Eye on quality


Normah Medical Specialist Centre is aiming to achieve Joint Commission International (JCI) accreditation to further improve its wide range of medical services and enhance its reputation as a very high quality practising hospital.

SINCE its establishment in 1988, Normah Medical Specialist Centre at Petra Jaya, Kuching has been regarded as the leading health facility for the treatment and care of patients in the state.

This first local private hospital has come a long way — from being a 130-bed medical and surgical nonprofit centre to a world-class healthcare provider today.

Having achieved many accolades, including the Malaysian Society for Quality in Health with full certification in 2005, Normah is now in the process of further improving all facets of its comprehensive range of services to achieve the Joint Commission International (JCI) accreditation.

The Centre enlisted Dr  Daniel J Ahearn, an American board-certified physician in internal medicine and nephrology, as a consultant in November last year to help it attain this goal.

A mutual friend, who was the regional chief of staff for a medical centre in Pennsylvania, asked Dr Daniel how would he like to come to Malaysia where a hospital in the state of Sarawak had decided to go for JCI accreditation.

Although having already achieved the Malaysian Society for Quality in Health certification, this hospital, he was told, wanted to raise its profile even higher.

Dr Daniel said he was neither associated with JCI nor a consultant for them but his friend asked him to come to Kuching anyway, and see what he could do to get the Commission over and have a look at Normah vis-a-vis accreditation as a   very high quality practising hospital. He decided to take up the challenge.

The JCI, started in 1997, is basically a non-profit organisation that aims to continuously improve the safety and quality of care for patients in hospitals.

Through international accreditation, consultation, publications and education programmes, it has extended its mission worldwide to improve the quality of patients’ care by helping international health care organisations, public health agencies, health ministries and others  evaluate, improve, demonstrate and enhance the quality of patients’ care and safety in more than 60 countries.

To demonstrate quality,international hospitals seek JCI accreditation which is also considered a seal of approval by medical travellers from the US.

Stem to stern

According to Dr Daniel, the staff at Normah had, for the past year, been changing the way they were doing things.

He said the emphasis was on continuous improvement and increase in quality to the   point where JCI could be asked to come to Sarawak to conduct a survey — from top to bottom and stem to stern — and find that the Centre had met their stringent standards.

“We have to ensure the safety of the hospital and the adequacy of quality and care it delivers. First of all, do you think it’s safe to be in a hospital? I could tell you it’s pretty safe but it could be made safer.

“There is a risk of things happening in a hospital that could also have happened outside it. We have a lot of  medicines, so there’s a  possibility of making medication errors.

“We hire human beings, not robots. People get tired or the system that ensures you get the right dose, the right medication at the right time may not be perfect. For people who come here, there’s also a possibility they could fall and hurt themselves,” he added.

Dr Daniel said it was a commitment to improve the safety and quality of care for folks who came to the Centre — diseased, sick, ill, frail, babies and children.

“The job is never done and will never be perfect. Medicine is not perfect. It’s the art of probability and science underlined by how good you’re doing it. I can never tell you with 100 per cent certainty that what’s going to happen is going to  work out.

“Here at Normah, we try to make sure the ratio  between the benefit of whatwe do and the risk of doing it is maximum. We are constantly trying to improve the quality of patient care,” he explained.

Book of standards

According to Dr Daniel, JCI has a book of standards listing out some 13 standards, among which arepatient management, medication management and usage, governance of hospitals and functions of hospitals.

“Our job is to look at thestandards and continuously measure ourselves against them. We want to do a little better today than yesterday.”

To achieve this, he said “continuous effort to manage better” was pivotal, adding that instilling such a culture was a top priority in Normah.

He said getting ready for the surveyors to come in took a lot of work and key people throughout the organisation would be responsible for looking atthe standards and making sure elements of the standards were being adhered to on a daily basis. “Measure and feedback. The doctors are involved. They have adopted a new set of credentials, rules and regulations on improving quality and safety in line with the JCI. At the end of the day, that is where the standards are.

“We have adopted the International Patient Safety Goals (IPSG) which are measurable goals to ensure the safety and quality of patients care will improve.”

Hand hygiene

Dr Daniel emphasised that one of the goals was to decrease the risk of healthcare-associated infection through hand hygiene.

“Did the doctors and nurses wash their hands? What about the patients and their family members who came in? If we can have people practising good hand hygiene, we know we will decrease the risk of infection in our hospital.

“When you come to Normah, we want to make sure you get the medication you’re supposed to and it’s identified correctly.

