLlon maLerlals have been developed.
6. 1he number of vlslLors Lo Lhe lSn sLaLlons lncreased by 33 from 3,207 Lo 7,078. 1he number of flrsL-Llme and second-Llme
vlslLors lncreased by 83 from 1,407 Lo 2,379
7. 1he number of vlslLors per lSn lncreased from 33 Lo 30, showlng an average 46 vlslLs/day/lSn.

Conc|us|on: 1he resulLs of Lhe CA acLlvlLles aL SnuP show lmproved CS ln Lhe lSn servlce and an lncreased number of vlslLors Lo Lhe
lSn sLaLlons. 1hey are aLLrlbuLed Lo Lhe creaLlon of Lhe lndependenL lSn sLaLlons along wlLh Lhe expanslon of lSns' roles and all sLaff
members' cooperaLlon ln provldlng hlgh quallLy servlce Lo paLlenLs. Clven Lhe meanlngful resulL, besL posslble servlce by lSn sysLem
needs Lo be expanded along wlLh Lhe correcLlon for cusLomer-orlenLed servlces and all medlcal sLaff's empowermenL for CS.

1786

USING CLILN1'S LkLkILNCL 1C IMkCVL UALI1 CI MLDICAL SLkVICLS IN A CCMMUNI1 nCSI1AL IN nCNG
kCNG
Sheng S. Po
1,*
, lrene Lam
2
, uavld ual
3

1
Medlclne,
2
Allce Po Mlu Llng neLhersole PosplLal, 11, Chuen Cn 8oad, 1al o,
3
aLlenL 8elaLlon and SLaff LngagemenL,
rlnce of Wales PosplLal, 1he Chlnes unlverslLy of Pong kong, Pong kong


Cb[ect|ves: lnLerpersonal-based servlce encounLers wlll affecL Lhe LrusL of Lhe paLlenLs on our servlce and Lhelr
saLlsfacLlon. lL ls lmporLanL for Lhe servlce provlder and Lhe cusLomers Lo undersLand Lhe need of each oLher.
1o examlne cllenL experlence uslng paLlenL saLlsfacLlon survey and group lnLervlew ln order Lo lmprove quallLy of paLlenL
care.

Methods: We collecLed lnformaLlon from Lwo channels:

1) aLlenL saLlsfacLlon survey was done for ln-paLlenL dlscharges,
2) lnformaLlon was gaLhered Lhrough face-Lo face lnLervlews wlLh represenLaLlves from paLlenL groups regardlng
effecLlveness, safeLy and paLlenL orlenLaLlon

kesu|ts: uaLa were collecLed from 2,437 ln-paLlenL respondenLs lncludlng medlcal, paedlaLrlcs, orLhopaedlcs, psychlaLry
and mlxed surglcal ward of a communlLy hosplLal uslng sLandard oplnlon survey from 1 !an 2011 Llll 31 uec 2012.
1he average percenLage ln raLlng good" or very good" was demonsLraLed ln followlng aspecLs:

1) rovlslon of adequaLe lnformaLlon was 86.9,
2) SLaff performance was 94.7,
3) PosplLal faclllLles and envlronmenL was 83.3,
4) Cverall evaluaLlon was 90.7.

8esldes, we had recelved 980 wrlLLen appreclaLlons regardlng sLaff and hosplLal servlces from Lhe oplnlon survey. 191
suggesLlons for fuLure lmprovemenL were also recelved from Lhe survey regardlng hosplLal faclllLles, caLerlng servlce,
sLaff aLLlLude and cllnlcal managemenL.

We held focus group lnLervlews wlLh 27 paLlenLs who were represenLaLlves from 3 paLlenL supporL groups servlclng 920
paLlenLs from dlfferenL caLegorles, wlLh renal, resplraLory and sLroke from ueparLmenL of Medlclne, APnP. Cpen
quesLlons were asked durlng Lhe lnLervlews regardlng how we could lmprove our servlces ln varlous aspecLs.

Conc|us|on: aLlenL saLlsfacLlon survey and focus group lnLervlews have provlded useful lnformaLlon and valuable lnslghL
lnLo reflnemenL of exlsLlng lLems/servlces and consLrucLlon of new lLems/servlces for lmprovlng our medlcal servlces



1789

USL CI AN INNCVA1LD ASSIS1ING DLVICL 1C DLCkLASL 1nL INCIDLNCL CI IACIAL kLSSUkL SCkL INDUCLD 8 1nL USL CI
NCNINVASIVL CSI1IVL kLSSUkL VLN1ILA1Ck (NIV)
lang-?u kang
1,*
, ?l-xuan Chen
2
, 1sal-Pua ?ang
2
, Shuo-Suel Pung
1

1
ueparLmenL CrLhopedlcs,
2
Surgrlcal lnLenslve Care unlL, 8uddhlsL 1zu Chl Ceneral PosplLal, 1alpel 8ranch, 1alpel, 1alwan, 8CC, new
1alpel ClLy, 1alwan


Cb[ect|ves: uecrease Lhe laclal ressure Sore 8aLe.

Introduct|on: 1he lncldence of pressure sore ln Lhe surglcal lnLenslve care unlL (SlCu) of our hosplLal, whlch was a local Leachlng
hosplLal, durlng Lhe year 2008, reached 0.13, whlch was hlgher Lhan LhaL of 0.06, ln oLher peer hosplLals. Among whlch, 19.4 of
Lhem were faclal pressure sore caused by nlv, lncludlng four paLlenLs wlLh skln necrosls over boLh sldes of nasal brldge, Len
paLlenLs havlng bullae formaLlon and sllghL maceraLlon over Lhe forehead and boLh sldes of nasal brldge, and slx paLlenLs sufferlng
from mlnor skln breakage wlLh eryLhema over Lhe forehead and bllaLeral nasal brldge. 1he quallLy lmprovemenL Leam was
esLabllshed ln Lhe March of 2009, and Lhe members lncluded nurses, wound care nurse, and resplraLory LheraplsLs (81s). 1he goal
was seL as low as Lhe average of Lhe peer hosplLal of 0.06.

Methods: 1he sLudy was done ln Lhe SlCu wlLh a LoLal of 30 beds. 1hlrLy-elghL per cenL of paLlenL admlLLed Lo Lhls ln SlCu used
nlv, and Lhe mean duraLlon was 3 days. 1he skln care was provlded by nurses, 81s, and wound care nurse. ln Lhls pro[ecL, an
lnnovaLed asslsLlng devlce was used. 1hrough 80/20 prlnclple and maLrlx analysls, prlorlLles were deLermlned, and Lhe soluLlons
lncluded:

1) esLabllshlng Lhe sLandard operaLlon procedure for nlv care,
2) uslng Lhe modlfled make-up puff for faclal decompresslon supporL, and
3) provldlng on-Lhe-[ob Lralnlng courses. LvaluaLlon was Lhen done Lhrough audlLlons, demonsLraLlons, and LesLs.

kesu|ts:
1) 8egardlng Lhe compleLeness of nurslng care Lechnlque, Lhe raLe Lo perform skln care and cleanlng once every Lwo hours ls 92,
and Lo have a 2 flnger-breaLh space for Lhe faclal mask sLraps was 94.
2) 1he raLe of uslng make-up puff was 100, and Lhe saLlsfacLory raLe was also hlgher for Lhe nurses as well as for Lhe famllles.
3) A slgnlflcanL lncrease of score from 66.6 Lo 87.3 under a LoLal of 100 was noLed ln Lhe SlCu nlv 8elaLed nurslng AssessmenL
lorm among 49 nurses and 7 81s. 1he 81s would lnform Lhe nurses Lo use Lhls asslsLed devlce as soon as Lhe paLlenL needed Lo
use nlv, and Lhls also lmprove Lhe communlcaLlon envlronmenL ln Lhe Leam. 1he raLe of faclal pressure sore decreased from
19.4 Lo 11.4, and LhaL of Lhe overall pressure sore decreased from 0.13 Lo 0.04. 1he paLlenL saLlsfacLlon lncreased from
83 Lo 94, and Lhe cosL decreased from 490n1 (wlLh uuoderm) Lo 9n1 (make-up puff). 1he saLlsfacLory raLe for nurslng sLaff
also lncreased from 76 Lo 89.

Conc|us|on: 1he nlv masks used ln our hosplLal are deslgned for Caucaslans, whlch are overslzed for orlenLal, and Lhe sLraps
cannoL be ad[usLed lndlvldually Lo flL each paLlenL. 1hls ls a flrsL know sLudy of uslng make-up puff Lo successfully reduce faclal
pressure sore. lL has several advanLages over uuoderm, Lhe puffs can be removed from paLlenL skln surface freely, and reused by
Lhe same paLlenL afLer Lemporary removal for skln care. 1he puffs also ellmlnaLes Lhe llgnlfylng phenomenon of uuoderm afLer long
Lerm use, and may decrease Lhe chance of alr leakage ln case of unflLLlng faclal masks. ln concluslon, Lhe make-up puff noL only
lowers Lhe lncldence of faclal pressure sore, buL also reduces medlcal expenses for Lhe famllles. WlLh our new devlce and proLocol,
Lhe saLlsfacLory raLe for paLlenLs and famllles lncreases, and Lhe nurslng care quallLy was also lmproved.



1790

MUL1I-MCk8IDI1 CI nLAk1 IAILUkL AND CCD: A1ILN1S AND CAkLkS' LkLkILNCLS A1 nCSI1AL DISCnAkGL
Lucy uoos
1,*
, Lleanor 8radley
2
, Slmon !. uavles
1
, umesh 1. kadam
1

1
PealLh Servlce 8esearch unlL, keele unlverslLy, keele,
2
CenLre for racLlce and Servlce lmprovemenL, SLaffordshlre unlverslLy,
SLoke-on-1renL, unlLed klngdom


Cb[ect|ves: 1he maln ob[ecLlve of Lhe sLudy was Lo explore Lhe experlences of hearL fallure (Pl) and chronlc obsLrucLlve pulmonary
dlsease (CCu) mulLl-morbld paLlenLs and Lhelr carers on hosplLal dlscharge. Secondary ob[ecLlves lncluded ldenLlflcaLlon of gaps ln
Lhe healLh care of mulLl-morbldlLy and opLlmal soluLlons from paLlenLs and carers' perspecLlves.

Methods: AdulL parLlclpanLs were recrulLed from Lwo cardlology and resplraLory wards aL a large reglonal hosplLal ln Lngland, and all
had a mulLl-morbldlLy dlagnosls of CCu and Pl. Mlxed-meLhods were used Lo collecL daLa uslng paLlenL self-compleLe
quesLlonnalre and ln depLh lnLervlews. 1he survey quesLlonnalre lncluded an adopLed verslon of Lhe Amerlcan PCAPS
survey quesLlonnalre
1
, whlch speclflcally covers communlcaLlon wlLh docLors, nurses and medlcaLlon lssues aL Lhe polnL of dlscharge.
A seml-sLrucLured lnLervlew schedule was developed based on our revlew of Lhe llLeraLure and uslng modlfled quesLlons from Lhe
PCAPS" quesLlonnalre. AudloLaped lnLervlews were Lranscrlbed verbaLlm wlLh parLlclpanLs' consenL, and daLa ln LranscrlpLs were
analysed uslng LhemaLlc analysls.

kesu|ts: ln Lhe PCAPS survey, 14 ouL of 29 (48) compleLed quesLlonnalres were reLurned. Palf Lhe respondenLs were women and
Lhe average age was 74 years. Cverall, nurses scored beLLer (84) Lhan docLors (64) ln llsLenlng Lo paLlenLs. 1here were problems
ln communlcaLlon abouL medlcaLlon wlLh 73 noL aware of Lhe reasons for new medlcaLlon and 64 never been lnformed of Lhelr
slde effecLs. 1he overall saLlsfacLlon score was 6 ouL of 10 and 43 would deflnlLely or posslbly recommend (36) Lhe hosplLal.
ln-depLh lnLervlews were carrled ouL wlLh 6 paLlenLs and 3 carers ln Lhe home seLLlng one Lo Lwo weeks followlng hosplLal dlscharge.
lnLervlewees' descrlpLlons of Lhelr experlences on hosplLal dlscharge fell lnLo four maln Lhemes: clarlLy of lnformaLlon, lssues wlLh
medlcaLlon, communlcaLlon and conLlnulLy of care afLer dlscharge (1able 1). lnformaLlon on dlagnosls was ofLen provlded by
mulLlple cllnlclans, whlch could be conLradlcLory and resulLed ln confuslon. arLlclpanLs felL Lhey recelved very llLLle lnformaLlon
abouL how Lo cope aL home afLer Lhelr dlscharge, and LhaL Lhe hosplLal Leam dlsengaged lmmedlaLely posL-dlscharge. MosL
parLlclpanLs experlenced dlfflculLles ln undersLandlng whaL Lhey were Laklng and were uncerLaln abouL prescrlbed medlclnes
reglmen.

1ab|e 1: Ma|n themes and sub-themes from part|c|pants' |nterv|ews
Ma|n theme Sub-theme
1-C|ar|ty of |nformat|on -ulagnosls uncerLalnLy
-lnformaLlon Lo carers
-ulscharge lnformaLlon and lnconslsLenL lnformaLlon from dlfferenL
cllnlclans
2-Med|cat|on -8eLLer lnformaLlon on medlcaLlon changes (reglmen, dose, slde
effecLs)
3-Commun|cat|on -8eLween healLhcare professlonals
-8eLween paLlenLs and cllnlclans
-ercelved lack of communlcaLlon beLween hosplLal and prlmary
care
-Speclal communlcaLlon needs of elderly paLlenLs
4-D|scharge process and cont|nu|ty of care after d|scharge -ulscharge process
-lollow up afLer dlscharge and avallablllLy of a conLacL polnL

Conc|us|on: Cur sLudy showed LhaL gaps and delays ln communlcaLlon beLween healLhcare professlonals and poor dlscharge
documenLaLlon conLlnue Lo be recurrlng lssues ln carlng for paLlenLs wlLh Pl and CCu mulLl-morbldlLy. lL furLher polnLs Lo Lhe need
for a comprehenslve, coordlnaLed and lnLegraLed care LhaL lncorporaLes paLlenL preferences ln order Lo lmprove Lhe ouLcomes for
mulLlple-morbldlLy.

keferences: 1- PosplLal Consumer AssessmenL of PealLhcare rovlders and SysLems Survey (PCAPS), 2012- Avallable aL:
hLLp://www.sLerllngresearchgroup.com/8esources/flles/surveys/MallSurveyMaLerlalsLngllsh.pdf [Accessed: nov, 2012].



1800

LkLkILNCLS IN IMLLMLN1ING AN LMk LkCnANGL NL1WCkk IN 1AIWAN
ln Chang
1,*
, Wel W. Chen
1
, l C. Chlu
2
, Wun L. Cuo
1

1
Medlcal lnformaLlcs,
2
Medlcal affalrs, naLlonal Cheng-kung unlverslLy PosplLal, 1alnan, 1alwan


Cb[ect|ves: 1o lnLerconnecL cllnlclans ln 1alwan, a naLlonal elecLronlc medlcal record (LM8) exchange cenLer was
esLabllshed by Lhe ueparLmenL of PealLh ln 2012, ln order Lo lmprove Lhe paLlenL lnformaLlon sharlng and reduce
redundanL examlnaLlons across naLlon. 1he lmplemenLaLlon experlence of naLlonal Cheng-kung unlverslLy PosplLal
(nCkuP) case ln 1alwan was proposed and shared Lo encourage Lhe use of lnLeroperable LM8 exchange among
hosplLals.

Methods: A sysLemaLlc llLeraLure revlew was performed Lo evaluaLe Lhe lnLeroperablllLy of LM8 exchange. An LM8
sysLem was developed whlch used PL7-mandaLed codes Lo faclllLaLe Lhe LM8 exchange across naLlon. lour Lypes of LM8
exchange were provlded Lhrough Lhe naLlonal exchange cenLer, l.e. lnpaLlenL prescrlpLlons, blood examlnaLlons, medlcal
lmage and reporL, and dlscharge summary. A mulLldlsclpllnary Leam of quallLy clrcle pro[ecL of nCkuP was organlsed ln
2012. 1o enhance Lhe use of LM8 exchange among hosplLals, Lhe uCA meLhod of quallLy clrcle was adopLed Lo monlLor
Lhe frequencles of LM8 exchange beLween Lhe naLlonal exchange cenLer and Lhe hosplLal. uaLa collecLlon lncluded
group dlscusslon, monLhly meeLlng, and sLaLlsLlcs of LM8 exchange and use. 1he daLa were analysed perlodlcally and
sysLemaLlcally.

kesu|ts: lour lmprovemenL plans were ldenLlfled and proposed:

1) seLLlng up a one-sLop servlce wlndow and deslgnlng a sLandard operaLlon procedure of LM8 exchange among
hosplLals,
2) reduclng Lransmlsslon errors of Lhe LM8 exchange,
3) lncreaslng Lralnlng hours Lo enhance user's percepLlon of LM8 exchange,
4) bulldlng an LM8 knowledge managemenL sysLem Lo help users. AfLer a slx-monLh lmplemenLaLlon perlod, Lhe
correcL Lransmlsslon records of LM8 exchange lncreased from 233,470 Lo 343,843 monLhly. 1he number of LM8
users lncreased slgnlflcanLly. 1he frequencles of LM8 use lncreased from 2.3 Lo 361.3 monLhly.

Conc|us|on: 1he hosplLal LM8 sysLem coupled wlLh exchange funcLlons provlded by Lhe naLlonal exchange cenLer proved
Lo be effecLlve ln lmprovlng Lhe paLlenL lnformaLlon sharlng among hosplLals ln our sLudy. We belleved LhaL Lhe
lmplemenLaLlon experlence from Lhe nCkuP case wlll be beneflclal Lo oLher hosplLals or counLrles deallng wlLh Lhe LM8
exchange lssue.



1802

LIIICILNC CI nLAL1nCAkL: A ML1nCDCLCG 1C nIGnLIGn1, MLASUkL AND INVLS1IGA1L VAkIA1ICN IN
Ck1nCALDIC SUkGLk
lvan vellkanov
1,*
, Malrl MaclnLyre
1
, Samuel Arkle
2
, !ohn naybour
2

1
unlverslLy of Warwlck, CovenLry,
2
ueuy lnLernaLlonal, Leeds, unlLed klngdom


Cb[ect|ves: ln Lhe emerglng markeL of efflclenL healLhcare servlces, Lhe operaLlng room (C8) provldes plenLlful
opporLunlLles Lo dellver efflclency lmprovemenLs Lhrough Lhe reducLlon of varlablllLy. 1hls paper presenLs a
meLhodology Lo access, hlghllghL and evaluaLe varlaLlon ln CrLhopaedlc ArLhroplasLy. 1he use of Lhls meLhodology
enables Lhe ldenLlflcaLlon of surglcal procedures LhaL could beneflL from process lmprovemenL efforLs.

Methods: A sLrucLured llLeraLure revlew was conducLed Lo ldenLlfy healLhcare efflclency evaluaLlon meLhods. 1hese
meLhods were sub[ecLed Lo ugh maLrlx Lo compare and conLrasL agalnsL eLhlcal and funcLlonal requlremenLs of Lhe key
sLakeholders Lo deLermlne Lhe mosL approprlaLe. 1he selecLed meLhod was Lhen lmplemenLed and daLa collecLed over a
one monLh perlod from 12 hosplLals from around Lhe uk. uaLa was examlned and analysed sLaLlsLlcally.

kesu|ts: 1he moblle LableL devlse wlLh speclallsed sofLware packages was demonsLraLed Lo be Lhe mosL perLlnenL ln
Lerms of eLhlcal and funcLlonal requlremenLs. 8equlremenLs meL lnclude: non-lnLruslve (eLhlcal), moblle, easy Lo use,
easlly cleaned wlLh a sLerlllsed cover and neLwork connecLlve (funcLlonal). lmplemenLaLlon of Lhe meLhod ln Lhe
operaLlng room demonsLraLed hlgh quallLy resulLs ln comparlson Lo convenLlonal meLhods. lurLhermore, lL helped Lo
esLabllsh a greaLer awareness of Lhe hosplLals' relaLlve performance lndlcaLors consolldaLed ln one daLabase and
benchmarked agalnsL oLher organlsaLlons lnvolved ln Lhe sLudy. lnLulLlve represenLaLlons of delays, wasLeful operaLlons
and boLLleneck processes as well as esLlmaLed performance levels and economy opLlons have more Lhan ever
hlghllghLed Lhe need for efflclenL healLhcare servlce dellvery wlLh respecL Lo concreLe deflclencles of currenL surglcal
servlce provlslon.

Conc|us|on: Moblle servlce efflclency evaluaLlon meLhods provlde new scope for healLhcare effecLlveness
lmprovemenLs. A number of dlverse opLlons for Lhelr appllcaLlon are envlsaged lncludlng boLh hosplLals and Lhelr
suppllers. Such meLhods could be provlded by suppller as a supplemenLary servlce Lo lndlcaLe advanLages of new
producL soluLlons, or become a source of aggregaLe lnformaLlon for more sophlsLlcaLed process modelllng and profound
efflclency lmprovemenL. AdvanLages of Lhe Lechnlque are noL llmlLed Lo orLhopaedlc surgery cases: on-golng sLudles are
Lo be performed Lo appreclaLe Lhe full poLenLlal of Lhe meLhod.



1811

kLSLNCL AND SAIL1 S1A1US SS1LM ICk CLkA1ING kCCM DLVICLS
AnneL[e Cuedon
1,*
, Llnda Wauben
1
, Marlles Cvervelde
2
, !ohn van den uobbelsLeen
1

1
8lomechanlcal Lnglneerlng, uelfL unlverslLy of 1echnology,
2
Cllnlcal hyslcs, 8elnler de Craaf CasLhuls, uelfL,
neLherlands


Cb[ect|ves: 1he lncreaslng number of new Lechnologles ln Lhe operaLlng room (C8) has made Lhe surglcal envlronmenL
more complex. Mlsslng or malfuncLlonlng equlpmenL ofLen delay Lhe procedure and are a source of lncldenLs durlng
procedures. 1he ob[ecLlve of Lhls sLudy ls Lo deslgn and lmplemenL a sysLem Lo monlLor Lhe presence and Lhe safeLy
sLaLus of C8 devlces, Lo alerL Lhe sLaff abouL lrregularlLles and Lo slmpllfy Lhe noLlflcaLlon of a malfuncLlon.

Methods: 1he sysLem ls based on acLlve radlo frequency ldenLlflcaLlon Lechnology (8llu) and ls lmplemenLed ln an C8
complex of a uuLch Leachlng hosplLal conslsLlng of 4 C8s. lor Lhls sLudy a selecLlon of 100 devlces was made. 1he sysLem
ls composed of 100 acLlve 8llu Lags equlpped wlLh a buLLon and a LLu lamp, 10 readers for deLecLlng Lhe 8llu Lags and
4 LableL compuLers for lnLerfaclng wlLh Lhe C8 sLaff. All lnformaLlon gaLhered by Lhe sysLem ls saved on a server LhaL ls
llnked Lo Lhe hosplLal's Lechnlcal faclllLy managemenL sysLem.

1he locaLlon and malnLenance sLaLus of Lhe 100 C8 devlces are lnsLanLly deLermlned by Lhe sysLem. 1he developed
sofLware alerLs Lhe sLaff abouL lrregularlLles and slmpllfles Lhe noLlflcaLlon of a malfuncLlon. 1he C8 sLaff can reporL a
malfuncLlon by pushlng Lhe buLLon of Lhe 8llu Lag placed on Lhe malfuncLlonlng devlce and by fllllng ln Lhe asked
lnformaLlon abouL Lhe malfuncLlon on Lhe LableL placed ln Lhe C8. All Lhe lnformaLlon ls Lhen auLomaLlcally send Lo Lhe
Lechnlclans and reglsLered ln Lhe hosplLal's Lechnlcal faclllLy managemenL sysLem. 1he screen porLrays safeLy sLaLus and
presence of Lhe devlces. A green screen on Lhe LableL lndlcaLes a correcL safeLy sLaLus of Lhe devlces ln Lhe
correspondlng C8, when Lhe malnLenance ls up Lo daLe and Lhe devlces are LesLed Lo work properly. A red screen
lndlcaLes LhaL malnLenance ls overdue or a malfuncLlon has been reporLed. ueLalled lnformaLlon abouL Lhe safeLy sLaLus
can also be shown on Lhe screen. 1he sysLem ls currenLly belng LesLed for a plloL perlod of slx monLhs unLll March 2013.

kesu|ts: rellmlnary resulLs show an lncrease ln Lhe number of noLlfled malfuncLlons compared Lo Lhe prevlous years
(see Lable). ln LoLal, 24 more malfuncLlons were reporLed compared Lo lasL year and 62 compared Lo Lhe average of
Lhe lasL Lhree years.
erlod number of reporLed
malfuncLlons
CcLober 2009 - !anuary 2010 22
CcLober 2010 - !anuary 2011 27
CcLober 2011 - !anuary 2012 38
CcLober 2012 - !anuary 2013 (plloL) 47

CurrenL acLlvlLles are focussed on evaluaLlng Lhe user experlence ln Lerms of funcLlonallLy and lnLulLlveness. Also Lhe
rellablllLy of Lhe Lracklng sysLem ls belng evaluaLed.

Conc|us|on: AuLomaLlcally monlLorlng Lhe sLaLus of C8 devlces lncreases Lhe number of reporLed malfuncLlons
compared Lo prevlous years. 1hls provldes valuable lnslghL ln Lhe frequency of lncldenLs and recurrence of malfuncLlons
of lndlvldual devlces. Cn a longer Lerm, such a sysLem ls expecLed Lo prevenL lrregularlLles and lncrease Lhe safeLy
relaLed Lo medlcal C8 devlces.



1817

A CCMAkA1IVL ANALSIS CI nCSI1AL DISCnAkGL SUMMAkILS ACkCSS LUkCL: IS 1nLkL SCCL ICk kCCSING A
S1ANDAkDISLD 1LMLA1L?
keLevan ClonLl
1,*
, Ceclle knal
1
, Lmlly Warren
1

1
London School of Pyglene and 1roplcal Medlclne, London, unlLed klngdom


Cb[ect|ves: 1o ldenLlfy slmllarlLles and dlfferences ln Lhe channel of dlscharge summarles and Lhelr reclplenLs, Lo ellclL lnformaLlon
on caLegorles of lnformaLlon Lyplcally lncluded ln a dlscharge summary across Lurope, and Lo explore wheLher Lhere ls scope for
proposlng a sLandardlsed LemplaLe.

Methods: A comparaLlve analysls of hosplLal dlscharge summarles was conducLed uslng quallLaLlve and quanLlLaLlve daLa. 1hls mulLl-
meLhod approach lncluded:
1) A sysLemaLlc revlew underLaken ln accordance wlLh Lhe Cochrane meLhodology on Lhe use and scope of hosplLal dlscharge
summarles ln Lurope,
2) As parL of a larger pro[ecL on care paLhways, counLry-based surveys on Lhe managemenL of l) dlabeLes, ll) hlp surgery and lll)
AMl were performed, and relevanL quesLlons on dlscharge summarles were exLracLed and analysed.
3) ulsLrlbuLlon of a web-based quesLlonnalre Lo hosplLal auLhorlLles ln 27 Member SLaLes, whlch collecLed lnformaLlon on Lhe
followlng Loplcs: dlscharge processes, naLlonal sLandardlsaLlon of dlscharge summarles across hosplLals, accredlLaLlon of
dlscharge summary LemplaLes, conLenL and access (parLlcularly ln Lhe case of cross-border paLlenLs) and avallablllLy ln oLher
languages. 1hls survey Lool was of an exploraLory naLure Lo gaLher addlLlonal lnformaLlon LhaL would have oLherwlse proved
dlfflculL Lo acqulre, speclflcally LhaL relaLed Lo dlscharge summarles.

ln addlLlon Lo Lhe surveys, a sysLemaLlc lnLerneL search was performed Lo ldenLlfy any avallable dlscharge summary LemplaLes.
AnoLher source for obLalnlng dlscharge summarles was Lhrough prevlously-esLabllshed conLacL wlLh a relevanL compleLed Lu
pro[ecL.

8ecelved dlscharge summarles were analysed wlLh regards Lo Lhelr sLrucLural conLenL, wlLh parLlcular emphasls on:
1) Ma[or sLrucLural slmllarlLles/dlfferences,
2) MosL/leasL common caLegorles,
3) 8ange of Lermlnology and classlflcaLlon used, and
4) CuallLy and deLall of cllnlcal lnformaLlon.

kesu|ts:
1. 1wenLy-flve sLudles from 9 Lu counLrles were lncluded lnLo Lhe sysLemaLlc revlew, 21 papers provlded lnformaLlon on key
conLenL lLems. 1he mosL frequenLly clLed key caLegorles across Lhe sLudles were luLure LreaLmenL/lollow up" and ulagnosls".
2. A LoLal of 233 parLlclpanLs responded Lo Lhe relevanL quesLlons wlLhln Lhe dlsease managemenL survey. 1he ma[orlLy of
hosplLals across Lhe Lu for whlch daLa was collecLed provlde Lhelr paLlenLs wlLh a paper dlscharge summary upon dlscharge
(90). 33 send lL ln paper form Lo general pracLlLloners or speclallsLs. An elecLronlc reporL wlLh paLlenL daLa ls senL by 30 of
respondenLs Lo C/speclallsLs. 1he mosL common caLegorles ln dlscharge summarles lnclude: 'lnformaLlon on hosplLal sLay
(admlsslon and dlscharge daLe)' (93), 'dlagnosls aL admlsslon (90.1) and dlscharge (92.7)', 'procedures underLaken (94.8)'
as well as 'medlcaLlon lnformaLlon (87.9)'.
3. 1he web-based quesLlonnalre recelved 18 responses from Lhe 99 lndlvlduals conLacLed lnlLlally (18.1 response raLe) and
provlded lnslghL on dlfferenL regulaLlons wlLhln counLrles.

A LoLal of LwenLy Lwo dlscharge summary LemplaLes from 13 counLrles across Lurope LhaL had been supplled Lo paLlenLs and/or
referrlng physlclans upon hosplLal dlscharge were obLalned and analysed.

Conc|us|on: PosplLal dlscharge summarles play a crlLlcal role ln ensurlng safe and efflclenL conLlnulLy of care, parLlcularly Lhrough
Lransmlsslon of key lnformaLlon from secondary Lo prlmary care. ln Lhe cross border healLh care conLexL Lhey are ofLen Lhe only
meLhod of communlcaLlon beLween healLh provlders from dlfferenL counLrles. Powever, dlscharge processes and conLenL dlffer
across Lurope due Lo varlous naLlonal, reglonal and hosplLal-speclflc regulaLlons or guldellnes.


1823

1nL IMCk1ANCL CI CCMLLMLN1ING SUkVL WI1n IN1LkVILW IN ASSLSSING SAIL1 CUL1UkL IN nLAL1nCAkL
1lLa A. LlsLyowardo[o
1,*
, Anna P. 8oberLson
1
, SLephen Leyshon
1
, lnger-Marle 8llx
1

1
8esearch and lnnovaLlon, ueL norske verlLas AS, Povlk, norway


Cb[ect|ves: 1o LesL, adapL, and evaluaLe comblned meLhods of survey and lnLervlew used ln oLher safeLy crlLlcal
lndusLrles for assesslng safeLy culLure ln Lhree hosplLals ln norway and Lngland.

Methods: 1he SafeLy ALLlLudes CuesLlonnalre (SAC) was used Lo survey hosplLal sLaff' aLLlLudes Lowards paLlenL safeLy
pracLlces ln Lhree hosplLals (case sLudles). We adapLed a seml-sLrucLured lnLervlew gulde prevlously developed by unv
for oLher lndusLrles Lo assess safeLy culLure quallLaLlvely and lnLervlewed a selecLlon of sLaff ln each hosplLal. Welch
8obusL 1esLs were used Lo analyse survey resulLs. We conducLed lndlvldual lnLervlews ranglng from 23 Lo 29 per
hosplLal. noLes from Lhe lnLervlews were analysed quallLaLlvely Lo flnd common Lhemes. Survey and lnLervlew resulLs
were comblned and analysed quallLaLlvely Lo flnd slmllarlLles and dlfferences.

kesu|ts: PosplLals were analysed separaLely due Lo Lhe naLure of Lhe sLudy (l.e., case sLudy). We surveyed 239 sLaff ln
PosplLal 1 (8esponse raLe=70.27), 37 sLaff ln PosplLal 2 (8esponse raLe=32.93 ), and 262 sLaff (8esponse
raLe=38.93) ln PosplLal 3. lndlvldual lnLervlews achleved daLa saLuraLlon.

varlaLlons ln safeLy culLure scores were found beLween and wlLhln hosplLals. lnLervlews revealed common Lhemes such
as cooperaLlon and communlcaLlon", compeLence and developmenL", cosL and safeLy balance".
1he resulLs showed LhaL ln some cases Lhe lnLervlew survey resulL could be explalned by lnLervlews. lor example, for
PosplLal 1, Lhere was mosL varlablllLy beLween unlLs for Lhe dlmenslon for percepLlons Lowards Lhe managemenL". 1he
lnLervlews revealed LhaL role models" lnfluenced hosplLal sLaff's percepLlons meanlng LhaL lf Lhelr managemenL was a
good role model Lhey raLed Lhls dlmenslon hlgher Lhan sLaff LhaL percelved Lhelr managemenL as poorer role models.

AnoLher example of Lhls was observed ln PosplLal 2 where survey resulLs lndlcaLed LhaL sLaff belleved Lhe ward
managemenL was more commlLLed Lo paLlenL safeLy Lhan Lhe hosplLal managemenL. lnLervlews revealed a dlsconnecL ln
communlcaLlon beLween ward and hosplLal managemenL ln Lerms of Lhe lmplemenLaLlon of changes and Lhe use of
lncldenL reporLs. 1hls lnfluenced sLaff' percepLlons of ward and hosplLal managemenL.

1he meLhod also revealed more accuraLe lnformaLlon Lo glve a more compleLe plcLure of safeLy culLure. lor example, ln
PosplLal 1 Lhe raLlngs were relaLlvely hlgh ln Lhe survey on lLems relaLlng Lo sLaff awareness on Lhe proper channels Lo
ralse paLlenL safeLy concerns and Lhe encouragemenL by colleagues Lo reporL any paLlenL safeLy concerns. 1he
lnLervlews lmplled LhaL sLaff dld noL always use Lhe reporLlng sysLem due Lo Lhe percepLlon of Lhe reporLlng sysLem
belng compllcaLed, LhaL reporLlng would noL lead Lo lmprovemenL or poor handllng of prevlous cases on reporLlng.
WlLhouL lnformaLlon galned from Lhe lnLervlews, one may lnLerpreL LhaL sLaff do reporL uslng Lhe exlsLlng sysLem. SLaff
preferred Lo dlscuss lncldenLs ln a group Lhan reporLlng Lhem Lhrough a sysLem, as lnLervlews also revealed.

Conc|us|on: Cur flndlngs demonsLraLe LhaL lnLervlew as a complemenLary meLhod Lo survey can be used ln order Lo
ldenLlfy boLh Lhe sLaLus of Lhe safeLy culLure (l.e. whaL lL ls) and furLher explaln Lhe reasons for Lhls sLaLus (l.e. why lL ls
Lhe way lL ls). 1hls ls parLlcularly useful ln order Lo undersLand Lhe complexlLles of an organlsaLlon's safeLy culLure and
furLher deslgn and lmplemenL effecLlve changes ln order Lo lmprove lL. 1hese flndlngs Lherefore have lmpllcaLlons for
safeLy culLure lmprovemenL programs.


1824

UALI1-IMkCVLMLN1 INI1IA1IVL SUS1AINS IMkCVLMLN1 IN MLDICAL SLCIAL1- VLN1ILA1Ck WAkD AMCNG
NUkSING S1AIIS AND nLAL1n CAkL ASSIS1AN1S
k.M. Lee
1
, k.l. Mok
1,*
, W.P. Law
1
, P.W. Luk
1

1
Medlcal, PosplLal AuLhorlLy, Pong kong, Pong kong


Cb[ect|ves: use quallLy-lmprovemenL (Cl) meLhod Lo develop and LesL a mulLlmodal lnLervenLlon Lo lmprove hand-
hyglene compllance of healLh care provlders (PC) Lo 80.

Methods: lL ls an observaLlonal experlmenLal sLaggered lnLervenLlonal sLudy. A re-osL 1esL was conducLed ln a medlcal
SpeclalLy venLllaLor Ward. Compllance was deflned as accepLable hand hyglene before and afLer conLacL wlLh paLlenL or
paLlenL's care envlronmenL. MeasuremenL of PC hand-hyglene compllance was performed by coverL observaLlons
made durlng rouLlne paLlenL care. 1hree monLhs of pre-lnLervenLlon daLa were collecLed. Cl meLhods were used Lo LesL
and lmplemenL lnLervenLlons sequenLlally ln dlfferenL level of PC lncludlng Ward Manager (WM), Advanced racLlced
nurse (An), 8eglsLered nurse (8n), Lnrolled nurse (Ln), PealLh Care AsslsLanLs (PCA), ersonal PealLh Care Workers
(CW) and Clerks. lnLervenLlons addressed leadershlp supporL, lmprovlng all PCs' knowledge, hand-hyglene supply
avallablllLy, and behavlour. 1hree monLhs posL-lnLervenLlon, second seL of daLa were collecLed and analysls. Comparlng
Lhe dlfference beLween Lhe compllance raLes under Lhe World PealLh CrganlsaLlon (WPC) Pand hyglene formula, Lhe
effecLlveness has been shown.

kesu|ts: re-lnLervenLlon compllance raLe was collecLed on 1.3.2012. lnLervenLlons Lhen began on 1.4.2012-30.4.2012.
Compllance 8aLe was calculaLed 3 monLhs posL lnLervenLlon on 1.7.2012 as a washouL perlod. 8y 1.8.2012, compllance
lncreased on WM, An, 8n and Ln (from 73 Lo 91). Powever, compllance lncreased on PCA and CW (from 43 Lo
62). 1here was no slgnlflcanL dlfference wlLhln Lhe clerks. lmprovemenL on PCA and CW occurred only afLer Lhe
lnLervenLlons were lnLroduced. ldenLlfylng PCAs who falled Lo perform hand hyglene and offerlng alcohol-based hand
rub Lo Lhem before paLlenL conLacL resulLed ln Lhe greaLesL lmprovemenL. lmprovemenLs were susLalned on all Lhe
nurslng SLaffs and PealLh Care AsslsLanLs for more Lhan 3 monLhs.

1he numbers of newly dlagnosls of M8uA and M8A afLer admlLLed Lo venLllaLor ward were also measured. 1he
average admlsslon raLe ln venLllaLor ward from 1.3.2012 Lo 31.8.2012 was 33 paLlenLs /monLh. 1here were 3 newly
dlagnosls Mu8A and M8A paLlenLs before Lhe lnLervenLlon began. Cnly 1 newly dlagnosls Mu8A and M8A paLlenLs
noLed 3 monLhs afLer Lhe lnLervenLlon. AlLhough Lhere ls no slgnlflcanL dlfference on serlous lnfecLlon dlsease pre- and
posL-lnLervenLlon, buL Lhe decreaslng Lrend ls an encouraglng resulL for furLher sLudy.

Conc|us|on: use of Cl meLhods Lo lmplemenL a mulLlmodal lnLervenLlon resulLed ln susLalned lmprovemenL ln hand-
hyglene compllance. 8eal-Llme lndlvldual performance feedback or oLher hlgh-rellablllLy human-facLor lnLervenLlons
seem Lo be necessary Lo reach and susLaln hlgh levels of hand-hyglene compllance. 1here are dlfferenL confoundlng
facLors needed Lo furLher explored ln order Lo have a Lhorough plcLure of CuallLy-lmprovemenL lnlLlaLlve susLalns
lmprovemenL hand hyglene program.

keferences:
1. lLLeL, u., Allegranzl, 8., 8oyce, !. (2009) 1he World PealLh CrganlsaLlon guldellnes on hand hyglene ln healLh care
and Lhelr consensus recommendaLlons. lofectloo coottol nospltol plJemloloqy, 30(7):611-622
2. lnsLlLuLe for PealLhcare lmprovemenL. Pow-Lo gulde: lmprovlng hand hyglene.
www.lhl.org/lPl/1oplcs/CrlLlcalCare/lnLenslveCare/1ools/ PowLoCuldelmprovlngPandPyglene.hLm. Accessed
lebruary 20, 2012
3. Zerr, u.M., Allpress, A.L., PeaLh, !., 8ornemann, 8., 8enneLL, L.(2003). uecreaslng hosplLal-assoclaLed roLavlrus
lnfecLlon: a mulLldlsclpllnary hand hyglene campalgn ln a chlldren's hosplLal. loeJlottlc lofectloo Iootool, 397-403



1826

'8kLAk1nkCUGn' WI1n 1nA1 Lk1kA SMILL AND IMkCVL CLDLk LCLL'S CAkL
ulane Campbell
1,*
, !lll lerbrache
1

1
SafeLy, nPS 1ayslde, uundee, unlLed klngdom


Cb[ect|ves: ln !une 2012 nPS 1ayslde and nPS Cramplan launched an Clder eople ln AcuLe Care CollaboraLlve Lo geL Lhe
fundamenLals of care rlghL for older people. 1he alm of Lhe collaboraLlve ls Lo lmprove Lhe experlence of older people (ln parLlcular
Lhose wlLh cognlLlve lmpalrmenL) and Lhelr carers durlng Lhelr [ourney Lhrough AcuLe Care by november 2013. 14 plloL wards from
boLh 8oards are focuslng on lnLervenLlons LhaL emphaslse Lhe cllnlcal Lechnlcal skllls and carlng behavlours necessary Lo lmprove Lhe
paLlenL and famlly experlence. Plgh level alms are:

! 93 of paLlenL saLlsfacLlon scores are excellenL
! 300 days beLween formal complalnLs
! 93 of approprlaLe paLlenLs recelve a sLandardlsed screenlng

Methods: uslng lnsLlLuLe of PealLhcare lmprovemenL's 8reakLhrough Serles a comprehenslve change package was developed whlch
ldenLlfles Lhe lmprovemenLs requlred by Lhe mulLldlsclpllnary Leam. 1he model ls a shorL Lerm learnlng sysLem LhaL brlngs LogeLher
mulLldlsclpllnary Leams Lo seek lmprovemenL and uses Lhe Model for lmprovemenL as Lhe framework. 1he collaboraLlve wlll run for
18 monLhs and ln Lhls Llme Leams aLLend learnlng sesslons and reporL progress and share Lhe learnlng from LesLlng wlLh oLher Leams
and sLakeholders. 1he change package ls supporLed by a robusL collaboraLlve measuremenL plan wlLh Leams requlred Lo malnLaln
run charLs Lracklng Lhelr sysLem measures over Llme. 1he followlng flve measures wlll be presenLed:

1. aLlenL experlence scores
2. ercenLage of approprlaLe paLlenLs who recelve a sLandardlsed comprehenslve gerlaLrlc assessmenL
3. ercenLage compllance wlLh mulLldlsclpllnary Leam sLrucLured ward rounds
4. uays beLween complalnLs
3. ercenLage of paLlenLs who have had an assessmenL of Lhelr ablllLy Lo manage Lhelr medlclnes

kesu|ts: 1hls collaboraLlve lnvolves all members of Lhe mulLldlsclpllnary Leam (Mu1) and recognlses Lhe lnvolvemenL of supporL
servlces as key. Mu Leams are now demonsLraLlng lmprovemenLs agalnsL Lhe alms of Lhe collaboraLlve lncludlng: reducLlon ln
complalnLs, lmproved paLlenL experlence scores and rellable ldenLlflcaLlon of paLlenLs aL rlsk on admlsslon. naLlonal leads
were lnvlLed Lo aLLend Lhe second learnlng sesslon held on Lhe 17Lh & 18
Lh
of !anuary ln nPS Cramplan and have descrlbed Lhls work
as exemplary: 1he CACC ls a fanLasLlc example of lmprovemenL work led from Lhe fronL llne wlLh senlor execuLlve supporL. lL was
clear Lo see aL Learnlng Sesslon 2 how real mulLldlsclpllnary collaboraLlve Leamwork ls lmprovlng Lhe safeLy and effecLlveness of
cllnlcal sysLems ln 1ayslde and Cramplan wlLh Lhe person and famlly Lruly aL Lhe cenLre. 1hls collaboraLlve has lL all, safeLy, person
cenLeredness, lnLegraLlon, collaboraLlve efforL and flow. 1he commlLmenL and supporL of senlor leadershlp from each nPS 8oard ls
clear Lo see and early resulLs lmpresslve. l look forward Lo learnlng more from Lhose lnvolved wlLh Lhls CollaboraLlve" - ur Andrew
LongmaLe, naLlonal Cllnlcal Lead for aLlenL SafeLy, 1he CuallLy unlL, 1he ScoLLlsh CovernmenL.

or|entat|on commun|cat|on D & k |nvo|vement c|ean||ness overa|| care
!ul-12 37 73 87 34 68 73
Aug-12 64 74 90 62 69 78
Sep-12 77 83 89 73 78 81
CcL-12 71 82 88 78 83 84
nov-12 83 86 92 86 90 93
uec -12 78 80 93 78 84 93

Conc|us|on: 1he complexlLles of worklng as mulLldlsclpllnary Leam have been hlghllghLed due Lo Lhe people, processes and culLures
assoclaLed wlLh a busy acuLe hosplLal. 8ulldlng Lhe dream Leam" Lo drlve susLalnable lmprovemenLs Lo care ls crlLlcal. 8y removlng
Lhe Lop down approach Lo lmplemenLlng lmprovemenLs and glve Lhe permlsslon Lo Leams Lo lead lmprovemenLs wlLhln Lhelr own
areas susLalnable change ls achlevable.


1827

IN1LkNAL CCMMUNICA1ICN GCING SCCIAL - WCk1n I1 Ck NC1?
SLephanle S.-L.?eung
1, 2,*

1
nLw 1errlLorles LasL ClusLer,
2
rlnce of Wales PosplLal, Pong kong PosplLal AuLhorlLy, ShaLln, Pong kong


Cb[ect|ves: lotetool commoolcotloo Coloq 5oclol -wottb lt ot oot?

1he ob[ecLlve of Lhls research paper ls Lo explore Lhe rlsks and beneflLs of lnLroduclng soclal medla as a communlcaLlon
Lool ln lnLernal communlcaLlon ln healLhcare seLLlng.

1he new 1errlLorles LasL ClusLer (n1LC) ls one of Lhe seven hosplLal clusLers of Lhe Pong kong PosplLal AuLhorlLy. lL ls
geographlcally Lhe largesL hosplLal clusLer of Pong kong and serves a populaLlon of over 1.3 Mllllon people, Lhe second
largesL ln Lerms of populaLlon slze.

1he ClusLer conslsLs of seven hosplLals and lL has a mulLldlsclpllnary sLaff force of around 9300. Many of Lhose work ln
shlfLs and dlfferenL work unlLs of dlfferenL hosplLals. Pow Lo achleve effecLlve communlcaLlon ls a challenge.
ln leb 2003 lL hosLed a suggesLlon box called C&S (CuesLlon and SuggesLlon) on lLs lnLraneL homepage. lL ran on an
elecLronlc noLlce board formaL and has ofLen been crlLlclsed for belng unlnLeresLlng, slow and full of sLald and
bureaucraLlc replles.

Seelng Lhe success of soclal plaLforms llke lacebook, Lhe clusLer managemenL replaced Lhe CuesLlons and SuggesLlons
page wlLh a dlscusslon forum called ?ouSay ln March 2011. 1he forum has embraced Lhe key elemenLs of enLerprlse 2.0
Lechnology. lL allows anonymous posLlng and real-Llme uploadlng. 26 members of Lhe managemenL lncludlng Lhe
ClusLer Chlef LxecuLlve were recrulLed Lo parLlclpaLe as experL conLrlbuLors. 1he forum runs on slmple edlLorlal
guldellnes.

PlL raLe lnsLanLly surged from a few Lo a few hundreds each day. And Lhe number of posLlngs has lncreased from around
70 per quarLer Lo over 200 each monLh. 1he naLure of posLs are noL predomlnanLly welfare and beneflL focused, many
are on dally operaLlons and paLlenL servlces, and Lhey come ln dlfferenL formaLs, ranglng from suggesLlons Lo venLllaLlon
Lo ldeas Lo oplnlons.

Methods: 1he clusLer conducLed a survey ln leb 2012 uslng Lhe formaL of medla readershlp quesLlonnalre. lL ls dlvlded
lnLo Lwo parLs. 1he flrsL parL focuses on users' demographlc daLa and medla consumpLlon paLLerns whlle Lhe second parL
asks for readers' vlews on 10 sLaLemenLs whlch are seL Lo valldaLe Lhe beneflL and rlsk clalms of soclal medla as a
corporaLe communlcaLlon Lool as expounded ln Lhe llLeraLure. A dlfferenL seL of quesLlonnalre wlLh 12 sLaLemenLs were
dlsLrlbuLed Lo Lhe members of Lhe managemenL who parLlclpaLed as experL conLrlbuLors.

kesu|ts: 1he resulLs show LhaL Lhe ?ouSay has achleved 96 awareness and LhaL 70 of Lhe sLaff has ofLen/someLlme
vlslLed Lhe forum. 89 of Lhe users surveyed agreed LhaL ?ouSay ls venLllaLory ln naLure and yeL Lhey are aLLracLed Lo lL
as over 70 of Lhem found LhaL ?ouSay has dlverse and lnLeresLlng conLenL, Lhey have galned useful lnformaLlon from
?ouSay, and LhaL ?ouSay has shown openness and slncerlLy on Lhe parL of Lhe managemenL. Cn Lhe conLrlbuLors slde
Lhey have overwhelmlngly (l.e. 100) agreed LhaL ?ouSay has helped Lo ldenLlfy poLenLlal lssues and confllcLs and 93
has agreed LhaL ?ouSay has enabled Lhem Lo geL lnsLanL employer pulse-readlng and sLay ln Louch wlLh Lhe hoL lssues ln
Lhe organlsaLlon. Cver 70 of Lhose surveyed ln boLh caLegorles have opLed for keeplng Lhe forum/furLher enhance and
lmprove lL.

Conc|us|on: 1he experlence of golng soclal so far seems Lo suggesL LhaL sLaff do Lake Lo novel mode of communlcaLlon
whlch calls for a new communlcaLlon culLure from Lhe managemenL. So far, ?ouSay has become Lhe sLlcklesL plaLform on
Lhe lnLraneL. And llke any medla whlch has a sLrong readershlp base, lL has huge communlcaLlon poLenLlals Lo be
explored. lL ls a worLhwhlle Lrlal.

1829

USING nLAL1nCAkL IAILUkL MCDLS AND LIILC1S ANALSIS 1C kCMC1L 8LCCD 1kANSIUSICN SAIL1
Chlung !u Chen
1,*
, 1ong-!ong Chen
1

1
ulvlslon of 1ransfuslon Medlclne, ueparLmenL of aLhology and LaboraLory Medlclne, Shln kong Wu Po-Su Memorlal
PosplLal, 1alpel, 1alwan


Cb[ect|ves: 1he assurance of blood Lransfuslon safeLy depends on a mulLl-dlsclpllne Leamwork corporaLlon. Slnce lL ls a
process of hlghly complex and people's [udgmenL dependenL, any mlss of blood Lransfuslon ls a severe senLlnel evenL ln
Lhe hosplLal, as deflned by !CAPC. ln a reLrospecLlve analysls of 13 years perlod ln a medlcal cenLer ln norLhern 1alwan,
a near mlss Lransfuslon of 0.27 and adverse evenL of 0.001 were found. 1o prevenL Lhe lmmedlaLe dlsasLers or laLe
compllcaLlons, every sLeps lnvolved should be revlewed and revlsed repeaLedly, perlodlcally and sysLemlcally

Methods: lrom !une 2011 Lo May 2012, uslng PealLhcare lallure Modes and LffecLs Analysls (PlMLA) model we
conducLed a collaboraLed lnLerdeparLmenLal analysls of blood Lransfuslon safeLy lncludlng procedures, adverse evenLs
and fallure experlence of peers

kesu|ts: Among 39 deLalled procedures, 39 poLenLlal fallure causes were deflned, and Lherefore 28 prlmary correcLlve
proceedlngs and 12 correcLlve measures were worked ouL accordlngly. llrsL of all, Lhe lndlcaLlon of blood Lransfuslon
were revlewed and audlLed by 1ransfuslon CommlLLee. A consulLaLlon sysLem of paLhologlsL and haemaLologlsL was
esLabllshed. 1he adequacy of blood producLs dellvery (lncludlng package, LransporLaLlon, sLorage ln Lhe nurslng sLaLlons,
eLc) was monlLored by a compuLerlsed alarmlng sysLem. Moreover, Lhe lnLroducLlons of a barcode paLlenL ldenLlflcaLlon
sysLem slgnlflcanLly furLher reduced Lhe unexpecLed man-made mlsLakes. 1he promlslng lmprovemenLs lnclude
unquallfled raLe of blood Lransfuslon (9.9 vs. 3.18) and quallflcaLlon raLe of blood supplles (92.3 vs. 100). no mlss
Lransfuslon occurred.

Conc|us|on: ln concluslon, any efforLs of lmprovlng medlcal pracLlce are lmporLanL and some mlss or errors are
prevenLable.



1831

nLAL1n 1kUS1 ULSS20 CI VLkCNA - I1AL: 1nL ACCkLDI1A1ICN CI LkCLLLLNCL WI1n ACCkLDI1A1ICN CANADA
IN1LkNA1ICNAL
Monlca 1rolanl
1
, M. Clusepplna 8onavlna
2
, Chlara 8ovo
2
, 8achele 1ommasl
1,*

1
CuallLy Area, Azlenda ulss 20,
2
Senlor ManagemenL, Azlenda ulss 20, verona, lLaly


Cb[ect|ves: Compare acLlvlLles wlLh lnLernaLlonal sLandards. CbLaln recognlLlon of accredlLaLlon for excellence by an
lnLernaLlonal corporaLlon.

Methods: ln !une 2011, Lhe ulss20 has Laken Lhe paLh of excellence accredlLaLlon ln parLnershlp wlLh AccredlLaLlon
Canada lnLernaLlonal lnvolvlng all Lhe areas of healLh, soclal and admlnlsLraLlve servlces. 1he work, dlvlded lnLo Lwo
phases, based on sLandards for Lhe organlsaLlon, and for Lhe provlded servlces. SLep1: sLaff Lralnlng, self-assessmenL
quesLlonnalre on ACl webslLe. 1he self-assessmenL, made by abouL 900 employees, gave as resulL creaLed a speclflc
roadmap" LhaL ldenLlfled areas Lo be lmproved or noL. 8y Lhose resulLs we creaLed speclflc work group Lo ldenLlfy
acLlon plan Lo solve problems Lhe road map hlghllghLed. SLep2: wlLhln Lhe deparLmenLs have been creaLed worklng
groups whlch have lmplemenLed Lhe plans ldenLlfled ln SLep 1. AL Lhe same Llme have formed worklng groups LhaL have
been lnvolved ln cross-cuLLlng lssues, such as culLural medlaLlon, Lhe sysLem of evaluaLlon of Lhe resulLs. Lvery Leam,
wlLh a mulLl-professlonal pecullarlLy, had a Leam leader and abouL 13-20 parLlclpanLs. 1he work focused on Lhe elghL
dlmenslons of quallLy: accesslblllLy, securlLy, cenLrallLy of Lhe populaLlon, work envlronmenL, conLlnulLy of care, paLlenL-
cenLred, effecLlveness and efflclency. ln CcLober 2012 an evaluaLlon Leam of AccredlLaLlon Canada meL-on slLe wlLh
Azlenda ulss20, and verlfled Lhe organlsaLlon. uurlng Lhe vlslL, surveyors verlfled 38 locaLlons and 21 servlces areas,
lnLervlewed 2 paLlenLs ln home help, and meL buslness parLners ln speclflc focus group.

kesu|ts: ln november 2012, AccredlLaLlon Canada announced Lo Lhe ulss20 Lhe accredlLaLlon of excellence. 1he sLrengLh
polnL of Lhe pro[ecL was Lhe large number of employees who parLlclpaLed and Lhe varlous professlonals lnvolved: Lhe
cllnlcal operaLor and Lhe admlnlsLraLlve one.

Conc|us|on: 1he challenglng work wlLh AccredlLaLlon Canada has allowed Lo lncrease Lhe culLure and skllls ln Lhe fleld of
quallLy managemenL, especlally due Lo Lhe hlgh number of employees lnvolved. ln addlLlon, AccredlLaLlon Canada has
led Lo a sLrengLhenlng of pollcles on paLlenL safeLy, recalllng Lhe supporL Leam Lo Lhe lssues of rlsk.




1833

DCLS nAVING CLk1IIILD kCILSSICNALS IMAC1 UALI1 & A1ILN1 SAIL1 IN ICkDANIAN nLAL1nCAkL
CkGANISA1ICNS?
8abab M. ulab
1
, Cmalma nassar
2,*

1
LducaLlon and consulLaLlon, PealLh Care AccredlLaLlon Councll,
2
Surveys and SLandards uevelopmenL ueparLmenL,
PealLh Care AccredlLaLlon Councll, Amman, !ordan


Cb[ect|ves: 8y Lhe end of presenLaLlon Lhe parLlclpanLs wlll be able Lo:

1. know abouL quallLy and paLlenL safeLy educaLlon ln !ordan
2. CrlenL Lo healLhcare accredlLaLlon councll cerLlflcaLlon courses developmenL process
3. ldenLlfy lmpacL of cerLlflcaLlon courses on Lhe quallLy and rlsk managemenL programs ln healLhcare organlsaLlons

Methods: 1he educaLlon and consulLaLlon deparLmenL aL PCAC collaboraLed wlLh reglonal and lnLernaLlonal experLs Lo
develop cerLlflcaLlon courses addresslng Lhe Loplcs ln need. 1hese courses are deslgned based on adulL learnlng
prlnclples ln whlch LheoreLlcal and pracLlcal lmplemenLaLlon are comblned Lo ensure skllls are properly acqulred
LhroughouL Lhe courses and compeLency assessmenL framework has been developed Lo evaluaLe performance of
Lralnees. Lach course ls broken down lnLo a LheoreLlcal classroom Lralnlng perlod, followed by a 3 monLh menLorshlp
perlod ln whlch parLlclpanLs are expecLed Lo work on Loplc speclflc porLfollo asslgnmenLs. As prerequlslLes for
cerLlflcaLlon, Lhe courses requlre LhaL each parLlclpanL presenL Lhelr asslgnmenLs Lo Lhelr colleagues and course Lralners
and flnally slL for a flnal cerLlflcaLlon exam.

kesu|ts: Lhe resulLs wlll be ready ln Lhe conference as Lhe assessmenL of Lhe cerLlflcaLlon courses lmpacL wlll be
conducLed durlng flrsL quarLer of 2013

Conc|us|on: lloL cerLlflcaLlon courses were conducLed LhroughouL 2001 and 2012. 1hese courses ylelded a LoLal of 38
cerLlfled professlonals LhaL are now embedded wlLhln Lhe healLhcare professlonals worklng ln !ordan. 1hls plloL pro[ecL
also served ln LesLlng and evaluaLlng Lhe courses. 1he feedback from Lhe parLlclpanLs and Lralners allowed for revlslon of
Lhe course Lo develop Lhe flnal programs. 1hese programs are now lnLegraLed ln Lhe PCAC annual educaLlon plan.

keferences:
1. Agulnls, P. & kralger, k. (1997). racLlclng whaL we preach: CompeLency-based assessmenL of
lndusLrlal/organlsaLlonal psychology graduaLe sLudenLs. 1be loJosttlol-Otqoolsotloool lsycboloqlst, J4, 34-40.
2. Amerlcan SocleLy for 1ralnlng and uevelopmenL. (1996). Llnklng Lralnlng Lo performance goals. lofo-lloe (lssue
9606).
3. 8orman, W.C. (1974). 1he raLlng of lndlvlduals ln organlsaLlons: An alLernaLlve approach. Otqoolsotloool 8ebovloot
ooJ nomoo letfotmooce, 12, 103-124.
4. 8rown, L.., lranco, L.M., 8afeh, n., & PaLzell, 1. (1992). Ooollty ossotooce of beoltb cote lo Jeveloploq
cooottles. (8eporL for Lhe CuallLy Assurance ro[ecL). 8eLhesda: unlverslLy 8esearch CorporaLlon.
3. 8uLler, l.C. (1978). 1he concepL of compeLence: An operaLlonal deflnlLlon. Jocotloool 1ecbooloqy, 7-18.



1834

1nL kCLL AND CUL1IVA1ICN CI INILC1ICN CCN1kCL LINk NUkSLS
nlng-?u CPAnC
1,*
, ?a-Chuan CPAnC
2
, Chlen-Lln kuo
3

1
8n, 8Sn, ueparLmenL of nurslng, Chang Cung Medlcal loundaLlon PosplLal and CraduaLe SLudenL, CraduaLe lnsLlLuLe of
nurslng, looyln unlverslLy,
2
8n, 8Sn, ueparLmenL of nurslng, 1rl-Servlce Ceneral PosplLal and CraduaLe SLudenL,
CraduaLe lnsLlLuLe of nurslng, looyln unlverslLy,
3
8n, hu, AssoclaLe rofessor, School of nurslng, looyln unlverslLy,
kaohslung, 1alwan


Cb[ect|ves: As fronLllne personnel ln medlcal Leams, nurslng sLaff should conducL nurslng assessmenLs and medlcal
auxlllary behavlour, and should also prevenL and conLrol lnfecLlon, undersLandlng Lhe cause of lnfecLlons and
lmplemenLlng lnfecLlon conLrol measures. 8ecause Lhe lnfecLlon conLrol operaLlons ln hosplLals are complex, ln addlLlon
Lo an lnfecLlon conLroller and epldemlologlsLs, lnfecLlon conLrol llnk nurses (lCLns) should be asslgned Lo or esLabllshed
ln each care unlL or ward Lo faclllLaLe communlcaLlon and negoLlaLlon beLween wards and lnfecLlon conLrol
deparLmenLs.

Methods: 8egardlng Lhe Lralnlng of lCLns, we suggesL LhaL hosplLals selecL nurslng sLaff wlLh cllnlcal experlence, acuLe
observaLlon ablllLles, good communlcaLlon and negoLlaLlon skllls, and Leachlng knowledge. 1he lCLn Lralnlng program
should lnclude mlcroblology, LesL reporL lnLerpreLaLlon, envlronmenLal lnspecLlon, communlcaLlon/negoLlaLlon, and
crlLlqulng and managemenL skllls Lo lmprove Lhe applled knowledge, rlsk assessmenL, and declslon-maklng ablllLles of
lCLns regardlng lnfecLlon prevenLlon measures. We also recommend LhaL Lhe LransformaLlonal sLeps of unfreezlng,
movlng, and refreezlng should be employed Lo enhance organlsaLlonal and personnel changes.

kesu|ts: 1he prlmary responslblllLles of lnfecLlon conLrollers are Lo analyse, monlLor, and reporL lnfecLlon conLrol daLa
for Lhe enLlre hosplLal promoLe and gulde relaLed operaLlons, and offer professlonal counselllng servlces. 1he
responslblllLles of lCLns ln unlLs are Lo ldenLlfy lnfecLlon paLhs and analyse lnfecLlon causes ln Lhe early and mlddle
perlods of healLh care and parLlclpaLe ln Lhe recommendaLlons, promoLlon, and educaLlonal Lralnlng of lnfecLlon conLrol
plannlng. WlLh Lhese Lwo mechanlsms worklng ln parallel, medlcal lnsLlLuLlons can effecLlvely prevenL lnfecLlons and
Lhereby avold lnfecLlon ouLbreaks and spread.

Conc|us|on: 1he role of lCLns can reduce Lhe gap beLween lnfecLlon conLrol Lheorles and cllnlcal pracLlce Lo achleve
lnfecLlon conLrol. We suggesL LhaL medlcal lnsLlLuLlons recrulL and esLabllsh lCLns and relaLed mechanlsms Lo effecLlvely
Lraln cllnlcal nurslng sLaff Lo parLlclpaLe ln lnfecLlon conLrol acLlvlLles. 1hese acLlvlLles can reduce healLh care-assoclaLed
lnfecLlons (PAls) Lo achleve Lhe goal of zero lnfecLlons.

keferences:
Cooper, 1. (2007). uLLlng educaLlonal Lheory lnLo cllnlcal pracLlce. Iootool of nospltol lofectloo, 65(S2),124-127.
Chlu, ?. ., & Llao, M, n., (2011). PosplLal erspecLlve on nurslng SLaff 8ole and luncLlon ln lnfecLlon ConLrol. 1be
Iootool of Notsloq, 58(4), 16-20.




1839

ASSLSSING 1nL kCLL CI kLGULA1Ck 8CDILS IN ASSUkING A1ILN1 SAIL1 AND 1nL UALI1 CI nLAL1n CAkL IN
LUkCL: AN ANALSIS CI VIGNL11LS CI MLDICAL LkkCkS AND kCILSSICNAL ISSULS
lsabelle 8lsso-Clll
1,*
, ulmlLra anLell
2
, MarLln Mckee
3
, Pelena Legldo-Culgley
3

1
PealLh Servlces 8esearch and ollcy, London School of Pyglene and 1roplcal Medlclne, London, unlLed klngdom,
2
PealLh Care ManagemenL, 8erlln unlverslLy of 1echnology, 8erlln, Cermany,
3
London School of Pyglene and 1roplcal
Medlclne, London, unlLed klngdom


Cb[ect|ves: 1o deLermlne wheLher Lhere ls any conslsLency ln how medlcal regulaLory bodles ln nlne Luropean counLrles
conLrlbuLe Lo malnLalnlng quallLy of healLh care and paLlenL safeLy, uslng vlgneLLes descrlblng behavlours LhaL ralse
concerns abouL professlonal behavlour.

Methods: 1welve vlgneLLes descrlblng scenarlos LhaL ralse concerns abouL sLandards of physlclans were deslgned by Lhe
uk's Ceneral Medlcal Councll coverlng a range of dlsclpllnary and professlonal lssues, based on a concepLual framework
LhaL lncluded a comblnaLlon of cllnlcal, crlmlnal and admlnlsLraLlve maLLers. 1he vlgneLLes were senL Lo medlcal
regulaLory bodles of nlne Luropean counLrles who lndlcaLed whaL acLlon Lhey would normally Lake for each hypoLheLlcal
slLuaLlon. 1he daLa were compared wlLh each body's regulaLory mandaLe.

kesu|ts: 8esponses varled greaLly across parLlclpaLlng counLrles. All regulaLors are lnvolved where paLlenLs are aL rlsk or
where a crlmlnal offence ls commlLLed wlLhln a cllnlcal seLLlng, where severe, and ofLen punlLlve, acLlon (suspenslon of
llcense, sLrlke off medlcal reglsLer) are enforced. 1hese evenLs are relaLlvely rare, however, and Lhere are many
alLernaLlve self- regulaLory mechanlsms ln place relaLed Lo paLlenL safeLy and quallLy of healLh care noL reachlng Lhe
Lhreshold for regulaLory lnvolvemenL. non-crlmlnal medlcal lssues, such as Lhose relaLed Lo compeLency/Lralnlng or
aLLlLude, were generally handled by Lhe employer. 1hls shows dellneaLlon beLween a docLor's accounLablllLy for
professlonal sLandards, whlch are generally overseen by Lhe regulaLory bodles, and Lhelr accounLablllLy as an employee
or member of professlonal assoclaLlon or medlcal chamber, where Lhelr compeLency and ablllLy Lo pracLlce ln a
respecLful way ls regulaLed by LhaL body. Powever Lhere ls conslderable varlaLlon and some counLrles - AusLrla, Lngland,
Cermany and Slovenla - employed punlLlve acLlons more frequenLly Lhan oLhers, and covered a much broader scope of
acLlvlLy exLendlng beyond professlonal sLandards for quallLy and safeLy. Conversely Lhe regulaLory bodles of Lhe
neLherlands, Spaln and LsLonla seemed Lo have Lhe narrowesL scope of auLhorlLy, evldenL by Lhe frequency aL whlch
Lhey responded LhaL cerLaln vlgneLLe Lhemes saL ouLslde of Lhelr remlL, resulLlng ln a referral Lo anoLher regulaLory
auLhorlLy or no acLlon aL all.

Conc|us|on: 1here ls llLLle conslsLency across Lurope ln how evenLs quesLlonlng compeLency and quallLles of medlcal
professlonals are handled. 1here ls conslderable dlverslLy ln Lhe range of Loplcs LhaL regulaLory bodles admlnlsLer, wlLh
almosL all coverlng healLh care quallLy and safeLy, and oLhers explorlng Lhemes around repuLaLlon, respecL and LrusL.
WlLh lncreased professlonal and paLlenL moblllLy, Lhls has slgnlflcanL lmpllcaLlons regardlng paLlenL safeLy and quallLy of
care ln llghL of Lhe lack of reglonal sLandardlsaLlon.



1846

SUCk1ING DLN1AL kAC1I1ICNLkS IN 1nL DLVLLCMLN1 CI LCCAL DLCCN1AMINA1ICN UNI1S IN NnSSCC1LAND
SullsLl Polmes
1,*
, lrene 8lack
2
, ChrlsLlne ?oung
2
, !ohn Moodle
3

1
ueconLamlnaLlon Servlces, PealLh laclllLles ScoLland,
2
nPS LducaLlon for ScoLland,
3
naLlonal rocuremenL, Clasgow,
unlLed klngdom


Cb[ect|ves: 1hls collaboraLlve approach ls almed Lo supporL and coordlnaLe lnlLlaLlves, on behalf of 1he ScoLLlsh
CovernmenL PealLh and Soclal Care (SCPSC), Lo lmprove deconLamlnaLlon of prlmary care denLal lnsLrumenLs ln
nPSScoLland

Methods: Lngage wlLh Lhe sLakeholder lncludlng SCPSC, naLlonal organlsaLlons such as PealLh laclllLles ScoLland, nPS
LducaLlon for ScoLland, naLlonal rocuremenL, nPS 8oards, and uenLal racLlce Advlsers and denLal pracLlLloners.
uevelop compllance sLandards and guldance for safe deconLamlnaLlon of denLal lnsLrumenLs. rovlde on-slLe supporL
and guldance Lo local pracLlLloners ln plannlng upgrades Lo Lhe exlsLlng or new-bulld Luu. uevelop a vlsual learnlng
envlronmenL coverlng lnfecLlon conLrol and deconLamlnaLlon. rovlde ln-pracLlce Lralnlng Lo denLal workforce. lncluslon
of quallLy assurance of deconLamlnaLlon pracLlce ln uenLal racLlce lnspecLlons

kesu|ts: MosL denLal pracLlLloners have moved Lowards compllanL local deconLamlnaLlon faclllLles. Cver 12M
of deconLamlnaLlon equlpmenL and servlces have been purchased vla Lhe naLlonal rocuremenL lramework
n143. Cver 1000 denLal pracLlces have been vlslLed and supporLed Lhrough Lhe developmenL of acLlon plans. 11317
denLal sLaff has accessed nLS ln-pracLlce Lralnlng.

Conc|us|on: 1he lmprovemenL of denLal deconLamlnaLlon pracLlce can be achleved Lo meeL SCPSC LargeLs, Lhrough
careful plannlng and close collaboraLlon wlLh Lhe relevanL sLakeholders.

keferences:
1. SLerlle Servlces rovlslon 8evlew Croup, 1he Clennle 8eporL:, 2001.
2. ScoLLlsh LxecuLlve PealLh ueparLmenL, nPS PuL (2003) 1, ueconLamlnaLlon- Compllance ln prlmary care, 11 !anuary
2003
3. ScoLLlsh LxecuLlve PealLh ueparLmenL, nPS PuL (2006) 40, ueconLamlnaLlon- updaLed guldance on compllance ln
prlmary care, !uly 2006
4. ScoLLlsh LxecuLlve PealLh ueparLmenL, SCPu/CuC (2007)1 ueconLamlnaLlon of lnsLrumenLs ln denLal prlmary care,
november 2007
3. ScoLLlsh LxecuLlve PealLh ueparLmenL, SCPu/CuC (2009)1 ueconLamlnaLlon of denLal lnsLrumenLs ln prlmary care -
Llmescales for compllance. november 2009



18S2

AN LMIkICAL S1UD CN LIIICILNC CI INCIDLN1 MANAGLMLN1 SS1LM A1 A MLDICAL CLN1Lk IN 1AIWAN
Pung-Chl Puang
1,*
, Cheng-Pua Wang
2
, Szu-Chang Wang
3

1
ueparLmenL of Medlcal ManagemenL, kaohslung veLerans Ceneral PosplLal, kaohslung,
2
CraduaLe School of 8uslness
and CperaLlons ManagemenL, Chang !ung ChrlsLlan unlverslLy, 1alnan,
3
ueparLmenL of lnformaLlon ManagemenL,
kaohslung veLerans Ceneral PosplLal, kaohslung, 1alwan


Cb[ect|ves: 1o probe lmporLanL facLors of efflclency for Lhe lncldenL managemenL sysLem Lo be regarded as Lhe
reference for lmprovlng and assesslng Lhe lncldenL managemenL sysLem.

Methods: 1he auLhors examlned and analysed 3,262 lncldenL reporLs flled for Lhree years aL a medlcal cenLer ln 1alwan.
1he lmporLanL lnfluence facLors lncluded reporLer's ldenLlLy, ln[ury degree of lncldenL, anonymous or confldenLlal
reporL, and sLudy perlod. 1he managemenL procedure of Lhe lncldenL reporLlng sysLem was dlvlded lnLo Lhree sLages--
reporLlng, lnvesLlgaLlon, and LreaLmenL. We performed mulLlvarlaLe analysls by uslng olsson regresslon wlLh over-
dlsperslon Lo evaluaLe Lhe lag Llme of Lhose Lhree sLages among each of Lhe four facLors.

kesu|ts: 1he hlgher proporLlon ls mlnor lncldenLs (90.7), confldenLlal reporLs (93.3), and nurslng sLaff reporLs (76.9)
ln Lhe research daLabase. 1he lag Llme was lnfluenced wlLh reporLer's ldenLlLy aL Lhe reporLlng sLage, and Lhe docLor's
lag Llme ls Lhe longesL. 1he ln[ury degree of Lhe lncldenL lnfluenced Lhe lag Llme of lnvesLlgaLlon and LreaLmenL, and ls
much longer for serlous lncldenLs. AdopLlng anonymous reporL shows slgnlflcanL dlfference aL Lhe reporLlng and
lnvesLlgaLlon sLages. lurLhermore, Lhe lag Llme ln laLer sLudy perlod ls shorLer Lhan LhaL ln earller perlod aL Lhe
LreaLmenL sLage.

Conc|us|on: 1hose four facLors dld lnfluence Lhe managerlal efflclency of lncldenLs aL dlfferenL sLages separaLely. 1he
resulLs of Lhls sLudy noL only help Lhe medlcal organlsaLlon lmprove Lhe efflclency of paLlenL safeLy buL provlde fuLure
researchers wlLh Lhe slgnlflcanL reference Lo assess Lhe managerlal efflclency for Lhe lncldenL reporLlng sysLem.



18S4

INADVLk1LN1 LNDC8kCNCnIAL IN1U8A1ICN: A SLN1INLL
All S. AlqahLanl
1,*
, larouk M. Messahel
2
, Wa[lh C. A. Cuda
3

1
Ln1, College of Medlclne-klng khalld unlverslLy, Abha, Saudl Arabla,
2
AnesLhesla & lnLenslve Care, 8eLlred, 8lrmlngham,
unlLed klngdom,
3
AnesLhesla & lnLenslve Care, Armed lorces PosplLals, khamls MushayL, Saudl Arabla


Cb[ect|ves: unlnLenLlonal bronchlal lnLubaLlon may resulL ln serlous compllcaLlons such as lung collapse
or pneumoLhorax. 1hese compllcaLlons amounL Lo senLlnel evenLs should be reporLed, and a hosplLal senLlnel evenL
pollcy should be lmplemenLed, lncludlng correcLlve acLlons Lo prevenL recurrence.

Methods: A 12monLh prospecLlve observaLlonal sLudy ln a mulLldlsclpllnary adulL lnLenslve care unlL (lCu) Lo esLlmaLe
Lhe frequency of lnadverLenL bronchlal lnLubaLlon and lLs ma[or sequels ln lnLubaLed paLlenLs admlLLed Lo Lhe unlL.
CompllcaLlons wlll be reporLed as senLlnel evenLs aLLracLlng lnvesLlgaLlon by rooL cause analysls meLhod, acLlon plan,
and followup.

kesu|ts: 1here were 36 (12.9) cases of lnadverLenL bronchlal lnLubaLlons ln 279 orallylnLubaLed paLlenLs admlLLed Lo
Lhe lCu durlng Lhe sLudy perlod (1.3.2010 30.4.2011), 2 (0.7) of Lhem already developed LoLal lefL lung collapse. 1he
hosplLal senLlnel evenL pollcy was acLlvaLed followed by acLlon plan, whlch lncluded ralslng Lhe awareness of Lhe
problem, presenLaLlons, and regular checklng on Lhe poslLlon of Lhe Lube followlng Lracheal lnLubaLlon aL dlfferenL
locaLlon ln Lhe hosplLal.

Conc|us|on: Larly deLecLlon and correcLlon of endobronchlal lnLubaLlon wlll prevenL compllcaLlons developlng. Applylng
senLlnel evenL pollcy on compllcaLlons of lnadverLenL bronchlal lnLubaLlon wlll encourage flndlng permanenL soluLlon Lo
an old and prevenLable problem. AnaesLheLlc and resusclLaLlve regulaLory bodles should lncorporaLe meLhods of
checklng on correcL poslLlon of Lracheal Lubes ln Lhelr Lralnlng programs. knowlng LhaL Lhe Lube may advance lnLo a
bronchus, Lhey should lnslsL on regular checklng of Lhe Lube ln a manner slmllar Lo monlLorlng paLlenL's vlLal slgns.

keferences:
1. Cwen 8L, Cheney lW. Lndobronchlal lnLubaLlon, a prevenLable compllcaLlon. AnaesLheslology 1987,67:2337.
2. McCoy L, 8ussell W!, Webb 8k. AccldenLal bronchlal lnLubaLlon: An analysls of AlMS lncldenL reporLs from 1988 Lo
1994 lncluslve. AnaesLhesla 1997,32:2431.
3. 1lmmermann A, 8usso SC, Llch C, 8oessler M, 8raun u, 8osenblaLL WP, and Lndobronchlal lnLubaLlons erformed
by Lmergency hyslclans. AnesLh Analg 2007,104:61923.
4. 8runel W, Coleman uL, SchwarLz uL, eper L, Cohen nP. AssessmenL of rouLlne chesL roenLgenograms and Lhe et ol.
1he CuLofPosplLal Cesophageal physlcal examlnaLlon Lo conflrm endoLracheal Lube poslLlon. ChesL 1989,96:1043
3.
3. u 8onen S, Chadwlck C, nowak 8. LndoLracheal Llp poslLlon ln Lhe arresLed paLlenL. Ann Lmerge Med 1982, 11:116
7.
6. Morray !, Celduschek !, Caplan 8, Clld W, Cheney l. A comparlson of paedlaLrlc and adulL closed malpracLlce clalms.
AnaesLheslology 1993,78:46171.
7. Caplan 8, osner k, Ward 8, Cheney l. Adverse resplraLory evenLs ln anaesLhesla: A closed clalms analysls.
AnaesLheslology 1990,72:82833.
8. !olnL Commlsslon lnLernaLlonal AccredlLaLlon SLandards for PosplLals. 4Lh edlLlon: hLLp://www Lhe edlLlon:
hLLp://www [olnLcommlsslonlnLernaLlonal.org. Accessed 26.6.2011.


18S6

USING nLAL1n CAkL IAILUkL MCDL AND LIILC1 ANALSIS (nIMLA) IN LMLkGLNC kCCM VICLLNCL kLVLN1ICN
Mlng Po Lee
1,*
, Chun Pua Wu
1
, ua ?u ?ang
1
, Chlng ?a Puang
1

1
Chang 8lng Show Chwan Memorlal PosplLal, Changhua CounLy, 1alwan


Cb[ect|ves: Lmergency room(L8) ls an open, publlc area and ls concerned as a hlgh-rlsk unlL for dlrecL vlolence aLLack. ln recenL
years ln 1alwan, Lhere were many vlolence cases occurred ln L8. 1o decrease Lhe lncldence of vlolence aLLack, Lhe alarm sysLem and
sLaff Lralnlng are crlLlcal lssues. ln order Lo proLecL our sLaff and provlde a safeLy medlcal envlronmenL, we esLabllshed a new
vlolence prevenLlon algorlLhm accordlng Lo PlMLA analysls.

Methods: A mulLldlsclpllnary Leam was organlsed ln May 2011. We used Lhe healLhcare fallure mode and effecL analysls (PlMLA) Lo
analyse Lhe vlolence prevenLlon processes. 8ased on Lhe recommendaLlons from PlMLA concluslon, a new vlolence prevenLlon
algorlLhm was esLabllshed wlLh alms Lo lmprove Lhe alerLness and managemenL speed of Lhe sLaff. Several performance lndlcaLors
were used Lo measure Lhe effecLlveness:

1) nurslng sLaff are able Lo locaLe Lhe alarm sysLem and correcLly answer code kk and when alarm sysLems needs Lo be acLlvaLed.
2) uuLy managers are able Lo show up wlLhln 3 mlnuLes.
3) SecurlLy guard shows up ln one mlnuLe.
4) uuLy managers are able Lo successfully handle Lhe vlolence slLuaLlon wlLhouL lncldenL of sLaff ln[ury.
3) Lnglneer sLaff needs Lo show up wlLhln 3 mlnuLes.
6) ollce offlcers arrlve wlLhln 13 mlnuLes.

kesu|ts: Several crlLlcal fallure modes ln Lhe L8 vlolence prevenLlon processes were ldenLlfled:

1) L8 nurses lacked confldence and ablllLy Lo conLrol Lhe slLuaLlon.
2) Cn-duLy admlnlsLraLlon manager lacked knowledge and undersLandlng of Lhe role.
3) Alarm sysLem was lnsLalled ouLslde of L8. L8 sLaff has no dlrecL access Lo press Lhe buLLon and cause delay.
4) 1he pollce were noL aware of Lhe urgency.

Accordlng Lo weak polnLs ldenLlfled from Lhese analyses, a new vlolence prevenLlon algorlLhm was esLabllshed. When Lhere ls a
poLenLlal or acLual vlolence slLuaLlon, L8 sLaff musL acLlvaLe Lhe sysLem and Lhe Lelephone operaLor wlll noLlfy duLy admlnlsLraLlon
manager, duLy nurse manager, and securlLy guard wlLhouL delay. We lnsLalled alarm sysLem ln Lhe L8 and lnsLrucLed L8 sLaff when
and how Lo acLlvaLe Lhe alarm. We negoLlaLed wlLh pollce deparLmenL and reached agreemenL Lo show up wlLhln 13 mlnuLes once
alarm acLlvaLed. lurLhermore, more Lhan 10 vlolence prevenLlon Lralnlng programs were compleLed.

ln 2012, Lhe performance lndlcaLors were checked. 1he drlll resulLs were below:

1) Alarm was lnsLalled aL nurslng sLaLlon ln L8. 100 L8 sLaff answered correcLly.
2) uuLy managers showed up wlLhln 3 mlnuLes.
3) SecurlLy guard showed up ln one mlnuLe.
4) 1he duLy managers compleLed 10 sesslons of vlolence prevenLlon Lralnlng and were famlllar wlLh Lhe work lnsLrucLlon.
3) Lnglneer sLaff showed up wlLhln 3 mlnuLes.
6) ollce offlcers arrlved wlLhln 13 mlnuLes. 1he processes were formallsed.

Conc|us|on: 1hrough PlMLA analysls, we esLabllshed a new vlolence prevenLlon algorlLhm. Lveryone knows Lhelr role more clearly.
We are beLLer prepared and ready Lo handle vlolence slLuaLlon. We feel safer and also ensure paLlenL safeLy Lo avold furLher
harmlng of self and oLher.

keferences: ue8osler, !., SLalhandske, L., 8aglan, !. ., & nudell, 1. (2002). uslng healLh care lallure Mode and LffecL Analysls: Lhe vA
naLlonal CenLer for aLlenL SafeLy's prospecLlve rlsk analysls sysLem. Iolot commlssloo Iootool oo Ooollty ooJ lotleot 5ofety, 28(3),
248-267.



18S8

IMkCVING CAkL AND LNnANCING A1ILN1 SAIL1 8 kLSLAkCnING NLVLk LVLN1S IN 1nL CCMMUNI1
CaLhy Szabo
1,*
, Cheryl Cheung
2

1
Chlef LxecuLlve Cfflcer, CenLral CommunlLy Care Access CenLre, 1oronLo,
2
CommunlcaLlons, CenLral CommunlLy Care Access CenLre,
8lchmond Plll, Canada


Cb[ect|ves: 1o lmprove quallLy of care and enhance paLlenL safeLy, Lhe CenLral CommunlLy Care Access CenLre (CCAC) sponsored a
research sLudy wlLh Lhe unlverslLy of 1oronLo Lo deLermlne serlous reporLable evenLs (never LvenLs) for home healLhcare servlces.
1hls was Lhe flrsL Llme Lhe sLudy of never LvenLs was applled ln Lhe communlLy seLLlng ln Canada. 1he research was done ln
con[uncLlon wlLh a SafeLy ln Pome Care sLudy commlssloned by Lhe Canadlan aLlenL SafeLy lnsLlLuLe.

Methods: 1he research lncorporaLed a comprehenslve llLeraLure revlew, and used a pan-Canadlan panel of experLs uslng uelphl
meLhodology.

kesu|ts: 1he four Lypes of evenLs ldenLlfled by Lhe uelphl panelllsLs as boLh reporLable and prevenLable: Serlous ln[ury relaLed Lo
lnapproprlaLe servlce plan, medlcaLlon-relaLed evenLs requlrlng emergency deparLmenL (Lu) vlslL/hosplLallsaLlon, serlous evenLs
relaLed Lo care or servlces LhaL are conLrary Lo professlonal pracLlce sLandards, and new perlLoneal dlalysls lnfecLlon.

Conc|us|on: uslng our CuallLy and SafeLy lramework of SafeLy, Sclence and Servlce, CenLral CCAC wlll lnLegraLe Lhe sLudy flndlngs
lnLo pracLlce Lo lmprove quallLy and safeLy aL an organlsaLlonal level, and lnLo Lhe managemenL of our conLracLed servlce provlders
Lo dellver safer care ln Lhe home.

key sLeps lnclude engaglng fronL-llne sLaff, paLlenL servlces managemenL and senlor managemenL, assesslng Lhe organlsaLlon's
currenL sLaLe, and valldaLlng Lhe research ln Lhe conLexL of Lhe CenLral CCAC's CuallLy and SafeLy lramework.

8ased on Lhls lnformaLlon, Lwo never LvenLs were selecLed as Lhe lnlLlal focus for acLlon:

1. Adverse reacLlon requlrlng Lu vlslL or hosplLallsaLlon relaLed Lo a medlcaLlon-relaLed evenL
2. new wound lnfecLlons (communlLy acqulred)

lncorporaLlng flndlngs of Lhe sLudy's llLeraLure revlew, whlch ldenLlfled characLerlsLlcs of successful reporLlng sysLems and
faclllLaLors/barrlers Lo reporLlng, Lhe commlLLee wlll oversee Lhe esLabllshmenL of measures and Lracklng mechanlsms Lo supporL
evldence-based declslon-maklng.

1hls wlll lnclude Lhe use of Lean meLhodologles Lo leverage Lhe experLlse of sLaff aL all levels of Lhe organlsaLlon, servlce provlders
and oLher sLakeholders Lo:

! valldaLe roles and responslblllLles ln prevenLlng never LvenLs by speclflc operaLlonal areas
! develop a documenLed, sLandardlsed process for reporLlng on Lhe selecLed never LvenLs
! develop a measuremenL sysLem Lo faclllLaLe Lracklng and analyses of evenLs
! lnvesLlgaLe opporLunlLles Lo enhance accounLablllLy - across Lhe communlLy healLh sysLem - for prevenLlng and reporLlng never
LvenLs, Lhrough sLraLeglc pollcy changes and performance measures
! ensure paLlenLs do noL experlence never LvenLs ln our communlLy

Sesslon aLLendees wlll galn an undersLandlng of Lhe research flndlngs and how CenLral CCAC lncorporaLes Lhose flndlngs lnLo lLs
CuallLy and SafeLy lramework whlle promoLlng sysLem change, how Lhe complexlLles of provldlng care ln a communlLy seLLlng
lmpacLs safeLy and Lhe ablllLy Lo ascerLaln rooL causes of never LvenLs, Lhe Lypes of reporLable and prevenLable evenLs LhaL occur ln
communlLy care, and Lhe role of Lhe CCAC, provlders and oLher sLakeholders ln prevenLlng never LvenLs.


18S9

USING INNCVA1IVL SIMULA1IVL 1kAINING kCGkAM 1C kLDUCL IALL kISk IN nCSI1ALISLD NLUkCLCGICAL
A1ILN1S
Mlng-?l Chen
1,*
, Wel- Pua ?u
1
, Mel-Chlh Cu Ll
2

1
neurologlcal acuLe ward,
2
nurslng, Shln kong Wu Po-Su Memorlal PosplLal, 1alpel, 1alwan


Cb[ect|ves: lall ofLen occurs on hosplLallsed paLlenLs ln acuLe wards and lncurs physlcal ln[urles. ln 2009, our
neurologlcal acuLe ward's reporLed fall lncldenL raLe was 0.13 (19 lncldenLs). 1hls was flve Llmes hlgher Lhan Lhe
average ln Lhe same medlcal cenLer (0.03), more Lhan Lwlce hlgher Lhan Lhe average reporLed raLe of fall (0.06) by all
medlcal cenLers ln Lhe naLlon. ln hope Lo reduce Lhe hlgh raLe of fall from 0.13 Lo below 0.07, we developed an
lnnovaLlve slmulaLlve Lralnlng program, embedded ldenLlfled rlsks of fall ln varlous scenarlos of hosplLallsed neurologlcal
paLlenLs Lo Lraln nurses and sLudenLs Lo beLLer ldenLlfy paLlenL's fall rlsk and Lo lmplemenL fall prevenLlon.

Methods: ln !anuary 2010, we observed how nurses pracLlced on paLlenL safeLy for one monLh. We also lnLervlewed 72
paLlenLs ln our unlL abouL how Lhelr nurses had helped Lhem on malnLalnlng Lhelr safeLy durlng hosplLallsaLlon. Applled
Lhe Cause-LffecL ulagram on Lhe collecLed daLa, we ldenLlfled LhaL nurses' underesLlmaLlon of paLlenLs' fall rlsk, paLlenL's
confuslon, aglLaLlon and noL uslng call bell, and gaps of bed ralls were facLors accounLed for Lhe hlgher raLe of reporLed
fall ln our unlL. We Lhen used Lhe ueclslon MaLrlx Analysls Lo deLermlne Lhe mosL crlLlcal lnLervenLlon was Lo develop a
serles of case-based (sLroke, head ln[ury, and hernlaLlon of lnLerverLebral dlsk, Lhe Lop Lhree dlagnoses of paLlenLs ln our
unlL) slmulaLlve Lralnlng program for all nurses ln Lhe acuLe neurologlcal ward Lo asslsL Lhem Lo be able Lo accuraLely
assess paLlenL's rlsk of fall, and Lo lmplemenL a proLocol of malnLalnlng paLlenL's safeLy. lour Lralnlng sesslons were
provlded ln lebruary, 2010, Lhe conLenL lncludlng nurses' compeLence Lo assess fall, prompL and proper response Lo
paLlenLs' call bell, applylng slmulaLlve Leachlng Lo paLlenLs Lo use call bell, rearranglng confused and aglLaLed paLlenLs'
beds nexL Lo walls, uslng cushlon pads Lo block gaps of bed ralls. ln March of 2010, we also deslgned educaLlonal fller,
wlLh slmulaLlve sLorles of scenarlo of paLlenLs' fall lncldences, Lo glve Lo all neurologlcal paLlenLs Lo call for Lhelr
aLLenLlon Lo fall precauLlon. LaLer ln Lhe CcLober of 2010, we broadcasLed fall precauLlon programs on hosplLal Lelevlslon
sysLem Lo ralse paLlenLs' and famlly's awareness of paLlenLs' falls.

kesu|ts: AfLer Lwo monLhs of carrylng ouL our lnnovaLlve slmulaLlve Lralnlng program, Lhe descrlpLlve sLaLlsLlcs showed
LhaL reporLed raLe of falls had dropped from 0.13 (19 lncldenLs ln Lhe 2009) Lo 0.04 (3 lncldenLs ln 12 monLhs from
May, 2010 Lo Aprll, 2011). ln Lhe followlng 7 monLhs from May, 2011 Llll Lhe end of Lhe year, Lhere was only one
reporLed fall occurred. no fall lncldenL was due Lo gaps of bed ralls or noL uslng Lhe call bell.

Conc|us|on: Cur lnnovaLlve slmulaLlve Lralnlng program had reduced fall rlsk effecLlvely. nurses and sLudenLs had
exerclsed Lhelr crlLlcal Lhlnklng Lo accuraLely assess paLlenLs' fall rlsk and lmplemenL proLocol of fall prevenLlon. lrom
May, 2010 Lo uecember, 2011, Lhose four lncldenLs of fall all occurred when famlly helped paLlenLs uslng Lhe LolleL
seaLs. 1hls ls our nexL phase of conLlnulng work on fall prevenLlon ln Lhe neurologlcal paLlenLs.




1868

1nL kLLIMINAk kLSUL1S CI nLAL1n CLCUD IN nLAL1n kCMC1ICN-1AIWAN LkLkILNCL
Pslng-Pslen Wu
1,*
, Pslao-1lng Lee
2
, uer-Aur Chou
3
, Pol-8or Chan
3

1
1horaclc Surgery, Show-Chwan PealLhcare SysLem, 1alnan,
2
ro[ecL ManagemenL, Show-Chwan PealLhcare SysLem,
1alpel,
3
Surgery, Show-Chwan healLhcare sysLem, Changhua, 1alwan


Cb[ect|ves: Many researches and arLlcles have documenLed lnformaLlon and communlcaLlon Lechnology-based
lnLervenLlons on healLh promoLlon and behavlour change. Cloud compuLlng ls Lhe emerglng Lrend ln many fleld and
healLhcare lndusLry ln Lhe fuLure. 1here ls very few arLlcle focused on Lhe effecL of Lhe cloud compuLlng pracLlced on
healLh promoLlon. We collaboraLed wlLh sofLware provlders and consLrucLed Lhe healLh cloud based on Lhe healLh
promoLlon cenLer (evl servlce) ln Lhe Show-Chwan healLhcare sysLem. now we wlll presenL Lhe ploneerlng experlence
of Lhe flrsL healLh cloud ln 1alwan. We conducLed a quesLlonnalre Lo clarlfy Lhe saLlsfacLlon of many characLerlsLlcs and
Look Lhe suggesLlons from Lhe end users.

Methods: A Len-senLence quesLlonnalre was glven aL Lhe healLh cloud and Len characLerlsLlcs of cloud compuLlng was
lncluded. 1he LargeL populaLlons were Lhe members of Lhe healLh cloud. Lvery quesLlon was glven 1 Lo 3 polnLs from
sLrongly unsaLlsfled" Lo sLrongly saLlsfled". Cne open quesLlon was added for suggesLlons from end users. 1he daLa
was collecLed from 1 november Lo 9 november ln 2012. SSS was used Lo analyse Lhe daLa. 1-LesL was used Lo LesL Lhe
samples.

kesu|ts: 1hlrLy-one answers were gaLhered. 1he overall mean of all characLerlsLlcs ls 4.04. 1he quanLlLaLlve mean of Len
characLerlsLlcs are llsLed ln Lable 1. Lach characLerlsLlc ls LesLed Lo be sLaLlsLlcally slgnlflcanL. 1he overall saLlsfacLlon raLe
of healLh cloud ls 80.8. 1he resulLs lndlcaLe LhaL Lhe healLh cloud ls accepLable by Lhe end users. 1he mosL unsaLlsfled
characLerlsLlc ls elasLlclLy of funcLlons". 1he mosL saLlsfled characLerlsLlcs are rellablllLy of ouLpuL lnformaLlon" and
conLrlbuLlon of ouLpuL lnformaLlon for users' work".

Conc|us|on: PealLh cloud ln 1alwan ls consLrucLed from Lhe Lechnology of cloud compuLlng. Meanwhlle lL owns Lhe
characLerlsLlcs and dellvery models of cloud compuLlng Lechnology. 1he resulLs of Lhls prellmlnary sLudy conclude LhaL
Lhe members of healLh cloud accepL Lhe operaLlon model of healLh cloud and are saLlsfled wlLh Lhe characLerlsLlcs.




1874

1nL nIGn SS kL-CLkA1IVL SUkGICAL CnLCkLIS1 - kLSUL1S IkCM CVLk 60.000 SUkGICAL CASLS IN GLkMAN
uanlel 8ernlng
1,*
, uanlela 8enner
2
, ChrlsLlan 1homeczek
2
, ConsLanze Lesslng
1

1
lnsLlLuLe for aLlenL SafeLy (lfS) by order of Lhe Cerman CoallLlon for aLlenL SafeLy (AS), unlverslLy of 8onn, 8onn,
2
Cerman Agency for CuallLy ln Medlclne (ACuMed), 8erlln, Cermany


Cb[ect|ves: Cne ob[ecLlve of Lhe WPC lnlLlaLlve AcLlon on aLlenL SafeLy: Plgh 3s" ls Lo opLlmlse correcL slLe surgery
(CSS) by lnLroduclng a sLandardlsed operaLlng procedure (SC) wlLhln parLlclpaLlng hosplLals ln a ln a mulLl-naLlonal
conLexL. key sLeps of Lhe SC are recurrenL ldenLlLy checks, surglcal slLe marklng, and Leam-Llme-ouL. An lmporLanL Lool
Lo supporL cllnlcal sLaff and Lo documenL progresses ls Lhe Plgh 3s surgery checkllsL. Slnce 2010 slxLeen Cerman
hosplLals have gradually lmplemenLed Lhe SC CSS. lor evaluaLlon purposes checkllsLs are revlewed and lndlcaLor
measures are calculaLed. 1hls allows for assessmenL on performance measures and documenLaLlon quallLy over Llme.

Methods: aper based Plgh 3s surgery checkllsLs were compleLed by cllnlcal sLaff of Lhe parLlclpaLlng Cerman hosplLals
(n=16) for each surglcal case and carbon coples were senL Lo lfS for evaluaLlon. CheckllsLs of 2012 were revlewed for
Lhe followlng lndlcaLor measures: roporLlon of verlflcaLlon checkllsLs for all ellglble surglcal cases (CS0), proporLlon of
cases wlLh a compleLe preoperaLlve verlflcaLlon process (CS1), proporLlon of cases wlLh properly marked surglcal slLe
(CS2), proporLlon of cases wlLh compleLe flnal Llme-ouL (CS3), proporLlon of cases wlLh dlscrepancy noLed aL flnal Llme-
ouL (CS4), proporLlon of cases undergolng surgery wlLh unresolved Llme-ouL dlscrepancles (CS3), proporLlon of surglcal
cases LhaL are cancelled or posLponed due Lo dlscrepancles ldenLlfled aL any polnL ln Lhe conducL of Lhe SC (CS6).
CheckllsLs recelved slnce november 2010 were also revlewed for compleLeness of documenLaLlon. 8evlew of checkllsLs
was done elecLronlcally, frequency of slngle checkllsL lLems was calculaLed and compleLeness of documenLaLlon was
reglsLered. Composed lndlcaLor measures were calculaLed accordlng Lo Lhe lnLernaLlonal Plgh 3s calculaLlon sheeLs and
aggregaLed daLa were generaLed for each hosplLal and monLh. lor each measure a hosplLal ranklng was drawn and hlgh-
and low-performers were ldenLlfled.

kesu|ts: We analysed 111,960 checkllsLs for compleLeness of documenLaLlon. 1he medlan for checkllsL compleLlon was
83.7. 10.6 of checkllsLs were compleLed Lo 100. We calculaLed Plgh 3s lndlcaLor measures for 61.684 checkllsLs of
Lhe year 2012. 4 hosplLals conslsLenLly performed hlgh for CS0-CS3 measures. 2 of Lhese 4 hosplLals were also parL of Lhe
Lop 23 for CS4. 1hese hosplLals, however, ranged compleLely dlfferenL for CS3 and CS6.

We ldenLlfled 2 hosplLals conLlnuously ranklng ln Lhe lower 23 for all of Lhe flrsL 4 lndlcaLors CS0-CS3. 1hese hosplLals
also ranked ln Lhe lower 33 for CS3. 8oLh presenLed a very low raLe of case cancellaLlons due Lo dlscrepancles (CS6,
0.00 and 0.01).

Conc|us|on: WlLhln Lhe Cerman Plgh 3s hosplLals checkllsLs have become a common Lool Lo monlLor and documenL
surglcal paLlenLs' care. 1wo years afLer sLarLlng SC CSS lmplemenLaLlon hosplLals have reached conslsLenL levels of
performance measures. lrom our revlew of checkllsLs lL ls clearly evldenL LhaL wlLh regard Lo Lhe flrsL 4 lndlcaLor
measures pro[ecL hosplLals are dlvlded ln groups of hlgh- and low-performers wlLh mosL hosplLals movlng ln Lhe cenLre
span. lor Lhe lndlcaLor measures deallng wlLh dlscrepancles (CS4-CS6) hlgh- and low-performers cannoL clearly be
ldenLlfled. Cur resulLs are compromlsed by Lhe adherence Lo compleLe documenLaLlon. lurLher lnvesLlgaLlon ls needed
Lo clarlfy Lhe relaLlonshlp beLween adherence Lo SC, documenLaLlon quallLy and resulLs of Plgh 3s lndlcaLor
measuremenL.

1877

DLSIGNING A GUIDLLINL 1C IMkCVL MLDICA1ICN kLSCkI1ICN IN CCMLLk CLDLk A1ILN1S
ConxlLa MesLres
1,*
, Anna AgusL
2
, Laura uerLa
3
, Laura Cuarga
3

1
harmacy, Crup MuLuam, 8arcelona,
2
harmacy, CSS MuLam Clrona, Clrona,
3
harmacy, CSS MuLam Cell, 8arcelona, Spaln


Cb[ect|ves:

! 1o know medlcaLlon prescrlpLlon quallLy ln Lwo long care faclllLles for elderly paLlenLs (CSS-MuLuam Cell, 8arcelona wlLh 163
beds and CSS-MuLuam Clrona wlLh 103 beds), of publlc asslsLance Lhrough Lhe CaLalan PealLh SysLem.
! 1o draw a guldellne for prescrlpLlon revlslon by pharmaclsLs, adapLed Lo cllnlcally complex elders.

Methods: ln order Lo know Lhe prevalence of poLenLlal lnapproprlaLe medlcaLlons and Lhe prescrlpLlon quallLy, we followed
LhroughouL 2012, Lhe lnapproprlaLe prescrlblng, uslng 8eers' crlLerla and number of paLlenLs ln LreaLmenL wlLh more Lhan 9 drugs
(1,2).

1he guldellne has been deslgned uslng dlfferenL Lools:

! LlLeraLure search (8eers' crlLerla, de-prescrlblng, S1CC (Screenlng 1ool of Clder erson's rescrlpLlons) and S1A81 (Screenlng
1ool Lo AlerL docLors Lo 8lghL 1reaLmenL, cllnlcal relevanL lnLeracLlons ln elderly).
! 1herapeuLlc subsLlLuLlon proLocol
! MeeLlngs beLween pharmaclsLs, nurses and docLors.

kesu|ts: uurlng 2012, we found LhaL Lhe LreaLmenLs noL meeLlng Lhe 8eer's crlLerla, ln Lhe Lwo lnsLlLuLlons have been 13,4 and
16,6. 1he more prescrlbed drugs agalnsL 8eer's crlLerla have been: Amlodarone, Pydroxyzlne, Clonazepam, CxybuLynln and
ClorazeopaLe. Powever, ln some cases lL has been problemaLlc, because lL ls dlfflculL for docLors Lo change Lhe drug lf Lhe paLlenL has
been already conLrolled wlLh lL durlng a long Llme (Clonazepam), or Lhey have more experlence wlLh lLs use (Amlodarone). aLlenLs
LreaLed wlLh more Lhan 9 drugs have been 82,63 and 70,13. 1o only conslder pollpharmacy as an lndlcaLor of a low quallLy
prescrlpLlon, ls noL an accuraLe way Lo know Lhe paLLerns of rlsk-beneflLs of Lhe drugs prescrlbed Lo our paLlenLs. lL was clear for
pharmaclsLs LhaL we need crlLerla adapLed Lo Lhese paLlenLs ln order Lo make a Lhorough revlslon of Lhe prescrlpLlons and deLecL
lssues Lo be lmproved. 1herefore, we have sLarLed a pro[ecL orlenLed Lo lmprove Lhe quallLy and safeLy of drug prescrlpLlon adapLed
Lo our paLlenLs.

ln a flrsL phase, we have:

! LsLabllshed a 1herapeuLlc subsLlLuLlon proLocol, relaLed Lo our harmacologlc Culde.
! CreaLed a check llsL of crlLerla for pharmaclsLs Lo assess Lhe prescrlpLlons, LhaL lncludes, besldes Lhe usual revlslon of dose,
frequency, admlnlsLraLlon rouLe, eLc:
! CrlLerla Lo deLermlne lnapproprlaLe medlcaLlon (unnecessary drug Lherapy- need addlLlonal Lherapy)
! 8eer's crlLerla adapLed Lo our paLlenLs
! S1A81-S1C crlLerla
! LffecLlveness
! verlflcaLlon of Lhe sulLablllLy of Lhe admlnlsLraLlon form, for older paLlenLs
! ConLralndlcaLlons
! SelecLed drug-drug and drug-food lnLeracLlons
! SafeLy
! uosage adapLaLlon for rlsk and narrow LherapeuLlc range medlcaLlon
! SelecLed drug-drug and drug-food lnLeracLlons

Conc|us|on: aLlenLs ln our faclllLles have complex LreaLmenLs wlLh many drugs. WlLh a 1herapeuLlc subsLlLuLlon proLocol and a
guldellne adapLed Lo Lhese paLlenLs, pharmaclsLs can revlew Lhe prescrlpLlons ln a homogeneous and coherenL way. 8epeLlLlve
errors or lnaccuracles can be deLecLed and lmprovemenL measures proposed Lo docLors.
ln Lhe second phase of our pro[ecL we wlll evaluaLe Lhe resulLs of Lhe lmplemenLaLlon of Lhe guldellne, Lhrough Lhe pharmaclsL's
lnLervenLlons and Lhe prevalence of poLenLlal lnapproprlaLe medlcaLlon use.

keferences:
1. 8eers MP. LxpllclL crlLerla for deLermlnlng poLenLlally lnapproprlaLe medlcaLlon use by Lhe elderly. Arch.lnLern.Med 1997,137:331-6
2. Parms SL. Carrad !. 1he lleeLwood Model: an enhanced meLhod of pharmaclsLs' consulLaLlon. ConsulL.harm. 1998,13:1330-3

1882

AUDI1ING SLLI-kLCk1LD UALI1 INDICA1CkS: LLSSCNS LLAkNLD
!acob urelher
1,*
, Shlomo vlnker
2
, Lhud uavldson
3
, Arnon u. Cohen
2

1
ueparLmenL of PosplLal AccredlLaLlon, PosplLal ulvlslon,
2
Chlef hyslclan's Cfflce, ClallL PealLh Servlces,
3
PosplLal
ulvlson, ClallL PealLh Servlces, 1el Avlv, lsrael


Cb[ect|ves: ClallL ls Lhe largesL publlc healLhcare provlder organlsaLlon ln lsrael wlLh 4,100,000 enrolees. ClallL has a
sysLem of 36 quallLy lndlcaLors for 14 hosplLals lL operaLes. lnlLlally, quallLy lndlcaLors were based on auLomaLlcally
exLracLed daLa from ClallL's cllnlcal and admlnlsLraLlve daLabase, (e.g. excesslve lengLh of sLay followlng colecLomy, or a
laparoscoplc cholecysLecLomy converLed Lo an open procedure). ln 2012, cllnlclans recommended lnLroduclng quallLy
lndlcaLors based on Lhe medlcal record. Lacklng a sLandard compleLe compuLerlsed medlcal record, Lhese lndlcaLors had
Lo be based on self-reporLlng process. 1hese lndlcaLors lnclude medlcaLlons prescrlbed aL dlscharge followlng an acuLe
myocardlal lnfarcLlon (Ml), anLlbloLlcs glven wlLhln slx hours for communlLy-acqulred pneumonla ln Lhe elderly, prlmary
percuLaneous coronary lnLervenLlon (Cl) conducLed wlLhln 90 mlnuLes for S1-elevaLlon Ml, acqulred pressure sores,
paLlenL falls, and paLlenL falls wlLh ln[ury. 1he purpose of Lhe presenL sLudy was Lo conducL an exLernal audlL of self-
reporLed daLa submlLLed for Lhese lndlcaLors.

Methods: An exLernal audlL was conducLed by physlclans and nurses from Lhe PosplLal ulvlslon of ClallL. ln each hosplLal,
relevanL closed records were revlewed. lor pressure sores and paLlenL falls, a hlgh-rlsk populaLlon of paLlenLs over 73
wlLh Lhe longesL sLay wlLhln Lhe survey perlod was selecLed, ln order Lo deLecL a maxlmal number of cases. Accordlng Lo
Lhe valldaLlon meLhodology endorsed by !olnL Commlsslon lnLernaLlonal, each record was classlfled as elLher (1)
lncluded ln Lhe denomlnaLor only, (2) lncluded boLh ln Lhe numeraLor and ln Lhe denomlnaLor, or (3) excluded from Lhe
denomlnaLor. 1he per cenL agreemenL beLween Lhe audlLor and Lhe self-reporL was calculaLed for each lndlcaLor aL each
hosplLal. ln compllance wlLh !Cl deflnlLlons, a Lhreshold of 73 agreemenL was deflned as saLlsfacLory. 1he performance
calculaLed by Lhe audlLor was compared wlLh Lhe self-reporLed performance and gaps were ldenLlfled

kesu|ts: lor Lhe proporLlon of paLlenLs wlLh a communlLy-acqulred pneumonla glven anLlbloLlcs wlLhln slx hours,
agreemenL ranged from 70 Lo 100. Cne hosplLal was <73. lor Cl conducLed wlLhln 90 mlnuLes ln S1LMl,
agreemenL ranged from 0 Lo 93, wlLh 3 hosplLals achlevlng <73 agreemenL (mosLly due Lo under-reporLlng of cases).
8egardlng medlcaLlons prescrlbed for Ml paLlenLs, agreemenL was hlgh for asplrln, beLa blockers and sLaLlns (86-100
for all 3 medlcaLlon groups), buL lower for ACLl/A88s (36-100, wlLh 4 hosplLals achlevlng <73 agreemenL), 8egardlng
acqulred pressure sores (grade 2 or hlgher) agreemenL was 84-100 ln all hosplLals, alLhough compleLe reporLlng of all
ldenLlfled pressure sores was seen ln only ln 3/8 hosplLals. Self-reporLed daLa regardlng paLlenLs' falls and paLlenLs' falls
wlLh ln[ury had 100 agreemenL ln all records revlewed.

Conc|us|on: LxLernal audlLlng and valldaLlon of self-reporLed quallLy lndlcaLors proved Lo be a useful meLhod for
deLecLlng dlscrepancles ln reporLlng, malnly due Lo mlsundersLandlng of lncluslon crlLerla or due Lo under-reporLlng.
uaLa reporLed by hosplLals operaLed by ClallL were found Lo be rellable ln mosL cases.



1883

NA1ICNAL kCGkAMS 1C kLVLN1 AND MANAGL n AND L]L 2012: S1A1US kLCk1 CI 37 CCUN1kILS
Sheena M. Currle
1,*
, !effrey M. SmlLh
1
, !ulla errl
2

1
MCPl, !hplego, WashlngLon, unlLed SLaLes,
2
PalLl CounLry rogram, MSP, orL o rlnce, PalLl


Cb[ect|ves: ulscuss flndlngs of a mulLl counLry analysls conducLed by MCPl (uSAlu's flagshlp MaLernal and Chlld PealLh
lnLegraLed rogram) ln 2011 and 2012 on counLry-level acLlvlLles on Lhe prevenLlon and managemenL of posL-parLum
haemorrhage (P) and pre-eclampsla/eclampsla (L/L).

Methods: 1o Lrack progress ln expanslon P and L/L prevenLlon and managemenL ln counLry programs, focuslng on
hlgh lmpacL lnLervenLlons and commodlLles. Analysls used Lwo Lools compleLed Lhru consulLaLlons wlLh governmenLs
and parLners: scale up maps" coverlng Loplcs from pollcy Lo coverage of key lnLervenLlons and a 44-lLem quesLlonnalre
ln Lngllsh, lrench & Spanlsh.

kesu|ts: lllusLraLlve daLa from 37 counLrles lncludes: pollcles Lo supporL AcLlve ManagemenL of Lhe 1hlrd SLage of Labour
(AM1SL) are almosL unlversal for P prevenLlon wlLh 90 of counLrles sLaLlng LhaL mldwlves are auLhorlsed Lo do
AM1SL, 43 have plloLed MlsoprosLol for P prevenLlon aL home blrLhs yeL only 14 are scallng up, Magneslum
SulphaLe ls on Lhe essenLlal medlclne llsL of 100 counLrles, wlLh mldwlves auLhorlsed Lo admlnlsLer lL ln 78 of
counLrles. re-servlce educaLlon or ln-servlce Lralnlng may noL address requlred compeLencles and servlce dellvery
guldellnes were someLlmes lncompleLe or ouLdaLed.

Conc|us|on: Access Lo oxyLocln and magneslum sulphaLe has lmproved, buL noL all skllled blrLh aLLendanLs are
auLhorlsed Lo use magneslum sulphaLe. CpporLunlLles Lo scale up Lhe use of mlsoprosLol for prevenLlon of P aL
homeblrLhs are belng mlssed. AlLhough pollcy and program efforLs for P and L/L are belng prlorlLlsed, lnLernal
lnconslsLencles of naLlonal guldellnes and oLher documenLs are noLable.



1884

UALI1 IMkCVLMLN1 8 IMLLMLN1ING A MUL1IDISCILINAk CAkL A1nWA ICk 8kLAS1 CANCLk A1ILN1S IN 1nkLL
nCSI1ALS
!olanda van Poeve
1,*
, Llnda de Munck
2
, !an de vrles
3
, Sablne Slesllng
4

1
neLworks, Comprehenslve Cancer CenLre Lhe neLherlands, Cronlngen,
2
8esearch, Comprehenslve Cancer CenLre Lhe neLherlands,
8oLLerdam,
3
laculLy of Lconomlcs and 8uslness, unlverslLy of Cronlngen, Cronlngen,
4
PealLh 1echnology and Servlces 8esearch,
unlverslLy of 1wenLe, Lnschede, neLherlands


Cb[ect|ves: 1he Comprehenslve Cancer CenLre Lhe neLherlands supporLed Lhe developmenL and lmplemenLaLlon of Lhe breasL
cancer paLhway ln hosplLals by uslng Lhe lnLegraLed Cncologlcal Care aLhways (lCC). 1he sLudy hypoLheslses LhaL Lhe
lmplemenLaLlon of a mulLldlsclpllnary breasL cancer paLhway wlll lmprove Lhe care for breasL cancer paLlenLs.

Methods: 8eLrospecLlvely daLa on almosL 800 paLlenLs wlLh breasL cancer, dlagnosed ln Lhree hosplLals, ln whlch a mulLldlsclpllnary
care paLhway was lmplemenLed ln 2008, were selecLed from Lhe neLherlands Cancer 8eglsLry (nC8). lourLeen quallLy lndlcaLors
were selecLed and resulLs before lmplemenLaLlon of Lhe paLhway ln 2006-07 (basellne measuremenL) were compared Lo Lhose afLer
lmplemenLaLlon ln 2009 (posL measuremenL). lurLhermore, sLrucLured lnLervlews wlLh Lhe lnvolved pro[ecL leaders were used Lo
verlfy Lhe lmpacL of Lhe lmplemenLed care paLhway on Lhe resulLs.

kesu|ts:
nA8Cn norm 8asellne
measuremenL
(2006-07,
paLlenLs), n LoLal =
366
osL
measuremenL
(2009,
paLlenLs), n LoLal
= 427
Slgnlflcance
(p 0.03)
lndlcaLors
wlLh
medlcal
lnformaLlo
n
1. PL82neu deLermlnaLlon 92 96 0.016
2. SenLlnel node procedure ls
performed
73 78 0.303
3. Axlllary lymph node dlssecLlon
by pn0(l-)
17 8 0.012
4. number of breasL cancer
surgerles per year per surgeon
74 92 <0.001
3. 8adloLherapy and chemoLherapy
noL slmulLaneously
87 99 <0.001
lndlcaLors
wlLh
lnformaLlo
n abouL
walLlng-
and
Lhroughpu
L Llmes
6. 1lme beLween flrsL vlslL and A-
conflrmaLlon (medlan, mean:
days)
0 / 3,7 0 / 3,0 0.703
7. 1lme beLween flrsL vlslL and flrsL
surgery(medlan, mean: days)
21 / 28,6 21 / 27,8 0.764
8. 1lme beLween lasL surgery and
flrsL chemoLherapy
wlLhln 4 weeks 33 43 0.129
9. 1lme beLween lasL surgery and
flrsL radloLherapy
wlLhln 4 weeks 33 39 0.312

Seven ouL of elghL lndlcaLors wlLh medlcal lnformaLlon and four ouL of flve lndlcaLors wlLh lnformaLlon abouL walLlng- and
LhroughpuL Llmes lmproved (see Lhe mosL lmporLanL resulLs ln Lable). 8eLLer compllance wlLh Lhe evldence based guldellne for
breasL cancer was achleved e.g. more paLlenLs underwenL Lhe senLlnel node procedure and Lherefore needed less axlllary lymph
node dlssecLlons. lurLhermore, Lhe breasL cancer care complled beLLer Lo Lhe norms of Lhe naLlonal 8reasL Cancer CrganlsaLlon of
Lhe neLherlands (nA8Cn). AfLer lmplemenLlng Lhe care paLhway more paLlenLs sLarLed wlLh Lhelr flrsL chemoLherapy or
radloLherapy wlLhln 4 weeks afLer surgery.

Conc|us|on: 8y lmplemenLlng Lhe mulLldlsclpllnary breasL cancer paLhway, breasL cancer care lmproved and resulLed ln beLLer
compllance wlLh Lhe evldence based guldellne and Lhe nA8Cn norms. 1he developmenL and lmplemenLaLlon of a breasL cancer
paLhway accordlng Lo Lhe lCC model ls worLh Lhe efforL as lL lmproves Lhe quallLy of Lhe care for breasL cancer paLlenLs.


1886

A1ILN1-MCVILS CN 1nL WL8: nCW 1C CCL WI1n CCD AND 1L 2 DIA8L1LS
MorLen klerkegaard
1
, Lone Polm
1,*

1
kuk, CaplLal 8eglon of uenmark, Plllerd, uenmark


Cb[ect|ves: Cur ob[ecLlve was Lo complemenL healLh lnformaLlon wlLh a user based experlence on a llfe wlLh a chronlc
dlsease. We wanLed Lo sLrengLhen Lhe paLlenLs' ablllLy Lo self-care and sLrengLhen Lhelr declslon maklng regardlng Lhe
llfesLyle cholces when you have a chronlc dlsease

Methods: We performed a serles of focus group-lnLervlews wlLh people sufferlng from 1ype-2 dlabeLes and CCu. lrom
Lhese, we were able Lo plnpolnL relevanL Lhemes for each paLlenL group. AfLerwards we conducLed/held a workshop
wlLh paLlenL organlsaLlons, sLaff members, Munlclpal workers and paLlenLs. 1hrough Lhe use of Lhe nA8C-model ln Lhe
workshop we creaLed a user experlence-based plaLform. Pence Lhe ouLcome of Lhe focus group-lnLervlews and
workshop was a web based paLlenL porLal wlLh focus on shorL lengLh vldeos, where people wlLh CCu and Lype 2-
dlabeLes reflecLed on Lhelr llfe wlLh chronlc dlsease.

We recrulLed volunLeers for Lhe vldeos from Lhe parLlclpanLs of Lhe focus groups. We shoL more Lhan 30 vldeos based on
Lhemes such as Work and CCu", 1ype 2-dlabeLes and Lhe gullLy/bad consclence". Whlle Lhe vldeos were edlLed, we
esLabllshed a webslLe based upon Lhe flrms exlsLlng CMS. 1hls was aL lnlLlally meanL Lo be Lhe maln plaLform for Lhe
vldeos. 1he webslLe ls found here: www.grlbomllveL.dk. When Lhe webslLe was ready Lo launch, we performed a
screenlng ln Lhe uanlsh lllm lnsLlLuLe where pollLlclans, healLh-care workers, parLlclpanLs, paLlenL organlsaLlons and
clLlzens were lnvlLed. 1hls gave Lhe porLal publlclLy ln newspapers and reglonal Lelevlslon.

We qulckly reallsed LhaL ln order Lo have a closer dlalogue wlLh our users, we could make use of lacebook whlch mosL of
our users already were uslng ln Lhelr everyday llfe. lrom lacebook we llnked Lo all of our vldeos on Lhe homepage and
called for our users Lo commenL on Lhe vldeos.

kesu|ts: We have frequenLly been lnvlLed Lo screen Lhe vldeos on local hosplLals for employees and clLlzens. 1hls
resulLed ln a very consLrucLlve feedback whlch we have used ln our fuLure work. 1eachers ln communal healLhcare
cenLers use Lhe vldeos when Lhey Leach paLlenLs ln coplng wlLh Lhelr chronlc dlsease. aLlenL counsellors ln hosplLals
recommend Lhe vldeos for Lhelr paLlenLs. 1he parLlclpanLs from Lhe vldeos now acL as paLlenL ambassadors ln dlfferenL
conLexLs, noL only relaLlng Lo our pro[ecL buL oLher pro[ecLs ln Lhe reglon as well.

As a parL of Lhe pro[ecL evaluaLlon we had a consulLanL agency Lo perform a serles of quallLaLlve lnLervlews and a larger
quanLlLaLlve lnLerneL survey wlLh chronlc paLlenLs. 1he evaluaLlon showed us LhaL our vldeos were
predomlnanLly percelved as credlble, relevanL and lnformaLlve by Lhe paLlenL groups.

Conc|us|on: 1he resulLs from Lhe evaluaLlon show LhaL uslng an audlo-vlsual medlum ls an effecLlve way Lo dlsplay a llfe
wlLh a chronlc dlsease. Lveryday slLuaLlons ln Lhe llfe of a chronlc paLlenL geL vlsuallsed and Lherefore become
concreLlsed for Lhe vlewer. 1he vldeos may conLaln new lnformaLlon for newly dlagnosed and/or relaLlves and Lhey may
be able Lo ldenLlfy Lhemselves wlLh Lhe represenLed slLuaLlons, sLrengLhen Lhem ln Lhe bellef LhaL Lhey are noL alone
Lrylng Lo cope wlLh a chronlc dlsease.

keferences: uanlsh MlnlsLry of PealLh & CaplLal 8eglon of uenmark.



1887

1nL USL CI 8USINLSS IN1LLLIGLNCL AS A 1CCL 1C SUCk1 A MCDLL CI CCkCkA1L GCVLkNANCL LCCNCMIC
LIIICILNC - nCSI1AL SC kAIALL
AnLonlo 8abelo
1,*

1
SLraLeglc Advlsory, PosplLal So 8afael, Salvador, 8razll


Cb[ect|ves: 1he search of a model of managemenL LhaL guaranLees galns for all lLs acLors has been a problem worLh of
consLanL moblllsaLlon ln many healLh care sysLems worldwlde. 1he evaluaLlon of Lhe role of Lhe acLors lnvolved ln Lhls
sysLem, belng elLher suppllers, healLh lnsurers, physlclans, hosplLals, ls cruclal Lo Lhe developmenL of a susLalnable and
manageable sysLem. 1he hlgh cosLs of Lhe servlces lmpllcaLe LhaL Lhe healLh-producL need Lo be lncreaslngly predlcLable.

Methods: 1he use of Lhe meLhodology of 8uslness lnLelllgence (8.l), ln PosplLal So 8afael, has gulded Lhe sLraLeglc
declslons of Lhe lnsLlLuLlon, dlrecLlng lL Lo a model of corporaLe governance economlc efflclency. 8.l has been used for
analysls and consLrucLlon of lndlcaLors of healLhcare, servlces, procedures, surgerles, LreaLmenL reglmens, calculaLlon of
Lhe proflLablllLy of procedures, and made managers able Lo ldenLlfy whlch paLlenL proflles, speclflc dlseases, Lype of
surgerles, and healLh lnsurers LhaL achleve beLLer resulLs. Cn Lhe basls of Lhls performance measuremenL and
predlcLlons of ouLcome, galn negoLlaLlon sLraLegles are deflned beLween Lhe acLors lnvolved ln Lhe producLlon process.

kesu|ts:
MLDICAL SLkVICLS Cutcome - Days
stays |n hosp|ta| and
hosp|ta| rates
Cutcome - Mater|a|s and
Med|c|nes (drugs)
Cutcome - Med|ca|
Income
1ota|
nLu8CLCC? (103.609,68) 2.911.324,22 36.677,81 2.842.392,3
3
C81PCLu? (1.482.261,03) 3.444.667,10 143.381,36 2.107.987,4
1
CnCCLCC? (267.773,77) 2.198.334,47 41.783,26 1.972.343,9
7
PorlzonLal Analysls - 1ype of lLems
MLDICAL SLkVICLS Cutcome - ICU Cutcome - Departments Cutcome - Surg|ca|
Center
1ota|
nLu8CLCC? 2.637.242,10 2.726.638,84 113.933,31 3.138.138,3
1
C81PCLu? 373.393,00 718.082,91 1.389.904,30 2.243.180,1
6
CnCCLCC? 1.193.073,80 1.832.183,69 140.160,28 3.043.032,9
9
PorlzonLal Analysls - CuLcomes for buslness deparLmenLs

Conc|us|on: WlLh Lhls meLhod lL ls posslble Lo deflne whlch speclalLy, surglcal procedures, medlcal sLaff, eLc. ls
economlcally more advanLageous and where lL ls mosL advanLageous. ln a scenarlo of markeL LranslLlon as ls currenLly
seen ln 8razll, Lhls meLhodology has enabled Lhe PosplLal So 8afael Lo face Lhe challenges already known and Lhose
LhaL are sLlll Lo come.



1888

USL CI LA8 DA1A8ASLS 1C MCNI1Ck CnkCNIC kIDNL DISLASL IN A CULA1ICN USING CUMULA1IVL LGIk
GkAnS
uavld M. kennedy
1,*
, Pugh C. 8ayner
2
, kamal[lL ChaLha
1
, !alshree 8a[u
1

1
Cllnlcal 8lochemlsLry,
2
8enal Medlclne, PearL of Lngland nPS loundaLlon 1rusL, 8lrmlngham, unlLed klngdom


Cb[ect|ves: Chronlc kldney dlsease (Cku) ls common and prevalence ls lncreaslng ln Lhe uk. 1he ma[orlLy have mlld-
moderaLe dlsease and are asympLomaLlc. A mlnorlLy progress Lo end-sLage kldney dlsease (LSku) requlrlng kldney
replacemenL Lherapy (k81). k81 ls assoclaLed wlLh poor quallLy of llfe and cosLs 30k per paLlenL pa. Larly deLecLlon
and lnLervenLlon can halL or delay progresslon Lo LSku buL many paLlenLs are deLecLed Loo laLe [1].

Cur alm was Lo develop a populaLlon survelllance sysLem uslng exlsLlng laboraLory daLa Lo enable early deLecLlon of
paLlenLs aL hlgh rlsk of LSku by revlewlng cumulaLlve graphs of a kldney funcLlon marker - esLlmaLed glomerular
fllLraLlon raLe (eCl8). We reporL resulLs from Lhe flrsL audlL of cllnlclans recelvlng Lhe reporLs slnce Lhls sysLem was
lnLroduced.

Methods: A bespoke sofLware daLabase was developed, whlch ls updaLed dally wlLh blochemlcal daLa from Lhe
laboraLory compuLer sysLem (LlMS). uaLa ls collecLed for all paLlenLs havlng an eCl8 LesL from communlLy or ouL-paLlenL
locaLlons wlLhln Lhe 1rusL caLchmenL c.1 mllllon populaLlon. 1he sofLware ls capable of creaLlng llsLs of paLlenLs uslng a
varleLy of search crlLerla and dlsplaylng cumulaLlve eCl8 graphs for each paLlenL conLalnlng up Lo 3 years daLa.
1he cumulaLlve eCl8 graphs are revlewed by a healLhcare sclenLlsL for all paLlenLs fulfllllng Lhe followlng crlLerla, a new
eCl8 resulL wlLhln Lhe lasL 7 days and age 63 years and eCl8 30 ml/mln/1.73 m
2
or age 63 years and eCl8 40
mL/mln/1.73 m
2
. uependlng on Lhe Lrend, paLlenLs are caLegorlsed as elLher ul - requlrlng urgenL lnvesLlgaLlon by Lhe
renal Leam, lC - lnform Lhe requesLlng cllnlclan vla a paper reporL lncludlng Lhe eCl8 graph or nA - no furLher acLlon
requlred.

kesu|ts: Slnce Aprll 2012, we reporLed 370,000 eCl8 resulLs, of whlch approx. 12,000 (3.3) fulfllled our fllLer crlLerla
(c. 400 per week) and Lhe cumulaLlve eCl8 graph was revlewed. Cn average 13 of Lhe 12,000 graphs revlewed are
flagged as hlgh rlsk (ul or lC) and paper reporLs are senL ouL Lo Lhe requesLlng cllnlclan conLalnlng Lhe eCl8 graph wlLh
deLalls of where Lo geL advlce.

AfLer 6 monLhs, feedback was soughL from cllnlclans for 96 consecuLlve paLlenLs reporLed as hlgh rlsk. We assessed
cllnlclan's exlsLlng hablLs for revlewlng kldney funcLlon resulLs, 30 sLaLed Lhey only look aL Lhe lasL few resulLs and 33
look back aL less Lhan 2 years of daLa. 74 found lL useful and 41 clalmed Lo change managemenL ln response Lo Lhe
graph. Average score for ease of use was 8/10 (10 hlghesL).

Conc|us|on: We have developed a sysLem for lab sLaff Lo revlew cumulaLlve eCl8 graphs for a large populaLlon and
ldenLlfy paLlenLs aL hlghesL rlsk of developlng LSku. 8eporLs wlLh eCl8 graphs are senL Lo cllnlclans hlghllghLlng paLlenLs
so LhaL approprlaLe lnLervenLlons Lo delay or halL deLerloraLlng kldney funcLlon can happen earller.
8ecause Cku progresses over many years, lL ls Loo early for cllnlcal ouLcome daLa from our pro[ecL. Powever, slnce
2004, Lhls sysLem was lnLroduced for dlabeLlcs aLLendlng hosplLal cllnlcs ln our 1rusL. SLaLlsLlcal process charLs show a
slgnlflcanL reducLlon ln Lhe number of paLlenLs needlng k81 slnce 2010 (<0.001).

keferences: SysLemaLlc kldney dlsease managemenL ln a populaLlon wlLh dlabeLes melllLus: Lurnlng Lhe Llde of kldney
fallure. 8ayner PC, PolllngworLh L, Plgglns 8, uodds S. 8M! CualSaf. 2011 CcL,20(10):903-10. Lpub 2011 !un 30.


1896

IMkCVING MANAGLMLN1 CI A1ILN1S WI1n ACU1L CCkCNAk SNDkCML 8 LNICkCLD CLIC AND
S1kINGLN1 AUDI1 1C IACILI1A1L DCCk-1C-8ALLCCN 1IML
Shu-Chen Pslang
1,*
, !lln-Paur Chuang
1
, Pul-Chln Wang
1
, Chlu-Pul Puang
1

1
Councll for CuallLy PealLh Care, kaohslung Chang Cung Memorlal PosplLal, kaohslung, 1alwan


Cb[ect|ves: AcuLe myocardlal lnfarcLlon (AMl) ls one of Lhe leadlng causes of deaLh ln 1alwan. Lmergency lnLervenLlon ls
llfe-savlng ln many paLlenLs wlLh acuLe coronary syndrome (ACS) and lmpendlng myocardlal lnfarcLlon. uoor-Lo-balloon
(u28) Llme ls crlLlcal and should besL be wlLhln 90 mlnuLes.

Methods: ln Lhe flrsL quarLer of 2011, u28 Llme ln our hosplLal was 68 for Lhose paLlenLs wlLh ACS who were flnally
conflrmed Lo have AMl, whlch was below Lhe level of 73 seL by Lhe ueparLmenL of PealLh ln 1alwan. We esLabllshed a
pollcy Lo faclllLaLe Lhe process, whlch lncluded esLabllshmenL of a speclal chesL paln area Lo serve Lhose paLlenLs
susplclous of ACS, so LhaL Lhey could pass Lrlage ln Lhe Lmergency ueparLmenL wlLhouL unduly delay Lo recelve LkC
wlLhln 10 mln and wlLhdrawal of blood for 1roponln l. 1he Councll for CuallLy PealLh Care ln Lhls hosplLal also adopLs a
sLrlngenL audlL of Lhe performance. 1he reporL of Lhe 1roponln l level could reach Lhe physlclans wlLhln 60 mlnuLes ln
more Lhan 80 of Lhe cases.

kesu|ts: ln Lhose ACS paLlenLs who flnally belng dlagnosed Lo have AMl wlLh S1 elevaLlon, 93.7 had a u28 Llme less
Lhan 90 mlnuLes ln Lhe flrsL quarLer of 2012 and 96.2 ln Lhe lasL Lhree quarLers of 2012, whlch was slgnlflcanLly hlgher
Lhan 68 ln Lhe flrsL quarLer of 2011 and 78 ln Lhe oLher Lhree quarLers ln 2011.

Conc|us|on: Cur flndlngs lndlcaLe LhaL enforced pollcy and sLrlngenL audlL are helpful Lo faclllLaLe door-Lo-balloon Llme
and Lo lmprove managemenL of Lhe paLlenLs wlLh ACS who are flnally conflrmed Lo have AMl.



1899

1nL kCGkAM CI 1nL III1n VI1AL SIGN: AIN kNCWLLDGL AND A11I1UDLS AMCNG NUkSLS IN SCU1nLkN 1AIWAN
Chla-!ung Chen
1,*
, Pslen-!y Ma
1
, Chlng-?lng Chen
1
, Pul-Chu Psu
1

1
nurslng ueparLmenL, naLlonal Cheng kung unlverslLy PosplLal, 1alnan, 1alwan


Cb[ect|ves: 1he purposes of sLudy were Lo:

1) develop an educaLlonal program abouL Lhe flfLh vlLal slgn,
2) LvaluaLe Lhe effecLlveness of a program abouL Lhe flfLh vlLal slgn on paln knowledge and aLLlLudes among nurses.

Methods: 1he sLudy was a cross-secLlonal deslgn. 1he nurses ln a medlcal cenLer were lnvlLed Lo parLlclpaLe ln a Lwo-
hour educaLlonal program of paln managemenL. 1he educaLlonal program focused on Lhe slgnlflcance of flfLh vlLal slgn,
Lhe Lools of paln assessmenLs, and Lhe sLandards of paln care. 1he educaLlonal program was lmplemenLed 12 Llmes
wlLhln Lwo weeks LhaL allowed all nurses Lo aLLend. A quesLlonnalre abouL Lhe knowledge and aLLlLude of paln was
admlnlsLraLed Lo nurses before and afLer Lhe educaLlonal program. 1he quesLlonnalre conslsLed of 33 lLems ranglng from
0 Lo 37. 1-LesL and AnCvA were used Lo examlne Lhe dlfference of pre-posL program on paln knowledge and paLlenLs'
saLlsfacLlon.

kesu|ts: A LoLal of 736 nurses parLlclpaLed ln Lhe sLudy. AfLer lmplemenLaLlon of Lhe program, scores on Lhe paln
knowledge and aLLlLude lncreased slgnlflcanLly from 23.28 (Su = 4.38) Lo 23.60 (Su = 3.27) (p<.001). 1he score range 80-
100 of paln knowledge and aLLlLude slgnlflcanLly lncreased from 11 Lo 31, whlle Lhe score range < 60 slgnlflcanLly
decreased from 32 Lo 22. nurses' paln knowledge scores slgnlflcanLly dlffered by educaLlon levels, cllnlcal ladder
levels. Powever, paln knowledge dld noL dlffered by worklng years. A LoLal of 438 paLlenLs wlLh paln care saLlsfacLlon
lncreased from 94.2 Lo 97.3.

Conc|us|on: 1he educaLlonal program of paln managemenL and flfLh vlLal slgn lmproves nurses' paln knowledge and
aLLlLudes ln paLlenL care.



1901

1nL SCCIAL SIGNIIICANCL CI 1nL AC1ICN CI NUkSING S1AII CCNCLkNING 1nL ADVLkSL LVLN1S kLCk1ING
SS1LM
Mlrlam C. alva
1,*
, 8eglna C. oplm
1
, MarLa M. Mellelro
2
, Carmen M. !ullanl
1

1
Lnfermagem, laculdade de Medlclna de 8oLucaLu - unLS, 8oLucaLu,
2
CrlenLao roflsslonal, Lscola de Lnfermagem -
uS, So aulo, 8razll


Cb[ect|ves: 8ecognlslng Lhe need Lo Lake acLlon so LhaL adverse evenLs and rlsks can conLrlbuLe Lo a revlew of care
processes and reduce harm Lo paLlenLs, Lhls sLudy was conducLed ln order Lo undersLand Lhe meanlng LhaL Lhe nurslng
sLaff aLLrlbuLed Lo Lhe adverse evenLs reporLlng sysLem (AL8S) ln effecL aL Lhe lnsLlLuLlon.

Methods: 1o achleve Lhls, a quallLaLlve research approach based on Lhe soclal phenomenology of Alfred SchuLz was
chosen. uaLa were collecLed durlng !une and !uly 2011, Lhrough open lnLervlews, uslng Lhe followlng guldlng quesLlons:
1ell me wbot oo oJvetse eveot ls fot yoo. use exomples lf yoo llke." and 1ell me oboot yoot expetleoce teqotJloq tbe
occotteoce of oJvetse eveots ooJ tbelt ootlflcotloo". 1hlrLy-one nurslng professlonals parLlclpaLed ln Lhe sLudy, 17 nurses
and 14 nurslng asslsLanLs or Lechnlclans, who had experlence wlLh Lhe AL8S ln a LerLlary unlverslLy hosplLal ln Lhe
lnLerlor of Lhe sLaLe.

kesu|ts: Meanlng was revealed Lhrough slx caLegorles:

1) all Lypes of occurrence musL be reporLed,
2) reporLlng as an auxlllary sysLem Lo care managemenL,
3) Lhe culLure of punlshmenL ln LranslLlon,
4) Lhe nurse as Lhe agenL responslble for volunLary reporLlng,
3) sharlng problems wlLh upper managemenL, and
6) achlevlng quallLy ln Lhe work process.

Analysls hlghllghLed Lhe need Lo dlssemlnaLe Lhe WPC Laxonomy for paLlenL safeLy ln order Lo lmprove Lhe quallLy of
lnformaLlon and sLlmulaLe noLlflcaLlon. Analysls also revealed Lhe parLlclpaLlon of Lhe lnsLrumenL ln lnsLlLuLlonal
communlcaLlon, Lhe managemenL of personnel and maLerlals, medlclnes and equlpmenL, ln monlLorlng Lhe resulLs of
Lhe unlL and ln Lhe lndlcaLlon of conLlnulng educaLlon needs. 1he lnsLrumenL conLrlbuLed Lo crlLlcal analysls of Lhe flaws
ln Lhe work process, permlLLed Lhe healLhcare professlonal Lo share responslblllLles wlLh managemenL and encouraged
correcLlve acLlons. 1he non-punlLlve purpose of reporLlng was guaranLeed and efforLs Lo publlclse Lhls feaLure were
hlghllghLed. Among Lhe professlonals lnLervlewed, feellngs of fear ln relaLlon Lo Lhe process of research and analysls
were observed, however, Lhey reporLed poslLlve undersLandlng experlences. When reporLlng adverse evenLs, Leam
members percelved Lhemselves Lo be ln a collaboraLlve relaLlonshlp wlLh Lhe lnsLlLuLlon and expecLed a response ln Lhe
form of a revlew of Lhe conducL Laken and ln achlevlng hlgher levels of solvablllLy. 1eam members are confldenL LhaL
Lhey wlll be granLed admlnlsLraLlve supporL and professlonal securlLy, condlLlons LhaL encourage Lhem Lo conLlnue
reporLlng. 1he moLlvaLlon Lo reporL Lo achleve conLlnuous lmprovemenL of Lhe work process, conLrlbuLlng Lo non-
repeLlLlon of Lhe error and Lo prevenL fuLure adverse evenLs was hlghllghLed by Lhe soclal experlence of Lhe Leam.

Conc|us|on: 1he professlonals percepLlon ls LhaL Lhe adverse evenLs reporLlng sysLem ls lnsLrumenL LhaL asslsLs care
managemenL and allow Lhem Lo share responslblllLles wlLh managers and fomenL correcLlves acLlons, looklng forward Lo
avold errors repeLlLlon and prevenL fuLure adverse evenLs.




1909

IMkCVLMLN1 IN A1ILN1 AND nCSI1AL S1AII SA1ISIAC1ICN 8 INCkLASING ADnLkLNCL 1C DISCnAkGL LAN
Ml ?oung !eon
1,*
, Chae-Seo 8hee
2
, !l Sun Lee
1

1
8eferral CenLer,
2
CLorhlnolaryngology, Seoul naLlonal unlverslLy 8undang PosplLal, Seongnam-sl, korea, 8epubllc Cf


Cb[ect|ves: A paLlenL would llke Lo be lnformed of hls/her LreaLmenL and dlscharge plan and anLlclpaLed dlscharge daLe
beforehand durlng lnpaLlenL sLay. Powever, Snu8P does noL have a sLandard procedure Lo follow for dlscharglng
paLlenLs. Lack of sLandardlsaLlon and communlcaLlon makes unexpecLed changes ln physlclan orders whlch leads Lo
delay of dlscharge. aLlenLs are noL provlded wlLh proper dlscharge lnformaLlon and/or Lhe admlnlsLraLlve work of Lhe
supporLlng sLaff are done lnefflclenLly. An lnLerdlsclpllnary Leam wlLh Lhe Lask of lmprovlng lnpaLlenL dlscharge process
used Slx Slgma meLhodology Lo lmprove adherence Lo dlscharge plan and dlscharge cycle Llme.

Methods: 1he course of Lhe pro[ecL was an elghL monLh Llme for lmprovemenL ln dlscharge procedures and one year
Llme for posL managemenL perlod. 1hrough LreaLmenL process analysls, benchmarklng, bralnsLormlng sesslons and volce
of Lhe CusLomers analysls, Lhe Leam ldenLlfled flve rooL causes LhaL conLrlbuLe Lo delay of dlscharge. 1he flve causes
were:
1) unpuncLual physlclan rounds
2) a lack of awareness of dlscharge procedure
3) a lack of need for dlscharge paLlenLs on expecLed dlscharge daLe
4) a lack of reward and punlshmenL on adherence Lo dlscharge plan
3) re-schedullng follow-up appolnLmenLs for paLlenLs.

lor cllnlcal provlders such as nurses and physlclans Lo ralse awareness of Lhe lmporLance of a dlscharge plan whlch
allows paLlenLs Lo be dlscharged on an expecLed dlscharge daLe, Lhe followlng lmprovemenLs were lmplemenLed:

1. rovlded Lhe sLandard for dlscharge plannlng and response Lo LhaL feed back
2. rovlded Lhe dlscharge plannlng educaLlon sesslons Lo each cllnlcal deparLmenL
3. romoLed dlscharge procedures Lo hosplLal sLaff
4. LsLabllshed a raLe of dlscharge on Llme lnqulry sysLem
3. 8ewarded physlclans who followed dlscharge plannlng successfully
6. 8eflecLed dlscharge plannlng Lo hosplLal managemenL lndex
7. 8evlsed follow-up ouLpaLlenL appolnLmenL schedullng sysLem
8. LsLabllshed a channel of communlcaLlon beLween hosplLal sLaff

kesu|ts: All lmprovemenLs llsLed lnfluenced all cllnlcal deparLmenLs and lncreased adherence Lo dlscharge plan. aLlenLs
who were dlscharged on Llme lmproved, a 27.3 lncrease, from 40.9 Lo 68.4. uMC (uefecL per Mllllon CpporLunlLy)
and Slgma level showed a 97 and 3.4 slgma lncrease respecLlvely. lmprovlng dlscharge cycle Llme boosLed paLlenL and
hosplLal sLaff saLlsfacLlon.

Conc|us|on: 1he pro[ecL Leam developed a dlscharge plannlng pro[ecL Lo evaluaLe Snu8P's currenL dlscharge process,
provlde an excellenL paLlenL care experlence and mlnlmlse delay of dlscharge. 1he mosL slgnlflcanL achlevemenLs were
Lo brlng cllnlcal provlder's aLLenLlon Lo dlscharge plan and creaLe an aLmosphere of volunLary quallLy lmprovemenLs by
ldenLlfylng paLlenLs and hosplLal sLaff's needs. 1he success of Lhe resulLs from Lhls pro[ecL can be aLLrlbuLed Lo
monlLorlng paLlenL saLlsfacLlon and conLlnuous supporL of cllnlcal deparLmenLs. 1herefore, Lhe Leam plans Lo devlse a
proper measure Lo conLlnue quallLy lmprovemenLs.

1918

1nL ASSCCIA1ICN 8L1WLLN NUkSLS' CnANGLS IN kAC1ICL AND kLSCNSLS CI CCLLLAGULS 1C 1nLIk MLDICAL
LkkCkS IN IAAN
8elko Segawa
1,*
, Ayako nagaLa
2
, 1omohlro Shlnozakl
2
, kaLsuya kanda
3

1
ueparLmenL of PealLh Care SafeLy ManagemenL, CraduaLe School of Medlclne,
2
CraduaLe School of Medlclne,
unlverslLy of 1okyo, 1okyo,
3
laculLy of PealLh Sclence, Alno unlverslLy, Csaka, !apan


Cb[ect|ves: Larller sLudles have found a relaLlonshlp beLween managerlal or lnsLlLuLlonal responses and healLhcare
professlonals' changes ln pracLlce afLer an error. Powever, Lhe effecL of colleagues' responses Lo such errors has noL
been lnvesLlgaLed Lhoroughly. 1he purpose of Lhls sLudy was Lo classlfy Lhe change ln nurses' pracLlce afLer experlenclng
an error and Lo explore colleagues' responses Lo such errors ln !apan.

Methods: A self-admlnlsLered quesLlonnalre was dlsLrlbuLed Lo 1,373 nurses aL Lhree hosplLals ln !apan from november
Lo uecember 2011. 1he quesLlonnalre lncluded Lhe mosL serlous medlcal errors LhaL nurses felL Lhey had made durlng
Lhelr careers, percelved response or no response from colleagues (81 lLems), and nurses' change ln pracLlce subsequenL
Lo Lhe error (18 lLems). SLaLlsLlcal analyses conslsLed of:

1) facLor analysls of Lhe change ln nurses' pracLlce, and
2) correlaLlon analysls beLween subscales ldenLlfled from Lhe facLor analysls, Lhe number of supporLlve responses from
colleagues, and Lhe presence of Lhelr [udgmenLal responses. We calculaLed Lhe parLlal correlaLlon coefflclenLs
beLween every Lwo varlables and ad[usLed for oLher candldaLe varlables.

kesu|ts: valld responses were obLalned from 1,172 parLlclpanLs and daLa from 1,022 parLlclpanLs were analysed. lacLor
analysls ldenLlfled four Lypes of changes ln pracLlce: cauLlonary aLLenLlveness," growlng awareness of organlsaLlonal
safeLy," lncreased worry," and becomlng more self-defenslve." CorrelaLlon analyses showed:

a) a negaLlve correlaLlon beLween Lhe number of supporL vs. becomlng more self-defenslve" (parLlal correlaLlon t = -
0.17, p < 0.01), and a poslLlve correlaLlon
b) beLween Lhe number of supporLlve response vs. cauLlonary aLLenLlveness" (t = 0.194, p < 0.01) and growlng
awareness of organlsaLlonal safeLy" (t = 0.104, p < 0.01), and (c) beLween Lhe presence of Lhelr [udgmenLal response
vs. lncreased worry" (t = 0.234, p < 0.01).

Conc|us|on: 1he Lypes of changes ln pracLlce LhaL had been convenLlonally classlfled lnLo Lwo Lypes were newly dlvlded
lnLo four Lypes ln Lhls sLudy. AddlLlonally, we apparenLly revealed some weak relaLlonshlps Lo Lhe changes ln pracLlce
and Lhe responses from colleagues. 1hls lnformaLlon may be helpful ln provldlng supporL for nurses who commlL medlcal
errors ln !apan.

keferences: Wu, A. W., lolkman, S., Mchee, S. !., & Lo, 8. (1991). uo house offlcers learn from Lhelr mlsLakes? !AMA,
263(16), 2089-2094.



1919

LkLkILNCL CI nAkMAC IN1LkVLN1ICNS CN UALI1 CI nCSI1AL INA1ILN1 kLSCkI8ING IN SCU1nLkN
1AIWAN
langLlng Chen
1,*
, Chun-Chl Chlu
2
, ?.C Wang
1
, .? Lee
1

1
Chang Cung Memorlal PosplLal ,kaohslung ,1alwan(8.C.C),
2
ulvlslon of Cllnlcal harmacy ueparLmenL of harmacy,
kaohslung Chang Cung Memorlal PosplLal, kaohslung, 1alwan


Cb[ect|ves: 1o analyse and characLerlse Lhe lnpaLlenL prescrlpLlon errors afLer pharmaclsLs lnLervened ln elecLronlc
prescrlblng sysLem .1he resulL may be used as a reference Lo develop a compuLer-based monlLor for lmprovlng
medlcaLlon safeLy.

Methods: A reLrospecLlve sLudy was conducLed from !anuary 1, 2011 Lo uecember 31, 2011 aL a 2600-bed, LerLlary-care
academlc hosplLal ln 1alwan. AfLer pharmaclsL lnLervened Lhose medlcaLlon and made recommendaLlon whlch was
accepLed by physlclan Lhen lL became a record. All daLa were collecLed and analysed from Lhese records.
.
kesu|ts: 1he research checked 1276727 lnpaLlenL medlcaLlon order sheeLs across Lhe whole year. WlLh Lhe help of
connecLlng elecLronlc medlcal record sysLem, pharmaclsL generally used charL revlews aL deLecLlng order errors. ln Lhls
way, all cllnlcal monlLorlng and dosage ad[usLmenLs are ln place when requlred. Cf Lhese, 4264 errors were deLecLed, an
error raLe of 0.33. oLenLlally leLhal errors were found ln 0.04 of Lhese prescrlpLlons. 1he mosL common errors were
lmproper dose of medlclne, accounLlng for 43 of Lhe medlcaLlon errors. Among Lhem abouL 17 relaLed Lo
lnapproprlaLe drug selecLlon and doslng for paLlenLs wlLh chronlc kldney dlsease. Confuslng Lwo medlcaLlons wlLh
slmllar-soundlng names and overdoslng by comblnlng more Lhan one medlcaLlon wlLh slmllar properLles accounLs for up
Lo 23 of all reporLed errors. Clvlng Lhe wrong drug (dosage, rouLe) wlLh lnsufflclenL or unavallable drug lnformaLlon
accounLed for 18 of Lhe errors. Mlsslng lndlcaLlon were 4 .lnLeracLlon beLween medlcaLlons were 8 . urugs mosL
frequenLly assoclaLed wlLh prescrlpLlon errors lncluded anLl-lnfecLlve agenLs, cardlac agenLs, and gasLrolnLesLlnal agenLs.

Conc|us|on: lnpaLlenL ln a medlcal cenLer may have mulLlple comorbld condlLlons and subsequenL polypharmacy. 1hls
leads Lo a hlgher rlsk ln medlcaLlon safeLy .lrom Lhose experlences, we can deslgn compuLer sofLware LhaL glve alerLs Lo
recommend dose reducLlons for paLlenLs wlLh renal lmpalrmenL or llmlLaLlon of lmproper rouLe of admlnlsLraLlon or Lo
flash up warnlng messages abouL lnLeracLlons and allergles. 1haL can gulde Lhe physlclan whlle prescrlblng medlcaLlon.




193S

1nL SA1ISIAC1ICN CI NUkSING CAkL IN1LkVLN1ICN CN MANAGLMLN1 CI A1ILN1S' AIN LkLkILNCL
Pslen-!y Ma
1,*
, Chla-!ung Chen
1
, Chlng-?lng Chen
1
, Pul-Chu Psu
1

1
nurslng deparLmenL, naLlonal Cheng kung unlverslLy PosplLal, 1alnan, 1alwan


Cb[ect|ves: 1he purposes of Lhe sLudy were Lo:

1) develop an educaLlonal program whlch lnLegraLed paln as Lhe flfLh vlLal slgn,
2) evaluaLe Lhe effecLlveness of Lhe nurses' educaLlonal program abouL paln managemenL on paLlenLs' saLlsfacLlon.

Methods: 1hls sLudy was a cross-secLlonal deslgn. 1he sub[ecLs were paLlenLs who admlLLed Lo adulL wards aL a medlcal
cenLer ln souLhern 1alwan. 1he excluslon crlLerla for paLlenLs lncluded Lhe paLlenLs who were paedlaLrlc, psychlaLrlc
paLlenLs as well as Lhose who vlslLed ouLpaLlenL deparLmenLs. A scale of saLlsfacLlon regardlng paln managemenL was
developed by Lhe researchers. 1he scale conslsLed of 13 lLems whlch assessed paLlenLs' paln experlence and Lhelr
saLlsfacLlon Lo paln rellef or conLrol. 1he nurses ln Lhe medlcal cenLer were requlred Lo aLLend an educaLlonal of program
abouL flfLh vlLal slgn and paln managemenL. 1he educaLlonal program was lmplemenLed ln 10 Llmes wlLhln Lwo weeks
LhaL allowed all nurses Lo aLLend Lhe paln educaLlon. A survey was conducLed before and afLer Lhe educaLlonal program.

kesu|ts: ln pre-survey, 870 quesLlonnalres were dlsLrlbuLed Lo paLlenLs, only 438 quesLlonnalres (30.3) were collecLed.
ln posL-survey, 870 quesLlonnalres were dlsLrlbuLed Lo paLlenLs, only 422 quesLlonnalres (48.3) were collecLed. ln pre-
survey, Lhe sub[ecLs reporLed Lhe mean score of paln endurance (0-10) was 3.26 (Su =2.3). lemales were more llkely Lo
endure paln Lhan males (L= -1.86, p = .002). 1he mean score of seeklng paln rellef was 3.87 (Su= 1.93). ln posL-survey,
Lhe sub[ecLs reporLed Lhe mean score of paln endurance (0-10) was 3.07 (Su =2.12). 1he mean score of seeklng paln
rellef was 3.33 (Su= 1.93). lL was worLh Lo noLe LhaL a slgnlflcanL dlfference of paln endurance beLween pre-posL survey
(L=2.16, p < .01). ln pre-survey, 317 (72) sub[ecLs reporLed paln experlence durlng hosplLallsaLlon. Cf Lhe 317 sub[ecLs,
91.4 saLlsfled Lo physlclans' paln managemenL, 94.2 saLlsfled Lo nurses' paln managemenL, 91.7 saLlsfled Lo overall
paln rellef aL hosplLallsaLlon. ln posL-survey, 294 (70) sub[ecLs reporLed paln experlence durlng hosplLallsaLlon. Cf Lhe
294 sub[ecLs, 93.9 saLlsfled Lo physlclans' paln managemenL, 97.3 saLlsfled Lo nurses' paln managemenL, 93.2
saLlsfled Lo overall paln rellef aL hosplLallsaLlon.

Conc|us|on: aln ls a wldespread experlence for hosplLallsed paLlenLs. An educaLlon program of Lhe flfLh vlLal slgn and
paln managemenL Lo nurses lmproves paLlenLs' sLraLlflcaLlon abouL paln rellef. LducaLlonal program focuslng on paln
managemenL are needed Lo be wldely lmplemenLed for nurses.



1936

ALICA1ICN CI kISk MANAGLMLN1 S1kA1LGILS IN 1nL NCN-MLDICAL LkSCNNLL DUkING UNLkLC1LD IN-
nCSI1AL kLSUSCI1A1ICN A1 1nL U8LIC SACL
Pul-C Lln
1
, kuan-Chlh Chung
2,*
, !la-Shou Llu
3
, ?u-lung 1seng
3

1
SecLor of Medlcal 8ecord,
2
ueparLmenL of AnaesLheslology,
3
ueparLmenL of neurology, kaohslung Chang kung
Memorlal PosplLal, kaohslung, 1alwan


Cb[ect|ves: ln our hosplLal, serlal analysls of Lhe unexpecLed resusclLaLlon demonsLraLed LhaL mosL resusclLaLlon cases
happened ln Lhe publlc space wlLhouL medlcal sLaff (61.8). 1he ma[orlLy of Lhese cases were due Lo consclous change
or falnLlng. Powever, 34.2 of Lhese cases were consldered as false alarms and were dlscharged dlrecLly wlLhouL
medlcal evenLs afLer prlmary resusclLaLlon. Accordlng Lo Lhe concepL of rlsk managemenL, Lhe promoLlon of ablllLy Lo
assess Lhe unexpecLed resusclLaLlon cases by Lhe non-medlcal sLaff ln Lhe publlc space could deflnlLely enhance Lhe
efflcacy of resusclLaLlon. 1herefore, Lhls pro[ecL alms Lo lnvesLlgaLe Lhe awareness and percepLlon of non-medlcal sLaff ln
encounLerlng wlLh unexpecLed resusclLaLlon, and promoLe Lhelr approprlaLe response Lo Lhese evenLs.

Methods: 1hls cross-secLlonal sLudy was conducLed ln 4 non-medlcal unlLs LhaL mosL frequenLly faced wlLh unexpecLed
resusclLaLlons, namely Lhe guard sLaLlon, general admlnlsLraLlon counLers, ouLpaLlenL area ln Lhe radloLherapy
deparLmenL, and speclallsL admlnlsLraLlve offlce. 1he members ln Lhese 4 unlLs randomly recelved a serlal of
quesLlonnalre surveys. llrsL, lL analysed Lhe responses of non-medlcal sLaff Lo Lhe followlng lLems: wllllngness Lo recelve
Lralnlng, famlllar wlLh Lhe prlnclples of managemenL, reacLlon Lo resusclLaLlon, and crlLlcal assessmenL of resusclLaLlon
scene. 1he relaLlonshlps and dlfferences beLween Lhese lssues were compared across each unlL and senlorlLy of Lhe
sLaff.

kesu|ts: 92 quesLlonnalres were dellvered and 73 of Lhe compleLed sheeLs were collecLed. Analysls of Lhe 4 facLors
showed LhaL Lhere were slgnlflcanL relaLlonshlps among Lhese facLors (<0.01). All sLaff were mosL enLhuslasLlc
parLlclpaLlng Lhe Lralnlng courses, and also afflrmed Lo be famlllar wlLh Lhe prlnclples of managemenL. 8uL Lhey were less
confldenL wlLh assessmenL of Lhe scene of resusclLaLlon. osL-Poc showed LhaL members ln Lhe guard sLaLlon responded
beLLer Lhan Lhe members of Lhe general admlnlsLraLlon counLer ln famlllar wlLh Lhe prlnclples of managemenL" and
crlLlcal assessmenL of resusclLaLlon scene" (1.23*, 1.34*).And Lhe former also beLLer Lhan Lhe speclallsL admlnlsLraLlve
offlcers ln crlLlcal assessmenL of resusclLaLlon scene" (1.77*). uslng sLrucLural equaLlon models, 1here were Lwo
slgnlflcanL rouLes wlLh crlLlcal assessmenL of resusclLaLlon scene" (<0.03). 8ouLe 1 was wllllngness Lo recelve
Lralnlng" vla reacLlon Lo resusclLaLlon" Lo crlLlcal assessmenL of resusclLaLlon scene" (0.319*, 0.216*). 8ouLe 2 was
wllllngness Lo recelve Lralnlng" vla famlllar wlLh Lhe prlnclples of managemenL" Lo crlLlcal assessmenL of resusclLaLlon
scene" (0.322*, 0.408*).

Conc|us|on: lrom our daLa, 42.3 of all responders had lnvolved ln unexpecLed resusclLaLlon durlng Lhe pasL slx monLhs.
AfLer prlmary resusclLaLlon, mosL of Lhese cases Lurned ouL Lo be false alarms. 1herefore, approprlaLe response Lo Lhese
unexpecLed resusclLaLlon evenLs could be essenLlal. Cur sLudy underscores LhaL non-medlcal sLaff members of all
senlorlLles are enLhuslasLlc abouL recelvlng baslc Lralnlng ln resusclLaLlon. lollowlng proper Lralnlng courses, Lhey could
develop hlgher confldence ln Lhe crlLlcal assessmenL and managemenL of resusclLaLlon evenLs. Cur on-golng pro[ecL
lnLegraLes Lhe resources of Lhe medlcal and non-medlcal deparLmenLs Lo promoLe Lhe efflcacy of prlmary ln-hosplLal
resusclLaLlon, reduce lnapproprlaLe calllngs, and enhance Lhe compeLence ln Lhe assessmenL of resusclLaLlon scenes.



1943

kCMC1ING A CSI1IVL A1ILN1 LkLkILNCL AND S1AII LNGAGLMLN1 CUL1UkL 1nkCUGn A1ILN1 SA1ISIAC1ICN
SUkVL IN nCNG kCNG
aullne Wong
1,*

1
aLlenL 8elaLlons and LngagemenL, PosplLal AuLhorlLy, Pong kong, Pong kong


Cb[ect|ves: 1o enhance paLlenL experlence and sLaff engagemenL Lhrough esLabllshmenL of a aLlenL SaLlsfacLlon Survey
(SS) Mechanlsm ln Pk. 1he lncorporaLlon of paLlenL saLlsfacLlon as a parL of Lhe evaluaLlon of healLh care quallLy wlll
beneflL noL only Lhe wlder publlc lnLeresL ln healLh care pollcy and servlces, buL can also be employed as a Lool Lo engage
paLlenLs and sLaff wlLh asplraLlons and a common goal Lo enhance paLlenL experlence and sLaff saLlsfacLlon.

As a former 8rlLlsh colony, Pk clLlzens used Lo be relaLlvely lnexperlenced abouL playlng a ma[or role ln publlc
affalrs. lollowlng wlLh Lhe modern clvll rlghLs movemenL, and Lhe new medla Lechnologles lnsplrlng publlc parLlclpaLlon
ln pollLlcs, Lhe envlronmenL, soclal lssues, and of course healLhcare servlces Lhey recelve, paLlenLs nowadays are more
eager Lo express Lhelr feellngs and oplnlons, more concerned abouL self-lnLeresLs and rlghLs. 1hey are no longer
unquesLlonlng Lowards docLors' declslon and advlce. WlLh socleLal senLlmenLs Lowards hlgher accounLablllLy Lo Lhe
publlc rlghLs, Lhe lncluslon of paLlenLs' oplnlons ln servlce assessmenLs has galned greaLer promlnence over Lhe
years. 1he Pk PosplLal AuLhorlLy (PA), belng Lhe largesL publlc healLhcare provlder ln Pk, launched lLs flrsL basellne SS
ln 2010 for 3,000 paLlenLs. 1he SS was conducLed by an lndependenL academlc lnsLlLuLlon uslng a valldaLed Lool
adapLed from Lhe nPS SS quesLlonnalre by lcker lnsLlLuLe Lurope.

1he 2010 basellne survey (lull 8eporL aL www.ha.org.hk) reporLed Lo Lhe publlc ln !une 2011 was generally well recelved
by sLaff, paLlenL groups, publlc and medla. 1he overall resulL was encouraglng wlLh more Lhan 87 of Lhe paLlenLs
lndlcaLlng a hlgh degree of LrusL for our docLors and nurses, and 80 raLed LhaL Lhe LreaLmenL and care Lhey recelved
was good Lo excellenL.

Methods: As an lmporLanL sLraLegy Lo engage sLaff and enhance paLlenL experlence, Lhe PA has declded Lo deepen Lhe
governance arrangemenL Lo seL up a clear corporaLe pollcy, sLandards & proLocols, monlLorlng, follow up & publlc
reporLlng on SS. WhllsL LerrlLory-wlde SS benchmark survey wlll be conducLed every 3 years, lndlvldual publlc hosplLals
are encouraged and wlll be equlpped wlLh a sLandardlsed SS Lool Lo conducL small scale SS locally and aL
regularly. lmprovemenL acLlon plans arlslng from SS wlll be lncorporaLed ln Lhe annual servlce plannlng and corporaLe
programmes. ln-depLh sLudles were conducLed ln 2012 on:

a) secondary daLa analysls of Lhe 2010 SS resulLs,
b) engagemenL of docLors and nurses for Lhe vlews on Lhe enablers and barrlers of paLlenL engagemenL.

kesu|ts: 1he resulLs of ln-depLh sLudy on:
a) Lhe 2010 SS resulLs (secondary daLa analysls),
b) engagemenL sLudy lnvolvlng docLors and nurses for paLlenL engagemenL wlll be avallable ln Lhe second quarLer of
2013. WlLh Lhese resulLs, Lhe managemenL wlll be able Lo formulaLe sLraLegles and acLlon plans Lo enhance paLlenL
experlence and sLaff saLlsfacLlon Lhrough co-producLlon of a paLlenL-cenLred culLure.

Conc|us|on: As healLh pollcles/servlces come under publlc scruLlny, Lhe publlc becomes more crlLlcal of Lhe healLhcare
provlded. 1he PA SS Mechanlsm ls a Llmely movemenL Lo address Lhe publlc concern abouL Lhelr rlghLs as acLlve
parLlclpanLs ln Lhe plannlng and evaluaLlon of healLh servlces. ln addlLlon Lo respondlng Lo soclal demands for paLlenL
lnvolvemenL, SS lLself ls also a good means Lo relnforce Lhe paLlenL-cenLred culLure. lmproved paLlenL experlence and
Lhelr LrusL ln our cllnlcal sLaff wlll resulL ln paLlenLs wlLh greaLer compllance wlLh cllnlcal LreaLmenL and correspondlngly
enhance sLaff saLlsfacLlon.



19S8

C1IMISING 1nL WCkk kCCLSS 1nkCUGn IMkCVLMLN1 CI kLSLkVA1ICN SS1LM
Lunhee Seo
1,*
, Cwanhong Mln
1

1
8adlology, Seoul naLlonal unlverslLy 8undang PosplLal, 8undang, Sungnam, korea, 8epubllc Cf


Cb[ect|ves: As lncreaslng lnLeresL ln healLh care, Lhere has been a hlgh demand for more accuraLe, prompL dlagnosls and
LreaLmenL of Lhe paLlenLs and careglvers. ln Seoul naLlonal unlverslLy 8undang PosplLal (Snu8P), paLlenLs wlLh Lhe braln
dlseases and cancer demanded one sLop servlce hlghly accordlng Lo Lhe survey resulLs of Lhe exLernal cusLomer
saLlsfacLlon. 1he hlghesL demand for Lhe one sLop servlce was all Lhe exams under fasLlng condlLlon requlred Lo be
performed for a day. 1herefore, Lo enhance Lhe quallLy of Lhe one-sLop servlce, Lhls sLudy progressed opLlmlslng Lhe
work process Lhrough LoLal reservaLlon program Lo ouLpaLlenLs

Methods: 1hls sLudy proceeded Lhe lmprovemenL acLlvlLles wlLh Lechnlques of uMAlC (deflne, measure, analyse,
lmprove and conLrol) Lhrough Lhe slx slgma for LesL schedullng process. lo tbe stoqe of Jefloltloo, Lhls Lechnlque
conflrmed Lhe problem ln Lhe reservaLlon program of medlcal examlnaLlon. 1he survey was conducLed on Lhe
ouLpaLlenLs who were prescrlbed Lwo or more fasLlng LesLs Lo lnvesLlgaLe Lhe saLlsfacLlon and requlremenL regardlng Lhe
reservaLlon of fasLlng LesLs and walLlng Llme. lo tbe stoqe of Meosotemeot, Lhe sLaLlsLlcs were calculaLed by analyslng
Lhe reservaLlon raLe of Lhe paLlenLs prescrlbed wlLh more Lhan Lwo fasLlng LesLs over slx hours lncludlng C1, M8l,
ulLrasound, fluoroscopy, echocardlography and nuclear medlclne exams beLween 01/03/2011 and 02/29/2012. 1hls
Lechnlque selecLed Lhe reservaLlon raLe as a key lndlcaLor whlch lncluded more Lhan slx hours of fasLlng examlnaLlons
performed on Lhe same, and lL seL a goal as 83. ln Lhe sLage of Analysls, Lhls Lechnlque drew key reasons for Lhe
problems. 1hls Lechnlque conflrmed Lhe poLenLlal reasons of Lhe problem ln reservaLlon sysLem by Lhe Lechnlque of 3
why and selecLed a dlrecLlon of lmprovemenL by Lhe reasons drawn. ln Lhe sLage of lmprovemenL, Lhe lmprovemenL
acLlvlLles were progressed. Cne-sLop exam reservaLlon sysLem has been esLabllshed LhaL allowed on Lo make all Lhe LesLs
reservaLlon and docLor's appolnLmenL on one compuLer screen. ln Lhe sLage of ConLrol, Lhls Lechnlque conflrmed once
more Lhe currenL level and posL-lmprovemenL acLlvlLy level by Lhe key lndlcaLor selecLed ln Lhe sLage of measuremenL.

kesu|ts: 1hls sLudy ldenLlfled LhaL Lhe average of same day booklng raLe of Lhe fasLlng examlnaLlons was lmproved Lo
76.8 from 67 by 9.8 beLween SepLember 01 Lo CcLober 31, 2012. Also, wlLh one-sLop LesL reservaLlon program, Lhe
Llme Lo schedule Lhe LesLs done under fasLlng condlLlon has been conslderably decllned from 120 seconds Lo 29 seconds.
1herefore, Lhls effecLlve lmprovemenL of work process leads Lo Lhe saLlsfacLlon of Lhe lnpaLlenLs.

Conc|us|on: 1he resulL of Lhls sLudy ls LhaL Lhe number of paLlenLs' vlslLs Lo Lhe hosplLal was decreased by Lhe
reservaLlon of Lhe exams ln one day wlLh one fasLlng. AddlLlonally, sysLemlc conLrol of Lhe exam reservaLlon based on
Lhe prlorlLy and duraLlon of Lhe LesL allows Lhe work progresslng more efflclenLly and decreaslng Lhe error of Lhe
reservaLlon.



196S

kL1IkLMLN1 CI INDICA1CkS: nCW 1C DLCIDL WnICn INDICA1Ck NLLDS 1C GC?
8ramesfeld Anke
1, 2,*
, Mlchel Wenslng
3
, CnLher Peller
1
, !oachlm Szecsenyl
1, 4

1
ACuA-lnsLlLuLe for Applled CuallLy lmprovemenL and 8esearch ln PealLh Care CmbP, CLLlngen,
2
lnsLlLuLe for
Lpldemlology, Soclal Medlclne and PealLh SysLem 8esearch, Pannover Medlcal School, Pannover, Cermany,
3
SclenLlflc
lnsLlLuLe for CuallLy of PealLhcare (lC healLhcare), 8adboud unlverslLy nl[megen Medlcal CenLre, nl[megen,
neLherlands,
4
ueparLmenL of Ceneral racLlce and PealLh Servlces 8esearch, Peldelberg unlverslLy, Peldelberg,
Cermany


Cb[ect|ves: As large numbers of lndlcaLors are now ln use ln many healLhcare sysLems, Lhe quesLlon has arlsen when
lndlcaLors should be 'reLlred'. CurrenLly more Lhan 400 lndlcaLors for more Lhan 30 cllnlcal lndlcaLlons are ln mandaLory
use ln exLernal quallLy assurance ln Lhe Cerman healLh care sysLem. More lndlcaLors for furLher cllnlcal lndlcaLlons are ln
preparaLlon. 1he lederal !olnL CommlLLee, Lhe body responslble for exLernal quallLy assurance ln Lhe Cerman healLh
care sysLem, ls Lhus seeklng for a meLhodology for evaluaLlng quallLy lndlcaLors for Lhelr ellglblllLy for reLlremenL. 1he
ACuA-lnsLlLuLe has been commlssloned wlLh proposlng such a meLhodology

Methods: An analysls of meLhodologles ln use for selecLlng lndlcaLors for reLlremenL was conducLed. 8ased on Lhls, a
Lhree sLep graduaLe scheme for evaluaLlng lndlcaLors for Lhelr ellglblllLy for reLlremenL ls belng developed.

kesu|ts: A shorL analysls conducLed by lC healLhcare aL 8adboud unlverslLy nl[megen, of meLhodologles for lndlcaLor
reLlremenL" LhaL are pracLlced by Lhe leadlng lndlcaLor developlng agencles ln Lhe world, revealed LhaL ln facL no expllclL
procedures for removlng lndlcaLors exlsLs Loday. Powever, Lhe analysls revealed argumenLs and reasons LhaL are used ln
relaLlon Lo lndlcaLor reLlremenL. 1hey could be summarlsed under four headlngs:

1. lndlcaLor ls noL (longer) valld due Lo changes ln pollcles, ln healLh care pracLlce or sysLem and new research
evldence.
2. lndlcaLor does noL mlrror quallLy ln a useful way due Lo problems wlLh valldlLy and rellablllLy or lack of case mlx
ad[usLmenL.
3. 1here ls an alm Lo reduce Lhe burden of documenLaLlon.
4. 1he lndlcaLor seLs perverse lncenLlves.

ln Lhe meLhodology developed on Lhe basls of Lhls analysls lndlcaLors aL quesLlon for reLlremenL are selecLed Lhrough a
fllLer. 1he fllLer lncludes lssues such as Lhe duraLlon of use of an lndlcaLor, Lhe Llme slnce lasL daLa valldlLy check and
oLhers. AfLer ldenLlfylng lndlcaLors by Lhe fllLer, Lhey are evaluaLed by a Lhree sLep graduaLe scheme. 1hese Lhree sLeps
successlvely bulld on each oLher:

1. CuanLlLaLlve evaluaLlon: Lxplore valldlLy, ablllLy Lo dlscrlmlnaLe beLween servlce provlders, negaLlve quallLy resulLs,
developmenL of quallLy over Lhe lasL Lhree years.
2. CuallLaLlve evaluaLlon: LxperL oplnlon wheLher Lhe lndlcaLor has fulfllled lLs purposes.
3. ollcy evaluaLlon: based on Lhe lnformaLlon provlded ln 1 and 2 and conslderlng pollcy lssue, a pollcy declslon ls
soughL abouL reLlremenL of Lhe respecLlve lndlcaLors.

Conc|us|on: AL currenL Lhls meLhodology ls LesLed wlLh lndlcaLors for Lhe lndlcaLlon of hysLerecLomy and for decublLus
ulcer. 1he presenLaLlon wlll reporL abouL Lhe process, resulLs and experlences wlLh evaluaLlng lndlcaLors for Lhelr
ellglblllLy for reLlremenL wlLh Lhe meLhodology descrlbed.


1971

CA1UkING AND IMkCVING A1ILN1 LkLkILNCL ICk CLDLk LCLL IN nCSI1AL - NnS 1ASIDL
uelrdre Cameron
1,*
, Morag Macrae
2

1
SafeLy Cllnlcal Covernance & 8lsk,
2
Clder eoples CollaboraLlve, nPS 1ayslde, uundee, unlLed klngdom


Cb[ect|ves: ln !une 2012, nPS 1ayslde ln parLnershlp wlLh nPS Cramplan launched Lhe Clder eoples AcuLe CollaboraLlve. Seven
wards are lnvolved ln Lhe collaboraLlve. 1he alm of Lhls collaboraLlve ls Lo lmprove Lhe experlence of older people ln an acuLe
hosplLal seLLlng. lL ls recognlsed LhaL Lhe age proflle of our populaLlon ln ScoLland and oLher counLrles ls changlng slgnlflcanLly wlLh
greaLer llfe expecLancy and an lncrease ln older people uslng our servlces. ln llne Lhe number of older people wlLh cognlLlve
lmpalrmenLs ls also lncreaslng. 1hey and Lhelr famllles wlll requlre supporL Lo ensure Lhey are well cared for and are LreaLed wlLh
dlgnlLy and respecL ln a supporLlve envlronmenL whllsL ln hosplLal. WhllsL Lhe ma[orlLy of feedback from older people ls poslLlve, as
ldenLlfled by ScoLland's ln-paLlenL Survey 8eLLer 1ogeLher, lL ls recognlsed LhaL Lhere ls room for lmprovemenL wlLh complalnLs
relaLlng malnly Lo poor communlcaLlon and sLaff aLLlLudes Lowards older people and Lhelr carers'.

Methods: A paLlenL experlence survey was speclflcally developed for Lhe older peoples collaboraLlve (aged 63) based upon Lhe
collaboraLlve change package and followlng nlCL guldellnes for aLlenL Lxperlence. 1he survey comprlses a number of Lhemes
lncludlng orlenLaLlon Lo Lhe ward, communlcaLlon, dlgnlLy and respecL, lnvolvemenL and cleanllness wlLh an overall ouLcome
measure raLlng overall care provlded. A carer's survey was also developed Lo capLure Lhelr vlews, parLlcular for Lhose paLlenLs who
are unable Lo feedback due Lo cognlLlve lmpalrmenL. Carers can choose Lo compleLe a paper verslon or use Lhe alLernaLlve onllne
webslLe. CuallLaLlve feedback ls capLured from paLlenLs or carers by exLernal faclllLaLors on a monLhly basls Lo supplemenL Lhe
quanLlLaLlve daLa already recelved uslng Lhe CAC survey.

kesu|ts: uaLa ls capLured for 20 paLlenLs per ward each monLh. 1hls ls enLered and dlsplayed by Lhemes on run charLs wlLh Lhe
overall alm 93 of paLlenLs wlll raLe Lhelr care as excellenL. 1hese are owned by Lhe wards Lo encourage dlscusslons for
lmprovemenL. 1he Lable below lllusLraLes lmprovemenL over Llme for each Lheme and Lhe overall ouLcome measure slnce
commencemenL of Lhe collaboraLlve ln !une 2012.

or|entat|on commun|cat|on D & k |nvo|vement c|ean||ness overa|| care
Week 1 38 62 77 38 77 68
Week 2 34 60 81 31 64 67
Week 3 49 60 73 38 73 77
Week 4 71 37 78 31 76 61
!ul-12 37 73 87 34 68 73
Aug-12 64 74 90 62 69 78
Sep-12 77 83 89 73 78 81
CcL-12 71 82 88 78 83 84
nov-12 83 86 92 86 90 93

1he followlng lmprovemenLs have been made by Lhe wards:

! A welcome board wlLh dlrecLlons Lo Lhe LolleLs and lnformaLlon regardlng sLaff unlforms.
! 8educLlon and amendmenLs Lo slgnage aL ward enLrances Lo welcome raLher Lhan confuse and deLer vlslLors.
! ually board rounds Lo dlscuss paLlenLs wlLh all MulLl-ulsclpllnary 1eam Members presenL.
! A posLer Lo lmprove hyglene aL mealLlmes was developed uld you wash your hands - you spread germs lf you don'L".
! Lar plugs offered Lo help paLlenLs sleep.
! Larly dlalogue wlLh famllles Lo ldenLlfy crlLlcal pleces of lnformaLlon requlred for funcLlonal screenlng.

Conc|us|on: WhllsL early days Lhere ls an lncreaslng Lrend for each Lheme and Lhe cumulaLlve ouLcome measure over Lhe lasL slx
monLhs. 1hls ls expecLed Lo conLlnue as furLher lmprovemenLs are made durlng Lhe perlod of Lhe collaboraLlve by Lhe wards
lnvolved. 1he CAC paLlenL experlence Lool has enabled wards Lo ldenLlfy areas for dlscusslon and lmprovemenL accordlng Lo
Lhemes whllsL sLrlvlng Lo provlde excellenL care aL all Llmes for older people.


1972

kISM S1UD: A S1UD CI ADVLkSL LVLN1S ICLLCWING DISCnAkGL IkCM 1nL CS1-ANALS1nL1IC CAkL UNI1
Maryann SLreeL
1, 2,*
, nlcole M. hllllps
1
, 8rldle kenL
3
, Ann WhlLfleld
4

1
School of nurslng & Mldwlfery, ueakln unlverslLy, 8urwood,
2
LasLern PealLh - ueakln unlverslLy nurslng and Mldwlfery
8esearch CenLre, LasLern PealLh - ueakln unlverslLy, 8ox Plll, AusLralla,
3
School of nurslng & Mldwlfery, lymouLh
unlverslLy, lymouLh, unlLed klngdom,
4
lnLenslve Care unlL, LasLern PealLh, 8ox Plll, AusLralla


Cb[ect|ves: ln Lhe osL-AnaesLheLlc Care unlL (ACu) a paLlenL ls observed conLlnuously by nurses so LhaL early
compllcaLlons of surgery or anaesLhesla can be ldenLlfled and LreaLed before Lhey develop lnLo ma[or problems. 1he alm
of Lhls sLudy was Lo ldenLlfy Lhe frequency and naLure of paLlenL adverse evenLs relaLed Lo dlscharge from Lhe osL-
AnaesLheLlc Care unlL (ACu).

Methods: A reLrospecLlve case-analysls of posLoperaLlve adverse evenLs, where Lhere was cllnlcal deLerloraLlon wlLhln
24 hours of compleLlon of surgery. All adulL paLlenLs admlLLed Lo Lhe ACu aL Lhree AusLrallan meLropollLan publlc
hosplLals, beLween !anuary and uecember 2009 and who experlenced cllnlcal deLerloraLlon resulLlng ln an adverse evenL
were lncluded. uaLa were sourced from paLlenL records, vlcLorlan PealLh lncldenL ManagemenL SysLem (vPlMS)
reporLs, lCu admlsslon records, Medlcal Lmergency 1eam and Code 8lue (Cardlac ArresL) call logs. aLlenL adverse
evenLs wlLhln 24 hours of ACu dlscharge and Lhe paLlenL ouLcome were ldenLlfled.

kesu|ts: lrom a LoLal of 19,389 surglcal procedures, 84 paLlenLs experlenced 113 serlous adverse evenLs wlLhln 24 hours
of ACu dlscharge, lncludlng 43 (38) unplanned lCu admlsslons, 4 (4) hosplLal Lransfers, 4 (4) reLurned Lo LheaLre,
36 (32) delayed hosplLal dlscharge, 4 (4) readmlsslons and 2 deaLhs (2). 1he 84 paLlenLs experlenced one (73),
Lwo (20) or Lhree (3) adverse evenLs. 1he medlan age of paLlenLs ln Lhls group was 72 years (range 20 - 93) and 46
were male. 1he mosL frequenL slgns of cllnlcal deLerloraLlon were: resplraLory, lncludlng resplraLory arresL, dyspnoea,
and hypoxemla (31, n= 26/84) or cardlac compllcaLlons, lncludlng aLrlal flbrlllaLlon, bradycardla, Lachycardla, hearL
fallure (21, n=18/84), excesslve bleedlng (20, 17/84) and hypoLenslon (18, n=13/84). CLher compllcaLlons lncluded
unconLrolled paln (33, n=28/84) and unconLrolled nausea and vomlLlng (8, n=7/84). very few of Lhe evenLs were
capLured ln Lhe healLh servlce lncldenL reporLlng sysLem. 1he average lengLh of sLay ln ACu for paLlenLs experlenclng a
compllcaLlon leadlng Lo an adverse evenL was 98 mlnuLes (93Cl: 76-119 mlnuLes, range 10 mlnuLes Lo 8 hours 23 mlns)
and 30 (n= 23) remalned ln ACu more Lhan 2 hours. 1he average lengLh of hosplLal admlsslon for Lhese paLlenLs was
8.3 days (93Cl: 6.3-10.6 days, range 1 day Lo 47 days).

Conc|us|on: 1hls sLudy demonsLraLed an overall prevalence raLe of 3.8 per 1000 procedures for Lhose experlenclng a
serlous adverse evenL wlLhln 24 hours followlng surgery, and a morLallLy raLe of 0.01. 1he mosL common adverse
evenLs ldenLlfled were unplanned lCu admlsslon and delayed hosplLal dlscharge. 1hese flndlngs hlghllghL Lhe lmporLance
of paLlenL monlLorlng ln Lhe lmmedlaLe posL-operaLlve perlod, ln ACu and conLlnulng on Lhe ward. lurLher prospecLlve
sLudles of adverse evenLs and predlcLors of cllnlcal deLerloraLlon followlng anaesLhesla and surgery are warranLed.



1979

"LL1'S CLLAN U 1nIS MLSS!"- A CCMMUNI1-8ASLD S1kA1LG 1C IMkCVL ICCD nGILNL AND SANI1A1ICN A1 A
nIGnWA 1kAVLL S1C: LUGCNC LkLkILNCL, MCkCGCkC kLGICN, 1AN2ANIA
larldah M. Mgunda
1
, Carle S. Lylmo
1,*

1
8eglonal PealLh ManagemenL, Morogoro, 1anzanla, unlLed 8epubllc of


Cb[ect|ves: 1anzanla has many sLopplng polnLs for Lravellers along lLs roads where Lravellers purchase food from sLreeL
vendors and frequenLly exlL Lhelr vehlcles Lo relleve Lhemselves. Lugono CenLer ls one of Lhese sLopplng polnLs for
Lravellers. lL sLarLed as a mlnor sLopplng polnL for selllng sugar cane, became a ma[or sLopplng sLaLlon for Lravellers Lo
purchase food, especlally roasLed meaL processed under unsanlLary condlLlons. WlLhouL LolleLs, a waLer supply, or a safe
food preparaLlon area, condlLlons were hazardous, and ln 2010 Lhe area suffered an ouLbreak of cholera. uue Lo Lhe
fllLhy condlLlons aL Lhls sLop, Lhe 8eglonal and Councll PealLh ManagemenL Leams Lwlce demanded LhaL Lhe area be
closed down, buL Lhe local populaLlon reslsLed because Lhey had come Lo depend on proflLs from food sales. 1he
ob[ecLlve of Lhls quallLy lmprovemenL (Cl) lnlLlaLlve was Lo lmprove sanlLaLlon and hyglene aL Lugono CenLer.

Methods: PealLh offlclals had experlence applylng Cl for Plv/AluS care and LreaLmenL programs and declded Lo apply
Lhese meLhods Lo Lhe sanlLaLlon problem aL Lugono. llrsL, healLh offlcers were approached and engaged ln performlng a
basellne assessmenL aL Lhe slLe ln order Lo undersLand Lhe problems, followed by senslLlsaLlon of ward and vlllage
leaders on Lhe lmporLance of brlnglng abouL change. llnally communlLy members, lncludlng vendors, were engaged ln
analyslng Lhe problems, ldenLlfylng opporLunlLles for change and developlng a plan for overcomlng challenges Lo
lmprove Lhe quallLy of servlces and food avallable Lo Lravellers sLopplng Lhere. 1he dlsLrlcL commlssloner was also
lnvolved Lo ensure governmenL supporL.

kesu|ts: AfLer much dlscusslon communlLy members who ralsed and sold llvesLock Lo Lhe food vendors flnanced and
arranged Lhe consLrucLlon of a laLrlne wlLh 8 sLalls Lo be used by Lravellers. A youLh organlsaLlon called 1WlkALLWCSL
supporLed Lhe consLrucLlon of a second laLrlne wlLh 10 sLalls. 1wo slaughLer slabs and sheds were also consLrucLed uslng
communlLy funds. A LoLal of 12 meaL chambers are now ln place on Lhese slabs whlch lnclude a baslc arrangemenL for
food handllng and sanlLaLlon. uslng communlLy funds, a waLer Lank wlLh capaclLy of 3000 llLres was lnsLalled Lo faclllLaLe
sanlLaLlon. 1o complemenL Lhe flnanclng and labour provlded by Lhe communlLy, Lhe governmenL provlded a
veLerlnarlan Lo lnspecL all meaL before lL could be sold.

Less Lhan a year afLer Lhe launch of Lhls acLlvlLy, Lravellers' are uslng LolleLs aL Lhe cosL of 200 1anzanlan shllllngs. 1he
pracLlce of meaL lnspecLlon revealed LhaL 13 of Lhe 660 goaL carcasses lnspecLed over a 6 monLh perlod were lnfecLed
by PydaLld cysLs. 1hese lnspecLlons prevenLed a conslderable amounL of hazardous meaL from enLerlng Lhe food supply.
8ecause Lhe number of LolleLs remalns lnsufflclenL for Lhe number of Lravellers needlng Lhem, an exLenslon of Lhe laLrlne
wlLh 4 addlLlonal sLalls ls already underway. lurLhermore, anoLher youLh organlsaLlon recenLly consLrucLed 1 laLrlne
LolleL and 12 food klosks. 1he ulsLrlcL Councll has commlLLed Lo drllllng a well as a permanenL waLer supply.

Conc|us|on: Where governmenL mandaLes fall Lo solve cerLaln communlLy problems, communlLy engagemenL ln
problem solvlng can Lransform a problem slLuaLlon lnLo a model of lmprovemenL. 1hrough engagemenL of local leaders
and communlLy members ln sLraLeglc problem solvlng, Cl meLhods LhaL have proven successful ln cllnlcal seLLlng can be
Lransferred Lo cosL-effecLlvely address baslc hyglene and sanlLaLlon lssues ln low-resource seLLlngs.



1982

LkSLC1IVLS CI kIMAk CAkL CLINICIANS CN AN IN1LkVLN1ICN AIMING 1C IMkCVL CAkL ICk A1ILN1S WI1n 1L 2
DIA8L1LS 1nkCUGn LkAMINING, ADVISING AND kLSCkI8ING (IDLA 1kIAL): A SCCING S1UD
!oan L. MacklnLosh
1,*
, !usLln resseau
1
, Cllllan PawLhorne
2
, !lll lrancls
3

1
lnsLlLuLe of PealLh and SocleLy, newcasLle unlverslLy,
2
ulabeLes Care CenLre, newcasLle upon 1yne PosplLals nPS loundaLlon 1rusL,
newcasLle upon 1yne,
3
ulvlslon of PealLh Servlces 8esearch and ManagemenL, ClLy unlverslLy, London, unlLed klngdom


Cb[ect|ves: revlous research and nlCL quallLy sLandards ldenLlfy key cllnlclan behavlours for provldlng hlgh quallLy care for people
wlLh Lype 2 dlabeLes: prescrlblng, advlslng and examlnlng. 8efore developlng and dellverlng an lnLervenLlon LargeLlng Lhese
behavlours, lL ls lmporLanL Lo conslder Lhe perspecLlves of prlmary healLhcare professlonals (PCs) abouL how Lhey care for people
wlLh Lype 2 dlabeLes and facLors LhaL lmpede care. 1he sLudy ob[ecLlves were Lo explore PCs' perspecLlves and preferences Lo
lnform lnLervenLlon deslgn.

Methods: Scoplng sLudy uslng a convenlence sample. Seml-sLrucLured lnLervlews wlLh 3 Cs and 3 pracLlce nurse prescrlbers ln 3
general pracLlces ln Lhe norLh-easL of Lngland. lnLervlews focused on conLexL, knowledge, skllls, goals, moLlvaLlon, resources and
soclal lnfluences Lo help PCs ldenLlfy barrlers Lo performlng Lhe behavlours. We also explored Lhelr lnLervenLlon dellvery
preferences. uaLa were analysed LhemaLlcally and dlscurslvely.

kesu|ts: 74(,%;,$"# <"**-%*+
PCs expressed a Lenslon beLween keeplng drug cosLs down and lmprovlng dlabeLes care. Cllnlc organlsaLlon, good Leamwork and
one person belng responslble for dlabeLes care ln each pracLlce were vlewed as lmporLanL.

=%"#,0 7"*% 5*4>%++-4("# <"**-%*+
PCs found lL demandlng Lo Lallor paLlenL educaLlon Lo meeL needs of lndlvldual paLlenLs and Lo balance glvlng necessary
lnformaLlon wlLh overloadlng paLlenLs.

! 8egardlng welghL managemenL advlce, PCs reporLed flexlblllLy ln Lhelr adherence Lo guldellnes and llnked welghL managemenL
advlce Lo glycaemlc conLrol. 1hey percelved LhaL Lhe PC/paLlenL relaLlonshlp affecLs adherence Lo advlce.
! lor self-managemenL advlce, PCs sLressed Lhelr alm Lo supporL paLlenLs Lo Lake ownershlp of Lhelr dlabeLes buL lL was
someLlmes easler Lo lncrease medlcaLlon Lhan Lo moLlvaLe paLlenLs Lo self-care.
! Cs felL LhaL prescrlblng for glycaemlc conLrol ls a nurslng role, buL nurses reporLed ofLen noL belng confldenL ln prescrlblng.
! Some Cs were Lralned Lo adhere Lo hlgher hyperLenslon LargeLs Lhan currenL guldance and saw lowerlng blood pressure Lo
currenL LargeL of 140/80 mmPg as a low prlorlLy.
! PCs descrlbed challenges ln accesslng formal Lralnlng ln fooL care for sLaff.

5",-%(, <"**-%*+
ulabeLes educaLlon was reporLed as group-based, ofLen some dlsLance away and lnconvenlenL for worklng paLlenLs. Clvlng advlce Lo
people wlLh no undersLandlng of Lhe lmporLance of dlabeLes was seen as challenglng.

! PCs descrlbed changlng healLh behavlours for welghL managemenL ln paLlenLs wlLh long-Lerm llfesLyle or moblllLy lssues as
dlfflculL. 1hey reporLed LhaL people wlLh unpredlcLable work schedules sLruggle Lo adhere Lo a healLhy llfesLyle.
! PCs percelved LhaL many of Lhelr paLlenLs do noL Lake prescrlbed medlcaLlon and felL paLlenLs were relucLanL Lo Lake addlLlonal
drugs when Lhey do noL feel lll.
! PCs reporLed LhaL poor paLlenL hyglene someLlmes makes paLlenLs relucLanL Lo have Lhelr feeL examlned.

?%#-6%*@ 4> ,0% A(,%*6%(,-4(
1he preference was for pracLlce-based Lralnlng, professlonally led, dellvered over lunchLlme or durlng dedlcaLed pracLlce learnlng
Llme.

Conc|us|on: Several barrlers Lo lmprovlng Lhe quallLy of care for people wlLh Lype 2 dlabeLes were ldenLlfled. We are developlng an
lnLervenLlon, uslng Laxonomy of behavlour change Lechnlques, Lo help cllnlclans overcome Lhese barrlers.



1993

ADC1ING A kCAC1IVL AkCACn 1C A1ILN1 SAIL1: CA1UkING DA1A LLLC1kCNICALL A1 1nL CIN1 CI CAkL
kaLhryn L. WenL
1,*
, Shaun McLeod
2
, Wendy Moncur
1
, kenny ScoLL
3

1
School of CompuLlng, unlverslLy of uundee,
2
AnaesLhesla,
3
ePealLh, nPS 1ayslde, uundee, unlLed klngdom


Cb[ect|ves: 1he prlmary ob[ecLlve of Lhls research ls Lo reduce human sufferlng resulLlng from avoldable errors ln cllnlcal care. 1hls
sLudy seeks Lo lmprove paLlenL safeLy Lhrough Lhe user cenLred developmenL of a sysLem whlch Lracks evldence-based pracLlce
provlded Lo paLlenLs ln a hosplLal seLLlng.

Methods: 1he ScoLLlsh aLlenL SafeLy rogramme alms Lo lmprove Lhe safeLy of hosplLal care ln ScoLland. 1hls programme has been
deslgned Lo develop real Llme daLa capLure sysLems Lo allow daLa Lo be produced LhaL reflecLs currenL work [3]. 1he currenL
approach Lo capLurlng Lhls daLa ls paper based. SlgnlflcanL resource ls requlred Lo collecL and collaLe Lhe lnformaLlon and compeLes
wlLh cllnlcal workload. 8esulLs are reporLed reLrospecLlvely. 1he poLenLlal for lnformaLlon Lechnology (l1) Lo lmprove paLlenL safeLy
has been unlversally recognlsed. user lnvolvemenL ls wldely acknowledged as a key facLor ln developlng usable and effecLlve l1
soluLlons. Powever, Lhe naLlonal nPS l1 programme has been crlLlclsed over Lhe lack of cllnlcal engagemenL [1]. SoluLlons wlLh poor
usablllLy noL only affecL Lhe raLe of adopLlon buL can lead Lo Lhe lnLroducLlon of errors [2]. A parLlclpaLory deslgn approach was used
ln Lhls sLudy Lo ensure LhaL Lhe end users were acLlvely engaged and lnvolved ln Lhe deslgn and developmenL of a novel l1 sysLem.
1hls sLudy was conducLed ln a Surglcal Plgh uependency unlL ln one of ScoLland's four Leachlng hosplLals. AL Lhe onseL of Lhe sLudy
a cllnlcal advlsory group was formed. 1hls group conslsLed of Lhe Pead of CrlLlcal Care nurslng, Senlor Charge nurse, Charge nurse,
lnfecLlon ConLrol nurse, Lead Surgeon for aLlenL SafeLy wlLhln Lhe nPS 1rusL, Lwo ConsulLanL AnaesLheLlsLs and a CrlLlcal Care
lellow. 8egular meeLlngs were held wlLh Lhe group. 1hese meeLlngs were used Lo ellclL Lhe user requlremenLs of Lhe sysLem,
evaluaLe rapld proLoLype deslgns and glve recommendaLlons for changes Lo Lhe deslgn.

kesu|ts: A proLoLype sysLem was deslgned and evaluaLed wlLh Lhe cllnlcal advlsory group. A Louch screen LableL pc was used Lo
lnpuL daLa allowlng docLors and nurses Lo capLure paLlenL safeLy daLa, relaLed Lo Lhe care of cenLral venous caLheLers, aL Lhe
paLlenL's bedslde. 1he proLoLype sysLem was evaluaLed ln parallel wlLh Lhe currenL paper sysLem ln a llve cllnlcal envlronmenL over
one monLh.

8esponse from Lhe evaluaLlon suggesLed LhaL:

! 1he elecLronlc sysLem made Lhe process for recordlng Lhe requlred lnformaLlon easler
! 1he sysLem was easy Lo use and people were confldenL uslng Lhe sysLem
! 1he sysLem supporLed real Llme daLa enLry
! SLaff were able Lo effecLlvely compleLe Lhelr cllnlcal work uslng Lhe sysLem
! SLaff dld noL feel LhaL Lhe sysLem Look longer Lhan Lhe paper sysLem or added Lo Lhelr workload.

Conc|us|on: A novel l1 sysLem was deslgned ln cooperaLlon wlLh Lhe end users. 1he proLoLype sysLem enabled daLa Lo be capLured
aL Lhe polnL of care. 1he cllnlclans llked Lhe compuLer sysLem and dld noL feel LhaL lL lnLerfered wlLh Lhelr workload. 1hls real Llme
daLa wlll allow cllnlclans Lo deLecL and reacL Lo adverse evenLs as Lhey occur enabllng a proacLlve approach Loward paLlenL safeLy.

keferences:
1. AlLmann, and Mlchael, !. (2011) Successful uellvery of lnformaLlon 1echnology ln Lhe nPS. 8MI, 343
2. Ash, !.S., 8erg, M and Colera, L. (2004) Some unlnLended Consequences of lnformaLlon 1echnology ln PealLh Care: 1he naLure
of aLlenL Care lnformaLlon SysLem-8elaLed Lrrors. 1be Iootool of tbe Ametlcoo MeJlcol lofotmotlcs Assoclotloo, 11,104-112.
3. Paraden, C and LelLch, !. (2011) ScoLland's Successful naLlonal Approach Lo lmprovlng aLlenL SafeLy ln AcuLe Care. neoltb
Affolts, 30(4), 733-763



199S

IMkCVLMLN1 CI NUCLLAk MLDICINL kCCLSSLS 1nkCUGn INICkMA1ICN 1LCnNCLCG ALICA1ICN
vlnlclus Menezes
1
, Marcos Machado
1,*
, ClelLon Cuelroz
1
, Adrlano vlgrlo
1

1
nuclear medlclne, PosplLal Sao 8afael, Salvador, 8razll


Cb[ect|ves: 1he lack of speclflc nuclear medlclne compuLerlsed Lools has llmlLed LraceablllLy, radlaLlon safeLy and quallLy
assurance managemenL. A sofLware proLoLype has been developed ln order Lo lmprove Lhe cllnlcal rouLlne, resources
managemenL, quallLy asslsLance and securlLy.

Methods: 1he relaLlonshlp beLween Lechnology and lnsLlLuLlonal daLa was analysed. 1he ma[or problems relaLed Lo
nuclear medlclne processes were hlghllghLed and compuLerlsed. 1he sysLem was creaLed based on Cnu Web 2.0 and
Lhe daLabase was based on MySCL for Lhe safe sLorlng of useful lnformaLlon. 1he sysLem was deslgned Lo be mulLl user
where every professlonal has access Lo speclflc lnformaLlon. AlgorlLhms Lo opLlmlse radlopharmaceuLlcal and
equlpmenL's usage were lncluded ln Lhe proLoLype. Moreover, Lhere ls a work llsL where ls posslble Lo ldenLlfy every
process of all paLlenLs ln an only screen. 1he sysLem was dlsLrlbuLed aL PosplLal So 8afael ln web and also porLable
verslons.

kesu|ts: 1he proLoLype has been a powerful Lool ln ldenLlfylng Lhe sources of errors ln Lhe processes, Lhe managemenL
of occupaLlonal doslmeLry and mlnlmlslng cosLs due Lo Lhe opLlmlsaLlon of lnpuL usage, schedule exams and worklng
Llmes. uaLa sLaLlsLlcs and lndlcaLors of performance have been generaLed Lo conLlnuously ldenLlfy posslblllLles of
lmprovemenL ln Lhe processes.

Conc|us|on: SofLware appllcaLlons released Lo oLher flelds have noL been effecLlve Lo nuclear medlclne managemenL
faclllLles. Cn Lhe oLher hand, Lhe proLoLype has shown lnformaLlon Lechnology ls a promlslng fleld Lo mlLlgaLe problems
ln nuclear medlclne processes, radlaLlon safeLy and quallLy assurance managemenL. CLher advanLages reslde ln Lhe fasL
manlpulaLlon and access Lo daLa reduclng human efforLs, lnLegraLed conLrol of lnformaLlon physlcally dlsLrlbuLed and
daLa sharlng. Cllnlcal daLa lndexlng allows lmprovlng Lhe quallLy of asslsLance by recognlslng speclflc populaLlon.

keferences:
Comlsso naclonal de Lnergla nuclear (CnLn) - CnLn- nn.3.01 ulreLrlzes 8slcas de roLeo 8adlolglca, 2003.
Sorenson !A, helps ML, Cherry S8. hyslcs ln nuclear Medlclne. 3nd ed. Saunders Co., 2003.
AnvlSA - Agncla naclonal de vlgllncla SanlLrla. 8esoluo 8uC n 38, 2008.
lALA - lnLernaLlonal ALomlc Lnergy Agency. SafeLy 8eporLs Serles n 40 - Applylng 8adlaLlon SafeLy SLandards ln nuclear
Medlclne, 2003.



1996

LVALUA1ICN CI 1nL IMLLMLN1A1ICN CI A ICUk-LAk NA1ICNAL nCSI1AL A1ILN1 SAIL1 kCGkAM IN 1nL NL1nLkLANDS
!anneke Schllp
1,*
, Carollen de 8lok
1
, Cordula Wagner
1

1
nlvLL, neLherlands lnsLlLuLe for PealLh Servlces 8esearch, uLrechL, neLherlands


Cb[ect|ves: 1o evaluaLe Lhe lmplemenLaLlon of flve safeLy Lhemes wlLhln a four-year naLlonal hosplLal paLlenL safeLy program ln Lhe
neLherlands.

Methods: ln 2008, a naLlonal hosplLal paLlenL safeLy program was sLarLed Lo lmprove paLlenL safeLy ln uuLch hosplLals. 1he safeLy
program focussed on 10 safeLy Lhemes, chosen Lhrough consulLaLlon wlLh experLs ln Lhe relevanL professlonal groups and medlcal
speclallsm. lor each safeLy Lheme a module was developed Lo supporL hosplLals wlLh Lhe lmplemenLaLlon of lnLervenLlons
concernlng Lhls Lheme. An observaLlonal prospecLlve sLudy was performed Lo evaluaLe Lhe quallLy of Lhe lmplemenLaLlon of Lhe
Lhemes. 1hls evaluaLlon sLudy was performed ln a represenLaLlve sample of 38 hosplLals, sLraLlfled by area and Lype of hosplLal,
durlng Lhe flnal year of Lhe safeLy program beLween november 2011 and uecember 2012. 1he presenL sLudy focussed on Lhe resulLs
of Lhe lmplemenLaLlon of flve Lhemes:

1) paln,
2) mlx-ups ln and among paLlenLs,
3) renal lnsufflclency,
4) medlcaLlon reconclllaLlon, and
3) admlnlsLraLlon of hlgh-rlsk medlcaLlon.

uurlng 10 monLhly vlslLs, Lhe lmplemenLaLlon of Lhe Lhemes was evaluaLed by paLlenL record research (Lheme 1, 3 and 4) or
observaLlons (Lheme 2 and 3) by Lralned research asslsLanLs. rocess lndlcaLors were formulaLed for each Lheme Lo evaluaLe Lhe
degree of lmplemenLaLlon of Lhls parLlcular Lheme. MulLllevel analysls was used Lo deLermlne lf Lhe percenLage of achlevemenL of
Lhe process lndlcaLors changed ln Lhe LoLal populaLlon and ln dlfferenL hosplLal Lypes (Leachlng versus non-Leachlng) durlng Lhe
sLudy.

kesu|ts: 1he ouLcomes of Lhe process lndlcaLors of Lhe flve safeLy Lhemes durlng Lhe 1-year follow-up were calculaLed. 1he mean
percenLage of paLlenL records/observaLlons meeLlng Lhe process lndlcaLors for Lhe flve Lhemes durlng Lhe follow-up are shown for
Lhe flrsL, medlan and flnal measuremenL ln 1able 1. lurLhermore, a mean percenLage for every process lndlcaLor durlng Lhe sLudy
was calculaLed and shown ln 1able 1. ulfferences were deLermlned beLween Lhe hosplLal Lypes ln meeLlng Lhe process lndlcaLors.

1ab|e 1. Mean percenLage paLlenL records or observaLlons meeLlng Lhe process lndlcaLors
1heme rocess |nd|cator 1=1 1=S 1=10 Cvera|| N
1. >3 posLoperaLlve paln measuremenLs 44 31 60 31 4206
2. CorrecLly execuLed 1C
1
before surgery 72 74 68 71 1281
3. PydraLlon of hlgh-rlsk paLlenL for Cln
2
64 69 67 67 337
4. MedlcaLlon reconclllaLlon durlng:
- Admlsslon

42

44

42

41

2137
- ulscharge 16 22 22 17 2813
3. CorrecLly performed bundle (9 lLems) of admlnlsLraLlon of
parenLeral drugs
23 8 24 19 2134
1
1C, Llme-ouL procedures,
2
Cln, conLrasL-lnduced nephropaLhy


Conc|us|on: AfLer a four year paLlenL safeLy program, ln whlch hosplLals gave a loL of aLLenLlon Lo Lhe lmporLance of paLlenL safeLy
Lhemes, Lhe lmplemenLaLlon of varlous safeLy Lhemes does noL seem Lo be opLlmally fulfllled ln uuLch hosplLals. 1he percenLage
paLlenL records/observaLlons meeLlng Lhe process lndlcaLors remalned relaLlvely sLable durlng Lhe 1-year follow-up for Lhe flve
Lhemes. SllghL dlfferences were observed beLween Leachlng and non-Leachlng hosplLals ln Lhe lmplemenLaLlon of Lhe safeLy Lhemes.
olnLs of aLLenLlon were formulaLed Lo achleve beLLer lmplemenLaLlon of Lhe safeLy Lhemes ln Lhe fuLure.

1998

1nL LMLkGLNC DLAk1MLN1S nAkMACLU1ICAL 1CCL8Ck IS U1 IN1C kAC1ICL 1C kLVLN1 ADVLkSL DkUG
IN1LkAC1ICNS AND kLAC1ICNS
Maura 8. krook
1,*
, Cunnar Chlen
2
, Susanne 8ergenbranL Clas
3

1
Lmergency ueparLmenL,
2
karollnska unlverslLy PosplLal SLockholm,
3
Medlcal ueparLmenL, norrLal[e PosplLal,
SLockholm, Sweden


Cb[ect|ves: coootetoctloq oJvetse Jtoq eveots ooJ ptovlJloq sofe pbotmoceotlcol ptoctlce fot tbe potleot lo ttooslt"
SeLLlng up gulde llnes, checkllsLs and devlaLlon analyses are essenLlal ln beneflLlng Lhe paLlenL, communlLy, and hosplLal
personnel. ManagemenL of Lhe paLlenL's medlcaLlon from Lhe Llme of admlsslon unLll dlscharge, securlng good
communlcaLlons regardlng Lhe paLlenL's medlcaLlon ln Pandovers beLween rlmary care and Lhe hosplLal, ls lmperaLlve
Lo susLaln paLlenL safeLy. 1he ma[orlLy of our older paLlenLs have a Lendency Lo move ln and ouL of Lhe healLh care
sysLem. AL lLs worsL Lhls Lype of yo-yo acLlvlLy undermlnes Lhe paLlenL's healLh and recovery, addlLlonally lL can have
deLrlmenLal economlc consequences for Lhe hosplLals and Lhe counLy councll.

Methods: ln order Lo prevenL Lhls paLLern from occurrlng we have Lo work on lmprovemenLs and work wlLh prevenLlng
re-admlsslons l.e.by assurlng safe pharmaceuLlcal pracLlce. 1he Lmergency deparLmenL aL Puddlnge has for many years
worked wlLh lmprovemenLs ln pharmaceuLlcal safeLy and paLlenL safeLy. uurlng 2009-2011 Lhe deparLmenL's
lmprovemenLs efforLs lnLenslfled, LesLlng dlfferenL meLhods/acLlvlLles/pro[ecLs.

ro[ecLs lnlLlaLed, uslng dlfferenL Lools and LargeLs ln order Lo reduce and counLeracL adverse drug reacLlons, slde
effecLs, lncorrecL drug prescrlblng began and Lo assure paLlenL safeLy ln LranslL. 1he deparLmenL managed Lo collecL ln
LoLal, 16 dlfferenL Lools ln counLeracLlng adverse drug reacLlons.

kesu|ts: 1he Loolbox has also glven Lhe Lmergency ueparLmenL a sLandardlsed, sLrucLured and unlque worklng process
hence opLlmlslng paLlenL safeLy ln relaLlon Lo drug relaLed lncldenLs. WhaL has been plvoLal ln Lhe ueparLmenL's paLlenL
safeLy ls our elecLronlc paLlenL [ournal sysLem momenLarlly belng lmplemenLed ln mosL of Lhe prlmary healLh care
faclllLles and ma[or hosplLals ln Lhe SLockholm counLy reglon. Cur focus has been on CeLLlng lL rlghL from Lhe
sLarL". 1hls ls one of Lhe Lmergency ueparLmenL's moLLos and one of Lhe hosplLals LargeL moLLos".

Conc|us|on: 1hese dlfferenL acLlvlLles have glven us a pharmaceuLlcal Loolbox", where speclflc Lools can be uLlllsed for
Lhe paLlenLs' lndlvldual and speclflc needs on dlfferenL occaslons. 1he Loolbox has also glven a sLandardlsed, sLrucLured
and unlque worklng process hence opLlmlslng paLlenL safeLy ln relaLlon Lo drug relaLed lncldenLs.
WhaL has been plvoLal ln Lhe deparLmenL's paLlenL safeLy ls our elecLronlc paLlenL sysLem.
Cur focus has been on CeLLlng lL rlghL from Lhe sLarL"

keferences:
lasLbom, !. (2003). ldre Lkemedel. lokos koppott, SLL, lorum fr kunskap och gemensam uLveckllng. lS8n 91-83209-
41-26.
krohwlnkel karlsson, Anna. Wlnberg, Pans. (2012). Leadlng PealLh Care 8eporL. l voq mot eo votJefoll stytoloq. nr l,
Clsson & Co.



2000

1nL ANALSIS CI 1C1AL UALI1 MANAGLMLN1 AND 1nL LIILC1IVLNLSS CI 1nL UALI1 AND A1ILN1 SAIL1
LDUCA1ICN kCGkAM
Psln-l Chlang
1,*
, Ll-lan Chen
1
, !la-lng Chang
1

1
nurslng ueparLmenL, naLlonal Cheng kung unlverslLy PosplLal, 1alnan, 1alwan


Cb[ect|ves: Applylng 1oLal CuallLy ManagemenL (1CM) can reduce medlcal errors, promoLe paLlenL safeLy, and
lncrease paLlenL saLlsfacLlon ln Lhe healLhcare. lmplemenLaLlon of Lhe quallLy educaLlon program ls ln order Lo enhance
Lhe nurses' knowledge and compeLency of applylng Lhose ln pracLlce. 1he ob[ecLlve of Lhe sLudy was Lo analyse Lhe
percepLlon, performance, and culLure of LoLal quallLy managemenL and lLs relaLed facLors and Lo predlcL Lhe facLors of
LoLal quallLy managemenL culLure ln nurslng dlvlslons. And furLher Lo evaluaLe Lhe effecLlveness of applylng Lhe quallLy
educaLlon program.

Methods: arLlclpanLs were recrulLed from a medlcal cenLer ln 1alwan and Lhe crlLerlon of lncluslon for nurse sLaffs was
LhaL Lhey had Lhe pracLlcal experlence for aL leasL Lhree monLhs. 1he measuremenLs of LoLal quallLy managemenL were
self-developed quesLlonnalres wlLh LoLal quallLy managemenL percepLlon, LoLal quallLy managemenL performance, and
LoLal quallLy managemenL culLure. uaLa were analysed wlLh SSS 17.0 for Wlndow. 1he analyses for descrlpLlve sLaLlsLlcs
were uslng mean, sLandard devlaLlon, frequency and so on. 1he analyses for lnferenLlal sLaLlsLlcs were L-LesL, one way
AnCvA and sLepwlse regresslon Lo predlcL Lhe ouLcomes. 1he sLudy deslgn ls Lhe one group pre-LesL-posL-LesL. 1he
parLlclpanLs were lnsLrucLed Lo lmplemenL Lhe quallLy educaLlon programs based on Lhelr nurslng cllnlcal ladders LhaL
programs lncludlng Lhe concepL of LoLal quallLy managemenL and paLlenL safeLy, Lhe esLabllshmenL of Lhe nurslng
sLandards, monlLorlng and evaluaLlng Lhe quallLy of nurslng wlLh seLLlng lndlcaLors by !CAPC 10 sLeps and uslng focus
uCA for quallLy lmprovemenL programs.

kesu|ts: 1he ma[or flndlngs ln Lhe sLudy were as Lhe follows: 1. Lhe mean scores of Lhe LoLal quallLy managemenL
performance for Lhe parLlclpanLs wlLh lmplemenLlng ln Lhe educaLlon Lralnlng programs was hlgher Lhan Lhose wlLhouL
parLlclpaLlng ln Lhe educaLlon Lralnlng programs slgnlflcanLly (mean: 31.3, Su: 6.6 versus mean: 48.3, Su: 7.7, p< .001), 2.
1he mean scores of Lhe LoLal quallLy managemenL culLure for Lhe parLlclpanLs wlLh lmplemenLlng ln Lhe educaLlon
Lralnlng programs was hlgher Lhan Lhose wlLhouL parLlclpaLlng ln Lhe educaLlon Lralnlng programs slgnlflcanLly (mean:
84.1, Su: 10.7 versus mean: 80.3, Su: 11.22, p< .001), 3. ln Lhe analysls of sLepwlse regresslon, Lhe LoLal quallLy
managemenL percepLlon (C8, .288, 93 Cl: .040- .337, p< .03) and LoLal quallLy managemenL performance (C8, .831,
93 Cl: .749- .933, p< .001) could predlcL Lhe LoLal quallLy managemenL culLure LhaL accounLed for 39of Lhe varlance ln
Lhe LoLal quallLy managemenL culLure (p< .001).

Conc|us|on: 1hls sLudy came Lo Lhe concluslon LhaL when Lhe hlgher Lhe LoLal quallLy managemenL percepLlon and Lhe
more Lhe LoLal managemenL performance, lL could be broughL ouL Lhe beLLer Lhe LoLal quallLy managemenL culLure. lL ls
recommended LhaL Lhe managers ln Lhe healLhcare can apply Lhe quallLy and paLlenL safeLy educaLlon programs Lo
enhance Lhe percepLlon of LoLal quallLy managemenL, and furLher, Lo promoLe Lhe performance and culLure of LoLal
quallLy managemenL.

keferences: ArmsLrong, C. L., Spencer, 1. S., & Lenburg, C. 8. (2009). uslng quallLy and safeLy educaLlon for nurses Lo
enhance compeLency ouLcome performance assessmenL: a synerglsLlc approach LhaL promoLes paLlenL safeLy and
quallLy ouLcomes. !ournal of nurslng LducaLlon, 48(12), 686-693. dol: 10.3928/01484834-20091113-02
1allb, l., 8ahman, Z., & Azam, M. (2011). 8esL pracLlces of LoLal quallLy managemenL lmplemenLaLlon ln healLh care
seLLlngs. neoltb Motketloq Ooottetly, 28(3), 232-232. dol: 10.1080/07339683.2011.393643


2002

A kCILC1 ICk IMkCVING CCkkLC1 AN1I8IC1IC USAGL kA1L ICk 1kLA1ING GkAM-NLGA1IVL 8ACILLUS (GN8) IN
nCSI1AL INA1ILN1S
Shu-1lng Chen
1,*
, !lan-Long Chen
2
, Shu-!u Puang
1

1
ueparLmenL of CuallLy ManagemenL,
2
ueparLmenL of lnLernal Medlclne, Landseed PosplLal, 1aoyuan, 1alwan


Cb[ect|ves: 8ecause Cram-negaLlve baclllus (Cn8) can lnduce sepsls, lL has Lo be LreaLed lmmedlaLely. 1hls pro[ecL ls
abouL Lhe pro[ecL's efforL on lmprovlng correcL anLlbloLlc usage raLe for LreaLlng Cn8 ln hosplLal lnpaLlenLs.