IPSG make sure we use two identifiers such as your name and IC numbers.”

He said another measure was to make sure people at the Centre communicate effectively by applying cockpit management, used in the airline industry.

“For instance, I ask a nurse to give a patient acertain medication — so that’s written down as an order.

The nurse would have to communicate back to me and re-confirm what I just said.

“We are working very hard to make sure our structure, process and outcome meet rigorous JCI standards and that we are ready for the survey — which is an extremely challenging one.”

Asked whether he had noticed any improvement at Normah since taking on the challenge to achieve JCI accreditation, he said they still had a way to go — a lot of things to do better.

He disclosed that initially, there was neither any group performance plan nor infection control plan nor time-out safeguard to double-check on ‘the correct patient and correct procedure’ before an operation.

But now, he pointed out, the Centre was doing all these not only in the OR (operating room) but also the cardio lab, A&E and radiology apart from incorporating the ‘pain management programme’.

“One of the things we want the most after surgery is pain medicine. We have it now,” he added.

Strengthening weaker areas

Are things at the Centre  perfect? Absolutely not, said DrDaniel, as they were still trying to change the things they were doing such as identifying weaker areas and trying to make them better.

“Code Pink, for instance, is used when a baby is abducted. Could that happen? It could. What would Normah’s reputation be if a baby were abducted there? It would go down without a doubt.”

He revealed the Centre did call a Code Pink (mock exercise) but somebody was still able to get out of the   hospital with a baby (substituted with a doll for the excercise).

So another mock drill was required. In fact, he added, such drills were needed every month ‘until we have closed off all possibilities’.

Is baby abduction probable? Not so much in Malaysia, Dr Daniel said, but it could happen — therisk is extremely high although the frequency may be low.

“We want to make sure it  never happens.

Continuous improvement, based on evidence and measurement, is the key.”

Asked how much time he was giving Normah to achieve JCI accreditation, hesaid he was not giving any timeframe just yet, adding that in a way, it was important, yet not important because the Centre was doing things better today than yesterday and getting there.

“I want to make sure when we’re ready, we’re really ready.”

Two groups had carried out a mini survey at the Centre — one before Dr  Daniel came and the otherafter. The Centre didn’t have much in place when the first group came but the second group with whom Dr Daniel had worked in  Pennsylvania visited in Julyand told the Centre it had done quite a number of things but Dr Daniel felt there was still more to do.

“I want to make sure when we decide to call JCI, we can say to them: “Whenever you want to come, you can drop in because I’m very comfortable we’re meeting your standards. We’remaking a commitment to do this and have made more than 50 per cent progress. We still have some way to go.”

Evaluation on request Dr Daniel said JCI surveyors came to evaluate Normah on request.

“We apply and they set a date and the survey usually runs for five days.”

He pointed out that in the US, they won’t tell you when they’re coming and could show up anytime.

“It applies to hospitals there because they have Medicare, a social insurance programme, administered by the government, to provide coverage for people 65 and above or who meet other special criteria.

“To qualify for Medicare payments, a hospital has to undergo some sort of survey so that the  Medicare people can feel comfortable they’re not giving their money for poor care.

“One of the ways to do this is to have the Joint Commission come in. If it accredits the hospital, then Medicare would say that’sgood enough for them.

So I would say close to 80 per cent of hospitals in the US, excluding VA (Veterans Affairs) hospitals, have Joint Commission accreditation.

They need the money to exist. Here, there’s no such requirement.”

Asked why Normah had decided to go for JCI accreditation, he said one of the Centre’s main goals was to prove it was among the best of the best and it wanted to do this based on JCI accreditation.

“When we get it, we’re still going to try and do even better,” he assured.

According to Dr Daniel, the JCI surveyors come backevery three years — so it’s a tri-annual accreditation, not a one-off thing where once they award you, they’re done.

“I’m sure JCI standardswill get even stricter.

I understand a revised book of standards will be out sometime in July next year.

We need to be fully compliant by July 2011.

Their job is to continuouslyimprove the safety and quality of hospitals. Ours is to continue doing that by measuring against JCI standards.”

Dr Daniel said this wasnot just a ‘western’ thing, pointing out that there were JCI-accredited hospitals in Singapore, and in Malaysia, two such hospitals were found in Penang and Kuala Lumpur.

“When it gets the accreditation, Normah will be the only hospital in East Malaysia to have it.

This is important for the people of Sarawak as they will be getting the best of the best. And it’s up to us with our vocation to continuously improve the care of those who come here and trust us,” he added.