Methods:
1. 1o enhance correcL anLlbloLlc usage for LreaLlng Cn8, Cn8 LreaLmenL guldellnes were developed for docLors Lo use
as a cllnlcal sLandard for LreaLlng paLlenLs, and moreover, relevanL educaLlonal Lralnlng was also held for docLors. 1o
ensure anLlbloLlcs are correcLly prescrlbed for LreaLlng Cn8, paLlenLs' medlcal records were revlewed, and feedbacks
are glven lmmedlaLely.
2. SLraLegles for lmprovemenL were lmplemenLed ln AugusL, 2012.

a) Cards wlLh Cn8 LreaLmenL guldellnes were prlnLed and glven Lo docLors Lo use as a reference. uocLors also Look
educaLlonal Lralnlng relaLed Lo Cn8 LreaLmenL.
b) Medlcal records were revlewed Lo check lf docLors had glven Cn8 lnpaLlenLs correcL anLlbloLlcs. 1he revlew resulLs
were lmmedlaLely glven Lo docLors as feedbacks.

kesu|ts: 8efore Lhe lmplemenLaLlon of Lhe pro[ecL, Lhere were a LoLal of 61 Cn8 lnpaLlenLs ln Lhe hosplLal from !anuary
Lo lebruary 2012, and 46 of Lhem were glven correcL anLlbloLlc prescrlpLlon, so Lhe correcL anLlbloLlc usage raLe ln
lnpaLlenLs ls 73. AfLer Lhe lmplemenLaLlon of Lhe pro[ecL, Lhere were 22 Cn8 lnpaLlenLs beLween SepLember and
CcLober 2012, and 18 paLlenLs were glven correcL anLlbloLlc prescrlpLlon, so Lhe correcL anLlbloLlc usage raLe ln
lnpaLlenLs ls 82. 1hese cards wlLh Cn8 LreaLmenL guldellnes noL only enabled dlfferenL speclalLles and deparLmenLs Lo
LreaL Cn8 paLlenLs conslsLenLly and conLlnuously buL also promoLed correcL anLlbloLlc usage. 1hose feedbacks from Lhe
revlew of medlcal records also helped docLors ad[usL Lhelr anLlbloLlc usage. 1hese sLraLegles can ensure besL LreaLmenL
efflcacy for hosplLal lnpaLlenLs.

Conc|us|on: 1reaLlng lnpaLlenLs accordlng Lo Cn8 LreaLmenL guldellnes enhances correcL anLlbloLlc prescrlpLlon, so Lhe
lncldence of shock and sepsls can be reduced, medlcal expendlLure can be mlnlmlsed, and medlcal care quallLy can be
elevaLed.



200S

kLDUCL 1nL kLSIkA1Ck CAkL CLN1Lk'S CLN1kAL VLNCUS CA1nL1Lk-kLLA1LD 8LCCDS1kLAM INILC1ICN kA1L
Pul-Chl Chlen
1
, Cuo-Zhou Psueh
2
, Pslao-?u Llu
1,*

1
nurslng ueparLmenL,
2
ueparLmenL of lnLernal Medlclne, Landseed PosplLal, 1aoyuan, 1alwan


Cb[ect|ves: lL was found on SepLember 1, 2011 LhaL our cenLral venous caLheLer-relaLed bloodsLream lnfecLlon raLe had
soared Lo 26.7, much hlgher Lhan LhaL of peer hosplLals (13.2). 1herefore, Lhe ob[ecLlve was Lo reduce Lhe
8esplraLory Care CenLre's cenLral venous caLheLer-relaLed bloodsLream lnfecLlon raLe Lo peer hosplLals' average, 13.2.

Methods:
1. 1he 8esplraLory Care CenLer has a LoLal of 12 beds, and Lhe paLlenLs we LreaL rely on a resplraLor and have
Lransferred from Lhe lnLenslve care unlL aL our hosplLal or oLher hosplLals. 1helr bodles are usually lefL wlLh a cenLral
venous caLheLer, an endoLracheal Lube and a urlnary caLheLer, reLenLlon raLe of Lhe Lhree Lubes sLandlng aL 80.
2. 1he CenLre's average of hosplLallsaLlon days sLood aL 38.6, and lLs bloodsLream lnfecLlon raLe had been kepL aL a
hlgh level, so lL was necessary Lo remove Lhe cenLral venous caLheLer as soon as posslble (Chen, Chen, uong, Su,
Chen and Zheng, 2010). As a resulL, before enLerlng Lhe CenLer, from now on every paLlenL has Lo recelve a cenLral
venous caLheLer reLenLlon/removal assessmenL. lf a paLlenL needs Lo be LreaLed wlLh lnLravenous medlclnes,
perlpheral venous llne lnserLlon should be employed lnsLead so LhaL Lhe he or she can conLlnue Lo be LreaLed wlLh
medlclnes wlLhouL belng affecLed.
3. Meanwhlle, Lhe nuLrlLlon consulLanL wlLh Lhe CenLer should conducL an assessmenL, and dlscusslon wlLh Lhe
nuLrlLlon consulLanL should be held Lo assess and conflrm Lhe paLlenL's currenL nuLrlLlonal sLaLe. Also, Lhe paLlenL's
calorles lnLake should be lncreased by ralslng Lhe frequency of nasogasLrlc Lube feedlng.
4. ln accordance wlLh Lhe nuLrlLlon screenlng and assessmenL form as well as Lhe paLlenL's dlsease condlLlon, Lhe
docLor should assess lf Lhe paLlenL's cenLral venous caLheLer needs Lo be removed wlLhln Lwo days of hls or her
enLerlng Lhe CenLer (Marschall eL al, 2008).

kesu|ts: 1he cenLral venous caLheLer-relaLed bloodsLream lnfecLlon raLe decreased Lo 8.3 ln !anuary 2012 from 26.7
ln 2011.

Conc|us|on: A rafL of facLors ls behlnd ln-hosplLal bloodsLream lnfecLlon, and bedrldden paLlenLs who suffer from chronlc
lllnesses have weaker lmmunlLy, so Lhey belong Lo an especlally frall group, so Lo speak, ln Lhe hosplLal. When an lllness
ls ln an acuLe sLaLe, cenLral venous caLheLer lnserLlon serves as a necessary LherapeuLlc means. Powever, lf we could
remove unnecessary Lubes for paLlenLs as early as posslble, we could boosL proLecLlon from cenLral venous caLheLer-
relaLed bloodsLream lnfecLlon by 30 (ParbarLh, eL al, 2003, Marschall eL al, 2008). We suggesL LhaL group care and
dlscusslon be employed, and LhaL nuLrlLlon assessmenL and oplnlons regardlng paLlenLs' nuLrlLlonal needs be provlded
so as Lo allow paLlenLs Lo recover hls or her physlcal sLrengLh and have Lhelr unnecessary caLheLers removed as early as
posslble. Accordlng Lo Lhe flndlngs from Lhe execuLlon of Lhls pro[ecL, explorlng Lhe necesslLy of reLalnlng Lhe cenLral
venous caLheLer and removlng Lhe caLheLer as early as posslble can boLh help prevenL ln-hosplLal lnfecLlon effecLlvely.
Some unlLs belleve LhaL Lhe cenLral venous caLheLer should noL be removed unLll Lhe sLlpulaLed perlod ends so LhaL
medlcal personnel's workload and medlcal cosLs could be reduced. neverLheless, Lhls could lnsLead lncrease paLlenLs' ln-
hosplLal bloodsLream lnfecLlon raLe, maklng Lhlngs worse raLher Lhan beLLer. Popefully, beglnnlng wlLh Lhls 8esplraLory
Care CenLer, we could reduce Lhe number of unnecessary caLheLer reLenLlon Lo decrease Lhe ln-hosplLal lnfecLlon raLe so
as Lo malnLaln paLlenLs' safeLy and enhance Lhe quallLy of medlcal care.



2007

"8L11Lk CCCLkA1ICN - 8L11Lk CAkL DLLIVLk ICk 1nL IkAILLS1 LLDLkL"
Marle 8ergsLrm
1,*

1
Llderly Care ueparLmenL, PgersLen-Lll[eholmen dlsLrlcL admlnlsLraLlon, ClLy of SLockholm, PgersLen, Sweden


Cb[ect|ves: 1o lmprove cooperaLlon and lmplemenL new rouLlnes among healLh and soclal care glvers who are lnvolved
ln dellverlng care Lo Lhe frallesL elderly ln order Lo lmprove quallLy and cosL efflclency.

Methods: Managers and change agenLs from 12 parLlclpaLlng healLhcare and soclal care glvers (lncludlng prlmary care,
soclal care glvers, local hosplLal eLc.) have [olned LogeLher wlLh a naLlonally funded pro[ecL managemenL Leam ln
PgersLen-Lll[eholmen, a dlsLrlcL ln SLockholm, Sweden, wlLh 74 000 lnhablLanLs - 12 aged 63 or more. 1he pro[ecL has
focused on engaglng employees from Lhe lnvolved organlsaLlons ln deslgnlng seven speclal and sLrengLhened work
rouLlnes uslng Lean meLhodology, regardlng areas such as:

! lmproved rlsk assessmenL
! MedlcaLlon revlews
! MulLl-dlsclpllnary plannlng conferences
! lmproved dlscharge handover

A key aspecL has been developlng a green blnder LhaL follows Lhe paLlenL across all conLacLs. 1he rouLlnes have been
LargeLed Lowards Lhe frallesL elderly, lndlvlduals aged 63 or more wlLh soclal care dellvery ln Lhelr homes and:

! 1wo hosplLal sLays or more durlng Lhe lasL 12 monLhs and/or
! Pome healLh care wlLh aL leasL one vlslL every oLher week

1hese lndlvlduals make up for 6 of Lhose aged 63 or more ln Lhe dlsLrlcL and Lhey accounL for:

! 31 of Lhe counLy councll's healLhcare cosLs ln Lhe dlsLrlcL for lndlvlduals aged 63 or more
! 36 of Lhe dlsLrlcL's soclal care cosLs for home care for lndlvlduals aged 63 or more

1he group ls also hlghly dynamlc-more Lhan 30 leave or enLer Lhe group durlng a one year perlod.

ln order Lo follow lmprovemenL Lhe followlng measures are used:

! CusLomer/employee saLlsfacLlon based on randomly selecLed lnLervlews
! ercelved cooperaLlon beLween Lhe parLlclpaLlng organlsaLlons based on employee web quesLlonnalre
! of acuLe hosplLallsaLlons ln Lhe LargeL group over Llme
! of avoldable readmlsslons over Llme and compared Lo Lhe counLy of SLockholm
! of rlsk assessmenLs performed over Llme
! medlcaLlon revlews performed over Llme

kesu|ts: LvaluaLlon ls on-golng slnce !anuary 2012. rellmlnary resulLs show lncreased cusLomer saLlsfacLlon and
lncreased sense of collaboraLlon among employees.

Conc|us|on: 1he dlverslLy of acLors supporLlng Lhe elderly poses a challenge ln coordlnaLlng Lhe care Lo Lhe lndlvldual. lL
ls lmporLanL Lo lnvolve Lhe employees who work wlLhln a complex and dlverse organlsaLlonal conLexL who meeL Lhe
lndlvlduals ln order Lo flnd Lhe easlesL and besL soluLlons for collaboraLlon.


2009

LNnANCLD MLDICA1ICN SAIL1 - kLDUCING 1nL NUM8Lk CI MLDICA1ICN ADMINIS1kA1ICN LkkCkS 8 1nL ICU
NUkSLS
Pslao-?ou Llu
1,*
, !ln-Mel Zheng
1
, el-?lng Chlen
1
, Ll-Shl Lo
1

1
nurslng ueparLmenL, Landseed PosplLal, 1aoyuan, 1alwan


Cb[ect|ves: 8arcode medlcaLlon admlnlsLraLlon (8CMA) sysLem has been lmplemenLed Lo reduce medlcaLlon errors and
lmprove medlcaLlon safeLy. Cf Lhe LoLalled 17 medlcaLlon error evenLs ln our PosplLal beLween !anuary and May 2011,
11 occurred ln Lhe lnLenslve care unlLs (lCu), accounLlng for 64.7 of all evenLs. 1hls sLudy almed Lo acLlvely promoLe
medlcal care quallLy for paLlenLs by uslng a 8CMA sysLem.

Methods: 1he approaches Lo lmprove medlcaLlon safeLy were lmplemenLed as follows:
1. 1he nurslng carLs were lnLegraLed wlLh addlLlonal devlces Lo become compacL moblle nurslng carLs for medlcaLlon
admlnlsLraLlon. SLandard operaLlng procedures (SCs) and malnLenance pracLlces were also developed.
2. 8e-plannlng Lhe workflow ln medlcaLlon admlnlsLraLlon process. 8edslde Medlclne CablneLs were re-equlpped Lo be
CompacL Moblle MedlcaLlon nurslng CarLs. urug 8oxes for CurrenL use and 8eLurn urug 8oxes were used Lo replace
Lhe unclasslfled medlclne cablneLs for drug dlsposal. urug 8oxes for CurrenL use enabled Lhe nurses Lo prepare
medlcaLlons dlrecLly.
3. 1o enhance ease of use of Lhe 8CMA sysLem, wearlng barcode wrlsLband's was llmlLed Lo a flxed poslLlon on
paLlenL's hand Lo save nurses' Llme looklng for wrlsLbands. 1he phoLo mask was flxed Lo lnsLalled boxes Lo unLangle
workflow and lncrease nurses' convenlence and wllllngness Lo use.
4. 1he SCs for medlcaLlon admlnlsLraLlon were lamlnaLed and hung on Lhe slde of compacL moblle nurslng carLs Lo
faclllLaLe Lhe convenlence of readlng. 1eachlng maLerlals of medlcaLlon admlnlsLraLlon were prepared for on-Lhe-[ob
Lralnlng Lo lmprove medlcaLlon admlnlsLraLlon accuracy. Small-group Lralnlng was conducLed Lo lmprove Lhe skllls of
preparlng drugs and lncrease parLlclpaLlon and response. 1he ouLcomes were lncluded ln Lhe annual audlLs of
quallLy managemenL sysLem.
3. 8e-educaLlon programs wlLh Lhe knowledge abouL consequences of medlcaLlon errors were conducLed. All
colleagues acLlvely provlded poslLlve feedback and expressed Lhelr LhoughLs afLer waLchlng Lhe vldeos of news of
SlgnlflcanL MedlcaLlon Lrror LvenLs aL ward meeLlngs. 1he Pandbook for new Lmployees lncludlng Lhe dlsc wlLh
vldeo coples was used Lo lnculcaLe Lhe lmporLance of Check, and Check Agaln concepL of new employees, whlch was
also used ln Lhe pre-employmenL Lralnlng for new nurslng sLaff of lCu.

kesu|ts: 1he number of medlcaLlon error evenL was zero durlng Lhe lnLervenLlon lmplemenLaLlon beLween !une 2011
and uecember 2012.

Conc|us|on: 1he number of medlcaLlon error evenL was reduced, Lhe quallLy of cllnlcal care was lncreased, and Lhus
achleved Lhe goal of safe medlcaLlon admlnlsLraLlon for paLlenLs. AlLhough Lhe 8CMA sysLem has been consldered Lo be
an effecLlve nurslng lnformaLlon sysLem for reduclng medlcaLlon errors, room for lmprovemenL remalned. Cur hosplLal
conLlnues lLs commlLmenL Lo prevenLlng Lhe occurrence of medlcaLlon errors. 1he slmpllfled dlsplay screen for 8CMA
sysLem, operaLlng procedures and modlfled ComblnaLlon urugs lnLerface have been compleLed. Powever, currenLly
used drugs are noL all dlsplayed on Lhe screen of 8CMA sysLem and noL easlly accesslble Lo query. 1o faclllLaLe Lhe ease
of medlcal sLaff revlewlng, Lhe Labs of aLlenL's CurrenL MedlcaLlons were lncluded. lurLhermore, Lo sLrengLhen Lhe
ldenLlflcaLlon of dlfferenL medlcaLlon doses, Lhe doses of < 1 were hlghllghLed ln red, whereas Lhe doses of 1 were
hlghllghLed ln green for enhanclng dlsLlngulshablllLy. 8y Lhe approaches of conLlnuous lmprovemenL, consLrucLlng a safe
medlcal envlronmenL and prevenLlng medlcaLlon errors, we alm Lo malnLaln paLlenL safeLy and Lo enhance medlcal care
quallLy.

2011

S1kA1LGILS 1C kLDUCL UNLANNLD kL-ADMISSICNS 8 ALING 1LAM kLSCUkCL MANAGLMLN1
!ul-Llng Pung
1,*
, lu-lang Wu
1
, ?u-8u Puang
2

1
nurslng ueparLmenL,
2
ueparLmenL of CuallLy ManagemenL, Landseed PosplLal, 1aoyuan, 1alwan


Cb[ect|ves: CommunlcaLlon and cooperaLlon of Lhe medlcal Leams can resulL ln profound effecLs on Lhe ouLcomes of
paLlenLs. unplanned readmlsslon raLe ls used as an lmporLanL lndlcaLor of Lhe quallLy of medlcal care LhaL may reflecL
Lhe quallLy of care and less medlcal cosLs. 1he 14-day unplanned readmlsslon raLe ln our hosplLal has been hlgher Lhan
oLher hosplLals slnce 2010. 1herefore, Lhls sLudy almed Lo achleve a 30 decrease ln unplanned readmlsslon raLe by
applylng Lhe concepL of Leam resource managemenL.

Methods: An lnLegraLed pro[ecL Leam was organlsed and esLabllshed ln 2012. A hlgh 14-day readmlsslon raLe was
ldenLlfled afLer conducLlng medlcal record revlews and quesLlonnalre surveys. ln addlLlon Lo dlsease characLerlsLlcs,
many problems relaLed Lo organlsaLlonal and sysLemlc facLors were also assoclaLed wlLh readmlsslons, such as Lhe lack
of effecLlve communlcaLlon and comprehenslve dlscharge plannlng. 1herefore, Lhe concepLs of Leam resource
managemenL, lncludlng brlef, debrlef, shared menLal model, hand off, collaboraLlon, uLSC (descrlbe, express, speclfy,
consequences), feedback and eL al., were used as Lhe approaches of lmprovemenL sLraLegles for Lhe ueparLmenL of
Medlclne. 1hls pro[ecL was conducLed Lo lmprove Lhe medlcal record revlew process of readmlsslons, Lo promoLe Lhe
home-care skllls of prlmary careglvers of paLlenLs, Lo enhance Lhe knowledge on preparlng dlscharge of dlscharge
plannlng Leam, Lo enhance Lhe compleLeness of nurslng documenLaLlon, and Lo sLrengLhen cooperaLlon beLween Leams.

kesu|ts: 1he 14-day readmlsslon raLe was 2.33 afLer Lhe lmplemenLaLlon of Lhls pro[ecL. AlLhough an 11 decrease
reporLed lmprovemenL, Lhe ouLcomes noL yeL reached Lhe LargeLed value.

Conc|us|on: uesplLe falllng Lo reach Lhe LargeL value, decreases ln Lhe readmlsslon raLe and medlcal resource uLlllsaLlon
were achleved by Lracklng Lhe paLlenLs aL hlgh rlsk for readmlsslon Lhrough Leam cooperaLlon and conLlnuous
monlLorlng of lndlcaLors. 1he resulLs lndlcaLed lmprovemenL of paLlenL safeLy and Lhe quallLy of medlcal care. lL ls
suggesLed LhaL Lhls goal can be lncluded ln Lhe organlsaLlonal plans of oLher hosplLals and become Lhe paLlenL safeLy
focus.



2016

IAC1CkS ASSCCIA1LD WI1n 30-DA AND 1-LAk kL-ADMISSICN AND 1-LAk MCk1ALI1 kA1LS AI1Lk CI IN LS1CNIA
Cerll aaL-Ahl
1,*
, 8aul A. kllveL
1
, Pelle vlsk
1

1
ueparLmenL of ubllc PealLh, unlverslLy of 1arLu, 1arLu, LsLonla


Cb[ect|ves: 30 days readmlsslon afLer Cl (ercuLaneous coronary lnLervenLlon) ls a frequenLly used lndlcaLor for measurlng Lhe
quallLy of LreaLmenL. LsLonla (populaLlon 1.3 mllllon) has Lhree cenLral hosplLals performlng Cl and unLll now Lhe ouLcome of Cl
has noL been measured uslng lnLernaLlonal sLandards. 1hls sLudy almed Lo ldenLlfy facLors assoclaLed wlLh 30-days readmlsslon afLer
prlmary Cl, uslng admlnlsLraLlve daLabases, and concenLraLlng on Lhe lmpacL of co-morbldlLles.

Methods: uslng daLa from Lhe LsLonlan PealLh lnsurance, we ldenLlfled all 1966 Cl procedures conducLed ln 2008 ln LsLonla on
paLlenLs, who had noL been re-vascularlsed durlng Lhe prevlous 3 years. uemographlc characLerlsLlcs sLudled lncluded age and
gender, cllnlcal varlables lncluded all prlmary and concomlLanL dlagnoses and procedural characLerlsLlcs lncluded Lhe number of
sLenLs and lengLh of hosplLal sLay. We used mulLlvarlaLe loglsLlc regresslon models Lo esLlmaLe Lhe rlsk facLors LhaL conLrlbuLe Lo Lhe
30-day readmlsslon. ln addlLlon, Lhe assoclaLlon beLween 30-day readmlsslon and 1-year morLallLy was analysed by applylng Cox
proporLlonal hazards models wlLh readmlsslon as a Llme-dependenL covarlaLe and by uslng landmark analysls. 1he maln ouLcome
measures were all cause 30-day readmlsslon Lo any hearL dlsease hosplLallsaLlon followlng Cl and 1-year morLallLy.

kesu|ts: 1he loglsLlc regresslon analysls provlded us wlLh Lhe slgnlflcanL facLors LhaL lnfluence Lhe 1-year readmlsslon and 1-year
morLallLy. 1he analysls ls conducLed on lnfarcL and wlLhouL lnfarcL paLlenLs. 1he hlghesL rlsk facLors LhaL conLrlbuLe Lo readmlsslon
among lnfarcL paLlenLs ls dlabeLes wlLh compllcaLlons (C8=2.9) and prevlous dlagnosls of hearL fallure (C8 = 2.4). 1he hlghesL rlsk
facLors among non-lnfarcL paLlenLs for 1-year readmlsslon ls pepLlc ulcer dlsease (C8 = 6.4) and renal dlseases (C8 = 6.2).

1oLal number of readmlsslons ln one year ls 173 (9) paLlenLs. 1 year morLallLy afLer Cl was 3.2 of paLlenLs noL readmlLLed ln 30-
days and among Lhose wlLh readmlsslon 1.9. 1hus, Lhe morLallLy ls slgnlflcanLly hlgher among paLlenLs noL readmlLLed (p=0.00).

Conc|us|on: lmporLanL rlsk facLors for 30-day, 1 year readmlsslon and 1 year morLallLy afLer prlmary Cl are age and comorbldlLles
(especlally dlabeLes wlLh compllcaLlons). 1hese resulLs are slmllar ln boLh wlLh and wlLhouL Ml paLlenLs.
1he numbers of rlsk facLors LhaL aLLrlbuLe Lo Ml paLlenLs groups are hlgher Lhan for wlLhouL Ml paLlenLs. 1hls resulL ls expecLed, as
Lhese paLlenLs are already ln a more serlous condlLlon.

lor several rlsk facLors, Lhe odds raLlos were relaLlvely hlgh buL wlLh large confldence lnLervals. 1hls could be aLLrlbuLed Lo raLher
small samples for some quallLy lndlcaLors.

Compared Lo oLher sLudles, Lhls sLudy could noL conflrm LhaL such poLenLlal rlsk facLors as gender, average lengLh of sLays, repeaLed
revascularlsaLlon and use of sLaLln have sLaLlsLlcally slgnlflcanL conLrlbuLlon Lo rlsk.

keferences:
1. 1.Saman 8, !an -C, Menko-!an 8, eL al. redlcLors of 30-day and 1-year morLallLy afLer prlmary percuLaneous coronary
lnLervenLlon for S1-elevaLlon myocardlal lnfarcLlon. Coronary ArLery ulsease 2009, vol 20 no 6:413-421.
2. khawa[a l.!, Shah n.u, Lennon 8.!, eL al. lacLors AssoclaLed WlLh 30-uay 8e-admlsslon 8aLes AfLer ercuLaneous Coronary
lnLervenLlon. Arch lnLern Med. 2012, 172(2):112-117.
3. Pannan L.L, Zhong ?, krumholz P, eL al. 30-uay 8eadmlsslon for aLlenLs undergolng ercuLaneous Coronary lnLervenLlons ln
new ?ork SLaLe. Cardlovascular lnLervenLlons 2011, vol 4 no 12:1333-42.



2029

1nL WCkk LNVIkCNMLN1 ICk nIV-kLLA1LD SLkVICL DLLIVLk IN 2AM8IA: DCLS A UALI1 ASSUkANCL kCGkAM
CnANGL kCVIDLkS' LkCL1ICNS?
Lva 8azanL
1
, SLephanle 8elnhardL
2
, Suprlya Sarkar
2
, !oyce Mulllo
3,*

1
MonlLorlng, LvaluaLlon and 8esearch,
2
Clobal rogram CperaLlons, !PlLCC, An AfflllaLe of !ohns Popklns unlverslLy,
8alLlmore, unlLed SLaLes,
3
uefence lorce Medlcal SysLem, Zamblan uefence lorces, Lusaka, Zambla

Cb[ect|ves: 1he perspecLlves of healLh provlders, key acLors ln quallLy assurance, are lmporLanL Lo measure. rovlders
can shed llghL on Lhe lndlvldual and exLernal facLors affecLlng servlce dellvery from prolonged experlence. 1he alm ls Lo
deLermlne Lhe assoclaLlon of Lhe SLandards-based ManagemenL and 8ecognlLlon (S8M-8) program, led by !hplego wlLh
Lhe Zamblan uefence lorces (Zul), wlLh provlders' hlgher raLlngs of work envlronmenL and quallLy of Plv-relaLed
servlces.

Methods:
! ueslgn and Sample: ln a quasl-experlmenLal deslgn, Lhe sLudy collecLed daLa before and afLer Lhe 1.3 year
lnLervenLlon. lour Zul lnLervenLlon slLes and four maLched comparlson slLes (8 LoLal slLes) parLlclpaLed. All healLh
care provlders offerlng M1C1 and A81 follow up were asked Lo parLlclpaLe. 103 provlder lnLervlews were
conducLed (27 aL basellne and 33 aL end llne ln lnLervenLlon group & 16 aL basellne and 29 aL end llne ln comparlson
group).
! lnLervenLlon: 1he lnlLlal 3-day orlenLaLlon lnvolved assessmenL uslng checkllsLs, analyslng rooL causes, developlng
acLlon plans, and coachlng provlders. Zul and !hplego sLrengLhened supplles and equlpmenL and conducLed a 6-day
on-slLe Lralnlng. SupporLlve supervlslon and coachlng conLlnued. CommunlcaLlon wlLh Zul and donors led Lo
sLrucLural changes.
! uaLa collecLlon: 1ralned, exLernal assessors (mldwlves) used a Lool based on Lhe Workplace CllmaLe and !ob
SaLlsfacLlon Survey.
! CuLcome varlables and analysls: rovlders' work envlronmenL and confldence ln skllls and percelved quallLy of
several Plv servlces were Lhe ouLcomes. Lach lLem was raLed 1 Lo 3 (sLrongly dlsagree Lo sLrongly agree). Changes
were flrsL compared wlLhln each group uslng a L-LesL. nexL, mulLlvarlaLe llnear regresslon was used Lo model
ouLcomes as a funcLlon of group, Llme polnL, and lnLeracLlon of Lhese Lwo Lerms -- conLrolllng for provlder cadre and
ad[usLlng for wlLhln-faclllLy clusLerlng.

kesu|ts: ln Lhe lnLervenLlon group (l-qtoop), Lhe share of non-cllnlcal sLaff rose from 30 Lo 33 from basellne Lo end
llne, and ln comparlson group (c-qtoop), from 0 Lo 30. ln l-group, parLlclpanLs Lralned ln M1C1 rose from 41 Lo
76 from basellne Lo end llne (p=.006), whlle ln c-group decllned from 63 Lo 26 (p=.022). Powever, boLh groups
reporLed an lncrease ln recelpL of 2+ supervlslon vlslLs ln pasL 6 monLhs. Cn 3 of 9 aspecLs of work envlronmenL and
confldence, l-group raLlngs lncreased over Llme (adequacy of drugs/supplles (p=.02), adequacy of equlpmenL (p=.004),
recelpL of consLrucLlve feedback (p=.01), confldence ln crlLlcal skllls (p=.008), and provlder noL feellng lsolaLed (p=.02)).
Conversely, ln c-group, scores on 2 of 9 lLems sLarLed hlgh and decllned slgnlflcanLly, none lncreased. ln mulLlvarlaLe
analysls, Lhe lnLeracLlon Lerm was slgnlflcanL (p=.004 Lo .038) on 3 lLems, lndlcaLlng Lhe changes beLween groups were
sLaLlsLlcally dlfferenL. ln l-group, percelved quallLy lncreased ln 3 areas, for A81 LreaLmenL readlness, A81 lnlLlaLlon, A81
follow-up, M1C1 and LaboraLory (p=.001 Lo .01). ln c-group, percelved quallLy also lncreased ln 3 areas for A81
LreaLmenL readlness, A81 lnlLlaLlon, and LaboraLory (p=.01 Lo .03).

Conc|us|on: 1he S8M-8 group's provlder raLlngs lmproved slgnlflcanLly on 3 of 9 aspecLs of work envlronmenL and
confldence, whlle Lhe c-group decllned slgnlflcanLly on 2 aspecLs. uesplLe Lhls, Lhe c-group's lncreases ln percelved
quallLy of Plv servlces may be relaLed Lo conLlnued supervlslon. luLure evaluaLlons should examlne Lhe relaLlonshlp of
provlder raLlngs of work envlronmenL, reLenLlon and moLlvaLlon.

2031

kCMC1ING LIILC1IVL GCVLkNANCL 1C SUCk1 SAIL nIGn UALI1 CAkL
Mark 8randon
1,*
, Lyn lrwln
1

1
Aged Care SLandards and AccredlLaLlon Agency LLd, arramaLLa, AusLralla


Cb[ect|ves: 1o lmprove safeLy and quallLy of care and servlces ln long Lerm care homes by asslsLlng members of
governlng boards Lo lncrease Lhelr undersLandlng, knowledge and appllcaLlon of: governance prlnclples and pracLlces,
Lhelr roles and responslblllLles under relevanL leglslaLlon, Lhe accredlLaLlon sLandards and processes, and conLlnuous
lmprovemenL and performance managemenL Lools.

Methods: 1he Aged Care SLandards and AccredlLaLlon Agency's (ACSAA) role ls Lo promoLe hlgh quallLy care and servlces
Lhrough accredlLaLlon and provldlng Lralnlng Lo Lhe long Lerm care secLor. Many boards ln AusLralla's long Lerm secLor
are LranslLlonlng from a commlLLee or board of managemenL Lo a governlng board. 1o asslsL members of governlng
bodles Lo lncrease Lhelr undersLandlng and knowledge of Lhelr roles and responslblllLles Lhe Agency lnlLlaLed and funded
Lhe research and developmenL of a governance educaLlon package. An evaluaLlon of Lhe package was underLaken Lo
deLermlne lf lL meL Lhe needs of board members and Lo ldenLlfy areas for lmprovemenL.
uaLa collecLlon lnvolved:

! ln-depLh lnLervlews wlLh board members, Chlef LxecuLlve Cfflcers and senlor managers of long Lerm care homes
(n=13) and consulLanLs ln governance and leadershlp (n=2) who had been lnvolved ln developlng and dellverlng Lhe
package.
! LlecLronlc survey of represenLaLlves of organlsaLlons who had obLalned Lhe package (n=220, response raLe 28).
1he survey collecLed quanLlLaLlve and quallLaLlve daLa abouL: Lhe demographlc feaLures of respondenLs, level of
board members' knowledge of governance, and Lhelr roles and responslblllLles under relevanL leglslaLlon, pre and
posL educaLlon sesslons, Lhe componenLs of Lhe educaLlon package LhaL was mosL useful, and barrlers Lo lLs use.

kesu|ts: Analysls of Lhe survey responses revealed: Chlef LxecuLlve Cfflcers lnlLlaLed and faclllLaLed mosL of Lhe Lralnlng
sesslons (46.4), dlfferences beLween Lhe roles and responslblllLles of Lhe managemenL Leam and Lhe governlng body
were noL well undersLood, 82 of respondenLs belleved underLaklng Lhe educaLlon sesslons lncreased board members
undersLandlng of Lhe dlfferences beLween managemenL and governance roles, 72 reporLed Lhe sesslons asslsLed Lhe
board Lo assess lLs performance agalnsL leglslaLlve and regulaLlve requlremenLs, and Lhe ma[orlLy of respondenLs (61)
reporLed Lhe sesslons asslsLed Lhe board Lo prlorlLlse Lhelr program of work and develop an acLlon plan.
1hemaLlc analysls of Lhe lnLervlews and survey commenLs revealed LhaL Lhe ma[or barrlers Lo board members
underLaklng educaLlon and Lralnlng Lo develop Lhelr governance skllls and knowledge was an unwllllngness or lnablllLy Lo
commlL sufflclenL Llme Lo underLake Lhe Lralnlng, and/or a relucLance Lo recognlse and acknowledge deflclencles ln Lhelr
skllls and knowledge. arLlclpanLs noLed Lhe advanLages of uslng an exLernal consulLanL Lo faclllLaLe Lhe Lralnlng sesslons
because of Lhelr experLlse and knowledge of governance and Lhe lndusLry, and Lhelr ablllLy Lo asslsL organlsaLlons Lo use
Lhelr llmlLed Llme mosL effecLlvely.

A recenL revlslon has modularlsed Lhe package Lo provlde greaLer flexlblllLy Lo address Llme consLralnLs, and a scheme of
accredlLed faclllLaLors Lo dellver Lhe package has been developed.

Conc|us|on: An effecLlve governance framework supporLs Lhe dellvery of safe and hlgh quallLy servlces. 1hls ls
acknowledged by accredlLaLlon sLandards LhaL requlre servlces Lo meeL governance relaLed crlLerlon. AlLhough Lhe
framework and prlnclples of governance are belng lncreaslngly undersLood Lhese prlnclples and Lhelr lmpllcaLlons
remaln a challenge for some on governlng boards. 1he educaLlon package seeks Lo address Lhls challenge and hlghllghL
Lhe llnk beLween good governance and quallLy care.


2048

UALI1 INDICA1CkS CN kLVLN1ICN AND CAkL CI CS1-Ak1UM nALMCkknAGL IN IkANCL
Sandrlne Morln
1,*
, Sophle Cuerln
1
, lrancls uech
2
, Sophle Culllaume
3

1
naLlonal AuLhorlLy for PealLh, SalnL uenls La lalne,
2
lrench College of CbsLeLrlclans & CynaecologlsLs,
3
lrench College
of Mldwlfes, arls, lrance


Cb[ect|ves: osLparLum haemorrhage ls Lhe leadlng cause of maLernal morLallLy ln lrance. 1he ma[or facLor ln Lhe
adverse ouLcomes assoclaLed wlLh severe haemorrhage ls Lhe Llme for lnlLlaLlng approprlaLe managemenL. 1he alm of
Lhe sLudy was Lo assess Lhe resulLs of Lhe flrsL lrench generallsaLlon of process quallLy lndlcaLors.

Methods: ln 2012, all lrench maLernlLy unlLs gaLhered for Lhe flrsL Llme quallLy lndlcaLors (Cls) on prevenLlon and lnlLlal
care of posLparLum haemorrhage (P). 1hls collecLlon was organlsed by Lhe lrench naLlonal AuLhorlLy for PealLh and
concerned 3 Cls: 2 Cls relaLed Lo lmmedlaLe prevenLlon of P afLer dellvery: one concernlng mlnlmal monlLorlng afLer
blrLh ln dellvery room, Lhe oLher early admlnlsLraLlon of oxyLocln aL Lhe Lhlrd sLage of labour. 3 Cls relaLed Lo lnlLlal care
of P: dlagnosls (hour and volume of bleedlng aL Lhe Llme of dlagnosls), lnner-uLerlne gesLure and anLl-blo prophylaxls.
1he ob[ecLlve of Lhese Cls ls Lo lmprove paLlenL safeLy durlng dellvery and Lo make decrease Lhe number of serlous P.

All 336 lrench maLernlLy unlLs audlLed reLrospecLlvely 60 dellvery records and 60 P records of 2011, based on a
random selecLlon of paLlenL records. 31 032 dellvery records were analysed, as well as 17 830 P records (noL all
maLernlLles had 60 P records Lo collecL). Means of Cls were compuLed for each maLernlLy unlL. Mlsslng elemenLs
were examlned for lmprovemenL acLlons. Cls allowed lnLer-maLernlLy unlLs comparlson and follow-up overLlme and wlll
be publlcly reporLed ln 2013 (2012 daLa soon avallable).

kesu|ts: Cnly 3 paLlenLs' records ouL of 10 comply wlLh all quallLy and securlLy crlLerla on P prevenLlon. naLlonal
means were 67 for oxyLocln", 41 for mlnlmal monlLorlng". 1here was no Lrack or prophylaxls by oxyLocln ln 20 of
paLlenLs' records, even Lhough lL ls consldered as a ma[or elemenL of prevenLlon of P. Concernlng Cls on care of P,
naLlonal means were 64 for P dlagnosls" (Llme Lo care of paLlenLs ls lmporLanL), 90 for lnner-uLerlne gesLure" and 79
for anLl-blo prophylaxls". AlmosL 4 paLlenLs' records ouL of 10 complled wlLh all crlLerla necessary for P care. lnLer-
maLernlLy unlLs and lrench admlnlsLraLlve areas varlablllLy's were observed for all Cls.

Conc|us|on: Low 2011 naLlonal resulLs are unexpecLed. Powever, analysls of Lhese Cls allowed maLernlLy unlLs Lo assess
Lhelr pracLlce ln dellvery room, Lo compare Lhemselves Lo several references and Lo lmplemenL lmprovemenL acLlons lf
necessary. 1wo lmporLanL resulLs are expecLed followlng lmplemenLaLlon of Lhese Cls: flrsL, a decrease of Lhe number of
serlous P Lhrough beLLer managemenL of Lhls undeslrable evenL, second, a beLLer prevenLlon and a decrease of Lhe
number of P Lhrough a beLLer monlLorlng of Lhls rlsk perlod. 1o compleLe Lhe assessmenL of Lhe P managemenL,
Lhe raLe of P wlll be valldaLed for comparaLlve measure and would be lnLeresLlng ln order Lo compare Lhls daLa Lo
process Cls Lo follow pracLlces lmprovemenL.



2049

1nL WCkkILCW CI nLAL1n kCVIDLkS A1 AN1LNA1AL CLINICS IN A kLSCUkCL LIMI1LD AIkICAN SL11ING
naLhan Mensah
1, 2,*
, lellx Sukums
1, 3
, AnL[e 8lank
1
, WalLer L. Paefell
1

1
ueparLmenL of Cllnlcal harmacology and harmacoepldemlology, Medlzlnlsche kllnlk (krehl kllnlk), unlverslLy PosplLal
of Peldelberg, lm neuenhelmer leld 410, u - 69120, Peldelberg, Cermany,
2
navrongo PealLh 8esearch CenLre,
navrongo, Chana,
3
ulrecLoraLe of lnformaLlon and CommunlcaLlon 1echnology, Muhlmblll unlverslLy of PealLh and
Allled Sclences, uar Ls Salaam, 1anzanla, unlLed 8epubllc of


Cb[ect|ves: uesplLe Lhe greaL poLenLlal for lmprovlng safeLy and quallLy of healLh care by CompuLerlsed ueclslon
SupporL SysLems (CuSS), workflow lssues are among Lhe slgnlflcanL challenges whlch need Lo be closely observed and
addressed durlng lmplemenLaLlon of such a sysLem. CuSS ls one of Lhe lnLervenLlon Lools Lo be LesLed by Lhe CuALMA1
pro[ecL almed aL lmprovlng Lhe quallLy of maLernal and neonaLal care ln selecLed dlsLrlcLs of Lhree sub-Saharan Afrlcan
counLrles. CuSS may have an lmpacL on Lhe workflow of healLhcare provlders and needs Lo be well embedded ln Lhere
Lo be effecLlve. 1hls sLudy evaluaLed Lhe workflow paLLern before lmplemenLaLlon of a CuSS aL AnLenaLal Cllnlcs (AnC) ln
resource llmlLed dlsLrlcLs ln Chana and 1anzanla.

Methods: A dlrecL observaLlon, Llme moLlon sLudy was conducLed ln lnLervenLlon and non-lnLervenLlon CuALMA1
pro[ecL slLes. A researcher and an asslsLanL observed AnC provlders ln 12 prlmary healLh faclllLles from an unobsLrucLed
poslLlon and recorded sLarL and end Llme and Lhe sequence of Lask caLegorles performed uslng a sLrucLured daLa
capLurlng Lool and a sLopwaLch. rovlders were lnLervlewed aL Lhe end of Lhe observaLlon Lo valldaLe Lhe observaLlons.

kesu|ts: Cverall 214 observaLlons (144 ln Chana, 70 ln 1anzanla) were carrled ouL and 12 ma[or Lask caLegorles were
recorded. 1he sequence of evenLs was hlghly varlable and dlffered beLween healLh cenLers. 1he Lasks wlLh Lhe mosL
varlable poslLlon ln Lhe LreaLmenL paLh were physlcal examlnaLlon, vlLal slgns assessmenL, obsLeLrlc examlnaLlon,
prevenLlve drug admlnlsLraLlon, and cllenL educaLlon wlLh 84.3 cllenLs of flrsL AnC vlslLs educaLed ouL of sequence. 1hls
ls due Lo mass educaLlon of cllenLs ln some cllnlcs Lo save Llme. lf only Lhe mosL frequenL consulLaLlon Lype (flrsL AnC
vlslL) was analysed (33.0 of all vlslLs), slgnlflcanL devlaLlons from Lhe guldellne, whlch deflnes anLenaLal care acLlvlLles,
were observed: only 30.0 of Lhe requlred laboraLory analyses (flrsL AnC vlslL) were performed and pregnanL women on
average spenL 1.3 hours on laboraLory lnvesLlgaLlons. ulfflculLles wlLh Lhls Lask are mosLly due Lo lack of equlpmenL's,
reagenLs or sLaff. Comparlson of Lhe resulLs ln Lhe Lwo counLrles revealed only mlnor dlfferences wlLh a Lrend Lowards
more frequenL educaLlon ln 1anzanla (93.7) compared Lo Chana (77.8).

Conc|us|on: aLhways ln Lhe AnC process vary. LaboraLory lnvesLlgaLlons were rare and Look much Llme. lurLher
lnvesLlgaLlons are needed Lo ldenLlfy Lhe causes of delay ln performlng Lhls Lask. 8e-sLrucLurlng Lhe order of performlng
some Lasks may beneflL Lhe cllenL and Lhe provlder and lmprove Lhe quallLy of care.



20S2

A1ILN1 SAIL1 IN CANCLk CAkL - IkCM kNCWING 1C DCING
PenrleLLe Llpczak
1,*
, LoLLe L. 8nfeldL
1
, !anne L. knudsen
2
, 1orben alshof
3

1
CuallLy & aLlenL SafeLy,
2
uanlsh Cancer SocleLy,
3
uanlsh MulLldlsclpllnary Cancer Croups, Copenhagen, uenmark


Cb[ect|ves: 1he alm of Lhe work has been Lo recommend and lnlLlaLe acLlons Lo enhance safeLy for cancer paLlenLs ln
uenmark ln a process lnvolvlng sLakeholders ln uanlsh cancer care.

Methods: 46 persons represenLlng 22 sLakeholders were gaLhered ln a naLlonal Lask force. 1he group lncluded cancer
paLlenLs and represenLaLlves from medlcal cancer grouplngs lncludlng general pracLlLloners, oncologlsLs, surgeons,
speclallsL nurses, represenLaLlves from all flve healLh reglons, deslgnaLed experLs, uanlsh MulLldlsclpllnary Cancer
Croups and Lhe uanlsh Cancer SocleLy. revlous works on safeLy problems ln uanlsh cancer care were used as a basls for
Lhe work (1). Seven subgroups were esLabllshed around safeLy challenges relaLed Lo chemoLherapy, radlaLlon Lherapy,
hosplLal acqulred lnfecLlons, LranslLlons, posL LreaLmenL Lra[ecLory, paLlenL lnvolvemenL ln safeLy and monlLorlng of
paLlenL safeLy parameLers. 1he subgroups were all commlssloned Lo Lhe same Lask: descrlbe Lhe mosL lmporLanL safeLy
problems and recommend acLlons Lo enhance paLlenL safeLy ln uanlsh cancer care.

kesu|ts: uurlng a one year perlod each of Lhe seven subgroups ldenLlfled and prlorlLlsed rlsks as well as descrlbed and
proposed prevenLlve acLlons relaLed Lo Lhelr speclflc Lheme. CuLpuL from each of Lhe seven subgroups varled ln boLh
conLenL and number. Some focus areas were addressed by more Lhan one group, e.g. paLlenL lnformaLlon and supporL,
paLlenL access Lo Lhelr own medlcal record, organlsaLlonal anchorlng of paLlenL safeLy ln Lhe cllnlcal envlronmenL, need
for l1 supporL, access Lo and use of exlsLlng paLlenL safeLy daLa as well as Lhe use of paLlenL reporLed ouLcome measures.
1he recommendaLlons addressed varlous levels and auLhorlLles wlLhln Lhe uanlsh healLhcare sysLem. CuLpuL from all
subgroups was gaLhered and Lhe LoLal of 43 recommendaLlons was prlorlLlsed and handed over Lo Lhe naLlonal hosplLal
operaLors. lmplemenLaLlon of some recommendaLlons may be lnlLlaLed lmmedlaLely, oLhers may be puL lnLo process
laLer.

Conc|us|on: A dlsease speclflc approach Lo safeLy enhancemenL ls rewardlng. CaLherlng sLakeholders across Lhe
conLlnuum of cancer care holds Lhe poLenLlal Lo presenL safeLy enhanclng lnlLlaLlves LhaL cuLs across Lhe sllos of care. A
naLlonal, mulLldlsclpllnary and dlsease speclflc Lask force provldes a forum where parLles wlLh dlfferenL poslLlons ln Lhe
cancer paLlenL Lra[ecLory can meeL and dlscuss safeLy aspecLs LhaL are noL addressed elsewhere. lL supporLs Lhe
awareness of paLlenL safeLy ln cancer care as a common lnLeresL LhaL should be enhanced Lhrough speclflc lnlLlaLlves and
Lhrough furLher developmenL of safeLy culLure. 1he naLlonal Lask force helps sLakeholders Lo undersLand Lhe Lasks and
challenges ln dlfferenL parLs of Lhe paLlenL Lra[ecLory and enables replacemenL of local plecemeal soluLlons wlLh naLlonal
lnlLlaLlves. Accordlng Lo Lhe Lask force ranklng 'Lop-3- recommendaLlons' were relaLed Lo:

1) enhancemenL of Lhe quallLy of LranslLlons durlng Lhe cancer paLlenL Lra[ecLory,
2) reducLlon of errors ln prescrlpLlon and dellverlng of chemo- and radlaLlon Lherapy, and
3) reducLlon of lnfecLlons relaLed Lo surgery and chemoLherapy.

ConLenLs of Lhese and Lhe remalnlng recommendaLlons can be shared aL Lhe conference. Many safeLy problems ln
cancer care are slmllar Lo safeLy problems ln oLher dlsease groups hence Lhe descrlbed efforLs and Lhe poLenLlal safeLy
galn may be generallsed Lo oLher Lypes of paLlenLs.

keferences:
1. Llpczak P, knudsen !L, nlssen A. SafeLy hazards ln cancer care: flndlngs uslng Lhree dlfferenL meLhods. 8M! Cual Saf
2011 uec,20(12):1032-6.


2062

IMLLMLN1A1ICN CI 1nL CkI1ICAL A1ILN1 kC1CCCL IN INA1ILN1 UNI1 IkCM 8kA2IL U8LIC 1LACnING SCnCCL
nCSI1AL
Carollne L. C. Sllva
1
, Carlos AnLunes
1,*
, Marla L. 1elxelra
2

1
urgency unlL,
2
lnLenslve Care unlL, Sumare SLaLe PosplLal, Sumare, 8razll


Cb[ect|ves: uurlng hosplLallsaLlon, some paLlenLs may have paLhophyslologlcal changes, manlfesLed by slgns percepLlble
Lo cllnlcal deLerloraLlon. Larly recognlLlon of Lhese slgns and emergency care performed by mulLl-professlonal Leam
deLermlnes dlrecLly Lhe ouLcome and hence Lhe morLallLy reducLlon, seeklng care quallLy and paLlenL safeLy. 1he
ob[ecLlve was Lo descrlbe Lhe process of lmplemenLaLlon of a proLocol of care for crlLlcal paLlenLs ln lnpaLlenL unlLs ln a
publlc Leachlng hosplLal locallsed ln So aulo sLaLe, and Lo characLerlse Lhe crlLlcal paLlenLs wlLh opened proLocol ln
2012.

Methods: 1hls ls a descrlpLlve sLudy. 1he Leam of crlLlcal paLlenL began Lhls work ln !uly 2010, ln Sumare SLaLe PosplLal,
a publlc Leachlng hosplLal ln So aulo sLaLe, conslsLlng of 260-bed hosplLal, whlch ls a reference Lo clLles around lL wlLh
1,100,000 lnhablLanLs. 1he Leam conslsLs of docLors, nurses, physloLheraplsLs, speech LheraplsLs and admlnlsLraLlve
asslsLanL. lnlLlally we conducLed a llLeraLure revlew on Lhemes and proflle analysls of crlLlcally lll paLlenLs ln lnpaLlenL
unlLs. 8ased on Lhe Modlfled Larly Warnlng Score (MLWS) were deflned warnlng slgns for adulL and paedlaLrlc paLlenLs
and Lhe crlLerla for lncluslon ln Lhe proLocol of crlLlcal paLlenLs. We esLabllshed flows care and Lhe care needed by
ldenLlfylng Lhe crlLlcal paLlenL, boLh for Lhose wlLh worsenlng of cllnlcal sLaLus ln lnpaLlenL unlLs, and paLlenLs dlscharged
from lnLenslve care unlLs (48 hours). 1he mulLldlsclpllnary Leams of professlonals worklng ln varlous secLors of Lhe
lnsLlLuLlon were Lralned and lmproved on Lhe lmplemenLaLlon of Lhe proLocol. uurlng !anuary and lebruary 2013, Lhe
professlonals who make up Lhe Leam performed a reLrospecLlve analysls of Lhe proLocols lnlLlaLed durlng Lhe monLhs
from !anuary Lo uecember 2012, Lo ldenLlfy Lhe number of open proLocols, Lhe secLors of hosplLallsaLlon of paLlenLs and
ouLcomes. uaLa were recorded ln Lxcel Lables and graphs were used for beLLer vlsuallsaLlon.

kesu|ts: Slx hundred and flfLy-Lwo proLocols were lnlLlaLed ln 2012. Cf Lhese, 499 (76.33) were dlscharged from
lnLenslve care unlLs, 463 (93.18) had beLLer cllnlcal ouLcome, 12 (2.40) dled and 22 (4.40) also dled, however, were
under palllaLlve care.

lor Lhe paLlenLs wlLh cllnlcal worsenlng ln lnpaLlenL unlLs, 133 (22.2) proLocols were lnlLlaLed, 112 (73.20) had beLLer
cllnlcal ouLcome and 41 (26.80) dled.

1he surglcal cllnlc ls Lhe secLor where Lhe largesL number was lnlLlaLed proLocol (n = 200, 30.62) and 141 of egress
(28.2) and 39 sLarLed ln Lhe unlL (38.81). ln Lhls secLor, Lhe proLocols sLarLed aL Lhe hosplLal, was ldenLlfled Lhrough
analysls of a sample of 36 medlcal records LhaL: ln 100 of records Lhere was evldence on Lhe use of llfe supporL
maLerlals, ln 21 (38.33) of cases, happened Lhe Lransfer of Lhe paLlenL Lo Lhe bed closesL Lo Lhe nurslng sLaLlon, and ln
one case LhaL dldn'L happen, was [usLlfled ln Lhe record, abouL Lhe sLandard of verlflcaLlon of vlLal slgns, 27 (73.00) of
Lhe records, showed records of vlLal slgns, 19 (32.77) of Lhe records conLalned evldence of medlcal evaluaLlon. Cnly
Len (27.77) medlcal records conLalned evldence of physloLheraplsL, nuLrlLlonlsL and soclal worker evaluaLlon.

Conc|us|on: lL ls observed LhaL Lhe deploymenL of crlLlcal paLlenL proLocol enabled Lhe Lralnlng of professlonals Lo
ldenLlfy slgns of cllnlcal deLerloraLlon of paLlenLs ln varlous lnpaLlenL unlLs. 1he sLandardlsaLlon of care ls sLlll a challenge,
malnly lnvolvlng Lhe work of Lhe mulLldlsclpllnary Leam.


2064

1nL IMAC1 CI DLCLN1kALISA1ICN CN LkCLIVLD IC8 CnAkAC1LkIS1ICS: A SUkVL WI1nIN A SAMLL CI nCSI1AL DCC1CkS
eLer Adam
1,*
, 8lk verhaeghe
1
, aul Cemmel
2

1
laculLy of Medlclne and PealLh sclences,
2
laculLy of economlcs and buslness admlnlsLraLlon, ChenL unlverslLy, ChenL, 8elglum


Cb[ect|ves: 1hls reporL covers a sLudy LhaL examlned Lhe lmpacL of organlsaLlonal change, more speclflcally, Jeceottollsotloo on
experlenced [ob characLerlsLlcs wlLhln a sample of hosplLal docLors. 8ased on Lhe uemooJs-coottol-5oppott MoJel (karasek &
1heorell, 1990) a serles of hypoLheses was LesLed concernlng Lhe lmpacL of decenLrallsaLlon on docLors' level of experlenced:

a) [ob saLlsfacLlon,
b) [ob demands,
c) [ob conLrol, and
d) Lhelr level of percelved soclal supporL ln Lhe organlsaLlon.

lurLhermore, Lhe assoclaLlons beLween Lhese varlables -as ouLllned ln Lhe uemands-ConLrol-SupporL-Model- were examlned wlLhln
cenLrallsed and decenLrallsed organlsaLlonal hosplLal sLrucLures, whlch was Lhe secondary goal of Lhe currenL lnvesLlgaLlon.

1he assoclaLlons beLween Lhese [ob characLerlsLlcs are seen as an lmporLanL predlcLor for [ob sLress, absenLeelsm, Lurnover and burn
ouL.

Methods:
! arLlclpanLs: Self-reporL daLa from Lwo samples of docLors, worklng ln a large 8elglan hosplLal were used. 1he flrsL sample
lnvolved 26 docLors LhaL were worklng wlLhln a Lyplcal ceottollseJ organlsaLlonal sLrucLure wlLhln Lhe hosplLal. 1he second
sample lnvolved 21 docLors LhaL were worklng wlLhln a JeceottollseJ organlsaLlonal sLrucLure wlLhln Lhe same hosplLal.
! rocedure: uocLors who were undergolng a medlcal conLrol examlnaLlon were asked Lo parLlclpaLe ln a research on
organlsaLlonal change wlLhln Lhelr currenL work seLLlng. uocLors who were wllllng Lo parLlclpaLe were asked Lo compleLe a seL of
self-reporL quesLlonnalres.
! Measures: 1he !ob ConLenL CuesLlonnalre (karasek, 1983) was used Lo examlne parLlclpanLs' level of [ob demands, [ob conLrol,
and Lhelr level of percelved soclal supporL. 1hese measures were supplemenLed wlLh a measure of percelved [ob saLlsfacLlon.
! SLaLlsLlcs: A serles of Mann-WhlLney u analyses were used Lo LesL wheLher docLor's percelved [ob characLerlsLlcs dlffered as a
funcLlon of organlsaLlonal sLrucLure (cenLrallsed vs. decenLrallsed). 1o examlne Lhe lnLerrelaLlons beLween docLor's level of [ob
saLlsfacLlon, [ob demands and conLrol, and Lhelr level of percelved soclal supporL, a serles of Spearman correlaLlons were carrled
ouL.

kesu|ts: Cverall, Lhe self-reporL measures ylelded no slgnlflcanL dlfferences ln [ob characLerlsLlcs, lncludlng [ob demands (p=.72), [ob
conLrol (p=.49), percelved soclal supporL (p=.93) and [ob saLlsfacLlon (p=.66) beLween Lhe Lwo samples. 8oLh docLors worklng ln a
cenLrallsed and decenLrallsed organlsaLlonal sLrucLure wlLhln Lhe hosplLal reporLed hlgh levels of [ob saLlsfacLlon, [ob demands,
percelved soclal supporL and [ob conLrol.

1he Spearman analyses revealed LhaL hlgher levels of percelved [ob conLrol corresponded wlLh hlgher levels of [ob saLlsfacLlon
(p<.01). 1he laLLer, however, was only found wlLhln Lhe cenLrallsed organlsaLlonal sLrucLure and noL wlLhln Lhe decenLrallsed
hosplLal sLrucLure. llnally, docLor's level of [ob saLlsfacLlon was slgnlflcanLly predlcLed by Lhelr level of percelved soclal supporL
(p<.01), wlLh hlgher levels of soclal supporL conLrlbuLlng Lo hlgher levels of [ob saLlsfacLlon. 1hls assoclaLlon was conslsLenL across
organlsaLlonal seLLlng. 1hese flndlngs proved Lo be lndependenL of docLor's gender and age.

Conc|us|on: Cur flndlngs seem Lo suggesL LhaL decenLrallsaLlon has llLLle or no lmpacL on docLor's level of percelved [ob demands,
[ob conLrol, soclal supporL, and [ob saLlsfacLlon. 1he second ma[or concluslon ls LhaL soclal supporL may play a cenLral role ln Lhe
predlcLlon of [ob saLlsfacLlon ln cenLrallsed as well as decenLrallsed organlsaLlonal sLrucLures. 1he presenL flndlngs awalL repllcaLlon
wlLhln fuLure research LhaL deals wlLh Lhe presenL sLudy's llmlLaLlons.


2066

SUCk1ING 1nL SLkVICL USLk, CnANGING 1nL CLINICIAN, AND CnANGING 1nLIk kLLA1ICNSnI: IINDINGS IkCM
1WC IMkCVLMLN1 kCILC1S WnICn nAVL IN1kCDUCLD LLk SUCk1 kCLLS IN1C LkIS1ING CLINICAL SLkVICLS
lay Sulllvan
1,*

1
1he PealLh loundaLlon, London, unlLed klngdom


Cb[ect|ves: 1he PealLh loundaLlon programme closloq tbe Cop tbtooqb cbooqloq kelotloosblps supporLed seven
lmprovemenL pro[ecLs Lo lmprove paLlenL-cenLred care. 1wo of Lhese pro[ecLs lnLroduced new roles lnLo exlsLlng servlces
based on Lhe model of peer supporL. eer SupporL workers (wlLh experlence of uslng menLal healLh servlces) were
lnLroduced lnLo a menLal healLh LrusL and Care navlgaLors (wlLh experlence of homelessness) were lnLroduced lnLo an
acuLe LrusL. Whlle Lhe concepL of peer supporL has been dlscussed ln Lhe llLeraLure for some Llme, reporLs of
lmplemenLaLlon have Lo daLe been llmlLed. 1hese pro[ecLs soughL Lo lmprove paLlenL and servlce user experlence by
Lralnlng and recrulLlng Lo pald peer supporL roles, people who expllclLly draw on Lhelr own experlence of belng a paLlenL
or servlce user Lo promoLe and model paLlenL-cenLred care.

Methods: 1he Lwo lmprovemenL pro[ecLs uLlllsed recognlsed lmprovemenL meLhodologles, whlch lncluded
measuremenL acLlvlLy Lo demonsLraLe wheLher changes Lhey were maklng were resulLlng ln lmprovemenL (or
unanLlclpaLed effecLs). ln addlLlon, each conducLed a self-evaluaLlon supporLed by exLernal evaluaLors who also
underLook a programme-level evaluaLlon uslng a reallsLlc evaluaLlon approach.

kesu|ts: 1o varylng exLenLs, boLh pro[ecLs can evldence lmprovemenLs ln paLlenL or servlce user experlence. 1helr work
suggesLs, for lnsLance, LhaL Lhe mere reallsaLlon LhaL a member of Lhe servlce Leam has 'been where you're slLLlng' can
have a LransformaLlve effecL, wlLh paLlenLs and servlce users seemlngly more able Lo feel comforLable around workers
who have slmllar experlences Lo Lhelr own. SLaff aLLlLudes and behavlours have been lnfluenced, as peer workers model
boLh poslLlve aLLlLudes Lowards paLlenLs and servlce users, and demonsLraLe LhaL recovery and poslLlve ouLcomes can be
a reallLy. Cne pro[ecL has anecdoLal evldence Lo suggesL LhaL some servlce users became open Lo dlfferenL LreaLmenL
opLlons and experlenced lmproved ouLcomes. llndlngs abouL how Lo effecLlvely lmplemenL Lhese approaches have also
been generaLed. 1hese lnclude: maklng approprlaLe adapLaLlons Lo Lhe usual employmenL processes, such as senslLlve
handllng of references, supporLlng Lhe peer workers Lhemselves ln roles whlch can be emoLlonally demandlng, and
hlghllghLlng Lhe need Lo guard agalnsL poLenLlally negaLlve effecLs such as uslng Lhe peer supporLer role as a Lool Lo
persuade a paLlenL or servlce user Lo accepL a parLlcular LreaLmenL. 1he long Lerm susLalnablllLy of Lhe roles has yeL Lo
be demonsLraLed, buL boLh pro[ecLs conLlnue Lo operaLe afLer Lhe llfe of PealLh loundaLlon fundlng, wlLh one belng
scaled-up wlLhln Lhelr home organlsaLlon.

Conc|us|on: eer supporL can lmprove paLlenL experlence and may lmprove healLh ouLcomes. 1he pro[ecLs demonsLraLe
LhaL LhoughLful lmplemenLaLlon ls requlred, and provlde valuable lnslghLs lnLo how Lo operaLlonallze such roles. lurLher
research ls needed Lo see lf flndlngs from Lhese pro[ecLs are Lransferable and Lo robusLly demonsLraLe an lmpacL on
healLh ouLcomes.

keferences:
Sln, C eL al. (forLhcomlng) volootloo of tbe neoltb loooJotloo closloq tbe Cop tbtooqb cbooqloq kelotloosblps
ltoqtomme, 1he PealLh loundaLlon,
8epper, ! eL al (forLhcomlng) 1toosfotmloq tbe coltote of Meotol neoltb 5etvlces. llool tepott to tbe neoltb loooJotloo,
1he PealLh loundaLlon,
PeweLL, n eL al (forLhcomlng) 1be looJoo lotbwoy ptoqtomme. llool tepott to tbe neoltb loooJotloo, 1he PealLh
loundaLlon.


2068

A 1CCL 1C LNnANCL nSICIAN LNGAGLMLN1 IN ACCkLDI1A1ICN
Wendy nlcklln
1,*
, Loulse ClemenL
1
, 8ernadeLLe Macuonald
1
, PeaLher Powley
2

1
AccredlLaLlon Canada, CLLawa, Canada,
2
rogram uevelopmenL, AccredlLaLlon Canada, CLLawa, Canada


Cb[ect|ves: hyslclan engagemenL ln sLraLeglc lnlLlaLlves Lo lmprove Lhe healLhcare sysLem ln Canada ls essenLlal. AL
AccredlLaLlon Canada we are commlLLed Lo enhanclng physlclan engagemenL ln order Lo achleve quallLy, paLlenL-cenLred
healLh servlce dellvery. hyslclan lnpuL ls provlded Lhrough a hyslclan Advlsory CommlLLee, physlclan surveyors and
recognlsed physlclan champlons ln Lhe fleld of quallLy lmprovemenL as well as physlclan-led organlsaLlons and
assoclaLlons. An lmporLanL new lnlLlaLlve Lo supporL healLh care organlsaLlons ln enabllng physlclan lnvolvemenL ln
CmenLum ls Lhe developmenL of a survey Lool Lo measure Lhe physlclan work envlronmenL based on Lhe survey resulLs.

Methods: 8ecognlslng Lhe evldence llnklng an organlsaLlon's work envlronmenL and Lhe quallLy of care provlded, Lhe
AccredlLaLlon Canada CmenLum program lncludes a survey Lool Lo measure Lhe quallLy of Lhe work envlronmenL. 1hls
survey Lool ls known as Lhe Work llfe ulse. 1hls ls compleLed by sLaff of many caLegorles LhroughouL Lhe organlsaLlon,
aL mlnlmum, once ln Lhe survey cycle. ln 2012, wlLh Lhe guldance of Lhe hyslclan Advlsory CommlLLee and wlLh Lhe
experL advlce of Lhe researcher who developed Lhe orlglnal Work llfe ulse, a work llfe Lool speclflcally Lallored Lo
physlclans worklng ln accredlLed organlsaLlons was developed. 1hls new survey Lool was plloL LesLed ln Len healLh care
organlsaLlons across Canada ln lall 2012.

kesu|ts: 1he new hyslclan Work llfe ulse 1ool ls deslgned Lo assess lssues of lmporLance Lo physlclans, such as Lhelr
pracLlce envlronmenL, worklng relaLlonshlps wlLhln Lhe Leam/unlL and wlLh senlor leaders, healLh and safeLy lssues and
overall professlonal saLlsfacLlon. lnformaLlon gaLhered from Lhe admlnlsLraLlon of Lhls Lool wlll help healLh care
organlsaLlons Lo ldenLlfy lmprovemenL prlorlLles relaLed Lo physlclan work llfe. 1he Lool conLalns 24 quesLlons and offers
Lhe opporLunlLy for open commenLs. ln !anuary 2013, lL was lnLroduced as an opLlonal Lool avallable Lo healLh care
organlsaLlons parLlclpaLlng ln Lhe CmenLum program.

Conc|us|on: 1he hyslclan Work llfe ulse Lool ls a Lool for healLh care organlsaLlons Lo lmprove quallLy of care Lhrough
ldenLlfylng and addresslng work envlronmenL lssues of lmporLance Lo physlclans. ln addlLlon Lo Lhe lnLroducLlon of Lhls
new physlclan Lool, AccredlLaLlon Canada ls acLlvely lnvolved ln oLher lnlLlaLlves Lo enhance physlclan parLlclpaLlon ln
accredlLaLlon acLlvlLles. lor example, efforLs are underway Lo sLrengLhen Lhe way ln whlch cllnlcal governance ls
ldenLlfled and assessed ln Lhe CmenLum accredlLaLlon process Lhrough Lhe developmenL of speclflc sLandards conLenL
relaLed Lo cllnlcal governance and organlsed medlcal sLaff. 1hls conLenL would speclflcally address medlcal governance,
credenLlallng, appolnLmenL processlng, prlvlleglng, on-golng performance evaluaLlons and medlcal leadershlp ln
deslgnlng servlces.



2076

A1ILN1 SAIL1 IN 1nL CUkkICULUM IN GkADUA1L SCnCCLS CI NUkSING AND MIDWIILk IN 1nL CI1 CI SC
AULC - 8kA2IL
MarLa M. Mellelro
1,*
, 1erezlnha Cennarl
2
, 8osa koda
3
, ualsy 8. 1ronchln
1

1
nurslng School of unlverslLy of Sao aulo,
2
laculdades MeLropollLanas unldas,
3
unlversldade SanLo Amaro, So aulo,
8razll


Cb[ect|ves: 1o analyse Lhe LhemaLlc paLlenL safeLy on currlcular ln Lhe nurslng and mldwlfery schools.

Methods: 1hls ls a documenLary sLudy of currlculums ln graduaLe schools of nurslng and mldwlfery ln Sao aulo, 8razll,
whlch dlscussed aLlenL SafeLy. ln 8razll, Lhe esLabllshmenL of pollcles by Lhe World PealLh CrganlzaLlon focused on
quallLy and paLlenL safeLy as well as Lhe lmpacL of errors ln healLh care of Lhe populaLlon have demanded educaLlonal
lnsLlLuLlons of healLh professlonals Lo reLhlnk and lmplemenL changes ln Lhelr currlculum. ln 2008, Lhe an Amerlcan
PealLh CrganlsaLlon esLabllshed Lhe 8razlllan neLwork of nurslng and aLlenL SafeLy (8L88ALnS), ln order Lo
consolldaLe Lhe safeLy culLure ln healLhcare organlsaLlons, unlverslLles, non-governmenLal organlsaLlons and beLween
users. 1he 8L88ALnS ls a group of oles and 8eglonal CenLers. 1he 8eglonal CenLer of nurslng and mldwlfery schools ls
composed of 13 unlverslLles, of whlch derlves Lhls sLudy. uaLa collecLlon occurred ln 2012 Lhrough a form. 1he flrsL parL
of form was consLlLuLed of Lhe ldenLlflcaLlon daLa of Lhe schools whlle Lhe second varlables abouL year, semesLer,
dlsclpllne and programmaLlc conLenL. 1o ldenLlfy elLher dlrecLly or lndlrecLly Lhe lssue of paLlenL safeLy currlculum were
esLabllshed 16 keywords: safeLy ln healLh servlces, safeLy processes, safeLy healLh professlonals, paLlenL safeLy, care
quallLy nurslng, evaluaLlon of healLh servlces, quallLy measuremenL Lools, quallLy lndlcaLors, rlsk managemenL, adverse
evenLs, senLlnel evenLs, laLrogenlc occurrences, rlghLs of users of healLh servlces, consumer code, code of eLhlcs and law
of professlonal pracLlce.

kesu|ts: 1he parLlal resulLs of Lhls sLudy showed LhaL paLlenL safeLy ls belng addressed on currlculum, ln dlfferenL
dlsclpllnes, dlrecLly ln Lhe dlsclpllnes of PealLh ollcy, nurslng as a soclal pracLlce, 8loeLhlcs, LLhlcs and Law ln nurslng,
8losecurlLy, reparedness and urug AdmlnlsLraLlon, nurslng AdmlnlsLraLlon, PealLh Servlces ManagemenL, CuallLy
ManagemenL, rocess lundamenLals of Care, rlmary Care nurslng, nurslng and Surglcal CenLer wlLh Lhese dlsclpllnes
LaughL ln Lhe flrsL and lasL semesLers of courses.

Conc|us|on: 1he currlculum of Lhe schools nurslng and mldwlfery also has gaps Lo be complemenLed wlLh respecL Lo
paLlenL safeLy. We belleve Lo be lmperaLlve Lhe lmplemenLaLlon of new Leachlng sLraLegles coverlng Lhe sLudenLs,
professors and healLh professlonals of Lhe mulLldlsclpllnary Leam Lo ensure LhaL Lhls lssue ls Lhoroughly dlscussed and
lnLegral of Lhe currlculum.



2079

CCMLIANCL CI nAND nGILNL IN LVALUA1ING 1nL SLkVICL INDICA1Ck 1LMCkAk DCU8LL LUMLN CA1nL1Lk
ICk nLMCDIALSIS IN A UNIVLkSI1 nCSI1AL IN SAC AULC - 8kA2IL
ualsy 8. 1ronchln
1,*
, kesla 8oseLLl
1
, MarLa Mellelro
1

1
unlversldade de So aulo, So aulo, 8razll


Cb[ect|ves: 1o assess Lhe compllance of healLhcare pracLlce of malnLalnlng Lhe Lemporary double lumen caLheLer for
haemodlalysls, Lhrough Lhe employmenL lndlcaLor ln Lhe model uonabedlan gulded process, ln Lhe haemodlalysls unlL of
a unlverslLy hosplLal ln Sao aulo, 8razll.

Methods: 1hls ls a quanLlLaLlve, exploraLory, descrlpLlve, observaLlonal sLudy wlLh prospecLlve daLa collecLlon. 1he
research was conducLed aL Lhe Servlce of ulalysls, unlverslLy PosplLal, unlverslLy of Sao aulo. 1he sample was
comprlsed of 133 opporLunlLles for analysls of Lhe pracLlce of malnLalnlng Lhe Lemporary double lumen caLheLer for
haemodlalysls, each opporLunlLy conLalned 13 componenLs, LoLalllng 2013 lLems observed. uaLa collecLlon occurred
from March Lo november 2011, Lhrough dlrecL observaLlon, and Lhe use of Lwo forms. uaLa were analysed accordlng Lo
Lhe descrlpLlve sLaLlsLlcs and Lhe appllcaLlon of Lhe equaLlon of general and speclflc lndlcaLor - hand hyglene.

kesu|ts: 1he characLerlsaLlon of Lhe users, lL was found LhaL Lhe ma[orlLy (73.6) were male, wlLh a mean age of 33
years (Su 16.3), 32.6 had a dlagnosls llke PyperLenslon, Lhen of Chronlc kldney ulsease worsened (39.3) and
dlabeLes melllLus (36.8). WlLh regard Lo Lhe lndex of Lhe lndlcaLor accordlngly, Lhls corresponds Lo 63.8. ln relaLlon Lo
13 speclflc componenLs of Lhe lndlcaLor, 9 (69.2) had 100 compllance. 1he worsL percenLage of compllance (83.9)
were aLLrlbuLed Lo Lhe pracLlce of hand hyglene by healLh professlonals.

Conc|us|on: 1he flndlngs of Lhls research allowed Lo esLabllsh Lhe relevance of procedural revlews ln malnLalnlng
Lemporary double lumen caLheLer for haemodlalysls and lnfer LhaL Lhere ls need Lo lmplemenL sLraLegles and LargeLs
care and managemenL ln order Lo reduce Lhe raLes of non-compllance lndlcaLor, especlally ln Lhe pracLlcal componenL of
hand hyglene before Lhe hlgh percenLage of non-compllance. Also, explore elemenLs LhaL are lnLerferlng wlLh Lhe
process of hand hyglene, as sLrucLural lssues and behavloural of Lhe healLh professlonal.



2084

NA1ICNAL UALI1 INDICA1CkS ICk kLVLN1ICN AND CAkL CI CAkDICVASCULAk DISLASL IN kIMAk
nLAL1nCAkL IN ISkALL
Crly Manor
1
, uena !affe
1,*

1
lsrael naLlonal rogram for CuallLy lndlcaLors ln CommunlLy PealLhcare, Pebrew unlverslLy-Padassah, !erusalem, lsrael


Cb[ect|ves: CuallLy ln communlLy healLhcare ls a cornersLone of Lhe healLhcare sysLem ln lsrael. Slnce 1993 all resldenLs
recelve medlcal lnsurance and a baslc baskeL of care from one of four healLhcare provlders - ClallL PealLh Servlces,
LeumlL PealLh lund, Maccabl PealLhcare Servlces, and MeuhedeL PealLh lund. 1he naLlonal rogram for CuallLy
lndlcaLors ln CommunlLy PealLhcare ln lsrael (ClCP) uLlllses populaLlon-based lndlcaLors, whlch cover slx areas of dlsease
prevenLlon and managemenL. 1hese lndlcaLors are used Lo assess changes Lo Lhe healLhcare sysLem over Llme and
varlaLlons ln Lhe quallLy of care beLween subgroups. 1he presenL sLudy examlnes ClCP quallLy lndlcaLors for
cardlovascular care prevenLlon and dlsease managemenL.

Methods: LlecLronlc paLlenL records are collecLed for Lhe enLlre lsraell populaLlon from all four healLh plans ln lsrael for
Lhe perlod 2003-2010. uaLa are aggregaLed Lo creaLe Lhe naLlonal lndlcaLor seL (numeraLors and denomlnaLors). PearL
dlsease ls deflned as paLlenLs who underwenL a percuLaneous coronary lnLervenLlon or coronary arLery bypass grafL.
ClCP lndlcaLors are reporLed annually by age group, sex, and soclo-economlc poslLlon (SL).

kesu|ts: Adherence Lo prevenLlve care guldellnes for cardlovascular dlsease lncreased over Llme ln lsrael. 8aLes of
documenLaLlon of body mass lndex for adulLs aged 20-74 years lncreased from 6 ln 2003 Lo 77 ln 2010. lor adulLs 33-
74 years old, cholesLerol documenLaLlon raLes lncreased from 61 ln 2003 Lo 81 ln 2010 and blood pressure
documenLaLlon raLes lncreased from 24 Lo 86 durlng Lhe same perlod. ln 2010, documenLaLlon raLes were hlgher for
younger Lhan older adulLs. 1he percenLage of adulLs wlLh conLrolled low-denslLy llpoproLeln (LuL) cholesLerol levels
(160 mg/dL) was 92 (2010) and dld noL vary subsLanLlally by age group, sex or SL. CuallLy lndlcaLors of effecLlveness
of care and lnLermedlaLe healLh ouLcomes for paLlenLs wlLh hearL dlsease showed conslsLenL lmprovemenL over Lhe 8-
year assessmenL perlod. lor adulLs aged 33-74 years wlLh hearL dlsease, long-Lerm LreaLmenL wlLh llpld lowerlng
medlcaLlons grew by 10 (absoluLe lncrease) from 74 ln 2003 Lo 84 ln 2010. varlaLlons ln raLes over Llme were
observed by age group, sex, and SL. noLably, dlsparlLles ln long-Lerm LreaLmenL wlLh llpld lowerlng medlcaLlons
accordlng Lo SL dlmlnlshed from an absoluLe dlfference of 3 ln 2003 Lo 0.3 ln 2010. lnLermedlaLe healLh ouLcomes,
measured as Lhe per cenL of paLlenLs wlLh hearL dlsease who had conLrolled levels LuL cholesLerol (100 mg/dL)
lncreased from 48 ln 2003 Lo 72 ln 2010. 8aLes of conLrolled levels of LuL for paLlenLs wlLh hearL dlsease were hlgher
for older age groups, men, and Lhe hlgher SL group.

Conc|us|on: CuallLy lndlcaLors ln healLhcare are essenLlal Lools for assesslng adherence Lo prlmary and secondary
prevenLlon guldellnes and examlnlng healLh ouLcomes. Whlle varlaLlons ln healLhcare lndlcaLor raLes dlffered by sex,
age, and SL, conslsLenL lmprovemenLs were observed from 2003 Lo 2010. lurLher research wlll be necessary Lo
evaluaLe Lhe effecL of lmproved quallLy of care on cardlovascular morbldlLy and morLallLy.



2086

DLVLLCING ML1nCDS 1C CA1UkL 1nL A1ILN1 A1nWAS LkLkILNCL
Cro k 8osvold 8ernLsen
1,*
, ueede Cammon
2
, Cornella 8uland
2
, vln[ar lnneb
3

1
norweglan CenLre for lnLegraLed care and 1elemedlclne, unlverslLy PosplLal of norLh norway, 1roms,
2
CenLre for Shared ueclslon
Maklng and CollaboraLlve Care 8esearch , Cslo unlverslLy PosplLal, Cslo,
3
naLlonal 8esearch CenLer ln ComplemenLary and
AlLernaLlve Medlclne, unlverslLy of 1roms , 1roms, norway


Cb[ect|ves: 1he Chronlc Care Model (CCM) ls a well-documenLed model for lmprovlng ouLcomes ln long-Lerm care. CCM ls allgned
wlLh oLher besL pracLlces such as paLlenL-cenLeredness" and conLlnulLy of care". When care ls provlded by mulLlple professlons
over Llme, quallLy of care more Lhan ever relles on Lhe weakesL llnk ln Lhe paLlenL paLhway. 1he ablllLy Lo capLure experlences of
besL-pracLlce LhaL are llnked Lo boLh Llme / place and ouLcomes ln Lhe paLhway ls essenLlal for quallLy lmprovemenL efforLs.
Powever, currenL lnsLrumenLs, llke Lhe aLlenL AssessmenL of Chronlc lllness Care do noL address Lhese needs. We Lherefore wlshed
Lo comblne evenL Llmellnes wlLh quallLaLlve meLhods as an orlglnal and new way of generaLlng emplrlcally founded scalable
meLhodology Lo capLure Lhe paLlenL experlence.

Methods: lnLervlew daLa from 9 cancer paLlenLs were used as a basls for Lhls meLhodology developmenL. aLlenLs revlewed, ln a
seml-sLrucLured lnLervlew, Lhelr pasL healLh care evenLs, and were encouraged Lo descrlbe and glve Lhelr evaluaLlon. 1he lnLervlews
were Lranscrlbed ad verbaLlm. ln sLage1 we developed Lhemes relevanL for descrlpLlon and evaluaLlon of slngle healLh care evenLs
by comblnlng a deducLlve and lnducLlve approach accordlng Lo Lhe framework analysls". ln sLage2, Lhe maLerlal from 2 paLlenLs was
sLrucLured as serles of healLh care evenLs organlsed by Llme. Lach evenL was coded wlLh quanLlfled sLage1 caLegorles, yleldlng a
quanLlLaLlve descrlpLlon of Lhe paLlenL paLhway.

kesu|ts: 1he followlng Lypology for evenLs emerged from Lhe quallLaLlve analysls:
1. purpose of Lhe encounLer,
2. Lhe parLlclpanLs, and
3. Lhe naLure of Lhe evenL. lmporLanL evenLs were descrlbed ln rlcher deLall, and were accompanled wlLh boLh process evaluaLlon,
ranglng from poslLlve Lhrough mlxed Lo negaLlve, and percelved shorL-Lerm ouLcomes for paLlenL.

CuLcomes were grouped lnLo:
1. lncreased paLlenL burden,
2. Lemporary healLh lssues, and
3. long-Lerm healLh lssues.

1he researcher separaLely assessed processes ln Lerms of besL-pracLlce. 1he models of CCM, paLlenL cenLeredness and conLlnulLy of
care were useful ln descrlblng poslLlve paLlenL experlences. negaLlve paLlenL experlences could noL readlly be classlfled ln Lerms of
lack of speclflc besL-pracLlces, and were LenLaLlvely dlvlded lnLo Lhe sub-groups glven ln Lable below, wlLh examples. CuanLlLaLlve
paLhways descrlpLlons wlll be presenLed aL Lhe conference as descrlpLlve evenL Llmellnes.

aLlenL expecLaLlon
noL meL
l wos o blt sotptlseJ. Aftet tbe sotqety tbe Joctot come toooJ fot jost o mloote, ooJ be solJ lt oll lookeJ
qooJ, ooJ evetytbloq wos os expecteJ, ooJ tbeo be sttesseJ oo. AoJ yoo coolJ soy tbot. l boJ expecteJ to
be oble to tolk to blm o blt mote (.), bot be wos polck-polck-polck (koockloq oo tbe toble) ooJ tbeo be wos
qooe.
lnformaLlon
dlsconLlnulLy
lnLervlewer: 1be Cl wtltes bete lo tbe tecotJ tbot be bos tecelveJ o pbooe coll ftom tbe potleot, tbe ooe
yoo ote tefettloq to. Lhe paLlenL has been lnformed, buL Lhe C-offlce has noL recelved any dlagnosLlc
lnformaLlon. aLlenL. No, be JlJot koow ooytbloq. lnLervlewer. es, be wtltes os mocb, ooJ lt ls cleot be
Joesot llke lt.
CrganlsaLlonal
dlsconLlnulLy
l oseJ 9 Joys to qet bolJ of tbe ptesctlptloos l oeeJeJ to stott tteotmeot (.) lo tbe eoJ l boJ to soy. wbo
ls tespooslble? 8y tbeo l boJ cootocteJ tbe mommoqtopby ceotet, tbe wotJ ooJ tbe ootpotleot cllolc. AoJ
lo tbe eoJ l solJ, l wlll oot qlve op. oo nAv to floJ me o Joctot.

Conc|us|on: We lack preclse Lermlnology for paLlenL's negaLlve care experlences. 1he reflnemenL of such Lermlnology ls essenLlal for
care quallLy lmprovemenLs. A quanLlLaLlve Lypology of care experlences wlll enable scalable paLlenL paLhway assessmenLs.

2088

nCSI1AL SUkVL CN A1ILN1 SAIL1 CUL1UkL IN IkANCL WI1nIN 1nL WnC nIGnSs AC1ICN
Anne 8royarL
1,*
, karen langeL
2
, Clalre Chabloz
3
, Charles 8runeau
4

1
ulvlslon of CuallLy and SafeLy lmprovemenL ln PealLh Care, PauLe AuLorlLe de SanLe, SalnL uenls La lalne,
2
CoordlnaLlon pour l'evaluaLlon des praLlques professlonnelles en sanLe en 8hne-Alpes., Lyon ,
3
CoordlnaLlon pour
l'evaluaLlon des praLlques professlonnelles en sanLe en 8hne-Alpes., Lyon,
4
PauLe AuLorlLe de SanLe, SalnL uenls la
lalne, lrance


Cb[ect|ves: 1o assess professlonals' percepLlons and values regardlng paLlenL safeLy ln seven lrench hosplLals
parLlclpaLlng ln Lhe World PealLh CrganlzaLlon Plgh3s pro[ecL. Plgh3s ls a paLlenL safeLy" collaboraLlon among a group
of parLlclpaLlng counLrles, WPC and Lhe WPC CollaboraLlve CenLer for SafeLy, lL alms aL faclllLaLlng Lhe lmplemenLaLlon
and evaluaLlon of sLandardlsed soluLlons wlLhln a global learnlng communlLy. Assesslng Lhe paLlenL safeLy culLure aL Lhe
beglnnlng of Lhe pro[ecL ls parL of Lhe evaluaLlon sLraLegy.

Methods: Seven lrench hosplLals Look parL ln Lhls lnLernaLlonal survey lncludlng 3 oLhers counLrles (Slngapore, AusLralla,
unlLed, klngdom, neLherland) wlLh a LoLal of 39 hosplLals. 1he PosplLal Survey on aLlenL CulLure CuesLlonnalre
released by Lhe AP8C ln november 201C was used and Lhe analysls done by WesLaL. 1he quesLlonnalre assesses
hosplLal sLaff oplnlons abouL paLlenL safeLy lssues, medlcal error and evenL reporLlng. lL lncludes 42 lLems deslgned Lo
measure 12 composlLes regardlng paLlenL safeLy culLure, Lwo overall paLlenL safeLy ouLcomes asked Lhe respondenLs
abouL overall paLlenL safeLy grade and number of evenLs reporLed over Lhe pasL 12 monLhs. lor each lLem, Lhe
percenLage of poslLlve response was calculaLed and a score was esLlmaLed for each areas. 1hls score was Lhe mean of
percenLages of poslLlve answers Lo Lhe areas' respecLlve lLems. An area wlLh a mean of 73 was consldered as
developed, an area wlLh a mean of aL leasL 30 poslLlve responses was consldered as requlrlng lmprovemenL. lollowlng
Lralnlng of Lhe Leams, 1000 paper-based quesLlonnalres LranslaLed ln lrench were dlsLrlbuLed elLher hosplLal wlde - ln 3
locaLlons - or ln Lhe unlLs of Lhe 4 oLher hosplLals, all lmplemenLlng Lhe soluLlon correcL slLe surgery(malnly surglcal
unlL, obsLeLrlc, operaLlng room). A sysLemaLlc feedback of Lhe resulLs was glven Lo Lhe fronL llne sLaff and managers by
Lhe naLlonal Plgh3s Leam.

kesu|ts: 1he overall parLlclpaLlon raLe was 62 over Lhe 7 hosplLals (mln 42max 93). 78 of Lhe respondenLs were
nurses/ nurslng asslsLanLs (409/621) and14 were physlclans (73/621). no composlLe had a score above 73. 1he score
of flve composlLes were less Lhan 30 and lncluded 1eam work across unlLs" 46, SLafflng" 41, and Lhe Lhree lowesL
scores lncludlng were Pandoffs and LranslLlons"(39),"non punlLlve response Lo error" (32), ManagemenL supporL
for paLlenL safeLy"(28).llve composlLes had a score above 30:1eamwork wlLhln unlLs" (39), CrganlsaLlonal
learnlng and conLlnuous lmprovemenL" (38),CommunlcaLlon openness" (36), Supervlsor manager expecLaLlons and
AcLlons promoLlng paLlenL safeLy" (34),Cverall percepLlons of paLlenL safeLy (31)".1he overall paLlenL safeLy grade
was reporLed Lo be very good" Lo excellenL" ln 47 of respondenLs.

Conc|us|on: 1hls sLudy demonsLraLes a hlgh moLlvaLlon of healLhcare professlonals lnvolved ln Lhe Plgh3s pro[ecL for Lhe
lssue of paLlenL safeLy culLure, desplLe a poorly developed safeLy culLure ln lrench hosplLals. 1he resulLs of Lhls survey
emphaslse Lhe need for a sLrong developmenL of paLlenL safeLy culLure ln lrance. Compared wlLh oLher parLlclpaLlng
counLrles ln Lhe Plgh 3s lrance demonsLraLes sllghLly lower scores. llve composlLe lndexes among Lhe 12 have a score
wlLhln Lhe Plgh3s average range (32). AfLer 3 years of experlenclng Lhe Plgh3s pro[ecL, Leamwork, overall leadershlp,
beLLer communlcaLlon, exchange of lnformaLlon among Leams and Lhe developmenL of a non-punlLlve culLure, appear as
key success facLors ln Lhe spreadlng of Plgh 3s safeLy soluLlons wlLhln lrench hosplLals.



2093

CC-DLSIGNING LCCAL A1ILN1 SAIL1 IN1LkVLN1ICNS: IS USING 1nL 1DI ILASI8LL, ACCL1A8LL AND LIILC1IVL?
naLalle 1aylor
1
, 8everley SlaLer
1
, 8ebecca LawLon
1,*

1
8radford lnsLlLuLe for PealLh 8esearch, 8radford 8oyal lnflrmary, 8radford, unlLed klngdom


Cb[ect|ves: 1here ls evldence of unsafe care ln healLhcare sysLems globally. lnLervenLlons Lo lmplemenL recommended
pracLlce ofLen have modesL and varlable effecLs. ldeally, selecLlng and adapLlng lnLervenLlons accordlng Lo local conLexLs
should enhance effecLs. Powever, Lhe means by whlch Lhls can happen ls seldom sysLemaLlc, based on Lheory, or made
LransparenL. 1hls sLudy almed Lo develop and plloL a flexlble and Lransferable approach Lo embed lnLervenLlons Lallored
Lo paLlenL safeLy pracLlces ln Lhe local conLexL.

Methods: We worked wlLh Lhree hosplLals Lo supporL Lhe lmplemenLaLlon of guldance Lo reduce Lhe rlsk of feedlng lnLo
mlsplaced nasogasLrlc (nC) feedlng Lubes. Cur sLepped process was lnformed by Lhe LheoreLlcal domalns framework
(1ul, Mlchle eL al., 2003) and key prlnclples from lmplemenLaLlon llLeraLure. lollowlng dlscusslons wlLh sLaff and
basellne audlLs Lo conflrm Lhe LargeL behavlour for change, a valldaLed quesLlonnalre was used Lo ldenLlfy barrlers Lo
healLh professlonal behavlour change and focus groups were conducLed Lo co-develop Lheory-based pragmaLlc
lnLervenLlons. 8epeaL audlLs were underLaken ln each 1rusL followlng lnLervenLlon lmplemenLaLlon.

kesu|ts: AudlL daLa lndlcaLed LhaL Lhe LargeL behavlour for change was Lhe flrsL llne meLhod Lo check nC Lube poslLlon.
CuesLlonnalre resulLs lndlcaLed Lhe maln barrler Lo uslng Lhe correcL meLhod Lo check Lhe poslLlon of nC Lubes across
each organlsaLlon was 'soclal lnfluences', buL Lhere were dlfferences ln oLher ldenLlfled barrlers. locus groups generaLed
some lnnovaLlve, generallzable, and adapLable sLraLegles for overcomlng barrlers. SlgnlflcanL lmprovemenLs ln Lhe LargeL
behavlour were seen ln all Lhree 1rusLs (1rusL A: x = 16.03, p < .001, 1rusL 8: x = 4.38, p < .03, 1rusL C: x = 44.72, p <
.001). 8un charL daLa from 1rusL A provlded addlLlonal lnformaLlon abouL Lhe lmpacL of lndlvldual lnLervenLlons over an
18 monLh perlod. uaLa from conLrol organlsaLlons ls currenLly belng collecLed and wlll be reporLed.

Conc|us|on: We have demonsLraLed Lhe appllcablllLy, feaslblllLy and plloL-level effecLlveness of Lhe 1ul as a framework
for co-deslgnlng paLlenL safeLy lnLervenLlons. luLure work should LesL Lhe effecLs of Lhls approach across oLher areas of
paLlenL safeLy guldellne lmplemenLaLlon.

keferences: Mlchle, S., M. !ohnsLon, C. Abraham, 8. LawLon, u. arker, and A. Walker. 2003. Maklng psychologlcal
Lheory useful for lmplemenLlng evldence based pracLlce: a consensus approach. Ooollty ooJ 5ofety lo neoltb cote 14:
26-33.




2097

CCMAkING S1AkLnCLDLk LkSLC1IVLS: A MCDLL CI DLCISICN-MAkING ICk AMC1kCnIC LA1LkAL SCLLkCSIS
MUL1IDISCILINAk CAkL
Anne Pogden
1,*
, uavld Creenfleld
1
, eLer nugus
1
, MaLLhew klernan
2

1
AusLrallan lnsLlLuLe of PealLh lnnovaLlon,
2
rlnce of Wales Cllnlcal School, unlverslLy of new SouLh Wales, Sydney,
AusLralla


Cb[ect|ves: normaLlve models of declslon-maklng do noL accounL for Lhe complex and changlng needs of amyoLrophlc
laLeral sclerosls (ALS) care LhroughouL Lhe shorL dlsease Lra[ecLory. We lnvesLlgaLed ALS paLlenL declslon-maklng from
Lhe perspecLlves of paLlenLs, carers and healLh professlonals, Lo derlve a declslon-maklng model for speclallsed ALS
mulLldlsclpllnary care.

Methods: llfLy-four respondenLs (32 healLh professlonals, 14 paLlenLs and elghL carers) from Lwo speclallsed ALS
mulLldlsclpllnary cllnlcs parLlclpaLed ln seml-sLrucLured lnLervlews beLween Aprll 2011 and May 2012. lnLervlew Loplcs
were derlved from Lhe paLlenL declslon-maklng llLeraLure body, reflned ln reference Lo ALS. Audlo recordlngs of
lnLervlews were Lranscrlbed, coded and analysed LhemaLlcally.

kesu|ts: Comparlson of healLh professlonals, paLlenLs and carers perspecLlves revealed broad agreemenL on ALS
declslon-maklng for sympLom managemenL and quallLy of llfe. Slx key facLors were percelved Lo lnfluence paLlenL-
cenLred declslon-maklng. 1hese were: Lhe declslon-maklng process, paLlenL-cenLred focus, Llmlng and plannlng,
lnformaLlon sources, engagemenL wlLh speclallsed ALS servlces, and access Lo non-speclallsed servlces. ln addlLlon,
psychosoclal facLors and conLlnually changlng sympLoms, lncludlng physlcal, cognlLlve and behavloural deLerloraLlon,
lmpacLed on paLlenLs' capaclLy Lo parLlclpaLe. arLlclpanLs agreed LhaL speclallsed ALS mulLldlsclpllnary cllnlcs offered an
opLlmal seLLlng for declslon-maklng. noneLheless, lssues of Llmlng of evldence-based care dellvery and Lhe role of carers
were conLenLlous.

ALS declslon-maklng was acknowledged Lo be a collaboraLlve, complex and cycllcal process. 1he derlved model ls
embedded ln Lhe declslon-maklng envlronmenL of Lhe speclallsed ALS mulLldlsclpllnary cllnlc, where paLlenLs' healLh
sLaLus and readlness Lo parLlclpaLe ls deLermlned. PealLh professlonals, paLlenLs and carers form a declslon-maklng Lrlad,
and move Lhrough a cycle of four lnLerllnked sLages. SLages may occur wlLhln Lhe Llmeframe of a slngle consulLaLlon, or
over a prolonged perlod. aLlenLs may cycle wlLhln and beLween each sLage of Lhe model unLll ready Lo proceed. 1he
flrsL sLage, 'aLlenL LngagemenL', ldenLlfles Lhe parLlclpanLs and esLabllshes Lhelr values, preferences and expecLaLlons.
ln sLage Lwo, 'CpLlon lnformaLlon', lnformaLlon and guldellnes on Lhe avallable managemenL opLlons are deLermlned,
lncludlng Lhe opLlmal Llmlng for lmplemenLaLlon of each cholce. uurlng Lhe Lhlrd sLage, 'uellberaLlon', paLlenLs welgh up
Lhe rlsks and beneflLs, and declde beLween proceedlng wlLh an opLlon, deferrlng Lhelr declslon, or chooslng Lo do
noLhlng. 1he flnal 'lmplemenLaLlon' sLage resulLs once an opLlon ls chosen.

Conc|us|on: arLlclpanL engagemenL ln ALS paLlenL-cenLred declslon-maklng ls LesLed by Lhe dynamlc naLure of Lhe
dlsease, llmlLed LreaLmenL opLlons, and paLlenL and famlly dlsLress. 1he roles and expecLaLlons of sLakeholders lnfluence
Lhe declslon-maklng process. Cur model capLures Lhese complexlLles and offers a framework for healLh professlonals,
researchers and pollcy makers ln Lhls challenglng envlronmenL.



2099

kAID LkANSICN CI kCkLAN DkUG U1ILISA1ICN kLVILW (kDUk): 8ASLD kCGkAM CCNSIDLkING VAkICUS I1
LNVIkCNMLN1S CI MLDICAL INS1I1U1ICNS
8! kwag
1,*
, ?L Pur
1
, PC ?eo
1
, Cu klm
1

1
uu8 managemenL, PealLh lnsurance 8evlew & AssessmenL Servlce (Pl8A), Seoul, korea, 8epubllc Cf


Cb[ect|ves: uu8 sysLem lnforms proper usage of drugs Lo physlclans and pharmaclsLs ln order Lo prevenL accldenLs
caused by abuslng drugs and decrease a cosL of drug usage. 1he more hosplLals and pharmacles parLlclpaLe ln uu8, lLs
beneflLs are Lhe blgger. Powever, lL ls dlfflculL Lo spread uu8 sysLem ln shorL perlod due Lo varlous l1 envlronmenLs of
each medlcal faclllLy. 1hls sLudy ls abouL provldlng Lhe program whlch easlly lnLegraLes wlLh Lhelr sysLem for rapld
expanslon of kuu8.

Methods: korean medlcal faclllLles have varlous l1 envlronmenLs (hardware, programmlng language, operaLlng sysLem,
eLc.).1herefore, PealLh lnsurance 8evlew & AssessmenL Servlce (Pl8A) deslgned a CCM (ComponenL Cb[ecL Model)
based program whlch ls lndependenL from Lhese envlronmenLs as below.

1. 1hls program runs wlLh LM8(LlecLronlc Medlcal 8ecord) program and communlcaLes each oLher for uu8 lnspecLlon
2. rovlde common lnLerfaces (funcLlons) for uu8 lnspecLlon and sample program sources.
3. 1he llsL of conLralndlcaLed drugs should be synchronlsed auLomaLlcally, because lL can be changed ofLen.
4. rovlde sLandardlsed lnformaLlon wlndow ln order Lo noLlfy users when drug dupllcaLlons or prohlblLlons occur.
3. lor a safeLy daLa Lransfer, all daLa are encrypLed.
6. 8un Lhe self-uu8 (self-checklng ln a prescrlpLlon) ln case lnLerneL connecLlon ls unreachable.

Also, we provlded guldellnes abouL how Lo develop uu8 funcLlons Lo some hosplLals (abouL 100 faclllLles) whlch can'L
use above program due Lo oLher reasons.

CCM: 1he MlcrosofL ComponenL Cb[ecL Model (CCM) ls a plaLform-lndependenL, dlsLrlbuLed, ob[ecL-orlenLed sysLem
for creaLlng blnary sofLware componenLs LhaL can lnLeracL. CCM ls Lhe foundaLlon Lechnology for MlcrosofL's CLL
(compound documenLs), AcLlve (lnLerneL-enabled componenLs), as well as oLhers. (Mlctosoft. (2012, Octobet 27). 1be
compooeot Object MoJel. kettleveJ ftom bttp.//msJo.mlctosoft.com/eo-eo/llbtoty/ms694J6J.ospx)

kesu|ts: 8ecause we provlded Lhls program, medlcal faclllLles could mlnlmlse developmenL cosL and Llme.(AbouL
7,764uSu saved per each LM8 manufacLurer or medlcal faclllLy). ln addlLlon, kuu8 could be rapldly spread by publlc
release of Lhe program slnce uecember 2010. ln 2012, 63,936(98.9) faclllLles have used uu8 sysLem ouL of a LoLal
66,689 hosplLals and pharmacles. And 63,869(99.8) are uslng Lhe CCM based program, ouL of whlch kuu8 sysLem ls
consLrucLed ln 63,936 faclllLles.

Conc|us|on: 1he program conslderlng varlous l1 envlronmenLs of medlcal faclllLles noL only conLrlbuLes Lo rapld uu8
expanslon buL also has a loL of poLenLlal for glvlng oLher servlces Lo faclllLles ln real-Llme. We wlll conLlnuously sLudy Lhe
program uLlllsaLlon and how Lo apply kuu8 sysLem Lo oLher plaLforms.



2104

NCNS1C DUk INICkMA1ICN SS1LM ICk kLVLN1ING DkUG SAIL1 INCIDLN1S ICk 24 nCUkS A DA, 36SDAS
S Pong
1,*
, ?L Pur
1
, PC ?eo
1
, Cu klm
1

1
uu8 managemenL, Pl8A, Seoul, korea, 8epubllc Cf


Cb[ect|ves: ln 2011, PealLh lnsurance 8evlew & AssessmenL servlce (Pl8A) bullL Lhe korean urug uLlllzaLlon 8evlew
(kuu8) lnformaLlon SysLem LhaL provldes Lhe real-Llme safe drug lnformaLlon based on personal prescrlblng daLa from
abouL 63,000 cllnlcs and pharmacles wlLhln prescrlpLlons and dlspenslng ones.

1hls sLudy was performed ln order Lo explaln how Lo bulld and evaluaLe uu8 lnformaLlon sysLem whlch ls consLrucLed Lo
run 24 hours a day for 363 days because prescrlblng and dlspenslng a prescrlpLlon could happen anyLlme durlng Lhe day
lncludlng dayLlme of consulLaLlon hours and even Lhe nlghL Llme, weekends and holldays.

Methods: We proceed as follow Lo bulld nonsLop uu8 lnformaLlon sysLem whlch can geL Lhe paLlenL's safe drug
lnformaLlon ln real Llme aL a prescrlblng and dlspenslng level aL all Llmes. kuu8 ls LargeLlng all Lhe medlcal lnsLlLuLlons
lncludlng Lhe cllnlcs and pharmacles for 24 hours a day, 363 days.

1. All servers of uu8 lnformaLlon sysLem ls duplex conflguraLlon. lf one server happens Lo error, Lhe oLher server can
work normally.
2. We esLabllshed Lhe excluslve neLwork for only uu8 lnformaLlon sysLem, so lL can remaln unaffecLed by oLher's
sysLem or neLwork errors.
3. We bulld Lhe sysLem whlch can recover Lhe sysLemlc faulLs lmmedlaLely by uslng Lhe Cracle AcLlve uaLa Cuard whlch
ls separaLed compleLely from Lhe operaLlng daLabase.
4. ln occurrlng a few dlsasLer (flre, flood, Lerror, war, eLc.), we consLrucLed a dlsasLer recovery sysLem aL dlfferenL
locaLlon for rapld resLoraLlon.

AfLer bulldlng Lhe uu8 lnformaLlon sysLem, we used Lhe prescrlpLlon daLa for Lhe perlod of 3 monLhs from CcLober 2012
Lo uecember 2012 Lo measure Lhe effecLlveness of nonsLop uu8 sysLem. We analysed Lhe prescrlpLlon Lransmlsslon
sLaLus of Llme-based lncludlng weekends and holldays.

kesu|ts: Pl8A have operaLed nonsLop uu8 sysLem wlLhouL any faulL wlLhln Lhe sysLem for 2012, and lL have provlded Lhe
safe drug lnformaLlon wlLhouL ever mlsslng a day for 363 days.

Cn analyslng Lhe prescrlpLlon daLa for Lhe fourLh quarLer of Lhe 2012 year, we revlewed 276,782,610 prescrlpLlons ln
prescrlblng level and dlspenslng level, revlewed 3,476,813(1.26) prescrlpLlons aL nlghL(.M 20 A.M 08), revlewed
3,067,641(1.83) prescrlpLlons of weekends and holldays.

Conc|us|on: rescrlblng and dlspenslng occurs a loL even durlng Lhe nlghL Llme or holldays lncludlng weekends. 1he
nonsLop kuu8 lnformaLlon sysLem could prevenL Lhe drug safeLy lncldenLs for 363 days even lncludlng nlghL Llme,
weekends and holldays whlch could be remalnlng ln Lhe bllnd spoL of drug accldenLs.



2110

GL11ING 1nL 8LS1 IkCM CNLINL kLSCUkCLS 1C IMkCVL UALI1 CI CLINICAL CAkL
Andrea 8aker
1,*
, 8everley 8easanL
1
, !ean ker
2

1
Cllnlcal Skllls Managed LducaLlonal neLwork, nPS LducaLlon for ScoLland,
2
Cllnlcal Skllls CenLre, unlverslLy of uundee,
uundee, unlLed klngdom


Cb[ect|ves: A naLlonal e-learnlng resource for Lhe admlnlsLraLlon of lnLravenous (lv) medlclnes was developed by Cllnlcal
Skllls Managed LducaLlonal neLwork, nPS CreaLer Clasgow and Clyde, nPS LoLhlan and nPS 1ayslde ln 2011/2012. 1he
alm was Lo develop a naLlonal mulLl-professlonal resource LhaL supporLed lndependenL learnlng and supplemenLed
pracLlcal cllnlcal skllls Leachlng.

As parL of Lhe evaluaLlon of Lhe resource Lralnees were asked Lo flll ln a quesLlonnalre abouL Lhelr confldence relaLlng Lo
cerLaln aspecLs of lv medlclnes admlnlsLraLlon and also Lhelr access Lo compuLers.

Methods: 1he e-learnlng resource was launched on Lwo plaLforms:

1. learnro - a secure vLL requlrlng a logln, and
2. knowledge neLwork - freely avallable no logln requlred. 1ralnees were asked Lo flll ln Lwo onllne quesLlonnalres one
before Lhey sLarLed learnlng and anoLher afLer Lhey had compleLed Lhe resource.

All quesLlonnalres were anonymous and were deslgned Lo provlde lnformaLlon abouL Lhe Lralnee, Lhelr place of work
and Lhelr LhoughLs abouL lv medlclnes admlnlsLraLlon and Lralnlng ln general, as well as Lhelr percepLlon of Lhe resource
and how useful Lhey found lL. 1hey were also asked quesLlons abouL Lhelr professlon, how Lhe resource was accessed (aL
home or aL work), whlch plaLform Lhey used and how confldenL Lhey felL ln carrylng ouL cerLaln cllnlcal skllls assoclaLed
wlLh lv medlclnes admlnlsLraLlon.

kesu|ts: lrom Lhe launch of Lhe resource ln !uly 2012 unLll uecember 2012, 90 Lralnees compleLed Lhe pre-course
quesLlonnalre and over 200 Lralnees compleLed Lhe posL-course quesLlonnalre from 12 dlfferenL healLh boards ln
ScoLland. 1he ma[orlLy of respondenLs (73) were nurses. Some Lralnees underLook Lralnlng as parL of a larger,
blended, Lralnlng programme lnvolvlng slmulaLed workshops afLer Lhe Lheory whllsL oLhers compleLed lL lndlvldually.

ln Lhe pre course quesLlonnalre, more Lhan 70 of Lralnees would descrlbe Lhemselves as l1 llLeraLe. 1wo Lhlrds of
Lralnees compleLed Lhe resource aL work and a Lhlrd aL home. nearly 90 used learnro Lo access Lhe resource. WhllsL
everyone had access Lo a work compuLer, for Lhe ma[orlLy (73) Lhe compuLer was shared wlLh oLher sLaff and only a
Lhlrd LhoughL Lhe compuLer was ln a place LhaL was conduclve Lo learnlng.

1ralnees were generally confldenL ln Lhelr cllnlcal skllls assoclaLed wlLh lv medlclnes admlnlsLraLlon, however Lhey were
noL confldenL ln recognlslng speclal conslderaLlons concernlng paedlaLrlcs". Cver 90 of Lralnees raLed Lhe resource as
elLher good or very good and a slmllar number would recommend lL Lo a colleague.

Conc|us|on: 1he resource lLself was well recelved and had many poslLlve commenLs. 1he evaluaLlon has shown lL has
meL lLs LargeL of belng relevanL naLlonally (used by many dlfferenL healLh boards) and ls also used mulLl-professlonally as
nurses, mldwlves, allled healLh professlons lncludlng ambulance Lechnlclans as well as sLudenLs all used Lhe resource. lL
ls also adapLable ln lLs use as elLher a sLand-alone resource or as use ln a blended learnlng course enabllng Lralnees Lo
access and learn Lhe LheoreLlcal knowledge wlLh more Llme devoLed Lo face Lo face pracLlcal slmulaLlon workshops.
Powever, lf healLh boards are Lo fully promoLe Lhe use of eLearnlng some LhoughL musL go Lo provldlng sLudy areas LhaL
are more conduclve Lo learnlng and posslbly dedlcaLed sLudy Llme.



2113

LkLAINING 1nL UNLkLAINA8LL - 1nL IMAC1 CI LI1IGA1ICN kISk CN INCIDLN1 DISCLCSUkL 8LnAVICUk CI
nSICIANS
Lrlk (P.) 8enkema
1,*
, Manda 8roekhuls
1
, kees Ahaus
1

1
CperaLlons, unlverslLy of Cronlngen, laculLy of Lconomlcs and 8uslness, CperaLlons ueparLmenL, Cronlngen,
neLherlands


Cb[ect|ves: 1he dlsclosure of medlcal lncldenLs Lo paLlenLs ls a way of acknowledglng human dlgnlLy and respecLlng
paLlenLs. hyslclans heslLaLe Lo dlsclose lncldenLs Lo paLlenLs due Lo Lhe fear of malpracLlce llLlgaLlon. ln Lhls sLudy we
lnvesLlgaLe how dlfferences ln physlclans' aLLlLude Lowards malpracLlce llLlgaLlon affecL Lhelr dlsclosure behavlour. We
also lnvesLlgaLe Lhe lnfluence of Lhe percelved paLlenL's response on dlsclosure behavlour of physlclans. 8y sLudylng
Lhese Lwo Loplcs we alm Lo conLrlbuLe Lo flll currenL gaps ln dlsclosure Lheory and lmprove Lhe lncldenL dlsclosure
process.

Methods: A quallLaLlve fleld sLudy was carrled ouL ln 8 hosplLals ln 1he neLherlands. ln LoLal 31 ln-depLh sLrucLured
lnLervlews were carrled ouL wlLh physlclans. 1oplcs LhaL were dlscussed ln Lhe lnLervlews were Lhelr LhoughLs and
emoLlons Lowards malpracLlce llLlgaLlon rlsk, and how LhaL affecLed Lhelr lncldenL dlsclosure behavlour. 1he daLa were
clusLered uslng hlerarchlcal clusLer analysls (PCA). lndexlng and codlng helped Lo develop emplrlcally drlven Lhemes.

kesu|ts: PCA revealed LhaL only half of Lhe parLlclpanLs scored hlgh on worry and fear Lowards Lhe rlsk of malpracLlce
llLlgaLlon. uesplLe Lhelr fears half of Lhls group dlsclosed lncldenLs because Lhey Lhlnk LhaL dlsclosure prevenLs llLlgaLlon.
Speclflc paLlenL behavlour, percelved as aggresslve and lrresponslble, made a Lhlrd of Lhe physlclans relucLanL Lo
dlsclose.

Conc|us|on: hyslclans' dlsclosure behavlour varles and ls affecLed by Lhe complex lnLerplay beLween Lhe physlclan's
LhoughLs and emoLlons Lowards Lhe rlsk of malpracLlce llLlgaLlon and Lhe paLlenL's response Lo dlsclosure. 1he emoLlons
LhaL posslble consequences of dlsclosure evoke and Lhe reclplenL's response Lo dlsclosure should be addressed as
facLors ln dlsclosure Lheory. 1hls knowledge can help hosplLals and pollLlclans ln deflnlng and lmplemenLlng dlsclosure
pollcles Lo lmprove lncldenL dlsclosure Lo paLlenLs.




2129

ADDkLSSING 1nL nSICAL nLAL1n CAkL CI LCLL WI1n SLVLkL AND LNDUkING MLN1AL ILLNLSS
Mlchael Spence
1,*
, Anna 8eLzlbacher
1
, Llz klng
2
, Anya 1elford
2

1
1he CollaboraLlon for Leadershlp ln Applled PealLh 8esearch and Care (CLAP8C) for CreaLer ManchesLer, Salford,
2
ManchesLer MenLal PealLh and Soclal Care 1rusL, ManchesLer, unlLed klngdom


Cb[ect|ves: eople wlLh severe and endurlng menLal lllness (SMl) ofLen experlence poor physlcal healLh (P) whlch can
lead Lo cardlo meLabollc dlsease. eople wlLh SMl dle on average 13-23 years premaLurely, wlLh poor physlcal healLh
belng a preclplLaLlng facLor. 1he alm of Lhls pro[ecL was Lo develop and LesL an lnLegraLed model of physlcal healLh care
beLween a communlLy menLal healLh Leam (CMP1) ln norLh ManchesLer and parLlclpaLlng prlmary care pracLlces
(Cs).

Methods: Cne CMP1 and flve Cs were lnvolved ln Lhls pro[ecL. 1he pro[ecL was deslgned from Lhe feedback of a
formaLlve evaluaLlon, lnvolvlng lnlLlal scoplng lnLervlews n=28 wlLh ManchesLer MenLal PealLh and Soclal Care 1rusL sLaff
and prlmary, communlLy and secondary healLh care professlonals (PCs), formal seml-sLrucLured quallLaLlve lnLervlews
wlLh general pracLlLloners (Cs) n=2, pracLlce nurses (ns) n=3, servlce users (Sus) n=19 and a faclllLaLed focus group
wlLh CMP1 cllnlcal sLaff n=17. 8aslc P daLa of Lhe CMP1's Sus was obLalned from C cllnlcal sysLems, uLlllslng C8lSk2
cardlovascular dlsease (Cvu) rlsk lndlcaLors. lnLervenLlons lnvolved Lhe lnLroducLlon of:

1. a physlcal healLh llnk worker (PLW)
2. mulLl-dlsclpllnary Leam (Mu1) meeLlngs
3. llfesLyle and P educaLlon
4. communlLy-based P assessmenLs.

1he summaLlve evaluaLlon ls currenLly on-golng and wlll lnvolve seml-sLrucLured lnLervlews wlLh PCs and Sus,
supplemenLed wlLh Mu1 acLlon-based daLa analysls.

kesu|ts: AL basellne 187 people wlLh SMl were [olnLly managed by Lhe CMP1 and Cs. 1he formaLlve lnLervlew resulLs
lndlcaLed llmlLed co-ordlnaLlon, skllls/knowledge and responslblllLy for P. P daLa collecLed from Cs conflrms Lhe
lssues ouLllned from Lhe lnLervlews, n=102 (34.3) Sus were overwelghL (8Ml 23+), wlLh no daLa avallable for n=42
(22.3), lmporLanL Cvu rlsk daLa was noL recorded (wlLhln prevlous 12 monLhs) n=77 (42.2) had mlsslng
PuL/CholesLerol daLa, n=43 (23) mlsslng smoklng daLa, and n=43 (23) mlsslng blood pressure daLa. 8elylng on Lhe
formaLlve fleld work and Lhe exlsLlng evldence base, Lhe lnLervenLlons LesLed were Lallored Lo Lhe speclflc conLexL.

lnLerlm resulLs from Mu1 acLlon-based daLa lllusLraLe LhaL [olnL acLlon plans produced aL Lhe Mu1 meeLlngs (held elLher
monLhly or bl-monLhly) have addressed lssues relaLlng Lo mlsslng Su Cvu daLa and effecLlve P managemenL. CurrenLly
(afLer 4 monLhs of daLa collecLlon) Lhere have been n=102 acLlons from n=71 Sus aL n=17 Mu1 meeLlngs, n=23 (23.6)
relaLed Lo cardlo meLabollc dlsease LesLs/revlews l.e. dlabeLes, hyperLenslon, coronary hearL dlsease and cancer, n=21
(20.6) lnvolved prlmary care P assessmenLs. 1he PLW has faclllLaLed Lhe sharlng of lnformaLlon, co-ordlnaLlon of
acLlons beLween Lhe CMP1 and Cs and provlded professlonal guldance and co-ordlnaLlon for Lhe P care of Sus. An
lnLervlew wlLh a Su demonsLraLes Lhe lmprovemenL my menLal healLh worker opened Lhe process of brlnglng everyone
LogeLher Lo dlscuss Lhelr roles and my needs".

A communlLy-based P assessmenL has been lnLroduced, currenLly n=33 have been performed, wlLh Lhe lnformaLlon
shared wlLh Cs and dlscussed aL Mu1 meeLlngs by Lhe PLW. A process of conLlnuous educaLlon wlLh CMP1 sLaff,
communlLy-based llfesLyle servlces and Cs has been dellvered.

Conc|us|on: 1he lnLerlm daLa lndlcaLes LhaL Lhe lnLroducLlon of mulLl-faceLed lnLervenLlons lncludlng a PLW and Mu1
meeLlngs has lmproved Lhe managemenL of Lhe P care for people wlLh SMl [olnLly managed by Lhe CMP1 and Cs.



2130

nANDLING CI 1nL 8LCCD SAMLING (VLNIUNC1UkL)-kLLA1LD ADVLkSL LVLN1S: kLSUL1S CI A NA1ICNWIDL SUkVL IN
IAAN
Sholchl Maeda
1
, 8lka kobayashl
2
, LLsuko kamlshlrakl
3
, Meguml 8aba
4,*

1
CraduaLe School of PealLh ManagemenL, kelo unlverslLy,
2
Shonan Chuo PosplLal, lu[lsawa,
3
unlverslLy of kochl, kochl, !apan,
4
unlverslLy PosplLal of Wales, Cardlff and vale unlverslLy PealLh 8oard, Cardlff, unlLed klngdom


Cb[ect|ves: 8ackground: Cases of adverse evenLs assoclaLed wlLh blood sampllng (venlpuncLure) have been evldenL Lhrough varlous
cllnlcal lncldenL reporLs. Some of Lhese develop lnLo medlcal dlspuLes and llLlgaLlons. lL ls ofLen dlfflculL Lo deLermlne wheLher such
an adverse evenL ls due Lo cllnlcal negllgence or noL.

Cb[ect|ve: 1o lnvesLlgaLe Lhe exlsLence of pollcles and guldellnes on blood sampllng pracLlce and Lhe currenL handllng of adverse
evenLs such as lncldenL lnvesLlgaLlon procedures by Lhe medlcal lnsLlLuLlons.

Methods: Cf all Lhe medlcal lnsLlLuLlons founded by a member of !apan Medlcal AssoclaLlon, 938 hosplLals (20.0 of LoLal 4688) and
1468medlcal cllnlcs (2.0 of LoLal 73402) have been randomly selecLed for Lhe sLudy. An anonymlsed quesLlonnalre was posLed Lo
Lhem and Lhelr responses were collecLed over Lhe perlod beLween 8Lh and 28Lh uecember 2011. SSS SLaLlsLlcs 20 was used for Lhe
sLaLlsLlcal analysls of Lhe daLa. Chl-square LesL or ulrecL llsher LesL was used Lo assess Lhe assoclaLlons beLween Lhe seLs of Lhe
relevanL resulLs. unanswered quesLlons were LreaLed as mlsslng daLa and excluded from Lhe analysls.

kesu|ts: 201 (21.4) hosplLals and 418 (28.3) cllnlcs PosplLals and Cllnlcs responded.127 hosplLals (64.1) had some pollcles on
Lhe procedure whlle lL was Lhe case for 104 medlcal cllnlcs (23.1) (1able 1(1)).73 hosplLals (37.9) and 94 cllnlcs (22.3) have
experlenced adverse evenLs assoclaLed wlLh blood sampllng (venlpuncLure).lor Lhose who have experlenced adverse evenLs Lable
1(2) shows how Lhey handled Lhe lncldenL.

1ab|e 1. (1)1he ex|stence of po||c|es and gu|de||nes on b|ood samp||ng pract|ce, (2) nand||ng of an adverse event.
(1) 1he ex|stence of po||c|es and gu|de||nes on b|ood
samp||ng pract|ce
PosplLal
(n=201)
n ()
Medlcal Cllnlc
(n=418)
n ()
1oLal
(n=641)
n ()

1) Pave a wrlLLen pollcles.
2) Pave lnformal guldellnes.
3) Pave no wrlLLen pollcles or guldellnes aL all.
78 (39.4)
49 (24.7)
71 (33.9)
9 (2.2)
93 (22.9)
310 (74.9)
87 (14.2)
144 (23.3)
381 (62.3)
<0.00
1
(2) nand||ng of an adverse event* negllgence case non-negllgence case
PosplLal
(n=34)
n ()
Cllnlc
(n=43)
n ()
1oLal
(n=79)
n ()
PosplLal
(n=24)
n ()
Cllnlc
(n=29)
n ()
1oLal
(n=33)
n ()
1) Lxpressed sorrlness 12 (33.3) 23 (33.3) 36
(43.6)
10 (41.7) 13
(31.7)
23 (47.2)
2) Apologlsed 27 (79.4) 30 (69.8) 38
(73.4)
9 (37.3) 7 (24.1) 16 (30.2)
3) ald medlcal cosL for physlcal harm 13 (38.2) 8 (18.6) 22
(27.8)
3 (20.8) 0 (0.0) 3 (9.4)
4)ald solaLlum 4 (11.8) 1 (2.3) 6 (7.6) 1 (4.2) 0 (0.0) 1 (1.9)
3)ald compensaLlon 4 (11.8) 1 (2.3) 3 (6.3) 0 (0.0) 0 (0.0) 0 (0.0)
6) CLher 14 (41.2) 3 (7.0) 18
(22.8)
10 (41.7) 3 (17.2) 13 (28.3)
*Sub[ecLs: PosplLals and cllnlcs answered Lhe number of experlence of negllgence/non-negllgence. MulLlple responses

Conc|us|on: ln as much as a 30 of cases apologles are noL belng offered even when negllgence was ldenLlfled. 1hls ls noL conslsLenL
wlLh Lhe currenL recommendaLlon as demonsLraLed by Lhe Sorry Works" ln Lhe uSA. 1he reasons for noL offerlng apologles need Lo
be lnvesLlgaLed urgenLly. Cn Lhe oLher hand Lhere are slLuaLlons where apologles are belng offered and compensaLlons are belng
pald ln Lhe absence of negllgence. Such slLuaLlons are poLenLlally avoldable and we plan Lo lnvesLlgaLe furLher lnLo Lhese cases. 1he
pollcles and guldellnes should be developed Lo faclllLaLe approprlaLe handllng of venlpuncLure-relaLed adverse evenLs.

D|sc|osure of Interest: S. Maeda CranL / 8esearch supporL from: !apan Medlcal AssoclaLlon 8esearch lnsLlLuLe, 8. kobayashl: none
ueclared, L. kamlshlrakl: none ueclared, M. 8aba: none ueclared.


2136

A NLW CCNCL1: ANNUAL ACCUMULA1LD DUkA1ICN CI 1IML (AAD1) CI kIMAk CAkL VISI1S - IS 1nLkL AN
ASSCCIA1ICN WI1n 1nL UALI1 CI DIA8L1LS CAkL.
Shlomo vlnker
1,*
, Palm 8lLLerman
1
, uoron CormaneshLer
1
, Arnon u. Cohen
1

1
Chlef hyslclan offlce, ClallL PealLh Servlces, 1el Avlv, lsrael


Cb[ect|ves:
8ackground
1he encounLer of Lhe dlabeLlc paLlenL may be an opporLunlLy for medlcaLlon lnLenslflcaLlon and llfesLyle counselllng even
durlng vlslLs wlLh acuLe unrelaLed complalnLs. Culdellnes are usually deallng wlLh Lhe conLenL and frequency of vlslLs buL
noL wlLh Lhe duraLlon of vlslLs. WlLh Lhe lncreased workload, prlmary care physlclans (Cs) vlslLs had become shorLer.
1o follow Lhls Lrend we esLabllshed a unlque cenLral daLabase wlLh documenLaLlon of number of vlslLs as well as
duraLlon of each lndlvldual vlslL Lo Lhe C.

A|m
1o evaluaLe Lhe assoclaLlon beLween annual accumulaLed duraLlon of Llme (AAu1) of C vlslLs and Lhe quallLy of
dlabeLes care.

Methods: An observaLlonal sLudy of adulL dlabeLes paLlenLs enrolled ln one dlsLrlcL of ClallL PealLh Servlces (CPS) ln
lsrael durlng 2010. 1he number of vlslLs and Lhe AAu1 of vlslLs of each lndlvldual paLlenL Lo a C were reLrleved wlLh
oLher cllnlcal and soclo-demographlc daLa. CuallLy assessmenL lncluded follow-up measures (annual PbA1c,
mlcroalbumlne, LuL-c, blood pressure (8) and fundus examlnaLlons), and Lhree ouLcome measures (PbA1c<7 mg, 8
<130/80 mmPg, and LuL-c<100 mg/dl). MulLlvarlable regresslon model was employed Lo evaluaLe Lhe assoclaLlon
beLween AAu1 and quallLy of care, conLrolllng for Lhe number of vlslLs and oLher cllnlcal and soclo-demographlc
varlables.

kesu|ts: 1he sLudy lncluded 40,116 dlabeLlc paLlenLs, 30.2 males, average age 64.7+/-12.8 years. 1he average duraLlon
of dlabeLes was 6.3 years. Medlan number of vlslLs was 13 and medlan AAu1 of vlslLs was 90 mlnuLes. 1he flnal
regresslon model lncluded: annual number of vlslLs, dlabeLes duraLlon, lnsulln LreaLmenL, age, gender, soclo-economlc
sLaLus and chronlc dlseases burden. 1here was a llnear poslLlve correlaLlon beLween AAu1 of vlslLs and Lhe performance
of all flve follow-up measures. lor example ln comparlson beLween paLlenLs wlLh AAu1 of 16-30 mlnuLes and AAu1120
mlnuLes Lhe laLLer had an C8=1.76, C8=2.41, C8=1.63 and C8=1.63 ln performance of fundus examlnaLlon, PbA1c LesL,
mlcro albumln LesL, and blood pressure measuremenL, respecLlvely. 1here was no assoclaLlon beLween AAu1 and Lhe
ouLcome measures.

Conc|us|on: Annual accumulaLed duraLlon of Llme of vlslLs was poslLlvely assoclaLed wlLh dlabeLes follow-up buL had no
effecL on dlabeLes conLrol. CpLlmal AAu1 duraLlon of vlslLs should be added Lo Lhe number of annual vlslLs ln guldellnes
and for fuLure cosL-effecLlveness analyses of dlabeLes care by C.

2137

INCIDLNCL CI ACCIDLN1AL nC1nLkMIA IN A1ILN1S UNDLkGCING AM8ULA1Ck SUkGLk: AN LkLCkA1Ck
S1UD
Amellsa lruLLl
1
, MarlsLela . n. 8amos
2,*
, Marla L. LsLevo
2
, lernnada 8. L. Clmenes
3

1
lCC, So aulo,
2
Sumare SLaLe PosplLal, Sumare,
3
uS, 8lbelro reLo, 8razll


Cb[ect|ves: 1o ldenLlfy Lhe lncldence of accldenLal hypoLhermla ln paLlenLs undergolng ambulaLory surgery before and
afLer dlrecL lnLervenLlons from nurse Manager and lmplemenLaLlon of an lnsLlLuLlonal proLocol.

Methods: A descrlpLlve exploraLory sLudy was conducLed ln a 8razlllan SLaLe PosplLal. We performed medlcal record
audlLs of 108 ouLpaLlenLs ln lebruary 2011 Lhrough checkllsL especlally developed for Lhe purposes of Lhe sLudy. 8ased
on resulLs, meeLlngs and regular dlscusslons wlLh nurslng sLaff were performed by nurse Manager. Also, a proLocol Lo
prevenL accldenLal hypoLhermla ln paLlenLs undergolng ambulaLory surgery was lmplemenLed aL all paLlenLs admlsslon.
ln SepLember 2012 new audlL was performed ln 200 medlcal records Lo evaluaLe Lhe effecLlveness of Lhese
lnLervenLlons.

kesu|ts: nlneLy-elghL paLlenLs (92) had Lhelr LemperaLure measured ln lebruary 2011 aL Lhe admlsslon. lrom Lhose, 20
(16) had hypoLhermla, and 10 (83) dld noL have Lhelr LemperaLure measured. AfLer lnLervenLlons, 194 (93)
ouLpaLlenLs had Lhelr LemperaLure measured aL Lhelr admlsslon. lrom Lhose, 10 (3) had hypoLhermla and 4 (2) dld
noL have Lhelr LemperaLure measured.

Conc|us|on: 1he resulLs relnforce Lhe need for conLlnuous educaLlon of nurses concernlng Lhe LemperaLure
measuremenL of all paLlenLs undergolng ambulaLory surgery aL Lhelr admlsslon. 1he lmplemenLaLlon of Lhe proLocol
mlghL help nurses Lo ldenLlfy early hypoLhermla and LreaL lL, mlnlmlslng adverse evenLs.



2139

1nL Lk1kACCkCkLAL LIIL SUCk1 (LCLS) INI1IA1IVL: CkLA1ING AN IN1Lk-kCILSSICNAL MCDLL CI CAkL ICk
A1ILN1S CN LCLS IN 1nL IN1LNSIVL CAkL UNI1
LllzabeLh Cordon
1,*
, uPn LCLS 1eam
2

1
Medlcal-Surglcal lnLenslve Care unlL,
2
unlverslLy PealLh neLwork, 1oronLo Ceneral PosplLal, 1oronLo, Canada


Cb[ect|ves: 1o develop a new lnLer-professlonal model of care for Lhe provlslon of safe, Llmely and effecLlve LCLS for
crlLlcally lll paLlenLs, whlle ensurlng Lhe efflclenL use of resources wlLh mlnlmal operaLlonal lmpacL Lo surglcal and crlLlcal
care servlces.

Methods: A needs AssessmenL was conducLed Lo deLermlne Lhe educaLlonal requlremenLs of nurslng sLaff. CuesLlons
focused on whlch knowledge, skllls and [udgemenL would be requlred for nurses Lo safely and lndependenLly monlLor
and LroubleshooL LCLS Lechnologles. An educaLlonal program was developed LhaL conslsLed of dldacLlc lecLures,
slmulaLlon Lralnlng, as well as pracLlcal hands-on experlence wlLh Lhe LCLS clrculL. 1he LargeL audlence LhaL lnlLlally
lncluded 130 lnLenslve care unlL nurses was expanded Lo lnclude resplraLory LheraplsLs, physloLheraplsLs and fellows and
resldenLs from crlLlcal care, medlclne and surgery.

kesu|ts: Croup dlscusslons as well as anonymous wrlLLen evaluaLlons of conLenL and pracLlcal experlence gulded
revlslons of Lhe program. SLaff who had Lhe opporLunlLy Lo aLLend Lhe course expressed lncreased confldence ln Lhelr
ablllLles Lo care for LCLS paLlenLs, and esLabllshed Lhe LCLS program as a core compeLency for MSlCu nurses. 1o daLe, 63
nurses have compleLed Lhe course wlLh addlLlonal sesslons offered monLhly.

1he success of Lhls educaLlonal endeavour lead Lo Lhe developmenL of a new model of care. A classlflcaLlon sysLem was
developed based on Lhe degree of paLlenL sLablllLy and whlch Lhen deflnes Lhe level of perfuslon supporL (aL bedslde, ln
hosplLal or on call) dependlng on severlLy of lllness and lnLenslLy of bedslde care requlred. 1o malnLaln conslsLency and
quallLy of LCLS paLlenL care, sLandardlsed pollcles and procedures and pre-prlnLed physlclan orders were developed.

Conc|us|on: WlLh Lhe conLlnued lnLroducLlon of advanced lnnovaLlve Lheraples for crlLlcally lll paLlenLs, hosplLals and
crlLlcal care unlLs should conLlnuously re-evaluaLe models of care Lo enhance quallLy, safeLy and efflclency. A model of
care LhaL challenges nurslng sLaff Lo expand Lhelr compeLency, cllnlcal experLlse and fosLers lnLerprofesslonal
collaboraLlon has proven Lo be a safe and efflclenL approach Lo provldlng LCLS Lheraples Lo paLlenLs ln Lhe lnLenslve care
unlL.



2140

IMkCVING SAIL1 AND LkICkMANCL USING VALUL S1kLAM MAING (VSM) CCM8INLD 1C nLAL1nCAkL IAILUkL MCDL
AND LIILC1 ANALSIS 1CCL (VSM-nIMLA)
Carlos l. lnLo
1, 2,*
, SLela M. Coelho
1, 2
, Marcelo l. 1aborda
2, 3
, Lvelln S. MaroLLa
3, 4

1
P8v, 1aubaLe,
2
lnsLlLuLo de Cncologla do vale, Sao !ose dos Campos,
3
P8v,
4
lnsLlLuLo de Cncologla do vale, 1aubaLe, 8razll


Cb[ect|ves: aLlenL SafeLy ls a ma[or concern for our organlsaLlon and, by uslng lean meLhods we were able lmprove dramaLlcally
our capaclLy. WlLh Lhls capaclLy lmprovemenL we requlred beLLer Lools Lo measure and manage safeLy Lhrough Lhese new lean
flows and procedures. Cur organlsaLlon ls an ouLpaLlenL cancer cenLer, wlLh 4 locaLlons ln 3 clLles ln So aulo SLaLe, 8razll. value
SLream Mapplng ls Lhe mosL valuable Lool Lo ellmlnaLe wasLe and lmprove flow whlle uslng lean Lhlnklng. 1o address safeLy and rlsk
managemenL ln our processes, we assoclaLed a solld and rellable Lool Lo prospecLlvely evaluaLe rlsks, Lhe PlMLA (PealLhcare lallure
Mode and LffecL Analysls).

Methods: 1he value SLream Mapplng meLhod followed Shook & 8oLher as proposed ln Learnlng Lo See" (ref 1). A Cu88Ln1 S1A1L
was ldenLlfled, followed by problem analysls and wasLe removal Lo lmprove flow, a lu1u8L S1A1L was deslgned and an acLlon plan
developed (as a regular uCA).

1o add Lhe PlMLA each box ln Lhe flow" for Lhe lu1u8L S1A1L was revlewed for lallure Mode and LffecL Analysls for rlsk
ldenLlflcaLlon and furLher lmprovemenL, addlng exLra boxes lf needed, Lhen Lhe vSM-PlMLA lu1u8L S1A1L ro[ecL"(Lhe acLlon
plan) was execuLed.

We used Lhe PlMLA Lool and scores as proposed by Lhe vA nCS (ref 2). 1he vSM-PlMLA pro[ecL and acLlons plans Look place
durlng 2010-2011, and resulLs are presenLed for 2010, 2011 and 2012 up Lo SepLember.

kesu|ts: 1wo vSMs were developed and execuLed beLween 2010-2012 ln our Lwo ma[or unlLs, wlLh dlfferenL resulLs and ouLcomes.
We developed a comparaLlve score for senLlnel evenLs (never evenLs) ad[usLlng daLa Lo our huge capaclLy lmprovemenL (over 100)
Lhrough 2009-2012.

Score k|sk

VSM-nIMLA
Current
State 2011
Iuture State
2012 *
nIMLA k|sk
keduct|on
Cutcome:
Sent|ne|
Lvents **

2010

2011

2012
#
Lvent rate
reduct|on 2011 -2012
Cancer
at|ent I|ow
ICV
S,098 1,927 62 ICV un|t 0,001
7
0,003
1
0,000
S
84
Care ath
ICV-nkV
27,261 17,08S 37 ICV-nkV
un|t
0,001
7
0,002
0
0,000
3
8S
* As of March 2012,
** 8aLe of SenLlnel LvenLs per medlcal procedure/monLh, updaLed up Lo SepLember/2012,
# lCv has 7,000 medlcal procedures/year and lCv-P8v 20,000.

Conc|us|on: 1he use of value SLream Mapplng (vSM) comblned Lo PealLhcare lallure Mode and LffecL Analysls (PlMLA) ls a
powerful Lool Lo ldenLlfy and mlLlgaLe rlsks ln complex processes. 1he galns assoclaLed wlLh flow lmprovemenL and wasLe removal
uslng vSM and Lhe deep rlsk analysls provlded by Lhe PlMLA were able Lo reduce dramaLlcally (80) our senLlnel evenLs (never
evenLs) ln 2 years, even ln an envlronmenL wlLh fasL growlng demand. 1he vSM ls a powerful Lool buL lL does noL seL a clear message
of safeLy lmprovemenL aL flrsL slghL, Lhls comblnaLlon enllghLen Lhe safeLy perspecLlve and clearly correlaLes wlLh beLLer safeLy
ouLcomes. We suggesL LhaL Lhe assoclaLlon of vSM-PlMLA should be LesLed by oLher organlsaLlons for process and safeLy
lmprovemenLs.

keferences:
1. 8oLher M and Shook !. Learnlng Lo See: value SLream Mapplng Lo Add value and LllmlnaLe MuuA .1he Lean LnLerprlse lnsLlLuLe,
Cambrldge, 2002.
2. ue8osler, SLalhandske L, 8aglan !, nudell 1. uslng PealLh Care lallure Mode and LffecL Analysls`: 1he vA naLlonal CenLer for
aLlenL SafeLy's rospecLlve 8lsk Analysls SysLem. !C! CuallLy lmprovemenL 27(3):248-267,2002.


21S1

kLLA1ICNSnI 8L1WLLN nCSI1AL CLkA1ICN VCLUML AND 1nL IMkCVLMLN1 CI LkICLkA1IVL A1ILN1 SAIL1
INDICA1CkS.
1akefuml klLazawa
1,*
, kunlchlka MaLsumoLo
1
, Shuhel llda
2
, 1omonorl Pasegawa
1

1
ueparLmenL of Soclal Medlclne, 1oho unlverslLy School of Medlclne,
2
All !apan PosplLal AssoclaLlon, 1okyo, !apan


Cb[ect|ves: PosplLal admlnlsLraLlve daLa can be used Lo clarlfy frequency of adverse evenLs and Lhe sLaLus of effecLlveness of paLlenL
safeLy acLlvlLles. 1he uS Agency for PealLhcare 8esearch and CuallLy (AP8C) has developed aLlenL SafeLy lndlcaLors (Sls) whlch are
serles of lndlcaLors provldlng lnformaLlon abouL compllcaLlons followlng procedures. Cur prevlous sLudy suggesLed LhaL Sls could
be calculaLed uslng Lhe dlagnosls procedure comblnaLlon/per-dlem paymenL sysLem (uC/uS) daLa. 1he uC/uS was
lnLroduced ln 2003 Lo relmburse acuLe care hosplLals ln !apan. 1he daLa of uC/uS lncludes admlnlsLraLlve clalm daLa and
paLlenLs' lnformaLlon and compllcaLlons, as well as lnformaLlon of day-by-day procedures. We reporLed Lhe relaLlonshlp beLween
hosplLal operaLlon volume and Lhree perloperaLlve Sls, 'ueaLh among surglcal lnpaLlenLs wlLh serlous LreaLable compllcaLlons'
(Sl#4), 'osLoperaLlve haemorrhage or hemaLoma' (Sl#9), and 'osLoperaLlve sepsls' (Sl#13). 1he purpose of Lhls sLudy ls Lo
lnvesLlgaLe Lhe relaLlonshlp of hosplLal operaLlon volume and lmprovemenL of perloperaLlve Sls ln !apan.

Methods: 1he daLabase of Medl-1argeL" pro[ecL was used for Lhls analysls. Medl-1argeL" pro[ecL ls a benchmarklng pro[ecL uslng
uC/uS daLa and ls managed by Lhe All !apan PosplLal AssoclaLlon (A!PA). 1he A!PA ls one of Lhe blggesL naLlon-wlde hosplLal
assoclaLlons wlLh 2,200 member hosplLals. We used Lhe daLaseL of paLlenLs dlscharged from 2009 Lo 2011. lf 2011 daLa were beLLer
Lhan 2009 daLa, Lhe hosplLal was deflned as lmproved".

kesu|ts: We used 1.96mllllon paLlenL dlscharge daLa from 140 hosplLals. uurlng Lhe observaLlon perlod, proporLlon of hosplLals
whlch lmproved Lhelr Sls was 73.0 (Sl#4), 36.4 (Sl#9) and 33.6 (Sl#13). Among hosplLals whlch lmproved Sl#4, 36.2 had
also lmproved ln Sl#9 and 46.7 ln Sl#13, respecLlvely (p<0.03).
We dlvlded hosplLals lnLo Lhree groups based on Lhelr operaLlon volume by 33.3 and 66.7 percenLlles. Average score of Sl#4 was
slgnlflcanLly lmproved on Mlddle-volume hosplLals and Plgh-volume hosplLals (p<0.01) (1able1).

1able 1. Average Score of perloperaLlve Sls
Sl#4 Sl#9 Sl#13 AM8
Low-volume hosplLals (n=47) Score of 2009 344.8 23.2 4.9 983.3
Score of 2011 281.1 18.8 4.9 1,180.8
p value 0.10 0.10 0.99 -
Mlddle-volume hosplLals (n=46) Score of 2009 308.1 28.8 3.2 974.4
Score of 2011 202.9 33.8 7.0 1,166.6
p value 0.00 0.19 0.08 -
Plgh-volume hosplLals (n=47) Score of 2009 222.7 40.3 11.3 1,181.0
Score of 2011 140.2 47.2 11.6 1,328.2
p value 0.00 0.12 0.91 -
1oLal (n=140) Score of 2009 291.8 31.3 7.2 1,111.2
Score of 2011 208.1 33.9 7.8 1,284.3
p value 0.00 0.36 0.33 -
Score of Sls are lndlcaLed by raLe per 1,000 dlscharges.
AM8 ls a number of deaLhs per 100,000 operaLlve paLlenLs. !apanese sLandard populaLlon was used for age ad[usLmenL.

Conc|us|on: Among Lhree Sls, Sl#4 lmproved slgnlflcanLly ln Mlddle and Plgh-volume hosplLals. 8esulLs of our sLudy suggesL LhaL
hosplLal operaLlon volume mlghL lnfluence Lhe lmprovemenL of perloperaLlve Sls. AM8 lncreased suggesLlng paLlenLs ln more
serlous condlLlon were belng operaLed, buL Lhe deLalled analysls ls needed wlLh severlLy, compllcaLlons and Lhe Lype of operaLlons
Laken lnLo accounL. CuallLy and safeLy of healLhcare should be evaluaLed based on lmprovemenL as well as basellne Sls, and Lhe
mechanlsm how hosplLal operaLlon volume lmproves Sls should be lnvesLlgaLed.



2160

LS1A8LISnMLN1 CI A S1ANDAkD 1kLA1MLN1 CLIC
!lnah klm
1,*
, ?ou[eong klm
1
, Moonsook klm
1
, !aeyoung Lee
1

1
Seoul naLlonal unlverslLy PosplLal, Seoul, korea, 8epubllc Cf


Cb[ect|ves: 1o propose a course of sLaLe acLlon based on Lhe evaluaLlon guldellnes of ouLslde agencles, almed aL
lmprovlng Lhe quallLy of medlcal care Lhrough Lhe esLabllshmenL of a sLandard LreaLmenL pollcy

Methods: A [olnL 1l1, under Lhe supervlslon of Lhe ulrecLor of Lhe Cfflce of lannlng & CoordlnaLlon, Lhe Pead of Lhe CA
CenLer, professors from Lhe relevanL medlcal deparLmenLs, and members of Lhe lnsurance LvaluaLlon Leam, 8uslness
lnnovaLlon Leam, CA Leam, was formed wlLh Lhe purpose of esLabllshlng a sLandard LreaLmenL pollcy. 1he professor of
Medlcal ManagemenL coordlnaLed locused Croup lnLervlews wlLh Lhe professors of Lhe relevanL deparLmenLs, whlch
provlded Lhe 1l1 a sound undersLandlng of Lhe currenL sLaLe of Lhe hosplLal's LreaLmenL pollcy.

1he flrsL Lheme Lhe 1l focused on was 8reasL Cancer. Cancer ls Lhe leadlng cause of deaLh ln korea and 8reasL Cancer
has Lhe hlghesL lncldence raLe as well as Lhe hlghesL deaLh raLe among all cancers. 1he 1l1 hosLed Lwo conferences wlLh
Lhe leadlng professors from ulvlslon of 8reasL Surgery, ulvlslon of PemaLo-oncology, ueparLmenL of 8adlaLlon Cncology,
ueparLmenL of aLhology Lo dlscuss ln deLall and esLabllsh sLandard LreaLmenL pollcy concernlng Lhe approprlaLe
medlclnes and lengLh of hosplLallsaLlon for paLlenLs. 1hrough Lhese dlscusslons, Lhe prescrlpLlon of unnecessary
anLlbloLlcs have been reduced and oLher sLeps such as Laklng consenL forms for anLl-oesLrogen Lherapy, have been puL
ln place so as Lo reform exlsLlng processes.

ColorecLal cancer whlch has Lhe second hlghesL lncldence raLe among cancers ln korea was Lhe second Lheme of focus.
1he 1l1 hosLed Lhree separaLe conferences wlLh Lhe leadlng professors ln ulvlslon of ColorecLal Surgery, ulvlslon of
PemaLo-oncology, ueparLmenL of 8adlaLlon Cncology, and ueparLmenL of aLhology. 1here exlsLed no unlform
guldellne for chesL C1 examlnaLlons for SLage 1 8ecLal cancer paLlenLs. 1he 1l1 was able Lo convlnce Lhe ueparLmenL of
8reasL Surgery and ueparLmenL of 8adlology Lo agree on a unlfled process LhaL would slmulLaneously Lake boLh Lhe
abdomen C1s as well as Lhe chesL C1s needed prlor Lo surgery. 1hls would resulL ln slgnlflcanLly reduce Lhe overall
walLlng perlod for cancer paLlenLs.

1he 1l1's Lhlrd Lheme was AcuLe Myocardlal lnfarcLlon, a condlLlon LhaL requlres speedy, prompL, and preclse LreaLmenL
and Lhe Lhlrd leadlng cause of deaLh ln korea. 1he 1l1 was able Lo keep up Lo daLe Lhrough regular meeLlngs wlLh Lhe
professors from Lhe ulvlslon of Cardlology. 1he prlnclpal focus of Lhese deLalled dlscusslons was on how Lo effecLlvely
lmplemenL Lhe S1LMl (S1-LlevaLlon Myocardlal lnfarcLlon) PoL-llne, and as a resulL, Lhe PoL-llne has become a key
agenda for Lhe hosplLal.

kesu|ts: uurlng Lhe second half of 2012, Lhe 1l1 has headed Lhe efforL ln esLabllshlng a sLandard LreaLmenL pollcy for Lhe
Lhree leadlng causes of deaLh ln korea. 1he 1l1, Lhrough acLlve consulLaLlon wlLh Lhe relevanL deparLmenLs, was able Lo
successfully lmplemenL a sLandard LreaLmenL pollcy and has Laken sLeps Lo reform processes almed Lo promoLe correcL
and more efflclenL dlagnosls. 1he 1l1's flndlngs have been publlshed Lhree whlLe papers so LhaL any member of Lhe
hosplLal may easlly follow and undersLand Lhe newly esLabllshed sLandard LreaLmenL pollcy.

Conc|us|on: ln 2012, a 1l1 was launched wlLh Lhe purpose of lmprovlng Lhe quallLy of medlcal care and Lo propose a
course of sLaLe acLlon. 1he 1l1 ldenLlfled Lhree key Lhemes and proceeded Lo lmplemenL varlous reforms and form a
sLandard LreaLmenL pollcy. ln 2013, Lhe 1l1 ls currenLly worklng Lo lmplemenL a sLandard LreaLmenL pollcy for dlseases
ln Lhe fleld of CbsLeLrlcs and Cynaecology. Seoul naLlonal unlverslLy PosplLal wlll conLlnue Lo work Loward bulldlng a
unlfled process almed aL provldlng paLlenLs wlLh hlgh quallLy care.

2176

VALUL 8ASLD DLCISICN MAkING - A 1CCL ICk UALI1A1IVL AND UAN1I1A1IVL ASSLSSMLN1 CI nLAL1nCAkL
INNCVA1ICNS
Marlan Schoone
1,*
, Lvellen 8l[ken
1

1
PealLhcare lnnovaLlon, 1nC, Poofddorp, neLherlands


Cb[ect|ves: lL ls lmporLanL Lo know Lhe value for all sLakeholders Lo supporL declslon maklng, when you have an ldea for
a new producL or worklng meLhod Lo lmprove quallLy of care, quallLy of llfe and enhance lndependence of Lhe elderly. ln
a socleLal buslness case a range of lmporLanL varlables, boLh cosLs and beneflLs, quallLaLlve and quanLlLaLlve, are
consldered ln a sLrucLured way. 1hls wlll provlde lnslghLs lnLo Lhe effecLs and wlll form Lhe basls of a dlscusslon on Lhe
real added value of Lhe lnnovaLlon.

WlLh fundlng from Lhe uuLch agency for PealLhcare 8esearch, ZonMw, 1nC has been developlng several Lools Lo puL
LogeLher socleLal buslness cases for lnnovaLlons ln healLh care. LasL summer an Lngllsh web Lool for composlng socleLal
buslness cases ln long-Lerm care has become avallable: www.bosloesscose-looqtetmcote.com. WlLh Lhls Lool healLh care
provlders and advlsors can assess Lhe effecLs of an lnnovaLlon ln an early sLage. 1he assessmenL wlll make clear whaL Lhe
lnvesLmenL wlll offer ln Lerms of producLlvlLy, quallLy of care, lncome, work saLlsfacLlon and feaslblllLy of
lmplemenLaLlon. 1he Lool ls unlque because boLh quanLlLaLlve measures llke Llme and money spenL and quallLaLlve
measures llke quallLy of care or work are assessed. 8y presenLlng Lhese ouLcomes slde by slde Lhe welghlng of pros and
cons ls easler for clearer declslon maklng.

Methods: WlLh help of Lhe Lool Lhe slLuaLlon before Lhe lnnovaLlon ls scored on a range of lLems, lncludlng: Llme spenL
quallLy of care, lncome, operaLlng expenses, lncome and work saLlsfacLlon. nexL, Lhe same lLems are scored for Lhe
expecLed slLuaLlon afLer lmplemenLaLlon of Lhe lnnovaLlon. 1he Lool presenLs an overvlew of expecLed dlfferences.
CuanLlLaLlve measures llke spenL Llme or lncome are presenLed ln hours or euros. CuallLaLlve measures are presenLed ln
marks ranglng from 1 Lo 10.

Cnce an lnnovaLlon has been lmplemenLed a real-llve assessmenL can be performed wlLh help of Lhe Lool, for lnsLance,
by measurlng Llme spenL or by leLLlng a Leam of healLhcare speclallsLs or a group of poLenLlal cllenLs raLe Lhe new
slLuaLlon.

ln a plloL Lhree lnnovaLlve pro[ecLs ln long-Lerm care have applled Lhe Lool Lo develop Lhelr own socleLal buslness case.
1he Lhree pro[ecL leaders lnvolved where lnsLrucLed ln a workshop on Lhe concepL and worklng of Lhe Lool. SubsequenLly
Lhey were supporLed lndlvldually when maklng Lhelr assessmenLs on all relevanL lLems.

kesu|ts: 1he pro[ecL leaders found Lhe Lool easy Lo use and lL gave Lhem a compleLe plcLure of Lhe (expecLed) effecLs of
Lhe lnnovaLlon. 1he Lool presenLs checkllsLs wlLh lLems for cllenLs, employees and managemenL and proved Lo be a good
sLarLlng polnL for Lhe dlscusslon on Lhe effecLs of Lhe lnnovaLlon wlLh sLakeholders. 1he varlable llsLs made Lhem
conslder all relevanL lLems lncludlng socleLal aspecLs.

Conc|us|on: 1he Lool helps Lhe healLhcare lnnovaLors Lo make and lnLegral plcLure of Lhe changes lnfllcLed by an
lnnovaLlon. Composlng such a socleLal buslness case ls one of Lhe lmporLanL flrsL sLeps ln Lhe successful developmenL
and lmplemenLaLlon of new healLhcare lnnovaLlons. 1hey now use Lhe resulLs Lo convlnce parLners wlLhln an lnnovaLlve
consorLlum, buL also Lo presenL Lhe beneflLs of Lhe lnnovaLlon Lo exLernal lnvesLors or publlc fundlng parLles. 1he web
Lool www.buslnesscase-longLermcare.com ls avallable for free.

keferences: Schoone M, 8l[ken LMS. Ootwlkkelloq eo eetste etvotloqeo bosloesscose tool voot looqJoteoJe zotq.
juotcb, uevelopmeot ooJ fltst expetleoces wltb bosloess cose tool fot looq-tetm cote.] 1nC reporL, lebruary 2013.

2177

WAI1ING 1IMLS IN NCkWLGIAN nCSI1ALS
lngrld S. Saunes
1,*
, nen 8lngard
1
, Anne karln Llndahl
1

1
norweglan knowledge CenLre for Lhe PealLh Servlces, Cslo, norway


Cb[ect|ves: Cb[ecLlve: WalLlng Llme for hosplLal care ls ln Lhe cenLer of Lhe healLh pollcy debaLe ln norway. We wanLed Lo examlne
Lhe assoclaLlon beLween walLlng Llmes measured by paLlenL admlnlsLraLlve daLa and paLlenL reporLed walLlng Llmes from Lhe
naLlonal paLlenL experlence survey.

Methods: We comblned daLa from Lhe naLlonal aLlenL 8eglsLry (n8), presenLed by Lhe Cfflce of Lhe AudlLor Ceneral(1) and paLlenL
reporLed ouLcomes from asCpp(2), a naLlonal paLlenL experlence survey (n=10314). WalLlng Llme ls deflned as Llme from recelved
referral aL Lhe hosplLal Lo sLarL of LreaLmenL/operaLlon. 1he governmenL goal for average walLlng Llme was 63 days ln 2012. ln Lhe
survey paLlenL were asked: uld you have Lo walL Lo recelve an offer from Lhe hosplLal?" We compare Lhe resulLs on Lhese Lwo
sources for Lhe four healLh reglons ln norway ln order Lo see how paLlenL reporLed ouLcomes compares Lo daLa from Lhe paLlenL
reglsLrles.

kesu|ts: none of Lhe healLh reglons meL Lhe LargeLed goal of an average aL 63 days. 1he naLlonal mean ls 77 days, and Lhe medlan
walLlng Llme ls 30 days. 1here are some reglonal dlfferences, Lhe Lwo largesL reglons average aL 73 and 76 days, abouL Len days less
Lhan ln Lhe CenLral norway 8PA.

8eglonal PealLh AuLhorlLy (8PA) Average walLlng Llme ln days of paLlenL who reporLed qulLe/Loo long walLlng Llme
SouLh-LasLern norway 8PA 73 27
WesLern norway 8PA 76 29
CenLral norway 8PA 83 23
norLhern norway 8PA 79 31

SomewhaL surprlslng Lhe reglon wlLh Lhe hlghesL recorded average walLlng Llme, has Lhe lowesL percenLage of paLlenLs who
reporLed LhaL Lhey had Lo walL for Loo long. aLlenL from Lhe Lwo largesL reglons, Lhe WesLern and SouLh-LasLern 8PAs has abouL
Lhe same average walLlng ln Lhelr reglsLrles, and lL corresponds wlLh reporLlng on paLlenL experlences. norLhern norway has sllghLly
hlgher walLlng Llmes, and has Lhe largesL per cenL of paLlenL reporLlng long walLs. 1he lncrease ln percenLage corresponds well wlLh
Lhe lncrease ln walLlng Llme measured ln Lhe reglsLrles.

Measurlng walLlng Llme ls a challenge, and uslng Lhe average walLlng Llme ln days glves a sllghLly skewed dlsLrlbuLlon. aLlenL wlLh
an excesslve walL wlll helghLen Lhe mean. lL ls also a speclal challenge Lo compare Lhe mean walLlng Llme wlLh paLlenL experlences,
slnce Lhe paLlenL admlnlsLraLlve daLa wlll conLaln walLlng Llmes for paLlenL who has yeL noL been LreaLed, and Lhe paLlenL experlence
survey wlll only address paLlenLs who have recelved LreaLmenL.

Conc|us|on: We have seen how paLlenLs experlence ln general ls conslsLenL wlLh recorded walLlng Llmes ln paLlenL admlnlsLraLlve
sysLems. 1he resulLs from CenLral norway emphasls Lhe need of lncludlng measures from dlfferenL perspecLlves, such as paLlenLs
perspecLlve. Cne lmporLanL noLe ls LhaL some paLlenLs may choose Lo delay non-urgenL operaLlons for varlous reasons. We have no
lnformaLlon avallable on how Lhls may affecL walLlng Llme. Analyses of walLlng Llmes should also lnclude measures of serlousness of
condlLlon. WalLlng Llmes should be explored wlLh furLher analysls of how paLlenL experlence Lhelr hosplLal sLay, and ouLcome of
operaLlons. AnoLher lmporLanL lesson ls Lo sLrengLhen Lhe measures of walLlng Llmes, Lo lnclude measures of boLh mean and
medlan. lL would be useful Lo lnclude measures based on Lhe dlsLrlbuLlon, such as Lhe proporLlon of paLlenLs who had long walLs.
WalLlng Llme for Lhe whole paLlenL [ourney, boLh for ln and ouL-paLlenL LreaLmenL should be recorded.

keferences:
1. 8lksrevls[onens konLroll med forvalLnlngen av sLaLllge selskaper for 2011. uokumenL 3:2 (2012-2013)
2. Skudal kL, Polmboe C. asCpp-rappor nr 4 - 2012. lS8n 978-82-8121-436-9 lSSn 1890-1363



2187

IAC1CkS ASSCCIA1LD WI1n LCLAMSIA IN A 1Lk1IAk nCSI1AL
Chlng-Mlng Llu
1, 2,*
, Shuenn-uyh Chang
3
, o-!en Cheng
3

1
CbsLeLrlcs and Cynaecology, Chang Cung Memorlal PosplLal, 1alpel clLy,
2
CbsLeLrlcs and Cynaecology, Chang Cung
unlverslLy,
3
CbsLeLrlcs and Cynaecology, Chang Cung Memorlal PosplLal, 1ao yuan, 1alwan


Cb[ect|ves: 1o deLermlne, ln a mulLlvarlaLe analysls, some assoclaLed facLors for maLernal morbldlLy and pregnancy
ouLcome, as well as some lssues relaLed Lo subsLandard care beLween eclampsla and severe preeclampsla ln 1alwanese
women. SubsLandard care may LhreaLen Lhe pregnancy ouLcome of hyperLenslve pregnanL women.

Methods: A case-conLrol sLudy of eclampsla and severe preeclampsla. 1he deflnlLlon of subsLandard care was
demonsLraLed. Women who gave blrLh aL a LerLlary hosplLal durlng beLween 1994 and 2003, 33 cases of eclampsla
versus 226 severe preeclampsla, non-eclampLlc paLlenLs were analysed. 8lnary loglsLlc-regresslon analysls of Lhe
ouLcome measures were performed Lo ldenLlfy unlvarlaLe predlcLors assoclaLed wlLh eclampsla, aL Lhe level of sLaLlsLlcal
slgnlflcance of "0.03. MulLlvarlaLe loglsLlc-regresslon analysls was performed Lo ad[usL for poLenLlal confoundlng
facLors.

kesu|ts: 1he slgnlflcanL facLors assoclaLed wlLh eclampsla, lncludlng sysLollc blood pressure (S8) !180 mmPg, dlasLollc
blood pressure (u8) !103 mmPg, haemolysls, elevaLed llver enzymes, low plaLeleLs (PLLL), dlssemlnaLed
lnLravascular coagulaLlon (ulC), hypoxlc encephalopaLhy, acuLe resplraLory fallure, preLerm labour. AfLer ellmlnaLlng Lhe
confoundlng facLors, a mulLlvarlaLe loglsLlcal regresslon revealed LhaL preLerm labour (ad[usLed odds raLlo, 0.333, 93 per
cenL confldence lnLerval, 0.103 Lo 1.74, p= 0.066), mulLlple organ dysfuncLlon syndrome (MCuS) (ad[usLed odds raLlo,
10.83, 93 per cenL confldence lnLerval, 4.23 Lo 27.37, p < 0.001), u8 !103 mmPg (ad[usLed odds raLlo, 0.418, 93 per
cenL confldence lnLerval, 0.166 Lo 1.033, p= 0.063) had made slgnlflcanL conLrlbuLlons ln Lhe developmenL and
progresslon of eclampsla. 1he prevenLable procedures of paLlenL safeLy lssues and ln relaLlon Lo subsLandard obsLeLrlc
care wlll be demonsLraLed as Lo process lndlcaLors, Lhe proporLlon of eclampsla cases from local medlcal cllnlcs who
were noL recelved magneslum sulfaLe prlor Lo L8, Lhe proporLlon of eclampsla cases ln whlch Lhe lacLaLe dehydrogenase
were noL checked ln order Lo exclude Lhe posslblllLy of PLLL syndrome. Among 33 eclampsla cases, 29(34.7) were
referred from local medlcal cllnlcs emergenLly. 1hey mlghL noL have magneslum sulfaLe use prlor Lo our L8. ln addlLlon,
no approprlaLe laboraLory LesL such as lacLaLe dehydrogenase was avallable. As a resulL, Lhe suspecLed PLLL syndrome
ln whlch Lhe posslblllLy was abouL 30 cannoL be excluded. 1hey were all subsLandard procedure occurred ln our dally
pracLlce. .

Conc|us|on: Women wlLh eclampsla had slgnlflcanLly hlgher lncldences of mulLlple organ dysfuncLlon syndrome (odds
raLlo, 10.828, 93 confldence lnLerval, 4.232-27.324, p < 0.001). ln conLrasL, women wlLh severe preeclampsla were
more llkely Lo have preLerm labour develop (83.6 versus 71.7, p < 0.066) and dlasLollc blood pressure !103 mmPg
(60.6 versus 33.8, p = 0.063) Lhan were Lhose wlLh eclampsla.

8eferences: key words: Lclampsla, Severe reeclampsla, MulLlple Crgan uysfuncLlon Syndrome, MaLernal MorbldlLy,
SubsLandard CbsLeLrlc Care


2189

kA1ICNAL USL CI AN1I8IC1ICS- A UALI1 INI1IA1IVL IN nCSI1AL SL11ING
Sldrah nausheen
1,*
, Malra[ Shah
2
, Puma naz
3

1
CbsLeLrlcs and Cynaecology,
2
lamlly Medlclne,
3
AdmlnlsLraLor kharadar, Aga khan unlverslLy hosplLal, karachl, aklsLan


Cb[ect|ves: 1o decrease lrraLlonal use of anLlbloLlcs by lmplemenLlng guldellnes for anLlbloLlc use ln obsLeLrlcs and gynaecology.

Methods: uescrlpLlve sLudy where anLlbloLlc gulde llnes are lmplemenLed ln maLernlLy unlL of Aga khan PosplLal for Women and
chlldren kharadar, a secondary care faclllLy. uaLa was collecLed from medlcal records from !anuary 2010 Lo uecember 2010.
rophylacLlc anLlbloLlcs were glven accordlng Lo ACCC guldellnes 2009, slngle dose of 1gm cefazolln ls glven preoperaLlvely.
Survelllance ls done by surglcal slLe lnfecLlon raLes and lnfecLlous morbldlLy. uaLa was analysed on SSS.

All paLlenLs wlLh gynaecologlc problems for elecLlve vaglnal or abdomlnal hysLerecLomy, laparoLomy , dllaLaLlon and evacuaLlon,
cureLLage of uLerus and all pregnanL females undergolng elecLlve or emergency caesarean secLlon, sponLaneous or lnsLrumenLal
dellvery wlLh eplsloLomy were glven slngle dose prophylaxls wlLh cefazolln 1gm lnLravenous aL Lhe Llme of lnducLlon of anaesLhesla
ln gynae paLlenLs and afLer cord clamplng ln obsLeLrlc paLlenLs. All paLlenLs who dellvered sponLaneously wlLhouL eplsloLomy were
noL glven any anLlbloLlc. aLlenLs wlLh dlabeLes melllLus, fever, rupLure membranes more Lhan 18hours, premaLure pre-labour
rupLure of membranes were glven LherapeuLlc anLlbloLlcs for flve days. A proLocol ls lmplemenLed emphaslslng on glvlng baLh prlor
Lo surgery, avold removal of halrs wlLh razors, effecLlve hand washlng scrubblng Lechnlques, decreaslng C8 Lrafflc durlng surgery,
glvlng baLh on 1
sL
and 2
nd
posL-operaLlve day. uurlng posL-operaLlve perlod 4 hourly LemperaLure charLlng malnLalned. Wound was
lnspecLed for slgns of superflclal and deep lnfecLlon. lf body LemperaLure was greaLer Lhan 38 C and laLer whlLe blood cell counL was
greaLer Lhan 12,000, LherapeuLlc anLlbloLlcs were sLarLed. aLlenLs are followed for 30 days posLoperaLlvely. 1he ouLcome measures
were febrlle anf lnfecLlous morbldlLy lncludlng wound lnfecLlon.

kesu|ts: A 1oLal of 1710 paLlenLs were sLudled durlng Lhe perlod of one year. CuL of Lhese 1364(91.3) were obsLeLrlc paLlenLs and
146 (8.3) gynae surglcal paLlenLs. aLlenLs wlLh caesarean secLlon were 311 and 1033 were vaglnal dellverles. Mean age of
obsLeLrlc paLlenLs was 23 years and gynae paLlenLs 33 years. uecrease ln lrraLlonal use of anLlbloLlcs and lLs lmpacL on surglcal slLe
lnfecLlons ls glven ln Lable. ConLlnuous monlLorlng and emphasls has broughL Lhe usage of LherapeuLlc anLlbloLlc Lo 8 by uecember
2010 wlLhouL lncreaslng lnfecLlous morbldlLy above 3.. CuL of SSl 23 paLlenLs developed superflclal wound lnfecLlon, only 3 cases
of deep lnfecLlon wlLh compleLe gaplng of wound, no case of pelvlc abscess or wound dehlscence. uurlng Lhe posL Cp perlod, 20
paLlenLs reporLed fever of whlch 7 had lnfecLlon on blood counLs, and were glven anLlbloLlcs. 1he resL seLLled wlLhln 24 hours. no
case of u1l or chesL lnfecLlon reporLed.

MCn1P aLlenLs recelvlng LherapeuLlc anLlbloLlcs 1oLal paLlenLs ercenLage *Surglcal slLe lnfecLlon raLes
!anuary
leb
march
160
62
43
163
113
107
97
34
42
3
3.2
2.8
Aprll
may
!une
43
30
36
108
130
136
40
33
23
4
3.3
2.9
!uly 63 137 40 4.2
AugusL 33 181 20 2.8
SepL 13 130 10 2.2
CcLober 20 136 13 2.3
november 12 160 8 3.8
uecember 10 123 8 2.6

Conc|us|on: lmplemenLlng guldellnes for anLlbloLlc use ln obsLeLrlcs and gynaecology and LranslaLlng lL lnLo our proLocols was
effecLlve ln decreaslng Lhe lrraLlonal anLlbloLlc consumpLlon ln our hosplLal .lL has decreased Lhe cosL lncurred Lo Lhe paLlenL and
work load on nurslng sLaff.


2192

IUNC1ICNAL IMkCVLMLN1 1LAMS AkL CSI1IVLL ASSCCIA1LD WI1n LINkAGL CI nIV CSI1IVL MC1nLkS IN1C
nIV CAkL
!ohn 8. 8yabagambl
1, 2,*
, LsLher karamagl nkolo
1, 2
, Pumphrey Megere
1, 2

1
unlverslLy 8esearch Co., LLC,
2
uSAlu PealLh Care lmprovemenL ro[ecL, kampala, uganda


Cb[ect|ves: 1o deLermlne facLors LhaL affecL funcLlonallLy of lmprovemenL Leams and Lo deLermlne lf Lhere ls an
assoclaLlon beLween Leam funcLlonallLy and llnkage of Plv-poslLlve moLhers lnLo Plv care aL slxLeen Plv cllnlcs ln CenLral
and WesLern uganda and Lhus valldaLe Lhe funcLlonallLy lndex

Methods: 1he uSAlu PealLh Care lmprovemenL ro[ecL (PCl) supporLed slxLeen Plv cllnlcs ln CenLral and WesLern
uganda Lo lmprove llnkage of Plv-poslLlve moLhers lnLo Plv chronlc care. A cross secLlonal sLudy was done afLer a perlod
of 21 monLhs Lo deLermlne Lhelr funcLlonallLy and performance. uaLa was collecLed from Cl Leam leaders uslng a
sLandard quesLlonnalre, exLracLlon of records and by observaLlon. luncLlonallLy was assessed uslng a composlLe
lndlcaLor (Leam composlLlon, Leam acLlveness, use of rlghL daLa Lools and coachlng) ln whlch Leams were classlfled as
funcLlonal or non-funcLlonal. 1he assoclaLlon of Leam funcLlonallLy and llnkage of Plv-poslLlve moLhers lnLo Plv chronlc
care was assessed uslng Lrend analysls of percenLage of Plv-poslLlve moLhers ldenLlfled aL anLenaLal cllnlc and llnked
lnLo Plv care by Lhe lmprovemenL Leams.

kesu|ts: CuallLy lmprovemenL Leams slgnlflcanLly lmproved Lhe llnkage of Plv-poslLlve moLhers from an average of 23
before Leam formaLlon Lo70 afLer 12 monLhs of Lhelr exlsLence (p<0.001). 1he performance of Cl Leams ln llnklng of
Plv- poslLlve moLhers lnLo Plv care was poslLlvely assoclaLed wlLh Leam funcLlonallLy, wlLh funcLlonal Leams performlng
beLLer Lhan Lhe non-funcLlonal Leams, (k
2
0.84 vs. 0.30 respecLlvely). Cl Leam acLlveness was Lhe blggesL challenge Lo
Leam funcLlonallLy, wlLh Leams scorlng an average of 34.1, whlle use of rlghL daLa Lools was Lhe leasL challenglng wlLh
Leams an average score of 86.

Conc|us|on: Cl Leams slgnlflcanLly lmproved Lhe llnkage of Plv-poslLlve moLhers lnLo Plv chronlc care aL slxLeen Plv
cllnlcs, wlLh Lhe funcLlonal Leams performlng beLLer Lhan Lhe non-funcLlonal Leams. CuallLy lmprovemenL Leam
acLlveness ls Lhe blggesL hlndrance Lo Cl Leam funcLlonallLy. 1here ls need Lo address facLors LhaL lead Lo poor Leam
acLlveness lf Cl Leams are Lo be made funcLlonal and Lhus posL beLLer performance.



2196

NUkSLS' CINICNS kLGAkDING 1nL DISCLCSUkL 1C A1ILN1 CI NLAk MISSLS AND MLDICAL LkkCkS IN IAAN
naLsuko 1abaLa
1
, Sholchl Maeda
2,*

1
?okohama 8osal PosplLal, ?okohama,
2
CraduaLe School of PealLh ManagemenL, kelo unlverslLy, lu[lsawa, !apan


Cb[ect|ves: 8espondlng Lo adverse evenLs when Lhey do occur ls now regarded as an lmporLanL parL of paLlenL safeLy managemenL.
1hls lncludes communlcaLlon wlLh Lhe paLlenL ln Lhe form of dlsclosure and apology [1]. 1he purpose of Lhls sLudy ls Lo descrlbe and
evaluaLe Lhe nurses' oplnlons regardlng Lhe dlsclosure Lo Lhe paLlenLs of near mlsses and medlcal errors ln !apan.

Methods: 8eLween 3
rd
and 19
Lh
of CcLober 2011, anonymous quesLlonnalres were dlsLrlbuLed Lo all nurses (n=840) ln a unlverslLy
hosplLal wlLh abouL 900 beds ln Pyogo, !apan. 1he quesLlonnalres lncluded 8 hypoLheLlcal scenarlos dlffered ln serlousness of Lhe
adverse evenL ranglng from a near mlss case Lo a paLlenL deaLh. We asked Lhe nurses' oplnlons on wheLher Lhe medlcal error
should be dlsclosed Lo Lhe paLlenLs or noL on each of Lhe elghL cases. 1helr responses were measured on a 3-polnL LlkerL scale (from
sLrongly dlsagree" Lo sLrongly agree"). 1hese responses were classlfled lnLo 3 groups (agree", uncerLaln", dlsagree"). SSS
SLaLlsLlcs 19.0 was used for Lhe sLaLlsLlcal analysls of Lhe daLa. Chl-square LesL or Mann-WhlLney u LesL was used Lo assess Lhe
assoclaLlons beLween Lhe seLs of Lhe relevanL resulLs. unanswered quesLlons were LreaLed as mlsslng daLa and excluded from Lhe
analysls.

kesu|ts: 1he response raLe was 40.4 (340/840). 1here are nurses who do noL Lhlnk dlsclosure of medlcal error Lo Lhe paLlenL ls
approprlaLe ln serlous adverse evenL cases. 1able 1 shows Lhe nurses' oplnlons ln relaLlon Lo Lhelr year of professlonal experlence
(wlLhln one year or over one year).

1ab|e 1. 1he nurses' op|n|ons |n d|st|nct|on of year of exper|ence (w|th|n one year or over one years)
Serlousness of Lhe adverse evenL nurses' oplnlons ?ears of experlence n ()
WlLhln one year (n=30) Cver one years (n=301)
near Mlss Agree
uncerLaln
ulsagree
2 (6.7)
4 (13.3)
24 (80.0)
18 (6.0)
46 (13.4)
234 (78.3)
.874
Level 1 Agree
uncerLaln
ulsagree
23 (76.7)
3 (10.0)
4 (13.3)
231 (83.7)
38 (12.7)
11 (3.7)
.249
Level 2 Agree
uncerLaln
ulsagree
22 (73.3)
6 (20.0)
2 (6.7)
282 (94.0)
12 (4.0)
6 (2.0)
<.001
Level 3 Agree
uncerLaln
ulsagree
26 (86.7)
4 (13.3)
0 (0.0)
297 (99.3)
1 (0.3)
1 (0.3)
<.001
Level 4 Agree
uncerLaln
ulsagree
27 (93.1)
2 (6.9)
0 (0.0)
297 (99.3)
1 (0.3)
1 (0.3)
.004
Level 3 Agree
uncerLaln
ulsagree
29 (96.7)
1 (3.3)
0 (0.0)
296 (99.3)
1 (0.3)
1 (0.3)
.147
aLlenL ueaLh Agree
uncerLaln
ulsagree
29 (96.7)
1 (3.3)
0 (0.0)
298 (99.7)
1 (0.3)
0 (0.0)
.044
Mann-WhlLney u LesL.

Conc|us|on: ln Lhe u.S., Lhe Parvard unlverslLy afflllaLed hosplLals publlshed a consensus paper, When 1hlngs Co Wrong" and more
recenLly Lhe Sorry Works CoallLlon" ls galnlng lnLeresL. ln Lngland, Lhe naLlonal PealLh Servlce lnlLlaLed Lhe 8elng Cpen ro[ecL" ln
2006[1]. Cur sLudy revealed LhaL Lhere are nurses who do noL Lhlnk dlsclosure of medlcal error Lo Lhe paLlenL ls approprlaLe ln
serlous adverse evenL cases. 1here were sLaLlsLlcal dlfferences ln Lhe Lwo groups ln Lhelr oplnlons on Lhe level 2 and 3 lncldenLs
(1able 1). A sysLem Lo asslsL nurses ln dlscloslng medlcal errors Lo paLlenLs and furLher educaLlon Lo enable nurses Lo do so needs Lo
be esLabllshed.

keferences: Maeda S, kamlshlrakl L, !ay S: aLlenL SafeLy LducaLlon aL !apanese Medlcal Schools: 8esulLs of a naLlonwlde Survey.
8MC 8esearch noLe: 3:226, 2012

2197

DLVLLCMLN1 CI nCSI1AL S1ANDAkDISLD MCk1ALI1 kA1ICS IN kCkLA
!ln-Seok Lee
1,*
, Sang-!un Lun
2
, Soo-Pee Pwang
3

1
ueparLmenL of PealLh ollcy and ManagemenL, Seoul naLlonal unlverslLy, College of Medlclne,
2
1he Seoul lnsLlLuLe,
3
PealLh lnsurance 8evlew and AssessmenL Servlce, Seoul, korea, 8epubllc Cf


Cb[ect|ves: ln korea, hosplLal evaluaLlon and publlc dlsclosure programs were sLarLed ln Lhe early 2000s and Lhese
broughL lmprovemenL of hosplLal quallLy. Powever, unLll now, Lhese acLlvlLles have focused Lo speclflc condlLlons and
procedures. PealLh lnsurance 8evlew and AssessmenL Servlces (Pl8A) has Lhe maln responslblllLy of Lhese acLlvlLles.
Pl8A ls conslderlng Lhe lnLroducLlon of PosplLal SLandardlsed MorLallLy 8aLlos (PSM8) Lo evaluaLe hosplLal's overall
performance. 1he purpose of Lhls sLudy ls Lo develop Lhe korean verslon PSM8 and evaluaLe Lechnlcal feaslblllLy.

Methods: We analysed naLlonal healLh lnsurance clalm daLa (2008-2010). korea has Lhe naLlonal PealLh lnsurance
program lncludlng almosL people (abouL 97 of populaLlon). 1he clalm daLa of Lhese people are collecLed Lo Pl8A. We
classlfled all cases Lo 236 dlsease groups by uslng Cllnlcal ClasslflcaLlons SofLware developed by AP8C. Among 236
dlsease groups, 31 dlsease groups accounLed for 80 of ln-hosplLal morLallLy. 1hese 31 dlsease groups are our analysls
ob[ecL. We calculaLed respecLlve hosplLal's PSM8 by applylng Lhe morLallLy probablllLy model.

kesu|ts: We calculaLed PSM8 ln Lwo ways.

1) CaLerplllar ploL: 30.1 hosplLals had a PSM8 value caLegorles as 'as expecLed'. Powever, 43.1 hosplLals had a
PSM8 value caLegorles as 'hlgher Lhan expecLed'. And oLhers had a PSM8 value caLegorles as 'lower Lhan expecLed'.
2) lunnel ploL: 36.1 hosplLals had a PSM8 value caLegorles as 'as expecLed'. Powever, 27.6 hosplLals had a PSM8
value caLegorles as 'hlgher Lhan expecLed'. And oLhers had a PSM8 value caLegorles as 'lower Lhan expecLed'. 1here
ls Lendency LhaL blgger hosplLals have hlgher performance.

Conc|us|on: 1hese resulLs suggesL LhaL Lhe lnLroducLlon of PSM8 ls feaslble ln korea. Powever, korean verslon PSM8
calculaLlng model lsn'L yeL compleLe. 1herefore, meLhodologlcal lmprovemenL ls needed for applylng PSM8 ln pracLlcal
flelds.



2208

1nL LIILC1IVLNLSS CI A NUkSL-IMLLMLN1LD SLDA1ICN MANAGLMLN1 CN UNLANNLD Lk1U8A1ICN
Mok kl lung vlncenL
1,*
, Law !enny
1
, Luk Plng Wah
2
, Leung Anne
2

1
Medlcal SpeclalLy,
2
lnLenslve Care unlL, PosplLal AuLhorlLy Cueen LllzabeLh PosplLal, Pong kong, Pong kong

Cb[ect|ves: 1o examlne Lhe effecLs of a nurse-lmplemenLed sedaLlon managemenL on unplanned exLubaLlon raLe ln
venLllaLor ward.

Methods: 5toJy ueslqo. A quasl-experlmenL meLhod was used. lrom 1
sL
!anuary 2012 Lo 31
Lh
uecember 2012, 364
paLlenLs fulfllled Lhe lncluslon crlLerla for Lhe sLudy and were recrulLed. ConvenLlonal Croup recrulLed Lhose sub[ecLs
who were prescrlbed wlLh a flxed dosage of sedaLed medlcaLlon or even no sedaLlon prescrlbed. lnLervenLlonal Croup
recrulLed Lhose who were prescrlbed wlLh a range of sedaLed medlcaLlon LlLraLed by Lralned nurses. Maln ouLcome
measures of Lhe sLudy lnclude Lhe lengLh of sLay (LCS) of venLllaLors days, raLe of successful exLubaLlon, lncldenL raLe of
unplanned exLubaLlon and sedaLlon score.

losttomeots. 1he sedaLlon managemenL ls a package of nurse-lmplemenLed proLocols whlch lnclude:
l. AlgorlLhm-based sedaLlon proLocol,
ll. ually awakenlng proLocol, and
lll. SponLaneous breaLhlng Lrlal proLocol.

kesu|ts: 1he mean age of Lhe lnLervenLlonal group (lC) and Lhe convenLlonal group (CC) are 78.9 and 73.8 respecLlvely (
= 0.63, nS). 1he LCS of venLllaLor days had been measured beLween 2 groups. 1he lC were 3.3 days and Lhe CC were 6.3
days (= 0.33). 1he sedaLlon score was 3.2 among lC and Lhe CC was 3.1 (p<0.003) whlch reflecLed Lhe sub[ecLs ln Lhe CC
were aglLaLed whereas Lhe lC were opLlmally sedaLed. Meanwhlle Lhe unplanned exLubaLlon raLe from Lhe lC was 3.23
comparlng wlLh Lhe CC 16.33 (<0.001). lL showed Lhere was greaL slgnlflcanL poslLlve dlfference beLween Lhe nurse-
lmplemenLed sedaLlon managemenL wlLh Lhe convenLlonal group.

Conc|us|on: 1he lmplemenLaLlon of nurse-lmplemenLed sedaLlon managemenL showed effecLlveness ln Lhe unplanned
exLubaLlon raLe. lL may reduce duraLlon of Mv and lengLh of sLay ln venLllaLor ward. 1he nurse-lmplemenLed sedaLlon
managemenL provlde lmmedlaLe response Lo relleve paLlenLs dlscomforL on Mv and helps Lo dellver approprlaLe
sedaLlon accordlng Lo Lhe LlLraLlon auLonomy delegaLed. 1hls nurse-lmplemenLed sedaLlon managemenL may lmprove
paLlenL safeLy by mlnlmlslng unplanned exLubaLlon. Areas on paLlenLs and relaLlve saLlsfacLlon as well as nurslng
compeLence ln Lhls nurse-lmplemenLed sedaLlon managemenL should be examlned. More lnLervenLlonal sLudles should
be execuLed ln Lhe fuLure Lo consolldaLe Lhe effecLlveness of Lhls sedaLlon managemenL.

keferences:
1. ChrlsLle, !. M., ueLhlefsen, M. & Cane, 8. u. (1996). unplanned endoLracheal exLubaLlon ln Lhe lnLenslve care unlL.
Iootool of cllolcol Aooestbeslo, 8, 4, 289-293.
2. klng, !. n. &LllloLL, v. A. (2012). Self/unplanned LxLubaLlon: SafeLy, Survelllance, and MonlLorlng of Lhe Mechanlcally
venLllaLed aLlenL. ctltlcol cote Notsloq cllolcs of Nottb Ametlco, 24,3, 469-479.
3. Sessler, C. n. & edram, S. (2009). roLocollzed and 1argeL-based SedaLlon and Analgesla ln Lhe lCu. ctltlcol cote
cllolcs, 23, 3, 489-313.
4. 1ung, A., 1adlmeLl, L., Caruana-MonLaldo, 8., ALklns. M., Mlon, L. C., almer, 8. M., Slomka, !. & Mendelson,
W.(2001). 1he relaLlonshlp of sedaLlon Lo dellberaLe self-exLubaLlon. Iootool of cllolcol Aooestbeslo, 13,1, 24-29
3. ?eh, S. P., Lee, L. n., Po, 1. P., Chlang, M. C. & Lln, L. W. (2004). lmpllcaLlons of nurslng care ln Lhe occurrence and
consequences of unplanned exLubaLlon ln adulL lnLenslve care unlLs. lotetootloool Iootool of Notsloq 5toJles, 41, 3,
233-262.

2209

IACILI1A1CkS, 8AkkILkS AND A1ILN1 CLN1LkLDNLSS IN MUL1IDISCILINAk CANCLk 1LAMS
8en[amln W. Lamb
1, 2,*
, !onaLhan n. Lamb
3
, Sophle L. SLrlckland
4
, !ames S. Creen
3

1
CenLre for aLlenL SafeLy and Servlce CuallLy, ueparLmenL of Surgery and Cancer, lmperlal College London, London,
2
urology, LlsLer PosplLal, SLevenage,
3
1rauma and CrLhopaedlcs, Mld ?orkshlre PosplLals nPS LrusL, eLersfleld,
4
Ceneral
racLlce, Leeds Leachlng hosplLal nPS LrusL, Leeds,
3
urology, 8arLs PealLh nPS 1rusL, London, unlLed klngdom


Cb[ect|ves: MulLldlsclpllnary Leams (Mu1s) are Lhe sLandard means of maklng cllnlcal declslons ln surglcal oncology and
oLher arenas. Cur ob[ecLlve ls Lo address lssues LhaL affecL cllnlcal declslon-maklng ln Mu1 meeLlngs, such as Lhe
represenLaLlon of paLlenLs, deallng wlLh dlsagreemenLs, and facLors LhaL lmpalr Leam worklng LhaL have noL prevlously
been lnvesLlgaLed.

Methods: 8esponses Lo open quesLlons from Lhe 2009 naLlonal survey ln Lhe uk were analysed uslng sLandard
quallLaLlve research meLhods. 1hemes were LabulaLed, and verbaLlm quoLes were exLracLed Lo valldaLe and lllusLraLe
emergenL Lhemes.

kesu|ts: lree-LexL responses from 1636 Mu1 members were analysed. key Lhemes were:

1) Lhe lmporLance of non-Lechnlcal skllls, organlsaLlonal supporL and good relaLlonshlps beLween Leam-members for
effecLlve Leam worklng,
2) recordlng of dlsagreemenLs (poLenLlally sharlng Lhem wlLh paLlenLs), and Lhe lmporLance of paLlenL-cenLred
lnformaLlon ln relaLlon Lo Leam declslon-maklng,
3) Lhe cenLral role of cllnlcal nurse speclallsLs as Lhe paLlenL's advocaLes, complemenLlng Lhe role of physlclans ln
relaLlon Lo paLlenL-cenLeredness.

Conc|us|on: ueveloplng Leam-members' non-Lechnlcal skllls and provldlng organlsaLlonal supporL are necessary Lo help
ensure LhaL Mu1s are dellverlng hlgh quallLy, paLlenL-cenLred care, wlLh Lhe ulLlmaLe alm of lncreaslng survlval raLes and
paLlenLs' quallLy of llfe. 1he quesLlon of how besL Lo represenL Lhe paLlenL ln Mu1 meeLlngs requlres furLher exploraLlon.



2226

DULICA1L kLSCkI1ICN CS1-kLCA1UkL CI SAML AC1IVL INGkLDILN1 IN NnI 8 nIkA
kyunghwa kang
1,*
, Pyangock !ung
1
, Pea[ung klm
1

1
Pl8A, Seoul, korea, 8epubllc Cf


Cb[ect|ves: 1hls sLudy, based on Lhe posL-recapLure of uupllcaLe rescrlpLlons wlLh Lhe Same AcLlve lngredlenL urug Lo
Lhe same paLlenLs from Lhe same hosplLal from 2009 Lo 2011, drew a concluslon Lo prevenL medlclnes mlsuse and
conslder Lhe fuLure healLh care pollcy.

Methods: SLudy sub[ecLs were all Lhe hosplLal-based posL-recapLure of uupllcaLe rescrlpLlons wlLh Lhe Same AcLlve
lngredlenL urug whose ellglblllLy for healLh lnsurance was assessed by Lhe PealLh lnsurance 8evlew (Pl8A) & AssessmenL
Servlce from 2009 Lo 2011. 1he sLaLus of uupllcaLe rescrlpLlons wlLh Lhe Same AcLlve lngredlenL urug was compared
and analysed, sorLed by years, hosplLals, paLlenLs and hlgh drug of dupllcaLlon days.

! Same AcLlve lngredlenL urug: Medlclnes wlLh Lhe same serlal number of acLlve lngredlenL
! uupllcaLe rescrlpLlons: 1he same lngredlenLs of prescrlpLlon drug hlsLory from paLlenLs wlLh Lhe same hosplLal LhaL
exceeds 214 days durlng slx monLh (oral drug)

osL-recapLure of uupllcaLe rescrlpLlons wlLh Lhe Same AcLlve lngredlenL urug dlffer from uu8 for provlng real-Llme
safe drug managemenL and lnformaLlon ln korea

kesu|ts: As a resulL of uupllcaLe rescrlpLlons wlLh Lhe Same AcLlve lngredlenL urug, Lhe number of hosplLals decllned
from 2,978 (2009) Lo 2,362 (2010) and Lo 2,232 (2011). 1he number of paLlenLs also decllned from 11,410 (2009) Lo
8,412 (2010) buL lncreased Lo 9,789 (2011). 1he hlgh drug of dupllcaLlon days were chronlc condlLlon medlclnes such as
anLl-Lhyrold hormone, anLl-dlabeLlcs, cardlovascular drug and anLl-llpldemlcs.

(1able: SLaLus of uupllcaLe rescrlpLlons wlLh Lhe Same AcLlve lngredlenL urug)
?ear 2009 2010 2011
number of hosplLals 2,978 2,362 2,232
number of aLlenLs 11,410 8,412 9,789
1he hlgh drug of dupllcaLlon
days
(1op 3)

AnLl-Lhyrold, hormone, anLl-
dlabeLlcs, cardlovascular -drug
AnLl-Lhyrold, hormone,
cardlovascular -drug, anLl-
llpldemlcs
AnLl-Lhyrold, hormone,
cardlovascular-drug
anLl-llpldemlcs

Conc|us|on: AfLer Lhe posL-recapLure of uupllcaLe rescrlpLlons wlLh Lhe Same AcLlve lngredlenL urug from 2009 Lo
2011, Lhe number of hosplLals decreased conLlnuously, and Lhese resulLs affecLed on Lhe docLor's dupllcaLe prescrlblng
behavlour and lnfluenced Lhe paLlenL's medlcal use. Powever, ln Lerms of correcLly uslng Lhe hlgh drug of dupllcaLlon
days (Lop 3) as LreaLmenL for chronlc paLlenL as well as docLor' prescrlblng behavlour, need on-golng managemenL and
also Lhe revlew of medlcal pollcles should be consldered.



2227

1C ANALSL AND ASSLSS 1nL ML1nCDCLCG ICk C1IMISA1ICN CI CCMU1LD 1CMCGkAn (C1) AND
MAGNL1IC kLSCNANCL IMAGING (MkI) kCCLDUkLS IN A 1Lk1IAk CAkL ICI ACCkLDI1LD 1LACnING nCSI1AL IN
1nL DLVLLCING WCkLD
Mlrza 8ehanullah 8alg
1,*
, Muhammad Akbar khan
1
, Sohall Syed M
1
, ?usuf Mohammad
1

1
8adlology ueparLmenL, 1he Aga khan unlverslLy PosplLal, karachl, aklsLan


Cb[ect|ves: 1he ob[ecLlve of Lhls quallLy pro[ecL was Lo analyse and opLlmlse Lhe operaLlonal aspecLs (markeLlng and
flnanclal) of C1 and M8l servlces.

Methods: 1he Aga khan unlverslLy PosplLal has been ln Lhe process of expandlng lLs faclllLles ln order Lo caLer for Lhe
lncreased healLhcare servlces demand. ln llne wlLh lnsLlLuLlonal ob[ecLlve, Lhe deparLmenL of 8adlology has plans Lo
lnsLall addlLlonal unlLs of M8l and C1 Scan. AcLlng proacLlvely before Lhe funcLlonallLy of Lhe planned new servlces, Lhe
managemenL ln radlology ldenLlfled a quallLy lmprovemenL pro[ecL Lo assess Lhe currenL slLuaLlon and propose
recommendaLlons for opLlmlsaLlon. 1he pro[ecL was done ln collaboraLlon wlLh a Leam of flnal year sLudenL of Lhe mosL
repuLed buslness school ln Lhe clLy. 1he pro[ecL meLhods lncluded uaLa Mlnlng, CbservaLlon of Work racLlce, 1eam
lnLervlews, 1lme and MoLlon SLudy, aLlenL Survey and Senslng, and Schedullng and Cueulng. 1here were also
llmlLaLlons perLlnenL Lo each area of focus whlch was also consldered.

kesu|ts: 1he pro[ecL revealed Lhe followlng ouLcomes:

! Lack of coordlnaLlon was observed ln M8l and C1 Scan operaLlons.
! non-uLlllsaLlon of machlne was noL belng monlLored parLlcularly ln M8l.
! 8elucLance Lo schedule appolnLmenLs afLer 7 pm.
! uaLa, already avallable ln varlous lnformaLlon managemenL sysLems was noL belng analysed properly.
! ComplexlLy and varlablllLy ln Lhe procedures resLrlcL Lhe modelllng of an lndlvldual procedure's cosL.
! non-aggresslve markeLlng sLraLegy.
! uue Lo hlgher cosLs of M8l and C1 Scan procedures, ouLslde referral ls low.
! Ceneral lack of quallLy awareness ln paLlenLs

Conc|us|on: Cn Lhe basls of Lhe sLudy we concluded:

! LsLabllsh sLraLeglc parLnershlps wlLh corporaLes as well as pursue aggresslve markeLlng sLraLegy wlLh referrlng
physlclans.
! Lxplore varlous opLlons Lo promoLe uLlllsaLlon of M8l and C1 ln off-hours for opLlmum uLlllsaLlon
! Schedule procedures based on Lhe queulng model.
! lnLroduce performance-based lncenLlves. 1hls ls meanL Lo moLlvaLe Lhe sLaff even furLher Lhrough exLrlnslc rewards.
! lncrease seaLlng capaclLy ln Lhe walLlng area and provlde free Wl-ll servlce.
! 1hese lnlLlaLlves are meanL Lo lmprove Lhe cusLomer's walLlng experlence.
! lnLroduce dlfferenLlal prlclng model and offer dlscounLs Lhrough LoyalLy Cards and dlscounLs based on Lhe frequency
of procedures.
! lncrease general quallLy awareness ln masses by dlfferenLlaLlng C1 and M8l servlces based on cllnlcal feaLures.




2232

kLSIkA1Ck NUkSL-LLD SLkVICL LNnANCLS LIILC1IVLNLSS CI NCN-INVASIVL MLCnANICAL VLN1ILA1ICN IN
GLNLkAL WAkDS
Suk long Wal
1,*
, Chol ?lng Chan
1
, kah Lln Choo
1

1
Medlcal, norLh ulsLrlcL PosplLal, Pong kong, Pong kong


Cb[ect|ves: 1o evaluaLe Lhe effecLlveness of resplraLory nurse-led nlv round ln general wards

Methods: uurlng dally nlv round, resplraLory nurse performs mask lnLerface-flLLlng, lnspecLs nlv clrculL connecLlons,
and assesses mask hyglene and monlLors compllcaLlons such as nasal brldge or faclal skln sore. lf necessary, nlv seLLlngs
lncludlng oxygen concenLraLlon (llC
2
), lnsplraLory poslLlve alrway pressure (lA), explraLory poslLlve alrway pressure
(LA), resplraLory raLe (88), rlse Llme (81) and lnsplraLory Llme (1l) would be ad[usLed accordlng Lo a local nlv LlLraLlon
proLocol developed by resplraLory physlclan. nurslng lnLervenLlons are backed by resplraLory speclallsLs who perform
weekly nlv rounds wlLh nurse and are avallable for consulLaLlons.

kesu|ts: llfLy-seven paLlenLs were managed from !uly Lo uecember 2012 among seven medlcal wards. 1wenLy-four
paLlenLs requlred furLher nurse-led nlv LlLraLlon wlLh ad[usLmenLs made Lo lA, LA, 88, 81, 1l and llC2. 1welve
paLlenLs were under-venLllaLed, as reflecLed by low Lldal volume (1v). lour paLlenLs' resplraLlon was noL synchronlsed
wlLh nlv. Weanlng process was expedlLed for four paLlenLs. 1hree were found Lo have obsLrucLlve sleep apnoea. lor one
paLlenL, boLh backup 88 and 1v were seL Loo low. Whlle 13 paLlenLs were evenLually Lransferred Lo resplraLory beds, 11
remalned ln general beds. LlghL paLlenLs' blood gas resulLs lmproved ln elLher pP or CC
2
afLer nurse-led nlv LlLraLlon.

Conc|us|on: under close collaboraLlon wlLh resplraLory speclallsLs and backed by an nlv LlLraLlon proLocol, experlenced
and Lralned resplraLory nurses are empowered Lo have role expanslon ln Lhe care of resplraLory fallure paLlenLs on nlv.
As a resulL, paLlenLs conLlnue Lo recelve hlgh quallLy care ln general medlcal beds whlle ward colleagues beneflL from
speclallsL nurslng supporL and guldance.



2234

MCNI1CkING CI CS1-kLGIS1kA1ICN UL1kASCUND A1ILN1 DLLAS USING AVAILA8LL C1ICNS IN 1nL CUkkLN1
kADICLCG INICkMA1ICN SS1LM (kIS) AND IC1UkL AkCnIVING AND CCMMUNICA1ICN SS1LM (ACS) IN A
1Lk1IAk CAkL ICI ACCkLDI1LD 1LACnING nCSI1AL IN 1nL DL
Mohammad ?usuf
1,*
, Waslf Slddlqul
1
, Syed M. Sohall
1
, Munawwar !abeen
1

1
8adlology, Aga khan unlverslLy, karachl, aklsLan


Cb[ect|ves: 1he ob[ecLlve of Lhls sLudy was Lo use 8lS and ACS Lo monlLor Lhe walLlng Llmes of paLlenLs reglsLered for
ulLrasound examlnaLlon and expedlLe where unnecessary delays were ldenLlfled.

Methods: 1he Aga khan unlverslLy PosplLal, karachl, aklsLan ls a LerLlary care Leachlng hosplLal lncepLed ln 1983. Slnce
lLs lncepLlon, Lhe lnsLlLuLlon has been qulLe recepLlve Lo Lhe Lechnology advancemenLs and has a blend of boLh home-
grown and off-Lhe-shelf lnformaLlon Lechnology sysLems/appllcaLlons. ln Lerms of lnformaLlon Lechnology, Lhe back
bone of Lhe lnsLlLuLlon ls Lhe home-grown" PosplLal lnformaLlon SysLem (PlS), coupled wlLh many appllcaLlons such as
8lS and ACS and many oLhers perLlnenL Lo paLlenL care.

ulLrasound secLlon experlence heavy paLlenLs' Lurnover wlLh 9 rooms Lo carry ouL Lhe dlagnosLlc and lnLervenLlonal
procedures. 8ased on our observaLlon coupled wlLh paLlenL complalnLs relaLed Lo unnecessary walLlng, a sLraLegy was
deslgned Lo address Lhe lssue uslng exlsLlng 8lS and ACS.

kesu|ts: 1he 8lS and ACS were used Lo exLracL real Llme daLa relaLed Lo paLlenL reglsLraLlon and lmage archlvlng
respecLlvely. 8ased on Lhe daLa, paLlenLs who had been walLlng beyond 60 mlnuLes, afLer reglsLraLlon, were approached
Lo deLermlne Lhe acLual reasons for delay. ln cases where Lhe delays were due Lo Lechnlcal reasons (e.g., lncompleLe
preparaLlon, eLc) such paLlenLs were counselled and ln paLlenLs where Lhe delay was avoldable, such paLlenLs were
expedlLed.

1he lnlLlaLlve proved exLremely useful by provldlng lnformaLlon abouL Lhe quanLum of paLlenLs walLlng beyond a cerLaln
llmlL, Lhe exLenL of walLlng Llmes, and Lhe reasons for delays ln calllng for Lhe procedure. 1hese reasons were analysed
and wlll prove valuable ln developlng a sLraLegy, ln fuLure, Lo reduce Lhe walLlng Llmes Lo a mlnlmal level desplLe heavy
paLlenL lnflow.

Conc|us|on: uLlllsaLlon of unorLhodox feaLures of hlgh-Lech appllcaLlons (8lS and ACS) and monlLorlng and efflclenLly
managlng walLlng Llme for radlology procedures.



223S

USING LDUCA1ICN, S1kUC1UkLD 1kAINING kCGkAM AND A MCDIIILD CLN1kAL VLNCUS CA1nL1Lk DkLSSING kI1
1C LLIMINA1L kL1AINLD GUIDLWIkL ICLLCWING CLN1kAL LINL INSLk1ICN
Wann !la Loh
1,*
, Chee Chee hua
2
, Lmlly Po
3
, Chlan Mln Loo
2

1
ulvlslon of Medlclne,
2
8esplraLory and CrlLlcal Care Medlclne,
3
Lndocrlnology, Slngapore Ceneral PosplLal, Slngapore,
Slngapore


Cb[ect|ves: CenLral venous caLheLer lnserLlon ls a common and essenLlal procedure ln Lhe lnLenslve care unlL. lL allows
admlnlsLraLlon of flulds, vasopressors and cenLral venous pressure monlLorlng. A rare buL posslbly faLal compllcaLlon of
cenLral venous caLheLer (CvC) lnserLlon ls gulde wlre reLenLlon. 8eLalned gulde wlres may fracLure and embollse, or
cause lnfecLlon and vascular ln[ury. 1here were 3 cases of gulde wlre reLenLlon ln Lhe Medlcal lnLenslve Care unlL
(MlCu) ln Slngapore Ceneral PosplLal ln a 3 monLh perlod beLween uecember 2011 and lebruary 2012. 1hese alarmlng
lncldences necesslLaLed urgenL acLlon. 1he alm of Lhls quallLy lmprovemenL pro[ecL was Lo ellmlnaLe gulde wlre
reLenLlon durlng CvC lnserLlon ln MlCu and Plgh uependency.

Methods: A mulLldlsclpllnary pro[ecL Leam was formed lnvolvlng lnLernal medlclne resldenLs, medlcal lnLenslvlsLs and
speclallsed nurses. 8ooL cause analysls of Lhe 3 cases ldenLlfled ma[or facLors leadlng Lo such compllcaLlons.
lnLervenLlons were planned and LesLed uslng lan-uo-SLudy-AcLlon cycles. 1he analysls showed LhaL Lhe ma[or facLors
were lnsufflclenL Lralnlng and lack of awareness of CvC lnserLlon compllcaLlons. lollowlng Lhls analysls, we lnsLlLuLed Lhe
followlng lnLervenLlons:

1) a sLrucLured Lralnlng program whlch lncluded dldacLlc lecLures wlLh a focus on sLraLegles Lo reduce gulde wlre
compllcaLlons, hands-on Lralnlng on Lask Lralners, and sLrucLured procedural sklll assessmenLs,
2) enforclng mandaLory supervlslon by a senlor docLor for all procedures,
3) modlflcaLlon of Lhe CvC dresslng klL (CvC LuS) Lo lnclude a sLerlle drape wlLh remlnder sLlckers. vldeo
demonsLraLlon and prlnLed posLer guldes of CvC LuS were made Lo educaLe on Lhe use Lhe CvC LuS. 8eLween
!une 2012 and leb 2013, CvC compllcaLlons were monlLored.

Also, surveys were conducLed among MlCu and Plgh uependency procedurlsLs (n=39) beLween !une 2012 and lebruary
2013 Lo assess efflcacy of changes. Survey of Lhe CvC LuS was conducLed among Lhe procedurlsLs (n=13).

kesu|ts: 8eLween !une 2012 Lo leb 2013, Lhere were 320 CvC lnserLlons ln MlCu and Plgh uependency. 1here was no
gulde wlre reLenLlon durlng Lhe sLudy perlod. 97 (38) of parLlclpanLs found Lhe Lralnlng program Lo be useful, ln
parLlcular Lhe hands-on slmulaLed lnserLlons and educaLlon of compllcaLlons. 1he resulL was conslsLenL ln boLh posL
Lralnlng and aL 3 Lo 4 monLhs. Survey of CvC LuS showed LhaL 13/13 (86.7) of Lhe procedurlsLs found lL easy Lo use.
11/13 (73) found Lhe remlnder sLlckers on Lhe drape useful. lurLher cosL analysls sLudles showed a cosL reducLlon of
S$29 for every CvC lnserLlon.

Conc|us|on: 1hls lmporLanL paLlenL safeLy quallLy lmprovemenL efforL, whlch encompassed educaLlon, Lralnlng and a
modlfled CvC klL, was effecLlve ln ellmlnaLlng gulde wlre reLenLlon durlng Lhe sLudy perlod.







2236

A1ILN1 LDUCA1ICN VIA 1LLLMCNI1CkING LNnANCLS DISLASL SLLI-MANAGLMLN1 AND kLDUCLS
nCSI1ALISA1ICN
Chlu Sln Man
1,*
, kah Lln Choo
1
, Suk long Wal
1
, Chol ?lng Chan
1

1
Medlcal, norLh ulsLrlcL PosplLal, Pong kong, Pong kong


Cb[ect|ves: 1o evaluaLe paLlenL accepLance and Lhe lmpacL of educaLlon dellvered by 1elemonlLorlng devlce on dlsease
self-managemenL and hosplLallsaLlon

Methods: A proLoLype 1ele18Lk (Celkl) 1ouch devlce LhaL faclllLaLed self-reporLlng of CCu AssessmenL 1esL (CA1)
scores was developed ln 2011. 1he 2012 verslon now lncorporaLes educaLlonal maLerlals developed by 8esplraLory
CollaboraLlve Care 1eam (8CC1), norLh ulsLrlcL PosplLal (nuP). Lach score Lo Lhe flrsL Lhree quesLlons on CCu
exacerbaLlon ls dlrecLed Lo dlfferenLlal lnformaLlon lf lL reaches 3 or hlgher. uependlng on scores enLered, lnsLrucLlons
lnclude ad[usLmenL of lnhaler dosage or oxygen flow raLe and use of crlsls managemenL pack of anLlbloLlcs and
prednlsolone. Cough managemenL lncludes lnformaLlon on gasLro-oesophageal reflux or posL-nasal drlp. AnlmaLed
demonsLraLlons of breaLhlng and coughlng Lechnlques, and Llps on sleep hyglene or healLhy llfesLyle were also avallable.
Scores are LransmlLLed Lo a password-proLecLed webslLe where nurses monlLor and render phone supporL when
necessary.

aLlenLs' feedback on usefulness of Lhe lnformaLlon was soughL.

kesu|ts: 8eLween May 2012 and !anuary 2013, 22 paLlenLs were recrulLed. Cne paLlenL was recrulLed because of
sympLom deLerloraLlon aL home. 1he resL were all recenLly dlscharged.

Mean CA1 score no. of paLlenLs: 22 - (Mean age:70)
3(14)
11-20 (medlum dlsease lmpacL) 9(41)
21-30 (hlgh dlsease lmpacL) 9(41)
30 (very hlgh dlsease lmpacL) 1(4)

Slx eplsodes of exacerbaLlon were deLecLed amongsL flve paLlenLs based on lncrease ln LoLal scores by aL leasL 3. Mean
score lncreased from 18 Lo 24 durlng exacerbaLlons and lmproved Lo 18 durlng recovery. none requlred hosplLallsaLlon.
1wo paLlenLs, whose basellne CA1 scores exceeded 20 and 30 respecLlvely, were re-admlLLed. Cverall 28-day hosplLal
readmlsslon was 9.3 (2/21). aLlenLs unanlmously agreed LhaL Lhe educaLlon lmproved Lhelr self-managemenL of
cough, dyspnoea and spuLum clearance. MosL (93) felL LhaL sympLom conLrol was enhanced and anxleLy reduced when
Lhelr condlLlon worsened. Cverall undersLandlng of dlsease and self-managemenL were enhanced accordlng Lo 96
paLlenLs.

Conc|us|on: aLlenL educaLlon bundled wlLh sympLom monlLorlng relnforced knowledge learnL, enhanced dlsease self-
managemenL and reduced hosplLallsaLlon.



2244

1nL CkGANISA1ICN CI CAkL ICk CnkCNIC C8S1kUC1IVL ULMCNAk DISLASL A1ILN1S kLCLIVING NCN-INVASIVL
VLN1ILA1ICN IN U8LIC nCSI1ALS CI nCNG kCNG
Pol ?ee kwan
1,*
, kah Lln Choo
1
, Chung Mlng Chu
2
, Wal Cho ?u
3

1
Medlclne, norLh ulsLrlcL PosplLal, Sheung Shul,
2
Medlclne, unlLed ChrlsLlan PosplLal, kwun 1ong,
3
Medlclne and
CerlaLrlcs, rlncess MargareL PosplLal, kwal Chung, Pong kong


Cb[ect|ves: 1o sLudy Pong kong (Pk) publlc hosplLals' organlsaLlon of care for chronlc obsLrucLlve pulmonary dlsease
(CCu) paLlenLs recelvlng non-lnvaslve venLllaLlon (nlv) for hypercapnlc resplraLory fallure and lLs lmpacL on paLlenL
morLallLy.

Methods: CuesLlonnalres were senL elecLronlcally Lo resplraLory Leam heads of 21 publlc hosplLals of Pk ln !uly 2011.
uaLa on nlv servlce seLLlngs, avallablllLy of deslgnaLed nurslng sLaff, sLrucLured Lralnlng and proLocol, level of paLlenL
monlLorlng and speclallsL lnvolvemenL were collecLed. uaLa on admlsslons and morLallLy of CCu paLlenLs recelvlng nlv
for hypercapnlc resplraLory fallure beLween !uly 2010 and !une 2011 were reLrleved from hosplLal daLabase - Lhe cllnlcal
daLa analysls and reporLlng sysLem (CuA8S). 8elaLlonshlp beLween morLallLy and organlsaLlonal facLors were analysed by
non-parameLrlc Mann-WhlLney u LesL.

kesu|ts: 1wenLy responses (93.2) were recelved. nlv was provlded ln general wards ln 80 of surveyed hosplLals,
followed by 8esplraLory beds (33), venLllaLor unlL (33) and nlv unlL (20). 1here were deslgnaLed nlv nurses ln 23
hosplLals. Pourly monlLorlng was Lhe norm ln 64.7 hosplLals. 8esplraLory speclallsLs were lnvolved ln nlv managemenL
ln 78.9 hosplLals. 8egular sLaff Lralnlng was provlded ln 63 hosplLals and nlv proLocols/guldellnes were avallable ln
23. 8eLween !uly 2010 and !une 2011, Lhe number of nlv paLlenLs ranged from 1.6 Lo 33.4 per hosplLal per monLh. nlv
MorLallLy ranged from 14 Lo 36 per hosplLal. PosplLals havlng an nlv proLocol were assoclaLed wlLh lower medlan
morLallLy among CCu paLlenLs requlrlng nlv supporL (p=0.036). 1here was a Lrend showlng an assoclaLlon beLween
lower nlv morLallLy and resplraLory speclallsLs' supervlslon (p=0.060).

Conc|us|on: ln splLe of Lhe need for close monlLorlng, nlv care frequenLly occurred ln publlc hosplLals' general wards ln
Pk. lew hosplLals had deslgnaLed nurses or proLocols/guldellnes for nlv care. lL was noLeworLhy LhaL lower morLallLy
was assoclaLed wlLh Lhe avallablllLy of proLocols. A Lrend Lowards lmproved morLallLy wlLh 8esplraLory speclallsLs'
supervlslon suggesLed LhaL cllnlcal leadershlp as well as sLandardlsed care could lmpacL upon Lhe ouLcome of resplraLory
fallure paLlenLs on nlv.




224S

1nL DLILkkLD 8LCCD DCNCk- kISING LIkL 1nL nCLNIk
!yoLsna CodaLy
1,*
, Suresh Arumugam
1

1
1ransfuslon Medlclne, lorLls PealLhcare, lorLls Malar PosplLal, Chennal, lndla


Cb[ect|ves: A healLhy communlLy houses a robusL blood donor and hls blood ln Lurn vlLallses an alllng paLlenL. Pe has Lhe poLenLlal
Lo donaLe blood over a hundred Llmes ln hls llfeLlme. Lvery wllllng person ls however noL accepLed as a donor. A frequenL reason for
defermenL ls anaemla. 1hls ls an lmporLanL hurdle LhaL musL be crossed falllng whlch we are forced Lo refuse an lndlvldual's alLrulsLlc
gesLure. We were deallng wlLh an urban, educaLed demographlc and noLlced Lwo facLs. 1hese volunLeers were noL overLly anaemlc
and Lhey were dlsappolnLed aL deferral. We worked on Lhe premlse LhaL Lhe gap ln haemoglobln shorLfall ls mlnlmal and LhaL slmple
remedlal measures can rlghL Lhls slLuaLlon. 1hls nlche segmenL can Lhus be broughL back lnLo Lhe malnsLream by lmprovlng a donor's
healLh, boLh for lndlvldual and communlLy wellbelng.

Methods: Cur sLudy sample ls Lhe quanLum of blood donors aL our blood bank from 1 !an Lo 31 uecember 2012. Lach one flrsL
answered a quesLlonnalre LhaL excludes dlsease condlLlons. We Lhen LesL Lhe lndlvldual's haemoglobln levels uslng Lhe
cyanhemoglobln meLhod. A dally lnLernal and exLernal conLrol assures rellable resulLs. 1he machlne dlsplays Lhe lndlvlduals
Paemoglobln level. 1he sLandard for haemoglobln ls based on naLlonal Culdellnes. Cur accepLable sLandard ls 12.3 gms/dl Lo 18
gms/dl. 1he volunLeer ls lnformed of hls haemoglobln level. WlLh Lhe sole moLlve of changlng Lhls slLuaLlon Lo a poslLlve by
lmprovlng Lhe general healLh of Lhe volunLeer, ln Lhe nexL sLep, a quesLlonnalre of cllnlcal hlsLory ls asked and ellclLed. 1hls
comprlses quesLlons such as a hlsLory of eaLlng hablLs, worm lnfesLaLlon, bleedlng per recLum and mensLrual hlsLory ln Lhe case of
female donors. AfLer ascerLalnlng from Lhe hlsLory LhaL Lhere ls no reason Lo suspecL any serlous medlcal or surglcal condlLlons, we
Lhen advlse Lhe person abouL Lhe beneflLs of a wholesome dleL. We also recommend a de-wormlng and lron LableLs. A prlnLouL of
food sLuffs LhaL are llkely Lo lncrease Lhe haemoglobln level ls glven Lo hlm. AL Lhe end of Lhree monLhs, we call Lhem for a
Paemoglobln check. Many were found Lo meeL sLandards and several gladly donaLed blood. 1hose who dld noL were advlsed Lo
meeL Lhelr famlly physlclan for furLher lnvesLlgaLlons. 1esLs done ln Lhls sLudy are only Lhose mandaLed for 8lood 8anks by law.

kesu|ts:
ueferral
number
Paemoglobln Sex uevlaLlon
from
sLandard
<12.3
gms/dl
PlsLory of
worm
lnfesLaLlon
PlsLory of plles,
bleedlng ulcers
lood hablLs Paemoglobln
AfLer 3
monLhs
AccepL
/
8efer

1hls Lable was used Lo log daLa of deferred donors and resulLs were derlved from lL.
SLudy sample: 3086
number deferred: 61
Sex: Male 60 lemale 1
8ange of Paemoglobln: 9.3 gms/dl - 12.4 gms/dl
CorrecLlon requlred: . 8 Lo 23.2
8esponse afLer 3 monLhs: 68.8
Cf Lhese, Successful donaLlon: 83
8eferred: 16.6
8epeaL donaLlon: 11.1

Conc|us|on: 68.8 of our deferred donors showed lmprovemenL ln Lhelr hemoglobln levels and 83 of Lhem wenL on Lo donaLe
blood. lndeed, 11.1 of Lhem have slnce donaLed blood more Lhan once. We belleve LhaL we have noL only reversed a Lrend buL also
earned Lhe goodwlll of Lhe lndlvldual and ln Lurn lmproved ln Lhe healLh of a communlLy. 1he once deferred buL redeemed blood
donor ls our ambassador for Lhe cause of blood donaLlon.

keferences: urug and CosmeLlc AcL 1943, CovernmenL of lndla, nCCLS, uocumenL P13- A3, 2000 , Cllnlcal uleLeLlcs and nuLrlLlon,
l..AnLla, 1hlrd LdlLlon, ChapLer 67 ages 277-279 , Parrlson's rlnclples lf lnLernal Medlclne, 18
Lh
LdlLlon, ChapLer 37



2248

CCGNI1ICN CI kISk IAC1CkS AND nLAL1n 8LLILI CN 1nL UALI1 CI LIIL ICk 1nL A1ILN1S nAVING CCkCNAk
Ak1Lk 8ASS GkAI1 SUkGLk
Mel-Pua Sun
1,*
, Psueh-Lrh Llu
2

1
ueparLmenL of nurslng, lar LasLern Memorlal PosplLal, new 1alpel ClLy,
2
CraduaLe lnsLlLuLe of nurslng, Chang Cung
unlverslLy, 1ao-?uan, 1alwan


Cb[ect|ves: 1he purposes of Lhls longlLudlnal, descrlpLlve and correlaLlonal sLudy were Lo explore cognlLlon of rlsk
facLors, healLh bellef and quallLy of llfe (CCL), and Lo examlne Lhe lmpacL of varlous varlables on CCL among coronary
arLery bypass grafL (CA8C) paLlenLs.

Methods: A LoLal of 27 sub[ecLs who meL Lhe selecLlon crlLerla were selecLed from a medlcal cenLer around Lhe norLhern
parL of 1alwan. 1hree quesLlonnalres were compleLed by each sub[ecL pre-operaLlvely, posL-operaLlvely, and 3 monLhs
afLer CA8C. 1hese quesLlonnalres are Lhe 8lsk lacLors Scale, Lhe PealLh 8ellef Scale, and Lhe CuallLy of Llfe lndex ( QLI ) .
uescrlpLlve analysls, Mcnemar Chl-square LesL, Wllcoxon slgned-rank LesL, kruskal-Wallls LesL, and Spearmen rank-order
correlaLlon coefflclenL were performed for daLa analysls.

kesu|ts: 1he resulLs showed:

1) aLlenLs reporLed moderaLe degrees of cognlLlon of rlsk facLors. AL posL-operaLlvely and 3 monLhs afLer CA8C,
cognlLlon of rlsk facLors was slgnlflcanLly lmproved Lhan pre-operaLlvely.
2) aLlenLs reporLed slmllar condlLlon was found ln regard Lo healLh bellef.
3) 1he range of proporLlonal means for CLl durlng Lhe Lhree Llmes are 69.772.7. Among Lhese facLors, paLlenLs
reporLed Lhe hlghesL saLlsfacLlon ln Lhe lnLlmacy facLor and lowesL saLlsfacLlon ln boLh Lhe healLh facLor,
psychosoclal facLor.
4) 1he cognlLlon of rlsk facLors was poslLlve relaLed Lo CCL.

Conc|us|on: Coronary hearL dlsease ls a ma[or cause of morLallLy and morbldlLy and ls a growlng problem. 1hls sLudy
flndlngs can promoLe Lhe efflclency of medlcal Leams Lo lmprove CCL of CA8C paLlenLs ln cllnlcal pracLlce.

keferences:
1. Cohen, u. !., van PouL, 8., Serruys, . W., Mohr, l. W., Macaya, C., den Pel[er, ., eL al. (2011). CuallLy of llfe afLer
Cl wlLh drug-eluLlng sLenLs or coronary-arLery bypass surgery.
2. nLngl!Med,364(11),1016-1026. uleLz, u., 8upprechL, P. !., de 8elder, M. A., Wl[ns, W., Cuarles van ufford, M. A.,
klues, P. C., eL al. (2002).
3. Anglographlc analysls of Lhe angloplasLy versus roLaLlonal aLherecLomy for Lhe LreaLmenL of dlffuse ln-sLenL
resLenosls Lrlal (A81lS1).
4. Am!Cardlol,90(8),843-847. Lchahldl, n., lbaroL, ., uespres, ., ualgle, !. M., MohLy volslne, ., eL al.(2007).
MeLabollc syndrome lncreases operaLlve morLallLy ln paLlenLs undergolng coronary arLery bypass grafLlng surgery.
!ournal of Lhe Amerlcan College of Cardlology, 30(9), 843-831.



2249

ACLLC nCSI1ALS UALI1 kCGkAM
ShaveLa uewan
1
, 8avlnder S. uberol
2
, ArplL 8haLnagar
1
, Anupam Slbal
3,*

1
Croup Medlcal Servlces, Apollo PosplLals Croup,
2
Chlef CuallLy Cfflcer, lndraprasLha Apollo PosplLals,
3
Croup Medlcal
ulrecLor, Apollo PosplLals Croup, uelhl, lndla


Cb[ect|ves: 1he ob[ecLlve was sLandardlsaLlon of processes for cllnlcal handovers, medlcaLlon safeLy, surglcal safeLy,
paLlenL ldenLlflcaLlon, verbal orders, hand washlng compllance and falls prevenLlon across 32 hosplLals ln Lhe Apollo
Croup ln geographles varylng from rural Lo seml urban, urban and meLropollLan. 1he alm was Lo educaLe all our
hosplLals abouL Lhe lmporLance of paLlenL safeLy, lmplemenL paLlenL safeLy pracLlces ln all our Apollo hosplLals make
care safe for all our paLlenLs.

Methods: lor each of Lhese areas, Lhe Apollo CuallLy plan descrlbed Lhe need and Lhe raLlonale, Lhe lmplemenLaLlon
meLhod, Lhe Lralnlng needs and 20 parameLers for monlLorlng compllance wlLh ouLcomes colour coded as green, orange
and red e.g. age of paLlenLs recelvlng anLlmlcroblal prophylaxls wlLhln one hour before surgery scored a green for
93, an orange for 90 - 93 and a red for < 90.

Cllnlcal handovers were sLandardlsed Lo lnvolve Lhe use of Lhe SlLuaLlon-8ackground-AssessmenL-8ecommendaLlon
formaL. 1he Slx lnLernaLlonal aLlenL SafeLy Coals (lSCs) of !Cl were lmplemenLed aL all locaLlons lrrespecLlve of
accredlLaLlon sLaLus. 1hls covered correcL paLlenL ldenLlflcaLlon uslng Lwo paLlenL ldenLlflers, lmprovlng communlcaLlon
Lhrough Lhe use of read back for verbal orders, lmprovlng Lhe safeLy of hlgh alerL medlcaLlon Lhrough segregaLlon,
proper labelllng and cross checks durlng admlnlsLraLlon, lmplemenLlng Lhe process for prevenLlng wrong paLlenL, wrong
slde, wrong procedure surgery uslng preoperaLlve checkllsLs, surglcal slLe marklng and Llme ouLs, prevenLlng healLhcare
assoclaLed lnfecLlons Lhrough an effecLlve hand hyglene program and lmplemenLlng a falls rlsk assessmenL and
prevenLlon program. Surglcal Care lmprovemenL lan envlsaged LargeLlng surglcal slLe lnfecLlons (SSls) and forelgn body
reLenLlon durlng surgery. SLeps for movlng Lowards Zero MedlcaLlon Lrrors were dellneaLed. An lmplemenLaLlon
checkllsL gulded Lhe lmplemenLaLlon process. A Leam of 20 quallLy represenLaLlves from varlous Apollo PosplLals was
senL Lo oLher Apollo hosplLals Lo gulde lmplemenLaLlon, audlL Lhe monlLorlng process and valldaLe Lhe daLa reporLed.

kesu|ts:
l. uocumenLed cllnlcal handovers were lnLroduced for Lhe flrsL Llme aL many locaLlons for ln house paLlenL Lransfer,
nurslng handover and physlclan handover. Croup compllance levels for each of Lhese lmproved over Lhe year (e.g.
from 84.9 Lo 96.7 for use of ln-house Lransfer form before paLlenL Lransfer).
ll. lSCs were belng followed only by !Cl accredlLed hosplLals. 1hey were lmplemenLed by oLher hosplLals wlLh
lncreaslng compllance (1lme ouL compllance lncreased from 83.8 Lo 93.2).
lll. 1here were hosplLals whlch dld noL Lrack Lhe Llme of admlnlsLraLlon of anLlmlcroblal prophylaxls before surgery.
1hey lnlLlaLed Lhls Lo be able Lo ensure LhaL Lhe prophylaxls was glven wlLhln one hour before surgery. (Croup
average compllance lmproved from 79.4 Lo 89.4). Whlle Lhe blgger hosplLals measured Surglcal SlLe lnfecLlon
(SSl) for 30 days posL operaLlvely, smaller hosplLals dld noL have a sysLem of followlng up paLlenLs afLer Lhey were
dlscharged from hosplLal afLer surgery. 1hey devlsed mechanlsms for Lhls.
lv. 1here were hosplLals wlLh well-deflned mechanlsms for audlL of all prescrlpLlons of lnpaLlenLs, buL Lhey mlssed ouL
on coverlng Lhe audlL of medlcaLlons prescrlbed ln Lhe dlscharge summarles whlch was sLarLed.

Conc|us|on: 1he average Apollo CuallLy rogram scores for all group hosplLals lmproved from 62 ln Aprll 2011 Lo 82 ln
March 2012. AC has broughL abouL lmprovemenL ln processes for paLlenL safeLy for Lhousands of paLlenLs vlslLlng
Apollo hosplLals ln varled geographles. 1hls has LranslaLed lnLo lmproved paLlenL safeLy sLaLlsLlcs.



22S1

WCMLN'S DLSCkI1ICNS CI SUCk1 ICk 8kLAS1ILLDING Ck AL1LkNA1IVL NU1kI1ICN IN MA1LkNI1 WAkDS: ASSCCIA1ICNS
WI1n CCN1Lk1UAL CCNDI1ICNS IN A NA1ICNAL NCkWLGIAN CkCSS-SLC1ICNAL S1UD
lngeborg S. S[eLne
1,*
, !ohanne C. k[llesdal
1
, Pllde P. lversen
1

1
user Surveys unlL, norweglan knowledge CenLre for Lhe PealLh Servlces, Cslo, norway


Cb[ect|ves: AdequaLe nuLrlLlon ls an obvlous parL of moLher and chlld healLh, ln faclllLaLlng a sound shorL Lerm developmenL and
prevenLlng fuLure healLh problems such as obeslLy. 1he phllosophy and knowledge LhaL are lmpllclL ln Lhe baby frlendly hosplLal
lnlLlaLlve pervades norweglan healLh care and more Lhan 90 of chlldren are born ln cerLlfled lnsLlLuLlons. ln a naLlonal survey
among moLhers and parLners abouL pregnancy, blrLh and posL naLal care we revlewed Lhe conLenLs of Lhe respondenLs' verbal
responses. We observed a large number of commenLs LhaL expressed frusLraLlon abouL Lhe supporL provlded ln hosplLal posL naLal
care wlLh regard Lo breasL- and oLher feedlng.

Cb[ecLlve: 1o explore ln Lhe quanLlLaLlve daLa wheLher varlaLlon ln women's experlences wlLh lnformaLlon and guldance ln breasL-
and alLernaLlve feedlng can be explalned by lndlvldual and conLexLual condlLlons.

Methods: 1he lncluslon process almed Lo obLaln represenLaLlve samples for all blrLh lnsLlLuLlons, and used daLa from Lhe Medlcal
8lrLh 8eglsLry of norway. 1he women were conLacLed by mall, and presenLed a quesLlonnalre LhaL was developed by Lhe knowledge
CenLre speclflcally for Lhls LargeL populaLlon. 1he ouLcome was measured by Lhe average of Lwo lLems ln Lhe posL naLal sLay parL of
Lhe quesLlonnalre:

! uld you recelve sufflclenL gu|dance on breasL feedlng or oLher ways of feedlng Lhe chlld durlng Lhe posL-naLal sLay?"
a

! uld you recelve sufflclenL |nformat|on abouL breasL feedlng or oLher ways of feedlng Lhe chlld?"
a


LxplanaLory varlables:
lndlvldual characLerlsLlcs:
! revlous blrLhs
! Caesarean
! PlghesL compleLed educaLlon
b

! Self-raLed healLh
c


ConLexLual condlLlons:
! no of days posL naLal sLay
! SLaylng ln a mulLlple bed room
! SufflclenL peace and quleL
a

! ersonnel had enough Llme
a

! Well organlsed servlces
a

! ConfllcLlng lnformaLlon from sLaff
a


a
8esponse scale: lrom noL aL all"=1 Lo 1o a very large exLenL"=3, and noL appllcable"
b
.

8esponse scale: lrom rlmary/lower
secondary school"=1 Lo College/unlverslLy (4 years)"=4.
c
8esponse scale: lrom LxcellenL"=1 Lo oor"=3.

kesu|ts: AbouL 8900 women were conLacLed ln 2012 and [usL above 4900 (37) answered Lhe survey. AddlLlonal daLa were [olned Lo
Lhe maLerlal afLer Lhe survey was closed. We consLrucLed an CLS regresslon model wlLh Lhe lndlvldual characLerlsLlcs as explanaLory
varlables, and Lhls model explalned abouL 1 of Lhe varlaLlon ln Lhe ouLcome varlable. Plgher number of prevlous blrLhs was
assoclaLed wlLh a sllghLly poorer descrlpLlon of lnformaLlon /guldance, and a poslLlve raLlng of own healLh was assoclaLed wlLh
hlgher scores. When Lhe conLexLual varlables were enLered ln Lhe model, Lhe proporLlon explalned varlaLlon rose Lo over 41.
number of prevlous blrLhs sLlll had small, negaLlve effecL. Well organlsed servlces" had by far Lhe sLrongesL effecL on Lhe ouLcome
varlable, followed by personnel had enough Llme", lengLh of posL naLal sLay, and sufflclenL peace and quleL".

Conc|us|on: Concluslon: Lven wlLh Lhe phllosophy and knowledge well ln place, Lhere seems Lo be poLenLlal for maklng Lhe
lnsLlLuLlons even more baby frlendly. ln order Lo lmprove Lhe supporL glven Lo Lhe moLhers durlng Lhelr hosplLal sLay, Lhls sLudy
suggesL organlsaLlonal approaches. 1lme and space should be dedlcaLed Lo Lhls acLlvlLy durlng Lhe women's posL naLal sLay, and Lhe
sLaff musL have Llme Lo supporL Lhe women when needed.
ulsclalmer: 1hls sLudy has used daLa from Lhe Medlcal 8lrLh 8eglsLry of norway. 1he lnLerpreLaLlon and reporLlng of Lhese daLa ls
Lhe sole responslblllLy of Lhe auLhors, and no endorsemenL by Lhe Medlcal 8lrLh 8eglsLry of norway ls lnLended nor should be
lnferred".


22SS

LIGn1 LAkS CI LCW-VCLUML 1nkLSnCLDS ICk LLLC1IVL kCCLDUkLS IN GLkMAN - WnLkL AkL WL NCW?
ulrk eschke
1,*
, 1homas Mansky
1

1
SLrucLural AdvancemenL and CuallLy ManagemenL ln PealLh Care, 1echnlsche unlverslLL 8erlln, 8erlln, Cermany


Cb[ect|ves: MulLlple sLudles have shown sLrong evldence for a volume-ouLcome-relaLlonshlp for several elecLlve surglcal
procedures. 1herefore ln 2004 Lhe Cerman lederal !olnL CommlLLee (C-8A), whlch ls Lhe hlghesL declslon-maklng body
of Lhe [olnL self-admlnlsLraLlon of physlclans, denLlsLs, hosplLals and healLh lnsurance funds ln Cermany, passed a
resoluLlon on 'mlnlmum quanLlLy regulaLlons' for flve elecLlve surglcal procedures (LransplanLaLlons of llver, kldney or
sLem cells as well as complex oesophageal and pancreaLlc procedures). Mlnlmum quanLlLles for knee-replacemenL were
passed for 2006 and for Lhe LreaLmenL of premaLure new-borns wlLh a blrLh welghL of less Lhan 1230 grams for 2010.
1hese agreemenLs, alLhough parLly quesLloned ln courL dlspuLes, are mandaLory for all hosplLals LreaLlng paLlenLs wlLh
sLaLuLory healLh lnsurance and are meanL Lo lead Lo lmproved quallLy by reduclng Lhe number of low-volume-hosplLals.
ln our sLudy we lnvesLlgaLe Lhe effecLs of Lhe mlnlmum quanLlLy regulaLlons on Lhe proporLlon of low-volume-hosplLals
and paLlenLs LreaLed by Lhem.

Methods: 1he sLudy ls based on Lhe naLlonal u8C-daLa. 1he u8C-paymenL-sysLem ln Cermany has been lnLroduced as
an all-paLlenL/all-payer-sysLem ln 2003. 1he daLa cover all lnpaLlenL cases wlLh Lhe ma[or excepLlon of psychlaLrlc and
mlllLary hosplLals. We analysed Lhe procedure-codes from 2003 Lo 2011 and calculaLed Lhe number of cases wlLh Lhe
above menLloned procedures (excepL premaLure new-borns) per year for each hosplLal. 1he hosplLals are caLegorlsed
for each procedure as reachlng Lhe mlnlmum quanLlLles or noL. AddlLlonally we lnvesLlgaLed lf Lhe annual respecLlve
hosplLal-volume was ln llne wlLh Lhe mlnlmum quanLlLy regulaLlon or noL, Laklng lnLo accounL all general derogaLlons
(e.g. lmplemenLlng new servlces).

kesu|ts: 1he proporLlon of hosplLals whlch reach Lhe mlnlmum quanLlLles does noL change over Lhe years for kldney
(around 78) and sLem cell LransplanLaLlon (around 63) and complex oesophageal procedures (around 30) buL lL
lncreased from 16,8 ln 2006 Lo 29,3 ln 2011 for llver LransplanLaLlon, from 33,3 Lo 31,3 for complex pancreaLlc
procedures and sllghLly from 79,3 Lo 83,9 for knee-replacemenL. 1he proporLlon of paLlenLs who were LreaLed ln
Lhese hosplLals lncreased from 83,8 ln 2006 Lo 88,9 ln 2011 for llver LransplanLaLlon and from 81 Lo 88,6 for
complex pancreaLlc procedures buL Lhe proporLlon does noL change more Lhan 2 beLween 2006 and 2011 for Lhe oLher
4 procedures.

Conc|us|on: 1he proporLlon of paLlenLs LreaLed ln hosplLals wlLh a volume over Lhe deflned Lhresholds has been
lncreased by Lhe lmplemenLaLlon of Lhe low-volume Lhresholds (mlnlmum quanLlLy regulaLlons) only for llver
LransplanLaLlon and for complex pancreaLlc procedures. Powever, Lhe effecL ls sLlll dlssaLlsfylng. lurLhermore, Lhe
number of hosplLals wlLh procedure-volumes below Lhe mlnlmum quanLlLles could noL be reduced aL all for 3 ouL of 6
procedures by lnLroduclng Lhese regulaLlons. 1he regulaLlons should be enforced wlLhln Lhe yearly budgeL negoLlaLlons
beLween hosplLals and healLh lnsurance funds. Cur resulLs suggesL LhaL Lhls process may currenLly be lnsufflclenL.



22S6

USLkS SLAkING U ICk 1nLIk CWN SAIL1 IN ACU1L AND MA1LkNI1 CAkL: IINDINGS IkCM 1WC S1UDILS
Susanna 8ance
1
, Pelen 8alney
2
, nlcola MacklnLosh
1,*
, !ane Sandall
1

1
ulvlslon of Women's PealLh, klng's College London,
2
Cuy's PosplLal, klng's PealLh arLners, London, unlLed klngdom


Cb[ect|ves: 1o examlne users' experlences of speaklng up for Lhelr own safeLy ln acuLe and maLernlLy care, Lo
explore faclllLaLors and barrlers Lo speaklng up.

Methods: 2 eLhnographlc sLudles ln 6 nPS 1rusLs across Lngland carrled ouL ln 2010 as parL of Lhe 8lrLhplace ln Lngland
8esearch rogramme and nlP8 klng's aLlenL SafeLy 8esearch rogramme. We reporL on seml-sLrucLured lnLervlews
wlLh 79 users: 38 posLnaLal women, 14 acuLe paLlenLs and 7 relaLlves. 1ranscrlpL codlng uslng nvlvo8 sofLware.
lramework and LhemaLlc analysls wlLh LrlangulaLlon lnvolvlng researchers from boLh programmes.

kesu|ts: AcuLe paLlenLs and relaLlves' readlness Lo speak up was affecLed by ablllLy Lo recognlse changes ln cllnlcal
condlLlon, self-monlLorlng, LrusL ln sLaff, and culLure and sysLem of healLh care. Speaklng up was faclllLaLed by
knowledge from prevlous experlences, belng LreaLed as an lndlvldual, and sLaff reassurance/valldaLlon. lL was hampered
by sensory lmpalrmenL, uncerLalnLy abouL slgnlflcance of sympLoms, sLaff glvlng prlorlLy Lo ob[ecLlve measures of
lllness, and dlfflculLles wlLh sysLems noL expedlLlng access Lo care.

1he maLernlLy sLudy redeflned speaklng up as lnslsLenL and vehemenL communlcaLlon when faced wlLh fallure by sLaff Lo
llsLen or respond on aL leasL one occaslon. 30 of 38 women lnLervlewed, crosslng all soclo-demographlc groups, reporLed
speaklng up ln Lhelr laLesL pregnancy or blrLh. 14 reporLed speaklng up ln slLuaLlons Lhey felL Lo be urgenL and
experlenclng dlsLress or harm from sLaff fallure Lo llsLen. Speaklng up was faclllLaLed by senslng urgency of need, and
presence of a relaLlve. lL was hampered by sLaff lgnorlng or dlsmlsslng women's safeLy alerLs. 28 women dld noL speak
up because Lhey consldered professlonals had greaLer knowledge, because Lhey lacked personal or slLuaLlonal resources
Lo lnLervene, or because Lhey had dlaloglc communlcaLlon wlLh sLaff and '[usL speaklng' was sufflclenL Lo be heard.

Conc|us|on: AcuLe paLlenLs and maLernlLy servlce users do speak up, buL Lhls ls noL enough: sLaff need Lo llsLen and
respond Lo Lhelr concerns and safeLy alerLs. SLraLegles almlng Lo encourage speaklng up need Lo conslder speclflc
challenges faced by users wlLh chronlc healLh condlLlons and acuLe lllness, and Lhose experlenclng escalaLlon of
care. More research ls needed on organlsaLlonal pracLlces LhaL encourage and respond Lo servlce users' conLrlbuLlon Lo
Lhelr own safeLy, and on ways LhaL servlces can learn from paLlenLs and relaLlves who have suffered harm.

keferences:
1. uavls 8L, Sevdalls n, vlncenL CA. aLlenL lnvolvemenL ln paLlenL safeLy: how wllllng are paLlenLs Lo parLlclpaLe? Cual
Saf PealLh Care 2011,20:108e114.
2. LnLwlsLle vA, McCaughan u, WaLL lS, eL al. for Lhe lS (aLlenL lnvolvemenL ln aLlenL SafeLy) group. Speaklng up
abouL safeLy concerns: mulLl-seLLlng quallLaLlve sLudy of paLlenLs' vlews and experlences. Cual Saf PealLh Care
2010,19:e33.
3. MacklnLosh, n. 8alney, P. Sandall, !. (2012) undersLandlng how rapld response sysLems may lmprove safeLy for Lhe
acuLely lll paLlenL: Learnlng from Lhe fronLllne, 8MI Ooollty ooJ 5ofety, leb,21(2):133-44.
4. 8alney, P., Lhrlch, k., MacklnLosh n. and Sandall, !. (2013), 1he role of paLlenLs and Lhelr relaLlves ln 'speaklng up'
abouL Lhelr own safeLy - a quallLaLlve sLudy of acuLe lllness. neoltb xpectotloos dol: 10.1111/hex.12044
3. 8ance, S., McCourL, C., 8aymenL, !., MacklnLosh, n., WaLson, k., CarLer, W. and Sandall !. (2013), Women's safeLy
alerLs ln maLernlLy care: ls speaklng up enough? 8MI Oool 5of dol:10.1136/bm[qs-2012-001293

22S9

1nL LVCLU1ICN CI AN LIILC1IVL CLINICAL GCVLkNANCL AND A1ILN1 SAIL1
ulana SanLos
1
, Sandhya Mu[umdar
1,*
, Swee Chye Cuek
1
, Sophla Ang
1

1
naLlonal unlverslLy PealLh SysLem, Slngapore, Slngapore


Cb[ect|ves: A sysLemaLlc approach & framework was requlred Lhrough whlch naLlonal unlverslLy PosplLal (nuP) ls
accounLable for conLlnually lmprovlng Lhe quallLy of servlces and safeguardlng hlgh sLandards of care by creaLlng an
envlronmenL ln whlch excellence ln cllnlcal care wlll flourlsh.

1he approach Lo quallLy of care ln nuP was fragmenLed before 2002. nuP had acLlvlLles Lo lmprove and malnLaln Lhe
quallLy of care buL were somewhaL dlsLanL Lo rouLlne care dellvery and beneflLs were noL clearly apparenL Lo Lhe oLher
areas and Lo paLlenLs. Cllnlcal processes were governed aL deparLmenLal level wlLh varlaLlon ln pracLlces.

Methods: An overarchlng framework Lo look lnLo relevanL componenLs of cllnlcal governance as a whole had Lo be
effecLed. 1he relaLlve auLonomy of deparLmenLs and healLhcare professlonals parLlcularly cllnlclans has Lo be challenged
so LhaL lasLlng change could be effecLed. 8enchmarklng from model adopLed by naLlonal PealLh SysLem (uk), we looked
lnLo varlous aspecLs of Lhe cllnlcal governance and focused on cllnlcal effecLlveness, rlsk managemenL, paLlenL
experlence and communlcaLlon. Lmphasls was placed on uslng Lhe besL avallable evldence Lo LreaL and care for paLlenLs.
1hls was accompllshed by ensurlng use of besL pracLlce Lo manage paLlenLs, change pracLlce, developlng new proLocols
or guldellnes. use of evldence-based medlclne and sLandardlslng pracLlces ln hlgh volume, hlgh cosL and hlgh rlsk areas
was lmplemenLed. Cllnlcal pracLlce was conLlnuously monlLored and deflclencles were remedled. Cllnlcal 8evlew
rogramme allowed lndependenL revlew of care, and peer revlew. LxLernal accredlLaLlon programmes such as Lhe !olnL
Commlsslon lnLernaLlonal (!Cl) were leveraged upon as an lndependenL vlew of exlsLlng cllnlcal processes. Cllnlcal rlsk
managemenL helped Lo ldenLlfy sysLem changes LhaL were requlred Lo reduce adverse evenLs. AcLlve senlor leadershlp
lnvolvemenL ls exhlblLed ln Leadershlp Walk rounds, SenLlnel LvenL Sharlng sesslons, aLlenL SafeLy Workshops and
aLlenL SafeLy brleflngs. Walk rounds served as a plaLform for leaders Lo dlscuss crlLlcal lssues wlLh fronLllne
sLaff. Anonymlsed medlcal errors are hlghllghLed Lo sLaff buL falr accounLablllLy ls sLressed Lo obLaln sLaff's conLlnuous
supporL. ln our efforLs Lo llnk all Lhese LogeLher, Lhe concepL of accounLablllLy ln nuP has sLarLed Lo Lake rooL. lf an
unaccepLable behavlour or pracLlce ls noLed, reporLlng and correcLlng lL has become more of a rule Lhan an excepLlon.
1hls ls a very encouraglng shlfL ln culLure change.

kesu|ts: 1he blannual aLlenL SafeLy CllmaLe Survey resulLs (2003, 2007, 2009 and 2011) were reflecLlve of Lhe enhanced
safeLy and quallLy and role of governance and leadershlp. Cverall paLlenL safeLy percepLlon ln nuP lncreased from
97.4 (2003) Lo 98.3 (2011). 1he percenLage of sLaff who agreed on Lhe followlng quesLlons showed an lmproved
Lrend from 2003 Lo 2011: hosplLal managemenL provldes a cllmaLe LhaL promoLes paLlenL safeLy (76.8 Lo 82.8), Lhe
acLlons of hosplLal managemenL show LhaL paLlenL safeLy ls a Lop prlorlLy (78.3 Lo 81.4), Lhe hosplLal ls acLlvely dolng
Lhlngs Lo lmprove paLlenL safeLy lncreased (87.7 Lo 90.1.), afLer we make changes Lo lmprove paLlenL safeLy, we
evaluaLe Lhelr effecLlveness (77.2 Lo 81.8.).

A falr culLure ls evldenced by an lncrease ln volunLary lncldenL reporLlng 2001 aL 930 reporLs Lo 3969 ln 2011.

Conc|us|on: Cllnlcal governance ls composed of dlfferenL areas LhaL can funcLlon lndependenLly buL may noL achleve Lhe
level of success LhaL an lnLegraLed sysLem wlll have. 1he llnes beLween Lhese areas should be lndlsLlncL Lo achleve an
organlsaLlonal Leam concepL.


2264

UNDLkS1ANDING 1nL DIIILkLNCLS IN nA2AkD IDLN1IIICA1ICN kCCLSS IN nLAL1nCAkL AND C1nLk nIGn-nA2AkD
INDUS1kILS
MeclL Can Lmre Slmsekler
1,*
, !lellng Long
1
, !ames Ward
1
, !ohn Clarkson
1

1
Cambrldge unlverslLy, Cambrldge, unlLed klngdom


Cb[ect|ves: 1here ls a growlng awareness LhaL medlcal errors ln healLhcare dellvery are playlng vlLal roles wlLh serlous
consequences affecLlng paLlenL safeLy and Lhe quallLy of healLhcare servlces. As a resulL, healLhcare organlsaLlons are
expecLed Lo monlLor Lhelr care dellvery processes, ldenLlfy errors and lnvesLlgaLe Lhelr llnks Lo hazards. ln order Lo reach
Lhe sLorles behlnd errors and lnvesLlgaLe Lhelr llnks Lo hazards, hazard ldenLlflcaLlon ls an lmporLanL learnlng polnL
produces a greaL yleld ln maklng healLhcare envlronmenL safer for paLlenLs. As an lmporLanL aspecL of safeLy and quallLy,
hazard ldenLlflcaLlon ls also playlng a vlLal role ln oLher hlgh hazard lndusLrles such as avlaLlon, peLroleum and chemlcal
lndusLrles.

1he ob[ecLlve of Lhls sLudy ls Lo analyse boLh healLhcare and oLher hlgh-hazard lndusLrles Lo see how lmporLanLly hazard
ldenLlflcaLlon ls embedded ln Lhelr safeLy sysLems. We also looked aL Lhe maln dlmenslons whlch vlLally played
lmporLanL roles ln boLh lndusLrles' hazard ldenLlflcaLlon process Lo capLure posslble learnlng polnLs from oLher hlgh-
hazard lndusLrles Lo healLhcare ln Lerms of hazard ldenLlflcaLlon.

Methods: 1hrough Lhe comprehenslve llLeraLure revlew, we analysed Lhe dlfferences ln safeLy sysLems of healLhcare
and oLher hlgh-hazard lndusLrles ln Lerms of hazard ldenLlflcaLlon.

kesu|ts: AlLhough each hazard ldenLlflcaLlon meLhod used ln healLhcare has lLs own sLrengLhs, lL can be sald LhaL Lhere ls
no perfecL hazard ldenLlflcaLlon process ln healLhcare applled for paLlenL safeLy wlLhln Lhe scope of rlsk managemenL
when compared Lo oLher lndusLrles. Moreover, many of Lhe prospecLlve hazard ldenLlflcaLlon meLhods used ln hlgh-
hazard lndusLrles have noL been LesLed and evaluaLed ln dlfferenL healLhcare seLLlngs yeL, desplLe Lhelr lmporLance have
been recognlsed. 1herefore, sLlll Lhere ls a poLenLlal Lo lmprove hazard ldenLlflcaLlon process ln healLhcare by uslng
currenL meLhods more effecLlvely and applylng new meLhods, whlch are essenLlally capable of hazard ldenLlflcaLlon ln
hlghly hazardous lndusLrles. 1herefore, Lhe hazard ldenLlflcaLlon process would poLenLlally show Lhe sLrengLhs of each
meLhod, whlle mlnlmlslng Lhe weaknesses of Lhem Lo brlng ouL a beLLer meLhodology wlLhln Lhe scope of rlsk
managemenL for safeLy lmprovemenL. Moreover, lL can poLenLlally yleld a greaLer beneflL ln Lerms of learnlng abouL
hazards and proacLlvely prevenLlng posslble adverse lncldenLs. When we revlewed Lhe maln dlsparlLles beLween
healLhcare and hlgh-hazard lndusLrles ln Lerms of hazard ldenLlflcaLlon, lL was found ouL Lhe undersLandlng of sysLem
Lhlnklng, safeLy culLure ln Lhe envlronmenL and Lhe use of dlfferenL hazard ldenLlflcaLlon Lechnlques are Lhe maln
dlmenslons poLenLlally affecL Lhe success of Lhe hazard ldenLlflcaLlon process.

Conc|us|on: 8y lndlcaLlng Lhe lmporLance of hazard ldenLlflcaLlon ln boLh healLhcare and oLher hlgh-hazard lndusLrles,
Lhls sLudy parLlcularly sLaLed how Lhe dlsparlLles ln safeLy culLure, sysLem undersLandlng and Lhe Lechnlques used for
hazard ldenLlflcaLlon play lmporLanL roles ln Lhe success of hazard ldenLlflcaLlon process Lo promoLe paLlenL safeLy, Lhus
quallLy.

2270

kLSCUkCL U1ILISA1ICN ICk CLCS1kIDIUM DIIIICILL CASLS A1 AN ACU1L CAkL 1LACnING nCSI1AL
An[um khan
1,*
, !lanll ll
2
, aLrlcla Mckernan
1

1
8lsk ManagemenL & CuallLy lmprovemenL,
2
ueclslon SupporL, SL Mlchael's PosplLal, 1oronLo, Canada


Cb[ect|ves: 1o esLlmaLe resource uLlllsaLlon for ClosLrldlum dlfflclle ln an acuLe care Leachlng hosplLal by comparlng Lhe
lengLh of sLay (LCS) and 1oLal and ulrecL cosL per WelghLed Case of ClosLrldlum dlfflclle lnfecLlon (Cul) case versus
non Cul case.

Methods: 1he sLudy was based on hosplLal case cosLlng daLa base beLween March 2010 Llll SepLember 2012. 340
paLlenLs wlLh dlscharge dlagnosls of Cul and 21382 cases wlLhouL Lhe dlscharge dlagnosls of Cul as conLrols were
maLched based on slmllar Case Mlxed Croups (CMC). ulfferences ln Lhe burden of lllness, paLlenL age, or paLlenL
complexlLy were ad[usLed by ComplexlLy Cverlay MeLhodology (lx1M) and 8esource lnLenslLy WelghLs (8lW welghLed
cases) Lo achleve sLaLlsLlcal and cllnlcal homogenelLy beLween Lhe Lwo groups. uslng Lhe Cenerallsed Llnear Model and
LlfeLlme Models wlLh rlsk ad[usLmenL Lhe Cul and non Cul cases were Lhen compared for lengLh of sLay, 1oLal CosL per
WelghLed Case and ulrecL CosL per WelghLed case.

kesu|ts:
Cur daLa shows LhaL cases wlLh Cul had sLaLlsLlcally slgnlflcanL longer LCS compared Lo non Cul cases. (16 days versus 9
days, <0.0001) 1he LoLal cosL per welghLed case ($8092for Cul case versus $6922 for non Cul case) and Lhe dlrecL cosL
per welghLed case ($3683 for Cul case versus $ 4896 for non Cul case) was also slgnlflcanLly dlfferenL. (<0.0001)

Conc|us|on:
1he lmpacL of ClosLrldlum dlfflclle lnfecLlon on Lhe lengLh of sLay and cosL of care ls slgnlflcanL. LCS and cosL of care are
lmporLanL measures of hosplLal resource uLlllsaLlon managemenL. We lnvesLlgaLed Lhe hosplLal case cosLlng daLa for Lwo
and a half years and found LhaL Lhere were slgnlflcanL dlfferences ln Lhe ad[usLed LoLal cosL per welghLed case, dlrecL
cosL per welghLed case and lengLh of sLay of Cul and non Cul cases. Cur sLudy provldes a more accuraLe esLlmaLe of Lhe
lmpacL of ClosLrldlum dlfflclle on resource lnLenslLy, cosL and resource uLlllsaLlon and has fuLure lmpllcaLlons for fundlng
allocaLlon for Lhe hosplLals. CosL Lfflclency (cosL per welghLed case) needs Lo be lmproved by lnLroduclng value
lmprovemenL" changes whlch lmprove quallLy and efflclency of care.

keferences: An AppllcaLlon of LlfeLlme Models ln LsLlmaLlon of LxpecLed LengLh of SLay of aLlenLs ln PosplLal wlLh
ComplexlLy and Age Ad[usLmenL. !lanll Ll SLaLlsL Med, 18, 3337-3344(1999)



2275

1nL ALICA1ICN CI CCS1-LIILC1IVLNLSS MLASUkL ICk A ICk LkICkMANCL (4) kCILC1 IN kCkLA
?LCnPLL CPC
1
, ?CunC Ml A8k
1,*
, Ml k?unC kAnC
1
, SunPC !CunC
1

1
quallLy assessmenL, PealLh lnsurance 8evlew and AssessmenL Servlce, Seoul, korea, 8epubllc Cf


Cb[ect|ves: PealLh lnsurance 8evlew and AssessmenL Servlce (Pl8A) has been assesslng Lhe quallLy of AcuLe Myocardlal
lnfarcLlon (AMl) as aymenL for erformance (4) ro[ecL slnce 2007. uesplLe lmprovlng Lhe quallLy of care, Lhe lengLh
of sLay has been decreaslng whlle Lhe cosL has been lncreaslng. 1o ldenLlfy Lhe effecL and Lhe cases of uslng Lhe
CosLllness lndex (Cl) measure LhaL applled cosL-effecLlveness Lo excluslon crlLerla of lncenLlve paymenL ln 4 pro[ecL.

Methods: We analysed Lhe korea naLlonal PealLh lnsurance clalms daLa and Lhe cllnlcal daLa documenLed by hosplLals
of all paLlenLs admlLLed Lo hosplLals Lhrough emergency room from !an. Lo uec. ln 2011 wlLh AMl. A LoLal of 17,262
paLlenLs were hosplLallsed wlLh AMl ln 181 hosplLals.

Slx AMl measures - flve process measures, one ouLcome measure - were aggregaLed wlLh one ComposlLe CuallLy Score
(CCS) Lo [udge Lhe quallLy of Lhe hosplLals' servlces for AMl. We caLegorlsed Lhe hosplLals lnLo nlne groups and
lmplemenLed lncenLlve or dlslncenLlve paymenL accordlng Lo Lhe AMl resulLs. A LoLal of 43 hosplLals recelved lncenLlves
whlle Lhere were no dlslncenLlve hosplLals. lor Cl, all Lhe paLlenLs were classlfled accordlng Lo Lhe korean ulagnosls
8elaLed Croup (ku8C). ulfferences ln case mlx among hosplLals are ad[usLed uslng Lhe 8u8C (8eflned u8C). 8lsk-
ad[usLed cosLs were compuLed wlLh CosLllness lndex (Cl). Cl (lndex1.2) was applled lnLo excluslon crlLerla of lncenLlve
paymenL ln 4 pro[ecL and one of 43 hosplLals was excluded from lncenLlve paymenL (Cl=1.27).

kesu|ts: 1he lengLh of sLay was decreaslng conslsLenLly, on Lhe oLher hand, Lhe cosLs was lncreaslng ln AMl paLlenLs as
4 ro[ecL slnce 2007.

AfLer applylng Lhe cosL-effecLlveness measure Lo Lhe AMl quallLy assessmenL resulL of 2011, Lhe Lrend of lncreaslng cosL
per paLlenL has decreased (1able).

1able: Annual Lrends of cosLs and lengLh of sLay
varlables 2007 2008 2009 2010 2011
Lhe cosLs per paLlenL(k8W) 7.39 mllllon 7.33 mllllon 7.37 mllllon 8.04 mllllon 8.11 mllllon
(100.0) (96.8) (99.7) (103.9) (106.8)
Lhe lengLh of sLay per paLlenL(days) 9.1 8.7 8.7 8.6 8.1
(100.0) (93.6) (93.6) (94.3) (89.0)

Conc|us|on: AfLer applylng Lhe cosL-effecLlveness measure, we were able Lo conflrm Lhe effecL of hlgh quallLy-low cosL ln
4 pro[ecL. We wlll Lake lnLo conslderaLlon noL only Lhe cosL buL also Lhe lengLh of sLay as Lhe excluslon crlLerla of
lncenLlve paymenL.



2279

kLVLN1ING DULICA1ICN CI kADICGkAnIC LkAMINA1ICNS: ICCUSING CN CCMU1LD 1CMCGkAn (C1) - A
CASL CI A CANCLk nCSI1AL IN kCkLA
!lhyun klm
1,*
, Pee[ln klm
1
, ?oungmee klm
1

1
nurslng, Seoul naLlonal unlverslLy PosplLal Cancer CenLer, Seoul, korea, 8epubllc Cf


Cb[ect|ves: 1he ob[ecLlve of Lhls pro[ecL was Lo prevenL paLlenL harm (radlaLlon exposure, economlc loss, wasLe of Llme)
due Lo dupllcaLe radlographlc examlnaLlons ln a cancer deparLmenL of a LerLlary Leachlng hosplLal.

Methods: A dupllcaLe C1 scan was operaLlonally deflned as follows: lL ls a redundanL dupllcaLe C1 scan of Lhe same
anaLomlcal fleld(s) wlLhln one monLh by Lhe same prescrlpLlons from a paLlenL's varlous physlclans of boLh medlcal and
surglcal deparLmenLs. A Cl Leam has Laken a scrupulous approach Lo Cl Lhrough collaboraLlve Leam meeLlngs and
communlcaLlon acLlvlLles among ouLpaLlenL and radlology nurses slnce Aprll, 2012.

1. As a prellmlnary lnvesLlgaLlon, Lhe Cl Leam reLrospecLlvely revlewed Lhe records of 2,333 C1 scans LhaL a paLlenL
underwenL more Lhan Lwlce per monLh , 3 cases of 2,333 C1 scans were dupllcaLe examlnaLlons durlng a 6-monLh
perlod (from !uly 1, 2011, Lo uecember 31, 2011).
2. 1he Cl Leam developed LlecLronlc nurslng 8ecord (Ln8) dlsplay program LhaL ouLpaLlenL nurses can check wheLher
Lhe same radlographlc examlnaLlons have been prevlously done by oLher medlcal or surglcal docLors' prescrlpLlon ln
Aprll, 2012.
3. !usL before paLlenLs undergo C1, Lhe radlology nurse checks rouLlnely wheLher Lhe paLlenL has undergone Lhe same
C1 wlLhln one monLh, and prevenLs a dupllcaLe C1 Lhrough conflrmlng wlLh oLher medlcal Leam.
4. uslng Lhe same meLhod as Lhe prellmlnary lnvesLlgaLlon, Lhe Cl Leam lnvesLlgaLed 2,880 C1 scans durlng a 6-monLh
perlod (from Aprll 1, 2012, Lo SepLember 31, 2012).

kesu|ts:

1. CuLpaLlenL nurses can monlLor all Lhe radlographlc LesL records of paLlenLs by new Ln8 sysLem.
2. ln Lhe prellmlnary sLudy, 3 cases of 2,333 C1 (0.12) were dupllcaLe examlnaLlons.
3. AfLer Lhe Cl, 17 cases of 2,880 C1 prescrlpLlons (0.6) were found Lo be dupllcaLlons, so Lhe 17 dupllcaLe
prescrlpLlons were cancelled durlng a 6-monLh perlod (from Aprll 1, 2012, Lo SepLember 31, 2012).
4. llnally, Lhere was no lncldence of dupllcaLe C1 examlnaLlons afLer Lhe Cl.

Conc|us|on: We conLrlbuLed Lo paLlenL safeLy by prevenLlng dupllcaLlon of radlographlc examlnaLlons. lor Lhe fuLure, we
wlll recommend physlclan's LM8 program LhaL docLors can check prevlous radlographlc prescrlpLlons by oLher docLors.



2282

UALI1 CI nLMCDIALSIS 1kLA1MLN1 IN kCkLA DLLNDING CN 1nL AVAILA8ILI1 CI UALIIILD nSICIANS
Pyunsook klm
1,*
, Mlsun ?un
1

1
Pl8A (PealLh lnsurance 8evlew & AssessmenL Servlce), Seoul, korea, 8epubllc Cf


Cb[ect|ves: 1he alm of Lhls sLudy ls Lo compare Lhe quallLy of haemodlalysls (Pu) LreaLmenL beLween cllnlcs wlLh
quallfled physlclans and Lhose wlLhouL.

Methods: We analysed Lhe korea naLlonal PealLh lnsurance clalms daLa of 316 cllnlcs wlLh paLlenLs who have recelved
Pu more Lhan Lwlce a week from Aprll Lo !une ln 2010. 1he quallLy of Pu care was assessed uslng Lhe quallLy lndlcaLors:
Lhe frequency of dlalysls per day per physlclans and 8ns, frequency of Lhe Pu adequacy LesL and Lhe fulfllmenL raLe of
approprlaLeness of Pu wlLh regard Lo Pu adequacy, and Lhe admlnlsLraLlon raLe of supplemenLal lron and Lhe raLe of
lron sLorage capaclLy wlLh regard Lo anaemla managemenL. 1he researchers dlvlded cllnlcs lnLo 2 groups accordlng Lo
Lhe avallablllLy of quallfled physlclans: Croup(cllnlcs wlLh quallfled physlclans), Croup(cllnlcs wlLhouL quallfled
physlclans).

kesu|ts: 1he frequencles of dlalysls per day per physlclan and per 8n were lower ln group Lhan group. 1he Pu
adequacy and anaemla managemenL were beLLer ln group Lhan group.1able. Paemodlalysls assessmenL ouLcome
accordlng Lo Lhe avallablllLy of quallfled physlclans (MeanSu)

ClasslflcaLlon lndlcaLor 1oLal Croup Croup
Manpower lrequency of dlalysls per day per physlclans 26.314.3 26.411.6 30.122.6
lrequency of dlalysls per day per 8ns 4.31.3 4.21.3 4.31.0
Pu adequacy lrequency of Lhe Pu adequacy LesL 86.232.6 83.433.6 81.933.9
lulfllmenL raLe of Pu adequacy 87.313.1 87.213.9 83.911.3
Anaemla managemenL AdmlnlsLraLlon raLe of supplemenLal lron 26.829.2 32.431.2 27.928.7
8aLe of lron sLorage capaclLy 30.727.3 30.627.7 49.426.4


Conc|us|on: 1he care quallLy of Lhe cllnlcs wlLh quallfled physlclans was beLLer Lhan Lhose wlLhouL speclallsed physlclans.
1he quallLy lmprovemenL of Lhe cllnlcs LhaL perform Pu LreaLmenL ls requlred Lhrough conLlnued quallLy assessmenL.



2283

DC kAID kLSCNSL SS1LMS LNA8LL 1nL kCM1 DLLIVLk CI AkCkIA1L LMLkGLNC CAkL 1C A1ILN1S A1
kISk CI ACU1L DL1LkICkA1ICN: kLSUL1S IkCM AN AUDI1 CN nCSI1AL S1AII U1ILISA1ICN CI 1nL A1ILN1 WI1n
ACU1L CCNDI1ICN ICk LSCALA1ICN (ACL) kCGkAM
Mlchael A. lza
1
, Suzanne SchachL
2
, Ceorge 8ubln
1,*
, ACL LvaluaLlon Croup
1

1
Cllnlcal Covernance unlL,
2
ulsLrlcL Access, 8edeslgn and Cllnlcal Servlces, SouLh LasLern Sydney Local PealLh ulsLrlcL
(SLSLPu), Sydney, AusLralla


Cb[ect|ves: 1o esLlmaLe Lhe raLe of emergency call acLlvaLlons made for paLlenLs wlLh slgns of unexpecLed acuLe
deLerloraLlon as deflned by Lhe ACL crlLerla, and Lo measure Lhe lengLh of Llme from Lhe breach observaLlon Lo Lhe call
acLlvaLlon and, Lo Lhe arrlval of approprlaLe emergency medlcal asslsLance.

Methods: AudlL of hosplLal charLs referrlng Lo Lwo 24 hour perlods (Sunday and 1hursday), from all paLlenLs ln general
medlcal and surglcal wards of Lhe 3 largesL meLropollLan hosplLals ln one Sydney healLh dlsLrlcL. An audlL Lool was
developed for Lhls purpose, whlch capLured Lhe frequency and Lhoroughness of rouLlne paLlenL vlLal slgn observaLlons
and Lhe Llmes of key evenLs ln Lhe process of ldenLlfylng and respondlng Lo a ACL crlLerlon breach.
1he prlnclpal ouLcomes of lnLeresL were Lhe Llme lnLervals beLween Lhe followlng 3 evenLs, lnlLlal observaLlon of ACL
crlLerlon breach, ACL call acLlvaLlon and, arrlval of approprlaLe medlcal asslsLance.
8esulLs were reporLed uslng descrlpLlve sLaLlsLlcs. LoglsLlc regresslon modelllng was used Lo analyse Lhe effecL of ACL
crlLerlon breach Lype, shlfL and, ward on Lhe key prlnclpal ouLcomes of lnLeresL.

kesu|ts: rellmlnary daLa on 989 day eplsodes of care ln 3 hosplLals lndlcaLe 33 had a recorded vlLal slgn observaLlon
breachlng Lhe ACL crlLerla, 31 of Lhese were noL lnlLlally observed by Lhe prlmary care Leam (C1) and hence requlred a
ACL call.

A ACL call was acLlvaLed for 33 (69, Cl:36-81) of Lhe ACL breach evenLs, all lnlLlally Lo Lhe paLlenL care Leam (C1). ln
anoLher 16 (31, Cl:19-44) no ACL call was acLlvaLed and, of Lhese 3 (6) had a requesL for medlcal revlew made
wlLhouL uslng Lhe ACL sysLem and, no medlcal asslsLance was requesLed for Lhe oLher 13 (23 Cl:14-37). 1here were
fewer ACL call acLlvaLlons made on Sunday compared Lo 1hursday (acLlvaLed for 32 versus 80 of ACL breach
observaLlons, p=0.06).

1lmes were recorded for 28 of Lhe ACL calls. 1he medlan Llme from ACL breach observaLlon Lo Lhe call acLlvaLlon was
3 mlnuLes (ranglng from lmmedlaLely Lo 33 mlnuLes). 1lmes Lo Lhe C1 response were recorded for 27 of Lhe ACL calls
and Lhe medlan Llme Lo C1 arrlval was 12 mlnuLes (ranglng from less Lhan 1 mlnuLe Lo 34 mlnuLes). ln 3 paLlenLs (19,
Cl:13-36), Lhe C1 arrlved more Lhan 30 mlnuLes afLer Lhe call acLlvaLlon. 1wo of Lhe 3 Lhree evenLs for whlch medlcal
asslsLance was requesLed wlLhouL uslng Lhe ACL sysLem, were revlewed wlLhln 30 mlnuLes of Lhe recorded ACL
breach observaLlon.

1hree of Lhe evenLs lnvolvlng a ACL call acLlvaLlon were escalaLed Lo Lhe Advanced Llfe SupporL 1eam of whlch Lwo
were admlLLed Lo lnLenslve Care and one was made noL for Cardlo-ulmonary 8esusclLaLlon, all oLhers were sLablllsed.
Cf Lhe 13 evenLs for whlch no medlcal asslsLance was requesLed, one was observed wlLh perslsLlng ACL breach slgns for
aL leasL 3 hours and one for 18 hours unLll a ACL call acLlvaLlon, however all were evenLually sLablllsed.

Conc|us|on: rellmlnary daLa suggesLs LhaL ln almosL a Lhlrd of Lhe observaLlons of paLlenLs wlLh slgns of belng aL rlsk of
acuLe deLerloraLlon are noL havlng an emergency call acLlvaLed, as mandaLed ln Lhe ACL pollcy. Also, some of Lhe ACL
calls were noL aLLended Lo by Lhe C1 wlLhln Lhe 30 mlnuLe rule. ollcy dlrecLlves alone are noL sufflclenL Lo effecL
change ln complex healLh care sysLems. rocess orlenLed sLraLegles, such as educaLlon, may be necessary Lo supporL Lhe
ACL program ob[ecLlves.

C1: 1eam lncludlng SpeclallsL ConsulLanL and or 8eglsLrar.


2284

LkLCkA1ICN CI A1ILN1 SAIL1 CUL1UkL IN ICUS AI1Lk IN1kCDUCING 1LAM kLSCUkCLS MANAGLMLN1
Llang Su-Chln
1
, Mel-Pslng Chen
2,*
, Psuan Chen
1

1
Medlcal CuallLy ConLrol ulvlslon,
2
ueparLmenL of nurslng, kaohslung Medlcal unlverslLy PosplLal, kaohslung, 1alwan


Cb[ect|ves: aLlenL safeLy culLure ls Lhe core lssue of fosLerlng paLlenL safeLy ln medlcal lnsLlLuLlons, and Lhe survey of
paLlenL safeLy culLure can help measurlng Lhe exLenL of upholdlng paLlenL safeLy. MulLldlsclpllnary Leamwork has
become a globally plvoLal lssue ln fosLerlng paLlenL safeLy ln recenL years. ueflnlLe resulLs of relaLed researches also
ldenLlfled Lhe effecLlveness of Leam resources managemenL (18M) ln promoLlng Lhe paLlenL safeLy culLure. 1he purposes
of Lhls sLudy were Lo explore Lhe dlfference of paLlenL safeLy culLure of nurslng professlonals worklng ln lCus afLer
lnLroduclng 18M Lo Lhe hosplLal ln souLhern 1alwan, and furLhermore, Lo look lnLo wheLher Lhere wlll be poslLlve
feedback ln applylng 18M Lo oLher cllnlcal unlLs of Lhe hosplLal ln Lhe fuLure.

Methods: 1he survey of paLlenL safeLy culLure of nurslng professlonals worklng ln lCus was employed ln Lhls sLudy ln Lhe
end of year 2011. 1here are 10 lCu unlLs ln Lhe hosplLal, and Lhe pro[ecLs of 18M were lnLroduced ln 6 lCu unlLs slnce
March, 2011. 1he quesLlonnalre of paLlenL safeLy culLure was dlsLrlbuLed Lo 290 nurses worklng ln varlous lCu unlLs wlLh
or wlLhouL lnLroduclng 18M, and 237 quesLlonnalres wlLh 89 response raLe were collecLed, 134 parLlclpanLs worklng ln
lCus whlch 18M was applled. uescrlpLlve and lnferenLlal sLaLlsLlcs of Lhe daLa were analysed ln SSS12.0 ln Lhls sLudy.

kesu|ts: lrom Lhe demographlc analysls of Lhe parLlclpanLs, 98.4 (n=233) were female, 31.4 (n=132) were 31-40
years old, 3.3 (n=9) were nurslng admlnlsLraLors. 8egardlng Lhe experlence of lncldenL reporLlng, 37.3 (n=138) were
none. And nurses worklng for 3-10 years were 23.3 (n=63), 98.1 (n=232) were educaLed wlLh dlploma or
baccalaureaLe degree. no maLLer wheLher Lhe nurses worklng ln lCus wlLh or wlLhouL lnLroduclng 18M, Lhere were no
slgnlflcanL dlfferences among Lhe varlables of gender, age, admlnlsLraLlve poslLlon, cases of lncldenL reporLlng, worklng
experlence, and nurslng educaLlon preparaLlon. 1he average scores of ma[or dlmenslons of Lhe survey of paLlenL safeLy
culLure of nurslng professlonals ln lCus were demonsLraLed as follows, Leamwork cllmaLe was 80.3, worklng condlLlon
was 79.8, safeLy cllmaLe was 79.1, sLress recognlLlon was 78.8, percepLlon of managemenL was 78.6, [ob saLlsfacLlon was
74.0, handoffs & LranslLlons of medlcal professlonals was 69.3, managemenL supporL for paLlenL safeLy was 68.7, and
Leamwork across unlLs was 68.7. WlLh regard Lo Lhe lmpacL of 18M, paLlenL safeLy culLure of lCus wlLh lnLroduclng 18M
scored hlgher Lhan Lhe ones wlLhouL lnLroduclng 18M. Moreover, Lhere were slgnlflcanL dlfferences among Lhe
dlmenslons of Leamwork cllmaLe, [ob saLlsfacLlon, and worklng condlLlon.

Conc|us|on: llndlngs of Lhe survey of paLlenL safeLy culLure suggesLed LhaL nurslng professlonals of lCus scored hlghesL
ln Lhe dlmenslon of Leamwork cllmaLe, whlch lndlcaLed Lhe concern of effecLlvely lnLeracLlve communlcaLlon among
medlcal professlonals. lCus wlLh lnLroduclng 18M scored hlgher ln each dlmenslon of paLlenL safeLy culLure, and
poslLlvely slgnlflcanL dlfference were ldenLlfled among Lhe dlmenslons of Leamwork cllmaLe, [ob saLlsfacLlon, and
worklng condlLlon. nurses worklng ln lCus wlLh lnLroduclng 18M could easlly have access Lo communlcaLe wlLh
healLhcare Leam members by applylng Lhe sLraLegles and Lools of 18M when faclng Lhe problems and apprehenslon
relaLed Lo paLlenL care. Cenerally speaklng, lnLroduclng 18M noL only could fosLer Lhe awareness of paLlenL safeLy
among healLhcare professlonals, buL also could make Lhe paLlenLs acqulre safer quallLy of care and promoLe Lhe [ob
saLlsfacLlon of employees ln Lhe hosplLal.






2292

AkL WL IN 1nL SAML WCkLD? - LkSLC1IVLS IkCM SLNICk AND IUNICk NUkSLS IN ICUS
?un-Pslen Po
1,*
, Sheuwen Chuang
2
, Ll-Chlng Lln
1
, ?u-el Chen
3

1
uepL. of nurslng Servlce, 1alpel Medlcal unlverslLy PosplLal,
2
PealLh ollcy and Care 8esearch CenLer, 1alpel Medlcal
unlverslLy,
3
uepL. of CuallLy and aLlenL SafeLy, 1alpel Medlcal unlverslLy PosplLal, 1alpel, 1alwan


Cb[ect|ves: 1he sLudy alms Lo ldenLlfy Lhe hazardous condlLlons poLenLlally leadlng Lo unsafe sLaLes for paLlenLs ln Lhe
perspecLlves of nurslng sLaff ln a 18-bed surglcal lnLenslve care unlL (SlCu) and a 24-bed medlcal lnLenslve care unlL
(MlCu), and provlde suggesLlons Lo redeslgn Lhe convenLlonal Lralnlng program.

Methods: MulLl-meLhod was used, flrsLly, a focus group organlsed by elghL nurses represenLlng varled senlorlLy ln Lhe
lCus, whlch explored nurse's knowledge and experlences abouL Lhe hazardous condlLlons ln Lhe Lwo lCus, followed by a
survey of all nurses ln Lhe Lwo lCus uslng a seml-sLrucLure quesLlonnalre whlch was deslgned based on Lhe dlscusslon of
Lhe focus group.

kesu|ts: 1oLal 67 hazardous condlLlons were clarlfled and ldenLlfled by Lhe focus group. lorLy-flve of Lhe quesLlonnalres
were reLurned, glvlng a response raLe of 77.3. 47.4 (SlCu), 19.2 (MlCu) of nurses had less Lhan one year worklng
experlence ln lCu. nlne condlLlons ln MlCu, 43 condlLlons ln SlCu were deLermlned as Lhe hlgh rlsky sLaLes by over 30
of nurses ln Lhe Lwo lCus respecLlvely. Cral medlcal order and communlcaLlon beLween nurses durlng handover were
Lhe Lop Lwo hazards for Lhe [unlors ln MlCu, whlle handover beLween [unlors was concern mosLly ln SlCu. Pandover ln
Llme pressure, Lralnlng for new comers, and lnfecLlon conLrol were ldenLlfled slgnlflcanLly (p < 0.03) as dlfferenL
magnlLude Loward paLlenL safeLy beLween [unlors and senlors ln MlCu, whlle paLlenLs' sLaLus and unrellable devlces and
equlpmenL were ldenLlfled as hlgh magnlLude slgnlflcanLly by [unlors raLher Lhan senlors ln SlCu. 1he survey revealed
LhaL nurslng sLaff wlLh varled senlorlLy worklng ln MlCu and SlCu had dlfferenL perspecLlves ln hazardous condlLlons of
Lhe lCus' envlronmenL Loward paLlenL safeLy.

Conc|us|on: 8ased on Lhe flndlngs, a new Lralnlng sLraLegy was recommended. Learnlng from successes raLher Lhan
fallures has been planned. Share of adequaLe responses beLween nurses was scheduled by sub[ecLs ln Lhelr rouLlne
meeLlng.



2302

LIILC1IVLNLSS CI NUkSLS' USL CI DISCnAkGL LANNING SS1LM CI LkLkILNCL IN 1AIWAN
Lal ?l-lang
1,*
, ?uan Chlen-?l
1
, Lee 1.1
1

1
ueparLmenL of nurslng, lar LasLern Memorlal PosplLal, new 1alpel ClLy, 1alwan


Cb[ect|ves: ln Lhe era of lnformaLlon Lechnology, Lhere are varlous Lypes of lnformaLlon Lechnology lnLroduced lnLo
healLh care. ln order Lo slmpllfy Lhe nurslng process, Lo provlde declslon-maklng, and Lo lmprove Lhe care quallLy and
effecLlveness, healLh care lnsLlLuLlons acLlvely parLlclpaLe ln nurslng lnformaLlon sysLem developmenL whlch lncludlng
nurslng care, physlclan orders managemenL, care and quallLy conLrol, nurslng managemenL and educaLlonal research
appllcaLlons. aLlenL care relles on Leam work of all speclalLles ln every cllnlcal scenarlo. 1he Leam work requlred
speclflcally dlscharge plannlng lnformaLlon sysLems Lo achleve Lhe lnLegraLed nurslng care based on nurslng users'
feedback.

Methods: 1hls sLudy ls performed aL Lhe basls of lnformaLlon sysLem success model, whlch was lnLroduced by ueLone &
McLean (2003). 1he model conLalns flve domalns, lncluded Lhe sysLem quallLy, lnformaLlon quallLy, servlce quallLy, Lhe
wllllngness Lo use, saLlsfacLlon and neL beneflLs. 1he sLudy ls focus on Lhe nurses worklng prlmarlly ln a deparLmenL of
dlscharge plannlng servlces of a medlcal cenLer ln norLhern 1alwan. 1he alm of Lhls research ls Lo explore nurses'
oplnlon and saLlsfacLlon abouL Lhe effecLlveness of Lhe dlscharge plannlng sysLem. AfLer Lhe lmplemenLaLlon of
dlscharge plannlng lnformaLlon Lechnology, Lhe servlce volume and Lhe lengLh of consulLaLlon were collecLed and
compared. 1here are 177 nurses enrolled ln Lhe sLudy. A saLlsfacLlon quesLlonnalre was compleLed, and 176
quesLlonnalres were reLurned. aLlenLs' demographlc daLa are recorded by charL revlew. 1he flrsL ouLcome lndlcaLor
was medlcal Leam servlce volume and Lhe second one ls Llme response Lo consulLaLlon.

kesu|ts: 1he resulLs showed LhaL sysLem quallLy, lnformaLlon quallLy, servlce quallLy and overall saLlsfacLlon (wllllngness
Lo use/saLlsfacLlon) were poslLlve correlaLed. 1he neL beneflL was Lhe hlghesL average score, showlng LhaL nurses uslng
Lhe sysLem are saLlsfled wlLh sysLem effecLlveness. 1he domaln of lnformaLlon quallLy could mosL predlcL medlcal servlce
wlLh Lhe varlance was 33 (p <0.001). AfLer uslng Lhe dlscharge plannlng servlces sysLem, Lhe Llme response Lo
consulLaLlon requlremenL decreased 1.2 days. ln Lerms of consulLaLlon servlce, Lhe speclalLles lncludlng soclal workers,
dleLlclans, home care provlders showed slgnlflcanL greaLer volume (p <0.001), however, Lhe rehablllLaLlon program
showed no slgnlflcanL dlfference.

Conc|us|on: ln concluslon, Lhls sLudy could serve as Lhe reference for Lhose healLh care lnsLlLuLlons sLarLlng Lhe
appllcaLlon of dlscharge plannlng sysLem Lo achleve a hlgh-quallLy Leamwork.

keferences:
1. Colalzzl . sychologlcal research as a phenomenologlsL vlews lL. ln valle 8, klng M, eds. LxlsLenLlal
henomenologlcal AlLernaLlves for sychology.
2. new ?ork: Cxford unlverslLy ress, 1978. ueLone, W.P., and McLean, L.8. 1he ueLone and McLean Model of
lnformaLlon SysLems (19:4),2003, pp. 9-30.
3. ulllon, 1.W., 8lankenshlp, 8., & Crews, 1. (2003). nurslng aLLlLudes and lmages of elecLronlc paLlenL record sysLems.
Cln, 23(3),139-143
4. lllcker !, ark W, Slms A: PosplLal dlscharge lnformaLlon and older paLlenLs: do Lhey geL whaL Lhey need? ! Posp
Med, 2:291-6.


2303

8LCND ACCkLDI1A1ICN: AN LMLkGING NLW SS1LM ICk "UALI1 SUS1AINA8ILI1"
?ulchl lmanaka
1, 2,*
, Plroyukl Sugawara
1
, Plrobuml kawaklLa
1
, CuallLy SusLalnablllLy 1ask lorce
1

1
!apan Councll for CuallLy PealLh Care, 1okyo,
2
kyoLo unlverslLy CraduaLe School of Medlclne, ueparLmenL of PealLhcare Lconomlcs
& CuallLy ManagemenL, kyoLo, !apan


Cb[ect|ves: 1he mlsslon of Lhe !CCPC, a naLlonal healLhcare quallLy organlsaLlon ln !apan, ls Lo lmprove Lhe healLh and welfare of
Lhe people by lmprovlng healLhcare quallLy and ensurlng LrusLworLhy healLh care for Lhe people. 1he laLLer componenL acLually deals
wlLh Lhe susLalnablllLy of provldlng quallLy healLh care ln an accesslble manner, and ls greaLer galnlng lmporLance ln Lhls era of cosL
conLalnmenL ln soclal securlLy due Lo masslvely lncreaslng governmenL flnanclal debLs. 1he !CCPC has accredlLed Lhousands of
hosplLals so far, and has been lmprovlng Lhe currenL sLaLus of quallLy and safeLy LhroughouL Lhe naLlon. Powever, we have yeL Lo
address Lhe depLh of susLalnablllLy for quallLy healLh care.
ln Lhe conLexL of Lhese slLuaLlons, we have developed a new sysLem Lo evaluaLe and supporL already-accredlLed hosplLals sLrlvlng for
a sLronger sLraLeglc managemenL basls for quallLy susLalnablllLy.

Methods: We formed mulLldlsclpllnary Leams lncludlng professlonals on quallLy and safeLy, managemenL, flnance and pollcy, and
developed an evaluaLlon scheme based upon llLeraLure revlew, case sLudles, experLlse knowledge, and lnLeracLlons wlLh hosplLals
and professlonals. ln addlLlon Lo Lhe whole-sysLem approach Lo quallLy and safeLy of hosplLals, we lnLroduced reglonal and Llme-
Lrend axes for evaluaLlng hosplLal performance, whereln we looked wldely lnLo Lhe healLhcare demand and supply ln each relevanL
reglon and back lnLo Lhe hlsLory of hosplLal performance and managemenL, respecLlvely. We also seL up approaches speclflcally Lo
assess medlcal care achlevemenL wlLh hosplLal supply sLrucLure sLablllLy, organlsaLlonal culLure for quallLy and susLalnablllLy,
lncludlng professlonal growLh, and also flnanclal achlevemenL and mld-& long-Lerm plans.

kesu|ts: 1he new scheme has been developed Lo evaluaLe and supporL hosplLals ln Lhe above processes, and lL has a sLrucLure LhaL
lnLegraLes and neLworks Lhe followlng areas:

1) Mlsslon/vlslon/values and PlsLorlcal AchlevemenL
2) Medlcal Care AchlevemenL
3) llnanclal AchlevemenL
4) LxLernal and lnLernal LnvlronmenL
3) Puman 8esources and CrganlsaLlonal ManagemenL
6) rocesses and SysLems for Plgh CuallLy, SafeLy and roducLlvlLy

8esponslveness Lo paLlenL and communlLy needs ls regarded as vlLally lmporLanL, ln addlLlon Lo lnLernal processes of assurance
and lmprovemenL ln quallLy, safeLy and efflclency.

A quanLlLaLlve approach ls also employed and covers numerlcal daLa analysls of medlcal care achlevemenL, flnanclal ouLpuL and
reglonal demand and supply.

A mulLl-level mulLldlsclpllnary Leams approach was deslgned ln phases of pre- and posL-survey analysls, on-slLe surveys, lnLer-
acLlons wlLh hosplLals, valldaLlon panels and follow-ups.

1hls sysLem alms Lo sLrengLhen Lhe susLalnablllLy of healLhcare LhroughouL !apan. roceedlng from Lhe accumulaLed knowledge
bases Lhough revlews and supporL of mulLlple cases, we plan Lo dlssemlnaLe pracLlce and knowledge on lmprovemenLs and besL
pracLlces by mulLlple Lypes of medla and semlnars. ln addlLlon, wlLhln Lhese new processes, we have found and wlll llkely conLlnue Lo
flnd problems ln healLhcare sysLems and pollcles, and plan Lo publlclse pollcy proposals for naLlonwlde quallLy and susLalnablllLy.

Conc|us|on: A new sysLem, beyond accredlLaLlon, for accredlLed hosplLals, was developed Lo evaluaLe and supporL susLalnablllLy for
quallLy healLh care. 1hls ls expecLed Lo work well Lo faclllLaLe lndlvldual hosplLals and Lhe naLlonal healLhcare sysLem for quallLy
susLalnablllLy ln Lhe face of lmpendlng drasLlc healLhcare reforms.

2327

A11I1UDLS CI IAANLSL CI1I2LNS AND nLAL1n CAkL kCVIDLkS kLGAkDING AkLN1LkAL NU1kI1ICN IN INDIVIDUALS WnC LACk DLCISICN
MAkING CAACI1
LLsuko kamlshlrakl
1,*
, Sholchl Maeda
2
, !ay SLarkey
3

1
ueparLmenL of Soclal Welfare, unlverslLy of kochl, kochl,
2
CraduaLe School of PealLh ManagemenL, kLlC unlvL8Sl1?, lu[lsawa, !apan,
3
unlverslLy
of Callfornla, San ulego, unlLed SLaLes


Cb[ect|ves: 1he currenL sLudy alms Lo clarlfy aLLlLudes of !apanese clLlzens and healLh care provlders regardlng Lhe use of parenLeral nuLrlLlon glven
varlous scenarlos of paLlenL age and duraLlon of lncapaclLaLlon.

Methods: We senL sLandardlsed quesLlonnalres Lo a sample of clLlzens (1000 people) and healLh care provlders (2180 care mangers and 360 home
healLh nurses) beLween lebruary and March, 2012.

Spec|f|c c||n|ca| scenar|o shown |n quest|onna|res:
A ()-year old paLlenL was dlagnosed (?) years ago. SubsequenLly, s/he has recelved medlcal care aL home. 1he cancer has spread Lo her/hls lungs.
S/he ls currenLly unable Lo Lake food, waLer, or oLher nuLrlLlon by mouLh. 8oLh of her/hls feeL are very swollen and her/hls mouLh ls very dry. Lven
wlLh LreaLmenL, s/he ls only expecLed Lo llve anoLher 3 weeks. S/he has recenLly been sleeplng all day and ls noL very responslve. lf you repeaLedly
yell her/hls name, s/he opens her/hls eyes a Llny blL and mumbles someLhlng lncoherenLly. S/he ls dlfferenL Lhan before, wlLhouL wllful acLlvlLy."

kesu|ts: kesponse rates: clLlzens 76.2 (n=762), care managers 38.7 (n=832), nurses 33.9 (n=122)
80 year o|d pat|ent, compar|sons by t|me s|nce cancer d|agnos|s:
8espondenLs all supporLed use of parenLeral nuLrlLlon ln an 80-year-old paLlenL dlagnosed 1 year ago compared wlLh 3 years ago.
Cancer d|agnosed 1 year ago, compar|sons by pat|ent age:
8espondenLs all supporLed use of parenLeral nuLrlLlon ln a 30-year-old paLlenL compared Lo an 80-year-old paLlenL who was dlagnosed 1 year ago.
C|t|zens vs. hea|th care prov|ders:
ClLlzens supporLed use of parenLeral nuLrlLlon ln paLlenLs more Lhan dld healLh care provlders (1able1-1).
We asked parLlclpanLs who supporLed Lhe use of parenLeral nuLrlLlon ln end-of-llfe paLlenLs Lo selecL Lhe form Lhey mosL favoured (1able1-2).
8espondenLs from all groups mosL favoured lnLravenous perlpheral parenLeral nuLrlLlon. Powever, compared wlLh healLh care provlders, Lhe
proporLlon of clLlzens chooslng Lhls opLlon was less, wlLh relaLlvely more clLlzens selecLlng percuLaneous gasLrosLomy Lube or nasogasLrlc Lube
feedlngs as Lhelr preferred meLhod.

1able1. arenLeral nuLrlLlon ln paLlenLs wlLhouL declslon maklng capaclLy
1able1-1. ALLlLudes of respondenLs 8egardlng arenLeral
nuLrlLlon (<0.0001)
Age / lncapaclLaLlon SupporL arenLeral nuLrlLlon
ClLlzen n Care Manager n nurse n
80 / 3 years
80 / 1 year
30 / 1 year
67.4
68.3
83.3
312
313
623
33.0
60.3
70.3
443
482
330
37.7
40.3
33.4
46
47
62
1able1-2. MosL favoured form of parenLeral nuLrlLlon
nuLrlLlonal lorm
Age / ?ears slnce
dlagnosls
ClLlzen n Care manager n nurse n
ercuLaneous gasLrosLomy Lube
nasogasLrlc Lube
lnLermlLLenL orogasLrlc Lube feeds
CenLral venous LoLal parenLeral nuLrlLlon (1n)
erlpheral venous 1n
SubcuLaneous parenLeral nuLrlLlon
80 / 3 years 13.6
17.4
7.8
8.4
33.7
14.3
80
89
40
43
183
73
6.3
9.7
0.9
23.1
31.4
6.6
28
43
4
111
227
29
2.2
4.4
0.0
6.7
73.6
11.1
1
2
0
3
34
3
Same as above 80 / 1 year 16.4
17.7
8.0
8.4
34.8
13.3
84
91
41
43
179
69
8.1
10.4
1.3
23.0
47.7
7.4
38
49
7
118
223
33
2.2
6.3
0.0
6.3
73.9
10.9
1
3
0
3
34
3
Same as above 30 / 1 year 21.8
18.0
9.8
10.0
27.9
11.7
136
112
61
62
174
73
14.3
9.6
1.9
33.1
34.2
6.9
73
30
10
173
179
36
0.0
3.1
0.0
34.4
33.1
9.4
0
2
0
22
34
6

!M 10.0 was used for Lhe sLaLlsLlcal analysls. Chl-square LesL was used, blank responses were excluded.

Conc|us|on: ClLlzens and healLh care provlders dlffered ln Lhelr oplnlons regardlng Lhe use of parenLeral nuLrlLlon aL Lhe end-of-llfe Lo a sLaLlsLlcally
slgnlflcanL degree. 1hls suggesLs LhaL healLh care provlders need Lo work Lo adequaLely undersLand Lhe wlshes of Lhose served Lo provlde opLlmal
paLlenL care. 1he nexL sLep ls Lo research Lhe reasons for Lhese dlfferences.

2333

A kCILC1 CI MUL1IDISCILINAk CCLLA8CkA1ICN 1C kCMC1L MLDICA1ICN SAIL1 AMCNG nCML CAkL
CLILN1S
Chlen-?l ?uan
1,*
, Pul-wen ?u
1
, Mln-hsl Puang
1

1
ueparLmenL of nurslng, lar LasLern Memorlal PosplLal, new 1alpel ClLy, 1alwan


Cb[ect|ves: 1hls sLudy almed Lo esLabllsh a pro[ecL of mulLldlsclpllnary collaboraLlon Lo lmprove medlcaLlon safeLy
among home care cllenLs.

Methods: uaLa was obLalned by admlnlsLraLlng a sLrucLured- quesLlonnalre survey and medlcaLlon revlew. uemographlc
facLors and percepLlon of medlcaLlon safeLy were recorded on quesLlonnalre by careglver.
1hls pro[ecL was lmplemenLed vla four programs:
1) arrange pharmaclsL comblned home vlslL
2) lnLerprofesslonal case conference
3) developmenL and lmplemenLaLlon of medlcaLlon reconclllaLlon educaLlon
4) drug-drug lnLeracLlon (uul) alerLlng ln compuLerlsed physlclan order enLry (CCL). 1he lmplemenLaLlon perlod
ranged from AugusL Lo uecember ln 2009.

kesu|ts: 1he survey was compleLed by 146 paLlenLs. 1he average number of currenL medlcaLlons Laken by Lhe paLlenLs ln
Lhe sLudy was 6.7.

We observed 37 poLenLlal drug lnLeracLlons, and aL leasL one poLenLlal lnLeracLlon was ldenLlfled ln 22 paLlenLs. lorLy-
Lhree (29.4) paLlenLs were exposed Lo dupllcaLe medlcaLlons, Lhe prevalence of drug lnLeracLlons and dupllcaLe
prescrlpLlons ln home care paLlenLs was 61.7. AfLer Lhese lnLervenLlon sLraLegles, Lhe prevalence of drug lnLeracLlons
and dupllcaLe prescrlpLlons was reduced from 61.7 Lo 13.7. 1he percepLlon of medlcaLlon safeLy was lncreased from
3.82 Lo 4.26.

Conc|us|on: 1hls pro[ecL noL only lmprove careglver's percepLlon of medlcaLlon safeLy buL also quallLy of home care
nurslng. MedlcaLlon safeLy for paLlenLs cannoL be achleved wlLhouL lncludlng Lhe careglvers and mulLldlsclpllnary
collaboraLlon.

keferences:
1. Choo, !., PuLchlnson, A. & 8ucknall, 1.(2010). nurses' role ln medlcaLlon safeLy. Iootool of Notsloq Moooqemeot,
18(7), 833-861.
2. MeredlLh, S., leldmam, . P., lrey, u., Pall, k., Arnold, k., & 8rown, n. !., eL al. (2001). osslble medlcaLlon errors ln
home healLhcare paLlenLs. Iootool of tbe Ametlcoo Cetlottlcs 5oclety, 49(6), 719-724.
3. Sklblnskl, k.A., WhlLe, 8.A., Lln, Ll., uong, ?., Wu, W.(2007). LffecLs of Lechnologlcal lnLervenLlons on Lhe safeLy of a
medlcaLlon-use sysLem. Ametlcoo Iootool of neoltb-5ystem lbotmocy, 64(1), 90-96.



233S

A NUkSING LkLkILNCL IN CAkING ICk A GSD VLN1ILA1Ck USLk
Mel-Pul Pslao
1,*
, Mel-Pua Sun
1
, Meng-lng Shu
1

1
ueparLmenL of nurslng, lar LasLern Memorlal PosplLal, new 1alpel ClLy, 1alwan


Cb[ect|ves: 8are dlsease paLlenLs need more medlcal care supporL due Lo Lhelr frequenL vlslLs Lo Lhe hosplLal. 1hls case
reporL descrlbes a 26 year old female paLlenL who had suffered Clycogen SLorage ulsease (CSu) for 10 years. Chronlc
dependence on venLllaLor led Lo pulmonary Luberculosls (18) compllcaLlons, whlch requlred LreaLmenL and nurslng.

Methods: uurlng Lhe nurslng perlod from !anuary 31 Lo March 21, 2008, Lhe auLhor gaLhered daLa Lhrough observaLlon,
lnLervlew, physlcal assessmenL, and applled Cordon's funcLlonal healLh paLLerns as an evaluaLlon Lool.

kesu|ts: 1he resulL found LhaL Lhe paLlenL had varlous healLh relaLed problems, lncludlng lneffecLlve Alrway Clearance,
lnsomnla, 8elocaLlon SLress Syndrome (8SS), eLc. uurlng Lhe nurslng perlod, Lhe auLhor lnsLrucLed Lhe paLlenL Lo
effecLlvely carry ouL coughlng ln order Lo malnLaln a smooLh alrway. 1he lnsomnla problem was lmproved by arranglng
an envlronmenL LhaL was favourable Lo sleeplng and by ad[usLlng her dally reglmen. 8esldes, Lhe paLlenL was asslsLed Lo
undersLand a 18 lsolaLlon care program. Moreover, approaches llke acLlve carlng, llsLenlng, and company were adopLed
Lo bulld a LrusLful nurse-paLlenL relaLlonshlp Lo adapL Lhe paLlenL's physlology and psychology poslLlvely and reduce her
dlscomforL as a resulL of Lhe dlsease.

Conc|us|on: 1hrough lndlvldual nurslng lnLervenLlon, Lhe auLhors helped Lhe case Lo face Lhe progress of Lhe lllness
condlLlon. lL ls hoped LhaL Lhls nurslng experlence can provlde as a reference for nurslng personnel carlng for rare
dlsease paLlenLs and lmprove Lhe medlcal care quallLy.



2338

AN LkLkILNCL CI NUkSING CAkL ICk A nCMLLLSS A1ILN1 WI1n LIVLk CIkknCSIS, SLkICUS ASCI1LS, AND
CWLkLLSSNLSS
Ll-Psueh Chl
1,*
, Mel-Pua Sun
1

1
ueparLmenL of nurslng, lar LasLern Memorlal PosplLal, new 1alpel ClLy, 1alwan


Cb[ect|ves: 1he purpose of Lhls arLlcle was Lo descrlbe a 46-year-old homeless paLlenL who falnLed and was admlLLed Lo
hosplLal Lhrough a 119 call. 1he paLlenL losL confldence ln hls physlcal healLh condlLlon and fuLure llfe prospecLs, ln Lurn
Lrlggerlng a sense of powerlessness and oLher healLh problems. SubsequenLly, he was accepLed a reseLLlemenL plan due
Lo successful nurslng care and guldance.

Methods: uurlng Lhe perlod of nurslng care, from SepLember 7 Lo 27, 2010, Lhe auLhors used llsLenlng, observaLlon,
lnLervlews, and Cordon's funcLlonal healLh assessmenL Lool Lo conducL evaluaLlons ln order Lo ldenLlfy paLlenL's healLh
problems.

kesu|ts: 1he paLlenL's healLh problems lncludlng lneffecLlve breaLhlng paLLern, lmbalanced nuLrlLlon: less Lhan body
requlremenLs, a sense of powerlessness. uurlng Lhe nurslng process, Lhe paLlenL's progress was closely monlLored. 8y
healLh educaLlon LhaL flLLed Lhe paLlenL's, Lhe auLhors offered dleL prlnclples for llver clrrhosls and dally waLer
replacemenL compuLaLlons, Lhen hls fluld levels were conLrolled, Lhereby rellevlng Lhe sympLoms of dyspnoea. ln
con[uncLlon wlLh soclal resources LhaL glve Lhe procuremenL of regular food supplles and shelLer for meeL hls baslc need.
1hrough carlng, llsLenlng, and encouraglng hlm Lo express hls emoLlons. rovldlng self-care knowledge and nurslng
lnsLrucLlons abouL dlsease were glven Lo help Lhe cllenL lncreased level of self-conLrol ablllLy. Moreover, problems
relaLed Lo dlscharge from hosplLal were also dlscussed wlLh Lhe paLlenL, ln order Lo help Lhe paLlenL bulld a sense of
conLrol over hls llfe and reduce hls sense of powerlessness.

Conc|us|on: 1hrough Lhe nurslng process, would help Lhe cllenL Lo face llfe wlLh a poslLlve aLLlLude upon leavlng hosplLal
and Lo overcome Lhe dlfflculL challenges ahead. We hope Lhls hollsLlc nurslng experlence can prove Lhe nurslng sLaff a
reference when Laklng care of such paLlenLs and lmprove Lhe medlcal care quallLy.

keferences:
1. Madan, k., & MehLa, A. (2011). ManagemenL of renal fallure and asclLes ln paLlenLs wlLh clrrhosls. lotetootloool
Iootool of nepotoloqy, 2011, publlshed onllne, 1-7.
2. SargenL, S. (2006). 1he managemenL and nurslng care of clrrhoLlc asclLes.
8tltlsb Iootool of Notsloq, 15(4), 212-219.



2344

UNDLkS1ANDING AND kLDUCING MLDICA1ICN LkkCkS
8avlnder S uberol
1
, ArplLa Malanl
2
, rlLlndlra Sachdeva
2
, Anupam Slbal
3,*

1
Chlef CuallLy Cfflcer,
2
CuallLy, lndraprasLha Apollo PosplLals,
3
Croup Medlcal ulrecLor, Apollo PosplLals Croup, new
uelhl, lndla


Cb[ect|ves: 1he purpose of Lhls sLudy was Lo deLermlne Lhe varlous Lypes of medlcaLlon errors, Lhelr lncldence and Lo
analyse Lhe daLa Lo help reduce Lhe medlcaLlon errors. ln Lhe uS alone, medlcaLlon errors are amongsL Lhe mosL
common medlcal errors, harmlng aL leasL 1.3 mllllon people every year amounLlng Lo morbldlLy and morLallLy cosLs of
more Lhan $77 bllllon per year. lL musL be noLed here LhaL publlshed daLa regardlng medlcaLlon errors does noL exlsL as
on daLe ln developlng counLrles. WlLh a beLLer undersLandlng of cause and effecL relaLlonshlps, healLhcare professlonals
can learn whaL facLors Lend Lo make healLhcare processes prone Lo medlcaLlon errors and hence develop meLhods,
models and sysLems Lo reduce Lhe lncldence.

Methods: AL Lhe hosplLal under sLudy from !an 2010 Lo uec 2012, every medlcaLlon error was analysed Lo deLermlne Lhe
sysLemlc gaps LhaL resulLed lnLo an error. MeLhods for deLecLlng medlcaLlon errors lncluded dlrecL observaLlon audlLs aL
Lhe Llme of prescrlpLlon, LranscrlpLlon, dlspenslng and admlnlsLraLlon of medlcaLlon and lncldenL reporLs from across Lhe
hosplLal. 8efore dlspenslng of any medlcaLlon, lL was checked by Lhe Cllnlcal harmacologlsLs uslng dedlcaLed sofLware
Lo verlfy Lhe approprlaLeness of Lhe drug, dose, frequency, and rouLe of admlnlsLraLlon, LherapeuLlc dupllcaLlons,
poLenLlal allergles or senslLlvlLles, poLenLlal lnLeracLlons beLween Lhe medlcaLlons and medlcaLlons wlLh food, any
varlaLlon from Lhe organlsaLlon crlLerla for use, paLlenL's welghL and oLher physlologlcal lnformaLlon, and oLher
conLralndlcaLlons Lo ldenLlfy Lhe errors. areLo analysls of errors was carrled ouL and lL was found LhaL ouL of 1642 errors
36.1 were prescrlpLlon errors, 43.3 were LranscrlpLlon errors, 0.1 were dlspenslng errors and 0.3 were
admlnlsLraLlon errors.

As per our analysls, Lhe ma[or challenge undersLood, was Lo conLrol Lhe number of prescrlpLlon and LranscrlpLlon errors
whlch formed 99.4 of all medlcaLlon errors whlch Look place ln Lhe hosplLal. A mulLl-pronged approach was adopLed
whlch encompassed man, meLhods, maLerlals and machlne Lo brlng down Lhe medlcaLlon error raLe. lnLervenLlons Lo
reduce Lhe medlcaLlon errors lncluded focused Lralnlng, changes ln Lhe hyslclan Crder SheeLs, dlsLurbance free
lndenLlng, collaboraLlve rounds, Lall man leLLerlng for ldenLlfylng look allke, sound allke drugs and changes ln Lhe
PosplLal lnformaLlon SysLem module for reduclng LranscrlpLlon errors Lo enable 'mlsLake-prooflng'.

kesu|ts: As a resulL of analysls and lnLervenLlons underLaken over Lhe perlod of Lhree years from 2010 Lo 2012, Lhe
medlcaLlon error raLes came down from 11.9S medlcaLlon errors per 100 d|scharges ln !an 2010 to 2.2 medlcaLlon
errors per 100 d|scharges ln Lhe monLh of uec 2012, glvlng us an overall reducLlon of 83.1.

Conc|us|on: Avoldlng medlcaLlon errors requlres vlgllance and Lhe use of approprlaLe Lechnology Lo help ensure proper
processes. MedlcaLlon error reducLlon programs are necessary Lo achleve lmprovemenL ln paLlenL care and Lo saLlsfy Lhe
need for a safer healLh care sysLem.



2346

AkCkIA1L MANAGLMLN1 CI 8LCCD kCDUC1S IN 1nL Ck
Sunyoung ark
1,*
, Pyomln lm
1
, ?u[eong klm
1
, !aeyoung Lee
1

1
CA Leam, Seoul naLlonal unlverslLy PosplLal, Seoul, korea, 8epubllc Cf


Cb[ect|ves: 1he purpose of Lhls pro[ecL ls Lo enhance Lhe paLlenL and blood producLs ldenLlflcaLlon process ln Lhe chaoLlc
complex C8 seLLlng and so relnforce Lhe paLlenL safeLy.

Methods: 1he paLlenL ldenLlflcaLlon process ls Lhe mosL lmporLanL and cannoL be sklpped fundamenLal prlnclple ln every
cllnlcal procedure. And lL ls needed Lo be more cauLlous when handllng Lhe blood producLs because of Lhe hlgh-rlsk
naLure of Lhe servlce lLself.

ln our organlsaLlon we have barcode sysLem Lo ldenLlfy Lhe blood and paLlenL lnformaLlon buL unforLunaLely Lhe C8, Lhe
mosL complex and buslesL deparLmenL ln our hosplLal, ls lack of Lhe ldenLlflcaLlon sysLem or barcode supplles for Lhe
blood producLs. 1o guaranLee safe healLhcare servlce and quallLy care, Lhe elecLronlc blood producL managemenL
sysLem for Lhe C8 had developed and applled ln CcLober 2012.

1he elecLronlc blood producL managemenL sysLem for Lhe C8 ls based on Lhe barcode Lagglng sysLem. 1he blood bank
cross-maLches Lhe blood producLs and Lhe paLlenL blood sample and Lhen places a unlque barcode number on Lhe blood
bag. When Lhe recelvers Lake Lhe blood producLs ouL of Lhe excluslve blood refrlgeraLor, Lhey have Lo Lag Lhe barcode
and conflrm lf Lhe paLlenL and Lhe blood producL lnformaLlon on Lhe compuLer are perfecLly maLched or noL. 1he
recelvers Lake Lhe rlghL person's rlghL blood producL Lo Lhe nurses or docLors who wlll Lransfuse Lhe blood Lo paLlenLs.
1he provlders who had been dellvered Lhe blood producLs from Lhe recelvers can verlfy Lhe Lravel Llme of Lhe producL so
LhaL assure Lhe admlLLed blood producLs are ln approprlaLe condlLlon or noL.

1he healLhcare provlders double-check Lhe paLlenL and Lhe blood producL daLa agaln when Lhey had been dellvered Lhe
blood and rlghL before glvlng a blood Lransfuslon, wlLh anoLher provlder slmulLaneously. Llke Lhe precedlng, Lhe
barcode sysLem ls also used durlng Lhe double check process. And Lhe blood bank can monlLor Lhe usage of Lhe blood
producLs. 1he blood producLs are very llmlLed and prlceless resource ln Lhe healLhcare envlronmenL.

1he nurse manager can monlLor Lhe blood recelvlng Llme, arrlvlng Llme, and Lransfuslon Llme daLa on Lhe compuLer so
LhaL Lhe safe, hlgh-quallLy blood producL Lransfuslon servlce ls posslble. 1ransfuslon lnlLlaLlon raLe wlLhln 30mlnuLes
from dellvered" and ulsposal raLe of Lhe blood producLs" lndlcaLors are selecLed Lo ascerLaln Lhe safe Lransfuslon and
Lhe proper uLlllsaLlon of Lhe llmlLed, cosLly blood producLs.

kesu|ts: An organlsed elecLronlc blood producLs managemenL sysLem for Lhe C8 was developed. 1he healLhcare
provlder can see Lhe paLlenL and Lhe blood producL daLa on Lhe compuLer screen wlLh Lhelr bare eyes, now Lhe paLlenL
ldenLlflcaLlon process of our organlsaLlon has been more powerful and admlrable. 1he blood producL recelpL Llme has
been recorded on Lhe compuLer sysLem and LhaL enable safe, flne quallLy Lransfuslon servlce. 1he compaLlble lndlcaLors
were adopLed Lo monlLor Lhe whole process from Lhe release of Lhe blood producLs Lo Lhe Lransfuslon Lo Lhe paLlenLs.

Conc|us|on: 1he more elaboraLe elecLronlc sysLem Lo manage Lhe approprlaLe usage of Lhe blood producLs had been
developed. 1he healLhcare provlders now can supply Lhe safe, quallLy-guaranLeed blood Lransfuslon servlce wlLhouL
compllcaLed burdensome exLra works. 1he cusLomers can be glven fresh, well preserved blood producLs on Lhe very
opporLune Llme.

2348

IS8Ak nANDCVLk ICkM AS A 1CCL 1C IMkCVL 1nL SAIL1 CI Lk A1ILN1 DUkING 1kANSILk
kuang-Chau 1sal
1,*

1
Lmergency Medlclne, lar-LasLern Memorlal PosplLal, 8anclao ulsL., new 1alpel ClLy, 1alwan


Cb[ect|ves: Pandover ls a crlLlcal process of paLlenL safeLy especlally when Lhe paLlenL ls Lransferred from L8 Lo general
ward or lCu. Lrror durlng Lransfer and handover should be reduced as low as posslble.

Methods: Adverse Lransfer evenLs (A1Ls) were deflned and collecLed Lo all Lhe L8 admlsslon paLlenLs from 2010 Lo 2012.
lS8A8 handover form was deslgned and deployed slnce !an. 2011. All of Lhe admlLLed paLlenL should be evaluaLed and
caLegorlsed lnLo 3 levels of severlLy before Lhey lefL L8. Pandover should be execuLed exacLly accordlng Lo Lhe lS8A8
form. 1he numbers of A1Ls before and afLer Lhe deploymenL of lS8A8 form were compared.

kesu|ts: numbers of A1Ls per monLh were 2.30+/-1.24 before deploymenL and 1.00+/-0.83 afLer LhaL. value ls 0.0026.
SlgnlflcanL reducLlon of A1Ls were noLed ln our survey.

Conc|us|on: lS8A8 handover form can faclllLaLe Lhe process of paLlenL Lransfer and handover beLween medlcal
personnel. numbers of A1Ls could be reduced afLer Lhe appllcaLlons of Lhls lS8A8 handover form. lS8A8 (lnLroducLlon,
slLuaLlon, background, assessmenL, recommendaLlon).



23S0

LkLCkING 1nL A11I1UDLS CI nCSI1AL nAkMACIS1S 1C kLCk1ING MLDICA1ICN INCIDLN1S USING A 1nLCk CI
LANNLD 8LnAVICUk (18) SUkVL
SLeve u.Wllllams
1,*
, uenham L. hlpps
1
, uarren M. AshcrofL
1

1
School of harmacy and harmaceuLlcal Sclences, unlverslLy of ManchesLer, ManchesLer, unlLed klngdom


Cb[ect|ves: uue Lo Lhelr hlgh prevalence hosplLal pharmaclsLs admlL LhaL Lhey don'L always reporL medlcaLlon lncldenLs ,
wlLh Lhe complex declslon Lo reporL dependlng on Lhe severlLy of paLlenL harm, anxleLles abouL harmlng lnLer-
professlonal relaLlonshlps, prlor experlence of Lhe ouLcomes from reporLlng and Lhe percelved efforL requlred Lo use
reporLlng forms.
1he ob[ecLlve of Lhe sLudy was Lo assess Lhe effecL of facLors wlLhln hosplLal pharmaclsLs' pracLlce on Lhe llkellhood of
Lhelr reporLlng a medlcaLlon error, uslng a 18 quesLlonnalre. 1he 1heory of lanned 8ehavlour ls a soclal psychologlcal
model whlch alms Lo explaln human soclal behavlour, noL [usL predlcL lL, and posLulaLes LhaL behavlour resulLs from
lndlvlduals' sallenL bellefs abouL LhaL behavlour. lL has been valldaLed Lo assess Lhe lnLenLlons of healLh professlonals
and Lhelr subsequenL behavlour ln cllnlcal pracLlce.

Methods: A 18 quesLlonnalre

was developed based around a prescrlblng error scenarlo whlch lnvolved confuslon
beLween AzaLhloprlne and AzlLhromycln and resulLed ln serlous paLlenL harm. alred 18 quesLlons Lo LesL 8ehavloural,
normaLlve and ConLrol bellefs (l.e. Lhe pharmaclsL's own aLLlLude Lo reporLlng, Lhe pharmaclsL's percepLlon of oLher
people's aLLlLudes Lowards reporLlng, Lhe pharmaclsL's percepLlon LhaL (s)he has conLrol over Lhe reporLlng process)
were based on sallenL bellefs ldenLlfled Lhrough a prevlous quallLaLlve sLudy. 396 hosplLal pharmaclsLs ln a nPS reglon of
Lngland were lnvlLed Lo parLlclpaLe, vla paper or onllne verslons of Lhe survey. MulLlple regresslon, uslng SSS verslon
13, was used Lo deLermlne Lhe relaLlve lnfluence of Lhe Lhree dlfferenL 18 varlables and parLlclpanL demographlcs on
Lhe pharmaclsLs' behavloural lnLenLlon Lo reporL medlcaLlon lncldenLs.

kesu|ts: 270 quesLlonnalres were avallable for analysls, 179 paper (66.3) and 91 elecLronlc (33.7), wlLh an overall
response raLe of 43. 8ehavloural bellefs, normaLlve bellefs and conLrol bellefs accounLed for 32 of Lhe varlance ln Lhe
lnLenLlon Lo reporL medlcaLlon lncldenLs (8= 0.368, 8
2
=0.323, ad[usLed 8
2
= 0.293). harmaclsLs' senlorlLy (dlrecLly) (8=
0.187 p< 0.003) and gender (lndlrecLly) (8=0.19 p< 0.003) had a weaker lnfluence over lnLenLlon Lo reporL, wlLh senlor
pharmaclsLs belng more llkely and female pharmaclsLs havlng a sLronger lnLenLlon because of Lhelr normaLlve bellefs
abouL oLher pharmaclsLs reporLlng. Analysls of lndlvldual bellefs and Lhelr respecLlve regresslon coefflclenLs revealed,
bellefs LhaL reporLlng lncreases awareness of a medlcaLlon safeLy problem and reduces Lhe rlsk of a slmllar errors
(behavloural bellefs), and Lhe serlousness of Lhe ouLcome of Lhe error (conLrol bellefs) lnfluence pharmaclsLs' lnLenLlon
Lo reporL.

lncreaslng awareness abouL medlcaLlon safeLy problems and prevenLlng slmllar harm ln Lhe fuLure were consldered Lo
be an exLremely deslrable ouLcome, wlLh anxleLy abouL damaglng Lhe docLor-pharmaclsL professlonal relaLlonshlp Lhe
mosL undeslrable ouLcome. 1lme/workload pressures and Lhe facL LhaL paLlenLs commonly come Lo no harm (l.e. a near
mlss) were raLed as maklng reporLlng errors less llkely, whllsL a slmple reporLlng form and Lhe presence of a medlcaLlon
safeLy pharmaclsL, Lo asslsL wlLh Lhe compleLlon of Lhe reporLs, were raLed as maklng reporLlng more llkely.

Conc|us|on: LfforLs Lo lmprove Lhe reporLlng of medlcaLlon lncldenLs by hosplLal pharmaclsLs should focus on Lhelr
behavloural and conLrol bellefs. 1hls should lnclude lnsLllllng greaLer confldence abouL Lhe beneflLs of reporLlng and noL
harmlng professlonal relaLlonshlps wlLh docLors, greaLer clarlLy abouL whaL / noL Lo reporL and a slmpler reporLlng
sysLem.

2360

1nL LkLkILNCL CI ADA1ING 1nL 1nLCk CI CkLM SLLI CAkL 1C A CASL CI DISA8ILI1 SLNICk LIVING ALCNL
Shu Chln ?eh
1,*

1
nurslng ueparLmenL, lar LasLern Memorlal PosplLal, 1alpel, 1alwan


Cb[ect|ves: 1he purpose of Lhls sLudy ls Lo examlne a case of 37 year-old wlLh dlsablllLy and llvlng alone and bedrldden
for a long Llme. Pe was senL Lo L8 by ambulance for help. uurlng Lhe perlod of admlsslon, because of belng unable Lo
self-care lacklng Lhe famlly supporLs and oLher asslsLanL resources he became very passlve and hopeless.

Methods: 1he auLhor Look care of hlm beLween 02/09/ 2008 and 02/28/2008, glvlng nurslng assessmenL by means of
observaLlon, lnLervlew, physlcal assessmenL and self-care of Crem Lheory, he was found havlng 4 ma[or problems
lncludlng nuLrlLlon lmbalanced: less Lhen body requlremenLs, physlcal moblllLy lmpalred, self-care deflclL
(feedlng/dresslng/LolleLlng), hopelessness.

kesu|ts: Applylng Crem nurslng Lheory of wholly compensaLory, parLly compensaLory, supporLlve nurslng educaLlon
sysLem eLc, provlded nurslng lnLervenLlon lncludlng nuLrlLlonal care plan and food resources, llmbs poslLlonlng
properly and recovery exerclse plan, Leachlng and asslsLed Lhe paLlenL's hyglene and eaLlng, offerlng referral resource
sysLem Lo lmprove Lhe paLlenL's ablllLy of dally self-care and approved self-value.

Conc|us|on: 1hrough Lhls carlng experlence anLlclpaLes conLrlbuLlng a gulde Lo nurses as Lhey nurse Lhls speclflc paLlenLs,
noL only Laklng care of physlcal needs buL also menLal dlmenslon, Lhe mosL lmporLanL goal ls Lo provlde Lhe healLh
resources and supporLlve sysLem for paLlenLs, expecLlng Lo enhance nurslng quallLy for Lhls parLlcular case.

keferences:
1. CarpenlLo, L. !., (2000). Notsloq uloqoosls (pp. 99-120). new ?ork: hlladelphla.
2. Chen, C. C., Schllllng, L. S., & Lyder, C. P. (2001). A concepL analysls of malnuLrlLlon ln Lhe elderly. Iootool of
AJvooceJ Notsloq, J6(1), 131-142.
3. PerLh, k. A. (2001). uevelopmenL and lmplemenLaLlon of a hope lnLervenLlon program.
4. Oocoloqy Notsloq lotom, 28(6), 1009-1016.
3. 1homas, u., Ashmen, W., Morley, !. L., & Lvans, W. (2000). nuLrlLlonal ManagemenL ln long-Lerm care:
uevelopmenL of a cllnlcal guldellne.
6. Iootool of Cetootoloqy ooJ MeJlcol 5cleoce, 55, 723-734.



2362

CCN1INUCUS IMkCVLMLN1 IN nCSI1AL CAkL SLkVICL USING 8 INDICA1CkS 8ASLD CN nLAL1nCAkL
ACCkLDI1A1ICN S1ANDAkDS
Pyungsun klm
1,*
, Pyonam Woo
1
, Moonsook klm
1
, !aeyoung Lee
1

1
CuallLy & safeLy cenLer, Seoul naLlonal unlverslLy PosplLal, Seoul, korea, 8epubllc Cf


Cb[ect|ves: 1he alm of Lhls sLudy ls Lo check LhaL our organlsaLlon meeLs accredlLaLlon sLandards conLlnuously and
lmproves hosplLal care servlce uslng lndlcaLors based healLhcare accredlLaLlon sLandards.

Methods: AfLer acqulrlng accredlLaLlon ln 2011, our pro[ecL Leam developed 78 lndlcaLors sorLed lnLo 3 caLegorles
(paLlenL safeLy, human resource managemenL, effecLlveness and efflclency of care servlce, medlcal records and cllnlcal
lndlcaLors) wlLh accredlLaLlon sLandards. We deflned lndlcaLors, speclfled person ln charge for each lLem, frequency and
LargeL, Lhen measured and analysed as scheduled wlLh maklng besL use of our exlsLlng elecLronlc sysLems such as LM8
sysLem, MlS (medlcal lnformaLlon sysLem), CuW (cllnlcal daLa warehouse), examlnaLlon sysLem, cyber educaLlon sysLem,
eLc.

We lnformed Lhe relaLed people (docLors, nurses, managers, and admlnlsLraLors) of Lhe monlLorlng resulLs every quarLer
and performed acLlvlLles for quallLy lmprovemenL such as revlslon of LM8 program, revlslon of guldebooks, change ln
examlnaLlon process, lnLroducLlon of new procedures for paLlenL safeLy, eLc. We revlewed daLa and analysed Lhe effecLs
uslng lndlcaLors on malnLaln hlgh raLes of keeplng accredlLaLlon sLandards and lmprovlng hosplLal care quallLy from 2011
Lo 2012

kesu|ts: 1oLal 38 lndlcaLors were lmproved Lhe sLaLus, 30 lndlcaLors were malnLalned lLs level, 10 lndlcaLors were sllghLly
worsen. 7 lndlcaLors such as hand hyglene raLe, caLheLer assoclaLed urlnary LracL lnfecLlon, venLllaLor assoclaLed
pneumonla, acLlon raLe for crlLlcal value reporLs, Llme ouL for counL ln operaLlon room, arresL Lo C8 Llme, verbal/
Lelephone order ln nonemergency slLuaLlon ln paLlenL safeLy parL were beLLer Lhan 2011 Lhrough Lhe enLerprlse efforLs
Lo lmprove paLlenL safeLy culLure.

ln human resource managemenL caLegory, 9 lndlcaLors concernlng percenLages of sLaffs compleLlng essenLlal Lralnlngs
such as orlenLaLlon, sedaLlon, chemoLherapy, C8 and so on, were lmproved, buL Lhe percenLages of flre flghLlng safeLy
Lralnlng and educaLlon for paLlenL rlghLs, eLc goL worse Lhan 2011.

We obLalned good resulLs ln effecLlveness and efflclency of care servlce area. 11 lndlcaLors (Lurnaround Llme for
speclmens, hosplLallsaLlon wlLhln 3hours for severe emergency paLlenL, sLorage of drugs, counselllng for LherapeuLlc
dleLs and medlclne, follow up monlLorlng afLer nuLrlLlonal supporL, eLc) among 23 lndlcaLors became beLLer and Lhe
oLhers (Lhe deferral raLe of unused blood, wrlLLen prescrlpLlon of self-medlcaLlon, walLlng Llme of ouLpaLlenLs, eLc) were
malnLalned Lhe level LhaL we had achleved aL Lhe accredlLaLlon Llme.

lndlcaLors ln medlcal records remalned hlgh levels because we had revlsed LM8 program slnce 2010. 8uL records of
slgnlflcanL unusual evenLs before leavlng ln operaLlng room, consenL for Lransfuslon ln ouLpaLlenLs, eLc were someLlmes
omlLLed.

1he caLegory of cllnlcal lndlcaLors lnclude several klnds of core measures seLs such as pneumonla, sLroke, AMl (acuLe
myocardlal lnfarcLlon), SCl (surglcal care lmprovemenL pro[ecL) and morLallLy raLe of severlLy-ad[usLed for lCu
(lnLenslve care unlLs). lndlcaLors abouL SCl, sLroke, eLc goL so much beLLer, Lhere was no change ln lndlcaLors of
pneumonla, AMl, lCu care, eLc.

Conc|us|on: uslng lndlcaLors was helpful LhaL sLaffs were remlnded of healLhcare accredlLaLlon sLandards and
requlremenLs, and were moLlvaLed Lo lmprove care servlce. Cnly monlLorlng and feedback of lndlcaLors mlghL be less
effecLlve Lhan we had expecLed, buL we LhoughL LhaL all of Lhese acLlvlLles meanlngfully sLlmulaLe sLaffs' lnLeresL and
deslre for Lhe besL hosplLal. So, we conLlnuously monlLor and feedback 78 lndlcaLors develop new lndlcaLors relaLed Lo
on-golng lmprovemenL pro[ecLs.

2363

SMCkING CLSSA1ICN kAC1ICLS IN 1AIWAN: CCMMUNI1 nAkMACIS1S' kNCWLLDGL, A11I1UDLS, SkILLS, SLLI-
LIIICAC, AND GCVLkNMLN1 CLIC
Chla Wen Chuang
1, 2,*
, Chlh-Llng Puang
2
, Shan Puang
1

1
ueparLmenL of nurslng, Chang Cung Memorlal PosplLal, kaohslung,
2
nurslng, Chang !ung ChrlsLlan unlverslLy, 1alnan,
1alwan


Cb[ect|ves: 1he alms of Lhe sLudy were Lo deLermlne Lhe facLors lnfluenclng Lhe currenL smoklng cessaLlon pracLlces of
communlLy pharmaclsLs ln 1alwan, Lo examlne Lhelr knowledge, aLLlLudes, skllls, and self-efflcacy wlLh respecL Lo
smoklng cessaLlon, and Lo assess governmenL pollcy for smoklng cessaLlon counselllng.

Methods: A cross-secLlonal and correlaLlon survey of communlLy pharmaclsLs ln 1alwan has been conducLed from
uecember 2012 Lo March 2013. A plloL sLudy was lmplemenLed. nlneLeen pharmaclsLs compleLed Lhe quesLlonnalre
developed by Lhe auLhors. 1he conLenL valldlLy lndex of Lhe 60-lLem quesLlonnalre was .9 obLalned from flve experLs.
Cronbach's alpha for Lhe scale pracLlces, knowledge, aLLlLudes, skllls, self-efflcacy, and pollcy were .83, .93, .91, .89, .94,
and .80. A phone call was made Lo communlLy pharmaclsLs lnvlLlng Lhem Lo compleLe a quesLlonnalre. A LoLal of 330
pharmaclsLs were selecLed by sLraLlfled randomlsaLlon from 1162 communlLy pharmaclsLs parLlclpaLlng ln Lhe 2012
naLlonal-wlde smoklng cessaLlon program funded by 8ureau of PealLh romoLlon, ueparLmenL of PealLh. 1he sLudy was
approved by Lhe lnsLlLuLlonal 8evlew 8oard of a medlcal cenLer.

kesu|ts: 1hls sLudy ls sLlll ln progress. 1he maln sLudy wlll be compleLed ln March 2013.

Conc|us|on: CommunlLy pharmacy led smoklng cessaLlon servlces have been lmplemenLed ln several counLrles lncludlng
unlLed klngdom (uk). 1o our knowledge, Lhere are no publlshed reporLs ln 1alwan examlnlng Lhe lnfluence facLors of
communlLy pharmaclsLs' smoklng cessaLlon pracLlces. 8ased on Lhe resulLs of Lhls sLudy, exLenslve lnLervenLlons aL Lhe
professlonal and pollcy level should be lmplemenLed Lo relnforce Lhe predlcLors and Lo lmprove smoklng cessaLlon
acLlvlLles among communlLy pharmaclsLs

key words: communlLy pharmaclsL, smoklng cessaLlon, pracLlce, facLor, and governmenL pollcy.



2364

SAILCAkL: AN AkCACn 1C IDLN1II AND kICkI1ISL UALI1 IMkCVLMLN1 CI 8ASIC nLAL1nCAkL IACILI1ILS
IN kLSCUkCL-CCk SL11INGS
nlcole Spleker
1,*
, SLuarL WhlLLaker
2
, Allce Cglnk
1
, 1oblas 8lnke de WlL
3

1
harmAccess loundaLlon, AmsLerdam, neLherlands,
2
CCPSASA,
3
harmAccess loundaLlon, Cape 1own, SouLh Afrlca


Cb[ect|ves: 1he quallLy of baslc healLhcare provlded by faclllLles ln resource-resLrlcLed seLLlngs (88S) ls varlable and
rarely benchmarked wlLh lnLernaLlonally accepLed besL pracLlce. aLlenLs ln 88S face unknown rlsks and healLh sysLem
flnancers have llLLle lnslghL lnLo how funds provlded for quallLy lmprovemenL are spenL. 1he ob[ecLlve of Lhls sLudy was
Lo provlde evldence LhaL reallsLlc quallLy and safeLy sLandards for 88S (SafeCare) can benchmark (prlvaLe) faclllLles,
provlde conLexL for relaLlve quallLy lmprovemenL (Cl) Lra[ecLorles and ldenLlfy prlorlLy areas for quallLy lmprovemenL
lnLervenLlons. 1hls can asslsL paLlenLs, faclllLy sLaff, auLhorlLles and lnvesLors ln undersLandlng Lhe sLrengLhs and
weaknesses of Lhe servlces provlded and supporLs pollcy makers ln maklng lnformed declslons abouL besL use of
faclllLles, Laklng Lhelr currenL sLaLus lnLo accounL, and Lhelr lnvesLmenL poLenLlal. 1hls sLudy reporLs on 137 faclllLles LhaL
enLered Lhe SafeCare rogramme ln Chana, kenya and 1anzanla, as parL of an lnnovaLlve loan program for Cl.

Methods: SafeCare sLandards (by CCPSASA, harmAccess and !Cl) were recenLly accredlLed by Lhe lnLernaLlonal SocleLy
for CuallLy ln PealLhcare (lSCuA). SafeCare enLalls 13 servlce elemenLs LhaL are covered by 823 process and sysLem
crlLerla whlch can be scored compllanL, parLlally compllanL, non-compllanL and noL appllcable. 1he lmprovemenL process
supporLed by Lhese sLandards ls dlssecLed ln 3 deflned and measurable sLeps (levels) for Cl LhaL represenL consecuLlve
subgroups of Lhe 823 crlLerla and whlch can be rewarded wlLh cerLlflcaLes. Crdlnary leasL squares regresslon was used Lo
ldenLlfy slgnlflcanL assoclaLlons of SafeCare assessmenL resulLs wlLh faclllLy characLerlsLlcs such as geographlc locaLlon,
paLlenL flows, proxlmlLy of comparable healLhcare faclllLles and complexlLy of servlces provlded. 8lsks for paLlenLs, sLaff
and publlc healLh, relaLed Lo non-compllance were used Lo ldenLlfy prlorlLy crlLerla for quallLy lmprovemenL.

kesu|ts: Analyses were performed on 137 prlvaLe healLhcare faclllLles ln Chana (31), kenya (84) and 1anzanla (42),
assessed over a perlod of 21 monLhs. SafeCare scores for Lhe ma[orlLy of servlce elemenLs were low (<40 ouL of 100),
whlch ls a resulL of non- or parLlal compllance for Lhe ma[orlLy of crlLerla and represenLs hlgh rlsk Lo paLlenL care.
SLandard compllance scores for Lhe servlce elemenL 8lsk ManagemenL" were found Lo conslsLenLly be Lhe lowesL, whlle
rlmary PealLh Care" and ln-paLlenL Care" scored sllghLly beLLer. Cverall quallLy scores were slgnlflcanLly hlgher for
urban faclllLles, faclllLles wlLh hlgher paLlenL LhroughpuLs and wlLh shorLer dlsLances Lo nelghbourlng faclllLles. rlorlLy
areas were ldenLlfled for movlng upwards ln SafeCare level.

Conc|us|on: 1he sLudy lndlcaLes LhaL Lhe far ma[orlLy of prlvaLe healLhcare faclllLles ln 88S sLruggle wlLh provldlng safe
and quallLy healLhcare. ln parLlcular lssues wlLh medlcaLlon managemenL, Lrlage and consenL processes score
conslsLenLly low. SafeCare SLandards allowed for benchmarklng beLween faclllLles and for ldenLlflcaLlon of prlorlLy areas
for Cl lnLervenLlons. 1hese can supporL pollcy makers, franchlsors, PMC's and prlvaLe healLhcare provlders assoclaLlons
Lo make sLraLeglc declslons on allocaLlon of Cl resources and Lo measure efflclency and effecLlveness ln a performance-
based flnanclng framework.

2368

LIILC1S CI 1nL kLSCkI8ING GUIDLLINLS 1nA1 kLS1kIC1 1nL kLSCkI8LD NUM8Lk CI DAS CI nNC1IC
SLDA1IVL DkUGS CN 1nL nSICIAN kLSCkI8LD A11LkNS IN kLU8LIC CI kCkLA
!leun Chol
1,*
, Pyunsuk Chol
1
, Myoungsuk ark
1
, ?oungll Woo
1

1
PealLh 8evlew and AssessmenL Servlce, Seoul, korea, 8epubllc Cf


Cb[ect|ves:
8ecenLly, prescrlpLlon of long-Lerm hypnoLlc sedaLlve drugs of physlclan has become a soclal problem ln SouLh korea.
lor Lhls reason, Lhe PealLh lnsurance 8evlew and AssessmenL has llmlLed a prescrlbed number of days of hypnoLlc
sedaLlve drugs. 1he purpose of Lhls sLudy ls Lo examlne Lhe effecL on physlclan prescrlblng behavlour of hypnoLlc
sedaLlve drugs.

Methods:
We analysed Lhe ouLpaLlenL prescrlpLlon daLa of Lrlazolam, flurazepam PCl, zolpldem LarLaraLe, zolpldem and
flunlLrazepam from !anuary 2011 Lo uecember 2012.

1o lnvesLlgaLe Lhe effecL of resLrlcLlon of a prescrlbed number of days on Lhe prescrlpLlon of hypnoLlc sedaLlve drugs, Lhe
chl-square LesL was performed for Lhe change of prescrlpLlon raLe ln excess of 31 days and L-LesL was performed for Lhe
average prescrlpLlon days per prescrlpLlon.

kesu|ts:
rescrlpLlon raLe of a prescrlbed number of days exceedlng 31 days was changed from 3.32 ln Lhe flrsL half of 2011
(before) Lo 2.92 ln Lhe flrsL half of 2012(afLer). rescrlpLlon raLe afLer Lhe resLrlcLlon of Lhe prescrlbed number of days
was sLaLlsLlcally slgnlflcanL.

Powever, Lhe average prescrlpLlon days per prescrlpLlon was lncreased by 0.4 days ln less Lhan 31 days prescrlbed group
and was lncreased by 1.3 days ln more Lhan 30 days prescrlbed group. Comparlson of Lhe resulLs of Lhe full average
prescrlpLlon days per prescrlpLlon was lncreased by 0.3 days.

Conc|us|on:
ercenLage prescrlbed prescrlpLlon ln 31 days or longer was reduced ln Lhe presenL sLudy and change of Lhe prescrlpLlon
paLLern of hypnoLlc sedaLlve drugs was ldenLlfled Lhrough a resLrlcLlon of long-Lerm prescrlpLlon of psychoLroplc drugs.
Also, Lhe prescrlbed number of days exceedlng 31 days was reduced buL Lhe prescrlbed number of days per paLlenL was
lncreased. 1herefore, managemenL of prescrlbed number of days per prescrlpLlon ls urgenLly requlred raLher Lhan LhaL
of Lhe prescrlbed number of days per paLlenL.



2370

LVALUA1ICN CI A1ILN1 CCMLIANCL 1C kL-CLkA1ICN INS1kUC1ICNS (CI) IN kL-CLkA1ICN ASSLSSMLN1
CLINIC (CAC) ICk SAML DA ADMISSICN ICk SUkGLk (SDAS) IN A SUkGICAL DLAk1MLN1 CI A U8LIC nCSI1AL
Pol Llng Ll
1,*

1
ueparLmenL of Surgery, norLh ulsLrlcL PosplLal, PosplLal AuLhorlLy, Pong kong, Chlna


Cb[ect|ves:
1o lnvesLlgaLe paLlenL compllance Lo Cl glven ln CAC and facLors of non-compllance.

lnLroducLlon:
SuAS ls a growlng Lrend ln Pong kong, because of decreased lengLh of sLay ln hosplLal. Powever, lnvesLlgaLlons on
compllance Lo Cl, relaLed Lo hlgh rlsks groups lncludlng less healLhy and elderly, ls lnadequaLe Lo reveal Lhe whole
plcLure. lurLher lnvesLlgaLlons were requlred.

Methods:
1hls ls a cross-secLlonal and descrlpLlve sLudy. A reglsLered nurse approached parLlclpanLs [usL before operaLlon Lo
gaLher daLa. uaLa on paLlenL compllance Lo Cl was collecLed. lurLher, demographlcs, and resulLs of mlnl-menLal sLaLe
examlnaLlon (MMSL), 12-lLems Ceneral PealLh CuesLlonnalre (CPC-12) and slmple hearlng examlnaLlon were collecLed.
aLlenLs, who saLlsfled requlremenLs of Jtoq compllooce (urug dose compllance raLe (uuC8)=80 and<=110), and
ptoceJote compllooce (rocedure compllance raLe (C8)=100), were regarded as compllanL Lo Cl. LlLher uuC8<80,
uuC8110 or C8<100 was regarded as non-compllanL. erlod of sLudy was 1/1/2011-30/4/2011. 184 consecuLlve
paLlenLs for SuAS assessed ln CAC of norLh ulsLrlcL PosplLal (nuP) were recrulLed. Lxcluslon crlLerla lncluded paLlenLs
who were admlLLed one or more days before operaLlon.

kesu|ts:
Compllance raLe of sLudy parLlclpanLs was 140/184(76.09). unlvarlaLe analysls showed Age" (p=0.006<0.03) and
MMSL-score" (p=0.oo1<0.03), Sex"(p=0.026<0.03), Soclal_asslsLance"(p=0.026<0.03).
ALLend_CAC_wlLh_company" (p=0.001<0.03) and Slmple_hearlng_LesL" (p=0.004<0.03) were facLors of non-
compllance.
MulLlvarlaLe analysls showed LhaL aLLend CAC wlLh company was 13.929 Llmes more llkely compllanL (p=0.000<0.03).

Lvery year of age lncreased, paLlenL was 1.034 Llmes more llkely non-compllanL (p=0.006<0.03). Lvery MMSL-score
lncreased, paLlenL was 1.937 Llmes more llkely compllanL (p=0.000<0.03).

Conc|us|on:
1hls ls a ploneer sLudy lnvesLlgaLlng compllance Lo Cl of SuAS. lncreaslng age, alLered cognlLlve funcLlons, hearlng
lmpalrmenL and recelvlng soclal asslsLance should be concerned, when paLlenL undergolng SuAS. lurLher, aLLendlng
CAC wlLh company ls necessary.



237S

USL CI 1nLCk, LVIDLNCL AND LkLkILNCL 1C DLVLLC "1nINkSAIL": A MUL1I-IACL1LD IN1LkVLN1ICN 1C
kCMC1L A1ILN1 INVCLVLMLN1 IN IMkCVING A1ILN1 SAIL1
Susan Prlsos
1
, 8lchard 1homson
1,*

1
lnsLlLuLe of PealLh & SocleLy, newcasLle unlverslLy, newcasLle upon 1yne, unlLed klngdom


Cb[ect|ves: Many lnlLlaLlves worldwlde encourage a proacLlve paLlenL role ln lmprovlng Lhelr own safeLy, buL Lhere are
quesLlons abouL Lhelr effecLlveness and Lhelr accepLablllLy Lo elLher paLlenLs or healLhcare sLaff. 1hls may be because
few lnlLlaLlves lnvolved users ln Lhelr developmenL, provlded evldence for Lhe use of Lheory or were sub[ecLed Lo robusL
evaluaLlon. 1he presenL sLudy addressed Lhese shorLcomlngs by uslng a sysLemaLlc, evldence-based approach Lo Lhe
developmenL of a collaboraLlve lnLervenLlon LhaL ls fully user-lnformed and underplnned by relevanL Lheory.

Methods: lnLervenLlon developmenL was gulded by Lhe Medlcal 8esearch Councll lramework and comprlsed Lwo
phases. llrsL, evldence collaLlon (a quallLaLlve sLudy ellclLlng paLlenL, relaLlve and healLhcare professlonal perspecLlves
abouL Lhe paLlenL role, a sysLemaLlc revlew of currenL evldence for lnLervenLlons Lo promoLe paLlenL lnvolvemenL ln
lmprovlng paLlenL safeLy, scoplng of on-golng lnlLlaLlves world-wlde, and Lhe ldenLlflcaLlon of relevanL behavloural
Lheory). Second, lLeraLlve, user-drlven developmenL of Lhe componenLs of Lhe lnLervenLlon (a serles of lnLeracLlve
workshops wlLh paLlenLs, relaLlves, healLhcare professlonals and safeLy experLs).

kesu|ts: SLudy phase 1: 1he quallLaLlve sLudy ldenLlfled gaps ln boLh paLlenL and healLhcare professlonal knowledge and
undersLandlng abouL Lhe paLlenL role ln lmprovlng paLlenL safeLy, as well as hlghllghLlng lmporLanL envlronmenLal
consLralnLs. key paLlenL and healLhcare professlonal bellefs ldenLlfled as llkely faclllLaLors and barrlers Lo paLlenL
lnvolvemenL were also ellclLed. LlLeraLure revlew evldence was llmlLed buL conLrlbuLed, along wlLh examples of besL
pracLlce, Lo lnformlng Lhe selecLlon of Lhe lnLervenLlon approach. 8ehavloural Lheory, relevanL Lo ellclLed experlence and
avallable evldence, suggesLed key behavloural deLermlnanLs Lo LargeL, lnformed Lhe cholce of behavlour change
Lechnlques and provlded Lhe basls of an evaluaLlve framework. SLudy phase 2 resulLed ln Lhe developmenL of Lhe
"1hlnkSAlL" approach, comprlslng Lhree core paLlenL-medlaLed componenLs: a Lheory-based educaLlonal uvu (A gulde
Lo paLlenL safeLy for paLlenLs and Lhelr famllles"), a paLlenL held "PealLhcare Logbook" llnked Lo Lhe uvu conLenL and
lncludlng paLlenL quesLlon prompLs, and a dedlcaLed, one-Lo-one Lalk" sesslon wlLh a member of Lhe hosplLal ward
sLaff. A parallel healLhcare professlonal lnLervenLlon comprlsed a brlef, Lheory-based educaLlonal sesslon supporLed by
Lhe paLlenL uvu. aLlenLs and famllles are encouraged Lo 'Ask' quesLlons and Lo '1ell' sLaff when Lhlngs do noL seem
rlghL. SLaff are encouraged Lo acLlvely 'fosLer' paLlenL lnvolvemenL by saylng Lo paLlenLs lL ls Ck Lo ask me quesLlons
and lL ls Ck Lo Lell me lf you Lhlnk LhaL someLhlng ls noL qulLe rlghL wlLh your care, or lf you Lhlnk Lhere has been a
mlsLake.

Conc|us|on: We have used a mulLl-pronged, sysLemaLlc approach Lo develop a complex lnLervenLlon LhaL encourages
paLlenLs and healLhcare sLaff Lo work LogeLher Lo lmprove paLlenL safeLy. aLlenLs, relaLlves and sLaff were able Lo
ldenLlfy a number of paLlenL safeLy behavlours LhaL could be adopLed aL dlfferenL polnLs across Lhe lnpaLlenL
sLay. CuallLaLlve accounLs of sLaff and paLlenLs furLher ldenLlfled lmporLanL supporL needs for boLh, as well as key
bellefs suggesLed as lmporLanL barrlers Lo upLake. underplnned by behavlour-change Lheory, Lhe 1hlnkSAlL approach ls
deslgned Lo address Lhese bellefs, and provldes deLalled supporL and guldance LhaL promoLes a muLually accepLable,
collaboraLlve approach Lo lnvolvlng paLlenLs ln lmprovlng paLlenL safeLy. lL ls currenLly belng plloLed.



2376

nIGn UALI1 CI MLDICAL CAkL: CkLA1ING A SAIL, LIIICILN1 AND nLAL1n IN1LkNA1ICNAL AIkCk1
P.?. kang
1, 2,*
, ?.l. Pslao
2
, S.1. Psu
2, 3
, P.C. Chang
2, 4

1
ueparLmenL of lamlly Medlclne, 1alwan Landseed PosplLal, lng-Cheng ClLy, 1ao-?uan CounLy,
2
Landseed PosplLal
Medlcal Cllnlc aL 1aoyuan lnL'l AlrporL, 1ao-?uan CounLy, 1alwan,
3
vlce-resldenL, 1alwan Landseed PosplLal,
4
SuperlnLendanL, 1alwan Landseed PosplLal, lng-Cheng ClLy, 1ao-?uan CounLy, 1alwan


Cb[ect|ves: SLrengLhen Lhe lnLer-unlL co-operaLlon and lnLegraLlon of medlcal resources Lo lmprove Lhe quallLy of
medlcal servlce for Lhe Lravellers and workplace healLh managemenL of Lhe employees of 1alwan 1aoyuan lnLernaLlonal
AlrporL.

Methods: 1he Landseed PosplLal Medlcal Cllnlc aL 1aoyuan lnLernaLlonal AlrporL plays an lmporLanL role ln guardlng Lhe
healLh of passengers and alrporL employees. We offers 24-hr emergency medlcal care year around and Lhe medlcal
professlonals have Lo arrlve ln Lhe slLe for emergency LreaLmenL wlLhln Lhe flrsL Len mlnuLes. Lnhanclng Lhe efflclency of
medlcal servlce Lo Lhe Lravellers, we make efforL on lnLer-unlL co-operaLlon among Lhe alrporL companles, alrllnes and
alrporL collaboraLlon Lo compleLe Lhe reporLlng neLwork of emergency medlcal demand. 8esldes, Lo provlde lmmedlaLe
and good quallLy of medlcal servlces, we keep on revlewlng Lhe Lelephone records of emergency noLlflcaLlon and Lhe
process of medlcal care Lo lmproved weak polnLs of process and shorLen Lhe Llme beLween noLlflcaLlon-recelved Lo
paLlenL-vlslLed. lor paLlenL referral, we have dedlcaLed hosplLal Lo provlde efflclenL conLlnulng care. ln Lhe aspecL of
workplace healLh managemenL, we encourage employees parLlclpaLe ln Lhe CovernmenL CommunlLy PealLhcare Croup
and lmplemenL case managemenL of chronlc dlsease. revenLlon, screenlng, consulLaLlon, dlagnosls, LreaLmenL, and
follow-up of occupaLlonal dlseases are provlded for Lhe alrporL employees vla lnLegraLlon of varlable faclllLles and
manpower from Lhe hosplLal. 1lme beLween noLlflcaLlon-recelved Lo paLlenL-vlslLed, emergency vlslL raLe and
hosplLallsaLlon raLe of parLlclpanLs of CommunlLy PealLhcare Croup, olnL of conLacL -Lo-8alloon (28) Llme of Lravellers
wlLh acuLe myocardlal lnfarcLlon were evaluaLed.

kesu|ts: 1he average Llme beLween noLlflcaLlon-recelved Lo paLlenL-vlslLed was 9.23.68 mlnuLes (n=341) ln 2011 buL
wlLhouL slgnlflcanL change ln 2012. lor Lhe referral of paLlenLs wlLh acuLe myocardlal lnfarcLlon, Lhe average Llme of
olnL of conLacL-Lo-8alloon (28) Llme was around 93 mlnuLes, lower Lhan Lhe average sLandard (120 mlnuLes) of
developed counLrles . Accordlng Lo Lhe quallLy lndlcaLors sLaLlsLlcs of CovernmenL CommunlLy PealLhcare Croup, Lhe
emergency servlce vlslL raLe of our members was 2.17 and Lhe hosplLallsaLlon raLe was 2.9 ln 2011, lL revealed Lhe
slgnlflcanL effecLs ln our healLh managemenL of employees compared Lo Lhe one of oLher CovernmenL CommunlLy
PealLhcare Croup 6.02 and 3.06 respecLlvely. ln Lhe managemenL of workplace healLh and occupaLlonal dlsease, Lhe
abnormal raLlo of hearlng LesL of Lhe employees wlLh nolse [ob decreased from 3 ln 2009 Lo 2 ln 2010 and 1.3 ln
2011.

Conc|us|on: WlLh our hlgh quallLy emergency medlcal servlce and all-dlmenslon healLh care managemenL for Lravellers
and alrporL employees, Lhe Landseed PosplLal Medlcal Cllnlc aL 1aoyuan lnL'l AlrporL has been cerLlfled and awarded Lhe
2012 Symbol of naLlonal CuallLy- SafeLy and CuallLy ln 1alwan.




2377

kLDUCL UNLANNLD nCSI1AL kL-ADMISSICNS: A MUL1IDISCILINAk CLINICAL 1LAM kCGkAM
Wel-Lun Llu
1, 2,*
, el-Lun Lee
3
, Wen-1sung Puang
4
, Chln-leng Chang
1

1
CenLer for CuallLy ManagemenL,
2
lnLenslve Care Medlclne,
3
lnLernal Medlclne,
4
Cancer CenLer, Chl Mel Medlcal CenLer,
Llouylng, 1alnan, 1alwan


Cb[ect|ves: unplanned readmlsslon Lo Lhe hosplLal wlLhln 14 days of dlscharge ls consldered for poor quallLy of hosplLal
care. We lnLroduced a mulLldlsclpllnary cllnlcal Leam program Lo reduce unplanned readmlsslons.

Methods: 1hls sLudy was conducLed ln Lhe Chl Mel Medlcal CenLer, Llouylng branch, an 870 bed hosplLal provldlng
prlmary care ln souLhern 1alwan slnce 2003. We ldenLlfled four dlvlslons LhaL accounLed for Lhe largesL number of
readmlsslons wlLhln 14 days afLer dlscharge, whlch were dlvlslons of oncology, hepaLogasLroenLerology, pulmonary
medlclne, and lnfecLlous dlsease. 1he lnLervenLlons for reduclng readmlsslon were performed Lhrough mulLldlsclpllnary
Leam work, lncludlng aLLendlng physlclans, nurse pracLlLloners, cllnlcal pharmaclsLs and soclal workers. 1he
mulLldlsclpllnary program was lnLroduced slnce !anuary 1, 2012. llve maln lnLervenLlons were lncluded ln Lhe program,
lncludlng:

1. medlcaLlon reconclllaLlon for hlgh rlsk paLlenLs, accordlng Lo 8eers crlLerla, was carrled ouL by cllnlcal pharmaclsLs,
2. dlscharge plannlng for hlgh rlsk paLlenLs was carrled ouL by a full-Llme nurse dlscharge advocaLe,
3. cllnlcal nurses Lelephoned Lhe hlgh rlsk paLlenLs 2 Lo 4 days afLer dlscharge Lo relnforce Lhe dlscharge plan and
solved Lhelr slmple medlcal quesLlons,
4. enhance palllaLlve home care by home vlslLlng,
3. auLomaLlc compuLer remlndlng sysLem for emergency physlclans and paLlenL's aLLendlng physlclans lf Lhe paLlenL
vlslLed emergenL deparLmenL wlLhln 14 days of Lhe lndex dlscharge. ln Lhls pre-lnLervenLlonal and posL-
lnLervenLlonal sLudy, we compared Lhe raLes of unplanned readmlsslons, on a quarLerly basls, from !anuary 2011 Lo
uecember 2012.

kesu|ts: A LoLal of 24,020 lndex dlscharges ln 2011, and 23,690 lndex dlscharges ln 2012 were enrolled ln Lhls sLudy. 1he
mean raLes of 14-day unplanned readmlsslon were 3.24 ln 2011 and 4.23 ln 2012, a reducLlon of 1.01 (p<.0001)
(1able1). 1he lmplemenLaLlon of Lhe mulLldlsclpllnary lnLervenLlons slgnlflcanLly decreased Lhe 14-day unplanned
readmlsslon raLe. 1he overall medlcal expendlLure reduced abouL 927,730 uSu/year.

1able 1. Measures of 8e-admlsslon 8aLe 8efore and uurlng lnLervenLlons
8eadmlsslons lndex ulscharges 8eadmlsslon raLe
2011C1 312 6042 3.16
2011C2 313 6119 3.13
2011C3 344 6004 3.73
2011C4 287 3833 4.90
2012C1 271 3698 4.76
2012C2 283 3086 3.36
2012C3 213 6407 3.36
2012C4 238 6499 3.97

Conc|us|on: 1he mulLldlsclpllnary cllnlcal Leam lnLervenLlon effecLlvely reduced Lhe 14-day unplanned readmlsslons.


2379

A NA1ICNAL IkAMLWCkk ICk ACCkLDI1A1ICN CI nLAL1nCAkL CkGANISA1ICNS IN I1AL
Clovannl Caraccl
1,*
, 8arbara Labella
1
, vanda 8aho
1
, AnLonleLLa Cangale
1

1
CuallLy and AccredlLaLlon, Agenas, 8ome, lLaly


Cb[ect|ves: lmplemenLlng a naLlonal framework for accredlLaLlon of healLhcare organlsaLlons, Lhrough ldenLlfylng
sLandards and crlLerla shared wlLh 8eglons and AuLonomous rovlnces

Methods: ln llghL of Lhe Luropean guldellnes, whlch alm Lo promoLe cooperaLlon mechanlsms beLween Member SLaLes
Lo ensure quallLy and safeLy of healLhcare, lLaly recognlsed, aL boLh Lhe naLlonal and 8eglonal level, Lhe need for sharlng
Lhe meanlngful elemenLs of Lhe accredlLaLlon sysLem.

ln Lhls scenarlo ln 2009, Lhe lLallan naLlonal Agency for 8eglonal PealLhcare Servlces (Agenas), Lhe MlnlsLry of PealLh and
Lhe 8eglons and AuLonomous rovlnces, sLarLed a process of analysls and comparlson of Lhe varlous 8eglonal
accredlLaLlon models, ln order Lo ldenLlfy elemenLs of quallLy Lo be shared wlLhln Lhe sysLems for quallLy assurance. 1he
process ended wlLh Lhe deflnlLlon of a number of sLandards and crlLerla regarded as essenLlal and Lhe developmenL of
guldellnes Lo faclllLaLe a unlform lnLerpreLaLlon.

8oLh Lhese documenLs were Lhe basls upon whlch Lhe flnal drafL of a proposal shared wlLh Lhe Worklng group for
revlewlng leglslaLlon on accredlLaLlon, lnsLlLuLed by Lhe MlnlsLry of PealLh and composed of represenLaLlves of Lhe
MlnlsLry, Agenas, 8eglons and AuLonomous rovlnces.

kesu|ts: 1he flnal drafL of Lhe documenL, submlLLed Lo Lhe SLandlng Conference on Lhe relaLlons beLween Lhe SLaLe, Lhe
8eglons and Lhe AuLonomous rovlnces of 1renLo and 8olzano, was flnally approved wlLh a speclflc AgreemenL on Lhe
20
Lh
uecember 2012.
1he documenL, shared among Lhe 21 8eglons and AuLonomous rovlnces, ldenLlfles 8 sLandards and 28 crlLerla,
consldered as essenLlal for lnsLlLuLlonal" accredlLaLlon common Lo all Lhe 8eglonal sysLems. 1hese crlLerla musL be
lncluded wlLhln Lhe relevanL leglslaLlon of each 8eglon and AuLonomous rovlnce, and subsequenLly evaluaLed by uslng
unlform meLhods LhroughouL Lhe counLry.

1he documenL provldes for Lhe 8eglons and AuLonomous rovlnces Lo commlL Lhemselves Lo lmplemenL Lhe AgreemenL
wlLhln 6 monLhs from lLs approval, whlle procedures and deadllnes for adapLaLlon Lo lLs conLenLs, wlll be flnallsed by and
ad hoc worklng group by uecember 2013.

1hls naLlonal body, whlch ls belng developed aL Lhe MlnlsLry of PealLh, wlll be a reference polnL and supporL Lool for Lhe
8eglons and AuLonomous rovlnces ln developlng and lmplemenLlng sLandards and crlLerla. lurLhermore, lL wlll have
Lhe Lask of monlLorlng Lhe new sysLem lmplemenLaLlon meLhods, also Lhrough carrylng ouL audlLs by
audlLors/evaluaLors reglsLered on a naLlonal llsL, aL Lhe reglonal accredlLlng bodles.

Conc|us|on: AccredlLaLlon, as esLabllshed by Lhe naLlonal leglslaLlon, ls a Lool for conLlnuous quallLy lmprovemenL and
for selecLlng provlders on behalf of Lhe lnPS. lL ls characLerlsed by Lhe mandaLory compllance Lo a seL of crlLerla dlrecLly
relaLed Lo Lhe expecLed quallLy levels, and by Lhe Lemporary naLure of Lhe recognlLlon of havlng meL Lhese crlLerla, Lhus
requlrlng perlodlc verlflcaLlon. ueflnlLlon" and managemenL" of Lhls complex sysLem, lnLroduced ln lLaly ln Lhe flrsL
half of Lhe 90s, was delegaLed Lo 8eglons and led Lo a dlfferenL evoluLlon ln Lhe leglslaLlon processes and Lo Lhe adopLlon
of dlverse lmplemenLaLlon meLhods wlLhln Lhe 8eglons.

AdopLlng such a documenL ls an lmporLanL achlevemenL, slnce lL esLabllshes a shared framework for accredlLaLlon of
healLhcare organlsaLlons ln lLaly. lurLhermore, deflnlng sLandards and crlLerla aL Lhe naLlonal level ls a common basls Lo
ensure safe and hlgh quallLy care ls provlded.



2380

kAC1ICAL S1kA1LGIS1S: AN INNCVA1IVL WA ICk 1kAINING LLADLkSnI SkILLS
MargrleL Schnelder
1,*
, LllzabeLh van 8ensen
2
, aul 8oselle
3
, Mlrko noordegraaf
3

1
ueparLmenL of lnLernal Medlclne and uermaLology,
2
CuallLy and SafeLy, unlverslLy Medlcal CenLer uLrechL,
3
School of
Covernance, unlverslLy uLrechL, uLrechL, neLherlands


Cb[ect|ves: CanMLuS ls an educaLlonal framework descrlblng Lhe dlfferenL roles and skllls LhaL are relevanL for modern
medlcal docLors. WlLh Lhe rlse of cllnlcal managemenL, cerLaln new skllls sLand ouL, especlally leadershlp skllls. 1he
Lralnlng of leadershlp skllls however ls weakly developed ln resldency programs. 1hls paper analyses a pro[ecL almed aL
effecLlvely developlng medlcal leaders as pracLlcal sLraLeglsLs.

Methods: All lnLernal medlclne resldenLs were lnvlLed by Lhe head of Lhe deparLmenL Lo (volunLarlly) [oln quallLy
lmprovemenL sesslons. 1he ob[ecLlve of Lhese sesslons ls Lhreefold:

1. Lo lmprove quallLy of paLlenL care,
2. Lo opLlmlse process of care,
3. Lo (subLly) develop leadershlp skllls of resldenLs.

Sesslons are held 4 Llmes a year and lasL for 1 hour. uurlng Lhese sesslons resldenLs llsL crlLlcal lLems, l.e. experlences
wlLh paLlenL LreaLmenL and (organlsaLlonal) elemenLs of provldlng care LhaL surprlse and/or frusLraLe Lhem. ln small
groups, Lhe resldenLs ldenLlfy lmprovemenL pro[ecLs and make change plans, Lhey deLermlne how Lo respond Lo Lhese
experlences, whaL changes are requlred, how Lhese changes can be reallsed and who needs Lo be lnvolved. 1he sesslon
ends wlLh a clear descrlpLlon of Lhe mosL lmporLanL crlLlcal lLems LhaL need Lo be lmproved (prlorlLles), whlch resldenLs
are responslble (responslblllLles), an acLlon plan (acLlvlLles), and necessary supporL (operaLlonal supporL). A dedlcaLed
sLaff member of Lhe deparLmenL plans and coordlnaLes Lhe sesslons and monlLors Lhe progress of Lhe lndlvldual
lmprovemenL pro[ecLs. 1he supervlsor faclllLaLes Lhe parLlclpaLlon and lnvolvemenL of senlor professlonals. ln Lhls way,
leadlng and managlng healLh care dellvery and Lackllng sLraLeglc lssues (e.g. quallLy) are LaughL ln a very pracLlcal way.
Medlcal docLors learn how Lo become pracLlcal sLraLeglsLs.

kesu|ts: up Llll now, four lmprovemenL sesslons have been Laken place, lnvolvlng 20 of ln LoLal 43 resldenLs' lnLernal
medlclne. llfLeen lmprovemenL pro[ecLs have been compleLed and 17 pro[ecLs are sLlll runnlng. Accompllshed
lmprovemenLs lnclude: sLandards for appolnLlng chalrmen durlng handovers, lmprovemenL of handovers durlng shlfLs,
reducLlon of number of paLlenLs per work perlod for new resldenLs, renovaLlon of rooms for resldenLs. Work loglsLlcs on
Lhe wards durlng dayLlme are lmpresslvely lmproved. Moreover, resldenLs are very pleased wlLh sesslons. 1hey feel LhaL
Lhey are able Lo reallse change and Lhey feel Lhey can naLurally cooperaLe wlLh oLher (senlor) docLors and nurses. 1he
sLaff member appears Lo be essenLlal for Lhe progress. 8esldenLs who do noL parLlclpaLe lndlcaLe Lhey are busy wlLh
oLher Lasks llke research, buL Lhey supporL Lhe lmplemenLaLlon of lmprovemenLs.

Conc|us|on: 1hls sLudy shows LhaL lL ls posslble Lo Leach resldenLs leadershlp and managemenL skllls ln a very pracLlcal
way. 1ackllng sLraLeglc and organlsaLlonal lssues can become a naLural parL of medlcal reperLolres. new resldenLs can
learn by dolng and Lhereby supporL Lhe reallsaLlon of organlsaLlonal change, lnnovaLlon and quallLy sLraLegles.




2383

1nL LIILC1 CI nCSI1AL CCN1AC1 kLCAU1ICN CLICILS CN LMLkGLNC DLAk1MLN1 (LD) ILCW AND DISLASL
ACUISI1ICN
kevln koLkowskl
1,*
, ConsLance 8arysauskas
2
, 8lchard Llllson lll
3
, MarLln 8eznek
1

1
ueparLmenL of Lmergency Medlclne,
2
CuanLlLaLlve PealLh Sclences,
3
ulvlslon of lnfecLlous ulsease and lmmunology,
ueparLmenL of Medlclne, unlverslLy of MassachuseLLs Medlcal School and umassMemolral Medlcal CenLer, WorcesLer
MassachuseLLs, unlLed SLaLes


Cb[ect|ves: MulLldrug reslsLanL organlsms (Mu8C) burden healLhcare sysLems worldwlde. LfforLs have been made Lo
llmlL Lhelr spread vla rouLlne conLacL precauLlons for all lnfecLed or colonlsed paLlenLs. 1hese pracLlces recenLly have
been challenged ln llghL of growlng evldence suggesLlng adverse effecLs of Lhls pracLlce on falls, pressure ulcers and
paLlenL saLlsfacLlon. ?eL Lo be sLudled ls Lhe addlLlonal poLenLlal negaLlve lmpacL on Lu flow whlch can furLher erode
overall quallLy. Cur ob[ecLlve was Lo evaluaLe Lhe effecLs of Lwo dlfferenL Mu8C conLacL precauLlon pracLlces on Lu
lengLh of sLay (LCS) and Mu8C acqulslLlon.

Methods: We performed a reLrospecLlve observaLlonal lnLerrupLed Llme serles analysls of all adulL Lu admlsslons for 1
year prlor Lo and afLer an lsolaLlon pollcy change aL a 2 campus urban hosplLal. revlously, all paLlenLs wlLh a hlsLory of
Mu8C lnfecLlon or colonlsaLlon requlred lsolaLlon precauLlons regardless of Lhelr sympLoms. AfLer Lhe change Lo a
sympLom based pollcy, only paLlenLs wlLh acLlve dlarrhoea, producLlve cough or wound secreLlons noL conLalned by a
slmple dresslng requlred conLacL precauLlons, regardless of Mu8C sLaLus, excepL Mu8C gram negaLlve bacllll. LffecL on
Lu LCS was assessed by calculaLlng excess admlsslon Llme (LA1), Lhe dlfference beLween admlsslon Llmes for paLlenLs
wlLh Mu8Cs compared Lo paLlenLs wlLhouL Mu8Cs. (Admlsslon Llme = declslon Lo admlL a paLlenL from Lhe Lu Lo
paLlenL arrlval ln a hosplLal bed). re- and posL-lnLervenLlon hosplLal Mu8C acqulslLlon raLes (new colonlsaLlon or
lnfecLlon/1000 paLlenL days) were compared uslng Lhe sLandard L-LesL.

kesu|ts: AfLer Lhe lC pollcy change, admlsslon Llmes for Mu8C paLlenLs dld noL change slgnlflcanLly aL campus A (CA) buL
decreased slgnlflcanLly aL campus 8 (C8). C8 LA1 lmmedlaLely decreased 132 mlnuLes afLer Lhe pollcy change (p<0.073)
for M8SA and 133 mlnuLes (p=0.03) for v8L and boLh conLlnued Lo decrease followlng Lhe pollcy change. CA and C8
M8SA acqulslLlon remalned sLable from 0.71 Lo 0.38 (p=0.0783) and v8L acqulslLlon lncreased sllghLly from 1.13 Lo 1.46
(p=0.0182).

Conc|us|on: Changlng Lo sympLom-based Mu8C lsolaLlon lmmedlaLely lmproved Lu LCS for paLlenLs wlLh M8SA by over
2.3 hours and by 2.23 hours for paLlenLs wlLh v8L aL C8 buL noL CA. 1hls dlfference ls LhoughL Lo be due Lo a lower
proporLlon of prlvaLe rooms aL C8 and a hlgher occupancy raLe. AcqulslLlon of M8SA was noL affecLed. v8L acqulslLlon
sllghLly lncreased durlng Lhe sLudy perlod. Powever v8L acqulslLlon has slnce decreased Lo a level below LhaL prlor Lo
Lhe sLudy, desplLe Lhe pollcy change remalnlng ln place. lurLher lnvesLlgaLlon of Lhese lssues ls warranLed as Lhere was
clear beneflL aL one campus wlLhouL eroslon of quallLy.



238S

1nL IMAC1 CI A CLINICAL nAkMACIS1 CN MLDICA1ICN AkCkIA1LNLSS IN LLDLkL A1ILN1S ADMI11LD 1C
1nL DLAk1MLN1 CI MLDICINL
LsLl Lublch
1
, Shmuel klang
2
, LyLan WlrLhelm
3
, ?aron MushkaL
4,*

1
PosplLal harmacy ,
2
harmacology, ClallL PealLh Servlces, 1el Avlv,
3
Melr PosplLal, ClallL PealLh Servlces, kefar Saba,
4
Medlclne, ClallL PealLh Servlces, 1el Avlv, lsrael


Cb[ect|ves:
1o quanLlfy Lhe lmpacL of cllnlcal pharmacy servlces on medlcaLlon approprlaLeness ln paLlenLs 63 years or older.
lncreaslng paLlenLs' age, complexlLy and polypharmacy lncrease Lhe rlsk of lnapproprlaLe medlcaLlons.

8ackground: ConsLralnLs dlmlnlsh Lhe chance of ldenLlfylng and correcLlng Lhem parLlcularly ln decreaslng lengLh of
hosplLal sLay and physlclans' Llme elderly paLlenLs are hosplLallsed.

Methods: A cllnlcal pharmaclsL added Lo Lhe Leam of Lhe deparLmenL of medlclne (uCM) revlewed elderly paLlenLs'
charLs and medlcaLlons. MedlcaLlon approprlaLeness lndex (MAl), poLenLlal overuse (8eers or S1C crlLerla) or
underuse (ACCvL or S1A81 model) were deLermlned. roblems were recorded and communlcaLed Lo Lhe physlclans,
noLlng subsequenL changes ln LreaLmenL. 1hen, an experL physlclan's panel reLrospecLlvely revlewed paLlenLs'
lnLervenLlons and compared agreemenL beLween pharmaclsL and uCM physlclans.

kesu|ts: LlghL cllnlcal pharmaclsLs (6 MSc, 2 harmu) [olned 8 uCM ln academlc hosplLals ln lsrael for a LoLal of 144
monLhs (2009-2011) revlewlng 44939 paLlenLs' charLs accordlng Lo accepLed crlLerla. ln order Lo solve drug relaLed
problems, 36,742 recommendaLlons were made ln 17,720 charLs (39, mean 2.07 per charL). Cverall, 82.4 were
accepLed by Lhe LreaLlng physlclans lmprovlng MAl from 4.72 (meanSu) Lo 0.78 (83 lmprovemenL). Plgher (worse)
MAl correlaLed wlLh Lhe number of medlcaLlons (MAl3 wlLh 9 medlcaLlons/ paLlenL) and paLlenL's age (MAl3 ln
paLlenLs over 73). 1here was an average of 0.97 unnecessary medlcaLlons per paLlenL whlch was reduced Lo 0.16, and
underuse of 0.96 medlcaLlons per paLlenL whlch was reduced Lo 0.23. Several lnLrlgulng vlgneLLes are reporLed. Analysls
of a reLrospecLlve non-lnLervenLlon sample and an experL panel [udgmenL on an lnLervenLlon sample supporLed valldlLy
and quallLy of Lhe resulLs.

SaLlsfacLlon survey was conducLed durlng Lhe second year of Lhe pro[ecL. 71 quesLlonnalres were fulfllled by physlclans
and nurses. Analyse of Lhe quesLlonnalres lndlcaLe hlgh saLlsfacLlon from Lhe new servlce wlLh an average score of 9.6
from 10.

Conc|us|on: 8egular audlL of medlcaLlons of elderly paLlenLs hosplLallsed ln Lhe uCM by a cllnlcal pharmaclsL uncovered
a subsLanLlal amounL of medlcaLlon lnapproprlaLeness. harmaclsLs' lnLervenLlon was well recelved by hosplLal
physlclans and led Lo lmproved admlnlsLraLlon of medlcaLlons and lmproved paLlenL safeLy.



2393

LLAkNING IkCM 1nL 1kANSLA1ICN AND IMLLMLN1A1ICN CI A1ILN1 SAIL1 SCLU1ICNS ACkCSS DIIILkLN1
CAkL SL11INGS: 1nL CASL CI 1nL kAID kLSCNSL SS1LM
nlcola MacklnLosh
1,*
, Pelen 8alney
2
, kylle WaLson
3
, !ane Sandall
1

1
ulvlslon of Women's PealLh , klng's College London,
2
Cuy's PosplLal, klng's PealLh arLners, London,
3
CenLral
ManchesLer unlverslLy PosplLals loundaLlon nPS 1rusL, ManchesLer, unlLed klngdom


Cb[ect|ves: 1o explore Lhe lmplemenLaLlon and underplnnlng soclal mechanlsms of rapld response sysLems wlLhln
medlcal and maLernlLy care seLLlngs ln order Lo furLher undersLandlng of Lhelr deLermlnanLs of effecLlveness

Methods: An eLhnographlc case sLudy approach was used. uaLa was collecLed ln 2009 - 2010 wlLhln flve seLLlngs (Lwo
wards ln Lhe medlcal dlrecLoraLe, Lwo obsLeLrlc unlLs and one alongslde mldwlfery unlL)of Lwo uk hosplLals lncludlng
270 hours of observaLlon, 80 sLaff lnLervlews (docLors, nurses, mldwlves, healLhcare asslsLanLs and managers) and
documenLary revlew. uaLa was coded uslng nvlvo sofLware. 1he analysls used Lheme bulldlng and sLrucLurlng meLhods
from Lhe framework approach

kesu|ts: kapld response sysLems had been lmplemenLed ln each of Lhe seLLlngs Lo sLandardlse escalaLlon of care. Lach of
Lhe early warnlng scorlng sysLems enabled Leam slLuaLlon awareness of vlLal slgn recordlngs whlle Lrlgger prompLs
helped shape percepLlons of 'deLerloraLlon'.

ln maLernlLy, mldwlves used Lhe early warnlng charL on a case by case basls because of a relucLance Lo medlcallse
chlldblrLh glven Lhe low lncldence of maLernal compllcaLlons. 1hls dlscreLlonary approach undermlned Lhe deslgn brlef
of Lhe early warnlng sysLem whlch was Lo provlde a unlversal safeLy neL and enable deLecLlon of Lhose women whose
deLerloraLlon ln condlLlon mlghL oLherwlse go unnoLlced. ln conLrasL, ln some medlcal seLLlngs early warnlng scores were
observed Lo be parL of Lhe wrlLLen and verbal vernacular. Powever, where Lhls was Lhe case, markers of deLerloraLlon
noL asslmllaLed lnLo rlsk scores were aL rlsk of belng marglnallsed maklng lL harder for sLaff Lo escalaLe care wlLhouL Lhe
'ob[ecLlve evldence' provlded by Lhe score.

ln boLh maLernlLy and medlcal seLLlngs, escalaLlon proLocols provlded llcense for escalaLlon buL only medlaLed some
occupaLlonal and hlerarchlcal boundarles (nurse-docLor/mldwlfe-obsLeLrlclan). !urlsdlcLlonal baLLles beLween medlcal
sLaff, whlch lnfluenced escalaLlon of care, largely lay ouLslde Lhe remlL of Lhese rapld response sysLems.
ConLexLual feaLures (naLlonal pollcy, Lhe organlsaLlon's paLlenL safeLy Lrack record, pro[ecL managemenL resource, audlL
overslghL) faclllLaLed lmpacL ln boLh maLernlLy and medlcal seLLlngs. ulfferlng professlonal lnLerpreLaLlons of Lhe naLure
of Lhe problems wlLhln each of Lhe provlders (and Lhus Lhose soluLlons deemed approprlaLe) LogeLher wlLh Lhe 'mlxed'
evldence Lo daLe of Lhe effecLlveness of rapld response sysLems lmpeded local upLake

Conc|us|on: 1he flndlngs from Lhls research hlghllghL Lhe merlL of sLudylng how safeLy sysLems work across dlfferenL
care seLLlngs. Comparlng and conLrasLlng Lhe role of Lhe rapld response sysLem wlLhln maLernlLy and medlclne hlghllghLs
Lhe lnfluence of lmplemenLaLlon processes, Lhe soclal processes responslble for Lhelr lnLended, unlnLended and aL Llmes
conLradlcLory consequences, as well as Lhose aspecLs of rlsk LhaL appear largely reslsLanL Lo Lhe lnLended effecLs of Lhls
safeLy soluLlon

keferences: MacklnLosh, n. 8alney, P. Sandall, !. (2012) undersLandlng how rapld response sysLems may lmprove safeLy
for Lhe acuLely lll paLlenL: Learnlng from Lhe fronLllne, 8MI Ooollty ooJ 5ofety, leb,21(2):133-44.



239S

AkL WL 8LIND 1C 1nL CkI1ICAL WINDCW ICk kLVLN1ICN? AS SnCWN WI1n A CCnCk1 CI A1ILN1S WI1n DIA8L1LS
MLLLI1US AND DIA8L1IC kL1INCA1n
8achel S. varughese
1,*
, LllloLL 8ldgeon
1

1
Cxford unlverslLy Medlcal School, Cxford, unlLed klngdom


Cb[ect|ves: ulabeLes MelllLus (uM) ls a prevalenL condlLlon worldwlde, leadlng Lo slgnlflcanL morbldlLy across a number of organ
sysLems. uesplLe medlcal care shlfLlng Lowards prevenLaLlve sLraLegles, bllndness due Lo dlabeLlc reLlnopaLhy (u8) remalns a
common cause of vlsual loss. 1hls ls a largely prevenLable condlLlon wlLh lmplemenLaLlon of Lwo-pronged prophylaxls of conLrolled
blood sugar and regular screenlng. ?eL, amongsL Lhe dlabeLlc populaLlon, Lhe vlsual consequences of u8 are ofLen mlsundersLood,
and more lmporLanLly so are Lhe sLraLegles LhaL Lhey could Lake for prevenLlon. 1hls sLudy almed Lo assess wheLher paLlenLs have
Lhe correcL lnformaLlon Lo self-enforce prevenLlon sLraLegles before developmenL of a compllcaLlon.

Methods: 62 paLlenLs, aLLendlng u8 cllnlcs over 3 weeks were asked Lo parLlclpaLe ln a quesLlonnalre survey. All paLlenLs had uM
and had a dlagnosls of u8. 1hls sLudy assessed:

1) 1he prlmary sources of paLlenLs' medlcal lnformaLlon: aLlenLs were asked Lo choose from a pre-deLermlned llsL, whlch sources
of lnformaLlon Lhey would classlfy as Lhelr prlmary source.
2) 1he level of undersLandlng aL 2 Llme polnLs: before dlagnosls wlLh a compllcaLlon (Lhe wlndow for prevenLlon) and afLer Lhe
dlagnosls. aLlenLs were asked abouL undersLandlng lnLo four areas: Lhe meanlng of u8, vlsual consequences, causal
relaLlonshlp wlLh blood sugar and Lhe need for regular screenlng.

8esponses were presenLed on a 4-polnL LlkerL scale. lree LexL commenLs were lnvlLed LhroughouL.

kesu|ts: 37 paLlenLs responded.
1) 42 sLaLed Lhelr Ceneral racLlLloner (C) was Lhelr prlmary source of lnformaLlon abouL Lhe progresslon of u8, 33 sLaLed
paLlenL lnformaLlon leafleLs and 23 sLaLed Lhe lnLerneL. 0 chose books.
2) 8esulLs for Lhe undersLandlng lnLo Lhe four key areas of u8 knowledge were classlfled lnLo 'before' and 'afLer' dlagnosls. 1hls ls
demonsLraLed ln Lhe Lable presenLed here, whlch shows Lhe percenLage of paLlenLs who scored either 3/4 or 4/4 for Lhelr
undersLandlng of Lhe four caLegorles.

8efore ulagnosls of u8 AfLer ulagnosls of u8
Meanlng of u8 86 100
vlsual consequences 11 84
8elaLlonshlp wlLh blood glucose 18 86
need for regular screenlng 28 91

lree LexL commenLs lndlcaLed wlshes for a sLronger emphasls on Lhe prevenLablllLy of Lhls compllcaLlon, as many had consldered lL
an lnevlLable compllcaLlon.

Conc|us|on: aLlenLs Lend Lo rely heavlly on paLlenL leafleLs and Lhe lnLerneL, wlLh 38 chooslng one of Lhese, raLher Lhan Lhelr C.
rlor Lo dlagnosls, lnformaLlon paLlenLs have abouL prevenLablllLy of u8 ls lnadequaLe. uurlng Lhe crlLlcal wlndow where
prevenLaLlve sLraLegles are posslble, paLlenLs are unaware of Lhe lmporLanL facLs, ln Lhls case, vlsual consequences, a closely causal
relaLlonshlp wlLh blood glucose conLrol, and Lhe absoluLe necesslLy Lo aLLend regular screenlng appolnLmenLs. lollowlng dlagnosls,
paLlenLs galn an excellenL lnslghL lnLo Lhelr condlLlon, wlLh resulLs showlng a slgnlflcanL leap ln undersLandlng, suggesLlng paLlenL
lnformaLlon ls readlly dlgesLlble.

Cverall, Lhls sLudy hlghllghLs Lwo maln Lake home messages.
1) ln condlLlons where prevenLable compllcaLlons arlse, measures need Lo be Laken uLlllse Lhe wlndow for prevenLlon, ofLen noL
used Lo lLs full poLenLlal.
2) lnformaLlon ln paLlenL leafleLs and medlcally lnformaLlve lnLerneL slLes should be as meLlculously prlorlLlsed as lnformaLlon from
Lhe C. 8oLh of Lhese are evldenLly heavlly relled on by paLlenLs Lo refer Lo and learn from.



2398

AWAkLNLSS 1CWAkD IALLS kLVLN1ICN kLCk1 CN A SUkVL CI A kLGICNAL 1LACnING nCSI1AL INA1ILN1S IN
1AIWAN
Mel-!ung Wu
1,*
, Chaung !uan Wu
1
, Meel Llng Shyu
1

1
nurslng ueparLmenL, 1alpel Medlcal unlverslLy - Shaung Po PosplLal, new 1alpel ClLy, 1alwan


Cb[ect|ves: aLlenL safeLy ls regarded as an lmporLanL lndlcaLor of nurslng care quallLy. revenLlon paLlenL falls has
become a naLlonal pollcy lssue. 1he purpose of Lhls exploraLory survey was Lo ldenLlfylng Lhe lnpaLlenLs' awareness of
falls prevenLlon. 1he research were Lo measure awareness of Lhe rlsk and consequences of falls among hosplLallsaLlon
paLlenLs. Powever, Lo deLermlne aLLlLudes Loward falls prevenLlon and respondenLs' awareness of Lhelr own rlsk facLors
Lo reduce falls durlng hosplLallsaLlon

Methods: A cross-secLlon sLudy was performed, from !anuary 1
sL
2012 Lhrough !uly 31 2012. Lach paLlenL compleLed a
30-lLem sLrucLure quesLlonnalre. 1he quesLlonnalre lncluded demographlc daLa and flve dlmenslon (hlgh-rlsk group,
medlcal condlLlon, medlcaLlons, hazard envlronmenL and poLenLlal rlsk facLors)1he lnLernal conslsLency of
quesLlonnalre was Cvl values =0.92. 1he level of awareness Lo prevenL falls was from 1 Lo 10 (exLremely lower Lo
exLremely hlgher). All daLa analyses were done uslng SSS verslon17.0. lrequency dlsLrlbuLlon, descrlpLlvemean,
sLandard devlaLlon, earson correlaLlon, A nCvA.

kesu|ts: A LoLal of 400 coples of Lhe quesLlonnalre were dlsLrlbuLed Lo hlgh rlsk lnpaLlenLs ln a Leachlng hosplLal and 336
compleLed form reLurned durlng Lhls Llme, a good response raLe of 89.0. Average age was 68.63(Su13.36) and more
Lhan half of parLlclpanLs (n=224,63.3) wlLhouL falls experlence. 1he quesLlonnalre was dlsLrlbuLes Lo equal numbers
of male and female. ApproxlmaLely Lhree Lo Len of respondenLs (n=93,27.6) were dlagnosls nervous SysLem dlseases.
As a resulL, overall Lhe average of awareness Loward falls prevenLlon was 3.04(Su0.39), Lhe lowesL score wasmedlcal
condlLlon(2.44, Su0.91), on Lhe oLher hand, Lhey represenLed hlgh awareness Loward of hazard envlronmenL (3.33,
Su0.37). Powever, Lhe follows 2 lLems of hazard envlronmenL facLors lncrease chance of falllng: weL floor ln baLhroom
(1.66,Su0.98), lnsufflclenL llghL ln ward (1.66,Su0.98). oLenLlal facLors prone Lo paLlenL falls: golng Lo Lhe LolleL
durlng mldnlghL (1.93,Su0.93) .Accordlng Lo Lhls survey, lL polnLed ouL LhaL lnpaLlenLs overconfldence of pass Lhe weL
flood whlle Lhey be careful and lack of awareness wlLh paLlenLs' medlcal condlLlon lead Lo falllng: weak legs, balance
problem, hypoLenslon.

Conc|us|on: aLlenL fall ls Lhe ma[orlLy of Lhe lncldence reporL ln hosplLal and lead up Lo lncrease Lhe lengLh of sLay,
cause of dlsablllLy and hlgh cosLs. 1here are varlous facLors relaLed Lo fall of lnpaLlenLs. 8ase on Lhe resulL, Lhe
healLhcare provlder enhanced paLlenLs' awareness Loward Lo reduce paLlenL fall and provlde valuable daLabase Lo
ldenLlfy Lhe lmporLance lssues. 1he healLhcare provlders noL only provlde hlgh-quallLy nurslng healLhcare envlronmenL
buL also Lo reach Lhe goal of paLlenL safeLy when paLlenLs durlng hosplLallsaLlon.




2401

kISk-ADIUS1LD kL-ADMISSICN kA1LS IN nLAk1 IAILUkL: nCSI1AL VAkIA1ICN 8 LLNG1n CI ICLLCW-U AND
CAUSL CI kL-ADMISSICN
Alex 8oLLle
1,*
, uerek 8ell
1
, aul Aylln
1

1
lmperlal College London, London, unlLed klngdom


Cb[ect|ves: 1o compare hosplLal-level readmlsslon raLes followlng an lndex hosplLallsaLlon for hearL fallure (Pl) for
emergency readmlsslons aL 30 and 363 days for Pl and non-Pl causes. AlLhough a 30-day follow-up ls Lhe commonesL, lL
has been crlLlclsed for lacklng a LheoreLlcal basls and hosplLal performance may vary by Llme polnL. 1he managemenL of
Lhls paLlenL group ls compllcaLed by comorbldlLles, whlch are common, and hosplLal performance mlghL Lherefore vary
by readmlsslon cause.

Methods: We ldenLlfled each paLlenL's flrsL admlsslon for Pl (lndex admlsslon) from naLlonal admlnlsLraLlve daLa llnked
Lo deaLh reglsLraLlons for all publlc (nPS) hosplLals ln Lngland. 1wo cohorLs were consLrucLed: l) all paLlenLs, ll) Lhose
survlvlng 363 days from dlscharge. WlLh Lhe laLLer group, Lhe problem of Lhe compeLlng rlsk of deaLh afLer dlscharge
does noL arlse. Plerarchlcal loglsLlc regresslon models were consLrucLed for each Lype of readmlsslon (for Pl and for any
oLher prlmary dlagnosls) aL each Llme polnL. CovarlaLes lncluded demographlcs, comorbldlLles, number of prlor
ouLpaLlenL appolnLmenLs aLLended and mlssed and prevlous revascularlsaLlon, paclng or deflbrlllaLor lmplanLaLlon.
Cbserved and predlcLed counLs were summed by hosplLal and mulLlplled by Lhe overall crude raLe Lo glve ad[usLed
hosplLal-level readmlsslon raLes (88s).

kesu|ts: ln 2008/9 and 2009/10 comblned, Lhere were 88,760 paLlenLs havlng Lhelr flrsL admlsslon for Pl durlng whlch
14,133 (13.9) dled. Cf Lhe remalnlng 74,627 (all paLlenLs" cohorL), 32,880 survlved Lhe followlng year (one-year
survlvors" cohorL). 18 of all paLlenLs had any unplanned readmlsslon wlLhln 30 days, rlslng Lo nearly 30 by a year.
8eadmlsslons for Pl accounLed for 30 of Lhe LoLal aL 30 days and 21 of Lhe LoLal aL 363 days.

Ad[usLed all-cause ad[usLed readmlsslon raLes varled from 8.3 Lo 23.0 aL 30 days and 33.4 Lo 36.7 aL 363 days.
uesplLe Lhe poLenLlally dlfflculL lssue of Lhe compeLlng rlsk of deaLh, resulLs for all paLlenLs were slmllar Lo Lhose for Lhe
one-year survlvors: correlaLlons beLween Lhe Lwo cohorLs' 88s were 0.80 or hlgher and paLLerns were slmllar. lor all
causes comblned, early 88s were moderaLe predlcLors of laLer 88s (rho=0.31, p<0.001, for 30d v 363d all-cause raLes). ln
conLrasL, hosplLals showed llLLle or no correlaLlon beLween Lhelr readmlsslons for Pl and for oLher causes aL any Llme
polnL (largesL rho was 0.18, p=0.03, aL 7 days for all paLlenLs, for survlvors Lhls was 0.12, p=0.16).

Conc|us|on: PosplLals' performance as measured by rlsk-ad[usLed unplanned readmlsslon raLes ln Pl paLlenLs varled
wldely across Lngland buL llLLle by lengLh of follow-up Llme beLween 30 and 363 days afLer dlscharge when all causes of
readmlsslon were comblned. Powever, performance uslng Pl-only readmlsslon showed vlrLually no correlaLlon wlLh
LhaL uslng oLher causes aL any Llme polnL. 1hls suggesLs conslderable opporLunlLy for lmprovemenL ln Lhe managemenL
of Lhese complex paLlenLs.

D|sc|osure of Interest: A. 8oLLle: none ueclared, u. 8ell: none ueclared, . Aylln CranL / 8esearch supporL from: ur
losLer lnLelllgence, nlP8




2404

CC-kCDUCING LkSCNAL CU1CCMLS ICk CLDLk LCLL (SnINL kCILC1)
MargareL Pannah
1,*
, Allson Llnyard
1

1
ubllc PealLh, nPS llfe, Leven, unlLed klngdom


Cb[ect|ves:

1o flnd supporL soluLlons for older people, whlch would help Lhem noL slmply survlve, buL Lhrlve aL home.
1raln and supporL sLaff Lo have personal ouLcome-based conversaLlons wlLh paLlenLs and Lhelr famllles uslng a valldaLed
meLhod (1alklng olnLs) followed up wlLh peer supporL,

ulverslfy Lhe range of soluLlons avallable for paLlenLs Lo access and ensure Lhe safeLy, legallLy and susLalnablllLy of small
scale enLerprlses,

LsLabllsh a proof of concepL LhaL co-producLlon wlLh older people, Lhelr famllles and Lhe wlder communlLy can uncover
hldden resources Lo help people remaln well aL home.

Methods: A quallLaLlve approach lnLervlewlng paLlenLs, sLaff and provlders was underLaken Lo ellclL vlews on Lhe
approach.

kesu|ts: llfLy older people have had an ouLcome-based conversaLlon wlLh nlne members of sLaff Lralned ln Lhe
approach. A neLwork of elghLeen small-scale provlders has been ldenLlfled.

Staff comments |nc|ude:
Cteot to see bow smoll cbooqes coo moke o blq Jlffeteoce to someooes llfe,

at|ent Comments:
l om Joloq tbloqs l woot to Jo ooJ feel loJepeoJeot

rov|der comments:
l woot to tbook 8kAC ooJ tbe 5nlN ltoject - tbe soppott bos beeo excelleot

Conc|us|on: 1hls ls a radlcal culLure shlfL, whlch we are only beglnnlng Lo undersLand:

1. SLaff need supporL and permlsslon Lo do Lhlngs dlfferenLly.
2. CllenLs Loo need Llme Lo ad[usL Lo new ways of Lhlnklng abouL Lhlngs.
3. 1here ls a wealLh of enLhuslasm and creaLlve soluLlons from local enLerprlses, Lhe volunLary secLor and Lhe wlder
communlLy.
4. ConversaLlons wlLh paLlenLs have proved very frulLful, powerful and relnforce Lhe need Lo Lake Lhls work forward
desplLe lLs complexlLy.




2410

CCNCUkkLN1 DIAGNCSIS AND CU1CCMLS ICk AN INA1ILN1 CULA1ICN
Shannon 8emers
1,*

1
Pomewood PealLh CenLre, Cuelph, Canada


Cb[ect|ves: ConcurrenL dlsorders (subsLance and psychlaLrlc dlsorders) have become an lncreaslngly concernlng problem
across Canadlan menLal healLh faclllLles due Lo Lhe lmpllcaLlons of cosL and ouLcome of LreaLmenLs. 1he reallLy of
concurrenL dlsorders has sparked conversaLlons regardlng Lhe lmporLance of lnLegraLed care wlLhln acuLe menLal healLh
faclllLles. 1he purpose of Lhls research pro[ecL ls Lo examlne Lhe sympLom and funcLlonal ouLcomes of dlagnosLlc cohorLs
(varlous concurrenL dlsorders compllmenLs) wlLhln an lnpaLlenL menLal healLh faclllLy.

Methods: All paLlenLs admlLLed Lo an lnpaLlenL menLal healLh faclllLy beLween Aprll 1sL, 2011 and March 31sL, 2012,
wlLh a compleLed admlsslon and dlscharge assessmenL where lncluded ln Lhe sLudy (n=2043). 1hey were assessed wlLh
Lhe 8esldenLlal AssessmenL lnsLrumenL - MenLal PealLh (8Al-MP), a sLandardlsed assessmenL lnsLrumenL admlnlsLered
aL admlsslon and dlscharge by cllnlcal sLaff. A varleLy of scales assesslng sympLoms and funcLlonlng are embedded ln Lhe
8Al-MP. 1he scales are compared aL admlsslon and dlscharge Lo Lrack paLlenL ouLcomes whlle ln hosplLal. 1hese
ouLcomes were compared across dlfferenL dlagnosLlc cohorLs, where subsLance-relaLed dlsorders were Lhe prlmary
dlagnosls.

kesu|ts: When comparlng a slngle dlagnosls of subsLance-relaLed dlsorders Lo concurrenL dlsorders wlLh mood dlsorders,
anxleLy dlsorders, or boLh, paLlenLs presenL wlLh slmllar sympLoms aL admlsslon. Powever paLLerns emerge ln sympLom
ouLcomes wlLh dlagnosLlc cohorLs, where Lhe concurrenL dlagnosls (l.e. subsLance-relaLed, mood & anxleLy dlsorders)
have Lhe leasL opLlmal ouLcomes.

Conc|us|on: lnformaLlon on Lhe prevalence of concurrenL dlagnoses wlLhln a menLal healLh hosplLal, as relaLed Lo
sympLom and funcLlonlng ouLcomes, wlll help lnform declslon makers on Lhe need for lnLegraLed care pracLlces (LreaLlng
all dlagnoses slmulLaneously) as well as for lmprovemenL wlLhln speclflc areas of sympLom LreaLmenL. uescrlpLlve
models of concurrenL dlagnoses are needed Lo undersLand characLerlsLlcs assoclaLed wlLh fallure Lo lmprove on
ouLcomes, poLenLlally hlghllghLlng areas for LreaLmenL lmprovemenL. ln Lhe long Lerm, a deeper undersLandlng of
concurrenL dlagnoses may also lnform prevenLlon efforLs almlng Lo malnLaln opLlmal menLal healLh sLaLus.



2414

ASSLSSLMLN1 CI 1nL NUkSLS kNCWLLDGL A8CU1 VLN1kCGLU1LAL INILC1ICN: A 8LICkL AND AI1Lk S1UD
DLSIGN
lernanda 8. L. Clmenes
1
, MarlsLela . n. 8amos
2,*
, LllsabeLh C. ALlla
3

1
Ceneral and Speclallsed nurslng, unlverslLy of So aulo aL 8lbelro reLo College of nurslng, 8lbelro reLo,
2
Surglcal
CenLer, Sumare SLaLe PosplLal , Sumare, 8razll,
3
Cllnlcal Advlsor, AusLrallan College of nurslng, Sydney, AusLralla


Cb[ect|ves: 1o assess Lhe knowledge of nurslng sLaff regardlng lnLramuscular ln[ecLlon Lechnlques ln Lhe venLrogluLeal
slLe, before and afLer professlonal Lralnlng.

Methods: A slngle cenLre, before-and-afLer sLudy deslgn was carrled ouL beLween !anuary 2010 and !uly 2010 ln an
emergency unlL ln uescalvado-So aulo, 8razll. 1he research was conducLed ln Lhree phases. 8efore professlonal
Lralnlng (phase 1), 14 nurses were requlred Lo respond Lo a sLrucLured, self-admlnlsLered quesLlonnalre deslgned Lo
ldenLlfy Lhelr LheoreLlcal knowledge abouL lnLramuscular ln[ecLlon Lechnlque ln Lhe venLrogluLeal slLe. arLlclpanLs were
also requlred Lo demonsLraLe Lhe Lechnlque uslng a sLaLlc manlkln slmulaLor. We followed an assessmenL Lool used ln
prevlous research. ln Lhe second phase, a flve hour sesslon of professlonal Lralnlng was conducLed Lo Lwo groups of
nurses and lncluded LheoreLlcal and pracLlcal conLenLs. 1he LheoreLlcal conLenL was supporLed by audlo vlsual resources.
1here was exchange of experlences durlng Lhe Lwo groups' dlscusslons. 1he pracLlcal conLenL addressed Lhe aspecLs
relaLlng Lo Lhe recognlLlon of bony sLrucLures and muscles lnvolved ln Lhe venLrogluLeal slLe, cleanslng Lhe ln[ecLlon slLe,
and Lhe slmulaLlon of Lhe Lechnlque ln Lhe sLaLlc manlkln slmulaLor. We used Lhe Lechnlque descrlbed by oLLer and
erry (2009) for lnLramuscular ln[ecLlon ln Lhe venLrogluLeal slLe as a gulde. ln phase Lhree, daLa collecLlon was lnlLlaLed
wlLhln a perlod of 13 days afLer Lhe professlonal Lralnlng. 1herefore, we followed Lhe same sLeps, and we used Lhe same
assessmenL Lool followed ln Lhe flrsL phase.

kesu|ts: 8efore professlonal Lralnlng, Lhe quesLlon relaLlng Lo Lhe anaLomlcal sLrucLures lnvolved ln mapplng Lhe
venLrogluLeal slLe were answered correcLly by only 20.8 of Lhe parLlclpanLs. Powever, afLer professlonal Lralnlng,
63.6 of Lhe parLlclpanLs correcLly answered Lhls quesLlon. When parLlclpanLs were asked abouL Lhe muscles lnvolved ln
Lhe venLrogluLeal slLe, only 1 (4.2) nurse answered Lhe quesLlon correcLly before professlonal Lralnlng, compared wlLh
36.4 correcL answers afLer professlonal Lralnlng. Also, afLer Lhe lnLervenLlon, 100 successfully execuLed Lhe 13 sLeps
conLemplaLed ln Lhe assessmenL Lool. 1he resulLs are consldered sLaLlsLlcally slgnlflcanL, as Lhe L-observed was hlgher
LhaL Lhe L-crlLlcal (6.67 1.94), aL 3 probablllLy.

Conc|us|on: rofesslonal Lralnlng was effecLlve ln lncreaslng Lhe level of nurses' knowledge, buL Lhey sLlll sLruggled wlLh
Lermlnology regardlng muscle and bone sLrucLures lnvolved ln mapplng Lhe slLe. We belleve LhaL promoLlng conLlnulng
educaLlon programs conflgure as an lmporLanL aspecL for nurslng professlonals Lo acqulre skllls Lo admlnlsLer
medlcaLlons Lhrough lM ln[ecLlons ln Lhe venLrogluLeal slLe safely.



241S

ACCkLDI1A1ICN WI1nIN 1nL CCMMUNI1 nLAL1n AND nCML CAkL SLC1CkS: LLSSCNS LLAkNLD AND IU1UkL
DIkLC1ICNS ICk ACCkLDI1A1ICN CANADA
Wendy nlcklln
1,*
, alvl kaLLllakoskl
2
, 1oby ?an
2
, !onaLhan MlLchell
3

1
AccredlLaLlon Canada, CLLawa, Canada,
2
CllenL Servlces,
3
ollcy and 8esearch, AccredlLaLlon Canada, CLLawa, Canada


Cb[ect|ves: 1hls presenLaLlon showcases how AccredlLaLlon Canada has engaged CommunlLy PealLh and Pome Care
organlsaLlons wlLhln Lhe AccredlLaLlon program, resulLlng ln a program LhaL ls relevanL and valuable for Lhese secLors.

Methods: 1he CommunlLy PealLh and Pome Care secLors have unlque challenges Lo ensurlng quallLy of servlces and
safeLy of cllenLs lncludlng lsolaLlon of care, unregulaLed and unconLrolled seLLlngs and dlsLlncL organlsaLlonal culLure
[1],[2]. 1here ls also a hlgh prevalence of prevenLable adverse evenLs ln home care [3], yeL many communlLy agencles do
noL have Lhe capaclLy and resources Lo supporL an accredlLaLlon process. 1he communlLy secLor ls becomlng lncreaslngly
prevalenL ln healLh care dellvery [4] and as such, communlLy organlsaLlons are seeklng ouL accredlLaLlon as a mechanlsm
for lmprovlng quallLy and safeLy. 1o ensure LhaL AccredlLaLlon Canada ls meeLlng Lhe needs of lLs 200 communlLy and
home care cllenL organlsaLlons, Lhese organlsaLlons were conLacLed as parL of an evaluaLlon sLudy Lo deLermlne
sLrengLhs and opporLunlLles for program lmprovemenL.

kesu|ts: CllenL saLlsfacLlon resulLs from CommunlLy and Pome Care organlsaLlons lndlcaLed LhaL Lhe creaLlon of a
cusLomlsed accredlLaLlon program for Lhe communlLy and home care secLor was seen as a success. Speclflcally, Lhe
creaLlon of a rlmer AccredlLaLlon program for organlsaLlons new Lo Lhe accredlLaLlon process ln Lhe CommunlLy PealLh
and Pome Care secLors was seen as beneflclal. 1he cusLomlsaLlon of Lhe sLandards was seen as crlLlcal. CpporLunlLles for
lmprovemenL ldenLlfled were Lhe language used wlLhln Lhe sLandards and survey quesLlonnalres Lo beLLer reflecL
communlLy-based pracLlce.

Conc|us|on: 1he AccredlLaLlon Canada CmenLum program was shown Lo supporL and be valued by organlsaLlons wlLhln
Lhe CommunlLy PealLh and Pome Care secLors. 1he accredlLaLlon program conLlnues Lo be reflned and sLrengLhened ln
order Lo furLher engage Lhese secLors and meeL Lhelr needs. luLure dlrecLlons lnclude an evaluaLlon of Lhe aLlenL SafeLy
CulLure lnsLrumenL (survey quesLlonnalre) from a communlLy-care perspecLlve. 1he sLandards wlll be furLher cusLomlsed
for communlLy-based organlsaLlons by creaLlng core sLandards for leadershlp, medlcaLlon managemenL, and lnfecLlon
prevenLlon and conLrol speclflc Lo communlLy-based organlsaLlons.

keferences:
(1) Craven, C., 8yrne, k., Slms-Could, !., MarLln-MaLLhews, A. (2012). 1ypes and paLLerns of safeLy concerns ln home
care: sLaff perspecLlves. lotetootloool Iootool fot Ooollty lo neoltb cote, 24, 323-331.
(2) Lang, A., Ldwards, n., llelszer, A. (2008). SafeLy ln homecare: A broadened perspecLlve on paLlenL safeLy.
lotetootloool Iootool fot Ooollty lo neoltb cote 20, 130-133.
(3) Sears, n., 8aker, C. 8., 8arnsley, !., ShorLL, S. (2013). 1he lncldence of adverse evenLs among home care
paLlenLs. lotetootloool Iootool fot Ooollty lo neoltb cote, 23, 1: 16-28.
(4) Canadlan Pome Care AssoclaLlon. (2008). Pome Care Lhe nexL LssenLlal Servlce: MeeLlng Lhe needs of an Aglng
opulaLlon.



2418

A NA1ICNWIDL SUkVL CN A1ILN1 SAIL1 CUL1UkL IN IAAN
Masahlro Plrose
1,*
, ?ulchl lmanaka
2
, Paruhlsa lukuda
3
, 1oshlhlro kaneko
4

1
CenLer for LducaLlon on PosplLal Medlclne, Shlmane unlverslLy PosplLal, lzumo,
2
ueparLmenL of PealLhcare Lconomlcs
and CuallLy ManagemenL, kyoLo unlverslLy School of ubllc PealLh, kyoLo,
3
ueparLmenL of 8esearch, lnsLlLuLe for PealLh
Lconomlcs and ollcy, 1okyo,
4
ueparLmenL of aLlenL SafeLy and lnfecLlon ConLrol, Mle unlverslLy PosplLal, 1su, !apan


Cb[ect|ves: 1hls sLudy alms Lo explore safeLy culLure dlmenslons among healLh care professlonals uslng PosplLal Survey
on aLlenL SafeLy CulLure (PSCSC) by developed by AP8C (Agency for PealLhcare 8esearch and CuallLy).

Methods: We surveyed naLlonwlde Lhe slLuaLlon of paLlenL safeLy culLure ln 13 hosplLals (3,760 persons) allowed for
addlLlonal cosLs on paLlenL safeLy counLermeasures under Lhe soclal lnsurance medlcal fee schedule. 1he quesLlonnalre
conslsLs of seven unlL-level aspecLs of safeLy culLure lncludlng 24 lLems, Lhree hosplLal-level lncludlng 11 lLems, and four
ouLcome varlables lncludlng nlne lLems.

kesu|ts: An average number of beds was 360 beds (63 Lo 1,334 beds). WlLh regard Lo ownershlp, 13 hosplLals lncluded
Lhree munlclpallLy and local lncorporaLed agency hosplLals, one publlc hosplLal, Lwo [urldlcal person wlLh soclal
lnsurance hosplLals, slx medlcal corporaLlon hosplLals, and one oLher hosplLal. number of all respondenLs was 3,118
persons (response raLe: 88.9), and lncluded 293 physlclans (90.8), 2,909 nurses (93.3), and 146 pharmaclsLs
(96.7). ln Lerms of 12 dlmenslons, Lhe overall average poslLlve response raLe (88) for Lhe 12 paLlenL safeLy dlmenslons
of Lhe PSCS was 49.2, exLremely lower Lhan Lhe average poslLlve 88 for Lhe AP8C daLa (61). ln Lerms of healLh care
professlonals, Lhe overall average poslLlve 88 for pharmaclsLs (46.2) was lower Lhan LhaL for physlclans and nurses
(49.6 and 49.4). WlLh regard Lo pharmaclsLs, Lhe average poslLlve 88s for elghL dlmenslons of Lhe 12 dlmenslons
were Lhe lowesL among Lhree professlonals, and Lhree average poslLlve 88s were Lhe hlghesL, lrequency of evenL
reporLlng (pharmaclsLs: physlclans: nurses=73.6:33.3:67.9), non-punlLlve response Lo error (48.8:42.6:40.4),
and SLafflng (29.1:27.0:23.4).

Conc|us|on: 1he PSCSC measuremenL provldes Lhe evldence for assessmenL of paLlenL safeLy culLure ln !apan's
hosplLals. 1hls resulL LhaL paLlenL safeLy culLure has been ln a sLaLe of developmenL, compared wlLh Lhe uS hosplLals.

keferences:
1. Sorra !, khanna k, uyer n, Mardon 8, lamolaro 1.: Lxplorlng relaLlonshlps beLween paLlenL safeLy culLure and
paLlenLs' assessmenLs of hosplLal care. ! aLlenL Saf. 2012 Sep,8(3):131-9.
2. Mardon 8L, khanna k, Sorra !, uyer n, lamolaro 1.: Lxplorlng relaLlonshlps beLween paLlenL safeLy culLure and
adverse evenLs. ! aLlenL Saf. 2010 uec,6(4):226-32
3. Sorra !S, uyer n.: MulLllevel psychomeLrlc properLles of Lhe AP8C hosplLal survey on paLlenL safeLy culLure. 8MC
PealLh Serv 8es. 2010 !ul 8,10:19
4. Sorra !, nleva v, lemolaro 1, uyer n.: PosplLal Survey on aLlenL SafeLy CulLure: 2007 ComparaLlve uaLabase 8eporL
AP8C ubllcaLlon no. 07-0023 Aprll, 2007




2420

kLSSUkL ULCLkS AND IN-A1ILN1 IALL kA1LS: kLSUL1S IkCM 2 NA1ICNAL kLVALLNCL MLASUkLMLN1S AND
LIILC1S CI IIkS1 1IML U8LIC DISCLCSUkL MLASUkLS
ChrlsLa vangelooven
1,*
, 8egula Peller
2
, ulrk 8lchLer
1
, Sablne Pahn
1

1
8uslness, PealLh, Soclal Work, 8ern unlverslLy of Applled Sclences,
2
AnC, naLlonal AssoclaLlon for CuallLy uevelopmenL
ln PosplLals and Cllnlcs, 8ern, SwlLzerland


Cb[ect|ves: up unLll 2011, hosplLal performance daLa ln SwlLzerland were scarce. ConLlnuously rlslng healLh care cosLs
and changes ln Lhe Swlss healLh care relmbursemenL (u8C) called for naLlonal performance daLa. 1he naLlonal
AssoclaLlon for CuallLy uevelopmenL ln PosplLals and Cllnlcs (AnC) alms Lo measure, benchmark and publlcly reporL
performance daLa naLlonwlde. 1he naLlonal polnL prevalence measuremenL alms Lo collecL naLlonal daLa regardlng
hosplLal acqulred pressure ulcers (PAu) and ln-paLlenLs falls ln acuLe care hosplLals.

Methods: AnC, an organlsaLlon conslsLlng of all of Lhe lmporLanL sLakeholders ln Lhe Swlss healLh care sysLem,
developed a seL of naLlonal quallLy lndlcaLors for acuLe care seLLlngs wlLhln Lhe framework of a naLlonal quallLy conLracL.
ConsequenLly, Lhe legal foundaLlons regardlng quallLy assurance were reallsed and hosplLals adherlng Lo Lhe conLracL
were obllgaLed Lo parLlclpaLe ln Lhe measuremenLs.

naLlonal polnL prevalence daLa regardlng PAu and ln-paLlenL falls were collecLed ln Lwo subsequenL years. uaLa
collecLlon was coordlnaLed by 8ern unlverslLy of Applled Sclences, PealLh ulvlslon, ln uslng Lhe meLhod lnLernaLlonal
revalence MeasuremenL of Care problems LZ", from MaasLrlchL unlverslLy (neLherlands). 1hls meLhod capLures
ouLcome, sLrucLure and process lndlcaLors regardlng falls and pressure ulcers on lnsLlLuLlonal, ward and paLlenL levels.
uaLa analysls uLlllsed descrlpLlve and hlerarchlcal loglsLlc regresslon analysls (rlsk-ad[usLmenL). An onllne survey
addressed Lo Lhe parLlclpaLlng hosplLal coordlnaLors (who held responslblllLy for daLa collecLlon) was used Lo evaluaLe
Lhe measuremenL and Lo explore Lhe lnLernal use of Lhe daLa.

kesu|ts: ln 2011, 112 hosplLals cooperaLed ln Lhe flrsL naLlonal measuremenL and daLa from 10'608 paLlenLs (response
raLe 68) was obLalned. uescrlpLlve analysls showed a prevalence of PAu degree 2-4 of 2.1. ln-paLlenL fall prevalence
was 4.3. naLlonal rlsk-ad[usLed ouLcome resulLs from boLh lndlcaLors revealed qulLe a homogeneous dlsLrlbuLlon
among hosplLals. AppllcaLlon of prevenLlve and lnLervenLlon sLraLegles revealed more heLerogenelLy among hosplLals. ln
Lhe 2012 measuremenL, around 200 hosplLal slLes dellvered daLa from abouL.13'300 paLlenLs (response raLe 73). 1he
flrsL resulLs wlll be avallable ln Lhe summer of 2013 and wlll be presenLed aL Lhe 2013 lSCua-Conference. ln Lhe
evaluaLlon survey, half of Lhe 2011 coordlnaLors answered quesLlons regardlng lnLernal use of Lhe daLa. PosplLals wlLh
well-esLabllshed quallLy lmprovemenL sysLem appeared Lo focus more on naLlonal benchmarklng Lhan on lnLernal
lmprovemenL sLraLegles.

Conc|us|on: ln comparlson wlLh lnLernaLlonal research, ln 2011 Lhe prevalence of PAu was low and Lhe prevalence of
falls was sllghLly hlgher. 1he prevalence raLes provlde lmporLanL healLh care quallLy lnformaLlon as Lhe now aggregaLed
naLlonal daLa on Lwo (nurslng senslLlve) lndlcaLors and for Lwo measuremenLs, 2011, 2012) are avallable. 1hls ls a blg
sLep forward ln Lhe dlrecLlon of Lhe naLlonal monlLorlng of care quallLy. Lspeclally ln order Lo prevenL PAu and ln-
paLlenL falls and Lo monlLor adequaLe lnLervenLlon and quallLy lmprovemenL sLraLegles Lhls daLa may be useful aL Lhe
lnsLlLuLlonal level. ubllc dlsclosure of Lhe flrsL year measuremenL daLa ls scheduled for March 2013. 1hls wlll enable
users (paLlenLs) Lo galn lnslghL lnLo hosplLal performance. 8esulLs from Lhe evaluaLlon survey wlll reveal Lhe flrsL lmpacL
and effecLs of Lhe lnLroducLlon of naLlonal hosplLal performance measures and publlc dlsclosure.



2422

CCMLNSA1ICN CI CnILI LkLCU1IVL CIIICLkS A1 NCN-kCII1 U.S. nCSI1ALS: IMLICA1ICNS ICk IMkCVING
UALI1 CI CAkL
karen L. !oynL
1,*
, Sldney 1. Le
1
, L. !ohn Crav
2
, Ashlsh k. !ha
1

1
PealLh ollcy and ManagemenL,
2
8losLaLlsLlcs, Parvard School of ubllc PealLh, 8osLon, unlLed SLaLes


Cb[ect|ves: Whlle hosplLal Chlef LxecuLlve Cfflcers (CLCs) can shape Lhe prlorlLles and performance of Lhelr
organlsaLlons and have Lhe poLenLlal Lo profoundly affecL Lhe quallLy of care dellvered, Lhe degree Lo whlch CLC
compensaLlon ls based on hosplLal quallLy ls noL well known. We soughL Lo deLermlne Lhe varlaLlon ln pay among CLCs
of non-proflL u.S. hosplLals, and Lo ascerLaln wheLher a hosplLal's sLrucLural characLerlsLlcs, flnanclal performance,
Lechnologlcal capablllLles, measured quallLy, or meLrlcs of communlLy beneflL are assoclaLed wlLh Lhe flnanclal
compensaLlon of lLs CLC.

Methods: We used Medlcare lnpaLlenL daLa and Lhe Medlcare cosL reporLs from 2008 Lo obLaln daLa regardlng hosplLals'
flnanclal performance (Medlcare marglns), Lechnologlcal capablllLles (as measured by an lndex of advanced Lechnologles
avallable aL each hosplLal), measured quallLy (paLlenL saLlsfacLlon and performance on Lhe PosplLal Compare quallLy
measures for acuLe myocardlal lnfarcLlon, congesLlve hearL fallure, and pneumonla), and communlLy beneflL (hosplLal-
reporLed charlLy care provlded). We used federal 990 Lax forms, complled by CuldesLar, Lo bulld a daLabase of
compensaLlon of hosplLal and hosplLal sysLem CLCs ln 2009. We used regresslon models Lo deLermlne wheLher Lhere
were assoclaLlons beLween measures of hosplLal performance ln 2008 and CLC compensaLlon ln 2009.

kesu|ts: We ldenLlfled 1,833 execuLlves responslble for 2,671 hosplLals. 1he CLCs ln our sample had a medlan
compensaLlon of $403,768. CLCs overseelng a hlgher number of hosplLal beds, Lhose LhaL were assoclaLed wlLh
Leachlng hosplLals, and Lhose ln an urban locaLlon were compensaLed more hlghly. ConLrolllng for Lhese sLrucLural
facLors, we found LhaL CLC compensaLlon was noL assoclaLed wlLh hosplLal flnanclal performance ($7,708 of addlLlonal
pay aL hosplLals aL Lhe 73
Lh
versus Lhe 23
Lh
percenLlle of operaLlng marglns, p=0.33), Lhough CLC compensaLlon was
sLrongly assoclaLed wlLh Lechnology: hosplLals aL Lhe 73
Lh
percenLlle on Lechnologlcal capablllLles compensaLed Lhelr
CLCs $134,623 more Lhan hosplLals aL Lhe 23
Lh
percenLlle on Lhe lndex (p<0.001). aLlenL saLlsfacLlon was also
assoclaLed wlLh CLC pay, wlLh $31,160 of addlLlonal pay for Lhe 73
Lh
percenLlle of performance compared wlLh Lhe 23
Lh

percenLlle (p=0.007). Powever, we found no assoclaLlon beLween a hosplLal's PosplLal Compare quallLy measures and
CLC pay ($7,389 of addlLlonal pay aL hosplLals aL Lhe 73
Lh
percenLlle versus Lhe 23
Lh
percenLlle, p=0.36). Slmllarly, Lhere
was no relaLlonshlp beLween charlLy care provlded and CLC compensaLlon ($0 of addlLlonal pay aL hosplLals aL Lhe 73
Lh

percenLlle versus Lhe 23
Lh
percenLlle, p=0.88).

Conc|us|on: CLC compensaLlon aL non-proflL hosplLals varles wldely and ls assoclaLed wlLh greaLer use of Lechnology and
hlgher paLlenL saLlsfacLlon, raLher Lhan wlLh process quallLy, paLlenL ouLcomes, or communlLy beneflL. Clven LhaL
compensaLlon meLrlcs can have a profound lmpacL on behavlour, our flndlngs may polnL Lo an lmporLanL opporLunlLy Lo
lmprove care and enhance hosplLals' focus on communlLy beneflL by Lylng CLC compensaLlon Lo Lhose meLrlcs.




2424

1nL kILL LIILC1: DIIIUSING nLAL1n CLIC 1nkCUGn 1nL USL CI ICCNS
MargareL 8anks
1,*
, uavld Creenfleld
2
, uebora lcone
1
, !effery 8ralLhwalLe
2

1
AusLrallan Commlsslon on SafeLy and CuallLy ln PealLh Care,
2
CenLre for Cllnlcal Covernance 8esearch, AusLrallan
lnsLlLuLe of PealLh lnnovaLlon, unlverslLy of new SouLh Wales, Sydney, AusLralla


Cb[ect|ves: 1he effecLlve dlffuslon of healLh pollcy ls a ma[or challenge LhaL conLlnues Lo perplex governmenLs globally.
lor all Lhe resources, Llme and efforL commlLLed Lo Lhe developmenL of pollcy, a key quesLlon ls: how, and Lo whaL
exLenL, does healLhcare pollcy drlve change? 1hls sLudy almed Lo Lrack Lhe dlffuslon of a naLlonal healLhcare pollcy, Lhe
naLlonal SafeLy and CuallLy PealLh Servlce (nSCPS) SLandards, across and wlLhln Lhe AusLrallan healLhcare sysLem.

Methods: 1he nSCPS SLandards, developed by 1he AusLrallan Commlsslon on SafeLy and CuallLy ln PealLh Care (Lhe
Commlsslon), were deslgned wlLh lcons Lo ldenLlfy and brand each sLandard lndlvldually, and as a seL. 1he Commlsslon
esLabllshed a web-based approval process for organlsaLlons Lo uLlllse Lhe lcons. AppllcanLs are requlred Lo provlde
deLalls lnLo a daLabase regardlng Lhelr organlsaLlon and proposed use of Lhe lcons. 1he daLabase was lnLerrogaLed Lo
ldenLlfy geographlc locaLlon and Lype of appllcanL, and organlsaLlonal deparLmenL and purpose of lcon use.

kesu|ts: 8eLween !une 2012 and lebruary 2013, 168 appllcaLlons had been recelved. CrganlsaLlons from all SLaLes and
1errlLorles across AusLralla have adopLed Lhe use of Lhe lcons. CrganlsaLlons from Lhe four mosL populous SLaLes
accounLed for 90 of Lhe lcon use. 1he Lypes of organlsaLlons uslng Lhe lcons lncluded: publlc hosplLals, prlvaLe hosplLals
and day procedure cenLres, peak bodles and assoclaLlons, SLaLe healLh deparLmenLs, communlLy healLh servlces,
accredlLaLlon agencles, aged care servlces, and publlshlng companles. A dlverse range of organlsaLlonal deparLmenLs or
servlces have adopLed Lhe lcons, lncludlng: pollcy unlLs, educaLlon and Lralnlng deparLmenLs, quallLy and safeLy unlLs,
cllnlcal deparLmenLs, servlces and wards, and promoLlonal deparLmenLs. 1he lcons are embedded lnLo a varleLy of
maLerlals. CrganlsaLlons are uslng Lhem ln documenLs (for example, sLraLeglc and operaLlonal plans, reporLs, LoolklLs,
commlLLee Lerms of reference, and meeLlng mlnuLes), sLaff maLerlals (for example, posLers, newsleLLers, lnLraneL
homepage, memos, and emall fooLers) and educaLlon and Lralnlng resources, and paLlenL care resources (for example,
badges, L-shlrLs, and magneLs). lcons are also lmplanLed lnLo SLaLe and reglonal pollcy and procedure documenLs. 1he
lcons are belng used for brandlng or promoLlon of Lhe sLandards and as vlsual remlnder Lo sLaff of quallLy and safeLy
responslblllLles Lo paLlenLs.

Conc|us|on: 1he answer Lo our quesLlon - does healLhcare pollcy drlve change? - ls afflrmaLlve. We have evldence LhaL
Lhe nSCPS SLandards are becomlng lncreaslngly embedded across and lnLo Lhe AusLrallan healLhcare sysLem. 1he deslgn
of Lhe nSCPS SLandards wlLh accompanylng lcons has been a novel sLraLegy by whlch Lhe lnfuslon and spread of Lhe
lmpacL of Lhe sLandards can be monlLored and Lracked. 1he lcons are belng used as a vlsual sLlmulus slgnlfylng Lhe
quallLy and safeLy prlorlLles for healLhcare professlonals, Lhe rlpples of change conLlnue Lo permeaLe Lhrough Lhe healLh
sysLem vla a Langlble vlsual phenomenon.



2431

ASSCCIA1ICNS 8L1WLLN nSICAL kLS1kAIN1 AND IkAGILI1 CI 1nL LLDLkL A1ILN1S AI1Lk nCSI1ALISA1ICN
kanako Shlmmorl
1,*
, Sel[l 8lLo
1

1
Ceneral lnLernal medlclne, 1okyo Medlcal CenLer, 1okyo, !apan


Cb[ect|ves: PosplLallsed elderly paLlenLs ofLen suffer from harmful evenLs such as fall, decllne of acLlvlLles of dally llvlng
(AuL) and decllne of eaLlng funcLlons. Several cllnlcal lnLervenLlons may affecL Lhe decllne of funcLlonal and nuLrlLlonal
sLaLus of Lhe elderly paLlenLs. Cur alm ls Lo lnvesLlgaLe Lhe assoclaLlons beLween physlcal resLralnL and Lhe decllne of
funcLlonal and nuLrlLlonal sLaLus of Lhe elderly paLlenLs.

Methods: We examlned secondary daLa analysls uslng daLaseL exLracLed from elecLronlc medlcal record daLabase
LargeLlng Lhe elderly paLlenLs admlLLed from Aprll 1, 2011 Lo March 31, 2012. We ruled ouL sLroke paLlenLs and Lhose
who sLayed less Lhan 7 days or sLayed 43 days or more. uependenL varlables were lf Lhe paLlenL had had low funcLlonal
sLaLus and lf Lhe paLlenL's serum albumln level was below 3.0mg/dl on dlscharge. We used 12-polnL scale whlch
measured Lhe amounL of physlcal and nurslng supporL Lo [udge lf Lhe paLlenL had low funcLlonal sLaLus. We lndlcaLed
LhaL Lhe paLlenL had low funcLlonal sLaLus when Lhls score was 3 polnL or more. An lndependenL varlable was lf Lhe
paLlenLs goL any physlcal resLraln durlng hosplLallsaLlon. Age, sex, funcLlonal sLaLus on admlsslon and serum albumln
level on admlsslon, were lndlcaLed as ad[usLmenL varlables.

kesu|ts: Slx hundred slxLy-one lnpaLlenLs were ellglble for Lhe analysls. LoglsLlc regresslon analysls showed Lhere was a
slgnlflcanL dlfference beLween physlcal resLralnL and low funcLlonal sLaLus on dlscharge (Cdds raLlo 2.4 93Cl 1.4-4.1)
when ad[usLed wlLh paLlenLs case mlx varlables. 1here was also a slgnlflcanL dlfference beLween physlcal resLralnL and
low serum albumln level on dlscharge (Cdds raLlo 2.0 93Cl 1.1-3.4). lf Lhe elderly paLlenLs had had physlcal resLraln
showed sLronger assoclaLlons wlLh dependenL varlables Lhan lengLh of resLraln days.

Conc|us|on: Cur sLudy suggesLed adverse effecL of physlcal resLralnL on Lhe decllne of nuLrlLlonal sLaLus and AuL of Lhe
elderly lnpaLlenLs. hyslcal resLralnL may Lo be harmful Lo keep funcLlonal and nuLrlLlonal sLaLus of Lhe hosplLallsed
elderly paLlenLs.



2433

nAkNLSSING IMLLMLN1A1ICN SCILNCL 1C IMkCVL CAkL UALI1 AND A1ILN1 SAIL1
!effrey 8ralLhwalLe
1,*
, uanlelle Marks
1
, naLalle 1aylor
2

1
AusLrallan lnsLlLuLe of PealLh lnnovaLlon, unlverslLy of new SouLh Wales, Sydney, AusLralla,
2
8radford lnsLlLuLe for
PealLh 8esearch, 8radford, unlLed klngdom


Cb[ect|ves: CeLLlng greaLer levels of evldence lnLo pracLlce ls a key problem for healLh sysLems. lL ls compounded by Lhe
volume of research produced. 1here are 73 randomlsed Lrlals and 11 sysLemaLlc revlews publlshed every day.
lmplemenLaLlon sclence ls an emerglng fleld dedlcaLed Lo lmprovlng Lake-up and adopLlon of research evldence. 1he
llLeraLure has noL been synLheslsed recenLly. We wanLed Lo answer a quesLlon. WhaL does Lhe lmplemenLaLlon sclence
llLeraLure have Lo say abouL lmprovlng quallLy of care and maklng care safer for paLlenLs?

Methods: We conducLed a LargeLed search of key [ournals Lo examlne lmplemenLaLlon sclence ln Lhe quallLy and safeLy
domaln. Cf Lhe 461 references reLrleved, 32 were consldered relevanL followlng Lhe appllcaLlon of excluslon crlLerla.
non-research arLlcles, research ln developlng counLrles, arLlcles evaluaLlng Lhe effecLlveness of Lools, meLhods and
lnLervenLlons, and Lhose wlLhouL a focus on lmplemenLaLlon were excluded. 1he lncluded arLlcles were sub[ecLed Lo a
Lwo-parL conLenL analysls. llrsLly four revlewers exLracLed and documenLed Lhe key characLerlsLlcs of Lhe papers.
lollowlng Lhls an auLomaLed daLa mlnlng sofLware program ldenLlfled Lhe Lhemes and concepLs ln Lhe full LexLs.

kesu|ts: 1he llLeraLure lndlcaLes LhaL lmplemenLaLlon sclence conslsLs of Lhree componenLs: upLake (Lhe exLenL Lo whlch
evldence geLs lnLo pracLlce), spread (Lhe way besL pracLlces dlffuse across healLh sysLems), and Llme (Lhe duraLlon for
Lake-up and spread Lo achleve ouLcomes). LlghL success facLors of lmplemenLaLlon emerged: preparlng for change,
capaclLy for lmplemenLaLlon - people, capaclLy for lmplemenLaLlon - seLLlng, Lypes of lmplemenLaLlon, resources,
leverage, deslrable lmplemenLaLlon enabllng feaLures, and susLalnablllLy. CbsLacles ln lmplemenLaLlon are Lhe mlrror
lmage of Lhese: for example when people fall Lo prepare, have lnsufflclenL capaclLy for lmplemenLaLlon or when Lhe
seLLlng ls reslsLanL Lo change, Lhen quallLy of care ls aL rlsk, and paLlenL safeLy can be compromlsed.

Conc|us|on: 1hls revlew of key sLudles ln Lhe quallLy and safeLy llLeraLure dlscusses Lhe currenL sLaLe-of-play of
lmplemenLaLlon sclence. lL ldenLlfles Lhe faclllLaLors and barrlers of lmplemenLaLlon. lmplemenLaLlon occurs wlLhln
complex adapLlve sysLems sLrlvlng Lo dellver hlgh quallLy, safe care. 1hls sLudy provldes a foundaLlon on whlch fuLure
lmplemenLaLlon success can be achleved and barrlers overcome.



2437

A NLW IkAMLWCkk ICk LVALUA1ING CCNSUMLk AND CCMMUNI1 LNGAGLMLN1 IN nLAL1n CAkL SS1LMS:
kLSUL1S CI A ML1A-kLVILW
oorla Sarraml loroushanl
1
, !oanne 1ravaglla
2
, ueborah uebono
1
, !effrey 8ralLhwalLe
1,*

1
AusLrallan lnsLlLuLe of PealLh lnnovaLlon,
2
Lhe unlverslLy of new SouLh Wales, S?unL?, AusLralla


Cb[ect|ves: uesplLe an lncreaslng lnLernaLlonal supporL for consumer and communlLy engagemenL (CCL), Lhere ls yeL no
clear consensus on Lhe besL meLhod for evaluaLlng CCL ln healLh care sysLems. 1he alm of Lhls meLa-revlew ls Lo develop
a framework for evaluaLlng CCL ln healLh care sysLems.

Methods: uslng a LoLal of 47 phrases and 11 MeSP Lerms, a comprehenslve search of slx daLabases was underLaken
(ubMed, Lmbase, L8M revlews, ClnAPL, AA sycnL1, and Scopus). no Llme or geographlc llmlLs were placed on Lhe
searches. SLudles were excluded lf Lhey were noL sysLemaLlc revlews, dld noL focus on evaluaLlon and measuremenL of
CCL ln healLh care sysLems, or were noL avallable ln Lngllsh.

kesu|ts: 1hree sysLemaLlc revlews were ldenLlfled LhaL meL Lhe lncluslon crlLerla. 1hey lncorporaLed evaluaLlon meLhods
for CCL ln healLh care sysLems, uLlllslng evaluaLlon frameworks, and measuremenL lndlcaLors and meLhods. 1he beneflLs
and challenges of ldenLlfled evaluaLlon meLhods are dlscussed. 1he flndlngs of Lhese revlews lnform Lhe developmenL of
a new evaluaLlon framework, whlch lncorporaLes four areas for evaluaLlon: plannlng, process, ouLcome, and lmpacL, and
suggesLs evaluaLlon meLhods for each area.

Conc|us|on: 1he new framework wlll enhance pracLlcal appllcaLlon of meLhods for evaluaLlng CCL ln healLh care sysLems,
cruclal Lo Lhe success of CCL lnlLlaLlves. Areas for furLher work are ldenLlfled.



2438

kLDUCING ALL CAUSL kL-ADMISSICN kA1LS ICk A nCSI1AL SS1LM: 1nL MLDS1Ak LkLkILNCL
8ohlL CulaLl
1,*
, kaLhryn Walker
1
, kaLhy 1alboL
2
, Amy 1aylor
2

1
ueparLmenL of Medlclne, MedSLar unlon Memorlal PosplLal,
2
MedSLar PealLh, 8alLlmore, unlLed SLaLes


Cb[ect|ves:
1. 1o develop effecLlve sLraLegles Lo decrease readmlsslons ln MedSLar hosplLals.
2. 1o demonsLraLe effecLlveness of sLraLegles Lo decrease readmlsslons ln MedSLar hosplLals.

Methods: MedSLar creaLed a sysLem wlde lnlLlaLlve Lo sLandardlse readmlsslon reducLlon efforLs. ln May 2012, a 10
polnL plan was sLandardlsed and lmplemenLed across Lhe enLlre sysLem Lo LargeL hlgh rlsk paLlenLs. 1hls 10 polnL plan
conslsLed of Lhe followlng for LargeLed paLlenLs:

1. ulscharge medlcaLlon reconclllaLlon prlor Lo dlscharge. MedlcaLlon reflll lssues would be also addressed before Lhe
paLlenL lefL Lhe hosplLal.
2. 1argeLed CPl paLlenLs would be glven scales and LaughL how Lo use Lhese and who Lo call ln case Lhere was ma[or
welghL flucLuaLlon.
3. ulscharge summarles would be faxed Lo C's for follow up wlLhln 48 hours of dlscharge.
4. An appolnLmenL wlLh a C wlLhln 3 days of dlscharge.
3. 1ranslLlonal care cllnlcs would be creaLed for paLlenLs wlLhouL a C or unable Lo see one wlLhln 3 days.
6. When dlscharged home, home healLh nurses wlll follow up wlLhln 48 hours.
7. All enLlLles would meeL wlLh local nurslng homes Lo lmprove handoff and collaboraLlon of care.
8. 1elephone follow up wlLhln 48 hours of dlscharge.
9. MonLhly reporLs were Lo be generaLed Lo each hosplLal.
10. Lach MedSLar PosplLal would have a slLe speclflc readmlsslons leadershlp Leam whlch would meeL monLhly Lo
dlscuss progress ln readmlsslon reducLlon.

ln addlLlon Lo Lhls 10 polnL plan, a sLraLeglc lnlLlaLlve Lo expand palllaLlve care servlces across Lhe hosplLal sysLem was
lmplemenLed. 8eadmlsslon raLes wlll be compared for serlously lll paLlenLs ln Lhe lnLenslve care unlL of Lhe plloL hosplLal
wlLh and wlLhouL palllaLlve consulLaLlon.

kesu|ts: 8esulLs wlll be fully ready by Lhe conference. rellmlnary daLa ls promlslng.

Conc|us|on: 1he sLraLegles lmplemenLed by MedSLar hosplLals have been effecLlve ln reduclng all cause readmlsslons
and lmprovlng quallLy of care wlLhln our large hosplLal sysLem.


24S1

IMLLMLN1A1ICN CI A MUL1IDISCILINAk INA1ILN1 DIA8L1LS 1LAM IS ASSCCIA1LD WI1n CCS1 SAVINGS AND DLCkLASLD
nCSI1AL kL-ADMISSICNS
1racy 8reen
1,*
, Ayson Myers
1
, Andrea 8esLlfo
2
, vlckl Loachln
2

1
uepL of Medlclne, PofsLra norLh Shore Ll! School of Medlclne,
2
AdmlnlsLraLlon, norLh Shore unlverslLy PosplLal, ManhasseL, unlLed
SLaLes


Cb[ect|ves:
1. Lo undersLand how a co-dlagnosls of dlabeLes negaLlvely lmpacLs hosplLal course and safe dlscharge
2. Lo descrlbe how a mulLldlsclpllnary dlabeLes Leam can lmprove boLh paLlenL care as well as paLlenL and sLaff educaLlon
3. Lo ldenLlfy Lhe key groups wlLhln a hosplLal LhaL need Lo be moblllsed Lo effecL broad changes ln cllnlcal pracLlce and
organlsaLlonal culLure

Methods: As Lhe epldemlc of dlabeLes conLlnues Lo grow, lncreaslng numbers of paLlenLs wlLh dlabeLes (uM) are belng admlLLed Lo
hosplLals. lL ls known LhaL uM as a coexlsLlng condlLlon can lncrease Lhe lengLh of sLay and readmlsslon raLes across many dlagnosls-
relaLed groups (u8C's). aLlenLs wlLh uM who are admlLLed for oLher condlLlons may be aL rlsk from boLh hyper and
hypoglycaemla. oorly conLrolled uM durlng hosplLallsaLlon affecLs wound heallng and lnfecLlon raLes. lnpaLlenL hypoglycaemla ls
assoclaLed wlLh lncreased morbldlLy and longer hosplLal sLays. A dedlcaLed lnpaLlenL ulabeLes 1eam was creaLed aL a large LerLlary
care Leachlng hosplLal Lo help address Lhese lssues. 1he Leam conslsLed of a full-Llme hosplLal-based endocrlnologlsL, nurse
pracLlLloner and cerLlfled dlabeLes nurse educaLor. 1he Leam provlded medlcal consulLaLlon as well as paLlenL and sLaff
educaLlon. 1he ulabeLes 1eam members served as Lhe champlons for an lnLerdlsclpllnary ulabeLes 1ask lorce whlch lncluded
nurslng, hosplLallsLs, medlcal lnformaLlcs, quallLy, pharmacy, dleLary servlces, admlnlsLraLlon, case managemenL and soclal work. 1he
ulabeLes 1ask lorce meL monLhly Lo revlew unlL-based daLa on paLlenL safeLy as well as unlL-based reporLs of documenLed uM
educaLlon. 8ecommendaLlons by Lhe ulabeLes 1ask lorce led Lo slgnlflcanL changes belng made Lo Lhe compuLerlsed physlclan
order enLry (CCL) sysLem Lo promoLe safe and effecLlve lnsulln use. ulscharge processes were examlned and ad[usLed Lo promoLe
safer dlscharges of lnpaLlenLs wlLh uM. An lnLenslve sLaff educaLlon pro[ecL on Lhe lmpacL of uM ln Lhe hosplLal was underLaken
whlch lncluded:

a) formal grand round presenLaLlons Lo boLh physlclan and nurslng sLaff,
b) LargeLed ln-servlces Lo resldenL physlclans, pharmaclsLs, mld-level provlders and admlnlsLraLlve sLaff, and
c) Lhe developmenL of evldence-based declslon-supporL Lools LhaL were wldely dlsLrlbuLed Lo cllnlclans LhroughouL Lhe
hosplLal. 1he ulabeLes 1eam meL bl-weekly wlLh quallLy Lo revlew admlnlsLraLlve daLa, assess Lhe lmpacL of varlous uM
lnlLlaLlves and ldenLlfy new opporLunlLles for lmprovemenL.

kesu|ts: lor lnpaLlenLs wlLh elLher a prlmary or secondary dlagnosls of dlabeLes, we saw a reducLlon ln Lhe followlng measures from
l? 2011 (n = 9791 cases) vs. l? 2012-nov 2012 (n = 8718 cases):

! Average lengLh of sLay j from 6.60 Lo 6.44 days
! Lxcess days per case j from 1.26 Lo 1.17 days
! 30 day readmlsslon raLe j from 16.8 Lo 13.3

lor paLlenLs wlLh a prlmary dlagnosls of uM (l? 2011 n = 331 cases, l?2012-nov n = 313 cases, Lhe effecLs were even more
pronounced:

! Average lengLh of sLay j from 7.33 Lo 6.93 days
! Lxcess days per case j from 2.13 Lo 1.30 days
! 30 day readmlsslon raLe j from 18.8 Lo 16.1

Conc|us|on: A mulLldlsclpllnary lnpaLlenL ulabeLes 1eam, focused noL only on dlrecL paLlenL care buL also on sLaff educaLlon,
lmproved processes and paLlenL safeLy, can have a slgnlflcanL lmpacL on hosplLal cosL and uLlllsaLlon. AcLlve engagemenL of
lnLerdlsclpllnary sLaff, ln addlLlon Lo supporL from hosplLal leadershlp, has been cruclal Lo Lhe success of Lhls Leam's efforLs.




24S3

INIUSING 1nL kAC1ICL CI WCkkING CCLLA8CkA1IVLL IN 1LACnING nCSI1ALS: LASILk SAID 1nAN DCNL
!acquellne Mllne
1,*
, uavld Creenfleld
1
, !effrey 8ralLhwalLe
1

1
CenLre for Cllnlcal Covernance 8esearch, AusLrallan lnsLlLuLe of PealLh lnnovaLlon, unlverslLy of new SouLh Wales,
Sydney, AusLralla


Cb[ect|ves: 1he beneflLs of lnLerprofesslonal pracLlce (l) are wldely exLolled buL noL always easy Lo reallse ln Lhe
complex cllnlcal-organlsaLlonal envlronmenL of hosplLals. 1hls sLudy almed Lo explore facLors lnhlblLlng docLors' ablllLy Lo
parLlclpaLe ln collaboraLlve lnLerprofesslonal pracLlce (l) for lmprovlng paLlenL safeLy.

Methods: A framework was developed from Lhe llLeraLure Lo gaLher daLa from ln-depLh lnLervlews and eLhnographlc
observaLlons. lour flelds wlLhln Lhe framework were lnvesLlgaLed: culLure, communlcaLlon, collaboraLlon and
compeLency. 1hlrLy Lwo [unlor docLors from Lhree large AusLrallan Leachlng hosplLals parLlclpaLed ln Lhe sLudy. 1he
docLors were aL dlfferenL sLages of Lhelr posLgraduaLe Lralnlng. 1hey comprlsed a mlx of AusLrallan and lnLernaLlonal
medlcal graduaLes. A LhemaLlc analysls was applled Lo Lhe daLa agalnsL Lhe flelds lnvesLlgaLed.

kesu|ts: ulverslLy ln Lhe medlcal Lralnlng and Lhe naLlonal and eLhnlc culLures of parLlclpanLs revealed dlfferences ln
docLors' undersLandlng of Lhe connecLlons beLween l and paLlenL safeLy. MosL docLors were noL averse Lo Lhe concepL
of collaboraLlvely worklng wlLh nurses and oLher healLh professlonals. Powever, Lhelr communlcaLlon wlLh Lhem was
hlndered by Lhe sllos of professlonal culLures. 1hls resulLs ln lssues of dlsrespecL Lhrough docLors' poor undersLandlng
and appreclaLlon of Lhe roles and experLlse of oLher non-medlcal healLh professlonals. 1hls was especlally evldenL ln Lhe
lnLernaLlonal graduaLes. 1hese lssues have Lhe poLenLlal Lo dlrecLly lmpacL Lhe exLenL Lo whlch an envlronmenL of
collaboraLlon can be effecLed Lo offer a safer paLlenL [ourney. 8elaLed problems assoclaLed wlLh communlcaLlon
lncluded a Lendency for docLors noL Lo read nurse's noLes for ward rounds Lo be conducLed Lyplcally wlLh docLors only.
!unlor docLors have Lhe responslblllLy of conveylng paLlenL LreaLmenL orders Lo senlor nurses leavlng open Lhe posslblllLy
of error ln Lhe Lransmlsslon of lnformaLlon. CommunlcaLlon lnLra-professlonally was shown Lo be problemaLlcal. Many
[unlor docLors lack confldence ln communlcaLlng wlLh senlor cllnlclans. 1here ls a relucLance Lo ask quesLlons of
clarlflcaLlon abouL cllnlcal maLLers. 1hls LranslaLes Lo lnadequaLe supporL and mlssed opporLunlLles for learnlng. 1he
consequences of Lhe lssues ldenLlfled are lmporLanL Lo conslder ln Lhe conLexL of compeLency, safeLy and rlsk
managemenL. 1he mulLlpllclLy of Lasks compleLed dally by [unlor docLors removes Lhem from Lhe wards and Lhelr
paLlenLs. 1hey are sub[ecLed Lo Lhe pressures of Llme and compeLlng demands llmlLlng opporLunlLles for lnLeracLlng wlLh
nurses and oLher healLh professlonals lnvolved ln Lhe LreaLmenL and care of paLlenLs.

Conc|us|on: 1he barrlers Lo docLors worklng lnLer-professlonally are manlfesL ln Lhe research flndlngs. 1o address Lhe
barrlers and make progress wlLh Lhe upLake of l for lmprovlng safeLy requlres collecLlve commlLmenL Lo Lhe pervaslon
of lLs prlnclples aL Lhe governance level ln Leachlng hosplLals. lmproved communlcaLlon beLween [unlor and senlor
docLors ls a prerequlslLe for safer care and opLlmlsed learnlng opporLunlLles. CreaLer undersLandlng of Lhe speclallsed
experLlse of oLher healLh professlonals lnvolved ln paLlenL care ls a furLher facLor ln sLrengLhenlng Lhe muLual respecL
requlred for successful enacLmenL of more effecLlve, collaboraLlvely-orlenLed, paLlenL care.




24S7

kLDUCING IALL INCIDLNCL kA1L AND INIUk IN nLMA1CLCG AND CNCCLCG WAkDS
Pslu-Wen ?eh
1,*
, Chla-len Psleh
2
, Pslu-!u !en
2
, Llng-Pua Psu
2

1
lar LasLern Memorlal PosplLal, 2 lar LasLern Memorlal PosplLal, 1alpel, 1alwan.


Cb[ect|ves: lalllng ls Lhe mosL common cause of accldenLs ln haemaLology and oncology wards, Lhls may lead Lo adverse
ouLcomes such as ln[urles, prolonged hosplLallsaLlon, and lncreased medlcal expenses and healLhcare lnsurance cosLs.
1he lncldence of paLlenL falls was 0.13 and Lhe fall-lnduced ln[urles raLe were 39 ln 2011, hlgher Lhan 0.11 and 27
ln 2010 ln haemaLology and oncology wards. Cne of Lhe accldenLs lnduced lnLra-cerebral haemorrhage ln 2010 and one
case of bone meLasLasls underwenL an operaLlon for Llbla fracLure ln 2011. Cf Lhese paLlenLs, 27.69 were noL classlfled
as aL hlgh rlsk of falllng before Lhelr falls. 1here were 37.62 of Lhe hlgh rlsk paLlenLs lnslsLed on geLLlng ouL of bed
wlLhouL any help. 1he maln ob[ecLlve of Lhls pro[ecL was Lo reduce fall lncldence raLe and ln[ury ln haemaLology and
oncology wards.

Methods: 1o beLLer ldenLlfy paLlenLs wlLh a hlgh rlsk of falllng ln hosplLals and Lo promoLe Lhe use of effecLlve Lools Lo
enhance Lhe awareness of falllng among Lhose aL rlsk, a plcLorlal form of Lhe LvaluaLlon 1able of 8lsk lacLors 8esulLlng ln
lalllng lncldenLs was made. aLlenLs and famlly members were lnvlLed Lo parLlclpaLe ln ldenLlfylng rlsk facLors, wlLh Lhe
ldenLlflcaLlon process for hlgh-rlsk paLlenLs belng conducLed on lrldays and when Lhere was a change of paLlenLs'
consclousness. ln addlLlon, Lhe wards houslng hlgh-rlsk paLlenLs were glven warnlng slgns sLaLlng waLch your sLep wlLh
relevanL lmages. LducaLlon sesslons were conducLed for paLlenLs and Lhelr famllles on how Lo prevenL falllng accldenLs,
and Lhe sLandard procedure for prevenLlng falllng accldenLs was puL lnLo effecL.

kesu|ts: 1he resulLs showed LhaL Lhe lncldences of falllng and fall-lnduced ln[urles decreased Lo 0.14 and 38.89 ln
2012, respecLlvely, wlLh no severe ln[urles. 1he percenLage of fall paLlenLs classlfled under Lhe non-hlgh-rlsk group fell Lo
11. 1he proporLlon of hlgh rlsk paLlenLs who lnslsLed on geLLlng ouL of bed wlLhouL any help was down Lo 32.00.

Conc|us|on: revenLlon of falllng ls an lmporLanL Loplc ln a haemaLology and oncology wards whlch requlres Lhe
collaboraLlve efforLs of Lhe medlcal Leam, paLlenLs, and famlly members. lL ls noL easy Lo avold all falls, buL early
ldenLlflcaLlon of rlsky paLlenLs Lhrough effecLlve evaluaLlon and encouraglng paLlenLs and Lhelr famlly members Lo
parLlclpaLe ln prevenLlon-relaLed acLlvlLles could effecLlvely reduce Lhe lncldence of falllng and Lhe resulLlng severlLy of
ln[urles, Lherefore enhanclng Lhe safeLy of paLlenLs.

keferences:
kaLhleen, l., 1lna ., &PeaLher l., (2013). uevelopmenL and lmplemenLaLlon of Lhe Memorlal Lmergency ueparLmenL
lall 8lsk AssessmenL 1ool. Advanced Lmergency nurslng !ournal 33(1), 3766.Craham, 8rldgeL C. (2012). Lxamlnlng
Lvldence-8ased lnLervenLlons Lo revenL lnpaLlenL lalls. MLuSu8C nurslng 21(3), 267270.Lek, S., Coh, M.L. 8ahlma,
(2012). AdulL lnpaLlenLs havlng lmproved fall prevenLlon awareness durlng Lhelr hosplLallsaLlon. MLuSu8C nurslng
10(3),274.




24S8

A NLW AkCACn 1C ANALSING ACCkLDI1A1ICN DA1A 1C S1IMULA1L CkGANISA1ICNAL LkICkMANCL IMkCVLMLN1
Max Moldovan
1
, uavld Creenfleld
1,*
, SLephen Clark
2
, !effrey 8ralLhwalLe
1

1
AusLrallan lnsLlLuLe of PealLh lnnovaLlon, unlverslLy of new SouLh Wales, Sydney,
2
AusLrallan Ceneral racLlce AccredlLaLlon
LLd/CuallLy racLlce Ly LLd (ACAL), 8rlsbane, AusLralla


Cb[ect|ves: lnformaLlon rouLlnely collecLed by healLhcare accredlLaLlon agencles as a resulL of accredlLaLlon surveys ls underuLlllsed,
parLly due Lo Lhe lack of approprlaLe analyLlcal procedures. We lnLroduce and lllusLraLe a novel general meLhod for measurlng and
evaluaLlng performance of healLh care organlsaLlons (PCCs) as reflecLed by accredlLaLlon survey ouLcomes.

Methods: We conslder a seL of ouLcomes obLalned Lhrough accredlLaLlon survey vlslLs as lnformaLlve markers characLerlslng Lhe
sLaLe of dlfferenL areas wlLhln an PCC. uslng a sequence of regresslon models, Lhese markers are furLher relaLed Lo measurable
facLors LhaL are noL accounLed for by accredlLaLlon vlslLs, buL relevanL for measurlng and evaluaLlng PCC performance. 1he meLhod
ls lllusLraLed uslng accredlLaLlon ouLcomes awarded by Lhe AusLrallan Ceneral racLlce AccredlLaLlon LlmlLed (ACAL) Lo 3941
general pracLlces (Cs) locaLed ln slx sLaLes and Lwo LerrlLorles across AusLralla. CrganlsaLlonal lndlcaLors ldenLlfled by survey vlslLs
are modelled as a funcLlon of soclo-economlc condlLlons speclflc Lo each C locaLlon and measured by Lhe Soclo-Lconomlc lndexes
lor Areas (SLllA). 1he sLaLlsLlcal slgnlflcance of assoclaLlon paLLerns ls furLher characLerlsed by Lhe correspondlng p-values,
accounLlng for mulLlple LesLlng.

kesu|ts: 1he appllcaLlon of Lhe lnLroduced analyLlcal procedure ldenLlfled Lwo accredlLaLlon ouLcome lndlcaLors wlLhln Cs LhaL are
slgnlflcanLly assoclaLed wlLh Lhe correspondlng soclo-economlc condlLlons. llrsLly, 'Cur pracLlce has a helghL ad[usLable bed'
lndlcaLor Lends Lo be noL meL for Cs locaLed ln economlcally deprlved geographlcal areas. 1hls resulL ls conslsLenL wlLh Lhe
concluslon from Lhe lndependenL survey conducLed by Lhe 8oyal AusLrallan College of Ceneral racLlLloners: 1he survey sLrongly
suggesLs LhaL cosL was Lhe overall facLor LhaL deLerred mosL Cs from purchaslng helghL ad[usLable beds. Secondly, 'AL leasL 30 of
our acLlve paLlenL healLh records conLaln a healLh summary' lndlcaLor Lends Lo be noL meL for Cs locaLed ln areas wlLh beLLer soclo-
economlc condlLlons. 1hls resulL ls open for lnLerpreLaLlon, perhaps Cs ln Lhese areas are busler Lhan oLhers, and Lhls ls Lhe
ouLcome of a Llme facLor.

Conc|us|on: 1he suggesLed analyLlcal procedure for measurlng and evaluaLlng performance of PCCs ls capable of ldenLlfylng already
known phenomena as well as new never-noLlced aspecLs whlch are Lhus open for furLher lnvesLlgaLlon. 1hls analyLlcal approach ls
flexlble enough Lo accommodaLe daLa sLrucLures obLalned from accredlLaLlon surveys conducLed agalnsL dlfferenL Lypes of PCCs.



2463

CULA1ICN LkSLC1IVLS CN A1ILN1 SAIL1: ANkICUSL AWAI1ING 1nL GkLA1 LLA ICkWAkD
!oanne l. 1ravaglla
1,*
, Pamlsh 8oberLson
2

1
School of ubllc PealLh and CommunlLy Medlclne and AusLrallan lnsLlLuLe of PealLh lnnovaLlon,
2
AusLrallan lnsLlLuLe of
PealLh lnnovaLlon, unlverslLy of new SouLh Wales, Sydney, AusLralla


Cb[ect|ves: uesplLe Lhe lmpresslve developmenLs of Lhe paLlenL safeLy movemenL ln recenL years, some key quesLlons ln
paLlenL safeLy Lheory and pracLlce remaln unresolved and underexplored. 1hls paper examlnes a framework for
undersLandlng Lhe rlsks and responses Lo paLlenL safeLy aL a populaLlon level. lL argues LhaL one lmporLanL reason LhaL
Lhe raLe of errors has noL reduced slgnlflcanLly aL a global level ls because Lhe paLlenL safeLy movemenL has focused on
mlcro-scale errors wlLhln a macro sysLems framework, buL lgnored Lhe equally meso-level of populaLlon paLLerns and
dynamlcs.

Methods: 1hls paper ls a concepLual plece wlLh an emplrlcal base. lL applles frameworks and Lheorles from soclology and
phllosophy, as well as paLlenL safeLy research, Lo undersLand Lhe mechanlsms by whlch populaLlon level lndlcaLors of
harm can asslsL healLh servlces Lo address poLenLlal causes of error whlch lle wlLh broader soclal culLural and economlc
relaLlons.

kesu|ts: 8esponses Lo paLlenL safeLy problems are largely cenLred on Lhree ma[or shlfLs ln Lhe dellvery of healLh servlces:
evldence based medlclne/cllnlcal pracLlce, healLh sysLems and servlce level reporLlng of and response Lo errors, and
sysLemaLlc research lnLo Lhe causes of and responses Lo errors. 1hese shlfLs have been underplnned by an lncreased
publlc scruLlny of errors Lhrough mechanlsms such as publlc lnqulres, medla aLLenLlon and paLlenL engagemenL
mechanlsms. 1he lnqulrles speak Lo underlylng paLLerns of harm, many of whlch are dlrecLly llnked Lo Lhe vulnerablllLy of
populaLlons and populaLlon sub-groups lncludlng women, Lhe elderly, chlldren, people of lower SLS, people wlLh
dlsablllLles and people from lmmlgranL backgrounds. ln addlLlon, we know, for example, LhaL many groups are rouLlnely
under-represenLed ln mosL Lypes of healLh research. lew counLrles rouLlnely collecL or publlsh daLa on populaLlon level
dlfferences ln errors, and mosL do noL do reporL on Lhese flndlngs regularly. ockeLs of evldence exlsL, and Lhese supporL
flndlngs from lnqulrles: from Lhe uS, lezzonl's work hlghllghLs slgnlflcanL dlfferences ln Lhe raLes of errors of boLh
omlsslon and commlsslon for women wlLh dlsablllLles. SLudles ln new Zealand show dlfferenLlal raLes of errors for Lhe
lndlgenous Maorl communlLy, and lnLernaLlonal sLudles showed an assoclaLlon beLween lmmlgranL sLaLus and error
raLes. Lven less ls known abouL Lhe rlsks and raLes of errors for a varleLy of oLher groups.

Conc|us|on: As a communlLy of scholars and pracLlLloners, our focus has largely been on addresslng errors from Lhe
perspecLlve of sysLems and Lhe servlces, and whlle Lhe emergence of paLlenL-cenLred care has been a sLep forward ln
shlfLlng Lhe focus from cllnlclans Lo consumers, paLlenLs are more Lhan a collecLlon of lndlvlduals. 1he body of evldence
Lo daLe shows LhaL members of vulnerable groups recelve worse care, much laLer Lhan Lhe 'general' populaLlon. Cur
work Lo daLe shows LhaL noL only ln all llkellhood ls LhaL paLLern repllcaLed ln Lerms of Lhe safeLy of care, buL lL ls llkely Lo
be exacerbaLed by currenL approaches Lo pracLlce and gaps ln research. Cur work shows LhaL Lhls ls exacerbaLed by
slgnlflcanL gaps ln research. 1hls lSCuA conference has Lhe opporLunlLy by a 'Llpplng polnL' Lo move Lhe fleld beyond
lndlvlduals and sysLems and lnLo Lhe mlddle ground Lo examlne Lhe populaLlon-level facLors lnvolved ln rlsk
characLerlsLlcs and error raLes aL a populaLlon level.



2464

IMkCVING S1LMI A1ILN1 1kLA1MLN1 1IMLS USING LLAN 1nINkING kCCLSS kL-DLSIGN
kaLe SLeen
1,*

1
nurslng Servlces, Cabrlnl PealLh, Malvern, AusLralla


Cb[ect|ves: 1lmely LreaLmenL for acuLe cardlac paLlenLs ls seen as Lhe 'holy grall' for emergency and cardlac healLh care
professlonals, wlLh Lhe achlevemenL of recognlsed lnLernaLlonal benchmark LreaLmenL Llmes for paLlenLs experlenclng
S1-segmenL elevaLlon myocardlal lnfracLlon (S1LMl) demonsLraLlng a reduced morLallLy raLe. AchlevemenL of Lhls
benchmark Llme Lo LreaLmenL, however, ls noL unlform or always close Lo besL pracLlce Llmes, ralslng concerns and
quesLlons abouL why Lhere ls such a gap beLween Lhe benchmark LreaLmenL Llme and Lhe reallLles of cllnlcal pracLlce.
1hls paLlenL care lmprovemenL pro[ecL underLaken by Lhe cardlac and emergency healLh care Leams aL Cabrlnl PosplLal
ln Melbourne, AusLralla, 2010-2012 almed Lo answer Lhe followlng quesLlons:

1. uoes Lhe lnLroducLlon of Lean 1hlnklng rocess 8edeslgn reduce Lhe uoor Lo 8alloon 1lme" (u281) for S1LMl
aLlenLs?
2. uoes Lhe lnLroducLlon of Lean 1hlnklng rocess 8edeslgn enable achlevemenL of benchmark S1LMl paLlenL
LreaLmenL Llme?

1he key beneflLs Lo Lhe fleld of sLudy and cllnlcal pracLlce were Lhe ldenLlflcaLlon of sLraLegy and descrlpLlon of cllnlcal
pracLlce process deslgn, proLocols or paLhways LhaL lmproved Llme Lo S1LMl LreaLmenL, LhaL wenL beyond Lhe 'whaL' of
cllnlcal LreaLmenL Lo Lhe 'how' of effecLlve lmplemenLaLlon. Such proLocols offer a pracLlcal and repllcable, or adapLable,
'blueprlnL' for seLLlng up effecLlve sysLems of care for S1LMl paLlenLs. 1he 'how Lo' gulde can be used ln a range of
cllnlcal envlronmenLs, and ensure Lhe pracLlce guldellnes encompass LreaLmenL from Lhe paLlenL's polnL of vlew ln
addlLlon Lo Lhe lnpuL and experlences of all personnel and roles lmporLanL Lo LhaL paLlenL's experlence.

Methods: A quasl-experlmenLal deslgn was used Lo address Lhe quesLlons posed ln Lhls pro[ecL. ln whaL was effecLlvely a
'before and afLer' sLudy, Lhere was non-equlvalenL group comparlson of u281 before and afLer Lhe lnLroducLlon of Lhe
Lean 1hlnklng redeslgn of S1LMl paLlenL LreaLmenL access and care proLocols, an lnLerrupLed Llme serles, wlLh
measuremenLs Laken pre- and posL-lnLervenLlon. 1he deslgn lnvolved Lhe lnLroducLlon of a process manlpulaLlon or
redevelopmenL, and observlng or LesLlng whaL happened as a resulL.

1o answer Lhe flrsL quesLlon of wheLher Lean 1hlnklng 8edeslgn rocesses lmproved u281 for S1LMl paLlenLs,
comparlson was made beLween Lhe mean u281 before and afLer Lhe lnLervenLlon, wlLh a mean Llme afLer lnLervenLlon
sLaLlsLlcally slgnlflcanLly lower Lhan Lhe mean Llme before lnLervenLlon lndlcaLlng success. ln relaLlon Lo Lhe second
quesLlon of wheLher Lean 1hlnklng process redeslgn enabled Lhe achlevemenL of benchmark S1LMl paLlenL LreaLmenL
Llmes, lL was a maLLer of seelng lf benchmark Llme was achleved - LhaL 73 of paLlenLs had a u281 less Lhan 90
mlnuLes.

kesu|ts:
1. 1he mean u281 before Lhe lnLervenLlon was 90 mlnuLes and Lhe mean u281 for Lhe flrsL year afLer lnLervenLlon
was < 90 mlnuLes.
2. rlor Lo lnLervenLlon, less Lhan 73 paLlenL achleved a u281 of 90 mlnuLes. AfLer and slnce Lhe new S1LMl proLocol
lnLroducLlon, more Lhan 73 paLlenLs achleve a u281 of less Lhan 90 mlnuLes

Conc|us|on: uslng Lean 1hlnklng redeslgn meLhodology Lo ldenLlfy Lhe barrlers Lo Lhe paLlenL's LreaLmenL and poslLlve
experlence was Lhe flrsL sLep Lowards lmprovemenL. Worklng LogeLher Lo remove Lhose barrlers and Lhen Lo develop
and lmplemenL an agreed, sLandardlsed cllnlcal paLhway around acLlvlLy LhaL added value for Lhe paLlenL, meanL LhaL Lhe
mulLldlsclpllnary Leam carlng for Lhls paLlenL group was able Lo boLh achleve a slgnlflcanL reducLlon ln Llme Lo LreaLmenL
and demonsLraLe cllnlcal pracLlce beLLer Lhan lnLernaLlonal benchmark.



2466

1nL SAS1ICI1 MANAGLMLN1 kCGkAMML IN SUkGICAL DLAk1MLN1 CI SnA1IN nCSI1AL
Chan ?uk long
1
, Chul ?uk oon
1,*
, Sau Pa Chan
1
, Chol Wah Chan
2

1
Surgery,
2
hysloLherapy, ShaLln PosplLal, ShaLln, Pong kong


Cb[ect|ves: ln 2012, Lhere are 413 paLlenLs suffered from lnLra-cerebral haemorrhage and braln ln[ury ln our
deparLmenL. SpasLlclLy ls a common feaLure of sLroke. lL causes paln and llmlLs Lhe movemenL of Lhe conLracLed [olnL.
1he paLlenLs wlLh spasLlclLy requlre slgnlflcanL managemenL Lo resLore Lhelr quallLy of llfe. 1oLally, 33 paLlenLs were
recrulLed for Lhe managemenL programme ln 2012.

1he spasLlclLy managemenL programme ls a mulLldlsclpllnary Leam approach Lo manage our spasLlclLy paLlenLs. Cur
surglcal rehablllLaLlon Leam lncludes neurosurgeons, nurses, physloLheraplsL, and occupaLlonal LheraplsL. 1hls
programme faclllLaLes hlgher funcLlonal level and paln due Lo spasLlclLy. 1he managemenL also correcLs posLure, prevenL
[olnL conLracLure and pressure sore of Lhe paLlenLs.

Methods: aLlenLs under Lhls programme have dlfferenL severlLy wlLh conLracLed [olnL. AssessmenL lncludes A8CM,
8CM, Lone and paln for Lhe affecLed [olnLs. 1he rehablllLaLlon Leam lmplemenLs lnLervenLlon accordlng Lo dlfferenL
level of spasLlclLy. 1here are Lhree levels of Lherapy provlded Lo our paLlenLs. Level l Lherapy malnly ls sLreLchlng and
passlve exerclse Lo muscle. SpllnLs are offered for Lhe affecLed llmbs Lo faclllLaLe llmbs funcLlon. Level ll ls Lhe appllcaLlon
of oral anLlspasLlc drug for spasLlc Lone wlLh no [olnL conLracLure. Level lll ls Lhe lnvaslve LreaLmenL wlLh 8oLox ln[ecLlon
and lnLraLhecal balcofen ln[ecLlon Lo lmprove condlLlon.

kesu|ts: 1here are slxLeen paLlenLs wlLh level l and LhlrLeen paLlenLs wlLh level ll were recrulLed ln Lhe programme wlLhln
2012. 1welve paLlenLs wlLh level lll recelved Lherapy from 2007-2012.Level l paLlenLs were sllghLly lncrease ln Lone afLer
one monLh's Lherapy and sllghLly decrease ln paln. Level ll were deLerloraLed ln passlve range of Lone. Level lll paLlenLs
were lmproved ln passlve [olnL range of movemenL, Lone, resLlng posLure of Lhe llmbs.

Conc|us|on: 1he resulLs showed LhaL spasLlclLy managemenL programme can lmprove paLlenLs' conLracLure and paln
conLrol. A mulLldlsclpllnary Leam approach can ldenLlfy funcLlonal care goals ln Lhe managemenL of spasLlclLy. 1he
lmprovemenL of Lhe spasLlclLy faclllLaLes Lhelr quallLy of llfe. ln Lhe fuLure, we would plan Lhe new guldellnes for
enhance Lhe spasLlclLy managemenL.




2467

1nL IU1UkL kCILC1ICN CI CCS1 CI ILLNLSS ICk 8kLAS1 CANCLk
?uklko uezono
1,*
, kunlchlka MaLsumoLo
1
, kayoko Paga
1
, 1omonorl Pasegawa
1

1
ueparLmenL of Soclal Medlclne, 1oho unlverslLy School of Medlclne, 1okyo, !apan


Cb[ect|ves: ln 2011, Lhe LoLal number of female paLlenLs wlLh breasL cancer was Lhe hlghesL among all cancers ln !apan.
And lLs soclal burden ls also hlgh. Moreover Lhe morLallLy raLe has been lncreaslng conslsLenLly. 1he purpose of Lhls
sLudy ls Lo make clear Lhe fuLure change of soclal lnfluence of breasL cancer uslng Lhe cosL-of-lllness (CCl) meLhod.

Methods: We esLlmaLed Lhe CCl of breasL cancer (lCu10 code: C30) ln !apan aL 2008, 2014 and 2020. ln Lhls sLudy, we
used governmenL offlce sLaLlsLlcs and Lhe CCl meLhod developed by 8lce u Lo esLlmaLe burden of dlsease. 1he CCl
conslsLs of Lhree parLs, dlrecL cosL, morbldlLy cosL and morLallLy cosL. ulrecL cosL ls a medlcal expense of breasL cancer.
MorbldlLy cosL ls an opporLunlLy cosL for ouLpaLlenL vlslL or hosplLallsaLlon. MorLallLy cosL ls measured as Lhe loss of
human caplLal (human caplLal meLhod). As for fuLure pro[ecLlon we predlcLed CCl uslng Lwo meLhods. 1he flrsL meLhod
was flxed model esLlmaLlon", LhaL ls, Lhe esLlmaLlon LhaL assumed healLh relaLed lndlcaLors (morLallLy raLe, number of
Llmes of ouLpaLlenL vlslL per populaLlon, number of Llmes of hosplLallsaLlon per populaLlon, and average lengLh of sLay)
were flxed. We used Lhose values aL 2008, and only fuLure populaLlon esLlmaLlon was used as a varlable. 1he second
meLhod was varlable model esLlmaLlon", LhaL ls, Lhe esLlmaLlon where healLh relaLed lndlcaLors changed aL Lhe same
pace as ln Lhe pasL 12 years, ln addlLlon Lo Lhe change of populaLlon and age sLrucLure. luLure healLh relaLed lndlcaLors
are esLlmaLed uslng a llnear approxlmaLlon or a logarlLhmlc approxlmaLlon. We adopLed an approxlmaLlon wlLh Lhe
hlgher coefflclenL of deLermlnaLlon.
kesu|ts: CCl was esLlmaLed 1,286 bllllon yen ln 2008 (92 yen =1 uS$). As for fuLure pro[ecLlon, our 2 models showed
dlfferenL resulLs respecLlvely. 1he flxed model suggesLed LhaL CCl would be sLable. WlLh Lhe varlable model where
healLh relaLed lndlcaLors' change was Laken lnLo conslderaLlon, CCl was expecLed Lo lncrease. Average lengLh of sLay of
breasL cancer have decreased buL morLallLy raLe, number of Llmes of ouLpaLlenL vlslL per populaLlon, and number of
Llmes of hosplLallsaLlon per populaLlon would conLlnue Lo lncrease. 1he number of deaLhs was esLlmaLed Lo lncrease ln
boLh models. 8uL morLallLy cosL was esLlmaLed Lo show opposlLe resulL respecLlvely. LsLlmaLlon resulL ls shown ln 1able
1.
Table 1: COI of breast cancer in Japan billion yen
2008 2014 2020
'flxed' meLhod dlrecL cosL 1,686 1,730 1,787
morbldlLy cosL 472 476 480
morLallLy cosL 4,340 4,313 4,297
LoLal CCl 6,498 6,341 6,363
'varlable' meLhod dlrecL cosL 1,686 1,696 1,683
morbldlLy cosL 472 426 431
morLallLy cosL 4,340 4,632 4,914
LoLal CCl 6,498 6,771 7,028
Conc|us|on: Accordlng Lo our esLlmaLlon uslng 2 models, CCl of breasL cancer would be sLable or lncrease. ln splLe of
lncrease of morLallLy raLe, average age of deaLh of breasL cancer would conLrlbuLe Lo Lhe decrease of morLallLy cosL per
caplLa. When maklng healLh pollcles Lhese resulLs should be Laken lnLo accounL.



2476

LNnANCING SAILk 8LCCD 1kANSIUSICN SLkVICLS NA1ICNALL 1C LNSUkL A1ILN1 SAIL1
Zalna Mohammad
1
, kadar M. Marlkar
1
, kadar M. Marlkar
1,*

1
CuallLy PealLh, MSCP, eLallng !aya, Malaysla


Cb[ect|ves: 1o assess Lhe effecLlveness of hosplLals compllance Lo esLabllshed naLlonal sLandards for blood Lransfuslon
servlces.

Methods: 1hls ls a reLrospecLlve sLudy of 136 hosplLals naLlonwlde LhaL lmplemenLs Lhe naLlonal sLandards for blood
Lransfuslon servlces beLween 2009 Lo 2012.8lood Lransfuslon servlce sLandards ls one of Lhe many sLandards LhaL
hosplLals need Lo comply ln order Lo be accredlLed by Malayslan socleLy for CuallLy ln PealLh- Lhe Malayslan
accredlLaLlon body for healLhcare faclllLles and servlces.

kesu|ts: 124(91.2) hosplLals achleved subsLanLlal compllance ln Lhe blood Lransfuslon servlce sLandards.
12 (8.8) hosplLals achleved parLlal compllance agalnsL Lhe same sLandards.
none had non-compllance.

Conc|us|on: lL was observed LhaL Lhe lmplemenLaLlon of naLlonal sLandards across Lhe healLhcare sysLem naLlonwlde ls
achlevable and effecLlve ln enhanclng safer blood Lransfuslon servlces.




2477

A1ILN1S AND IAMILILS LkLkILNCLS 1C IMkCVL CAkL A1nWAS ICk CnkCNIC DISLASL A1 1nL LND CI LIIL:
1nL DLVICL CI NAkkA1IVL MLDICINL
Mlcol 8ronzlnl
1,*
, Clovanna vlcarelll
1
, AlberLo ueales
2
, 1eresa Medl
1

1
Crlss, unlverslLa ollLecnlca delle Marche,
2
PealLh Care 8eglonal Agency, Ancona, lLaly


Cb[ect|ves: 1he sLudy has been carrled ouL wlLhln a pro[ecL funded by Lhe lLallan MlnlsLry of PealLh concernlng Lhe
developmenL of care paLhways for advanced hearL fallure and chronlc obsLrucLlve pulmonary dlsease. 1he alm was Lo
concelve and lmplemenL a Lool for Lhe collecLlon of lllness narraLlves of paLlenLs wlLh a chronlc dlsease ln an advanced
sLage and Lhelr famllles, ln order Lo lmprove care paLhways.

Methods: 1he sLudy lncluded Lhe followlng sLeps:

1) revlew of Lhe naLlonal and lnLernaLlonal llLeraLure on palllaLlve care and on lllness narraLlves,
2) deslgn of research quesLlons for Lhe narraLlve lnLervlew,
3) lnLervlewers Lralnlng, parLlclpanLs recrulLmenL and conducLlon of Lhe lnLervlews,
4) analysls of Lhe collecLed maLerlal. arLlcular emphasls was placed on Lhe relaLlonal perspecLlve, lnvesLlgaLlng how
paLlenLs and Lhelr relaLlves percelve Lhe dlsease and how Lhey copy wlLh lL, how Lhey relaLe wlLh Lhelr changlng
self", Lhe relaLlonshlps wlLhln Lhe famlly, soclal relaLlons and Lhe relaLlonshlp wlLh healLh professlonals. 1he
recrulLmenL of paLlenLs was based on cllnlcal crlLerla for advanced Pl and CCu. 1he sLudy lnvolved 10 paLlenLs and
10 relaLlves (3 for each dlsease) ln LreaLmenL aL Lhe unlverslLy PosplLal of Ancona. narraLlve lnLervlews were
collecLed aL paLlenLs' home (separaLely for paLlenLs and careglvers) and lasLed on average 30 Lo 60 mlnuLes. 1he
lnLervlews have been Lranscrlbed and analysed Lhrough an lnLerpreLaLlve grld.

kesu|ts: ln all lllness narraLlves Lhe dlsease ls descrlbed as a deep blographlcal rupLure wlLh Lhe pasL llfe, whlch noL
necessarlly colncldes wlLh Lhe dlagnosls, especlally lf Lhe laLLer occurs when Lhe sympLoms are sLlll sllenL and Lhe
consequences shorLly percepLlble. Cllnlcal Lra[ecLorles are ofLen LorLuous: frequenLly (70) lL emerges an
underesLlmaLlon of Lhe sympLoms presenLed and lnapproprlaLeness ln Lhe dlagnosls or ln LreaLmenLs. 1he relaLlonshlp
wlLh healLh professlonals who are currenLly aLLendlng on paLlenLs ls very good. 1he ldeal healLh professlonal ls descrlbed
as characLerlsed by professlonallsm, avallablllLy, mlldness and closeness. ln evaluaLlng Lhe quallLy of servlces Lhe
relaLlonal componenL assumes, Lherefore, a slgnlflcanL lmporLance. 1he cenLral reference for all respondenLs ls Lhe
speclallsL. 1he Cs ls consulLed malnly for Lhe prescrlpLlons (40) and for Lhls reason paLlenLs conslder Lhem unwllllng Lo
pay aLLenLlon Lo Lhelr healLh condlLlons (70). 1he cenLrallLy of hosplLal speclallsLs causes some dlscomforL because
each hosplLallsaLlon or medlcal examlnaLlon requlres greaL organlsaLlonal and physlcal efforLs for paLlenLs. lL should be
also underllned LhaL no one recelves home healLh care and LhaL Lhere ls a lack of sLrucLured lnLerdlsclpllnary Leam for
Lhe supervlslon of paLlenLs. lllness narraLlves wlll be shared and dlscuss wlLh healLh professlonals ln order Lo ldenLlfy
posslble lmprovemenLs.

Conc|us|on: ln Lhe case of chronlc dlsease aL Lhe end sLage Lhe cure ls Lo be undersLood as a carlng process, almed aL
lmprovlng or malnLalnlng a good quallLy of llfe for boLh Lhe paLlenL and hls famlly. 1herefore, Lhe deslgn of healLh care
paLhways cannoL avold conslderlng sub[ecLlve experlences of Lhe dlsease. narraLlve based medlclne can be a useful
devlce Lo draw ouL parLlclpanL's accounL of a serlous chronlc dlsease as experlenced by hlm, as well as Lo flnd ouL needs,
resources deployed expecLaLlons and saLlsfacLlon wlLh healLh servlces. 1hls could be an lnnovaLlve way of evaluaLlng and
lmprovlng healLh servlces for Lhe end of llfe, lnvolvlng paLlenLs and Lhelr famllles ln Lhe perspecLlve of a co-producLlon of
healLh care paLhways.


2481

1nL LVCLU1ICN CI UALI1 AND SAIL1: 1nL CASL CI 1nL CAkL nCML
Sarah[ane !ones
1,*
, Clmlng ln
1
, Malrl MaclnLyre
1

1
WMC, unlverslLy of Warwlck, CovenLry, unlLed klngdom


Cb[ect|ves: A shared vlslon across nurslng homes ls Lo provlde hlgh quallLy, hollsLlc and lnLegraLed care. Powever, Lhe
assoclaLed sLraLegy deploymenL may prove problemaLlc wlLhouL a shared undersLandlng of whaL quallLy and hollsLlc care
ls. ln Lngland, Lhe Care CuallLy Commlsslon (CCC) regulaLes all healLhcare relaLed servlces agalnsL a seL of 26 ouLcomes,
13 of whlch are speclflc Lo care homes. 1radlLlonally, care homes sLrlve Lo meeL Lhe regulaLors sLandards buL as Lhe care
model evolves Lo encourage acLlve parLlclpaLlon of resldenLs, a conLemporary approach Lo quallLy and safeLy ls requlred.

1he purpose of Lhls work ls Lo explore Lhe perspecLlves of key sLakeholders on quallLy and safeLy ln Lhe care home.

Methods: A case sLudy approach was adopLed and a charlLy run care home wlLh a 20 bed capaclLy was recrulLed.
lnLervlews were conducLed wlLh mulLlple key sLakeholders lncludlng Lhe care manager, Lhe paLlenL represenLaLlve and
relaLlves. lurLhermore, observaLlons were made of Lhe quarLerly relaLlves meeLlng and monLhly sLaff meeLlng. llnally,
documenLary analysls was underLaken perLalnlng Lo quallLy and safeLy.

kesu|ts: ulfferences ln perspecLlves of quallLy and safeLy exlsL beLween key sLakeholders. SLaff Lend Lo descrlbe quallLy
and safeLy ln relaLlon Lo lagglng ouLcomes measures such as harm and Lhe process of rlsk reducLlon, placlng greaLer
prlorlLy on Lhe operaLlonal acLlvlLles LhaL prevenL harm and reduce rlsk. Whereas paLlenLs descrlbe quallLy and safeLy ln
Lerms of Lhe poslLlve sLrucLural condlLlons Lo encourage safeLy such as Lhe experlence of an exLended famlly.

Conc|us|on: ConsequenLly, assoclaLed governance sLrucLures should reflecL a comprehenslve vlew, oLherwlse care
provlslon wlll be subopLlmal. LfforLs Lo explore and undersLand mulLlple key sLakeholder perspecLlves lncludlng Lhe
resldenLs and Lhelr relaLlves would supporL care home organlsaLlons Lo dellver a more end user focused vlslon.



2483

IkCM kISk 1C SAIL1: DLVLLCMLN1 CI A NLW INI1IA1IVL 1C ASSIS1 CCkkLC1 GAU2L CCUN1ING IN CLkA1ICN
1nLA1kL
loonyee Chan
1,*
, Lllen Wong
1
, Plng ?u So
1

1
CuallLy and SafeLy, PosplLal AuLhorlLy, Pong kong, Pong kong


Cb[ect|ves: Cb[ect|ves: 8eLenLlon of swabs (gauze) or surglcal lnsLrumenL was ldenLlfled as Lhe mosL frequenLly reporLed
senLlnel evenL by !olnL Commlsslon ln 2010 and by Pong kong PosplLal AuLhorlLy ln 2011/12. A new surglcal counLlng
Lool was deslgned Lo ellmlnaLe Lhe swab-counLlng rlsk ln operaLlon LheaLres afLer a reLalned gauze lncldenL ln n1L
ClusLer (n1LC) of Pong kong PosplLal AuLhorlLy.

Methods: Methods:
1. LsLabllshmenL of a worklng group: a sLaff-lnlLlaLe group conslsLlng of experlenced operaLlon LheaLre managers,
experLs, nurses and Lhe rlsk managemenL Leam was assembled. lL almed aL explorlng a safe, effecLlve buL a low-
cosL Lool whlch could replace Lhe exlsLlng gauze rack. 1he new Lool should faclllLaLe accuraLe and rapld swab
counLlng durlng operaLlons, compromlse wlLh lnfecLlon conLrol, allow full vlsuallsaLlon by operaLlon Leam and asslsL
ln blood loss esLlmaLlon durlng surgery.
2. ueslgn of a new sysLem: 1he worklng group analysed Lhe local lncldenLs, revlewed lnLernaLlonal llLeraLures, and
sLudled Lhe local near-mlss lncldenL durlng Lhe Lrlal of Sponge AccounLlng sysLem. A local deslgned LransparenL-
plasLlc gauze conLalner, Lherefore, was developed. 1he worklng group also deslgned a swab holdlng Lrolley Lo
faclllLaLe Lhe counLlng process.
3. lloL and evaluaLlon: uue Lo budgeL consLralnL, only Lwo Lypes of conLalner (long and shorL rayLec gauzes) and few
holdlng Lrolleys were plloLed for 6 weeks ln early 2012. All scales of surglcal procedures were welcomed ln Lrlal of
Lhe new Lool. An evaluaLlon quesLlonnalre was dlsLrlbuLed Lo surgeons, anaesLheLlsL and nurses afLer plloL. 1oLal 83
quesLlonnalres were reLurned. 80 agreed Lhe new sysLem asslsL ln blood loss esLlmaLlon durlng operaLlon, 60
agreed LhaL Lhe new sysLem could reduce chance of counLlng error, 6068 agreed Lhe new sysLem was easy for
clear counLlng, neaL and Lldy and savlng Llme ln counLlng. Some sLaff clalmed LhaL lL was dlfflculL Lo adopL Lwo
counLlng sysLems (gauze rack for abdomlnal swab and new Lool) ln a Llme durlng plloL. 1he sLaff also provlded
commenL Lo modlfy Lhe deslgn of conLalner and holdlng Lrolley.
4. ModlflcaLlon: upon Lo Lhe evaluaLlon resulL and sLaff's feedback, Lhe gauze conLalners were modlfled. 1he
abdomlnal swab conLalner was deslgned. A colourful long gauze conLalner was used. 1he holdlng Lrolley was
slmpllfled. 1he modlfled gauze conLalners and holdlng Lrolley were fully lmplemenLed Lo replace Lhe gauze rack ln
operaLlon LheaLres ln n1LC by phases ln CcLober 2012.

kesu|ts: kesu|ts: AfLer Lhe modlflcaLlon, Lhe sLaff showed more accepLance of Lhe new Lool. An lnlLlal commenL from Lhe
sLaff showed LhaL LhaL Lhe new conLalners could save Lhelr Llme and asslsL Lhem much ln esLlmaLlng blood loss for very
compllcaLed emergency operaLlon. 1he mlnor sLaff also felL happy for easy cleanlng of swab Lrolley. 1he sLaff aLLlLude
Lowards Lhe new Lool became more poslLlve. AnoLher evaluaLlon would be conducLed ln March 2013 for conLlnuous
lmprovemenL of new Lool. Some hosplLals from oLher clusLers of Pong kong PosplLal AuLhorlLy also showed lnLeresL of
Lhe new Lool and could plloL ln Lhelr operaLlon LheaLres ln 2013,

Conc|us|on: Conc|us|on: A success of a rlsk reducLlon program ls noL a maLLer of a small group of people. lL ls
everybody's buslness ln Lhe organlsaLlon. SLaff lnlLlaLlon, engagemenL and recognlLlon ls very cruclal. WlLh Lhe efforLs,
lnpuL and parLlclpaLlon of n1LC colleagues, our rlsk managemenL Leam alms aL LwlLchlng Lhe palnful lncldenL from rlsk Lo
a safer envlronmenL for our paLlenLs and sLaff.


2489

1nL Ak1NLkSnI ML1nCD, SAIL1 WALk-AkCUND, ILC1S1UD
uorLhe uoehl oulsen
1,*
, 8lrglLLe CsLergaard
1

1
ueparLmenL of Surgery, 8oskllde and koege PosplLal, 8oskllde, uenmark


Cb[ect|ves: AL Lhe deparLmenL of surgery, 8oskllde and kge PosplLals, 8eglon Zealand, paLlenL safeLy ls sysLemaLlsed on
basls of Lhe uanlsh AccredlLaLlon Model, uukM 1, whlch lncludes 16 paLlenL safeLy sLandards wlLh apperLalnlng
guldellnes. Managers and employees are worklng deLermlnedly wlLh Lhe lmplemenLaLlon of Lhe guldellnes, and Lhe
achlevemenL of alms ls evaluaLed conLlnuously by a monLhly gaLherlng of daLa, by lnLern and exLern survey and by
sysLem Lraclng. Powever, Lhe employees express LhaL paLlenL safeLy walk-arounds have Lurned lnLo a meLhod wlLh a
prlmary focus on conLrol opposed Lo dlalogue and learnlng. lL happens LhaL managers ofLen lnqulre abouL speclflc areas
of paLlenL safeLy, mosL frequenLly on Lhe basls of uukM 1 sLandards, buL glve no room for dlalogue. 1hls lndlcaLes LhaL
oLher or maybe undeLecLed aspecLs of paLlenL safeLy cannoL be ldenLlfled.

Methods: CuesLlons: Pow can managers and employees work LogeLher, and wlLh a sLarLlng polnL ln cllnlcal pracLlce,
ldenLlfy areas of paLlenL safeLy whlch are noL lncluded ln Lhe 16 paLlenL safeLy sLandards?

CuesLlons: Pow can Lhe communlcaLlon beLween managers and employees lmprove as a means Lo help ldenLlfylng
oLher or new areas wlLhln paLlenL safeLy Lhan Lhe ones already encompassed ln Lhe uukM 1 sLandards? PosplLal
managers, deparLmenL managers, a paLlenL safeLy ambassador, a quallLy consulLanL and Lhe speclallsL of cllnlcal nurslng
Leam up for a day wlLh employees ln Lhe ward secLlons. 1hey form parLnershlps and [olnLly carry ouL Lhe cllnlcal work
and ldenLlfy consplcuous areas of paLlenLly safeLy regularly. 3 areas or challenges are prlorlLlsed. All parLnershlps meeL
wlLh employees from Lhe concerned secLlon. !olnLly, 2-3 areas are prlorlLlsed and hereafLer plans of acLlon are
compleLed.

kesu|ts: ln 2012, 2 paLlenL safeLy walk-arounds where compleLed on Lhe basls of Lhls parLnershlp meLhod. Cn Lhe whole,
33 areas of paLlenL safeLy were ldenLlfled - Lhereof 19 areas LhaL were noL encompassed ln uukM 1. lollowlng
evaluaLlon showed LhaL managers experlenced Lhe paLlenL safeLy walk-around as a [olnL experlence LhaL creaLed a
common language. 1he dlalogue became more personal and ln-depLh.

1he employees experlenced LhaL a [olnL cllnlcal pracLlce gave Lhe lndlvldual employee Lhe opporLunlLy of seLLlng Lhe
agenda. 1he dlalogue was consLrucLlve, Lhere was more Llme Lo be presenL and Lhe managers showed a greaLer lnLeresL
ln Lhe dally lssues.

Conc|us|on: 8y uslng Lhe 'arLnershlp MeLhod' ls was posslble for managers and employees Lo [olnLly ldenLlfy areas of
paLlenL safeLy LhaL are boLh encompassed ln Lhe uukM 1 and polnLs Lo oLher areas of focus wlLh paLlenL safeLy.
Managers as well as employees expressed LhaL Lhe 'arLnershlp MeLhod' greaLly sLrengLhened Lhe dlalogue beLween
managers and employees.

keferences: uen uanske kvallLeLsmodel: AkkredlLerlngssLandarder for sygehuse, verslon 1. lkAS



2491

S1UDLN1S IN NUkSING AND MIDWIILk AS "SLCCND VIC1IMS" IN nLAL1n CAkL
Lva van Cerven
1,*
, MarLln Luwema
2
, WalLer Sermeus
1
, krls vanhaechL
1

1
ueparLmenL of ubllc PealLh,
2
Work, CrganlsaLlonal and ersonnel sychology, unlverslLy of Leuven, Leuven, 8elglum


Cb[ect|ves: 8ecenL sLudles show LhaL serlous adverse evenLs occur ln one ouL of seven paLlenLs. Powever noL only Lhe
paLlenL, buL also Lhe lnvolved healLh care provlder can be LraumaLlsed afLer such an evenL. ln Lhls case, Lhe lnvolved
healLh care provlders are referred Lo as second vlcLlms". SLudenLs ln healLh care can become second vlcLlms as well.

Methods: A quanLlLaLlve sLudy was used Lo deLermlne Lhe prevalence of second vlcLlms among sLudenLs nurslng and
mldwlfery and Lhe lmpacL of adverse evenLs. 1he sLudy was performed wlLhln 9 uuLch-speaklng colleges ln 8elglum
whlch provlde a bachelor degree ln nurslng and Mldwlfery. A web survey was vla emall and sLudenL lnLraneL Lo all
nurslng and mldwlfery sLudenLs.

kesu|ts: AlmosL one ouL of flve of 970 bachelor sLudenLs have personally experlenced an adverse evenL ln Lhe lasL slx
monLhs, of whlch 3 wlLh a deadly ouLcome. 41 have experlenced an adverse evenL wlLhln Lhe Leam of whlch 8 wlLh
a deadly ouLcome. 36 says Lhls had an lmpacL on Lhelr professlonal llfe, 18 says lL also lmpacLed Lhelr personal llfe.
23 Lhlnks dally abouL belng lnvolved ln an adverse evenL.

Conc|us|on: Second vlcLlms can experlence sympLoms as sLress, low self-esLeem, sleeplessness, burnouL, eLc. 8ecause of
lmpalred funcLlonlng, Lhey are more llkely Lo make anoLher mlsLake. 1he Lralnlng coordlnaLors of Lhe parLlclpaLlng
colleges wlll be lnvlLed Lo dlscuss Lhe resulLs of Lhls sLudy durlng an lnformaLlon sesslon.

ollcy advlse wlll be formulaLed so LhaL supporL durlng lnLernshlps of sLudenLs nurslng and mldwlfery can be organlsed
accordlngly. SLudenLs wlll recelve more and approprlaLe supporL afLer experlenclng an adverse evenL. 1hls could prevenL
negaLlve consequences such as sLress, low self-esLeem or leavlng Lhe educaLlon enLlrely. lL ls very lmporLanL Lo provlde
supporL for sLudenLs ln healLh care who were lnvolved an adverse evenL. SupporL ls necessary Lo prevenL more mlsLakes,
lmpalred funcLlonlng or even leavlng Lhe professlon/educaLlon enLlrely. We have Lo care for our healLh care provlders lf
we wanL Lo care for our paLlenLs.



2494

USING A1ILN1 CCMLAIN1S AS kLDIC1CkS CI A1ILN1 SAIL1 INCIDLN1S
Pelen L. kroenlng
1
, 8ronwyn kerr
2, 3
, laln L. ?ardley
4,*

1
Ponorary 8esearch AsslsLanL, 8oyal ManchesLer Chlldren's PosplLal,
2
AssoclaLe Medlcal ulrecLor, CenLral ManchesLer
loundaLlon nPS 1rusL,
3
Cllnlcal CeneLlcs,
4
aedlaLrlc Surgery, 8oyal ManchesLer Chlldren's PosplLal, ManchesLer, unlLed
klngdom


Cb[ect|ves: aLlenLs and Lhelr famllles are currenLly an under used resource ln paLlenL safeLy lmprovemenL. 1he alm of
Lhls sLudy was Lo esLabllsh wheLher hlgh-level paLlenL safeLy lncldenLs (PLls) are predlcLed by paLlenL complalnLs and
wheLher analysls and monlLorlng of complalnLs offers an opporLunlLy Lo prevenL PLls from occurrlng.

Methods: 1he sLudy was carrled ouL ln a large, publlc-funded, speclallsL chlldren's hosplLal ln Lhe uk.
All level 4 (poLenLlal or acLual slgnlflcanL harm) and level 3 (poLenLlal or acLual severe harm) lncldenL reporLs recelved
beLween Aprll 2012 and SepLember 2012 were ldenLlfled uslng rlsk deparLmenL records. All paLlenL complalnLs beLween
november 2011 and !une 2012 were ldenLlfled uslng Lhe complalnLs deparLmenL daLabase. 1hese daLe ranges were
chosen Lo glve a manageable number of reporLs Lo analyse and creaLe a lead Llme Lo PLls durlng whlch complalnLs could
have been recelved. lL also allowed Lhe lncluslon of only PLls and complalnLs wlLh a compleLed lnvesLlgaLlon process.
PLls were caLegorlsed accordlng Lo Lhe locaLlon and cllnlcal servlce Lhey occurred ln and by Lhe naLure of Lhe lncldenL (eg
medlcaLlon error, sLafflng levels or communlcaLlon errors). ComplalnLs were caLegorlsed ln Lhe same way. A quallLaLlve
analysls was Lhen carrled ouL looklng for common facLors ln PLls and complalnLs occurrlng ln Lhe same locaLlon or
servlce.

kesu|ts: SlxLeen hlgh level lncldenLs and 32 complalnLs were ldenLlfled and all were analysed. 1here was a slgnlflcanL
mlsmaLch ln Lhe locaLlon of PLls and complalnLs. 1he paedlaLrlc lnLenslve care unlL generaLed Lhe mosL PLls (3) of any
cllnlcal area buL recelved only 2 complalnLs. 8y conLrasL, Lhe orLhopaedlc (10), emergency (6) and resplraLory (3)
deparLmenLs recelved Lhe mosL complalnLs buL generaLed only 0, 1 and 1 PLls respecLlvely. Cne PLl occurred when an
admlnlsLraLlve sLaff member had noL been replaced whlle on prolonged leave. ComplalnLs from a paLlenL abouL a delay
ln Lhelr lnvesLlgaLlons led Lo Lhe dlscovery of 43 un-acLloned radlologlcal lnvesLlgaLlon requesLs. AlLhough no paLlenL
harm was apparenL, Lhls was classlfled as a level 4 lncldenL as Lhere was poLenLlal for slgnlflcanL harm. 1he complalnL
leadlng Lo Lhe PLl belng reporLed had been preceded by slx oLher complalnLs over a slx-monLh perlod relaLlng Lo delays
ln radlologlcal lnvesLlgaLlons ln Lhe same deparLmenL.

AnoLher PLl (level 3) resulLed from Lhe severlLy of a chlld's asLhma noL belng recognlsed and acLed on, leadlng Lo a
cardlopulmonary arresL and slgnlflcanL hypoxla. Larly warnlng scores had been lgnored and no escalaLlon of care
lnlLlaLed. 1wo furLher PLls relaLed Lo fallures ln Llmely recognlLlon of crlLlcal lllness. ln Lhe monLhs precedlng Lhese PLls,
Lwo complalnLs had been recelved from parenLs who felL LhaL Lhelr chlldren's resplraLory condlLlons had noL been Laken
serlously and care noL escalaLed approprlaLely. no oLher PLls were preceded by complalnLs of Lhe same naLure.
Slmllarly, mosL complalnLs dld noL glve lnformaLlon LhaL could have been used Lo averL a paLlenL safeLy lncldenL.

Conc|us|on: ln some lnsLances, complalnLs clearly slgnal problems wlLh quallLy and safeLy of care and lf acLed on
prompLly could averL or mlLlgaLe hlgh-level lncldenLs. 1hese complalnLs however are Lhe mlnorlLy and are noL
currenLly rellably ldenLlfled.

lor complalnLs sysLems Lo funcLlon rellably as early-warnlng" sysLems for poLenLlal paLlenL safeLy
lncldenLs, mechanlsms Lo prospecLlvely ldenLlfy complalnLs LhaL do slgnposL crlLlcal falllngs need Lo be developed.


2496

1nkCM8CL1IC 1nLkA ICk A1ILN1S WI1n ACU1L ISCnLMIC S1kCkL
Sophle Cuerln
1
, Melanle CouraleL
1
, Sophle CoubeL
1
, CaLherlne Crenler
1,*

1
naLlonal AuLhorlLy for PealLh, SalnL-uenls La lalne, lrance


Cb[ect|ves: 1he ob[ecLlve of Lhe paper ls Lo presenL Lhe process and dlfflculLles for bulldlng a naLlonal comparaLlve
quallLy lndlcaLor on LhrombolyLlc Lherapy for acuLe lschemlc sLroke paLlenLs ln lrance.

Methods: ln 2012, Lhe lrench naLlonal AuLhorlLy for PealLh generallsed a seL of quallLy lndlcaLors (Cls) relaLed Lo Lhe
managemenL of acuLe sLroke paLlenLs, afLer Lhelr experlmenL ln a panel of hosplLals. Cls evaluaLed Lhe delay for a flrsL
lmaglng, Lhe percenLage of paLlenLs wlLh approprlaLe admlnlsLraLlon of asplrln, wlLh a re-educaLlon evaluaLlon and lLs
delay, Lhe delay for a muLaLlon Lo a rehablllLaLlon care secLor, and Lhe quallLy and conLenL of Lhe medlcal record. As ln
oLher lnlLlaLlves, Lhe percenLage of paLlenLs wlLh an approprlaLe LhrombolyLlc LreaLmenL was anoLher Cl we almed aL
measurlng. ApproprlaLe LhrombolyLlc LreaLmenL ls Lhe raLe of LhrombolyLlc LreaLmenL carrled ouL on Llme (4h30 afLer
Lhe flrsL sympLoms) beyond ellglble paLlenLs Lo Lhrombolysls. uaLe and Llme of flrsL sympLom and flrsL medlcal conLacL
daLa were necessary for Lhe calculaLlon, buL happened Lo be dlfflculL Lo record. Cne reason ls LhaL paLlenLs or Lhelr
relaLlves are noL always able Lo Lell Lhe preclse Llme of sympLoms. lnsLead, anoLher lndlcaLor, less sLrlcL, buL allowlng
comparlson and benchmarklng, was compuLed: number of paLlenLs' records wlLh daLe and hour of flrsL sympLoms. 1hls
Cl also ls an essenLlal sLep Lo be able Lo measure Lhe approprlaLe raLe of LhrombolyLlc LreaLmenL.

A daLa collecLlon from 80 medlcal records for each acuLe care hosplLal was led.

kesu|ts: 497 acuLe care hosplLals collecLed daLa and 23772 medlcal records were analysed. Cn Lhe 22173 lschemlc
sLroke records analysed, only 2033 (9.2) where ellglble for LhrombolyLlc Lherapy, meanlng LhaL only abouL 6 daLa were
avallable by hosplLal. 1here were 39 of paLlenLs' records for whlch delay beLween flrsL sympLom and flrsL medlcal
conLacL was noL compuLable. naLlonal mean of Lhe Cl measurlng daLe and Llme of flrsL sympLoms ls 76, meanlng ln
24 of cases no lnformaLlon concernlng Lhe occurrence of sympLoms was found ln Lhe medlcal record.

Conc|us|on: 1he raLe of approprlaLe LhrombolyLlc LreaLmenL ls an essenLlal daLa Lo assess Lhe lnlLlal care of paLlenLs wlLh
acuLe lschemlc sLroke. Powever, daLa necessary Lo compuLe Lhls Cl are hard Lo obLaln. Popefully a beLLer LraceablllLy of
daLa wlll evenLually allow Lhe compuLaLlon of Lhls Cl ln order Lo compare hosplLals. 1hls ls Lhe reason why Lhe naLlonal
AuLhorlLy for PealLh and professlonal bodles chose Lo publlcly release daLa concernlng LraceablllLy of occurrence of
sympLoms. 1here ls sLlll room for lmprovemenL for Lhls crlLerlon ln lrance.


2497

IMkCVING CN 1nL SAIL1 CI LkCSLD INIAN1S UNDLk NCN-ADnLkLNCL 1C NLVIkAINL SCnLDULLS IN kA8AkWA nLAL1n
CLN1kL III IN 8UkLDLA DIS1kIC1-UGANDA
SLephen Cklror
1,*
, CoreLLl Amongln
1

1
PealLh, 8ukedea ulsLrlcL Local CovernmenL, kampala, uganda


Cb[ect|ves: IN1kCDUC1ICN

1he naLlonal M1C1 program recommends LhaL durlng posL-parLum, a moLher who ls ellglble for A81 l.e. Cu4 cell counL less Lhan or
equals Lo 330 or WPC cllnlcal sLage lll and lv and has chosen elLher 8reasL feedlng or replacemenL feedlng, Lhe lnfanL should Lake
dally nevlraplne (nv) unLll 6 weeks of age. lor moLhers noL ellglble for A81 and has opLed for breasL feedlng, lnfanLs need Lo Lake
dally nv unLll one week afLer sLopplng breasL feedlng.(All our cllenLs ln care fall ln Lhls caLegory). lor Lhose on replacemenL feedlng,
Lhe lnfanL Lakes dally nv from blrLh unLll 6 weeks of age. All Lhe above ls whaL Lhe program calls opLlon A posL-parLum. 1he same ls
appllcable for opLlon 8 for lnfanLs. ln kabarwa PealLh CenLre lll, all exposed lnfanLs are on breasL mllk because of economlc
consLralns. lorLunaLely, all Lhe moLhers are noL ellglble for A81. WlLh Lhe help of our daLa, mosL of Lhe exposed lnfanLs who were
enrolled ln care had recelved nv syrup buL appolnLmenLs were noL followed. Some recelved Lhe syrup once, oLher Lwlce and
sLopped. 1hls ls noL accepLed by Lhe sLandard because Lhese chlldren should Lake Lhe syrup unLll one week afLer sLopplng breasL
feedlng. 1o lmprove on Lhe safeLy of Lhe upLake of nevlraplne among Lhe exposed lnfanLs. 1o reLaln exposed bables ln care

Methods: lnLervenLlon - uurlng our quallLy lmprovemenL meeLlngs, we ldenLlfled some of Lhe posslble causes Lo Lhe hlgh drop raLe:
1. Some moLhers upon LesLlng negaLlve sLopped comlng for refllls afLer 6 weeks(flrsL C8),
2. Some moLhers were noL clearly explalned Lhe duraLlon of Laklng Lhe medlclne,
3. SLock ouL of supplles affecLed medlclne lnLake,
4. CLher sLaffs supplled Lhe nv syrup wlLhouL documenLlng ln Lhe reglsLer,
3. Some sLaffs dld noL know Lhe doses Lhe chlldren were Lo Lake.
1he Leam Lhen came ouL wlLh some posslble soluLlon Lo Lhe ldenLlfled problem,
1. uurlng healLh educaLlon and counselllng sesslons Lhe moLhers were explalned clearly Lhe lmporLance of conLlnulng wlLh Lhe
appolnLmenL afLer 18 monLhs of age.
2. WlLh Lhe help of vP1s, losL bables were followed and Lhose found were broughL back lnLo Lhe program.
3. 1he Leam also agreed LhaL lL was a collecLlve responslblllLy Lo know how Lo flll Lhe reglsLer by all Lhe faclllLy sLaff and Lhe work
should noL be lefL enLlrely Lo Lhe Llu focal person alone.
4. neLworklng wlLh oLher lmplemenLlng healLh faclllLles also helped solve Lhe problem of sLock ouL of nv syrup and also Lo
mlnlmlse explrles from oLher healLh faclllLles.

uoslng charLs were supplled by our lmplemenLlng parLners (8A?LC8) and now dlsplayed on Lhe wall. 1hls has eased work.
kesu|ts:
Month Sept 11 Cct 11 Nov 11 Dec 11 Ian 12 Ieb 12 March 12 Apr 12 May 12
No. expected for S
th

v|s|t.
11 6 2 3 2 3 3 4 6
No.of |nfants who
turned up for the S
th

v|s|t.
2 1 0 1 1 3 2 3 3
tage. 18.2 16.7 0 33.3 30 60 40 73 83.3

Conc|us|on: Lessons
1. ConLlnuous professlonal developmenL wlLhln Lhe healLh unlL can play a role ln solvlng slmple manageable lssues
2. 1eam work ls a key for any success Lo be achleved
3. neLworklng wlLh oLher healLh unlLs can reduce unnecessary explrles of medlclnes
4. !ob alds ln healLh faclllLles can solve Lhe problem of doubL especlally ln dosages
3. CommunlLy arLlclpaLlon and lnvolvemenL ls a key Lo beLLer ouLcomes

keferences: keferences:
! uganda naLlonal aedlaLrlc A81 guldellne 2011
! MlnlsLry of healLh exposed lnfanL reglsLer
! leedlng algorlLhm for Plv exposed lnfanLs

2S03

kLSCNSLS 1C 1nL LAk 2011 MAICk ILCCD INCIDLN1 IN 1nAILAND: A CASL S1UD CI A 1Lk1IAk-CAkL nCSI1AL
IN 8ANGkCk
!lruLh SrlraLanaban
1,*
, ?uwaree lchlLchok
1

1
laculLy of Medlclne, Chulalongkorn unlverslLy, 8angkok, 1halland


Cb[ect|ves: 1o explore lssues, as well as prevenLlve and correcLlve measures, relaLed Lo paLlenL safeLy and quallLy of care
deployed by a LerLlary-care hosplLal due Lo Lhe dlsasLrous flood lncldenL ln 1halland ln Lhe year 2011.

Methods: A case sLudy was conducLed on a 1400-beds, unlverslLy-afflllaLed, LerLlary-care hosplLal ln download
8angkok. uaLa were collecLed by lnLervlews wlLh responslble hosplLal execuLlves and revlew key documenLs relaLed Lo
Lhe 1halland's ma[or flood lncldenL durlng CcLober Lo uecember 2011, lncludlng hosplLal plans, mlnuLes of execuLlve
meeLlngs, and paLlenL-care sLaLlsLlcs. llndlngs from dlfferenL sources were LrlangulaLed for accuracy and rellablllLy.

kesu|ts: 1he flood lncldenL, whlch lasLed around Lhree monLhs lnvolvlng 63 ouL of 77 provlnces naLlonwlde and causlng
hosplLals ln or close Lo Lhe flood areas Lo shuL down. AlLhough Lhe floodlng flnally dld noL reach Lhls hosplLal locaLlon,
Lhe lncldenL evenLually led Lo dlsrupLlons and poLenLlal dlsrupLlons of a number of key hosplLal supplles. 8lsks Lo
paLlenL safeLy were, Lherefore, revlewed and prlorlLlsed, parLlcularly for Lhose ln lnLenslve care unlLs and Lhose needlng
conLlnuous hosplLal-based medlcaLlon or lnLervenLlons, such as chemoLherapy and haemodlalysls. A number of acLlon
plans were re-examlned, and some were flrsL-hand formulaLed. 1he hosplLal worked proacLlvely wlLh key suppllers and
provlders Lo ensure sufflclency of elecLrlclLy, clean waLer, oxygen and gas, food, drugs and lv fluld, and crlLlcal medlcal
supplles. Moreover, some 1200 medlcal and oLher hosplLal sLaffs along wlLh Lhelr famllles llvlng ln or near flood areas
were allowed Lo move lnLo vacanL hosplLal rooms, as Lhey became reserve on manpower. 8esource consumpLlon raLes
assoclaLed wlLh volumes of ouLpaLlenL and lnpaLlenL servlces were esLlmaLed as plans for reduclng hlgh resource-
consumlng servlces were deployed sLep-by-sLep, sLarLlng wlLh deferrlng elecLlve surgery. A dllemma arose on wheLher,
whlch and when paLlenLs should be Lransferred or sLay wlLh Lhe hosplLal Lo ensure paLlenL safeLy. LvenLually lnpaLlenL
Lransfer Lo ouLslde hosplLals was prlorlLlsed based on crlLerla on severlLy and survlval llkellhood. A dedlcaLed call cenLer
was also esLabllshed for coordlnaLlng paLlenL care and referral. A LoLal of 31 lnpaLlenLs were Lransferred wlLh no deaLh
durlng Lransfer, whlle Lhe hosplLal admlLLed 29 referral paLlenLs durlng Lhe crlLlcal perlod. ln-hosplLal morLallLy raLes
remalned sLable durlng Lhe perlod. 1he hosplLal's emergency deparLmenL remalned open and kepL fully funcLlonal
LhroughouL Lhe perlod of Lhe flood lncldenL, however, slnce many oLher hosplLals ln Lhe clLy area needed Lo shuL
down. noneLheless, afLer Lhe evenL, Lhe hosplLal has declded Lo reformulaLe a new sysLemaLlc approach Lo deal wlLh
ma[or dlsrupLlve evenLs, Lo manage Lhe lncldenLs and malnLaln conLlnulLy of crlLlcal processes.

Conc|us|on: ln addlLlon Lo quallLy managemenL for dally operaLlon, a hosplLal needs Lo have sysLemaLlc buslness
conLlnulLy plans Lo manage emergenL ma[or dlsrupLlve evenLs Lo ensure paLlenL safeLy.



2S0S

LIILC1IVL USL CI UALI1 INDICA1CkS IN ANALS1nLSIA: S1kUC1UkL AND SCnCML1kIC kCLk1ILS CI AN
LVALUA1IVL SUkVL
!oanna Moore
1
, uanlelle u'Llma
1,*
, Clenn Arnold
2
, !onaLhan 8enn
1

1
CenLre for aLlenL SafeLy and Servlce CuallLy, lmperlal College London,
2
AnaesLheLlcs, lmperlal College nPS 1rusL,
London, unlLed klngdom


Cb[ect|ves: 1he lrancls lnqulry and nPS reforms pose quallLy monlLorlng as an lmporLanL fuLure focus of many
organlsaLlons. ueveloplng effecLlve quallLy monlLorlng and feedback programmes for lndlvldual cllnlclans ls necessary Lo
supporL Lhe revalldaLlon agenda. 8esearch suggesLs LhaL local lnlLlaLlves lnvolvlng quallLy lndlcaLor monlLorlng and
feedback Lo cllnlclans represenL an effecLlve quallLy lmprovemenL sLraLegy. 1he success of lnlLlaLlves ls llkely Lo be
dependenL upon cllnlclan's percepLlons of Lhelr purpose and uLlllLy along wlLh Lhe rellablllLy and credlblllLy of
lndlcaLors. We reporL a sLudy Lo valldaLe a survey measure deslgned Lo quanLlfy cllnlclans' percepLlons of Lhe
effecLlveness and accepLablllLy of an lndlvldual quallLy monlLorlng and feedback programme. 1he underlylng
dlmenslonallLy of scales deslgned Lo measure effecLlveness and conLexL for effecLlve engagemenL wlLh Lhe programme ls
explored.

Methods: 1he survey was developed and plloLed by a mulLldlsclpllnary Leam comprlslng cllnlclans and researchers. 89
anaesLheLlsLs across 2 nPS 1rusLs compleLed Lhe measure. lnLernal conslsLency was assessed uslng Cronbach's o and L
LesLs Lo ascerLaln lLem dlscrlmlnaLlon. 1o lnvesLlgaLe Lhe hypoLhesls LhaL Lhere would be ldenLlflable laLenL facLors
underlylng Lhe scales, exploraLory facLor analysls was used Lo lnvesLlgaLe Lhe underlylng survey dlmenslons wlLh
varlables lsolaLed lnLo facLors based on facLor loadlng. 1wo separaLe analyses were performed Lo ascerLaln Lhe laLenL
facLors underlylng percepLlons of quallLy lndlcaLors and feedback wlLhln Lhe programme (SecLlon C), and deparLmenLal
cllmaLe (SecLlon u). uurlng developmenL of Lhe survey, Lhree laLenL facLors were hypoLheslsed: quallLy lndlcaLor
effecLlveness, feedback adequacy and usefulness of lnformaLlon for lmprovemenL.

kesu|ts: Scale rellablllLy analysls showed excellenL lnLernal conslsLency (o 0.91-0.97), parLlcularly supporLlng grouplng of
lLems perLalnlng Lo percelved effecLlveness of quallLy lndlcaLors and feedback. ln Lhe flrsL facLor analysls, whlch
addressed Lhe scales deslgned Lo measure percelved effecLlveness of Lhe quallLy monlLorlng and feedback programme, 2
laLenL varlables were ldenLlfled, explalnlng 80 of Lhe LoLal varlance. 1hese were deflned as: resenLaLlon of daLa" and
usefulness of daLa Lo achleve quallLy lmprovemenL LargeLs". 1hese flndlngs were conslsLenL wlLh 2 of Lhe 3 proposed
survey dlmenslons. ln Lhe second analysls, Lhe scale ercelved local deparLmenLal cllmaLe for effecLlve use of
feedback was examlned resulLlng ln 3 laLenL varlables, explalnlng 66 of Lhe LoLal varlance. 8ased upon lnLerpreLaLlon
of hlgh-loadlng lLems, Lhese were deflned as: Cpen culLure for proacLlve daLa use", uaLa lnLerpreLaLlon" and
knowledge for measuremenL drlven lmprovemenL".

Conc|us|on: 1hls sLudy supporLs Lhe valldlLy and rellablllLy of Lhe survey consLrucLs. lL ls posslble Lo measure
mulLldlmenslonal concepLs such as percepLlons on performance feedback uslng mulLl-scale lLems. LxploraLory facLor
analysls suggesLs LhaL deparLmenLal cllmaLe for effecLlve use of feedback ls mulLldlmenslonal, comprlslng Lhe need for
an open culLure for consLrucLlve use of daLa, capablllLy for effecLlve perlodlc revlew and lnLerpreLaLlon of daLa from
quallLy lndlcaLors and cllnlclan knowledge and skllls for uslng Lhe daLa effecLlvely Lo drlve lmprovemenL. 1hls survey
represenLs an lmporLanL Lool ln Lhe analysls of feedback lnlLlaLlves, aldlng Lhe ldenLlflcaLlon of key facLors Lo Lallor Lhe
deslgn of fuLure lnLervenLlons and promoLe effecLlve, acLlonable feedback from quallLy lndlcaLors Lo lmprove care
processes and ouLcomes.



2S11

kISk-8ASLD kLVALIDA1ICN CI WnC? 1nL SLAkCn ICk "nIGn-kISk" nAkMAC kAC1I1ICNLkS
uenham hlpps
1,*
, eLer 8. noyce
1
, ulanne arker
1
, uarren M. AshcrofL
1

1
unlverslLy of ManchesLer, ManchesLer, unlLed klngdom


Cb[ect|ves: ln Lhe unlLed klngdom, Lhe ueparLmenL of PealLh has proposed LhaL Lhe healLh care professlons arrange
perlodlc revalldaLlon of Lhelr members' flLness Lo pracLlse. A key prlnclple of such a scheme ls LhaL lL should be
proporLlonaLe Lo Lhe level of rlsk LhaL lL addresses. Powever, Lhls proposlLlon ralses a quesLlon for Lhe lmplemenLaLlon
of rlsk-based revalldaLlon: how should Lhe relaLlve rlsk of reglsLranLs be assessed? Cur ob[ecLlve was Lo lnvesLlgaLe how
hlgh- and low-rlsk pharmaclsLs mlghL be dlsLlngulshed ln pracLlce.

Methods: We carrled ouL Lwo sLudles. ln Lhe flrsL, we conducLed seml-sLrucLured lnLervlews wlLh LhlrLy-Lwo
sLakeholders (pharmacy sLaff, managers and servlce users) Lo obLaln Lhelr vlews abouL Lhe naLure of rlsk ln pharmacy
pracLlce and Lhe characLerlsLlcs of hlgh- and low-rlsk pharmaclsLs. 1he lnLervlew daLa were sub[ecLed Lo LemplaLe
analysls ln order Lo ellclL quallLaLlve Lhemes. 1hese were supplemenLed by rlsk ranklngs of 12 flcLlLlous pharmaclsLs
from a card-sorLlng exerclse conducLed durlng Lhe lnLervlew. ln Lhe second sLudy, we used boLh Lhe lnLervlew daLa and
flndlngs from prevlous work
1
Lo creaLe a posLal quesLlonnalre assesslng Lhe presence and level of pracLlLloner rlsk
facLors. 1hls quesLlonnalre was admlnlsLered Lo all reglsLered pharmaclsLs ln norLhern lreland. uaLa from reLurned
quesLlonnalres were sub[ecLed Lo mulLlvarlaLe analyses of varlance ln order Lo esLabllsh Lhe paLLern of rlsk facLors across
Lhe workforce.

kesu|ts: ln Lhe flrsL sLudy, Lhree maln Lhemes were generaLed from Lhe lnLervlew daLa: lndlvldual characLerlsLlcs, Lask
characLerlsLlcs, and organlsaLlonal characLerlsLlcs. 1he ranklng scores ldenLlfled pharmaclsLs Lralned ouLslde Lhe unlLed
klngdom as belng percelved Lo be parLlcularly hlgh rlsk, however, Lhe level of rlsk was proporLlonal Lo Lhe exLenL Lo
whlch Lhe counLry of Lralnlng dlffered from Lhe unlLed klngdom ln Lerms of pharmacy sysLems and culLural norms. ln
Lhe second sLudy, a maln effecL of pharmaclsL role was found [l (20,818) = 6.06, p < 0.001, Wllks' lambda = 0.76], such
LhaL some rlsk facLors were more prevalenL amongsL communlLy pharmaclsLs, whlle oLhers were more prevalenL
amongsL hosplLal pharmaclsLs. Powever, lnLeracLlons were found beLween role and oLher pharmaclsL characLerlsLlcs,
lncludlng Lhe level of senlorlLy and level of paLlenL conLacL.

Conc|us|on: 1he flndlngs from Lhe Lwo sLudles suggesL characLerlsLlcs of pharmaclsLs LhaL could lncrease Lhelr level of
pracLlce rlsk, for example, havlng dlrecL paLlenL conLacL or belng Lralned overseas. Powever, our work also hlghllghLs
conLexLual facLors LhaL compllcaLe aLLempLs Lo ldenLlfy hlgh-rlsk pracLlLloners. 1hese lnclude Lhe llmlLed avallablllLy of
demographlc and performance daLa abouL pharmaclsLs, as well as varlaLlon beLween pharmacy employers wlLh regard
Lo Lhe handllng of flLness Lo pracLlce concerns. WlLh Lhls ln mlnd, Lhe lmpllcaLlons of our work are Lwo-fold. llrsLly, Lhe
flndlngs provlde an lnlLlal framework for assesslng flLness Lo pracLlce rlsk facLors. Secondly, Lhey lndlcaLe ways ln whlch
Lhe daLa collecLed by pharmacy employers, educaLors and regulaLors can be used Lo lnform declslons abouL Lhe
LargeLlng of regulaLory resources.

keferences: 1. hlpps uL, noyce, 8, Walshe k, arker u, AshcrofL uM. harmaclsLs sub[ecLed Lo dlsclpllnary acLlon:
characLerlsLlcs and rlsk facLors. lot I lbotm ltoct 2011,19:367-73.


2S21

DLVLLCMLN1 CI A1ILN1 SAIL1 CUL1UkL SUkVL ANALSIS IkAMLWCkk USING 1nL ADA1LD MSI A1ILN1
SAIL1 CUL1UkL SUkVL 2007
Marcelo 1aborda
1, 2,*
, Carlos lrederlco lnLo
1, 2
, Lvelln MaroLLa
1, 2
, Marcla Ambroslo
2

1
P8v, 1aubaLe,
2
lnsLlLuLo de Cncologla do vale, Sao !ose dos Campos, 8razll


Cb[ect|ves: CreaLe an analysls meLhod for Lhe aLlenL SafeLy Awareness Survey, adapLed from Lhe Modlfled SLanford
lnsLrumenL (MSl-2007), as used by Lhe AccredlLaLlon Canada lnLernaLlonal and LranslaLed Lo 8razlllan orLuguese. 1he
MSl aLlenL SafeLy CulLure Survey ls deslgned Lo capLure sLaff percepLlons of paLlenL safeLy culLure ln Lhelr healLhcare
organlsaLlon (ref 2). lL conslsLs of an lnqulry on Lhe percepLlons and oplnlons of Lhe lnsLlLuLlons personnel abouL paLlenL
safeLy awareness wlLh quesLlons relaLed Lo leaders' acLlons on safeLy, Leam work, dlsLressed, work saLlsfacLlon, work
condlLlons and safeLy envlronmenL. 1he survey evaluaLed Lhe level of accordance Lo each sub[ecL.

Methods: 1he survey was LranslaLed and adapLed Lo 8razlllan orLuguese and applled Lo all personnel worklng aL our
CrganlsaLlon Lwo ma[or unlLs, comprlslng around 110 survey sub[ecLs. 1he lnsLlLuLo de Cncologla do vale ls an
ouLpaLlenL cancer cenLer wlLh faclllLles ln Lhree clLles ln So aulo SLaLe, 8razll. 1he resulLs were analysed ln Lhree
dlfferenL ways: globally, for each unlL, and for each unlL accordlng Lo worklng area:

a) paLlenL care or
b) admlnlsLraLlve personnel.

Surveys were applled durlng 2011 every Lhree Lo four monLhs, for a LoLal of four surveys, as parL of our 8lannual SLraLegy
ueploymenL for aLlenL SafeLy (Poshln kanrl).
Answers were classlfled as 1 (LoLally agree) Lo 3 (LoLally dlsagree). ln order Lo beLLer ldenLlfy Lhe Loplcs whlch mlghL need
Lo be worked on, we esLabllshed a colour sysLem Lo ldenLlfy sLrengLhs and weaknesses of our condlLlon: blue, yellow and
red, from good percept|on of pat|ent safety requ|rements (blue), average percept|on (yellow), and poor percept|on
(red: aLLenLlon requlred).

kesu|ts: 1he colours sysLem used Lo grade Lhe answers allowed us Lo easlly deLecL Lhe problemaLlc areas among 140
lLems analysed by Lhe survey. LfforL ln analysls lmprovemenL could be dlrecLed Lo Lhese areas speclflcally, savlng us Llme
and useless work. 1he dlvlslon of our sLaff ln Lwo malns caLegorles provlded a more reallsLlc approach Lo Lhe areas whlch
needed Lo be worked on or noL. We used a colored framework (Loo large Lo be dlsplayed here, buL wlll be avallable as
A3 hand-ouL) Lo ldenLlfy areas requlrlng aLLenLlon and Lhls framework was Lled Lo our value sLream acLlon plans.
ln Lhe flrsL survey we had 32 areas requlrlng aLLenLlon, Lhen dropped Lo 19, agaln Lo 13, and flnally 12 on our flnal
survey. noLeworLhy, Lhese lasL 12 areas were all graded as average and mosL of Lhem reflecLed problems ouLslde our
own value sLream maps (ref 1).

Conc|us|on: 1he survey reflecLed Lhe conLlnuous undersLandlng and Lhe lncreaslng sLrengLh of paLlenL safeLy awareness
LhroughouL Lhe organlsaLlon. 1he evaluaLlon meLhod clearly polnLed areas for lmprovemenL, and supporLed acLlons ln
order Lo undersLand and lmprove safeLy lnLo speclflc organlsaLlonal areas and slLes Lo acL upon, when needed.

keferences:
1. 8oLher M and Shook !. Learnlng Lo See: value SLream Mapplng Lo Add value and LllmlnaLe MuuA .1he Lean
LnLerprlse lnsLlLuLe, Cambrldge, 2002.
2. MSl aLlenL SafeLy CulLure Survey 2007, accessed aL:
hLLp://www.yorku.ca/paLlenLsafeLy/psculLure/quesLlonnalre/MSl20verslon202007_llnAL.pdf


2S27

CCN1INUCUS MCNI1CkING CI A1ILN1 SA1ISIAC1ICN IN AM8ULA1Ck SUkGLk kCVIDLS CLULS ICk IMkCVING
UALI1 CI CAkL
lda Welle
1,*
, Anne-Clalre 8ae
1
, lerre Chopard
1

1
Medlcal and CuallLy ulrecLoraLe, CuallLy of Care ulvlslon, Ceneva unlverslLy PosplLals, Ceneva 14, SwlLzerland


Cb[ect|ves: An on-golng prospecLlve quesLlonnalre survey, lnlLlaLed ln november 2012, alms Lo gulde care provlders aL
all levels ln an ambulaLory surglcal unlL on speclflc areas for lmprovemenL. aLlenLs' expecLaLlons ln a same-day surgery
ambulaLory unlL may vary subsLanLlally from Lhose ln an overnlghL-sLay hosplLal surgery. ln a shorL span of Llme, Lhe
paLlenL musL recelve Lhe adequaLe lnformaLlon Lo enable LrusL and confldence Lowards Lhe healLh sysLem, as well as
reduce hls/her anxleLy regardlng Lhe surglcal procedure lLself, and Lhls seLs a ma[or challenge (1).

Methods: A modlfled verslon of Lhe lcker aLlenL Lxperlence quesLlonnalre, adapLed Lo Lhe acLlvlLles ln Lhls speclflc
unlL, was posLed 3 weeks afLer Lhe paLlenL's dlscharge durlng a perlod of 8 consecuLlve weeks. All paLlenLs undergolng
same-day surgery ln Lhls unlL were lncluded ln Lhe survey. 1he quesLlonnalre conLalned 47 lLems assesslng paLlenLs'
degree of saLlsfacLlon. Lach lLem was coded for sLaLlsLlcal analysls as a dlchoLomous problem score". 8egresslon
analysls was performed uslng a loglsLlc mulLlvarlaLe model.

kesu|ts: Cverall response raLe was 37 (96/168). Among Lhose, 11 refused Lo flll ouL Lhe quesLlons due Lo bad healLh,
unwllllngness Lo parLlclpaLe, or noL speaklng lrench, resulLlng ln Lhe 84 Lrue respondenLs (34) over 8 weeks of
monlLorlng. 1here was no effecL of age or gender on Lhe saLlsfacLlon ouLcomes. AlLhough all paLlenLs were saLlsfled wlLh
Lhe overall care (32 excellenL, 39 very good, 29 good), dlssaLlsfacLlon relaLed Lo walLlng Llmes beLween admlsslon,
operaLlon and dlscharge was noLed, wlLh 24 noL havlng been lnformed abouL a posslble delay ln schedule of surglcal
procedure. nlne per cenL answered no" or parLlally Lo Lhe lLem surgeon or docLor's answers Lo paLlenL's quesLlons
were clear" whlch was a ma[or deLermlnanL ln explalnlng paLlenL's feellng of noL belng LreaLed safely (Cl: 1.6-3.8, p-
value<0.001). lurLhermore, 44 dlsapproved wlLh Lhe lLem surgeon or anaesLheslologlsL explalned clearly how paLlenL
would feel afLer surgery" whlch was slgnlflcanLly relaLed Lo Lhe paLlenL noL sure abouL recommendlng Lhls hosplLal Lo
frlends/famlly (Cl:0.3-1.6, p-value=0.004).

Conc|us|on: 1hese flndlngs hlghllghL Lhe need for lmprovlng communlcaLlon sLraLegy and skllls Lo ensure LhaL Lhe paLlenL
knows whaL Lo expecL. AccuraLe preoperaLlve lnformaLlon enhances LrusL and confldence, Lhereby hlgher paLlenL
saLlsfacLlon wlLh Lhe care rendered. Cbvlously, Lhere ls room for lmprovemenL as far as communlcaLlon ls concerned.

keferences: Lloyd, 8C. lmprovlng AmbulaLory Care 1hrough 8eLLer LlsLenlng. I Ambolototy cote Moooqe.2003,26:100-
109



2S30

1nL LIILC1 CI 8UNDLL CAkL 1C DLCkLASL 1nL MICU CLN1kAL LINL ASSCCIA1LD 8LCCDS1kLAM INILC1ICNS
Mln-!ung Puang
1,*
, ?a-Wen Sung
1
, !ong-8ung 1sal
2
, Sue-Pul Chen
1

1
ueparLmenL of nurslng,
2
ueparLmenL of ChesL Medlclne, kaohslung Medlcal unlverslLy PosplLal (kMuP), kaohslung,
1alwan


Cb[ect|ves: 1he resulLs of Lhe sLudy wlll help Lo undersLand and flnd evldence Lo supporL Lhe cenLral llne bundle
lnLervenLlon Lo decrease Lhe cenLral llne assoclaLed bloodsLream lnfecLlon (CLA8Sl).

Methods: 1he CLA8Sl ls one of Lhe healLhcare assoclaLed lnfecLlons. 1he cenLral caLheLer usually uses as vascular access
for medlcaLlon, parenLal nuLrlLlon and hemodynamlc monlLor. AlLhough Lhese caLheLers can provlde cllnlclans many
LherapeuLlc beneflLs, lnfecLlve paLhogens also can lnvaslve lnLo body Lhrough Lhese cenLral caLheLers and lnduce
subsequenL unnecessary lnfecLlon. 1herefore, we should pay much aLLenLlon on Lhe CLA8Sl. 1he blood sLream lnfecLlon
raLe of medlcal lnLenslve care unlL of kaohslung medlcal unlverslLy hosplLal was lncreaslng progresslvely durlng 2011
!an- May wlLh average raLe (4.7). 1herefore, we sLarL our cenLral llne bundle lnLervenLlon Lo reduce Lhe CLA8Sl slnce
2011 SepLember. 1he prlnclples of bundle lnLervenLlon were lncluded:

(1) hand washlng,
(2) maxlmal barrler precauLlons (head Lo Loe),
(3) skln preparaLlon wlLh 2 chlorhexldlne,
(4) avoldance of femoral lnserLlon slLes,
(3) dresslng was changed every 48 hours lf uslng a gauze dresslng and every 7 days lf uslng a LransparenL dresslng, (6)
dally revlew of llne necesslLy wlLh prompL removal of unnecessary llnes by docLors and nurslng sLaff.

kesu|ts: AfLer Lhe bundle care lnLervenLlon sLarLed on 2011-SepLember, Lhe average CLA8Sl raLe Lo daLe was decreased
from4.7Lo 2.76. 1he duraLlon of caLheLer use was decreased from 6.7 days Lo 3.8 days. 1he lncldence of cenLral
caLheLer was also decreased from 62.1Lo 34.66.

Conc|us|on: WlLh Lralnlng course, educaLlon, slmpllfled check llsL and vlsuallsed lllusLraLlve card, our Leam could be
famlllar and correcL lmplemenLed bundle care. Cne of lmporLanL elemenL ln Lhls pro[ecL was organlsaLlon supporL made
lnLer-Leam wlLh good lnLeracLlon. 1he essenLlal facLor was physlclans and nurses assess necessary ln cenLral venous
caLheLer. We used poslLlve feedback and announce CLA8Sl raLe lmmedlaLely Lo enhance sLaff felL a parL of Leam. Cur
resulLs had shown bloodsLream lnfecLlon (8Sl) bundle care can decrease Lhe CLA8Sl raLe of medlcal lCu effecLlvely.
lurLhermore, Lhe 8Sl bundle care was applled Lo all lCus of our hosplLal successfully. We hope LhaL Lhe 8Sl bundle care
can be applled Lo all our hosplLal wards, lncludlng operaLlon room and emergency room.


2S33

LkCL1ICN kLCk1ING IN 1nL IkLNCn nCSI1AL UALI1 AND SAIL1 INDICA1CkS IkAMLWCkk: DISCkL1ICNAk LkCL1ICN
kLCk1ING CI CnkCNIC nLMCDIALSIS A1ILN1S
lrederlc Capuano
1,*
, Sophle CoubeL
1
, CaLherlne Crenler
1
, Marle-Annlck Le-ogam
1

1
PauLe AuLorlLe de SanLe, SalnL denls, lrance


Cb[ect|ves: We adapLed Lhe uk CuallLy and CuLcomes lramework excepLlon reporLlng concepL Lo lrench hosplLal quallLy and safeLy
lndlcaLors (Cls) and sLudled Lhe lmpacL of exempLlng paLlenLs from reporLlng on Lhe resulLs of chronlc haemodlalysls quallLy
lndlcaLors.

Methods: ln 2012, 10 Cls assesslng quallLy of hosplLal care ln chronlc haemodlalysls were generallsed aL a naLlonal level and publlcly
reporLed by Lhe naLlonal AuLhorlLy for PealLh (PAS). uaLa requlred for each Cl calculaLlon were obLalned uslng reLrospecLlve revlew
of 60 paLlenL medlcal records randomly selecLed ln 304 hosplLals (14307 records were analysed). 1o accommodaLe Lhe facL LhaL noL
all paLlenLs flL lnLo populaLlon averages, nephrologlsLs were permlLLed Lo use Lhelr cllnlcal [udgmenL Lo remove lnapproprlaLe
paLlenLs from achlevemenL calculaLlons for all Cls. LxcepLlon reporLs guldance noLes were glven Lo docLors. lor each hosplLal and
each Cl we calculaLed Lhe excepLlon reporLlng raLe (L88) as Lhe number of excepLed paLlenLs dlvlded by Lhe number of ellglble
paLlenLs. 1he overall raLe for a hosplLal was obLalned by summlng excepLlons for all Cls and dlvldlng by Lhe sum of ellglble paLlenLs.
1he lmpacL of exempLlng paLlenLs from reporLlng on Lhe resulLs of chronlc haemodlalysls Cls was sLudled uslng ad[usLed odds raLlos
(C8) relaLlng selecLed paLlenL characLerlsLlcs (age, gender) for blnary Cls. 1o accounL for wlLhln-hosplLal correlaLlon and Lhe
hlerarchlcal sLrucLure of Lhe daLa, we used generallsed llnear model and generallsed esLlmaLlon equaLlons Lo esLlmaLe Lhe
parameLers of Lhe model. We compared Lhe resulLs of composlLe quallLy scores uslng ad[usLed llnear mlxed model.

kesu|ts: 1he medlan L88 across hosplLals was 7.7 varylng from 7.6 for dlalysls prescrlpLlon orders" Lo 8.2 for monlLorlng of
lron sLaLus ln paLlenLs Laklng eryLhropolesls sLlmulaLlng agenLs. 1he medlan L88 across all 10 Cls was 3.8 (mln 0 max 100)
(lnLer-quarLlle range 0-10.1). Conslderlng Lhe lmpacL of exempLlng paLlenLs from reporLlng on Cls resulLs we found LhaL excepLlon
reporLed paLlenLs" (L8) had slgnlflcanLly poorer resulLs Lhan average paLlenLs" (A) for 6 Cls : anaemla managemenL", nuLrlLlon
managemenL", vascular access", dlalysls adequacy", laboraLory LesLs", dlalysls prescrlpLlon orders" (Lable). 1he flrsL 4 Cls are
publlcly reporLed excludlng L8 from calculaLlons. Cn Lhe conLrary, Lhe 2 oLhers are publlcly reporLed lncludlng L8 (L88 = 7.7).
CollecLed durlng daLa medlcal record revlew, reasons for excepLlon reporLlng were loglsLlcal and cllnlcal (conLralndlcaLlon or
lnLolerance, paLlenL unsulLable).

I Unad[usted I - A Unad[usted I - Lk Ad[usted Ck for b|nary |nd|cators -
p va|ues for compos|te scores
Anaem|a management Cl
Nutr|t|on management l
Vascu|ar access l
D|a|ys|s adequacy l
63
78
87
79
31
67
76
63
1.4 [1.3-1.6]
1.4 [1.1-1.8]
1.S [1.3-1.8]
1.6 [1.4-1.8]
Laboratory tests l
Mon|tor|ng of Ca- product l
Mon|tor|ng of |ron status |n LSA+ pat|ents
l
Sero|ogy for hepat|t|s l
D|a|ys|s prescr|pt|on orders Cl
Access to trans-p|antat|on l
73
89
74
88
77
70
63
83
76
83
68
72
<.0001
1.2 [1.0-1.3]
0.9 [0.8-1.1]
1.1 [0.9-1.3]
<.0001
1.0 [0.8-1.2]

l=rocess lndlcaLor / Cl=CuLcome lndlcaLor

Conc|us|on: LxcepLlon reporLlng could be a good sLraLegy Lo engage hosplLal physlclans ln quallLy lmprovemenL. lndeed, Lhe
provlslon Lo excepLlon reporL enables Lhem Lo exempL non-average paLlenLs" from calculaLlons for mandaLory publlcly reporLed
Cls. ln addlLlon, lL could proLecL paLlenLs from lnapproprlaLe or over-LreaLmenL. AL lasL, daLa collecLlon ls faclllLaLed and less Llme
consumlng. 1he lmporLanL varlablllLy of L88 across Cls could reflecL elLher a gamlng mechanlsm or lnsufflclenL excepLlon reporLs
guldance.

2S38

kLDUCING kLCCkDLD CLN1kAL VLNCUS CA1nL1Lk DISLCDGLMLN1 INCIDLN1S AND 1nL U1ILISA1ICN kA1L IN 1nL
NLUkCSUkGICAL IN1LNSIVL CAkL UNI1
Chao -?un Wang
1,*

1
lnLenslve Care unlL, kaohslng Medlcal unlverslLy Chung-Po Memorlal PosplLal, kaohslung, 1alwan


Cb[ect|ves: 1he cenLral venous caLheLer was used for ln[ecLlng hlgh permeablllLy drugs and monlLorlng Lhe hemodynamlc sLaLus. 1he
uLlllsaLlon raLe of cenLral venous caLheLer was approxlmaLely 61.8 Lo 77.3 and Lhe lndwelllng duraLlon was abouL 3 Lo 7 days ln
our neurosurglcal lnLenslve care unlL. 1he dlslodgemenL raLe was 0.83 Lo 1.34 durlng May 2010 and CcLober 2011. 1he lncldenL
occurred once per monLh ln average. 1he lnLegraLed care model, developed by our ad hoc group, uslng Lhe resources, decreased Lhe
average dlslodgemenL raLe of Lhe cenLral venous caLheLer Lo 0.3 or less, and, accordlngly, reduced Lhe usage of cenLral venous
caLheLer.

Methods: 1he ad hoc group was seL up ln november, 2011, and expecLed Lo reduce cenLral venous caLheLer dlslodgemenL raLe by
uslng Lhe resources lnLegraLed care model, as well as reduce Lhe usage of Lhe cenLral venous caLheLer. 1he pro[ecL perlod was
from november, 2011 Lo May, 2012. ln our unlL, Lhe posslble reasons of Lhe cenLral venous caLheLer dlslodgemenL lncldenLs were:

a) caLheLer ls overloaded and lndwelllng lengLh ls noL approprlaLe,
b) paLlenLs self-exLrlcaLe Lhe caLheLer
c) Lhe caLheLer ls noL well-flxed,
d) Lhe lack of Lhe communlcaLlon plaLform for healLh care provlders Lo dlscuss Lhe purpose of caLheLer replacemenL and Lo revlew
Lhe currenL slLuaLlon of Lhe caLheLer dlslodgemenL.

lnLervenLlons are as follows:

a) sLandardlse Lhe flxed meLhod and lengLh of a cenLral venous caLheLer and plcLure wlLh Lhls sLandardlsed procedure reLalned aL
Lhe nurslng sLaLlon or Lhe car's compuLer deskLop,
b) provlde Lhe admlnlsLraLlon of sedaLlon, proLecLlon consLralnLs, or removal of caLheLer accordlng Lo lndlvldual paLlenL and
speclflc dlsease,
c) reconflrm Lhe poslLlon and Lhe flxed suLures of Lhe caLheLer durlng every shlfL LranslLlon , and
d) seL Lhe shlfL whlLeboard, mark a flxed poslLlon, and record Lhe days of Lhe cenLral venous caLheLer replacemenL medlcal Leam
communlcaLe and dlscuss Lhe medlcaLlon and Lhe goal of Lherapy whlch are relaLed Lo Lhe necesslLy of caLheLer replacemenL
dally
e) use Lhe cenLral venous caLheLer usage and monlLorlng record, and nurses assess Lhe purposes, bleedlng / hemaLoma slLuaLlon,
flxed suLure condlLlon, dresslng, and obsLrucLlon of Lhe cenLral venous caLheLers, dally, (vl) produce lCu lndlcaLor managemenL
Lrafflc llghL posLers, posLed ln fronL of Lhe nurslng sLaLlon, and dlsplay Lhe accumulaLlve days wlLhouL dlslodgemenL and Lhe
monLhly uLlllsaLlon raLe of Lhe cenLral venous caLheLer.

kesu|ts: uurlng november, 2011 and May, 2012, Lhe cenLral venous caLheLer dlslodgemenL raLe was 0, and Lhe uLlllsaLlon raLe was
abouL 38.9 Lo 36.6. when applylng Lo oLher lCu, Llll SepLember 11, 2012, Lhe accumulaLlve days wlLhouL cenLral venous caLheLer
dlslodgemenL are344 days ln our unlL, and Lhe accumulaLlve days wlLhouL cenLral venous caLheLer dlslodgemenL are 268, 273, and
779 days respecLlvely ln oLher adulL lCus.

Conc|us|on: 8y repeaLed propaganda and Leam communlcaLlon, Lhe healLh care Leam conflrmed Lhe lmporLanL lLems and Lhe goal of
LreaLmenL durlng Lhe pro[ecL lmplemenLaLlon. 1he purpose of Lhe pro[ecL was achleved by Lhe way of Lhe Leamwork. Cur
expecLaLlon ls Lo keep uslng Lhe resource lnLegraLed care model Lo lmprovlng Lhe quallLy of medlcal care ln Lhe fuLure.

keferences:
1. kemper, l., de 8rul[ne, M., van uyck, C., Wagner, C. (2011). LffecLlveness of classroom based crew resource managemenL
Lralnlng ln Lhe lnLenslve care unlL: sLudy deslgn of a conLrolled Lrlal. 8Mc neoltb 5etv kes, 11(1), 304.
2. 8eader, 1W., llln, 8., Mearns, k., CuLhberLson, 8P. (2009). ueveloplng a Leam performance framework for Lhe lnLenslve care
unlL. ctltlcol cote MeJlcloe, 37,1787-1793.

2S43

NUkSING-INI1IA1IVL ASSLSSMLN1 AND MUL1IDISCILINAk CCLLA8CkA1IVL nIGn-kISk A1ILN1 CAkL
Shu-1al Sheen Pslao
1,*
, el-Llng Wang
1
, ?lh-!ong Psleh
2

1
nurslng ueparLmenL,
2
lnformaLlon ManagemenL Cfflce, 1alpel Medlcal unlverslLy PosplLal, 1alpel, 1alwan


Cb[ect|ves: 1o esLabllsh a slmpllfled, real-Llme hlgh-rlsk paLlenL assessmenL, Lo sLrengLhen Lhe hlgh-rlsk alerLness and
mulLldlsclpllnary communlcaLlon & collaboraLlon, Lo ensure Lhe paLlenL safeLy.

Methods: urposlvely sampllng was used. MulLldlsclpllnary healLhcare provlders ln a reglonal hosplLal of norLhern 1alwan were
lncluded. nurses were Lhe message-provlder and oLher healLhcare Leam members were as Lhe message-recelver. And followlng
approaches were lmplemenLed.

1. lnLegraLed mulLldlsclpllnary consensus regardlng Lhe hlgh rlsk crlLerla of nuLrlLlon, funcLlonal sLaLus, sulclde/self-harm, smoklng
and dlscharge preparaLlon lnLo Lhe nurslng-lnlLlaLlve assessmenL.
2. Modlfled and lnLegraLed mulLldlsclpllnary workflow lnLo hosplLallsed paLlenL [ourney.
3. urchased of wlreless devlce (nurslng lnformaLlon sysLem, nurslng moblle carL, smarL phone) and bullL up hosplLal-wlde Wl-ll
access envlronmenL.
4. LducaLlon on healLhcare members.

kesu|ts:
1. A new Cloud Plgh-8lsk nurslng-based AssessmenL SysLemn-CP8nbAS was seL up. lL's operaLlng easlly and lnformaLlon
Lransform auLomaLlcally anywhere any Llme wlLhln Lhe nurses performed monlLorlng. nurses LhoughL LhaL Lhe n-CP8nbAS
makes nurslng documenL slmpllfled, and less lnLerrupLlon wlLhln care. 1he average nurses monlLorlng Llme decrease 6.33
mlnuLes/paLlenL/day, esLlmaLes LoLal savlngs were 1,382.30 hours of monLhly nurses work Llme ln a 300 beds general hosplLal.
1hus nurses can work efflclenLly, make Lhe Llme reLurn Lo dlrecL paLlenL care, and paLlenL saLlsfacLlon elevaLed.
2. hyslclans can search and read Lhe paLlenLs' daLa and lnformaLlon by dlverslfled approaches llke smarL phone, nurslng
lnformaLlcs carL, personal compuLer, or panel C as avallable. lL lmproves Lhe communlcaLlon, and sharlng Lhe real-Llme paLlenL
lnformaLlon among healLhcare Leam members.
3. SLrengLhenlng Lhe rlsk alerLness of healLhcare Leam members, Lhe hlgh rlsk lnlLlal screenlng assessmenL raLes and reporLlng
cases boLh lncreased. MulLldlsclpllnary lnLervenLlons and conLlnuous follow-up were performed ln Llmellness.
4. 1he paLlenL saLlsfacLlon lmproved, lL's 1.3 hlgher afLer lnLervenLlon 2012.

(1) 1he nurslng-lnlLlaLlve assessmenL and mulLldlsclpllnary collaboraLlve hlgh-rlsk paLlenL care model was seL up. 1he assessmenL
lnformaLlon was encoded by nurses, and LransporLlng auLomaLlcally aL anyLlme and anywhere, slmulLaneously, hlgh-rlsk alerL
paLlenL llsL were ouLpuL.
(2) 1he sysLem makes nurslng documenL slmpllfled, and less lnLerrupLs whlle nurslng care. lL sLrengLhened Lhe rlsk alerLness of
healLhcare members, Lhe hlgh rlsk lnlLlal screenlng raLes and reporLlng cases boLh lncreased.
(3) MulLldlsclpllnary healLhcare members were able Lo read Lhe lnformaLlon by dlverslfled approaches as avallable. lL lmproves Lhe
mulLldlsclpllnary communlcaLlon.
(4) MulLldlsclpllnary lnLervenLlons and conLlnuous follow-up were performed ln Llmellness.

Conc|us|on: nowadays, medlcal resources and nurslng manpower are lmporLanL scarce resources. nurslng-lnlLlaLlve assessmenL and
mulLldlsclpllnary collaboraLlve hlgh-rlsk paLlenL care model ls an effecLlve sLraLegy Lo ldenLlfled Lhe nuLrlLlon, funcLlonal sLaLus,
sulclde /self-harm, smoklng, and dlscharge preparaLlon hlgh-rlsk paLlenL ln advance. Slmpllfy nurses worklng and wlLhouL repeaLed
Lranscrlblng ensure paLlenLs' daLa and lnformaLlon accuracy, and Lhe auLomaLlcally real-Llme LransporLlng also lmprove
mulLldlsclpllnary communlcaLlon and collaboraLlon. llnally, Lhls lmproves Lhe paLlenL safeLy and nurslng-frlendly workplace.



2S48

SkIN CAkL CI 1nL LLDLkL IN CnLSnIkL nCML, SnA1IN
Wal-Chl 1sung
1,*
, Susanna Chan
1
, Pelen Chan
2

1
nurslng dlvlslon, Cheshlre Pome, ShaLln,
2
neLhersole School of nurslng laculLy of Medlclne, Chlnese unlverslLy of Pong
kong, Pong kong, Pong kong


Cb[ect|ves: 1o lnvesLlgaLe Lhe effecLs of emolllenL Lherapy on skln condlLlons among Lhe elderly ln Lhe long-Lerm care
seLLlng.

Methods: lL ls a quasl-experlmenLal sLudy by comparlng an lnLervenLlon group agalnsL Lhe conLrol group. lL was a 8 week
sLudy from uec 2011 Lo leb 2012. 1he LargeLs were Lhe elderly 63yrs or above ln Lhe lnflrmary unlL of SCP. ln
lnLervenLlon group, emulslfylng olnLmenL was used as body wash whlch was followed by an emolllenL mlxLure of
emulslfylng olnLmenL, vasellne, aqueous cream and ollve oll. ln conLrol group, commerclal body wash and skln molsLure
producLs were used. 1he Cverall ury Skln Score (CuS) and Lhe ury Skln Area and SeverlLy lndex (uASl) are used as an
assessmenL Lools.
kesu|ts:
1he mean age of Lhe sub[ecLs was 81.62 ranglng from 63 Lo 97 years. 38 parLlclpanLs compleLed Lhe sLudy wlLh 30 and
28 of Lhem ln Lhe lnLervenLlon group and Lhe conLrol group respecLlvely. MosL of Lhem were female and LoLally AuL
dependenL. 8efore Lhe lnLervenLlon, more Lhan half of Lhe sub[ecLs had mlld Lo moderaLe skln dryness, especlally on Lhe
lower exLremlLles. Cnly a small number of Lhem had severe skln dryness problems. 8y comparlng Lhe CuS scores
beLween Lhe Lwo groups aL dlfferenL Llme polnLs, Lhere was slgnlflcanL lmprovemenL ln Lhe skln condlLlon of Lhe sub[ecLs
ln Lhe lnLervenLlon group aL Lhe end week (p=0.034 by Mann-WhlLney u LesL). 1he uASl of Lhe lnLervenLlon group had
dropped dramaLlcally lndlcaLlng LhaL Lhe skln condlLlons of Lhe sub[ecLs ln Lhe group were greaLly lmproved. Powever,
sLaLlsLlcal dlfference beLween Lhe lnLervenLlon and conLrol groups was only noLed ln Lhe lefL hands.

Conc|us|on: 1here are flndlngs whlch suggesLed LhaL emolllenL Lherapy was effecLlve ln lmprovlng skln hydraLlon of Lhe
elderly. Powever, Lhe sLudy was llmlLed by small sample slze, so cauLlon should be Laken ln Lhe lnLerpreLaLlon of Lhe
flndlngs.



2S49

INICkMA1ICN 1kANSILk AND CCMMUNICA1ICN DUkING 1nL MCkNING kCUNDS IN SUkGICAL DLAk1MLN1S: AN
C8SLkVA1ICNAL S1UD CN 1nL USL CI S8Ak
Panneke MerLen
1, 2,*
, Maalke Langelaan
2
, Cordula Wagner
1, 2

1
ueparLmenL of ubllc and CccupaLlonal PealLh, LMCC lnsLlLuLe for PealLh and Care 8esearch, AmsLerdam,
2
nlvLL,
neLherlands lnsLlLuLe for PealLh Servlces 8esearch, uLrechL, neLherlands


Cb[ect|ves: 1o sLudy Lhe sLrucLure and compleLeness of Lhe lnformaLlon Lransfer beLween nurses and physlclans durlng
Lhe mornlng rounds on surglcal wards afLer Lhe lmplemenLaLlon of Lhe S8A8-communlcaLlon Lool.

Methods: ln collaboraLlon wlLh Lhe care professlonals, we ad[usLed Lhe S8A8-Lool (SlLuaLlon, 8ackground, AssessmenL,
and 8ecommendaLlon) for use ln Lhe parLlclpaLlng surglcal wards. 1he Lool was lmplemenLed amongsL Lhe nurses of
Lhree surglcal wards ln uuLch hosplLals. resenLaLlons abouL Lhe background and Lhe use of Lhe S8A8-Lool were glven,
along wlLh example cases. 1he nurses Lhen recelved a pockeL-slze S8A8-card descrlblng Lhe relevanL Loplcs Lo dlscuss
durlng Lhe mornlng rounds.

An observaLlon proLocol was developed Lo observe Lhe use of Lhe S8A8-Lool durlng Lhe mornlng rounds. 1he observaLlon
proLocol conslsLed of Lwo dlfferenL parLs, Lhe flrsL parL was abouL Lhe process of Lhe mornlng rounds. 1o lllusLraLe,
lnformaLlon was collecLed on who Lakes Lhe lead durlng Lhe rounds and wheLher Lhe care professlonals parLlclpaLlng ln
Lhe rounds gave Lhelr oplnlon abouL Lhe suggesLed LreaLmenL. 1he second parL of Lhe observaLlon proLocol lncluded Lhe
Loplcs of Lhe S8A8 sLrucLure and wheLher Lhey were dlscussed for each lndlvldual paLlenL by Lhe care professlonals
(physlclans and nurses). CbservaLlons of Lhe mornlng rounds were done approxlmaLely once a monLh on Lhe Lhree
surglcal wards from SepLember 2008 unLll SepLember 2009. uescrlpLlve sLaLlsLlcs were used Lo analyse Lhe resulLs.

kesu|ts: ln LoLal, 43 mornlng rounds were observed ln whlch 719 paLlenLs were dlscussed by Lhe care professlonals LhaL
parLlclpaLed ln Lhe rounds. 1he observaLlons showed a subsLanLlal varlaLlon ln Lhe way Lhe mornlng rounds were
conducLed beLween Lhe hosplLals, such as Lhe average Llme per paLlenL (range 2-21 mlnuLes) and Lhe performed Lasks.
1here were also slmllarlLles, ln 36 of Lhe 43 rounds one of Lhe care professlonals Look Lhe lead, usually Lhe ward
physlclan or Lhe surglcal resldenL, never Lhe nurse. ln 30 rounds Lhere were (almosL) no lnLerrupLlons. uurlng 17 rounds
Lhe nurses asked quesLlons regularly and Lhe parLlclpanLs gave Lhelr unasked oplnlon regularly durlng slx rounds.
1he resulLs of Lhe lndlvldual paLlenL observaLlons showed LhaL all Lhe elemenLs and sLrucLure of S8A8 were dlscussed
and used for 20 paLlenLs (3). 1he SlLuaLlon was dlscussed for 86 of Lhe paLlenLs, Lhe 8ackground for 38, Lhe
AssessmenL for 73 and Lhe 8ecommendaLlons for 84 of Lhe paLlenLs. 1he speclflc Llmeframe for a requlred acLlon was
addressed for 32 of Lhe paLlenLs and for 3 Lhe acLlons were reporLed back for conflrmaLlon.

Conc|us|on: AlLhough some elemenLs of Lhe S8A8 were ofLen dlscussed for lndlvldual paLlenLs by Lhe care professlonals,
Lhe S8A8 sLrucLure was rarely used compleLely Lo sLrucLure Lhe lnformaLlon Lransfer and communlcaLlon beLween Lhe
nurses and Lhe physlclans. 1hls flndlng may be explalned by Lhe exlsLlng dlfferences beLween Lhe Lhree surglcal wards,
Lhe force of hablL durlng Lhe mornlng rounds as well as Lhe facL LhaL Lhe physlclans raLher Lhan Lhe nurses were leadlng
Lhe mornlng rounds.



2SSS

kLCIILN1S CI nLAL1nCAkL AND NUkSING SLkVICLS kCVIDLD 8 MUNICIALI1ILS IN NCkWA ICk 2011
Solvelg Marle Perbern
1,*1
ueparLmenL of sLaLlsLlcs, norweglan ulrecLoraLe of PealLh, Cslo, norway

Cb[ect|ves: 1he daLa presenLed ln Lhls absLracL are from Lhe lLCS reglsLer. 1he lLCS reglsLer (lLCS) ls a pseudonymous reglsLer,
conLalnlng deLalled lnformaLlon abouL all appllcanLs and reclplenLs of healLh- and care servlces aL home and ln nurslng homes ln
norweglan munlclpallLles over Llme. 1he ob[ecLlve of Lhls absLracL ls Lo show Lhe dlfference beLween Lhe number of reclplenLs of
munlclpal healLhcare servlces provlded per 31.12.11 and Lhe servlces LhroughouL Lhe enLlre year.

Methods: 1he user's reglsLered need for asslsLance ln 13 dlfferenL acLlvlLles of dally llfe ls used Lo generaLe a manageable
represenLaLlon of Lhe relaLlonshlp beLween Lhe user's healLhcare needs and hls or hers recelved servlces. 1he resulL ls Lhree levels of
need of care LhaL are used Lo caLegorlse Lhe reclplenLs, Lhls because Lhe funcLlonal level scores ln Lhe lLCS reglsLer ls a mlnlmum
daLa seL and does noL cover all facLors LhaL affecL needs for asslsLance. Powever, by sLandardlslng Lhe 13 AuL measures wlLh score
values, Lhe resulLs can be used for sLaLlsLlcal purposes, and Lo show Lhe healLhcare servlce needs for groups of reclplenLs (l.e.
sLaLlsLlcally robusL groups). 8ecause Lhe reclplenLs may have had several servlces durlng Lhe course of Lhe year Lhe sum of reclplenLs
of Lhe dlfferenL servlce-comblnaLlons ls hlgher Lhan Lhe LoLal sum of reclplenLs (463 263 vs. 333 070). 1he servlce-comblnaLlons
8oLh home-nurslng care and home-based asslsLance ln dally llvlng" and CLher home-based servlces" are based on Lhe servlces Lhe
reclplenLs recelve LhroughouL Lhe year. A reclplenL LhaL for example has recelved home-nurslng care aL one polnL, and Lhen home-
based asslsLance ln dally llvlng aL anoLher polnL over Lhe course of Lhe year wlll be porLrayed ln 8oLh home-nurslng care and home-
based asslsLance ln dally llvlng", Lhls reclplenL should ldeally have been counLed on each of Lhe separaLe servlces. 1he resulL ls LhaL
Lhe servlce-comblnaLlons boLh" and oLher home-based servlces" ls sllghLly overrepresenLed, buL Lhe problem ls marglnal.

kesu|ts:
kec|p|ents of hea|thcare and nurs|ng serv|ces prov|ded by mun|c|pa||t|es per 31.12.11, together w|th f|ow through 2011.

Number of
rec|p|ents
per 31.12.11
Sum Low]
||m|ted
need of
care
Med|um to
h|gh need of
care
Lxtens|ve
need of
care
Undec|ared need of
care] not re|evant
1ota| number of
rec|p|ents throughout
2011
I|ow of
rec|p|ents
through 2011
ercenLage
A|| 268 813 100 38 32 22 8 333 070 1,2
Cn|y home-based
ass|stance |n da||y
||v|ng
43 346 100 63 21 10 6 43 321 1,0
Cn|y home-nurs|ng
care
70 166 100 48 33 8 9 103 473 1,3
8oth home-nurs|ng
care and home-
based ass|stance |n
da||y ||v|ng
63 370 100 26 30 23 1 91 737 1,4
Cther home-based
serv|ces
48 300 100 49 22 9 21 118 197 2,4
1|me-||m|ted stay |n
nurs|ng home w|th
24-hour care
9 199 100 13 41 41 3 34 122 3,9
ermanent
res|dence |n nurs|ng
home w|th 24-hour
care
34 232 100 2 17 80 1 48 413 1,4

Conc|us|on: 1here are 268 813 reclplenLs of munlclpal healLh and nurslng care per 31.12.11 ln norway, and 66 237 reclplenLs more
LhroughouL Lhe year. 1hls represenLs a conslderable number of reclplenLs Lo Lhe munlclpallLles ln norway. Cne can also see LhaL
Lhere ls conslderable flow Lhrough Lhe Llme-llmlLed sLay ln nurslng home" servlce compared Lo Lhe oLher servlce caLegorles, Lhls ls
also ls Lhe purpose of Lhls servlce. ln addlLlon Lhe Lable glves a good represenLaLlon of Lhe care ladder" ln Lhe way LhaL 80 of Lhe
ones wlLh exLenslve need of care are ln a permanenL place ln a nurslng home, and 63 of Lhe ones wlLh llmlLed need of care only
have home-based asslsLance ln dally llvlng. And of LoLally 333 070 reclplenLs of servlces Lhrough 2011, only 14 llves permanenLly ln
a nurslng home, Lhls ls a parL of Lhe governmenLs goals, people should be able Lo llve aL home as long as posslble.

keferences: 1he lLCS reglsLer, SLaLlsLlcs norway.

2S67

IMAC1 CN 1nL kCILSSICNAL LkICkMANCL CI A SkILLS ACCkLDI1A1ICN kCCLSS 8ASLD CN A Ck1ICLIC MCDLL: 1nL
ACSA MCDLL
Ana 8o[as-de-Mora-llgueroa
1
, AnLonlo Almuedo-az
1
, !ose AnLonlo Carrasco-eralLa
2,*
, 8egona 8ulza-Camacho
2

1
CerLlflcaLlon,
2
Andaluslan Agency for PealLhcare CuallLy, Sevllle, Spaln


Cb[ect|ves: 1o analyse Lhe lnfluence of Lhe rofesslonal Sklll AccredlLaLlon rocess on Lhe healLhcare professlonals performance.
1o compare Lhe degree of compllance of lndlvldual ob[ecLlves beLween professlonals who haven'L lnlLlaLed Lhelr professlonal skllls
accredlLaLlon process and Lhose who have lnlLlaLed or flnlshed Lhelr accredlLaLlon process.

Methods:
1. Sub[ecL of sLudy: healLhcare professlonals wlLh an unlverslLy degree
2. Scope: Andaluslan PealLh Servlce (SAS)
3. 1lmeframe: !anuary 2009 - uecember 2011
4. Sample slze: 30332 healLhcare professlonals
3. 1ype of deslgn: exploraLory analysls
6. lnsLrumenL:

1he lndlvldual ob[ecLlves of Lhe healLhcare professlonal derlve from Lhelr unlL's ob[ecLlves and Lhese reflecL Lhe PealLh SysLem
sLraLeglc dlrecLlon. 1herefore, nowadays, Lhe degree of compllance of lndlvldual ob[ecLlves ls Lhe mosL rellable slgn for measurlng
Lhe professlonal performance. 1he daLa relaLed Lo Lhe degree of compllance of lndlvldual ob[ecLlves were obLalned by SAS. 1he
maxlmum score LhaL can be achleved by a healLhcare professlonal ls 10 polnLs.

1he Andaluslan Agency for PealLhcare CuallLy (ACSA), accredlLed by LnAC and lSCuA, ls an organlsaLlon whlch belongs Lo Lhe ubllc
PealLh SysLem. ACSA has developed a volunLary rofesslonal Skllls AccredlLaLlon rogramme Lo recognlse Lhe excellence of
healLhcare professlonals. 1hls programme ls based on Lhe professlonal skllls assessmenL wlLh a porLfollo meLhodology. 1he daLa
relaLed Lo Lhe accredlLaLlon of Lhe professlonals were obLalned by Me_[ora , Lhe AccredlLaLlon rogramme web appllcaLlon.

kesu|ts: 1he followlng Lable shows Lhe average score of lndlvldual ob[ecLlves ln professlonals who haven'L lnlLlaLed Lhelr professlonal
skllls accredlLaLlon process, professlonals who have lnlLlaLed lL and ln Lhose who have flnlshed lL:

ear rofess|ona|s who haven't
|n|t|ated the|r profess|ona|
sk|||s accred|tat|on process
rofess|ona|s who have
|n|t|ated the|r profess|ona|
sk|||s accred|tat|on process
rofess|ona|s who have f|n|shed the|r
profess|ona| sk|||s accred|tat|on
process
2009 average score of
|nd|v|dua|
ob[ect|ves
7,7044 8,2716 8,6374
standard dev|at|on
o
1,47406 1,23976 1,1211
2010 average score of
|nd|v|dua|
ob[ect|ves
8,30302 8,72302 9,09739
standard dev|at|on
o
1,330476 1,079281 0,948633
2011 average score of
|nd|v|dua|
ob[ect|ves
8,08397 8,33728 8,93986
standard dev|at|on
o
1,471831 1,217039 0,96178
-value=0,00.

rofesslonals who have lnlLlaLed Lhelr professlonal skllls accredlLaLlon process have beLLer resulLs Lhan professlonals who haven'L
lnlLlaLed lL. rofesslonals who have flnlshed Lhelr professlonal skllls accredlLaLlon process have Lhe besL resulLs. 1he averages
dlfferences are sLaLlsLlcally hlghly slgnlflcanL ln all cases (confldence lnLerval 99).

Conc|us|on: 1he obLalned resulLs make evldenL Lhe professlonal performance lmprovemenL ln Lhose professlonals who have
lnlLlaLed or flnlshed Lhelr professlonal skllls accredlLaLlon process wlLh Lhe ACSA Model.

2S70

IDLN1IIING SUkGICAL ADVLkSL LVLN1S IN Cn1nALMCLCGIC SUkGLk 1nkCUGn 1nL ANALSIS CI kL1UkN 1C
1nL CLkA1ING 1nLA1kL AND kL-ADMISSICNS
veronlque Merle
1,*
, !ulle Cueudry
2
, Carollne Savalle
1
, lerre Czernlchow
1

1
Lpldemlology and ubllc PealLh,
2
CphLalmology, 8ouen unlverslLy PosplLal, 8ouen, lrance


Cb[ect|ves: Lo assess Lhe performance of ldenLlfylng adverse evenLs assoclaLed wlLh ophLhalmologlc surgery by Lhe
analysls of reLurns Lo Lhe operaLlng LheaLre (8C1) and readmlsslons (8), ldenLlfled uslng Lhe hosplLal compuLerlsed
lnformaLlon sysLem.

Methods: 8C1/8 occurrlng 30 days or less afLer surgery or dlscharge from a hosplLal sLay ln ophLhalmology from Aprll Lo
!uly 2011 were ldenLlfled uslng Lhe hosplLal lnformaLlon sysLem. An epldemlologlsL revlewed compuLerlsed charLs ln
order Lo caLegorlse 8C1/8 lnLo: adverse evenL-assoclaLed (AL-8C1/8), non-adverse evenL assoclaLed, or undeLermlned
8C1/8. All charLs were Lhen revlewed by an ophLhalmologlc surgeon. 1he proporLlon of hosplLal sLays wlLh 8C1/8, and
poslLlve (v) and negaLlve (nv) predlcLlve values of 8C1/8 caLegorlsaLlon lnLo AL-8C1/8 by an epldemlologlsL as
compared Lo Lhe surgeon's [udgmenL (used as gold sLandard) were calculaLed.

kesu|ts: 1here were 37 (6, 2) 8C1/8 among 398 sLays. 1he resulLs of caLegorlsaLlon by Lhe epldemlologlsL and Lhe
ophLhalmologlc surgeon are dlsplayed below:



Surgeon's categorisation
(gold standard)
Epidemiologist's categorisation AE-ROT/R Non-AE-ROT/R
AE-ROT/R 9 2
In determined or Non-AE-ROT/R 2 24

v was 82, 93Cl [48-98] and nv was 92, 93Cl [73-99]. Adverse evenLs were: mass remalnlng lnslde Lhe lnLerlor
chamber afLer surgery (n=3), haemorrhage (n=2), nucleus luxaLlon requlrlng Lhe use of a fragmaLome (n=2), reLlnal
deLachmenL (n=2), oLher (n=2)

Conc|us|on: our meLhods helps Lo ldenLlfy serlous (l.e. assoclaLed wlLh readmlsslon or reoperaLlon) adverse evenLs ln
order Lo assess Lhelr frequency and Lype. 1he good epldemlologlsL-surgeon rellablllLy and especlally Lhe good nv
suggesL LhaL Lhe ldenLlflcaLlon of poLenLlal AL could be performed by Lhe epldemlologlsL, Lherefore avoldlng Llme loss for
surgeons. 1hls meLhod may be of lnLeresL ln Lhe process of selecLlng AL Lo be analysed ln a morbldlLy-morLallLy
conference, and could provlde an lndlcaLor of quallLy ln healLh care useful Lo assess Lhe efflcacy of lmprovemenL
measures ldenLlfled by Lhe morbldlLy-morLallLy conference.



2S73

USL CI 1LAM DL8kILIING 1C IMkCVL 1LAMWCkk IN 1nL CLkA1ING kCCM
Connle uekker - van uoorn
1, 2,*
, Llnda Wauben
3
, MarLlna 8ul[ac
1
, !ohan l. Lange
2

1
lnsLlLuLe of PealLh ollcy & ManagemenL, Lrasmus unlverslLy 8oLLerdam,
2
ueparLmenL of Surgery, Lrasmus MC
unlverslLy Medlcal CenLer 8oLLerdam, 8oLLerdam,
3
uepL. of 8lomechanlcal Lnglneerlng, laculLy of Mechanlcal
Lnglneerlng, uelfL unlverslLy of 1echnology,, uelfL, neLherlands


Cb[ect|ves: Crew 8esource ManagemenL (C8M) and Medlcal 1eam 1ralnlng (M11) have conLrlbuLed Lo a reducLlon ln
adverse evenLs. C8M and M11 are percelved as lnLenslve lnLervenLlons wlLh a hlgh lmpacL on Lhe work floor. As boLh are
complex Llme consumlng lnLervenLlons, Lhe C8M concepL was used Lo develop a Leam brleflng and debrleflng Lo lmprove
Leamwork and communlcaLlon Lhus reduclng Lhe number of lncldenLs ln Lhe operaLlng room (C8). 1he posL-operaLlve
debrleflng ls lmporLanL Lo dlscuss lncldenLs and ls Lherefore Lhe focus of Lhls sLudy.

Cb[ecLlves: 1o sLudy lf and how Lhe posLoperaLlve debrleflng was performed and how acLual usage could be enlarged Lo
lmprove Leamwork and communlcaLlon and enhance paLlenL safeLy.

Methods: LvaluaLlve sLudy deslgn. Surglcal Leam members from flve hosplLals were asked Lo compleLe a quesLlonnalre
and sLaLe Lhelr oplnlon on Lhe currenL slLuaLlon regardlng Lhe debrleflng. 1he quesLlonnalre conslsLed of Lwo parLs. 1he
flrsL parL comprlsed quesLlons Lo ellclL lnformaLlon on conLenL and formaL of Lhe debrleflng, and lf and how Lhe
lnformaLlon was reglsLered. 1he second parL conslsLed of quesLlons on lf and how Lhe lnformaLlon gaLhered could be
used Lo lmprove surglcal processes. MosL quesLlons were dlchoLomous (yes or no). Some quesLlons enabled
respondenLs Lo provlde addlLlonal lnformaLlon Lo polnL ouL anomalles ln Lhe debrleflng process and share Lhelr LhoughLs
on how Lo opLlmlse lLs ouLpuL.

kesu|ts: 87 (34 response) quesLlonnalres were compleLed, represenLlng all C8 dlsclpllnes. rellmlnary resulLs show
LhaL Lhe debrleflng Lakes place ln 80 of cases wlLh mosL Leam members presenL aL Lhe end of Lhe surglcal lnLervenLlon
[usL afLer wound closure. 1he surgeon ls always presenL, Lhe nurse anaesLheLlsL ln 92, and Lhe C8-nurse ln 88 of
cases. ln all hosplLals Lhe anaesLheLlsL ls absenL durlng mosL debrleflngs, whlch could be explalned by Lhe so-called 'Lwo-
Lable' sysLem LhaL ls used ln Lhe neLherlands. 1he anaesLheLlsLs leave Lhe C8 Lo prepare Lhe nexL paLlenL for surgery.
AlLhough documenLaLlon of Lhe debrleflng was reglsLered, ln dlglLal sysLems or mosLly wrlLLen down ln paLlenL records,
only 11 respondenLs conflrmed LhaL Lhe lnformaLlon resulLed ln acLlonable knowledge Lo lmprove safeLy. Causes
menLloned: lack of aLLenLlon by Lhe surglcal Leam (n=44), lack of communlcaLlon abouL Lhe ouLcome of Lhe debrleflng
(n=31), lack of feedback re lmprovemenLs by managemenL (n=32), and lack of Llme (n=14). nlneLy per cenL of
respondenLs suggesLed uslng 'evenL-based' lnformaLlon as feedback Lo Lhe enLlre C8-organlsaLlon and acLlve
parLlclpaLlon of Lhe C8-manager Lo enhance parLlclpaLlon of Leam members. MosL respondenLs (n=34) suggesLed Lo
lnLroduce formal mulLldlsclpllnary meeLlngs Lo dlscuss Lhe ouLcome of Lhe debrleflng, some (n=14) suggesLed Lo perform
Lhe debrleflng aL Lhe end of Lhe aesLheLlc procedure as Lhls ls a crlLlcal momenL ln Lhe procedure. MosL respondenLs
(n=33) lndlcaLed LhaL dlglLal reglsLraLlon would be Lhe besL way Lo documenL Lhe conLenLs of Lhe debrleflng, preferably
wlLh a sLandardlsed llsL of sub[ecLs.

Conc|us|on: AlLhough Lhe debrleflng ls regarded as useful, Lhere ls room for lmprovemenL. CommunlcaLlon could be
lmproved by dlscusslng Lhe ouLcomes ln mulLl-dlsclpllnary meeLlngs and shared wlLh Lhe enLlre C8 organlsaLlon. AcLlve
lnvolvemenL of C8 managemenL enhances Leam members parLlclpaLlon. lor dlglLal reglsLraLlon lL ls advlsable Lo lnclude
sub[ecLs, whlch are seen as hlghly lmporLanL ln Lhe local slLuaLlon.



2S7S

IMkCVING LIVLk 1kANSLAN1A1ICN SUkVIVAL kA1L 1nkCUGn nAkMACLU1ICAL CAkL IN1LkVLN1ICN 8
nAkMACIS1S
1S Wang
1,*
, 1? Wel
1
, 1P ?eh
1
, SP Sun
1

1
lar-LasLern Memorlal PosplLal, 1alpel, 1alwan


Cb[ect|ves: Accordlng Lo lnformaLlon provlded by 1alwan's naLlonal PealLh lnsurance daLabase from 2008 and 2009, Lhe
average 3 monLh survlval raLe for llver LransplanLaLlon was 90.69 and one-year survlval raLe was 83.64. 1eamwork
beLween all healLh professlonals ls lmporLanL because organ LransplanL paLlenLs need long-Lerm medlcal care.
lmmunosuppressanL pharmacoLherapy ls a crlLlcally lmporLanL aspecL of posL-LransplanL paLlenL care. Cur medlcal
cenLer ls engaged ln llver LransplanLaLlons slnce 2009. 1hls sLudy was Lo consLrucL a llver LransplanL paLlenL care model
by pharmaclsLs Lo lmprove Lhe quallLy of medlcal care.

Methods: 1hls sLudy consLrucLed a llver LransplanL paLlenL care model, lncludlng physlclans, nurses, pharmaclsLs,
dleLlclans and oLher healLhcare professlonals. 1hls sLudy was led by one of Lhe cllnlcal pharmaclsL. All paLlenLs who had
recelved a llver LransplanL from november 2010 Lo !une 2011 were lncluded ln Lhls sLudy. harmaclsL provlded lnpaLlenL
and ouLpaLlenL medlcaLlon educaLlon for Lhe paLlenL. ln addlLlon, pharmaclsL provlded consulLaLlon wlLh physlclans and
nurses. 1he pharmaclsL deslgned cllnlcal forms lncludlng paLlenL drug records and medlcaLlon dlarles. 1he sLudy
ouLcomes measured were survlval raLe, re[ecLlon raLe, lnfecLlon raLe, paLlenLs' medlcaLlon adherence, and physlclan,
nurses consulLlng accepLance.

kesu|ts: 1here were 130 face Lo face medlcaLlon educaLlon servlces provlded Lo 10 llver LransplanL paLlenLs. Lach
LransplanL paLlenL recelved on average 17 mlnuLes (range 10-33 mlnuLes) of medlcaLlon educaLlon. lor Lhese 10 llver
LransplanL paLlenLs, 3 monLh survlval raLe was 100. 1wo of 10 paLlenLs (20) were readmlLLed lnLo Lhe hosplLal due Lo
lnfecLlon and no one was admlLLed Lo hosplLal due Lo re[ecLlon. unforLunaLely, one of 10 paLlenLs (10) dled eleven
monLhs posL-LransplanL. All LransplanL paLlenLs recelved medlcaLlon educaLlon from pharmaclsLs, Lo monlLor Cnl drug
blood concenLraLlon were up Lo 90 Lhe proporLlon of Lhe LargeL range. lor cllnlcal pharmacy servlces, pharmaclsLs
provlded 34 consulLaLlons, lncludlng dose ad[usLmenL (38.8), drug lnformaLlon provlslon (32.4), assessmenL of
adverse drug reacLlons (3.9) and assessmenL of drug lnLeracLlons (2.9). All consulLlng of physlclans and nurses
accepLance were 100.

Conc|us|on: 1he llver LransplanL paLlenL care model provlded comprehenslve paLlenL care. 1he medlcal Leam
communlcaLlon and cooperaLlon lmproved llver LransplanL paLlenL care efflcacy and safeLy. WlLh Lhe pharmaclsLs'
parLlclpaLlon wlLh Lhe LransplanL Leam, paLlenL undersLandlng of medlcaLlon and LreaLmenL compllcaLlons were
enhanced. 1hls subsLanLlally beneflLs Lhe LransplanL paLlenL care. 1herefore, on-golng llver LransplanL paLlenL care model
would lmprove Lhe survlval raLe of LransplanL paLlenLs.



2S79

kLGICNAL CCMAkISCNS CI A MCkL nLAL1n-CkILN1LD nLAL1n-CAkL, UALI1 AND LIIICILNC, CCMAkISCNS
8L1WLLN CCUN1 CCUNCILS 2012
Marlanne AggesLam
1,*

1
1he naLlonal 8oard of PealLh and Welfare, SLockholm, Sweden


Cb[ect|ves: ln 2012 Lhe naLlonal 8oard of PealLh and Welfare publlshed for Lhe flrsL Llme a comparaLlve sLudy LhaL
ldenLlfled and compared lndlcaLors ln Lhe healLh care sysLem LhaL promoLes a poslLlve healLh developmenL from a
paLlenL perspecLlve and equallLy of healLh developmenL ln Lhe populaLlon as a whole. 1he reglonal comparlson Lrles Lo
answer how Lhe healLh care sysLem works wlLh healLh promoLlon and early dlsease prevenLlon, a reorlenLed healLh care
LhaL focuses noL [usL on Lhe Lechnlcal or pharmacologlcal LreaLmenL of a dlsease buL, comblnes lL wlLh above menLloned
aspecLs. Cf speclal concern are acLlons LhaL sLrengLhen and malnLaln Lhe physlcal, menLal and soclal well-belng,
lnvolvemenL and securlLy, as well as paLlenL's ablllLy Lo reach poslLlve effecLs ln Lhe LreaLmenL process. 1he alm ln Lhe
long Lerm perspecLlve ls Lo lmprove publlc healLh ln a general sense and reduce morLallLy and morbldlLy and lncrease
healLh-relaLed quallLy of llfe for paLlenLs wlLh an on-golng LreaLmenL. ulmenslons Lo conslder wlLhln Lhe healLh-orlenLed
framework are, a poslLlve healLh developmenL for paLlenLs, an equal healLh developmenL ln Lhe populaLlon as a whole, a
poslLlve healLh developmenL for healLh care professlonals Lo work more healLh orlenLed and flnally a healLh orlenLed
sLraLegy Lo manage a more effecLlve healLh care sysLem. 1hese dlmenslons are known and descrlbed ln Lhe CLLawa
CharLer for PealLh romoLlon (1986) by Lhe World PealLh CrganlzaLlon

Methods: MosL of Lhe Swedlsh healLh care ls publlcly flnanced. 1he naLlonal 8oard of PealLh and Welfare Lherefore
need Lo conLlnuously monlLor and evaluaLe Lhe healLh care sysLem ln publlc reporLlng. Cne way Lo monlLor Lhe healLh
care sysLem ls Lo compare performance assessmenLs on naLlonal and local levels. 8eglonal and local comparlsons ls a
meLhod LhaL have been ln use slnce 2003 ln Sweden and Lhe comparlsons are based on performance lndlcaLors
publlshed on a yearly basls. 1hese lndlcaLors reflecL dlfferenL perspecLlves ln healLh care for Lhe purpose Lo encourage
and Lo conLlnuously lmprove performance.

kesu|ts: 1he reporL lncludes a selecLlon of 30 lndlcaLors LhaL reflecL and compare resulLs on a reglonal level, how
professlonals ln Lhe healLh care advlce and supporL paLlenLs Lo reduce for lnsLance, unhealLhy hablLs llke smoklng LhaL
cause abouL 10 per cenL of Lhe burden of dlsease ln Sweden. 1o monlLor and LreaL rlsk facLors Lo LargeLed groups of
paLlenLs wlLh dlabeLes or sLroke ls lmporLanL ln order Lo reduce compllcaLlons. Some rlsk facLors have been ldenLlfled
and are frequenL among paLlenLs who are beLween 30 and 60 years of age LreaLed for dlabeLes ln prlmary care. More
Lhan half of Lhe women and half of Lhe men have obeslLy wlLh 8Ml over 30. Cne ouL of four paLlenLs ls smoklng and
physlcally lnacLlve. 1haL such a large proporLlon of paLlenLs wlLh dlabeLes have Lhese rlsk facLors ls worrylng. 1o reduce
smoklng among paLlenLs affecLed by sLroke ls lmporLanL slnce Lhey can be affecLed by a larger rlsk of oLher cardlo-
vascular dlseases. AbouL 43 per cenL of smokers have successfully qulL smoklng Lhree monLhs afLer Lhelr sLroke, Lhe
prevenLlve acLlons need Lo be more consldered.

Conc|us|on: 1he comparlson ls a flrsL sLep ln Lhe developmenL of how Lo monlLor healLh orlenLaLlon ln Lhe Swedlsh
healLh care sysLem. lor lnsLance, furLher developmenL of lndlcaLors LhaL reflecL paLlenL-reporLed ouLcome measures
(8CM) concernlng Lhelr healLh developmenL before and afLer LreaLmenL and paLlenL reporLed experlence measures
(8LM) concernlng acLlons LhaL relnforce empowermenL are of lnLeresL ln monlLorlng Lhls fleld.

keferences: 1he CLLawa CharLer for PealLh romoLlon, 1986, World PealLh CrganlzaLlon, CLLawa, Canada



2S81

IN1kCDUC1ICN CI A 1kIGGLk kCGkAM 1C AID kLCCGNI1ICN AND LSCALA1ICN CI DL1LkICkA1ING A1ILN1S IN
GLNLkAL WAkDS: LAkL CU1CCMLS A1 AN ACADLMIC MLDICAL CLN1Lk IN SINGACkL
SucharlLa PoLa
1,*
, uavld MaLhew
2
, Sandhya Mu[umdar
1
, aul !. Puggan
3

1
Medlcal Affalrs, naLlonal unlverslLy PosplLal, Slngapore, Slngapore,
2
Monash Medlcal School, Monash unlverslLy,
Melbourne, AusLralla,
3
ueparLmenL of Medlclne, naLlonal unlverslLy PosplLal, Slngapore, Slngapore


Cb[ect|ves: 1o lnLroduce a slmple recognlLlon and communlcaLlon Lool (Lhe 1rlgger") Lo help paLlenL care Leams (nurse,
[unlor and senlor docLor) ldenLlfy, assess and deflnlLlvely manage poLenLlally unsLable paLlenLs on general wards.

Methods: lannlng and lmplemenLaLlon of Lhls pro[ecL followed Lhe 8apld lmprovemenL LvenL (8lL) meLhod
recommended by Lhe nPS lnsLlLuLe for lnnovaLlon and lmprovemenL, ln use ln our 1069-bed hosplLal slnce 2008. re-8lL
core-Leam acLlvlLles encompassed llLeraLure revlew, quallLaLlve oplnlon survey and agreemenL on Lhe scope of Lhe
pro[ecL. 1he 8lL lLself was used Lo map process, ldenLlfy barrlers Lo recognlslng and managlng deLerloraLlng slLuaLlons on
general wards, wlden Lhe scope of consulLaLlon and agree acLlon. 1he concepL of a 1rlgger" was chosen for lLs slmple
crlLlcal meanlng and Lo llnk a menLal process model around whlch Lo lnLroduce communlcaLlon Lools, Lralnlng maLerlals,
documenLaLlon and publlclLy. Core lnLervenLlons lncluded redeslgn of Lhe hosplLal's colour-coded vlLal slgn charL and a
shorL cllnlcal paLhway for noLlflcaLlon and lnlLlal assessmenL of paLlenLs wlLh abnormal vlLal slgns (1rlggers). lollowlng a
plloL on Lwo general wards and followlng Lralnlng of 80 or more of all relevanL nurslng sLaff Lhe 1rlgger process was
rolled ouL Lo all adulL medlcal and surglcal wards (non-lCu) from mld-SepLember 2012. 1rlgger calls were made for Lhe
followlng reasons: resplraLory raLe >30, SpC
2
<93 wlLh a llC
2
0.28, pulse >130, sysLollc blood pressure < 90 mmPg,
acuLe change ln menLal sLaLus or serlous nurslng concern. We almed Lo sLudy early deaLh or lnLenslve Care unlL (lCu)
admlsslon, deflned as elLher ouLcome wlLhln 7 days of a Lrlgger.

kesu|ts: 8eLween CcLober and uecember 2012, 274 1rlgger evenLs were documenLed ln 230 paLlenLs, 244 of whom
conLrlbuLed ouLcome daLa. [19 paLlenLs Lrlggered Lwlce, one Lhree Llmes and one four Llmes]. 70/244 paLlenLs (28.6)
dled or were admlLLed Lo lCu wlLhln one week. 33/244 (14.3) were admlLLed Lo lCu of whom 33 (13.3) were
admlLLed wlLhln 48 hours. 33 of 42 deaLhs occurred ouLslde Lhe lCu. MonLhly raLes of 1rlgger evenLs were calculaLed per
1000 dlscharges and ranged from 3 per 1000 ln non-Plgh uependency unlL general surglcal paLlenLs Lo 83 per 1000
amongsL haemaLology-oncology paLlenLs, wlLh a hosplLal-wlde raLe of 20 per 1000 adulL dlscharges. 8esplraLory raLe was
Lhe mosL senslLlve lndlcaLor of elLher ouLcome. no slngle Lrlgger was less Lhan 23 senslLlve for lCu admlsslon or deaLh.

Conc|us|on: 1he 8lL meLhod addressed sysLem lssues relaLlng Lo deLerloraLlng paLlenLs. 1he 1rlgger paLhway emphaslsed
Lhe afferenL componenL of Lhe rapld response process and was successfully lmplemenLed ln cllnlcal areas, as evldenced
by hosplLal-wlde raLes. Success of Lhe program ls aLLrlbuLed Lo supporL from senlor managemenL, lnlLlaLlon and
lnvolvemenL of all key sLakeholders from Lhe sLarL and a successful plloL. SusLalnlng Lhe program wlll be Lhe key Lo lLs
success. Larly ouLcomes of 1rlggered paLlenLs can be used Lo [usLlfy Lhe lmplemenLaLlon of Lhls process.



2S82

IN SI1U SIMULA1ICN IN A LDIA1kIC LMLkGLNC DLAk1MLN1 IMkCVLS A1ILN1 SAIL1
1ommaso 8ellandl
1,*
, Sara Albollno
1
, Marco ue Luca
2
, lrancesco Mannelll
2

1
CenLre for aLlenL SafeLy, 1uscany 8eglon ueparLmenL of PealLh,
2
Lmergency ueparLmenL, Meyer Chlldren PosplLal,
llorence, lLaly


Cb[ect|ves: 1o analyse Lhe varlaLlon ln performance (Lechnlcal and non-Lechnlcal-skllls) ln Lhe LreaLmenL of a paedlaLrlc
paLlenL ln anaphylacLlc shock, Lhrough Lhe use of an lnLegraLed approach wlLh ln slLu slmulaLlon and sysLems analysls of
crlLlcal lncldenLs ln Lhe emergency deparLmenL of a chlldren hosplLal.

Methods: SeLLlng: Lhe red room of Lhe emergency deparLmenL aL Meyer Chlldren PosplLal ln llorence, lLaly. Meyer ls an
academlc hosplLal and cenLre of referral for Lhe 8eglonal PealLhcare Servlce of Lhe 1uscany 8eglon (3.3 mln clLlzens).

arLlclpanLs: 13 docLors and 13 nurses dlsLrlbuLed ln 3 lnLerdlsclpllnary groups, employed aL Lhe ueparLmenL of
Lmergency of Lhe Meyer hosplLal.

lnLervenLlon: A prospecLlve sLudy wlLh Lhe repeLlLlon of 3 sesslons of hlgh fldellLy, ln slLu slmulaLlon of Lhe scenarlo of
anaphylacLlc shock ln a paedlaLrlc paLlenL, before and afLer a sysLems analysls of crlLlcal lncldenLs (vlncenL, 2010)
conducLed on Lhe case sLudles LreaLed durlng slmulaLlon. AL Lhe end of each scenarlo a sLrucLured debrleflng was
performed regardlng Lhe observed shorLcomlngs ln Lechnlcal and non-Lechnlcal skllls, assessed Lhrough Lhe use of Lhe
proLocol of Lhe World Allergy CrganlzaLlon (2010) and Lhe Parvard Chlldren hosplLal approach Lo ln slLu slmulaLlon
(WelnsLock eL al, 2003). 1hen a sysLems analysls was conducLed on Lhe lssues ralsed by Lhe errors LhaL Lhe parLlclpanLs
reporLed uslng Lhe hosplLal lncldenL reporLlng forms. 1he analysls led Lo Lhe developmenL of lmprovemenL acLlons,
lncludlng Lhe deflnlLlon of a speclflc cllnlcal paLhway for Lhe LreaLmenL of anaphylaxls, Lhe creaLlon of a seL of remlnders
ln Lhe paLlenL record and also dlsplayed on a posLer ln Lhe red room. Cnce Lhese acLlons were lmplemenLed, 6 monLhs
afLer Lhe flrsL slmulaLlon, Lhe same docLors and nurses, dlsLrlbuLed ln dlfferenL groups, performed a new slmulaLlon wlLh
a slmllar scenarlo of anaphylacLlc shock. 1he absoluLe number of errors commlLLed before and afLer Lhe lnLervenLlon
were compared by calculaLlng Lhe percenLage change, or (pre error - error posL) / pre 100 errors. 1he llsher exacL LesL
was calculaLed Lo LesL Lhe sLaLlsLlcal slgnlflcance of Lhe assoclaLlon beLween lnLervenLlon and chance for error. SLaLlsLlcal
analyses were performed uslng SLaLa / SL 12.1.

kesu|ts: SLaLlsLlcally slgnlflcanL dlfferences were found beLween Lhe performance of Lhe groups before and afLer Lhe
sysLems analysls. 1he posL groups showed a clear reducLlon of errors ln prescrlpLlon (p <0.001) and admlnlsLraLlon (p
<0.001) of drugs for Lhe managemenL of anaphylacLlc shock (ln parLlcular adrenallne). 1he besL resulL was obLalned ln
Lhe analysls of communlcaLlon: no communlcaLlon error ln Lhe 3 posL groups (p = 0.0119), wlLh an lmprovemenL ln 100
of Lhe groups analysed.

Conc|us|on: 1hls sLudy showed LhaL Lhe use of hlgh-fldellLy slmulaLlon ln slLu, comblned wlLh a sLrucLured analysls of
crlLlcal lncldenLs, can resulL ln a slgnlflcanL lmprovemenL of Lhe performance ln Lhe managemenL of anaphylacLlc shock
ln a paedlaLrlc paLlenL. 1hls klnd of lnLervenLlon ls Llme-consumlng and requlres Lralned lnsLrucLors for ln slLu slmulaLlon
and a sysLem ln place for paLlenL safeLy managemenL.

keferences:
1. vlncenL C, 2010. aLlenL SafeLy. 8M! books: London
2. WelnsLock P, kappus L!, Carden A, eL al. SlmulaLlon aL Lhe polnL of care: reduced-cosL, ln slLu Lralnlng vla a moblle
carL. aedlaLrlc CrlL Care Med. 2009 Mar, 10(2):176-81.
3. World Allergy CrganlzaLlon anaphylaxls guldellnes. March 2011. ! Allergy Clln lmmunol 2011, 127:387-93.



2S84

1nL IMAC1 CI nCSI1AL CCkCkA1ISA1ICN CI GCVLkNMLN1 U8LIC nCSI1AL CN I1'S UALI1
ALlek Peru MaryanLl
1,*
, M. Ahmad u[o[osuglLo
2
, laLhema 8achmaL
2

1
8lomedlcal Lnglneerlng, unlverslLy of lndonesla,
2
8lomedlcal Lnglneerlng, 8lomedlcal 1echnology osLgrad rogram
unlverslLy of lndonesla, !akarLa, lndonesla


Cb[ect|ves: 1hls research was based on a sclenLlflc quesLlon, weaLher a pollcy of corporaLlsaLlon of a publlc hosplLal, wlll
affecL Lhe quallLy of lLs servlce. 1he research ls a prellmlnary research on how pollcles affecL Lhe cosL and how Lhe cosL
affecLs Lhe quallLy. 1he research was done ln one cllnlcal deparLmenL of a corporaLlzed publlc hosplLal.

1he background of Lhe sLudy ls LhaL, ln lndonesla, as a developlng counLry, whlch has a low coverage of healLh lnsurance,
mosL of Lhe paLlenLs (rlch or poor) have Lo pay Lhelr own healLh care expendlLure ouL of pockeL. Slnce 2003, a pollcy of
hosplLal corporaLlzaLlon of governmenL publlc hosplLals was lmplemenLed. ln Lhe corporaLlzed hosplLal, Lhe
managemenL glve auLonomy Lo Lhe cllnlcal deparLmenL Lo use lLs revenue for addlLlonal lncenLlve for docLors and
nurses, as well as for procurlng medlcal equlpmenL, afLer conslderlng Lhe proflLablllLy of Lhe equlpmenL ln accrulng Lhe
deparLmenL's revenue. Powever Lhere ls a cenLrallsaLlon of flnanclal admlnlsLraLlon ln Lhe admlnlsLraLlve dlrecLor. 1he
alms of Lhls pollcy was Lo enhance Lhe cllnlcal deparLmenL Lo be able Lo achleve a beLLer cosL recovery ln Lhe
deparLmenL. WlLh Lhls pollcy cllnlcal deparLmenL may run Lhelr prlvaLe wlng". 1he governmenL had an assumpLlon LhaL
Lhe auLonomy pollcy Lo Lhe cllnlcal deparLmenL can enhance a beLLer quallLy (ln publlc and prlvaLe servlces).

Methods: 8esearch was done ln Lhe deparLmenL of cardlology of a corporaLlzed publlc hosplLal, by revlewlng Lhe cosL
and Lhe quallLy of Lhe servlces, before and afLer Lhe corporaLlzaLlon. 1he cllnlcal and flnanclal daLa, ln Lhe deparLmenL of
Cardlology, durlng one year of 2002 and of 2010 were revlewed. 1he revlew of Lhe quallLy was ln Lerm of Lhe lnpuL
(efflclency of new medlcal equlpmenL lnvesLmenL), of Lhe process (puncLuallLy of servlce) and of ouLcome (morLallLy
raLe, paLlenL saLlsfacLlon and docLors saLlsfacLlon). LvaluaLlon of Lhe efflclency of servlce was done by calculaLlng Lhe
unlL cosL of Lhe servlce, by calculaLlng Lhe unlL cosL of each LreaLmenL. 1he cosL of lnpuL was Lhen compared wlLh cosL of
Lhe ouLpuL.

kesu|ts: 1he flndlngs showed LhaL, Lhe self-flnanclng procuremenL of new medlcal equlpmenL whlch was proflLable" Lo
Lhe servlce, whlch cause Lhe avallablllLy of Lhe deslred equlpmenL, can cause docLor's moLlvaLlon ln provldlng a beLLer
servlce as well as enhanclng Lhe docLor's saLlsfacLlon. ln Lerm of process, Lhere were Lhe beLLer puncLuallLy ln Lhe servlce
especlally Lhe ln prlvaLe wlng. ln Lerm of ouLcome, Lhere was no dlfference ln paLlenL saLlsfacLlon, however Lhere was a
lower paLlenL saLlsfacLlon ln Lhe prlvaLe wlng. Powever Lhere was a beLLer docLor's saLlsfacLlon, even Lhere was no
slgnlflcanL dlfference ln morLallLy raLe. 1he relaLlonshlp beLween Lhe cosL and Lhe quallLy was sLlll dlfflculL Lo be
ldenLlfled, slnce Lhere were a loL of facLors affecLlng Lhe cosL and Lhe quallLy.

Conc|us|on: 1he effecL of corporaLlzaLlon was more on Lhe moLlvaLlon of Lhe docLors whlch may cause Lhe beLLermenL of
Lhe quallLy of care. unlL cosL calculaLlon of Lhe servlces before and afLer corporaLlzaLlon showed a beLLer efflclency. 1he
beLLer quallLy, ln Lerm of docLor's saLlsfacLlon and ln Lerm of Lhe efflclency was also deplcLed. Powever Lhe cosL of Lhe
beLLermenL of Lhe quallLy sLlll cannoL be calculaLed.

2S89

LLAkNLk LNGAGLMLN1 IN A1ILN1 SAIL1 CNLINL LDUCA1ICN: IACILI1A1CkS AND 8AkkILkS
Slobhan McCarLhy
1,*
, Cllllan Walsh
2
, Ann C'Shaughnessy
2
, Claran C'8oyle
1

1
lnsLlLuLe of Leadershlp, 8oyal College of Surgeons ln lreland,
2
LducaLlon and rofesslonal uevelopmenL, 8oyal College of
hyslclans of lreland, uublln, lreland


Cb[ect|ves: AppllcaLlon and lnLegraLlon of learnlng from paLlenL safeLy educaLlon forms a ma[or challenge (1). LducaLors
are challenged Lo reflecL upon how Lhey Leach" and whaL Lhey Leach" and Lo conslder how Lhls conLrlbuLes Lo
professlonal behavlour (2). Cb[ecLlves were Lo reflecL upon Lhe flndlngs of a process evaluaLlon of a aLlenL SafeLy
Cnllne rogramme for uocLors, Lo ldenLlfy faclllLaLors and barrlers Lo learner engagemenL and appllcaLlon of learnlng.

Methods: 1he onllne programme conslsLed of flve modules: lnLroducLlon Lo paLlenL safeLy, undersLandlng adverse
evenLs and near mlsses, open communlcaLlon, carlng for Lhe second vlcLlm and learnlng from adverse evenLs and near
mlsses. A pre and posL onllne quesLlonnalre measured knowledge, aLLlLude, skllls, safeLy cllmaLe and programme
experlence among baslc speclallsL Lralnees of Lhe 8oyal College of hyslclans of lreland. SlxLy-Lhree baslc speclallsL
Lralnees compleLed boLh pre and posL quesLlonnalres. uaLa was analysed uslng SSS and a LhemaLlc analysls of
quallLaLlve daLa was conducLed.

kesu|ts: lacLors whlch faclllLaLed learner engagemenL ln Lhe paLlenL safeLy onllne learnlng programme were lncluslon of
case sLudles based on real llfe evenLs, lnLervlews wlLh famlly represenLaLlves whom have been affecLed by medlcal error,
lnLervlews wlLh medlcal represenLaLlves, use of vldeo cllps and lnLeracLlve feaLures. 1here were slgnlflcanL
lmprovemenLs (p<0.03) ln respondenLs' aLLlLudes, knowledge and skllls followlng programme compleLlon. 1here were
no slgnlflcanL changes (p0.03) ln respondenLs' percepLlons of safeLy culLure followlng Lhe programme.

Conc|us|on: aLlenL safeLy onllne educaLlon faclllLaLes lmproved self-raLed knowledge, aLLlLudes and skllls and can form
an engaglng learnlng experlence. Powever, Lhls research suggesLs LhaL educaLlonal lnLervenLlons need Lo LargeL Lhe
culLure of Lhe Lralnlng envlronmenL Lo help promoLe appllcaLlon of learnlng. aLlenL safeLy onllne educaLlon needs Lo be
Lled Lo pracLlce based lnlLlaLlves Lo help Lo reduce Lhe poLenLlal effecLs of underdeveloped safeLy culLures on learned
professlonallsm.

keferences:
1. Lukela M, arekh vl, Cosbee !W eL al. CompeLence ln paLlenL safeLy: a mulLl-faceLed experlenLlal educaLlonal
lnLervenLlon for resldenL physlclans. I CtoJ MeJ Joc 2011,3:360-366.
2. Shulman LS. SlgnaLure pedagogles ln Lhe professlons. uoeJolos 2003,134:32-39.



2S91

ALICA1ICN CI A WA1Lk SAIL1 LAN IN A nCSI1AL IACILI1 AND ASSLSSMLN1 CI I1S LIIICAC
Marla-Lulsa CrlsLlna
1,*
, Anna Marla Spagnolo
1
, aolo Crlando
1
, lernanda erdelll
1

1
ueparLmenL of PealLh Sclences, unlverslLy of Cenoa, Cenoa, lLaly


Cb[ect|ves: 1he WaLer SafeLy lan (WS) meLhodology, whlch alms Lo enhance Lhe safeLy of drlnklng waLer supplles, has
been recommended by Lhe World PealLh CrganlzaLlon slnce 2004. As Lhere ls a lack of sysLemaLlc evldence for Lhe
effecLlveness of WSs ln lmprovlng waLer quallLy and safeguardlng healLh, Lhe need for research has emerged. We
descrlbe Lhe resulLs of a Lhree-year monlLorlng programme applled Lo Lhe waLer dlsLrlbuLlon sysLem of a PosplLal ln
norLhern lLaly where Lwo cases of leglonellosls had occurred. 1he ob[ecLlve was Lo evaluaLe boLh cllnlcal ouLcomes and
Lhe efflcacy of a waLer safeLy plan ln conLrolllng leqlooello poeomopbllo colonlsaLlon of Lhe hosplLal waLer sysLem.

Methods: 1he plan lnvolved: acLlve cllnlcal survelllance for leqlooello poeomopbllo lnfecLlons, lmplemenLaLlon of an
PACC sysLem Lo ldenLlfy crlLlcal polnLs ln Lhe varlous waLer neLworks and Lhe Lype of sampllng and analysls Lo be
carrled ouL, monlLorlng of Lhe waLer sysLem Lhrough sysLemaLlc waLer sampllng aL Lhe end-polnLs of use of Lhe hoL
waLer dlsLrlbuLlon sysLem, ln order Lo assess varlous chemlcal-physlcal and mlcroblologlcal parameLers, lncludlng
leqlooello poeomopbllo colonlsaLlon.

kesu|ts: AppllcaLlon of a check-llsL aL Lhe beglnnlng of Lhe sLudy revealed several lnadequacles aL cerLaln crlLlcal polnLs:
41 of Lhe waLer samples examlned dlsplayed leqlooello poeomopbllo values beLween 10
3
and 10
4
Clu/L. Moreover,
Lhe concenLraLlon of free chlorlne ln Lhe waLer of Lhe hosplLal plumblng sysLem was conslsLenLly < 0.2 mg/L, whlle Lhe
LemperaLure of Lhe waLer aL Lhe ouLleL polnLs proved lnsufflclenL Lo conLrol conLamlnaLlon (mean value: 37.73 C).
AfLer lmplemenLaLlon of Lhe WS ln all parLs of Lhe hosplLal, lncludlng planned malnLenance of Lhe neLwork and hoL
waLer hyperchlorlnaLlon, Lhe overall mlcroblologlcal quallLy of Lhe waLer was seen Lo have lmproved. Moreover, Lhe
number of Lransgresslons regardlng leqlooello poeomopbllo decllned sLeadlly ln Lerms of boLh concenLraLlon and Lhe
percenLage of deflclenL ouLleL polnLs. AnoLher argumenL for Lhe efflcacy of Lhe WS ls Lhe facL LhaL no cases of
nosocomlal Leglonnalres' dlsease were recorded.

Conc|us|on: ldenLlflcaLlon of Lhe slLes and causes of lnadequacy and Lhe appllcaLlon of remedlal lnLervenLlon enabled
Lhe mlcroblal quallLy of Lhe waLer Lo be slgnlflcanLly lmproved over 3 years of observaLlon. Moreover, Lhe rlsk-
managemenL plan adopLed appeared Lo dlscourage furLher cases of nosocomlal leglonellosls. 1he overall ouLcome
Lherefore reveals Lhe lmporLance of WS ln provldlng safe waLer, whlch ls vlLal Lo ensurlng paLlenL safeLy and reduclng
cosLs, ln LhaL waLerborne lnfecLlons lncrease morbldlLy, morLallLy, LreaLmenL cosLs and compensaLlon clalms, and
prolong hosplLallsaLlon.



2S94

WCkkILCW DNAMICS AND NUkSLS' MANAGLMLN1 CI IN1LkkU1ICNS
Slmon Walne
1,*
, !lll Maben
1
, !aneL Anderson
1
, Anne Marle 8afferLy
1

1
naLlonal nurslng 8esearch unlL, klng's College London, London, unlLed klngdom


Cb[ect|ves: 8ecenL sLudles suggesL LhaL healLh professlonals worklng ln a range of seLLlngs are lnLerrupLed frequenLly,
and LhaL Lhls may lead Lo errors. LxlsLlng sLudles have generally framed lnLerrupLlons as lsolaLed, one-off evenLs ln whlch
an lndlvldual ls fotceJ Lo swlLch from a 'prlmary' Lask, Lo a 'secondary' one, and, posslbly, back agaln. PealLh
professlonals are Lhus vlewed as 'passlve reclplenLs' of lnLerrupLlons and Lhe rememberlng of Lhe lnLerrupLed Lask ls
seen as Lhe key lssue. 1hls sLudy examlnes how nurses acLlvely manage lnLerrupLlons wlLhln Lhe flow of dally work. 1he
research almed Lo develop a deeper undersLandlng of lnLerrupLlons, and Lhe sLraLegles LhaL nurses use Lo handle Lhem.

Methods: Cur eLhnographlc meLhod comblned unsLrucLured observaLlons and seml-sLrucLured lnLervlews of nurses ln
Lhree seLLlngs:

1) A uay ChemoLherapy CenLre,
2) AccldenL and Lmergency, and
3) A Surglcal Ward.

Around LhlrLy hours of unsLrucLured observaLlons were conducLed ln each seLLlng, and Lhe researcher made free-LexL
noLes on a smarLphone. Pe capLured deLalled daLa abouL observed evenLs Lo provlde a mlnuLe-by-mlnuLe accounL of
nurses' work. lnLervlews explored nurses' percepLlons of Lhe work envlronmenL and Lhe sLraLegles Lhey used Lo manage
Lhe workflow.

kesu|ts: ConslsLenL wlLh exlsLlng research, Lhe sLudy found LhaL nurses do face frequenL lnLerrupLlons, from a varleLy of
sources. AccldenL and Lmergency was Lhe mosL dynamlc envlronmenL buL nurses ln all seLLlngs faced conslderable
challenges ln managlng Lhe workflow. ln conLrasL Lo oLher research, Lhe sLudy found LhaL nurses were ofLen managlng
mulLlple 'acLlve' Lasks when lnLerrupLed, noL [usL a slngle 'prlmary' Lask. nurses' Lendency Lo mulLlLask, LogeLher wlLh
characLerlsLlcs of exlsLlng and addlLlonal Lasks, and oLher aspecLs of Lhe work conLexL (e.g. Lhe avallablllLy of resources,
Lhe physlcal envlronmenL) played a cruclal role ln deLermlnlng how Lhey handled lnLerrupLlons. 8aLher Lhan belng
'passlve reclplenLs' of Lhese evenLs, nurses acLlvely managed Lhem. 1hey dld Lhls by swlLchlng beLween Lasks aL
approprlaLe and convenlenL Llmes (lnsLead of always swlLchlng lmmedlaLely afLer lnLerrupLlon), and by uslng oLher
sLraLegles such as delegaLlon. 1he Lasks LhaL nurses swlLched Lo/from were ofLen on-golng Lasks and few could be
regarded as lsolaLed, one-off evenLs. Cverall, nurses' swlLchlng and Lask managemenL behavlour suggesLed LhaL raLher
Lhan belng solely concerned wlLh performlng Lhe lnLerrupLlon (Lhe 'secondary Lask'), and resumlng Lhe orlglnal Lask (Lhe
'prlmary Lask'), nurses were concerned more generally wlLh maxlmlslng Lhe efflclenL use of resources - lncludlng Lhelr
own Llme - Lo besL manage Lhe mulLlple, compeLlng demands made of Lhem. Such demands were Lhus far more
exLenslve Lhan Lhe need Lo remember Lhe lnLerrupLed Lask, nurses also had Lo plan, prlorlLlse and make declslons. ln
addlLlon, Lhey used a varleLy of Lools (lncludlng medlcal records and sLaLus boards) and sLraLegles (lncludlng rouLlnes and
heurlsLlcs) Lo help manage cognlLlve demands and Lo supporL mulLlLasklng.

Conc|us|on: lnLerrupLlons occur ln a parLlcular conLexL. lor nurses worklng ln complex healLhcare seLLlngs, Lhls conLexL ls
llkely Lo be a busy and dynamlc one, lnvolvlng Lhe managemenL of mulLlple Lasks. nurses conslder how Lo manage
lnLerrupLlons wlLhln Lhls mulLl-Lask conLexL, and declde how Lo maxlmlse Lhe use of resources Lo besL meeL Lhe demands
made of Lhem. 1hose lnLeresLed ln deslgnlng safer healLhcare sysLems LhaL are reslllenL Lo lnLerrupLlons, mlghL Lake
more accounL of conLexL when sLudylng Lhese evenLs. lnLerrupLlons need Lo be undersLood as parL of Lhe dynamlc
workflow, and conslderlng Lhem ln lsolaLlon may noL lead Lo workable soluLlons.



2S97

CCMAkISCNS CI nLAL1n AND SCCIAL CAkL ICk CLDLk LCLL IN SWLDLN
lngallll aulsson LLz
1,*
, Marlanne Lldbrlnk
1

1
ueparLmenL of SLaLlsLlcs, MonlLorlng and LvaluaLlon, naLlonal 8oard of PealLh and Welfare, SLockholm, Sweden


Cb[ect|ves: compotlsoos of beoltb ooJ soclol cote fot olJet petsoos lo 5weJeo. 1wo Jlffeteot pobllcotloos, two Jlffeteot
totqet qtoops. ln 2007, Lhe CovernmenL commlssloned Lhe naLlonal 8oard of PealLh and Welfare, n8PW, Lo develop a
sysLem for comparlsons ln care of older persons. oLenLlal users, users, famllles and relaLlves, care personnel, managers,
prlvaLe and publlc provlders and local and naLlonal pollLlclans should all have easy access Lo comparaLlve daLa abouL
servlce and care.

urpose
1he n8PW publlshes Lwo dlfferenL reporLs. Cne reporL conLalns lndlcaLors wlLh lnformaLlon on a local level and
addresses Lhe leaders and provlders carlng for older persons. 1he purpose ls Lo sLlmulaLe Lhe developmenL ln long-Lerm
care. 1he oLher reporL conLalns quallLy daLa ln speclal houslng and home-help care on a unlL level. 1he daLa ln Lhe lJetly
ColJe ls presenLed on Lhe lnLerneL and addresses older persons ln need of healLh and soclal care as well as Lhelr
relaLlves. 1he purpose ls Lo provlde comparable lnformaLlon abouL Lhe dlfferenL unlLs lncludlng whaL Lhey offer Lo
accompllsh quallLy ln care.

Methods:
Cne reporL addresses Lhe older persons ln need of healLh and soclal care, Lhe lJetly ColJe and Lhe oLher reporL, Ooollty
lo cote of olJet petsoos, ls dlrecLed Lowards Lhe provlders and pollLlclans ln charge. 1he posslblllLy Lo descrlbe, analyse
and evaluaLe Lhe developmenL ln care of older persons ls Lo a large exLenL based on daLa from quallLy reglsLers and
naLlonal offlclal sLaLlsLlcs. 1o presenL lnformaLlon on a unlL level, daLa ls malnly gaLhered Lhrough a yearly survey, whlch
addresses Lhe dlfferenL unlLs ln Lhe counLry. 1he resulLs of a naLlonal user survey LhaL covers all munlclpallLles ln Sweden
complemenL Lhe daLa used ln Lhe Lwo dlfferenL publlcaLlons.

kesu|ts:
1he reporL Ooollty lo cote of olJet petsoos lncludes a selecLlon of 33 lndlcaLors LhaL reflecL on and compare resulLs
beLween counLy counclls and munlclpallLles. lL was obvlous LhaL Lhe self-reporLed healLh had a greaL lmpacL on mosL of
Lhe lndlcaLors. 1he lJetly ColJe presenLs lnformaLlon abouL more Lhan 2 600 nurslng homes (93 per cenL) and almosL 2
100 home healLh servlces (86 per cenL). 1he vlslLor can flnd lnformaLlon abouL unlLs ln any munlclpallLy ln Sweden. 1he
Culde conLalns of a selecLlon of 30 dlfferenL lndlcaLors and Lhe vlslLor can compare Lhe resulLs wlLh oLher unlLs wlLhln
Lhe munlclpallLy. Average daLa on a naLlonal level ls also presenLed.

Conc|us|on:
1he comparlsons publlshed ln Lhe reporL Ooollty lo cote of olJet petsoos conLalns naLlonal, reglonal and local daLa and ls
parL of Lhe developmenL on how Lo monlLor healLh and soclal care for Lhe older persons ln Sweden. A user frlendly web
slLe for older persons ln need of healLh and soclal care ls a work ln consLanL progress. 1he conLenL has been developed ln
collaboraLlon wlLh older persons LhaL recenLly sLarLed Lo use home help care, also lnvolvlng Lhelr relaLlves.




2S98

IMkCVING 1nL UALI1 CI nIV]AIDS SLkVICLS IN nCSI1AL-8ASLD SL11INGS: USING MUL1ILL I 1LAMS 1C
S1kLNG1nLN 1nL CCN1INUUM CI CAkL
AnLhony Muslsl
1,*
, kenneLh MuLesaslra
1
, Mlchael lrlge
1
, Cordella kaLureebe
1

1
SuS1Aln ro[ecL, unlverslLy 8esearch Co., kampala, uganda


Cb[ect|ves: Slnce 2003, Lhe uganda MlnlsLry of PealLh (MCP) has lmplemenLed a naLlonal quallLy lmprovemenL (Cl)
program called Lhe CuallLy of Care lnlLlaLlve (CoC) for Plv/AluS care. lnlLlaLed ln 2010, Lhe uS Agency for lnLernaLlonal
uevelopmenL (uSAlu)-funded SLrengLhenlng uganda's SysLems for 1reaLlng AluS naLlonally (SuS1Aln) pro[ecL, managed
by unlverslLy 8esearch Co., LLC (u8C), supporLs 16 hosplLals ln Lhe counLry Lo provlde comprehenslve Plv/AluS servlces,
lncludlng counselllng and LesLlng, care and LreaLmenL, prevenLlon of moLher-Lo-chlld Lransmlsslon (M1C1), and Plv-
Luberculosls (18) co-lnfecLlon managemenL.

Plv servlces are provlded aL mulLlple servlce dellvery unlLs wlLhln each hosplLal, lncludlng Lhe anLenaLal care cllnlc,
maLernlLy unlL, ouL-paLlenL deparLmenL, laboraLory, and dedlcaLed chronlc care cllnlc for Plv-poslLlve cllenLs. SuS1Aln
has been worklng wlLh Leams aL all pro[ecL-supporLed hosplLals Lo lmprove sysLems and processes wlLhln and among
each of Lhese servlce dellvery polnLs wlLh Lhe alm of sLrengLhenlng Lhe conLlnuum of care for people llvlng wlLh Plv.

Methods: Culded by Lhe naLlonal CuallLy lmprovemenL lramework, SuS1Aln lnlLlaLed supporL for hosplLal Leams Lo
apply Cl meLhods for performance lmprovemenL ln november 2011. AfLer SuS1Aln provlded on-slLe Lralnlng, each
hosplLal formed mulLlple Cl Leams. 1hese Leams focused on lmprovlng enrolmenL lnLo care for exposed lnfanLs, Plv-
poslLlve pregnanL women, and cllenLs accesslng counselllng and LesLlng wlLhln Lhe hosplLal. 1he Leams also worked Lo
lmprove LreaLmenL compleLlon raLes for Luberculosls and reLenLlon ln care for Plv-poslLlve cllenLs.

Slx Lo elghL Cl Leams, each focused on a speclflc process wlLhln Lhe Plv conLlnuum of care, worked aL each hosplLal. 1he
mulLldlsclpllnary Leams lncluded healLhcare workers from Lhe key servlce dellvery polnL and from oLher unlLs lnvolved ln
Lhe process of care Lo be lmproved. ln addlLlon Lo each Cl Leam, Lhe hosplLals also formed an lnLegraLed Plv servlce
lmprovemenL Leam whlch provlded overslghL and coachlng supporL Lo Lhe Cl Leams. SuS1Aln conducLed rouLlne
coachlng vlslLs Lo supporL Lhe Cl Leams and monlLor progress.

kesu|ts: ln a perlod of 10 monLhs, hosplLals lmproved Lhe proporLlon of Plv-lnfecLed lnfanLs less Lhan Lwo years of age
lnlLlaLed on anLl-reLrovlral Lherapy (A81) from 38 Lo 79. 1he proporLlon of Plv-poslLlve women aLLendlng anLenaLal
care who were enrolled lnLo chronlc care cllnlcs lncreased from 34 Lo 79. ln addlLlon, Lhe proporLlon of paLlenLs who
compleLed 18 LreaLmenL lmproved from 30 Lo 60, and paLlenL reLenLlon on A81 afLer one year lmproved from 64 Lo
82.

Conc|us|on: Worklng wlLhln hosplLal seLLlngs where Plv servlces are provlded aL mulLlple polnLs by several dlfferenL
Leams presenLs unlque challenges Lo ensurlng Lhe conLlnuum of care for people llvlng wlLh Plv. lormaLlon of mulLlple Cl
Leams can lmprove llnkages among hosplLal unlLs, Lhus ensurlng LhaL Plv-poslLlve cllenLs have access Lo Lhe requlred
servlces for opLlmal cllnlcal ouLcomes.



2602

nCSI1AL A1ILN1S INIUkILS IkCM IALL: kISk IAC1CkS & CCS1 ANALSIS
lablo L. CasLal
1,*
, Mlchele MalLa
1
, Llenara 8lbas
1
, lablano Arau[o
1

1
Medlcal & PealLh AsslsLance CperaLlons, Mae de ueus PosplLal & PealLh SysLem, orLo Alegre, 8razll


Cb[ect|ves: 1he purpose of Lhls sLudy ls Lo verlfy rlsk facLors and cosLs of falls and serlous ln[urles suffered by paLlenLs ln
8razlllan PosplLal.

Methods: 1hls ls a reLrospecLlve deslgn Lo sLudy rlsk facLors and cosLs assoclaLed wlLh serlous ln[urles from falls, from
!anuary 2010 Lo march 2012. lL was used rlsk analysls Lo sLudy paLlenL falls. 1o compare Lhe rlsk facLors beLween Lhe fall
paLlenLs wlLh serlous ln[ury and Lhe oLhers who dld noL develop ln[ury we use llscher's exacL LesL, wlLh a slgnlflcance
0,03. lor cosL analysls we used Lhe average cosL and sLandard devlaLlon classlfled by ln[ury Lype.

kesu|ts: lncldence raLe of falls ln Lhe perlod was 1,33 falls per 1000 paLlenL-day. 8egardlng ln[ury lncldence, Lhe raLe of
serlous ln[ury was 1,47 falls. 1he odds Lo elderly (over 60 years old) lnpaLlenL fall raLe ls 2.14 hlgher Lhan Lhe
nonelderly. Comparlng rlsk facLors of faller paLlenLs wlLh and wlLhouL severe ln[ury, lL was observed LhaL poslLlve hlsLory
osLeoporosls (p. value 0,02) and prlor hlsLory falls (p. value 0,03) was sLaLlsLlcally slgnlflcanL when comparlng Lhe Lwo
groups. 1he cosL analysls of Lhe severe ln[urles connecLed Lo falls ls neurologlcal damage (1), musculoskeleLal ln[ury (3),
fracLure of femur (4) and wrlsL fracLure (1). Lach case was lndlvldually evaluaLed regardlng lLs consequences. 1o sLudy
LhaL cosL daLa of everyday maLerlals and medlclnes, use of equlpmenL, LesLs, LreaLmenLs and use of rosLhesls and
CrLhesls was collecLed. 1he general average cosL was uS$ 9,236.343 and Lhe Su uS$ 762.16 for Lhe all PosplLal neLwork.
When was grouplng by Lype, Lhe cosL of exLradural hemaLoma by fall was uS$ 8.880, Lhe cosL of femur fracLure LreaLed
by hlp ArLhroplasLy was uS$ 9,644.313 and Lhe Su uS$ 886,7 and Lhe cosL of wrlsL fracLure was uS$ 9,184.72.

Conc|us|on: ln[urles from falls ln hosplLals are a consLanL concern of Lhe auLhorlLles ln PealLh and PosplLals. lnsLlLuLlons
worklng wlLh 8lsk ManagemenL and CuallLy rogram already lnclude ln Lhelr prevenLlon plan Lhls evenL, Lven so lLs
lncldence ls lncreaslng. 8esldes Lhe flnanclal lmpllcaLlons for Lhe healLh lnsLlLuLlons lnvolved ln ln[urles from falls, lL ls noL
posslble Lo measure Lhe lmpllcaLlons for famlly and socleLy regardlng Lhls ouLcome. 1hls sLudy shows a klnd of approach
of Lhls complex problem and Lhe lmporLance of developlng lnlLlaLlves Lo conLrol and lmprove Lhe care process of Lhls
slLuaLlon.

keferences:
1. lPl - lnsLlLuLe for PealLhcare lmprovemenL. 1ransformlng Care aL Lhe 8edslde. Pow - Lo Culde: 8educlng aLlenL
ln[urles from lalls, 2008 ulsponvel em www.lhl.org. Acesso em 22 de agosLo de 2012.
2. C1PL8, M. L. WhaL ls value ln PealLh Care? 1he new Lngland !ournal of Medlclne, 2010.
3. 8oudsanl 8 eL all. 1he acuLe medlcal care cosLs of fall-relaLed ln[urles among Lhe u.S older adulLs. ln[ury, 2003.
4. vass, C, SahoLa, C, L1 AL. 8eflne (8educlng lalls ln ln-paLlenL Llderly) - a randomlsed conLrolled Lrlal, 1rlals, 2009.
3. veLerans Affalrs. naLlonal CenLer for aLlenL SafeLy lalls. ueparLmenL of veLerans Affalrs, unlLed SLaLes, 2004.



2603

CkGANISA1ICNAL CUL1UkL ASSLSSMLN1 CN kISk MANAGLMLN1 AND SAIL1 IN nLAL1n CAkL. LVALUA1ICN CI
1nL MLDICAL S1AII IN ACCkLDI1LD nCSI1AL IN 8kA2IL
Lvandro . v. lellx
1
, Ana M. Mallk
1,*

1
Cv Sade, So aulo 8uslness AdmlnlsLraLlon School - lundao CeLullo vargas, So aulo, 8razll


Cb[ect|ves: 1o evaluaLe Lhe organlsaLlonal safeLy culLure of medlcal sLaff aL a prlvaLe hosplLal ln clLy of So aulo, 8razll.
MeLhods: 1he sLudy was conducLed aL a !Cl AccredlLed and 8e-AccredlLed prlvaLe hosplLal wlLh a cardlologlcal focus wlLh
approxlmaLely 230 beds. 1hls ls a cross-secLlonal observaLlonal sLudy. 1he assessmenL of safeLy culLure was Lhrough
AP8C nospltol 5otvey oo lotleot 5ofety coltote quesLlonnalre, LranslaLed lnLo orLuguese, applled Lo Lhe employee
medlcal sLaff.

kesu|ts: 98 quesLlonnalres were senL ouL. 38 (39) were compleLed ln Lhe perlod beLween March and Aprll 2011.
Among Lhese, 39 conducL Lhelr acLlvlLles ln several hosplLal areas, 24 ln emergency, lCu 16, 11 ln medlcal cllnlc,
11 ln oLher areas. 89 (34) work ln dlrecL care for Lhe paLlenLs and 11 (4) perform admlnlsLraLlve acLlvlLles. 84 work
more Lhan 20 hours a week ln Lhe hosplLal. 1he percenLage of poslLlve responses accordlng Lo each dlmenslon of Lhe
quesLlonnalre ls shown ln 1able 1.

1he overall safeLy of paLlenLs was consldered excellenL by 24 of respondenLs, 63 very good and 13 accepLable.
none of Lhe respondenLs consldered lL poor or falllng. 1he number of evenLs reporLed by lnLervlewees ln Lhe 12 monLhs
precedlng Lhe survey were 0 (none) Lo 84, 1 or 2 Lo 8 and 3 Lo 3 for Lhe remalnlng 8.

1able 1. aLlenL SafeLy CulLure ComposlLes
1eamwork WlLhln unlLs
Supervlsor LxpecLaLlons & AcLlons romoLlng aLlenL SafeLy
ManagemenL SupporL for aLlenL SafeLy
CrganlsaLlonal Learnlng-ConLlnuous lmprovemenL
Cverall ercepLlons of aLlenLs SafeLy
leeJbock & CommunlcaLlon AbouL Lrror
lrequency of LvenLs 8eporLed
CommunlcaLlon Cpenness
1eamwork Across unlLs
5toffloq
Pandoffs & 1ranslLlons
non-punlLlve 8esponse Lo Lrror
72
38
77
78
62
43
33
43
68
43
72
18

Conc|us|on: ln general, Lhe evaluaLed medlcal sLaff reporLed a good or excellenL overall organlsaLlonal securlLy. Cood
resulLs for Leamwork and Lransfers beLween Lhe dlfferenL unlLs of Lhe hosplLal, encouraglng conLlnuously lmprovemenL
and organlsaLlonal learnlng, wlLh supporL from senlor managemenL of Lhe hosplLal were observed. Powever, lL ls
observed LhaL Lhe dlmenslons relaLed Lo open communlcaLlons, feedback and communlcaLlon abouL errors, frequency of
evenLs reporLlng and non-punlLlve responses Lo Lhem are Lhose whlch were evaluaLed more negaLlvely, as well as
acLlons Lo promoLe safeLy by leadershlp.
ln any organlsaLlon, communlcaLlon among employees wlLhln Lhelr own unlLs, among dlfferenL unlLs and dlfferenL
hlerarchlcal levels appears as one of Lhe maln challenges for Lhe lmprovemenL of processes, quallLy and safeLy ln healLh
care. lurLhermore, only few evenLs are reporLed, whlch may be relaLed Lo a punlLlve culLure feellng.
1hus, for Lhe professlonal caLegory sLudled, even ln an AccredlLed and 8e-AccredlLed hosplLal by !Cl, Lhere ls a clear
opporLunlLy and a need for lmprovemenL of communlcaLlon processes, error noLlflcaLlon and change from a punlLlve
culLure, or aL leasL lLs percepLlon, for lndlvldual errors, Lo a culLure ln whlch errors are LreaLed noL as personal fallures,
buL as opporLunlLles for lmprovemenL ln Lhe sysLem and damage prevenLlon.


2618

CCN1INUCUS UALI1 IMkCVLMLN1 WI1n AN IN1LkDISCILINAk 1LAM AND 1IMLL ILLD8ACk IMkCVL 1nL
CCMLIANCL CI kLSUSCI1A1ICN 8UNDLLS ICk SL1IC SnCCk
l-1lng 1sal
1,*
, el-Chen Puang
2
, Mel-lel Shlu
3
, ?u-Wel Puang
4

1
Lmergency Medlclne,
2
nurslng,
3
Medlcal CuallLy,
4
CrlLlcal Care Medlclne, L-uA PosplLal, kaohslung ClLy, 1alwan


Cb[ect|ves: Larly hemodynamlc opLlmlsaLlon ln sepLlc shock has been recommended for more Lhan a decade. Several
sLudles suggesLed LhaL conLlnuous quallLy lmprovemenL (CCl) based on Lhe Survlvlng Sepsls Campalgn guldellnes were
assoclaLed wlLh beLLer ouLcomes. 1he maln purpose of our sLudy was Lo deLermlne Lhe lmpacL of a hosplLal-wlde CCl
lnlLlaLlve wlLh Llmely feedback and lnLerdlsclpllnary Leam acLlvaLlon, measured by compllance wlLh Lhe resusclLaLlon
bundle, and Lhe ouLcomes of paLlenLs wlLh sepLlc shock ln a 1alwan LerLlary hosplLal.

Methods: 1hls was a prospecLlve, lnLervenLlonal cohorL sLudy. 1here 123 paLlenLs wlLh sepLlc shock who dlagnosed aL
Lhe emergency deparLmenL beLween Aprll 2012 Lhrough uecember 2012. SLudy perlods were dlvlded lnLo basellne
perlod (screenlng only) for four monLhs, Llmely feedback perlod for Lhree monLhs, and lnLerdlsclpllnary Leam acLlvaLlon
perlod for Lwo monLhs. Compllance wlLh resusclLaLlon bundles and ln hosplLal morLallLy was compared among Lhe Lhree
perlods.

kesu|ts: Compllance wlLh cenLral llne lnserLlon and monlLorlng of cenLral venous pressure lncreased from 13.0 durlng
basellne perlod Lo 61.3 and 68.4 durlng Llmely feedback and lnLerdlsclpllnary Leam acLlvaLlon perlods (p < 0.03) and
cenLral venous oxygen saLuraLlon (ScvC,) lncreased from 2.2 durlng basellne perlod Lo 33.9 and 30 durlng Llmely
feedback and lnLerdlsclpllnary Leam acLlvaLlon perlods (p < 0.03). Compllance wlLh all elemenLs of Lhe sepsls
resusclLaLlon bundle slgnlflcanLly lncreased from 2.2 durlng basellne perlod Lo 33.9 and 30 durlng Llmely feedback
and lnLerdlsclpllnary Leam acLlvaLlon perlods (p < 0.03). ln hosplLal morLallLy raLe was 34.8, 48.7, and 31.6 durlng
basellne, Llmely feedback and lnLerdlsclpllnary Leam acLlvaLlon perlods.

Conc|us|on: ln our sLudy, Lhe compllance of resusclLaLlon bundles for sepLlc shock was lmproved slgnlflcanLly afLer Lhe
lnLervenLlon of a hosplLal-wlde CCl lnlLlaLlve wlLh Llmely feedback and lnLerdlsclpllnary Leam acLlvaLlon ln a developlng
counLry.



2619

IMAC1 CI SAIL1 kCCLDUkLS CCMLIANCL IN 1nL kISk CI DLA1n IN LCW MCk1ALI1 DkGS
Susana vaz
1,*
, vanda lnhelro
1
, LllsabeLe Coelho
1
, L8S 8oard of ulrecLlon
1

1
L8S, C81C, orLugal


Cb[ect|ves: aLlenL SafeLy ls one of Lhe flve quallLy dlmenslons assessed wlLhln SlnAS [1]. lL ls measured under Lwo
dlfferenL perspecLlves: safeLy procedures (ex-anLe) and adverse evenLs lncldence (ex-posL).
1he purpose of Lhls sLudy was Lo evaluaLe Lhe lmpacL of safeLy procedures compllance ln Lhe rlsk of deaLh ln Low
MorLallLy u8Cs wlLhln Lhe hosplLals assessed by SlnAS.

SlnAS - SlsLema naclonal de Avallao em Sade (naLlonal SysLem of PealLh CuallLy AssessmenL), Lhe orLuguese
sysLem for assesslng mulLldlmenslonal healLhcare quallLy, creaLed by L8S- LnLldade 8eguladora da Sade (PealLh
8egulaLlon AuLhorlLy).

Methods: SafeLy procedures assessmenL:
SlnAS assesses wheLher lnsLlLuLlons comply wlLh guldellnes and have proLocols esLabllshed regardlng Lhe lmprovemenL
of paLlenLs' safeLy Lhrough Lhe appllcaLlon of a quesLlonnalre ln Lhe form of a checkllsL, based ln guldellnes form !olnL
Commlsslon lnLernaLlonal (!Cl), Lhe Agency for PealLhcare 8esearch and CuallLy (AP8C) and Lhe naLlonal CuallLy lorum
(nCl), dlvlded ln several caLegorles, from safeLy culLure Lo cllnlcal rlsks and hazards managemenL, lncludlng lnfecLlon.
lrom Lhe daLa collecLed Lhrough Lhe fllllng of Lhe checkllsL, a raLlo of compllance ls calculaLed for each hosplLal. 1hls
raLlo ls a sLrucLure lndlcaLor, correspondlng Lo Lhe number of condlLlons observed on Lhe LoLal number of condlLlons
lnqulred.

ueaLh ln Low MorLallLy u8Cs

1he SlnAS adverse evenLs lncldence assessmenL process was based upon a selecLlon of lndlcaLors ouL of Lhose
developed by Lhe Agency for PealLhcare 8esearch and CuallLy (AP8C). AlLhough SlnASPosplLals assesses elghL
lndlcaLors, for Lhe purpose of Lhe presenL sLudy only ueaLh ln Low MorLallLy u8Cs was consldered.
ueaLh ln Low MorLallLy u8Cs: Nometotot. ulscharges durlng Lhe year of 2011 wlLh dlsposlLlon of deceased".
ueoomlootot. ulscharges durlng Lhe year of 2011, 18 years and older, ln u8Cs or MS-u8Cs wlLh less Lhan 0.3 morLallLy
raLe, excludlng paLlenLs wlLh any code for Lrauma, cancer, or lmmuno-compromlsed sLaLe.

1he populaLlon sLudled lncluded all lnpaLlenLs dlscharged durlng Lhe year of 2011, on a sample of 13 hosplLals form Lhe
163 lncluded on SlnAS uaLa 8ase, on a LoLal of 41821 eplsodes, dlvlded lnLo: opulaLlon 1 - lnpaLlenLs ln hosplLals wlLh
=90 compllance on SlnAS SafeLy rocedures assessmenL. opulaLlon 2 - lnpaLlenLs ln hosplLals wlLh <90 compllance
on SlnAS SafeLy rocedures assessmenL.

kesu|ts: opulaLlon 1, lncludlng a LoLal of 14377 eplsodes wlLh Low MorLallLy u8Cs had 19 paLlenLs dlscharged as
deceased", opulaLlon 2, lncludlng a LoLal of 27444 eplsodes wlLh Low MorLallLy u8Cs had 39 paLlenLs dlscharged as
deceased". Analysls found LhaL Lhe safeLy procedures compllance was assoclaLed wlLh slgnlflcanL lmprovemenL ln deaLh
ln Low MorLallLy u8Cs. (C8 [Cdds 8aLlo]: 0.61, 93 Cl [Confldence lnLerval]: 0.36-1.03, [?aLes value]: 0.08).

Conc|us|on: When comparlng Lhe resulLs for Lhe Lwo populaLlons, lnpaLlenLs ln hosplLals wlLh =90 compllance on
SlnAS SafeLy rocedures assessmenL (opulaLlon 1) have a slgnlflcanL lower rlsk of deaLh ln Low MorLallLy u8Cs (1-
0.61=0.39*100=39) Lhan lnpaLlenLs ln hosplLals wlLh <90 compllance on SlnAS SafeLy rocedures assessmenL
(populaLlon 2).


2621

1nL IMAC1 CI IMLLMLN1A1ICN CI MUL1I-S1AGL INILC1ICN CCN1kCL S1kA1LGILS 1C IMkCVL CLN1kAL LINL-
ASSCCIA1LD 8LCCDS1kLAM INILC1ICN IN IN1LNSIVL CAkL UNI1
?u-Wel Puang
1,*
, ?l-Mlng Wang
1
, lu-8ln Lln
2
, Chung-Psu Lal
2

1
CrlLlcal Care Medlclne,
2
lnfecLlon ConLrol, L-uA PosplLal, kaohslung ClLy, 1alwan


Cb[ect|ves: CenLral Llne-AssoclaLed 8loodsLream lnfecLlon (CLA8Sl) ln our lnLenslve care unlLs (lCus) ls Lhe mosL
common and lmporLanL healLh care-assoclaLed lnfecLlons lndlcaLors. lrom !uly Lo uecember 2009, we found Lhe
slgnlflcanL lncrease ln Lhe Lrend of Lhe CLA8Sl denslLy (8.63 per 1,000 cenLral llne (CL) days, 36/4172 ) ln our lCus and lL
was hlgher Lhan oLher peer hosplLals. 1he use of a cenLral llne lnserLlon and care bundles has been shown Lo reduce Lhe
lncldence of CLA8Sl. 1herefore, we Lrled Lo lmplanL Lhe mulLl-sLage lnfecLlon conLrol sLraLegles Lo lmprove our CLA8Sl
lnfecLlon denslLy ln our lCus.

Methods: Survelllance for CLA8Sl was conducLed by Lralned lnfecLlon conLrol nurses uslng u.S. CuC deflnlLlons and
devlce-day measuremenL meLhods. 1here are elghL lCus ln our hosplLal wlLh LoLal 98 beds. 1he sLudy was dlvlded lnLo
Lhree perlods. ln 2010, our deparLmenL of lnfecLlon conLrol seL Lhe cenLral venous caLheLer (CvC) lnserLlon check llsL,
sLarLed Lo record Lhe CvC lnserLlon daLe on Lhe charL sheeL, and Look Lhe lnsLrucLlonal vldeos of CvC lnserLlon. ln 2011,
we esLabllshed lnLer-professlonal Leam for CLA8Sl prevenLlon. We Look Lhe second edlLlon of lnsLrucLlonal vldeos for
CvC lnserLlon and dally care. We hold serles educaLlonal programs of CLA8Sl prevenLlon for our sLaffs. ln 2012, we
promoLed and esLabllshed on-llne lnformaLlon sysLems for sLaLlsLlcal analysls, real Llme feedback Lo our cllnlcal unlLs,
and measuremenL for performance.

kesu|ts: 8efore lnLervenLlon, our lCus CLA8Sl denslLy was 8.63 per 1,000 CL days. AfLer lnLervenLlon, our lCus CLA8Sl
denslLy was 7.10 per 1,000 CL days (38/8163) ln 2010, 7.41 per 1,000 CL days (61/8234) ln 2011. llnally, our lCus CLA8Sl
denslLy decreased Lo 3.14 per 1,000 CL days (41/7982). Compared wlLh Lhe pre-lnLervenLlon perlod, our lCus CLA8Sl
denslLy decreased from 8.63 per 1,000 CL days Lo 2.27 per 1,000 CL days slgnlflcanLly (p=0.04).

Conc|us|on: 1hls sLudy shows LhaL lmplemenLaLlon of mulLl-sLage lnfecLlon conLrol sLraLegles was assoclaLed wlLh a
slgnlflcanL reducLlon ln Lhe CLA8Sl denslLy ln lCu.



2629

IMkCVING 1nL LIIICILNC CI 1nL MANI1C8A UALI1 ASSUkANCL kCGkAM
lan Wllklnson
1,*

1
ManlLoba CuallLy Assurance rogram, College of hyslclans and Surgeons of ManlLoba, Wlnnlpeg, Canada


Cb[ect|ves: 1he ManlLoba CuallLy Assurance rogram (MAnCA) ls responslble for assurlng LhaL all dlagnosLlc faclllLles
ln Lhe provlnce are held Lo quallLy sLandards esLabllshed by Lhe rogram 8evlew CommlLLee (8C) of Lhe College of
hyslclans and Surgeons of ManlLoba (CSM). MAnCA carrles ouL on-slLe lnspecLlons, monlLors exLernal quallLy
conLrols, develops sLandards and works wlLh sLakeholders Lo ensure LhaL hlgh quallLy dlagnosLlc LesLlng ls provlded Lo all
ManlLobans. 1he program ls funded by Lhe CovernmenL of ManlLoba and by revenues recelved from prlvaLely owned
dlagnosLlc faclllLles.

ln order Lo lmprove clarlLy, lncrease effecLlveness and efflclency and decrease cosLs assoclaLed wlLh lnspecLlons and
reporLs arlslng from Lhese lnspecLlons, MAnCA has developed Lhe followlng processes:

Methods: narraLlve reporLs have been dlsconLlnued and a ?es/no/noL Appllcable quesLlonnalre sysLem lnLroduced. An
MS Lxcel based pre-lnspecLlon quesLlonnalre ls senL ouL several weeks ln advance of an lnspecLlon. 1hls quesLlonnalre ls
based on Lhe enLlre seL of relevanL sLandards. 1he ?/n/nA answers are enLered by Lhe cllenL are Lhen compared wlLh
acLual observaLlons durlng Lhe on-slLe lnspecLlon. An lnLerlm reporL ls glven Lo Lhe cllenL on Lhe day of lnspecLlon. A
copy of Lhls reporL ls enLered lnLo a MS Access daLabase and a copy ls also revlewed by 8C whlch decldes Lhe
accredlLaLlon sLaLus of Lhe faclllLy and seLs deadllnes for any remedlaLlon (90 worklng days usually). As remedlaLlon
documenLaLlon ls recelved by MAnCA Lhe daLabase ls amended. When all remedlaLlons are saLlsfacLorlly compleLed
Lhe reporL goes back Lo 8C for Lhelr revlew and flnal accredlLaLlon sLaLus.

kesu|ts: 1hls new meLhod reduces amblgulLles, decreases cosLs and allows rapld access Lo lnformaLlon on any faclllLy
aL any Llme uslng Lhe MS Access daLabase

Conc|us|on: Cnce LesLlng of Lhls new process ls compleLe, Lhe sysLem wlll be become enLlrely elecLronlc uslng LableL Cs
or lads durlng Lhe on-slLe lnspecLlon whlch have been loaded wlLh pre-survey quesLlonnalre answers from Lhe slLe ln
quesLlon.



2637

ANALSIS CI IN1kAVLNCUS 1kCM8LISLS CI AIS kLALISLD A1 U8LIC LDUCA1ICN nCSI1AL IkCM 8kA2IL
Carlos AnLunes
1,*
, Carollne L. C. Sllva
1
, lranclslelne l. u. SanLos
1
, Cladla nasslf
1

1
urgency unlL, PLS - Sumare SLaLe PosplLal, Sumare/S, 8razll


Cb[ect|ves: AcuLe lschemlc SLroke. (AlS), has a large socloeconomlc lmpacL, malnly due Lo lLs sequels. lnLravenous
1hrombolysls wlLh AlLeplase (rL-a) has Lhe evldence class l, level A, so lLs prlnclpal ob[ecLlve ls early repaymenL of Lhe
blood flow ln Lhe affecLed area, resulLlng ln lmproved cllnlcal and funcLlonal from paLlenL. 1he naLlonal Crdlnance n.
664, 12 Aprll 2012, provldes for Lhe beglnnlng of Lhrombolysls Lherapy, Lhe Llme lnLerval up Lo 4h and 30mln from Lhe
sLarL of sympLoms Lo lnfuslon of Lhe drug. 1o reporL our experlence abouL Lhe performlng lnLravenous Lhrombolysls ln
lschemlc sLroke, accordlng Lo Lhe lnsLlLuLlonal proLocol, aL Sumare SLaLe PosplLal.

Methods: A descrlpLlve exploraLory and reLrospecLlve sLudy. We analysed Lhe records of all adulL paLlenLs undergolng
Lhrombolysls for AcuLe lschemlc SLroke. (AlS) wlLh lnLravenous AlLeplase (rL-a) ln Lhe year 2009 Lo 2012, aL Sumare
SLaLe PosplLal, whlch ls a reference Lo flve munlclpallLles ln Lhe reglon. SLaLe PosplLal Sumare, Lhe lmplemenLaLlon and
managemenL of sLroke proLocol began ln 2007 wlLh Lhe ob[ecLlve Lo deLermlne Lhe epldemlologlcal proflle of paLlenLs,
ldenLlfy paLlenLs requlrlng Lhrombolysls, and as a consequence, opLlmlse ln-hosplLal LreaLmenL. uaLa were recorded ln
an lnsLlLuLlonal daLabase, whlch allowed Lhe descrlpLlve sLaLlsLlcal analysls. 1he use of daLa obLalned approval of Lhe
healLh lnsLlLuLlon where Lhe sLudy was reallsed.

kesu|ts: uurlng Lhe perlod, we analysed Lhe medlcal records of 41 paLlenLs, 19 (46.34) women and 22 (33.34) men,
wlLh a average age of 60 years old. Among Lhe cases, Lwo paLlenLs for lnLravenous Lhrombolysls was noL lndlcaLed
because Lhere was no preclse Llme of onseL of sympLoms. All lndlcaLed for Lhrombolysls Lomography were performed
wlLhln Lhe alloLLed Llme less Lhan 30 mlnuLes, and ln 13 (77) were Lhrombolyzed ln Lhe Llme lnLerval provlded by Lhe
proLocol (60 mlnuLes). 1hlrLy-Lhree paLlenLs (82) had cllnlcal lmprovemenL and dlscharge, accordlng Lo Lhe modlfled
8ankln scale, and 33 of Lhese already wlLh lndependence for self-care (8ankln <= 3).

Conc|us|on: 1he sLudy hlghllghLs Lhe hlgh frequency of paLlenLs wlLh Lhe beLLer cllnlcal afLer compleLlon of Lhrombolysls,
wlLh noLlceable lmprovemenLs ln funcLlonal capaclLy. 1he fallure Lo ldenLlfy Lhe warnlng slgns for famlly and home
servlces, causlng a delay ln Lhe search emergency medlcal servlce, llnked Lo problems ln LransporLaLlon and paLlenL
referral Lo a speclallsL servlce, lnfluences Lhe prognosls of Lhe paLlenL. 1he lmplemenLaLlon of lnsLlLuLlonal proLocol for
lnLravenous Lhrombolysls ln lschemlc sLroke, based on sclenLlflc evldence, ensures Lhe safeLy of Lhe procedure.

keferences: uaLa base from Sumare SLaLe PosplLal.
Socledade 8rasllelra de uoenas Cerebrovasculares. rlmelro Consenso 8rasllelro para 1rombllse no AcldenLe vascular
Cerebral lsqumlco Agudo. Arq neuropslqulaLr 2002,60 (3-A):673-680.
nlnuS rL-A SLroke 1rlal lnvesLlgaLors and CoordlnaLors. A sysLems approach Lo lmmedlaLe evaluaLlon and managemenL
of hyper-acuLe sLroke: experlence aL 8 cenLers and lmpllcaLlons for communlLy pracLlce and paLlenL care. SLroke. 1997,
28:1330-40


!"#$

&''()*&+*(, (- &.(*/&012 3('4*+&1 &/5*''*(, 6&+2' &,/ 462.&12,)2 7 & 52+3(/(1(8*)&1
&446(&)3 (- 462.&12,)2 &/9:'+52,+

S. L. uroesler
1,*
, S. knorr
1
, C. ScheldL-nave
2
, M. Weyermann
1

1
laculLy of PealLh Care, nlederrheln unlverslLy of Applled Sclences, krefeld,
2
8oberL koch lnslLuLe,
8erlln, Cermany


(;<=>?@A=BC opulaLlon-based hosplLal admlsslons for cerLaln chronlc condlLlons are assumed Lo be
senslLlve Lo ambulaLory care and serve as a proxy for quallLy of prlmary care. lnsLlLuLlons such as Lhe
Agency for PealLhcare 8esearch and CuallLy (AP8C) or Lhe CrganlzaLlon for Lconomlc Co-CperaLlon and
uevelopmenL (CLCu) use Lhese lndlcaLors - based on Lhe prlnclpal dlagnosls of an adulL hosplLallzaLlon -
for publlc reporLlng. Marked geographlc varlaLlons occur across CLCu counLrles, e.g. Lhe 2009 CCu
hosplLal admlsslon raLes vary beLween 71 (orLugal) and 364 (lreland) per 100,000 populaLlon. We
found slmllar reglonal varlaLlons across Cerman sLaLes, e.g. for hyperLenslon and dlabeLlc ampuLaLlons
Lhe admlsslon raLes of 1hurlngla - Lhe sLaLe wlLh Lhe hlghesL raLes - are abouL Lhree Llmes hlgher
compared Lo Lhe sLaLes wlLh Lhe lowesL raLes (8erlln and Pamburg).We lnvesLlgaLed wheLher reglonal
varlaLlons ln hosplLal admlsslons for selecLed ambulaLory care senslLlve condlLlons correlaLe wlLh
reglonal prevalence esLlmaLes, and wheLher ad[usLmenL for prevalence reduces reglonal varlaLlon. lor
prevalence ad[usLmenL we used a quanLlLaLlve model accordlng Lo Lhe CLCu's reporLlng of paLlenL
safeLy lndlcaLors.

5=?DEFBC We performed a reLrospecLlve cross-secLlonal sLudy uslng 2010 hosplLal admlnlsLraLlve daLa
from Lhe Cerman u8C daLabase admlnlsLraLed by Lhe lederal SLaLlsLlcal Cfflce. 1he sLudy populaLlon
conslsLed of paLlenLs 13 years or older dlscharged from 1738 acuLe care hosplLals across all 16 Cerman
SLaLes. revalence daLa (12 monLh prevalence) were esLlmaLed from 2009 and 2010 naLlonwlde
Lelephone healLh surveys whlch are regularly performed and parL of Lhe Cerman healLh monlLorlng.

6=BGH?BC We found slgnlflcanL correlaLlons beLween Lhe prevalence of hyperLenslon and Lhe age-sex-
sLandardlzed hyperLenslon admlsslon raLes (earson's CC 0.86), Lhe prevalence of chronlc bronchlLls and
CCu admlsslons (CC 0.39), and beLween Lhe prevalence of dlabeLes and hosplLallzaLlons for dlabeLlc
long Lerm compllcaLlons (CC 0.87) and dlabeLlc lower exLremlLy ampuLaLlons (CC 0.74). An ordlnary leasL
squares unwelghLed regresslon model was esLlmaLed for each admlsslon raLe uslng Lhe prevalence as
Lhe predlcLor varlable (8
2
=34 Lo 73). LsLlmaLed sLaLe-speclflc reslduals were llnearly Lransformed lnLo
ad[usLed admlsslon raLes wlLh Lhe same mean value as Lhe unad[usLed buL sLandardlzed raLes. varlaLlon
among admlsslon raLes decreased subsLanLlally afLer Lhls ad[usLmenL. CoefflclenLs of varlaLlon dropped
as expecLed from 29.9 Lo 13.3 for hyperLenslon", from 13.7 Lo 12.7 for CCu", from 30.9 Lo 13.4 for
dlabeLes wlLh long Lerm compllcaLlons", and from 30.1 Lo 20.2 for dlabeLlc ampuLaLlons". 8anklng of
sLaLes was alLered such LhaL eleven sLaLes moved more Lhan Lwo ranks for Lhe lndlcaLor CCu
admlsslons", slx sLaLes moved more Lhan Lwo ranks for dlabeLlc ampuLaLlons", and four sLaLes moved
more Lhan Lwo ranks for hyperLenslon".1he model was noL applled Lo asLhma (CC 0.30) and chronlc
hearL fallure (CC 0.26) admlsslon raLes because Lhese were uncorrelaLed wlLh Lhe prevalence daLa.

)EI>HGB@EIC 8eglonal varlaLlon ln poLenLlally avoldable hosplLallzaLlons may be confounded by reglonal
dlfferences ln dlsease prevalence. lurLher research ls needed, why Lhls effecL relaLes Lo some buL noL all
chronlc condlLlons. erformance measures LhaL have been sLaLlsLlcally ad[usLed are less varlable Lhan
unad[usLed measures. lnformaLlon on prevalence should be consldered ln comparaLlve reporLlng of
poLenLlally avoldable hosplLallzaLlons.


2639

IMkCVLMLN1 CI 1nL kCCLSS CI 1kANSCk1A1ICN ICk SUkGICAL SLCIMLNS AI1Lk CLkA1ICN
Moonsook klm
1
, Sunyoung ark
1
, Pyungsun klm
1,*
, ?ou[eong klm
1

1
CuallLy Assurance 1eam, Seoul naLlonal unlverslLy PosplLal, Seoul, korea, 8epubllc Cf


Cb[ect|ves: Cur alm ls Lo make Lhe safe and exacL LransporLaLlon process for surglcal speclmens from Lhe operaLlon
room Lhrough Lhe deparLmenL of paLhology afLer surgery, we Lry Lo bulld Lhe sysLem of LransporLaLlon for surglcal
speclmens wlLh SMS malllng servlce, whlch was auLomaLlcally connecLed wlLh LM8 sysLem, and Lhereby lmprove paLlenL
safeLy ln Lhe operaLlng room.

Methods: ln Lhe process of a docLor dellverlng Lhe speclmen and goes Lhrough Lhe recelpL process, he or she may lose lL
or make recelpL error of some klnd. When Lhe speclmen ls noL recelved properly afLer Lhe compleLlon of Lhe operaLlon
wlLhln a flxed Llme, developmenL of SMS program Lo solve Lhe problems prompLly Lhrough SMS noLlflcaLlon Lo Lhe
proper docLor ls belng planned.

usually afLer operaLlon, only 80 of LoLal surglcal speclmens were recelved wlLhln 3 hours. llrsL SMS mall was senL 3
hours afLer operaLlon, and Lhen 2nd SMS mall was senL 3 hours afLer operaLlon Lo Lhe docLor on duLy. 8egular
monlLorlng was noLlced Lwlce a day, and Lhe acLlve feedback Lo Lhe surglcal deparLmenL was made by deparLmenL of
paLhology, lf lL was noL recelved unLll 3 hours. uelayed recelpL of surglcal speclmens was monlLored and shared Lhe daLa
of monlLorlng wlLh all surglcal and paLhology deparLmenLs.

kesu|ts: AfLer 2 monLhs monlLorlng and acLlve feedback, delayed recelpL of surglcal speclmens was decreased by 20
cases Lhan usual. 1here ls no losL of surglcal speclmens ln Lhe operaLlon room.

Conc|us|on: SMS reporLlng sysLem ls very convenlenL, effecLlve and safe meLhod Lo reduce Lhe loss and delayed recelpL
of surglcal speclmens. 8egular monlLorlng and acLlve feedback was cerLlfled Lhe rapld reporL of paLhologlc resulL. 1hls
has led Lo Lhe prevenLlon of lnspecLlon delay and accuraLe performance of Lhe lnspecLlon, so lL has greaLly conLrlbuLed
Lo lmprovlng paLlenL safeLy ln Lhe operaLlng room.



26S1

A UALI1 IMkCVLMLN1 (I) kCILC1 CI SLVLkL SLSIS AND SL1IC 8UNDLLS CAkL 8 8kLAk1nkCUGn SLkILS LLAkNING
kCGkAMS AND S1kA1LG CI 1LAM kLSCUkCL MANAGLMLN1
Chueh-Llen ?ang Chueh-Llen ?ang
1,*
, Pung-Chen Chen
1

1
ulvlslon of ulmonary and CrlLlcal Care Medlclne, ueparLmenL of lnLernal Medlclne, Chang Cung Memorlal PosplLal - kaohslung
Medlcal CenLer, 1alwan, kaohslung, 1alwan


Cb[ect|ves: 1o assess Lhe resulLs of a quallLy lmprovemenL (Cl) pro[ecL deslgned Lo lmprove safeLy of severe sepsls and sepLlc shock
bundles care (lncluded resusclLaLlon bundles care and managemenL bundles).
Methods:
ueslgn:
Slngle cenLer prospecLlve observaLlonal.
SeLLlng: 12-bed medlcal lnLenslve care unlL.

arLlclpanLs:
ulmonary/crlLlcal care vlslLlng sLaffs, fellows, resldenLs and nurslng sLaffs, resplraLory LheraplsLs

lnLervenLlons:
Severe sepsls and sepLlc bundles care performed durlng a perlod of 6 monLhs by Lhe medlcal lnLenslve care unlL Leam were analysed
Lo ldenLlfy lnLervenLlons LhaL would lmprove quallLy of Lhe program. 1he sLaffs parLlclpaLed Lhe breakLhrough serles (81S)
collaboraLlve learnlng program by 1alwan !olnL Commlsslon on PosplLal AccredlLaLlon. 8y segmenLal process analysls, Lhe procedure
of bundles care was sub[ecLed Lo lLeraLlve change. Ma[or componenLs of process lmprovemenL were developmenL of a comblned
Leam approach, a mandaLory checkllsL, posLer, revlslon of compuLerlsed medlcal order sulLes, and use of Leam resource
managemenL (18M) LacLlcs lncludlng slLuaLlonal awareness and recognlLlon of adverse slLuaLlons, communlcaLlon and crosscheck
Lechnlques, glve and recelve performance feedback, managemenL of sLress, workload and faLlgue, creaLlng and malnLalnlng Leam
sLrucLure and cllmaLe, leadershlp, rlsk managemenL and declslon-maklng, handoff sLraLegy(Concerned, uncomforLable, SafeLy- CuS
and lnLroducLlon, slLuaLlon monlLor , assessmenL, recommendaLlon -lS8A8) and Lhe plan-do-sLudy-acL cycles (uSA). CuallLy analysls
and lmprovemenL lncluded compllances of resusclLaLlon and managemenL bundles care.

kesu|ts: lor a 6-monLh perlod ( from lebruary, 2012 Lo ), Lhe compllances of resusclLaLlon and managemenL bundles care lncreased
from 17.8 and 11.1 Lo 43.7 and 37.3, respecLlvely.

Conc|us|on: 1he currenL safeLy paradlgm of paLlenL wlLh severe sepsls and sepLlc shock ls sLlll based on ways Lo llmlL human
varlablllLy ln oLherwlse safe sysLems, promoLlng sLrlngenL compllances of severe sepsls and sepLlc shock resusclLaLlon and
managemenL bundles. 1hls sLudy showed Lhe feaslblllLy and uLlllLy of adapLlng L Lo supporL Lhe broad lmplemenLaLlon and susLalned
use of bundles care ln lCu seLLlngs by parLlclpaLlng Lhe 81S learnlng programs. ln addlLlon, 18M focuses on lmprovlng lnLer-
professlonal cooperaLlon and Leam performance and Lhus paLlenL safeLy. Lven Lhough evldence of 18M on medlcal errors and
paLlenL ouLcome ls sLlll scarce, Lhe parallels beLween Lhe crlLlcal processes ln avlaLlon and lnLenslve Care suggesL LhaL a well-adapLed
medlcal 18M Lralnlng has poLenLlal for Lhe lCu envlronmenL.

keferences: 1aylor, C. 8., PepworLh, !. 1., 8uerhaus, ., ulLLus, 8., Seperoff, 1.2007.LffecL of crew resource managemenL on
dlabeLes care and paLlenL ouLcomes ln an lnner-clLy prlmary care cllnlc. Ooollty ooJ 5ofety lo neoltb cote, 16,244-247.
Levy MM, uelllnger 8, 1ownsend S8, eL al. 1he Survlvlng Sepsls Campalgn: 8esulLs of an lnLernaLlonal guldellne-based performance
lmprovemenL program LargeLlng severe sepsls. loteoslve cote MeJ 2010362: 222-231.
Zambon M, Ceola M, eL allmplemenLaLlon of Lhe survlvlng sepsls campalgn guldellnes, for sever sepsls and sepLlc shockWe
could fasLer. Iootool of ctltlcol cote.2008,23433-460.



26S6

"GCNNAL NC DAL 1nA1" - A NCVLL ILLD8ACk MCDLL ICk nCSI1AL kLSCkI8ING LkkCkS
Creg Waddell
1,*

1
Care of Lhe Llderly, nPS Lanarkshlre, LasL kllbrlde, unlLed klngdom


Cb[ect|ves: rescrlblng errors accounL for Lhe largesL number of poLenLlally prevenLable adverse drugs evenLs ln hosplLal
and are a paLlenL safeLy prlorlLy. uesplLe work on lncldence and causaLlon, llLLle ls known abouL effecLlve lnLervenLlons
Lo reduce harm Lo paLlenLs from such evenLs.

Methods: We have plloLed Connae no dae LhaL", a novel feedback model almlng Lo Lackle Lhe low percelved
lmporLance and lack of self-awareness assoclaLed wlLh prescrlblng errors. We alm Lo learn from each oLher's' mlsLakes.
lL dellvers personallsed, no-blame analysls of errors Lhrough regular, brlef, pracLlLloner-led presenLaLlons. SoluLlons
lnvolve prescrlbers ln ldenLlfylng sysLemlc weakness, and hlghllghLlng conLrlbuLory culLural aLLlLudes.

kesu|ts: A quesLlonnalre was dlsLrlbuLed durlng Lhe Connae no dae LhaL" plloL. All responder felL feedback Lo be
lnvaluable. lnLeresLlngly, lL also lllusLraLed LhaL only 23 of prescrlbers were aware of maklng a prescrlblng error ln Lhe
precedlng 4 monLhs, yeL nearly all could recall a colleague's error over Lhe same perlod. CLher Lhan correcLlng Lhe
prescrlpLlon, a Lhlrd of responders admlLLed Lo noL reporLlng Lhe error nor provldlng lnformal feedback Lo colleagues.
Learnlng polnL's Lo-daLe lncludes hlgh-rlsk medlcaLlon, Lhe lmporLance of medlclnes reconclllaLlon and lmprovlng
dlssemlnaLlon of knowledge of un-mlssable drugs such as anLl-epllepLlcs.

Conc|us|on: Connae no dae LhaL" ls becomlng an esLabllshed feaLure of on-golng medlcal educaLlon aL Palrmyres
PosplLal. lLs Lone and conslsLenLly poslLlve message are qulLe dlsLlncL from Lhe senLlmenL assoclaLed wlLh LradlLlonal
slgnlflcanL evenL or rooL cause analyses. lL has proven Lo be a foundaLlon for promoLlng good pracLlce and an accesslble
rouLe Lo engage wlLh cllnlcal governance locally. lL conLlnues Lo hlghllghL sysLem and knowledge weaknesses LhaL
become Lhe LargeL for subsequenL lnLervenLlons. Cn-golng developmenL of Lhe feedback model focuses on
susLalnablllLy, enhanclng personallsed feedback, collaLlng a 'drug errors' handbook. 1hls model ls slmple, effecLlve and
reproduclble ln oLher care seLLlngs.